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Nyondo-Mipando AL, Kapesa LS, Salimu S, Kazuma T, Mwapasa V. "Dispense antiretrovirals daily!" restructuring the delivery of HIV services to optimize antiretroviral initiation among men in Malawi. PLoS One 2021; 16:e0247409. [PMID: 33617561 PMCID: PMC7899340 DOI: 10.1371/journal.pone.0247409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 02/07/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Gender disparities exist in the scale-up and uptake of HIV services with men being disproportionately under-represented in the services. In Eastern and Southern Africa, of the people living with HIV infection, more adult women than men were on treatment highlighting the disparities in HIV services. Delayed initiation of antiretroviral treatment creates a missed opportunity to prevent transmission of HIV while increasing HIV and AIDS-associated morbidity and mortality. The main objective of this study was to assess the strategies that men prefer for Antiretroviral Therapy (ART) initiation in Blantyre, Malawi. METHODS This was a qualitative study conducted in 7 Health facilities in Blantyre from January to July 2017. We selected participants following purposive sampling. We conducted 20 in-depth interviews (IDIs) with men of different HIV statuses, 17 interviews with health care workers (HCWs), and 14 focus group discussions (FGDs) among men of varying HIV statuses. We digitally recorded all the data, transcribed verbatim, managed using NVivo, and analysed it thematically. RESULTS Restructuring the delivery of antiretroviral (ARVs) treatment and conduct of ART clinics is key to optimizing early initiation of treatment among heterosexual men in Blantyre. The areas requiring restructuring included: Clinic days by offering ARVs daily; Clinic hours to accommodate schedules of men; Clinic layout and flow that preserves privacy and establishment of male-specific clinics; ARV dispensing procedures where clients receive more pills to last them longer than 3 months. Additionally there is need to improve the packaging of ARVs, invent ARVs with less dosing frequency, and dispense ARVs from the main pharmacy. It was further suggested that the test-and-treat strategy be implemented with fidelity and revising the content in counseling sessions with an emphasis on the benefits of ARVs. CONCLUSION The success in ART initiation among men will require a restructuring of the current ART services to make them accessible and available for men to initiate treatment. The inclusion of people-centered approaches will ensure that individual preferences are incorporated into the initiation of ARVs. The type, frequency, distribution, and packaging of ARVs should be aligned with other medicines readily available within a health facility to minimize stigma.
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Affiliation(s)
- Alinane Linda Nyondo-Mipando
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Leticia Suwedi Kapesa
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Sangwani Salimu
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Thokozani Kazuma
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Victor Mwapasa
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
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Jopling R, Nyamayaro P, Andersen LS, Kagee A, Haberer JE, Abas MA. A Cascade of Interventions to Promote Adherence to Antiretroviral Therapy in African Countries. Curr HIV/AIDS Rep 2021; 17:529-546. [PMID: 32776179 PMCID: PMC7497365 DOI: 10.1007/s11904-020-00511-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review We reviewed interventions to improve uptake and adherence to antiretroviral therapy (ART) in African countries in the Treat All era. Recent Findings ART initiation can be improved by facilitated rapid receipt of first prescription, including community-based linkage and point-of-care strategies, integration of HIV care into antenatal care and peer support for adolescents. For people living with HIV (PLHIV) on ART, scheduled SMS reminders, ongoing intensive counselling for those with viral non-suppression and economic incentives for the most deprived show promise. Adherence clubs should be promoted, being no less effective than facility-based care for stable patients. Tracing those lost to follow-up should be targeted to those who can be seen face-to-face by a peer worker. Summary Investment is needed to promote linkage to initiating ART and for differentiated approaches to counselling for youth and for those with identified suboptimal adherence. More evidence from within Africa is needed on cost-effective strategies to identify and support PLHIV at an increased risk of non-adherence across the treatment cascade. Electronic supplementary material The online version of this article (10.1007/s11904-020-00511-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rebecca Jopling
- Health Service & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Primrose Nyamayaro
- Department of Psychiatry, University of Zimbabwe College of Health Sciences, Mazowe Street, Avondale, Harare, Zimbabwe
| | - Lena S Andersen
- HIV Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental Health, University of Cape Town, Groote Schuur Hospital Anzio Road, Observatory, Cape Town, South Africa
| | - Ashraf Kagee
- Department of Psychology, Stellenbosch University, Stellenbosch, 7602, South Africa
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Melanie Amna Abas
- Health Service & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
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Onoya D, Hendrickson C, Sineke T, Maskew M, Long L, Bor J, Fox MP. Attrition in HIV care following HIV diagnosis: a comparison of the pre-UTT and UTT eras in South Africa. J Int AIDS Soc 2021; 24:e25652. [PMID: 33605061 PMCID: PMC7893145 DOI: 10.1002/jia2.25652] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/07/2020] [Accepted: 11/17/2020] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Policies for Universal Test & Treat (UTT) and same-day initiation (SDI) of antiretroviral therapy (ART) were instituted in South Africa in September 2016 and 2017 respectively. However, there is limited evidence on whether these changes have improved patient retention after HIV diagnosis. METHODS We enrolled three cohorts of newly diagnosed HIV-infected adults from two primary health clinics in Johannesburg from April to November 2015 (Pre-UTT, N = 144), May-September 2017 (UTT, N = 178) and October-December 2017 (SDI, N = 88). A baseline survey was administered immediately after HIV diagnosis after which follow-up using clinical records (paper charts, electronic health records and laboratory data) ensued for 12 months. The primary outcome was patient loss to follow-up (being >90 days late for the last scheduled appointment) at 12 months post-HIV diagnosis. We modelled attrition across HIV policy periods with Cox proportional hazard regression. RESULTS Overall, 410 of 580 screened HIV-positive patients were enrolled. Overall, attrition at 12 months was 30% lower in the UTT guideline period (38.2%) compared to pre-UTT (47.2%, aHR 0.7, 95% CI: 0.5 to 1.0). However, the total attrition was similar between the SDI (47.7%) and pre-UTT cohorts (aHR 1.0, 95% CI: 0.7 to 1.5). Older age at HIV diagnosis (aHR 0.5 for ≥40 vs. 25 to 29 years, 95% CI: 0.3 to 0.8) and being in a non-marital relationship (aHR 0.5 vs. being single, 95% CI: 0.3 to 0.8) protected against LTFU at 12 months, whereas LTFU rates increased with longer travel time to the diagnosing clinic (aHR 1.8 for ≥30 minutes vs. ≤15 minutes, 95% CI: 1.1 to 3.1). In analyses adjusted for the time-varying ART initiation status, compared to the pre-ART period of care, the hazard of on-ART LTFU was 90% higher among participants diagnosed under the SDI policy compared to pre-UTT (aHR 1.9, 95% CI: 1.1 to 2.9). CONCLUSIONS Overall, nearly two-fifths of HIV positive patients are likely to disengage from care by 12 months after HIV diagnosis under the new SDI policy. Furthermore, the increase in on-ART patient attrition after the introduction of the SDI policy is cause for concern. Further research is needed to determine the best way for rapidly initiating patients on ART and also reducing long-term attrition from care.
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Affiliation(s)
- Dorina Onoya
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Cheryl Hendrickson
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Jacob Bor
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Matthew P. Fox
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
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Toward Universal HIV Treatment in Haiti: Time Trends in ART Retention After Expanded ART Eligibility in a National Cohort From 2011 to 2017. J Acquir Immune Defic Syndr 2021; 84:153-161. [PMID: 32084052 DOI: 10.1097/qai.0000000000002329] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The World Health Organization (WHO) recommends universal antiretroviral therapy (ART) for persons living with HIV (PLWH), but evidence about effects of expanded ART access on ART retention in low-resource settings is limited. SETTING Haiti's Ministry of Health endorsed universal ART for pregnant women in March 2013 (Option B+) and for all PLWH in July 2016. This study included 51,579 ART patients from 2011 to 2017 at 94 hospitals and clinics in Haiti. METHODS This observational, retrospective cohort study described time trends in 6-month ART retention using secondary data, and compared results during 3 periods using an interrupted time series model: pre-Option B+ (period 1: 1/11-2/13), Option B+ (period 2: 3/13-6/16), and Test and Start (T&S, period 3: 7/16-9/17). RESULTS From the pre-Option B+ to the T&S period, the monthly count of new ART patients increased from 366/month to 877/month, and the proportion with same-day ART increased from 6.3% to 42.1% (P < 0.001). The proportion retained on ART after 6 months declined from 78.4% to 75.0% (P < 0.001). In the interrupted time series model, ART retention improved by a rate of 1.4% per quarter during the T&S period after adjusting for patient characteristics (adjusted incidence rate ratio = 1.014; 95% confidence interval: 1.002 to 1.026, P < 0.001). However, patients with same-day ART were 14% less likely to be retained compared to those starting ART >30 days after HIV diagnosis (adjusted incidence rate ratio = 0.86; 95% confidence interval: 0.84-0.89, P < 0.001). CONCLUSIONS Achieving targets for HIV epidemic control will require increasing ART retention and reducing the disparity in retention for those with same-day ART.
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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: 35] [Impact Index Per Article: 11.7] [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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Mody A, Glidden DV, Eshun-Wilson I, Sikombe K, Simbeza S, Mukamba N, Somwe P, Beres LK, Pry J, Bolton-Moore C, Padian N, Holmes CB, Sikazwe I, Geng EH. Longitudinal Care Cascade Outcomes Among People Eligible for Antiretroviral Therapy Who Are Newly Linking to Care in Zambia: A Multistate Analysis. Clin Infect Dis 2020; 71:e561-e570. [PMID: 32173743 PMCID: PMC7744998 DOI: 10.1093/cid/ciaa268] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/13/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Retention in human immunodeficiency virus (HIV) care is dynamic, with patients frequently transitioning in and out of care. Analytical approaches (eg, survival analyses) commonly used to assess HIV care cascade outcomes fail to capture such transitions and therefore incompletely represent care outcomes over time. METHODS We analyzed antiretroviral therapy (ART)-eligible adults newly linking to care at 64 clinics in Zambia between 1 April 2014 and 31 July 2015. We used electronic medical record data and supplemented these with updated care outcomes ascertained by tracing a multistage random sample of patients lost to follow-up (LTFU, >90 days late for last appointment). We performed multistate analyses, incorporating weights from sampling, to estimate the prevalence of 9 care states over time since linkage with respect to ART initiation, retention in care, transfers, and mortality. RESULTS In sum, 23 227 patients (58% female; median age 34 years [interquartile range 28-41]) were ART-eligible at enrollment. At 1 year, 75.2% had initiated ART and were in care: 61.8% were continuously retained, 6.1% had reengaged after LTFU, and 7.3% had transferred. Also, 10.1% were LTFU within 7 days of enrollment, and 15.2% were LTFU at 1 year (6.7% prior to ART). One year after LTFU, 51.6% of those LTFU prior to ART remained out of care compared to 30.2% of those LTFU after initiating ART. Overall, 6.9% of patients had died by 1 year with 3.0% dying prior to ART. CONCLUSION Multistate analyses provide more complete assessments of longitudinal HIV cascade outcomes and reveal treatment gaps at distinct timepoints in care that will still need to be addressed even with universal treatment.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Sandra Simbeza
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Njekwa Mukamba
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Paul Somwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Laura K Beres
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, Maryland, USA
| | - Jake Pry
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, University of Alabama, Birmingham, Alabama, USA
| | - Nancy Padian
- Division of Epidemiology, University of California, Berkeley, Berkeley, California, USA
| | - Charles B Holmes
- Department of Medicine, Georgetown University, Washington, D.C., USA
| | - Izukanji Sikazwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
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Thompson MA, Horberg MA, Agwu AL, Colasanti JA, Jain MK, Short WR, Singh T, Aberg JA. Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2020; 73:e3572-e3605. [PMID: 33225349 DOI: 10.1093/cid/ciaa1391] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 12/15/2022] Open
Abstract
Advances in antiretroviral therapy (ART) have made it possible for persons with human immunodeficiency virus (HIV) to live a near expected life span, without progressing to AIDS or transmitting HIV to sexual partners or infants. There is, therefore, increasing emphasis on maintaining health throughout the life span. To receive optimal medical care and achieve desired outcomes, persons with HIV must be consistently engaged in care and able to access uninterrupted treatment, including ART. Comprehensive evidence-based HIV primary care guidance is, therefore, more important than ever. Creating a patient-centered, stigma-free care environment is essential for care engagement. Barriers to care must be decreased at the societal, health system, clinic, and individual levels. As the population ages and noncommunicable diseases arise, providing comprehensive healthcare for persons with HIV becomes increasingly complex, including management of multiple comorbidities and the associated challenges of polypharmacy, while not neglecting HIV-related health concerns. Clinicians must address issues specific to persons of childbearing potential, including care during preconception and pregnancy, and to children, adolescents, and transgender and gender-diverse individuals. This guidance from an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America updates previous 2013 primary care guidelines.
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Affiliation(s)
| | - Michael A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic Permanente Medical Group, Rockville, Maryland, USA
| | - Allison L Agwu
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Mamta K Jain
- Division of Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - William R Short
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tulika Singh
- Internal Medicine, HIV and Infectious Disease, Desert AIDS Project, Palm Springs, California, USA
| | - Judith A Aberg
- Division of Infectious Diseases, Mount Sinai Health System, New York, New York, USA
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Makurumidze R, Buyze J, Decroo T, Lynen L, de Rooij M, Mataranyika T, Sithole N, Takarinda KC, Apollo T, Hakim J, Van Damme W, Rusakaniko S. Patient-mix, programmatic characteristics, retention and predictors of attrition among patients starting antiretroviral therapy (ART) before and after the implementation of HIV "Treat All" in Zimbabwe. PLoS One 2020; 15:e0240865. [PMID: 33075094 PMCID: PMC7571688 DOI: 10.1371/journal.pone.0240865] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 10/03/2020] [Indexed: 12/30/2022] Open
Abstract
Background Since the scale-up of the HIV “Treat All” recommendation, evidence on its real-world effect on predictors of attrition (either death or lost to follow-up) is lacking. We conducted a retrospective study using Zimbabwe ART program data to assess the association between “Treat All” and, patient-mix, programmatic characteristics, retention and predictors of attrition. Methods We used patient-level data from the electronic patient monitoring system (ePMS) from the nine districts, which piloted the “Treat All” recommendation. We compared patient-mix, programme characteristics, retention and predictors of attrition (lost to follow-up, death or stopping ART) in two cohorts; before (April/May 2016) and after (January/February 2017) “Treat All”. Retention was estimated using survival analysis. Predictors of attrition were determined using a multivariable Cox regression model. Interactions were used to assess the change in predictors of attrition before and after “Treat All”. Results We analysed 3787 patients, 1738 (45.9%) and 2049 (54.1%) started ART before and after “Treat All”, respectively. The proportion of men was higher after “Treat All” (39.4.% vs 36.2%, p = 0.044). Same-day ART initiation was more frequent after “Treat All” (43.2% vs 16.4%; p<0.001) than before. Retention on ART was higher before “Treat All” (p<0.001). Among non-pregnant women and men, the adjusted hazard ratio (aHR) of attrition after compared to before “Treat All” was 1.73 (95%CI: 1.30–2.31). The observed hazard of attrition for women being pregnant at ART initiation decreased by 17% (aHR: 1.73*0.48 = 0.83) after “Treat All”. Being male (vs female; aHR: 1.45; 95%CI: 1.12–1.87) and WHO Stage IV (vs WHO Stage I-III; aHR: 2.89; 95%CI: 1.16–7.11) predicted attrition both before and after “Treat All” implementation. Conclusion Attrition was higher after “Treat All”; being male, WHO Stage 4, and pregnancy predicted attrition in both before and after Treat All. However, pregnancy became a less strong risk factor for attrition after “Treat All” implementation.
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Affiliation(s)
- Richard Makurumidze
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
- Institute of Tropical Medicine, Antwerp, Belgium
- Gerontology, Faculty of Medicine & Pharmacy, Free University of Brussels (VUB), Brussels, Belgium
- * E-mail:
| | | | - Tom Decroo
- Institute of Tropical Medicine, Antwerp, Belgium
- Research Foundation of Flanders, Brussels, Belgiums
| | | | - Madelon de Rooij
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | - Ngwarai Sithole
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
| | - Kudakwashe C. Takarinda
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Tsitsi Apollo
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
| | - James Hakim
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Wim Van Damme
- Institute of Tropical Medicine, Antwerp, Belgium
- Gerontology, Faculty of Medicine & Pharmacy, Free University of Brussels (VUB), Brussels, Belgium
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Incidence and risk factors for medical care interruption in people living with HIV in a French provincial city. PLoS One 2020; 15:e0240417. [PMID: 33057366 PMCID: PMC7561150 DOI: 10.1371/journal.pone.0240417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/26/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The aim of our study was to identify HIV-positive patients at risk of medical care interruption (MCI) in a provincial city of a high-income country. METHODS We estimated the incidence rate of MCI in 989 individuals followed in an HIV clinic in Caen University Hospital, Normandy, France, between January 2010 and May 2016. We enrolled patients over 18 years old who were seen at the clinic at least twice after HIV diagnosis. Patients were considered to be in MCI if they did not attend care in or outside the clinic for at least 18 months, regardless of whether or not they came back after interruption. We investigated sociodemographic, clinical and immunovirological characteristics at HIV diagnosis and during follow-up through a Cox model analysis. RESULTS The incidence rate of MCI was estimated to be 3.0 per 100 persons-years (95% confidence interval [CI] = 2.6-3.5). The independent risk factors for MCI were a linkage to care >6 months after HIV diagnosis (hazard ratio [HR] = 1.14; 95% CI = 1.08-1.21), a hepatitis C coinfection (HR = 1.76; 95% CI = 1.07-2.88), being born in Sub-Saharan Africa (HR = 2.18; 95% CI = 1.42-3.34 vs. in France) and not having a mailing address reported in the file (HR = 1.73; 95% CI = 1.07-2.80). During follow-up, the risk of MCI decreased when the patient was older (HR = 0.28; 95% CI = 0.15-0.51 when >45 vs. ≤ 30 years old) and increased when the patient was not on antiretroviral therapy (HR = 2.78; 95% CI = 1.66-4.63). CONCLUSIONS Our findings show that it is important to link HIV-positive individuals to care quickly after diagnosis and initiate antiretroviral therapy as soon as possible to retain them in care.
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Gomillia CES, Backus KV, Brock JB, Melvin SC, Parham JJ, Mena LA. Rapid Antiretroviral Therapy (ART) Initiation at a Community-Based Clinic in Jackson, MS. AIDS Res Ther 2020; 17:60. [PMID: 33032617 PMCID: PMC7545945 DOI: 10.1186/s12981-020-00319-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 09/26/2020] [Indexed: 02/08/2023] Open
Abstract
Background Rapid antiretroviral therapy (ART), ideally initiated within twenty-four hours of diagnosis, may be crucial in efforts to increase virologic suppression and reduce HIV transmission. Recent studies, including demonstration projects in large metropolitan areas such as Atlanta, Georgia; New Orleans, Louisiana; San Francisco, California; and Washington D.C., have demonstrated that rapid ART initiation is a novel tool for expediting viral suppression in clinical settings. Here we present an evaluation of the impact of a rapid ART initiation program in a community-based clinic in Jackson, MS. Methods We conducted a retrospective chart review of patients who were diagnosed with HIV at Open Arms Healthcare Center or were linked to the clinic for HIV care by the Mississippi State Department of Health Disease Intervention Specialists from January 1, 2016 to December 31, 2018. Initial viral load, CD4+ T cell count, issuance of an electronic prescription (e-script), subsequent viral loads until suppressed and patient demographics were collected for each individual seen in clinic during the review period. Viral suppression was defined as a viral load less than 200 copies/mL. Rapid ART initiation was defined as receiving an e-script for antiretrovirals within seven days of diagnosis. Results Between January 1, 2016 and December 31, 2018, 70 individuals were diagnosed with HIV and presented to Open Arms Healthcare Center, of which 63 (90%) completed an initial HIV counseling visit. Twenty-seven percent of patients were provided with an e-script for ART within 7 days of diagnosis. The median time to linkage to care for this sample was 12 days and 5.5 days for rapid ART starters (p < 0.001). Median time from diagnosis to viral suppression was 55 days for rapid ART starters (p = 0.03), a 22 day decrease from standard time to viral suppression. Conclusion Our results provide a similar level of evidence that rapid ART initiation is effective in decreasing time to viral suppression. Evidence from this evaluation supports the use of rapid ART initiation after an initial HIV diagnosis, including same-day treatment.
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Nel J, Dlamini S, Meintjes G, Burton R, Black JM, Davies NECG, Hefer E, Maartens G, Mangena PM, Mathe MT, Moosa MY, Mulaudzi MB, Moorhouse M, Nash J, Nkonyane TC, Preiser W, Rassool MS, Stead D, van der Plas H, van Vuuren C, Venter WDF, Woods JF. Southern African HIV Clinicians Society guidelines for antiretroviral therapy in adults: 2020 update. South Afr J HIV Med 2020; 21:1115. [PMID: 33101723 PMCID: PMC7564911 DOI: 10.4102/sajhivmed.v21i1.1115] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/21/2020] [Indexed: 12/13/2022] Open
Affiliation(s)
- Jeremy Nel
- Helen Joseph Hospital, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Sipho Dlamini
- Department of Infectious Diseases, Faculty of Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Rosie Burton
- Southern African Medical Unit, Médecins Sans Frontières (MSF), Cape Town, South Africa
| | - John M Black
- Department of Medicine, Division of Infectious Diseases, Livingstone Tertiary Hospital, Port Elizabeth, South Africa
| | | | - Eric Hefer
- Private Practice Medical Adviser, Johannesburg, South Africa
| | - Gary Maartens
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Phetho M Mangena
- Department of Internal Medicine, School of Medicine, Pietersburg Hospital, Polokwane, South Africa.,Department of Medicine, School of Medicine, University of Limpopo, Turfloop, South Africa
| | | | - Mahomed-Yunus Moosa
- Department of Infectious Diseases, Division of Internal Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Michelle Moorhouse
- Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jennifer Nash
- Specialist Family Physician, Amathole District Clinical Specialist Team, East London, South Africa
| | - Thandeka C Nkonyane
- Department of Infectious Diseases, Faculty of Medicine, Sefako Makgatho Health Sciences University, Pretoria, South Africa.,Department of Medicine, Dr George Mokhari Hospital, Pretoria, South Africa
| | - Wolfgang Preiser
- Department of Medical Virology, National Health Laboratory Service, Tygerberg, South Africa.,Department of Pathology, Faculty of Medicine and Health, Stellenbosch University, Cape Town, South Africa
| | - Mohammed S Rassool
- Clinical HIV Research Unit, Wits Health Consortium, Johannesburg, South Africa
| | - David Stead
- Department of Medicine, Faculty of Infectious Diseases, Frere and Cecilia Makiwane Hospitals, East London, South Africa.,Department of Medicine, Faculty of Health Sciences, Walter Sisulu University, Mthatha, South Africa
| | - Helen van der Plas
- Department of Infectious Diseases, Faculty of Medicine, University of Cape Town, Cape Town, South Africa
| | - Cloete van Vuuren
- Department of Internal Medicine, Military Hospital, Bloemfontein, South Africa.,Department of Internal Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Willem D F Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joana F Woods
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Birhanu MY, Leshargie CT, Alebel A, Wagnew F, Siferih M, Gebre T, Kibret GD. Incidence and predictors of loss to follow-up among HIV-positive adults in northwest Ethiopia: a retrospective cohort study. Trop Med Health 2020; 48:78. [PMID: 32943978 PMCID: PMC7488994 DOI: 10.1186/s41182-020-00266-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/26/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Despite the rapid expansion of antiretroviral therapy services, 'loss to follow-up' is a significant public health concern globally. Loss to follow-up of individuals from ART has a countless negative impact on the treatment outcomes. There is, however, limited information about the incidence and predictors of loss to follow-up in our study area. Thus, this study aimed to determine the incidence rate and predictors of loss to follow-up among adult HIV patients on ART. METHODS A retrospective cohort study was undertaken using 484 HIV patients between January 30, 2008, and January 26, 2018, at Debre Markos Referral Hospital. All eligible HIV patients who fulfilled the inclusion criteria were included in this study. Data were entered into Epi-data Version 4.2 and analyzed using STATATM Version 14.0 software. The Nelson-Aalen cumulative hazard estimator was used to estimate the hazard rate of loss to follow-up, and the log-rank test was used to compare the survival curve between different categorical variables. Both bivariable and multivariable Cox-proportional hazard regression models were fitted to identify predictors of LTFU. RESULTS Among a cohort of 484 HIV patients at Debre Markos Referral Hospital, 84 (17.36%) were loss their ART follow-up. The overall incidence rate of loss to follow-up was 3.7 (95% CI 3.0, 5.0) per 100 adult-years. The total LTFU free time of the participants was 2294.8 person-years. In multivariable Cox-regression analysis, WHO stage IV (AHR 2.8; 95% CI 1.2, 6.2), having no cell phone (AHR 1.9; 95% CI 1.1, 3.4), and rural residence (AHR 0.6; 95% CI 0.37, 0.99) were significant predictors of loss to follow-up. CONCLUSION The incidence of loss to ART follow-up in this study was low. Having no cell phone and WHO clinical stage IV were causative predictors, and rural residence was the only protective factor of loss to follow-up. Therefore, available intervention modalities should be strengthened to mitigate loss to follow-up by addressing the identified risk factors.
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Affiliation(s)
- Molla Yigzaw Birhanu
- Department of Public Health, College of Health Sciences, Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
| | - Cheru Tesema Leshargie
- Department of Public Health, College of Health Sciences, Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
| | - Animut Alebel
- Department of Public Health, College of Health Sciences, Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
| | - Fasil Wagnew
- Department of Public Health, College of Health Sciences, Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
| | - Melkamu Siferih
- Department of Gynecology and Obstetrics, School of Medicine, Debre Markos University, Debre Markos, Ethiopia
| | - Tsige Gebre
- Department of Public Health, College of Health Sciences, Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
| | - Getiye Dejenu Kibret
- Department of Public Health, College of Health Sciences, Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
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Changes in the HIV continuum of care following expanded access to HIV testing and treatment in Indonesia: A retrospective population-based cohort study. PLoS One 2020; 15:e0239041. [PMID: 32915923 PMCID: PMC7485792 DOI: 10.1371/journal.pone.0239041] [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: 05/13/2020] [Accepted: 08/30/2020] [Indexed: 11/19/2022] Open
Abstract
Background In 2013, the Indonesian government launched the strategic use of antiretroviral therapy (SUFA) initiative with an aim to move closer to achieving the UNAIDS 90-90-90 target. This study assessed the impact of SUFA on the cascade of HIV care. Methods We performed a two-year retrospective population-based cohort study of all HIV positive individuals aged ≥ 18 years residing in two cities where SUFA was operational using data from HIV clinics. We analysed data for one-year pre- and one-year post-SUFA implementation. We assessed the rates of enrolment in care, assessment for eligibility for antiretroviral therapy (ART), treatment initiation, loss to follow-up (LTFU) and mortality. Multivariate Cox regression was used to determine the pre-to-post-SUFA hazard ratio. Results A total of 2,292 HIV positive individuals (1,085 and 1,207 pre and post-SUFA respectively) were followed through their cascade of care. In the pre-SUFA period, 811 (74.6%) were enrolled in care, 702 (86.6%) were found eligible for ART, 485 (69.1%) initiated treatment, 102 (21%) were LTFU and 117 (10.8%) died. In the post-SUFA period, 930 (77%) were enrolled in care, 896 (96.3%) were found eligible for ART, 627 (70%) initiated treatment, 100 (16%) were LTFU and 148 (12.3%) dead. There was an 11% increase in the rate of HIV linkage to care (HR = 1.11; 95% CI 1.001, 1.22 p<0.05), a 13% increase in the rate of eligibility for ART (HR = 1.13, 95% CI 1.02,1.25, p<0.01) and a 27% reduction in LTFU (HR = 0.73, 95%CI 0.55, 0.97, p<0.05). Rates of ART initiation and mortality did not change. Conclusion SUFA was effective in improving HIV care in relation to linkage to care, eligibility and ART retention. Therefore, the scale up across the whole of Indonesia of the SUFA currently in the form of a test and treat policy, with improvement in testing and treatment strategies is justified.
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Patient Perspectives of Quality of the Same-Day Antiretroviral Therapy Initiation Process in Gauteng Province, South Africa: Qualitative Dominant Mixed-Methods Analysis of the SLATE II Trial. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 14:175-186. [PMID: 32909218 PMCID: PMC7884580 DOI: 10.1007/s40271-020-00437-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background HIV patients in South Africa continue to report operational barriers to starting antiretroviral therapy (ART). In the Simplified Algorithm for Treatment Eligibility (SLATE) II trial, same-day initiation (SDI) of ART increased the number of patients commencing ART and achieving HIV viral suppression by using a screening tool to distinguish between patients eligible for SDI and those requiring additional care before starting treatment. We conducted a mixed-methods evaluation to explore trial patients’ perceptions and experiences of SDI. Methods SLATE II was implemented at three urban, public primary health care clinics in Gauteng Province, South Africa. We conducted a short quantitative survey and in-depth interviews among a purposive sample of 89 of the 593 trial participants in the intervention and standard arms, using a mixed inductive–deductive framework approach. Results Nearly all respondents (95%) were satisfied with their care, despite reporting clinic wait times of ≥ 3 h (72%). Intervention patients found the initiation process to be easy; standard patients found it complicated and were frustrated with being shuffled around the clinic. No intervention arm patients felt that SDI was “too fast” or indicated a preference for a more gradual process. Both groups highlighted the need for good counselling and non-judgmental, respectful staff. Standard patients suggested improving patient–provider relations, strengthening counselling, reducing wait times, and minimising referrals. Conclusions While it is difficult to untangle the role of providers from that of the SLATE algorithm in influencing patient experiences, adoption of SLATE II implementation procedures could improve patient experience of treatment initiation. Trial registration Clinicaltrials.gov NCT03315013, registered October 19, 2017. Electronic supplementary material The online version of this article (10.1007/s40271-020-00437-4) contains supplementary material, which is available to authorized users.
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Brennan A, Maskew M, Larson BA, Tsikhutsu I, Bii M, Vezi L, Fox M, Venter WDF, Ehrenkranz PD, Rosen S. Prevalence of TB symptoms, diagnosis and treatment among people living with HIV (PLHIV) not on ART presenting at outpatient clinics in South Africa and Kenya: baseline results from a clinical trial. BMJ Open 2020; 10:e035794. [PMID: 32895266 PMCID: PMC7476481 DOI: 10.1136/bmjopen-2019-035794] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE We used screening data and routine clinic records for intervention arm patients in the Simplified Algorithm for Treatment Eligibility (SLATE) trials to describe the prevalence of tuberculosis (TB) symptoms, diagnosis and treatment among people living with HIV (PLHIV), not on antiretroviral therapy (ART) and presenting at outpatient clinics in South Africa and Kenya. We compared the performance of the WHO four-symptom TB screening tool with a baseline Xpert test. SETTING Outpatient HIV clinics in South Africa and Kenya. PARTICIPANTS Eligible patients were non-pregnant, PLHIV, >18 years of age, not on ART, willing to provide written informed consent. A total of 594 patients in South Africa and 240 in Kenya were eligible. RESULTS Prevalence of any TB symptom was 38% in Kenya, 35% (SLATE I) and 47% (SLATE II) in South Africa. During SLATE I, 70% of patients in Kenya and 57% in South Africa with ≥1 TB symptom were tested for TB. In SLATE II, 79% of patients with ≥1 TB symptom were tested. Of those, 19% tested positive for TB in Kenya, 15% (SLATE I) and 5% (SLATE II) tested positive in South Africa. Of the 28 patients who tested positive in both trials, 20 initiated TB treatment. The lowest median CD4 counts were among those with active TB (Kenya 124 cells/mm3; South Africa 193 cells/mm3). When comparing the WHO four-symptom screening tool to the Xpert test (SLATE II), we found that increasing the number of symptoms required for a positive screen from one to three or four decreased sensitivity but increased the positive predictive value to >30%. CONCLUSIONS 80% of patients assessed for ART initiation presented with ≥1 TB symptoms. Reconsideration of the 'any symptom' rule may be appropriate, with ART initiation among patients with fewer/milder symptoms commencing while TB test results are pending. TRIAL REGISTRATION NUMBER NCT02891135 and NCT03315013.
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Affiliation(s)
- Alana Brennan
- Departments of Epidemiology, Boston University, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University, Boston, Massachusetts, USA
| | - Mhairi Maskew
- 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
| | - Bruce A Larson
- Department of Global Health, Boston University, Boston, Massachusetts, USA
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute, Nairobi, Kenya
- Henry M. Jackson Foundation Medical Research International, Inc, Nairobi, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute, Nairobi, Kenya
- Henry M. Jackson Foundation Medical Research International, Inc, Nairobi, Kenya
| | - Lungisile Vezi
- 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 Fox
- Departments of Epidemiology, Boston University, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University, Boston, Massachusetts, USA
| | | | | | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University, Boston, Massachusetts, USA
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Mshweshwe-Pakela N, Hansoti B, Mabuto T, Kerrigan D, Kubeka G, Hahn E, Charalambous S, Hoffmann CJ. Feasibility of implementing same-day antiretroviral therapy initiation during routine care in Ekurhuleni District, South Africa: Retention and viral load suppression. South Afr J HIV Med 2020; 21:1085. [PMID: 32934830 PMCID: PMC7479383 DOI: 10.4102/sajhivmed.v21i1.1085] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/07/2020] [Indexed: 11/29/2022] Open
Abstract
Background Same-day initiation (SDI) of antiretroviral therapy (ART) has been advocated as an approach to increase linkage to care and overall ART initiation. Clinical trials have demonstrated impressive benefits. However, questions regarding patient preparedness and retention in care remain for routine implementation of this approach. Objectives In this study, we sought to describe SDI of ART during routine care delivery and compare time to ART initiation on longitudinal care outcomes. Method We performed a retrospective chart review of 100 consecutive individuals, newly diagnosed with HIV, from 10 health facilities across Ekurhuleni, from January to July 2017. Records were reviewed for a period of 1 year post-diagnosis. Abstracted data included demographics, time to ART initiation, clinic visits and laboratory test results (including viral load testing). Results A total of 993 patient records were reviewed, of which 826 were included in the analysis. The majority of patients (752, 91%) had ART initiation recorded, of which 654 (79%) had ART initiated within 30 days, and 224 (27%) had SDI. Uptake of SDI of ART was higher among women (36% vs. 10.4%; p < 0.001) and in younger patients (33.7% in those < 29 years; p < 0.01). Retention in care at 6 months was achieved in 477 (58%) patients. Of those with 6-month viral loads, 350/430 (73%) had a viral load < 400 c/m. Retention in care and viral suppression were similar among those with SDI of ART and later ART initiation. Conclusion Same-day initiation of ART was successfully delivered with similar retention and viral load outcomes as subsequent initiation, providing re-assurance for scale-up of this strategy in routine care.
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Affiliation(s)
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, United States of America.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Tonderai Mabuto
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Deanna Kerrigan
- Department of Sociology, American University, Washington, United States of America
| | - Griffiths Kubeka
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
| | - Elizabeth Hahn
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Salome Charalambous
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Christopher J Hoffmann
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America.,Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
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Maskew M, Brennan AT, Fox MP, Vezi L, Venter WDF, Ehrenkranz P, Rosen S. A clinical algorithm for same-day HIV treatment initiation in settings with high TB symptom prevalence in South Africa: The SLATE II individually randomized clinical trial. PLoS Med 2020; 17:e1003226. [PMID: 32853271 PMCID: PMC7451542 DOI: 10.1371/journal.pmed.1003226] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/22/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Many countries encourage same-day initiation of antiretroviral therapy (ART), but evidence on eligibility for same-day initiation, how best to implement it, and its impact on outcomes remains scarce. Building on the Simplified Algorithm for Treatment Eligibility (SLATE) I trial, in which nearly half of participants were ineligible for same-day initiation mainly because of TB symptoms, the study evaluated the revised SLATE II algorithm, which allowed same-day initiation for patients with mild TB symptoms and other less serious reasons for delay. METHODS AND FINDINGS SLATE II was a nonblinded, 1:1 individually randomized pragmatic trial at three primary healthcare clinics in Johannesburg, South Africa. It randomized adult patients presenting for an HIV test or any HIV care but not yet on ART. Intervention arm patients were assessed with a symptom screen, medical history, brief physical examination, and readiness questionnaire to distinguish between patients eligible for immediate ART dispensing and those requiring further care before initiation. Standard arm patients received usual care. Follow-up was by review of routine clinic records. Primary outcomes were (1) ART initiation in ≤7 days and (2) ART initiation in ≤28 days and retention in care at 8 months (composite outcome). From 14 March to 18 September 2018, 593 adult HIV+, nonpregnant patients were enrolled (median interquartile range [IQR] age 35 [29-43]; 63% (n = 373) female; median CD4 count 293 [133-487]). Half of study patients (n = 295) presented with TB symptoms, whereas only 13 (4%) standard arm and 7 (2%) intervention arm patients tested positive for TB disease. Among 140 intervention arm patients with TB symptoms, 72% were eligible for same-day initiation. Initiation was higher in the intervention (n = 296) versus standard arm (n = 297) by 7 days (91% versus 68%; risk difference [RD] 23% [95% confidence interval (CI) 17%-29%]) and 28 days (94% versus 82%; RD 12% [7%-17%]) after enrollment. In total, 87% of intervention and 38% of standard arm patients initiated on the same day. By 8 months after study enrollment, 74% (220/296) of intervention and 59% (175/297) of standard arm patients had both initiated ART in ≤28 days and been retained in care (RD 15% [7%-23%]). Among the 41% of participants with viral load results available, suppression was 90% in the standard arm and 92% in the intervention arm among patients initiated in ≤28 days. No ART-associated adverse events were reported after initiation; two intervention and four standard arm patients were reported to have died during passive follow-up. Limitations of the study included limited geographic generalizability, exclusion of patients too sick to consent, fluctuations in procedures in the standard arm over the course of the study, high fidelity to the trial protocol by study staff, and the possibility of overestimating loss to follow-up due to data constraints. CONCLUSIONS More than 85% of patients presenting for HIV testing or care, including those newly diagnosed, were eligible and ready for same-day initiation under the SLATE II algorithm. The algorithm increased initiation within 7 days without appearing to compromise retention and viral suppression at 8 months, offering a practical and acceptable approach that can be widely and immediately utilized by existing providers. TRIAL REGISTRATION Clinicaltrials.gov NCT03315013, registered 19 October 2017. First participant enrolled 14 March 2018.
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Affiliation(s)
- Mhairi Maskew
- 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
- * E-mail:
| | - Alana T. Brennan
- 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, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - 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, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Lungisile Vezi
- 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
| | - Willem D. F. Venter
- Ezintsha, Wits Reproductive Health and HIV Institute, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Peter Ehrenkranz
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
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Zaniewski E, Dao Ostinelli CH, Chammartin F, Maxwell N, Davies M, Euvrard J, van Dijk J, Bosomprah S, Phiri S, Tanser F, Sipambo N, Muhairwe J, Fatti G, Prozesky H, Wood R, Ford N, Fox MP, Egger M. Trends in CD4 and viral load testing 2005 to 2018: multi-cohort study of people living with HIV in Southern Africa. J Int AIDS Soc 2020; 23:e25546. [PMID: 32640106 PMCID: PMC7343336 DOI: 10.1002/jia2.25546] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 05/06/2020] [Accepted: 05/19/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The World Health Organization (WHO) recommends a CD4 cell count before starting antiretroviral therapy (ART) to detect advanced HIV disease, and routine viral load (VL) testing following ART initiation to detect treatment failure. Donor support for CD4 testing has declined to prioritize access to VL monitoring. We examined trends in CD4 and VL testing among adults (≥15 years of age) starting ART in Southern Africa. METHODS We analysed data from 14 HIV treatment programmes in Lesotho, Malawi, Mozambique, South Africa, Zambia and Zimbabwe in 2005 to 2018. We examined the frequency of CD4 and VL testing, the percentage of adults with CD4 or VL tests, and among those having a test, the percentage starting ART with advanced HIV disease (CD4 count <200 cells/mm3 ) or failing to suppress viral replication (>1000 HIV-RNA copies/mL) after ART initiation. We used mixed effect logistic regression to assess time trends adjusted for age and sex. RESULTS Among 502,456 adults, the percentage with CD4 testing at ART initiation decreased from a high of 78.1% in 2008 to a low of 38.0% in 2017; the probability declined by 14% each year (odds ratio (OR) 0.86; 95% CI 0.86 to 0.86). Frequency of CD4 testing also declined. The percentage starting ART with advanced HIV disease declined from 83.3% in 2005 to 23.5% in 2018; each year the probability declined by 20% (OR 0.80; 95% CI 0.80 to 0.81). VL testing after starting ART varied; 61.0% of adults in South Africa and 10.7% in Malawi were tested, but fewer than 2% were tested in the other four countries. The probability of VL testing after ART start increased only modestly each year (OR 1.06; 95% CI 1.05 to 1.06). The percentage with unsuppressed VL was 8.6%. There was no evidence of a decrease in unsuppressed VL over time (OR 1.00; 95% CI 0.99 to 1.01). CONCLUSIONS CD4 cell counting declined over time, including testing at the start of ART, despite the fact that many patients still initiated ART with advanced HIV disease. Without CD4 testing and expanded VL testing many patients with advanced HIV disease and treatment failure may go undetected, threatening the effectiveness of ART in sub-Saharan Africa.
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Affiliation(s)
- Elizabeth Zaniewski
- Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
| | - Cam H Dao Ostinelli
- Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
| | | | - Nicola Maxwell
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Mary‐Ann Davies
- 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
| | | | - Samuel Bosomprah
- Centre for Infectious Disease Research in ZambiaLusakaZambia
- Department of BiostatisticsSchool of Public HealthUniversity of GhanaAccraGhana
| | | | - Frank Tanser
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Lincoln International Institute for Rural HealthUniversity of LincolnLincolnUnited Kingdom
- School of Nursing and Public HealthUniversity of KwaZulu‐NatalDurbanSouth Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu‐NatalDurbanSouth Africa
| | - Nosisa Sipambo
- Chris Hani Baragwanath Academic HospitalJohannesburgSouth Africa
| | | | - Geoffrey Fatti
- Kheth’Impilo AIDS Free LivingCape TownSouth Africa
- Division of Epidemiology and BiostatisticsDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Hans Prozesky
- Division of Infectious DiseasesDepartment of MedicineStellenbosch UniversityCape TownSouth Africa
| | - Robin Wood
- Gugulethu ART Programme (Desmond Tutu HIV Centre)Cape TownSouth Africa
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Department of HIV/AIDS and Global Hepatitis ProgrammeWorld Health OrganizationGenevaSwitzerland
| | - Matthew P Fox
- Department of Global HealthBoston UniversityBostonMAUSA
- Department of EpidemiologyBoston UniversityBostonMAUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Matthias Egger
- Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
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Abstract
The benefits of “early” antiretroviral therapy (ART; ie, initiation when CD4 ≥500 cells/mm3) are now well accepted as reflected in the removal of the CD4-based eligibility from new ART guidelines by the World Health Organization (WHO). However, neither the “treat-all” strategy recommendations presented in the guidelines nor the HIV care cascade goals in the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets adequately address the issue of ART timing. Our recent study on “immediate” ART (ie, ≤30 days after HIV diagnosis) adds important evidence demonstrating the real and meaningful benefits of rapid ART initiation even among those who have CD4 ≥500 cells/mm3. We call on WHO and UNAIDS to consider this research and encourage a shift from the treat-all strategy to an “immediately-treat-all” strategy, and from a slow, fragmented, complicated, multistep HIV care cascade to a fast, easy, and simple cascade with effectiveness measures that incorporate the important aspect of time.
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Affiliation(s)
- Yan Zhao
- 1 National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jennifer M McGoogan
- 1 National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zunyou Wu
- 1 National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
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120
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Pascoe SJS, Scott NA, Fong RM, Murphy J, Huber AN, Moolla A, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fox MP, Fraser‐Hurt N. "Patients are not the same, so we cannot treat them the same" - A qualitative content analysis of provider, patient and implementer perspectives on differentiated service delivery models for HIV treatment in South Africa. J Int AIDS Soc 2020; 23:e25544. [PMID: 32585077 PMCID: PMC7316408 DOI: 10.1002/jia2.25544] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 04/15/2020] [Accepted: 05/08/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION In 2014, the South African government adopted a differentiated service delivery (DSD) model in its "National Adherence Guidelines for Chronic Diseases (HIV, TB and NCDs)" (AGL) to strengthen the HIV care cascade. We describe the barriers and facilitators of the AGL implementation as experienced by various stakeholders in eight intervention and control sites across four districts. METHODS Embedded within a cluster-randomized evaluation of the AGL, we conducted 48 in-depth interviews (IDIs) with healthcare providers, 16 IDIs with Department of Health and implementing partners and 24 focus group discussions (FGDs) with three HIV patient groups: new, stable and those not stable on treatment or not adhering to care. IDIs were conducted from August 2016 to August 2017; FGDs were conducted in January to February 2017. Content analysis was guided by the Consolidated Framework for Implementation Research. Findings were triangulated among respondent types to elicit barriers and facilitators to implementation. RESULTS New HIV patients found counselling helpful but intervention respondents reported sub-optimal counselling and privacy concerns as barriers to initiation. Providers felt insufficiently trained for this intervention and were confused by the simultaneous rollout of the Universal Test and Treat strategy. For stable patients, repeat prescription collection strategies (RPCS) were generally well received. Patients and providers concurred that RPCS reduced congestion and waiting times at clinics. There was confusion though, among providers and implementers, around implementation of RPCS interventions. For patients not stable on treatment, enhanced counselling and tracing patients lost-to-follow-up were perceived as beneficial to adherence behaviours but faced logistical challenges. All providers faced difficulties accessing data and identifying patients in need of tracing. Congestion at clinics and staff attitude were perceived as barriers preventing patients returning to care. CONCLUSIONS Implementation of DSD models at scale is complex but this evaluation identified several positive aspects of AGL implementation. The positive perception of RPCS interventions and challenges managing patients not stable on treatment aligned with results from the larger evaluation. While some implementation challenges may resolve with experience, ensuring providers and implementers have the necessary training, tools and resources to operationalize AGL effectively is critical to the overall success of South Africa's HIV control strategy.
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Affiliation(s)
- Sophie J S Pascoe
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Nancy A Scott
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Rachel M Fong
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Joshua Murphy
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Amy N Huber
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Aneesa Moolla
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | | | - Sydney Rosen
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | | | - Yogan Pillay
- National Department of HealthPretoriaSouth Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
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121
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Joseph Davey D, Kehoe K, Serrao C, Prins M, Mkhize N, Hlophe K, Sejake S, Malone T. Same-day antiretroviral therapy is associated with increased loss to follow-up in South African public health facilities: a prospective cohort study of patients diagnosed with HIV. J Int AIDS Soc 2020; 23:e25529. [PMID: 32510186 PMCID: PMC7277782 DOI: 10.1002/jia2.25529] [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: 09/16/2019] [Revised: 03/09/2020] [Accepted: 04/17/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION South Africa introduced Universal Test and Treat in 2016 including antiretroviral therapy (ART) initiation on the same-day as HIV diagnosis. Our study sought to evaluate the impact of same-day ART initiation on loss to follow-up (LTFU) and mortality comparing with patients who initiated ART after their HIV diagnosis. METHODS We conducted a file review of patients with a HIV diagnosis and ART start date on file between September 2016 and May 2018 in six high HIV burden districts. Our primary outcome was LTFU (>90 days from the last clinical visit or drug pick-up until database closure 31 July 2018). The secondary outcome was mortality after ART initiation. Time to outcome was assessed comparing same-day vs. one to seven, eight to twenty-one and ≥ twenty-two days to ART initiation using Kaplan-Meier estimators stratified by sex. We investigated predictors using univariate and multivariable Cox proportional hazards models, adjusting for a priori characteristics. RESULTS Overall, 92,609 ART patients contributed 43,922 person-years from ART initiation, with a median follow-up time of 246 days (IQR = 112 to 455). Of these patients, 33,399 (36%) initiated ART on the same-day as their HIV diagnosis date and had a median follow-up time of 174 days (IQR = 85 to 349). Same-day patients were predominantly non-pregnant females (56%) and aged 25 to 34 years (40%). Same-day ART initiation increased from 2.8% in September 2016 to 7.1% in April 2018. In same-day patients, 33% (n = 11,114) were classified as LTFU with a median time of 55 days (IQR = 1 to 185), compared to 371 mean days (IQR = 161 to 560) in patients who initiated ≥22 days after diagnosis. A similar proportion of LTFU was observed for patients who initiated later: 31% 1 to 21 day and 33% ≥22 day. Same-day ART patients had an increased risk of LTFU vs. ≥1 day (adjusted hazard ratio (aHR) = 1.28, 95% CI = 1.24 to 1.33) adjusting for covariates. Although all-cause mortality was slightly lower in same-day patients (0.9%) vs. >1 day (1.4%; aHR = 0.87, 95% CI = 0.72 to 1.05) adjusting for covariates. Men had highest risk of mortality and LTFU. CONCLUSIONS Same-day ART increased the risk of LTFU, but same-day patients experienced slightly lower mortality. Same-day patients may require additional counselling and interventions to improve retention. Additional research is needed on targeted interventions, including differentiated care, to reduce LTFU in patients initiating ART same-day.
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Affiliation(s)
- Dvora Joseph Davey
- Department of EpidemiologyFielding School of Public HealthUniversity of CaliforniaLos AngelesCAUSA
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownSouth Africa
| | - Kathleen Kehoe
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownSouth Africa
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122
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Rudman C, Viljoen M, Rheeders M. A retrospective descriptive investigation of adult patients receiving third-line antiretroviral therapy in the North West province, South Africa. Afr Health Sci 2020; 20:549-559. [PMID: 33163016 PMCID: PMC7609084 DOI: 10.4314/ahs.v20i2.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Greater access and prolonged exposure to ART may inevitably lead to more
treatment failure and increase the need for third-line ART (TLART) in a
resource-limited setting. Objective To describe characteristics and resistance patterns of adult patients
initiated on TLART in three districts of the North West province. Method All-inclusive retrospective descriptive investigation. Demographics and
clinical variables were recorded from adult patient health records
(2002-2017) and analysed. Results 21 Patients (17 females, 4 males) with median (IQR) age of 34 years
(30.2-37.8) at HIV diagnosis and 45 years (39.5–47) at TLART
initiation were included. Median duration (days) from HIV diagnosis to
first-line ART initiation was 101 (37-367), treatment duration on
first-line, second-line and between second-line failure and TLART initiation
were: 1 269 (765–2 343); 1 512 (706-2096) and 71 (58-126) days
respectively. High-level resistance most prevalent were: nelfinavir/r (85.7%), indinavir/r
(80.9%), lopinavir/r (76.2%), emtricitabine and lamivudine (95.2%),
nevirapine (76.2%) and efavirenz (71.4%). Resistance to 3 major PI mutations
in 95% of patients and cross resistance were documented extensively. Conclusion This study support the need for earlier resistance testing. It firstly
reported on time duration post diagnosis on various ART regimens and
secondly resistance patterns of adults before TLART was initiated in these
districts.
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Affiliation(s)
- Christian Rudman
- >Centre of Excellence for Pharmaceutical Services
(PharmaCen), Division of Pharmacology, North-West University, Private Bag X6001,
Potchefstroom 2520, South Africa
| | - Michelle Viljoen
- >Department of Pharmacology and Clinical Pharmacy, School
of Pharmacy, Faculty of Natural Sciences, University of the Western Cape, Private
Bag X17, Bellville 7535, South Africa
- Corresponding author: Michelle Viljoen Pharmacology and Clinical
Pharmacy, School of Pharmacy, University of the Western Cape, Private Bag X17,
Bellville 7535, South Africa Tel: +27 21 959 2641 Fax: +27 21 959 3407
| | - Malie Rheeders
- >Centre of Excellence for Pharmaceutical Services
(PharmaCen), Division of Pharmacology, North-West University, Private Bag X6001,
Potchefstroom 2520, South Africa
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123
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Batey DS, Dong X, Rogers RP, Merriweather A, Elopre L, Rana AI, Hall HI, Mugavero MJ. Time From HIV Diagnosis to Viral Suppression: Survival Analysis of Statewide Surveillance Data in Alabama, 2012 to 2014. JMIR Public Health Surveill 2020; 6:e17217. [PMID: 32045344 PMCID: PMC7275256 DOI: 10.2196/17217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/06/2020] [Accepted: 02/10/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Evaluation of the time from HIV diagnosis to viral suppression (VS) captures the collective effectiveness of HIV prevention and treatment activities in a given locale and provides a more global estimate of how effectively the larger HIV care system is working in a given geographic area or jurisdiction. OBJECTIVE This study aimed to evaluate temporal and geographic variability in VS among persons with newly diagnosed HIV infection in Alabama between 2012 and 2014. METHODS With data from the National HIV Surveillance System, we evaluated median time from HIV diagnosis to VS (<200 c/mL) overall and stratified by Alabama public health area (PHA) among persons with HIV diagnosed during 2012 to 2014 using the Kaplan-Meier approach. RESULTS Among 1979 newly diagnosed persons, 1181 (59.67%) achieved VS within 12 months of diagnosis; 52.6% (353/671) in 2012, 59.5% (377/634) in 2013, and 66.9% (451/674) in 2014. Median time from HIV diagnosis to VS was 8 months: 10 months in 2012, 8 months in 2013, and 6 months in 2014. Across 11 PHAs in Alabama, 12-month VS ranged from 45.8% (130/284) to 84% (26/31), and median time from diagnosis to VS ranged from 5 to 13 months. CONCLUSIONS Temporal improvement in persons achieving VS following HIV diagnosis statewide in Alabama is encouraging. However, considerable geographic variability warrants further evaluation to inform public health action. Time from HIV diagnosis to VS represents a meaningful indicator that can be incorporated into public health surveillance and programming.
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Affiliation(s)
- D Scott Batey
- Department of Social Work, University of Alabama at Birmingham, Birmingham, AL, United States
| | | | - Richard P Rogers
- Division of STD Prevention and Control, Alabama Department of Public Health, Montgomery, AL, United States
| | - Anthony Merriweather
- Division of STD Prevention and Control, Alabama Department of Public Health, Montgomery, AL, United States
| | - Latesha Elopre
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Aadia I Rana
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - H Irene Hall
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Michael J Mugavero
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
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Boyd MA, Boffito M, Castagna A, Estrada V. Rapid initiation of antiretroviral therapy at HIV diagnosis: definition, process, knowledge gaps. HIV Med 2020; 20 Suppl 1:3-11. [PMID: 30724450 DOI: 10.1111/hiv.12708] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2018] [Indexed: 01/14/2023]
Abstract
Initiating antiretroviral therapy (ART) as early as the day of HIV diagnosis is a strategy of increasing global interest to control the HIV epidemic and optimize the health of people living with HIV (PLWH). No detrimental effects of rapid-start ART have been identified in randomized controlled trials undertaken in low- or middle-income countries, or in cohort studies performed in high-income countries. Rapid-start ART may be a key approach in reaching the 2020 Joint United Nations Programme on HIV/AIDS goal of 90% of all PLWH knowing their status, 90% of those diagnosed receiving sustained ART, and 90% of those receiving ART achieving viral suppression; it may also be important for achieving the suggested fourth "90%" goal: improving health-related quality-of-life in PLWH. Presently there is insufficient broad evidence for guidelines to recommend universal test-and-treat strategies for all people, in all settings, at HIV diagnosis; consequently, there is a pressing need to conduct high-quality studies that investigate immediate ART initiation. This article evaluates global evidence regarding rapid-start ART, including same-day start, with particular focus on the implementation of this strategy in high-income countries.
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Affiliation(s)
- M A Boyd
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.,Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - M Boffito
- Chelsea and Westminster Hospital, London, UK.,Imperial College London, London, UK
| | - A Castagna
- Clinic of Infectious Diseases, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - V Estrada
- Hospital Clinico San Carlos, Universidad Complutense, Madrid, Spain
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Girum T, Yasin F, Wasie A, Shumbej T, Bekele F, Zeleke B. The effect of "universal test and treat" program on HIV treatment outcomes and patient survival among a cohort of adults taking antiretroviral treatment (ART) in low income settings of Gurage zone, South Ethiopia. AIDS Res Ther 2020; 17:19. [PMID: 32423457 PMCID: PMC7236275 DOI: 10.1186/s12981-020-00274-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/04/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Through universal "test and treat approach" (UTT) it is believed that HIV new infection and AIDS related death will be reduced at community level and through time HIV can be eliminated. With this assumption the UTT program was implemented since 2016. However, the effect of this program in terms of individual patient survival and treatment outcome was not assessed in relation to the pre-existing defer treatment approach. OBJECTIVE To assess the effects of UTT program on HIV treatment outcomes and patient survival among a cohort of adult HIV infected patients taking antiretroviral treatment in Gurage zone health facilities. METHODS Institution based retrospective cohort study was conducted in facilities providing HIV care and treatment. Eight years (2012-2019) HIV/AIDS treatment records were included in the study. Five hundred HIV/AIDS treatment records were randomly selected and reviewed. Data were abstracted using standardized checklist by trained health professionals; then it was cleaned, edited and entered by Epi info version 7 and analyzed by STATA. Cox model was built to estimate survival differences across different study variables. RESULTS A total of 500 patients were followed for 1632.6 person-year (PY) of observation. The overall incidence density rate (IDR) of death in the cohort was 3 per-100-PY. It was significantly higher for differed treatment program, which is 3.8 per-100-PY compared to 2.4 per-100-PY in UTT program with a p value of 0.001. The relative risk of death among differed cases was 1.58 times higher than the UTT cases. The cumulative probability of survival at the end of 1st, 2nd, 3rd, and 4th years was 98%, 90.2%, 89.2% and 88% respectively with difference between groups. The log rank test and Kaplan-Meier survival curve indicated patients enrolled in the UTT program survived longer than patients enrolled in the differed treatment program (log rank X2 test = 4.1, p value = 0.04). Age, residence, base line CD4 count, program of enrolment, development of new OIS and treatment failure were predicted mortality from HIV infection. CONCLUSION Mortality was significantly reduced after UTT. Therefore, intervention to further reduce deaths has to focus on early initiation of treatment and strengthening UTT programs.
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Affiliation(s)
- Tadele Girum
- Department of Public Health, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Fedila Yasin
- Department of Public Health, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Abebaw Wasie
- Department of Public Health, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Teha Shumbej
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Fitsum Bekele
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Bereket Zeleke
- Department of Pharmacy, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
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126
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van de Vijver DAMC, Nichols BE. Pre-treatment HIV drug resistance testing cost-effectiveness. EClinicalMedicine 2020; 22:100381. [PMID: 32478315 PMCID: PMC7251652 DOI: 10.1016/j.eclinm.2020.100381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
| | - Brooke E Nichols
- Department of Global Health, Boston University School of Public Health, Boston, United States
- 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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127
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Summers NA, Colasanti JA, Feaster DJ, Armstrong WS, Rodriguez A, Jain MK, Jacobs P, Metsch LR, del Rio C. Predictors for Poor Linkage to Care Among Hospitalized Persons Living with HIV and Co-Occurring Substance Use Disorder. AIDS Res Hum Retroviruses 2020; 36:406-414. [PMID: 31914790 DOI: 10.1089/aid.2019.0153] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Persons living with HIV (PLWH) with substance use disorders (SUD) remain a population difficult to engage in HIV care. Project HOPE (Hospital Visits as an Opportunity for Prevention and Engagement), a randomized controlled trial testing patient navigation with/without contingency management for PLWH with SUD, aimed to address this disparity. PLWH with SUD who were out of care were recruited from 11 hospitals across the United States from 2012 to 2014. Baseline socioeconomic factors, medical mistrust scores, and perceived discrimination surveys were collected at enrollment and evaluated for effects on linkage to care at the 6-month follow-up assessment. Linkage to care (attending an outpatient visit for HIV care), early linkage to care (attending first visit within 30 days of enrollment), and engagement in care (two HIV visits within the 6-month period) were determined by medical record abstraction, supplemented by self-report. Among 801 participants enrolled in the study (mean age 45 years, 33% women, and 73% African American), those who did not complete high school and with severe food insecurity had lower odds of being linked to care at 6 months. Those with high levels of medical mistrust, recent drug use, and who did not complete high school had lower odds of early linkage to care. Early linkage was associated with higher odds of engagement at 6 months and was mitigated by both patient navigator interventions (all p < .05). Addressing social determinants of health is critical to correct the disparity seen in HIV outcomes among PLWH with SUD. Identifying factors that alter the effect of interventions could help identify patients who would benefit most.
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Affiliation(s)
- Nathan A. Summers
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jonathan A. Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Emory Center for AIDS Research, Atlanta, Georgia, USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia, USA
| | - Daniel J. Feaster
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Wendy S. Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Emory Center for AIDS Research, Atlanta, Georgia, USA
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia, USA
| | - Allan Rodriguez
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mamta K. Jain
- Division of Infectious Diseases, Department of Medicine, UT Southwestern, Dallas, Texas, USA
| | - Petra Jacobs
- National Institute on Drug Abuse, Bethesda, Maryland, USA
| | - Lisa R. Metsch
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia, USA
- Department of Sociomedical Sciences, Columbia Millner School of Public Health, New York City, New York, USA
| | - Carlos del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Emory Center for AIDS Research, Atlanta, Georgia, USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Onoya D, Sineke T, Hendrickson C, Mokhele I, Maskew M, Long LC, Fox M. Impact of the test and treat policy on delays in antiretroviral therapy initiation among adult HIV positive patients from six clinics in Johannesburg, South Africa: results from a prospective cohort study. BMJ Open 2020; 10:e030228. [PMID: 32213514 PMCID: PMC7170559 DOI: 10.1136/bmjopen-2019-030228] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES To assess delays to antiretroviral therapy (ART) initiation before and after the Universal Test and Treat (UTT) and the same-day initiation (SDI) of ART policy periods in Johannesburg, South Africa. DESIGN Prospective cohort study. SETTING Patients were recruited from six primary health clinics in Johannesburg. PARTICIPANTS Overall, 1029 newly diagnosed HIV positive adults (≥18 years) were consecutively enrolled by referral from the testing counsellor between April and December 2015 (pre-UTT n=146), July and August 2017 (UTT, n=141) and October 2017 and August 2018 (SDI, n=742). MAIN OUTCOME MEASURES Cox proportional hazards regression was used to assess predictors of 30 days ART initiation. Additionally, predictors of immediate ART initiation were evaluated using Poisson regression. RESULTS Overall, 30 days ART proportions were 71.9% overall, 36.9% pre-UTT (44.3% of those eligible), 65.9% under UTT and 79.9% under the SDI policy. The median days to ART initiation declined from 21 pre-UTT (IQR: 15-30) to 8 (IQR: 6-16) under UTT and 5 days (IQR: 0-8) under the SDI policy. However, only 150 (20.2%) of the SDI cohort-initiated ART immediately after HIV diagnosis. Living in a two-adult home (adjusted HR (aHR) 1.2 vs living alone, 95% CI 1.0 to 1.5) increased the likelihood of 30-day ART. Missing baseline cluster of differentiation four (CD4) data decreased the likelihood of 30 days ART by 40% (aHR 0.6 vs CD4 <350 cells/µL, 95% CI 0.5 to 0.7). More women took up immediate ART (adjusted relative risk (aRR) 1.3, 95% CI 1.0 to 1.9). Participants ≥40 years (aRR 0.6 vs 18-24 years, 95% CI 0.4 to 0.9) were less likely to start ART immediately after HIV diagnosis. However, immediate ART rates increased with longer policy implementation time (aRR 0.2 for <3 months vs >10 months, 95% CI 0.1 to 0.4). CONCLUSIONS The study results highlight a positive move towards earlier ART initiation during the UTT and SDI periods and emphasise a need to increase same-day ART implementation further.
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Affiliation(s)
- Dorina Onoya
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Tembeka Sineke
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Cheryl Hendrickson
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Idah Mokhele
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence C Long
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Matthew Fox
- Health Economics & Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts, USA
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Predictors of Disengagement in Care for Individuals Receiving Pre-exposure Prophylaxis (PrEP). J Acquir Immune Defic Syndr 2020; 81:e104-e108. [PMID: 30985557 DOI: 10.1097/qai.0000000000002054] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND HIV pre-exposure prophylaxis (PrEP) reduces incident HIV infections, but efficacy depends on adherence and retention, among other factors. Substance use disorders, unmet mental health needs, and demographic factors are associated with nonadherence in HIV-infected patients; we studied whether these affect PrEP retention in care. METHODS To investigate potential risk factors disengagement in a comprehensive HIV prevention program, we conducted a retrospective cohort analysis of individuals starting tenofovir-emtricitabine between January 1, 2015, and November 30, 2017. The primary outcome was adherence to the initial 3-visit schedule after PrEP initiation. RESULTS The cohort was predominantly African American (23%) and Hispanic (46%). Race, ethnicity, substance use, patient health questionnaire 9 score, insurance, and housing status were not associated with retention at the third follow-up visit. Age <30, PrEP initiation in 2017, PrEP initiation in the sexual health clinic, and PrEP same-day start were associated with lower retention; male gender at birth, transition from post-exposure prophylaxis (PEP) to PrEP, feeling that they could benefit from, or participating in mental health services were associated with increased retention. Overall, retention in HIV preventative care at the first follow-up visit (68%) and third follow-up visit (35%) after PrEP initiation was low. CONCLUSION Clinic services and ancillary services (such as mental health) may facilitate retention in care. In this study, select social and behavioral determinants of health were not found to be linked to retention. Focused investigation of reasons for dropout may elucidate the challenges to maintaining individuals in PrEP care and direct resource allocation to those in greatest need.
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Time of HIV diagnosis, CD4 count and viral load at antenatal care start and delivery in South Africa. PLoS One 2020; 15:e0229111. [PMID: 32053679 PMCID: PMC7018033 DOI: 10.1371/journal.pone.0229111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 01/29/2020] [Indexed: 11/24/2022] Open
Abstract
Background Despite the success of prevention of mother to child transmission (PMTCT) program in South Africa, the 30% HIV prevalence among women of childbearing age requires the PMTCT program to be maximally efficient to sustain gains in the prevention of vertical HIV transmission. We aimed to determine the immunologic and virologic status at entry into antenatal care (ANC) and at childbirth among HIV positive women who conceived under the CD4<500 cells/μl antiretroviral therapy (ART) eligibility threshold and universal test and treat (UTT) policies in the Gauteng province of South Africa. Method We conducted a retrospective cohort study of 692 HIV positive adult (>18 years) postpartum women who gave birth between September 2016 and December 2017. Demographic, viral load (VL) and CD4 data at ANC start (3–9 months before delivery) and delivery (3 months before/after) were obtained from medical records of consenting women. We compared CD4≥500 cell/μl and viral load (VL) suppression (<400 copes/ml) rates at ANC start and delivery among women with a pre-pregnancy ART, women known HIV positive but with in-pregnancy ART and newly diagnosed women with in-pregnancy ART. Predictors of having a high CD4 and suppressed VL were assessed by log-binomial regression. Results Of the 692 participants, 394 (57.0%) had CD4 data and 326 (47.1%) had VL data. Overall women with a pre-pregnancy ART were more likely to start ANC with CD4 count≥500 cell/μl (46.3% vs 24.8%, adjusted risk ratio (aRR) = 1.9; 95% confidence interval (95% CI): 1.4–2.5), compared to newly diagnosed women. This difference was no longer apparent at the time of delivery (aRR 1.2 95% CI: 0.4–3.7). Similarly, viral suppression at delivery was higher among women with pre-pregnancy ART (87.2% vs 69.3%, aRR 1.3, 95% CI: 1.1–1.6) as compared to the newly diagnosed women. Viral suppression rate among newly diagnosed women increased substantially by the time of delivery from 43.5% to 69.3% (p = 0.001). Conclusion These results show that pre-pregnancy ART improves immunologic and virologic control during pregnancy and call for renewed efforts in HIV testing, linkage to ART and viral monitoring.
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Benson C, Emond B, Lefebvre P, Lafeuille MH, Côté-Sergent A, Tandon N, Chow W, Dunn K. Rapid Initiation of Antiretroviral Therapy Following Diagnosis of Human Immunodeficiency Virus Among Patients with Commercial Insurance Coverage. J Manag Care Spec Pharm 2020; 26:129-141. [PMID: 31747358 PMCID: PMC10391294 DOI: 10.18553/jmcp.2019.19175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND New guidelines for the treatment of human immunodeficiency virus (HIV) advocate for rapid initiation of antiretroviral therapy (ART) ≤ 7 days after HIV diagnosis with agents that have a high genetic barrier to resistance, good tolerability, and convenient dosing. OBJECTIVE To describe characteristics, time to ART initiation, and health care costs in commercially insured patients living with HIV in the United States who are treated ≤ 60 days after HIV diagnosis. METHODS IBM MarketScan Research Databases (January 1, 2012-December 31, 2017) were used to identify ART-naive adults with HIV-1, ≥ 6 months of continuous eligibility before first HIV diagnosis, and ART initiation ≤ 60 days of first diagnosis. ART regimen had to include a protease inhibitor (PI), an integrase strand transfer inhibitor (INSTI), or a non-nucleoside reverse transcriptase inhibitor (NNRTI) with ≥ 2 nucleoside reverse transcriptase inhibitors. Cohorts were formed based on time to ART initiation after diagnosis: ≤ 7 days or 8-60 days. Health care costs were evaluated at 6, 12, 24, and 36 months after diagnosis among patients with ≥ 36 months of continuous eligibility. RESULTS Among 9,351 patients, median time to treatment was 31.0 days. Patients initiating ART > 60 days after HIV diagnosis were excluded (N = 2,608 [27.9%]), while 6,743 (72.1%) initiated ART ≤ 60 days after diagnosis and were analyzed; 18.3% and 81.7% were classified in the ≤ 7 days and 8-60 days cohorts, respectively. For all analyzed patients, mean age was 38.0 (SD = 12.0) years and 13.2% were female; 12.7%, 56.2%, and 31.1% initiated a PI, INSTI, or NNRTI-based regimen, respectively. Elvitegravir (32.9%), efavirenz (20.9%), dolutegravir (18.5%), and darunavir (8.5%) were the most commonly used antiretrovirals; most patients (74.3%) were initiated on single-tablet regimens. PI-based regimens were more common in the ≤ 7 days cohort (PI = 18.1%; darunavir = 11.4%) than in the 8-60 days cohort (PI = 11.5%; darunavir = 7.8%). INSTI-based regimens were more common in the 8-60 days cohort (INSTI = 57.7%; elvitegravir = 33.8%) than in the ≤ 7 days cohort (INSTI = 49.2%; elvitegravir = 29.1%). NNRTI-based regimens were as common in the ≤ 7 days (32.7%) and 8-60 days (30.7%) cohorts. Mean total accumulated costs were lower among patients in the ≤ 7 days cohort than in the 8-60 days cohort at all time points analyzed after diagnosis (e.g., 36 months: ≤ 7 days = $109,456; 8-60 days = $116,870). Total per-patient per-month costs decreased over time in the ≤ 7 days (i.e., 6 months = $4,359; 36 months = $3,040) and 8-60 days cohort (6 months = $4,727; 36 months = $3,246). CONCLUSIONS Although 72.1% of patients initiated ART ≤ 60 days after HIV diagnosis, only 18.3% initiated ART ≤ 7 days. Many patients initiating ART ≤ 7 days used suboptimal agents with low rather than high genetic barriers to resistance (i.e., efavirenz and elvitegravir) or agents (dolutegravir) coformulated with other antiretrovirals that require testing to prevent hypersensitivity reactions. Patients in the ≤ 7 days cohort showed lower total health care costs relative to those in the 8-60 days cohort, highlighting the potential long-term benefits of rapid ART initiation. DISCLOSURES This study was supported by Janssen Scientific Affairs, which was involved in the study design, interpretation of results, manuscript preparation, and publication decisions. Emond, Lefebvre, Lafeuille, and Côté-Sergent are employees of Analysis Group, a consulting company that was contracted by Janssen Scientific Affairs to conduct this study and develop the manuscript. Benson, Tandon, Chow, and Dunn are employees of Janssen Scientific Affairs and stockholders of Johnson & Johnson. Part of the material in this study has been presented at the AMCP 2019 Annual Meeting; March 25-28, 2019; San Diego, CA.
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Affiliation(s)
| | | | | | | | | | - Neeta Tandon
- Janssen Scientific Affairs, Titusville, New Jersey
| | - Wing Chow
- Janssen Scientific Affairs, Titusville, New Jersey
| | - Keith Dunn
- Janssen Scientific Affairs, Titusville, New Jersey
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Benson C, Emond B, Romdhani H, Lefebvre P, Côté-Sergent A, Shohoudi A, Tandon N, Chow W, Dunn K. Long-Term Benefits of Rapid Antiretroviral Therapy Initiation in Reducing Medical and Overall Health Care Costs Among Medicaid-Covered Patients with Human Immunodeficiency Virus. J Manag Care Spec Pharm 2020; 26:117-128. [PMID: 31747357 PMCID: PMC10391060 DOI: 10.18553/jmcp.2019.19174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND New guidelines for the treatment of human immunodeficiency virus (HIV) suggest that morbidity and mortality could be reduced if antiretroviral therapy (ART) was initiated immediately after diagnosis, regardless of CD4 cell count. OBJECTIVE To assess real-world time to ART initiation and describe medical, pharmacy, and total health care costs in the 6-, 12-, 24-, and 36-month periods after HIV diagnosis based on time to ART initiation among Medicaid-covered patients. METHODS Multistate Medicaid data (January 2012-March 2017) was used to identify adults with HIV-1 initiating ART ≤ 360 days of initial HIV-1 diagnosis. People living with HIV (PLWH) were sorted into mutually exclusive cohorts based on time from diagnosis to ART initiation (≤ 14 days, > 14 to ≤ 60 days, > 60 to ≤ 180 days, and > 180 to ≤ 360 days). ART regimen had to include a protease inhibitor, an integrase strand transfer inhibitor, or a non-nucleoside reverse transcriptase inhibitor, with ≥ 2 nucleoside reverse transcriptase inhibitors. Medical, pharmacy, and total health care costs in the 6, 12, 24, and 36 months following HIV diagnosis were stratified by timeliness of ART initiation. RESULTS Of 974 patients, 347 (35.6%) initiated ART > 360 days after diagnosis and were excluded. Among the remaining 627 eligible patients, mean age was 39.9 years, 42.7% were female, and 53.9% were black. Among them, 128 (20.4%) were treated ≤ 14 days, 228 (36.4%) between > 14 and ≤ 60 days, 163 (26.0%) between > 60 and ≤ 180 days, and 108 (17.2%) between > 180 and ≤ 360 days. Among patients treated ≤ 180 days, 4.6% had ≥ 1 opportunistic infection in the 6-month period before ART initiation; this proportion reached 5.6% for patients treated >180 and ≤ 360 days. Over the 6-, 12-, 24-, and 36-month periods after diagnosis, per-patient-per-month (PPPM) medical costs were lower for patients who initiated ART ≤ 14 days than for those who initiated > 180 and ≤ 360 days after diagnosis (6 months: $1,611 [≤ 14 days] vs. $3,008 [> 180 and ≤ 360 days]; 12 months: $1,188 vs. $2,110; 24 months: $754 vs. $1,368; 36 months: $651 vs. $1,196). Over the same periods, medical costs generally accounted for > 50% of total health care costs for patients who initiated ART between > 60 and ≤ 180 days and > 180 and ≤ 360 days and for 30%-40% of total health care costs for patients treated ≤ 14 days and between > 14 and ≤ 60 days. Total PPPM health care costs increased with delay of ART initiation in the 36-month period after diagnosis ($2,058 [treated ≤ 14 days] vs. $2,310 [treated between > 180 and ≤ 360 days]). CONCLUSIONS In this study from 2012 to 2017 of Medicaid PLWH treated with ART, 20.4% initiated ART ≤14 days of HIV diagnosis. Patients with delayed ART initiation accumulated more total health care costs in the 36-month period after HIV diagnosis than those initiated within 14 days, highlighting the long-term benefit of rapid ART initiation. An important opportunity remains to engage PLWH in care more rapidly. DISCLOSURES This study was supported by Janssen Scientific Affairs, which was involved in the study design, interpretation of results, manuscript preparation, and publication decisions. Emond, Romdhani, Lefebvre, and Côté-Sergent are employees of Analysis Group, a consulting company that was contracted by Janssen Scientific Affairs to conduct this study and develop the manuscript. Shohoudi was an employee of Analysis Group at the time the study was conducted. Benson, Tandon, Chow, and Dunn are employees and stockholders of Johnson & Johnson. Parts of the material in this study have been presented at the HIV Drug Therapy Meeting; October 28-31, 2018; Glasgow, UK, and the AMCP Annual Meeting; March 25-28, 2019; San Diego, CA.
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Affiliation(s)
| | | | | | | | | | | | - Neeta Tandon
- Janssen Scientific Affairs, Titusville, New Jersey
| | - Wing Chow
- Janssen Scientific Affairs, Titusville, New Jersey
| | - Keith Dunn
- Janssen Scientific Affairs, Titusville, New Jersey
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Minchella PA, Adjé-Touré C, Zhang G, Tehe A, Hedje J, Rottinghaus ER, Natacha K, Diallo K, Ouedraogo GL, Nkengasong JN. Use of pre-ART laboratory screening to identify renal, hepatic and haematological abnormalities in Côte d'Ivoire. Trop Med Int Health 2020; 25:408-413. [PMID: 31960558 DOI: 10.1111/tmi.13364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND High demand for HIV-services and extensive clinical guidelines force health systems in low-resource settings to dedicate resources to service delivery at the expense of other priorities. Simplifying services may reduce the burden on health systems and pre-antiretroviral therapy (ART) laboratory screening is among the services under consideration for simplification. METHODS We assessed the frequencies of conditions linked to ART toxicities among 34,994 adult, ART-naïve patients with specimens referred to the RETRO-CI laboratory in Abidjan, Côte d'Ivoire between 1998 and 2017. Screening included tests for serum creatinine, alanine aminotransferase (ALT) and haemoglobin (Hb) to identify renal dysfunction (estimated glomerular filtration rate < 50 mL/min), hepatic abnormalities (ALT > 5× upper limit of normal) and severe anaemia (Hb < 6.5 g/dL), respectively. We considered screening results across four eras and identified factors associated with the conditions in question. RESULTS The prevalence of renal dysfunction, hepatic abnormalities and severe anaemia were largely unchanged over time and just 8.4% of patients had any of the three conditions. Key factors associated with renal dysfunction and severe anaemia were age > 50 years (adjusted odds ratio (aOR): 2.53; 95% confidence interval (CI): 2.19-2.92; P < 0.001) and CD4 < 100 cells/µl (aOR: 2.57; 95% CI: 2.30-2.88; P < 0.001). CONCLUSION The relative infrequency of conditions linked to toxicity in Côte d'Ivoire supports the notion that simplification of pre-ART laboratory screening may be undertaken with limited negative impact on identification of adverse events. Targeted screening may be a feasible strategy to balance detection of conditions associated with ART toxicities with simplification of services.
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Affiliation(s)
- P A Minchella
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - C Adjé-Touré
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - G Zhang
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - A Tehe
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - J Hedje
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - E R Rottinghaus
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - K Natacha
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - K Diallo
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Pretoria, South Africa
| | - G L Ouedraogo
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - J N Nkengasong
- Africa Centres for Disease Control and Prevention, Addis Ababa, Ethiopia
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Zhao Y, Wu Z, McGoogan JM, Sha Y, Zhao D, Ma Y, Brookmeyer R, Detels R, Montaner JSG. Nationwide Cohort Study of Antiretroviral Therapy Timing: Treatment Dropout and Virological Failure in China, 2011-2015. Clin Infect Dis 2020; 68:43-50. [PMID: 29771296 PMCID: PMC6293037 DOI: 10.1093/cid/ciy400] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/04/2018] [Indexed: 12/21/2022] Open
Abstract
Background People living with human immunodeficiency virus (PLWH) are still being diagnosed late, rendering the benefits of "early" antiretroviral therapy (ART) unattainable. Therefore, we aimed to evaluate the benefits of "immediate" ART. Methods A nationwide cohort of PLWH in China who initiated ART January 1, 2011, to December 31, 2014 and had baseline CD4 results >200 cells/μL were censored at 12 months, dropout, or death, whichever came first. Treatment dropout and virological failure (viral load ≥400 copies/mL) were measured. Determinants were assessed by Cox and log-binomial regression. Results The cohort included 123605 PLWH. The ≤30 days group had a significantly lower treatment dropout rate of 6.72%, compared to 8.91% for the 91-365 days group and to 12.64% for the >365 days group. The ≤30 days group also had a significantly lower virological failure rate of 5.45% (31-90 days: 7.39%; 91-365 days: 9.64%; >365 days: 12.67%). Greater risk of dropout (91-365 days: adjusted hazard ratio [aHR] = 1.33, 95% confidence interval [CI] = 1.25-1.42; >365 days: aHR = 1.55, CI = 1.47-1.54), and virological failure (31-90 days: adjusted risk ratio [aRR] = 1.35, CI = 1.26-1.45; 91-365 days: aRR = 1.66, CI = 1.55-1.78; >365 days: aRR = 1.85, CI = 1.74-1.97) were observed for those who delayed treatment. Conclusions ART within 30 days of HIV diagnosis was associated with significantly reduced risk of treatment failure, highlighting the need to implement test-and-immediately-treat policies.
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Affiliation(s)
- Yan Zhao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zunyou Wu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.,Department of Epidemiology, University of California, Los Angeles (UCLA) Fielding School of Public Health
| | - Jennifer M McGoogan
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yiyi Sha
- Tsinghua University, Beijing, China
| | - Decai Zhao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Ye Ma
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Ron Brookmeyer
- Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles, California
| | - Roger Detels
- Department of Epidemiology, University of California, Los Angeles (UCLA) Fielding School of Public Health
| | - Julio S G Montaner
- British Columbia Center for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada
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Lilian RR, Rees K, McIntyre JA, Struthers HE, Peters RPH. Same-day antiretroviral therapy initiation for HIV-infected adults in South Africa: Analysis of routine data. PLoS One 2020; 15:e0227572. [PMID: 31935240 PMCID: PMC6959580 DOI: 10.1371/journal.pone.0227572] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 12/21/2019] [Indexed: 01/13/2023] Open
Abstract
Same-day initiation (SDI) of antiretroviral therapy (ART) has been recommended to improve ART programme outcomes in South Africa since August 2017. This study assessed implementation of SDI over time in two South African districts, describing the characteristics of same-day initiators and evaluating the impact of SDI on retention in ART care. Routine data were analysed for HIV-infected adults who were newly initiating ART in Johannesburg or Mopani Districts between October 2017 and June 2018. Characteristics of same-day ART initiators were compared to later initiators, and losses to follow-up (LTFU) to six months were assessed using Kaplan Meier survival analysis and multivariate logistic regression. The dataset comprised 32 290 records (29 964 from Johannesburg and 2 326 from Mopani). The overall rate of SDI was 40.4% (n = 13 038), increasing from 30.3% in October 2017 to 54.2% in June 2018. Same-day ART initiators were younger, more likely to be female and presented with less advanced clinical disease than those initiating treatment at later times following diagnosis (p<0.001 for all). SDI was associated with disengagement from care: LTFU was 30.1% in the SDI group compared to 22.4%, 19.8% and 21.9% among clients initiating ART 1–7 days, 8–21 days and ≥22 days after HIV diagnosis, respectively (p<0.001). LTFU was significantly more likely among clients in Johannesburg versus Mopani (adjusted odds ratio (aOR) = 1.43, p<0.001) and among same-day versus later initiators (aOR = 1.45, p<0.001), while increasing age reduced LTFU (aOR = 0.97, p<0.001). In conclusion, SDI has increased over time as per national guidelines, but there is serious concern regarding the reduced rate of retention among same-day initiators. Nevertheless, SDI may result in a net programmatic benefit provided that interventions are implemented to support client readiness for treatment and ongoing engagement in ART care, particularly among younger adults in large ART programmes such as Johannesburg.
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Affiliation(s)
| | - Kate Rees
- Anova Health Institute, Johannesburg, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - James A. McIntyre
- Anova Health Institute, Johannesburg, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen E. Struthers
- Anova Health Institute, Johannesburg, South Africa
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Remco P. H. Peters
- Anova Health Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, School of Public Health & Primary Care (CAPHRI), Maastricht University Medical Centre, Maastricht, The Netherlands
- * E-mail:
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Masters MC, Krueger KM, Williams JL, Morrison L, Cohn SE. Beyond one pill, once daily: current challenges of antiretroviral therapy management in the United States. Expert Rev Clin Pharmacol 2019; 12:1129-1143. [PMID: 31774001 DOI: 10.1080/17512433.2019.1698946] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Modern antiretroviral therapy (ART) has revolutionized HIV treatment. ART regimens are now highly efficacious, well-tolerated, safe, often with one multi-drug pill, once-daily regimens available. However, clinical challenges persist in managing ART in persons with HIV (PWH), such as drug-drug interactions, side effects, pregnancy, co-morbidities, and adherence.Areas Covered: In this review, we discuss the ongoing challenges of ART for adults in the United States. We review the difficulties of initiating ART and maintaining therapy throughout adulthood and discuss new agents and strategies under investigation to address these issues. A PubMed search was utilized to identify relevant publications and guidelines through July 2019.Expert Opinion: Challenges persist in initiation and maintenance of ART. An individual's coexisting medical, social and personal factors must be considered in selecting and continuing ART to ensure safety, tolerability, and efficacy throughout adulthood. Continued development of new therapeutics and novel approaches to ART, such as long acting drugs or dual therapy, are needed to respond to many of these challenges. In addition, future research must address therapeutic disparities for populations historically underrepresented in clinical trials, including women, people aging with HIV, and those with complex comorbidities.
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Affiliation(s)
- Mary Clare Masters
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karen M Krueger
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Janna L Williams
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lindsay Morrison
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Susan E Cohn
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Crabtree‐Ramírez BE, Caro‐Vega Y, Belaunzarán‐Zamudio PF, Shepherd BE, Rebeiro PF, Veloso V, Cortes CP, Padgett D, Gotuzzo E, Sierra‐Madero J, McGowan CC, Person AK. Temporal changes in ART initiation in adults with high CD4 counts in Latin America: a cohort study. J Int AIDS Soc 2019; 22:e25413. [PMID: 31855320 PMCID: PMC6922020 DOI: 10.1002/jia2.25413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 10/16/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION In 2013, the World Health Organization (WHO) recommended initiating combination ART (cART) in all adults with HIV and CD4+ lymphocyte counts (CD4) <500 cells/mm3 . In 2015, this was updated to recommend cART initiation in all patients with HIV, regardless of CD4 count. Implementation of these guidelines in real-world settings has not been evaluated in Latin America. To assess changes in time to cART initiation during routine care, we estimated trends in time from enrolment in care to cART initiation in HIV-positive adults with high CD4 counts in the Caribbean, Central and South America network for HIV Epidemiology (CCASAnet) during 2003 to 2017. METHODS All cART-naive individuals ≥18 years of age from 2003 to 2017 with CD4 ≥350 cells/mm3 and without AIDS at enrolment at five CCASAnet sites (Brazil, Chile, Honduras, Mexico and Peru) were included. Patients without information regarding AIDS-defining events were excluded. We estimated unadjusted median time from enrolment to cART initiation by calendar year using Kaplan-Meier methods and calculated adjusted hazard ratios (HR) and 95% confidence intervals (95% CI) for trends in cART initiation using Cox models and restricted cubic splines for continuous variables, accounting for age, sex, CD4 at enrolment, route of HIV transmission and clinic site. RESULTS Of the 3171 patients included, 1,650 (52%) had CD4 ≥500 cells/mm3 at enrolment. Median time to cART initiation after 2013 was 6.21 weeks (interquartile range (IQR): 1.89, 23.21), and 4.71 weeks (IQR: 1.43, 9.57) after 2015. Among 763 (24%) patients who never initiated cART, 33 (4.3%) were reported as deceased, 481 (63%) were lost to follow-up, and 249 (33%) were administratively censored before initiation. Adjusted probability of cART initiation greatly increased in recent years, in particular after 2013 and 2015 (2013 vs. 2003: HR = 7.14; 95% CI: 5.84 to 8.73, and 2015 vs. 2003: HR = 12.60; 95% CI: 10.37 to 15.32). CONCLUSIONS Time to cART initiation decreased substantially, roughly following changes in WHO guidelines in this real-world setting in Latin America. However, a very high proportion of patients never started cART, compromising retention in care and survival, as shown by their higher proportion of LTFU and death, which reinforce the notion that earlier treatment implementation strategies are needed.
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Affiliation(s)
| | - Yanink Caro‐Vega
- Departamento de InfectologíaInstituto Nacional de Ciencias Médicas y NutriciónMéxico CityMexico
| | | | | | | | - Valdilea Veloso
- Instituto de Pesquisa Clínica Evandro ChagasFundacão Oswaldo CruzRio de JaneiroBrazil
| | - Claudia P Cortes
- Facultad de Medicina de la Universidad de Chile and Fundación ArriaránSantiago de ChileChile
| | - Denis Padgett
- Instituto Hondureño de Seguro Social and Hospital Escuela UniversitarioTegucigalpaHonduras
| | - Eduardo Gotuzzo
- Instituto de Medicina Tropical Alexander von HumboldtLimaPeru
| | - Juan Sierra‐Madero
- Departamento de InfectologíaInstituto Nacional de Ciencias Médicas y NutriciónMéxico CityMexico
| | | | - Anna K Person
- Vanderbilt University School of MedicineNashvilleTNUSA
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Bor J, Thirumurthy H. Bridging the Efficacy-Effectiveness Gap in HIV Programs: Lessons From Economics. J Acquir Immune Defic Syndr 2019; 82 Suppl 3:S183-S191. [PMID: 31764253 PMCID: PMC7388866 DOI: 10.1097/qai.0000000000002201] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Bridging the efficacy-effectiveness gap in HIV prevention and treatment requires policies that account for human behavior. SETTING Worldwide. METHODS We conducted a narrative review of the literature on HIV in the field of economics, identified common themes within the literature, and identified lessons for implementation science. RESULTS The reviewed studies illustrate how behaviors are shaped by perceived costs and benefits across a wide range of health and nonhealth domains, how structural constraints shape decision-making, how information interventions can still be effective in the epidemic's fourth decade, and how lessons from behavioral economics can be used to improve intervention effectiveness. CONCLUSION Economics provides theoretical insights and empirical methods that can guide HIV implementation science.
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Affiliation(s)
- Jacob Bor
- Department of Global Health, Boston University, Boston, MA
| | - Harsha Thirumurthy
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
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Pascoe SJS, Fox MP, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser‐Hurt N. Differentiated HIV care in South Africa: the effect of fast-track treatment initiation counselling on ART initiation and viral suppression as partial results of an impact evaluation on the impact of a package of services to improve HIV treatment adherence. J Int AIDS Soc 2019; 22:e25409. [PMID: 31691521 PMCID: PMC6831947 DOI: 10.1002/jia2.25409] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 09/06/2019] [Accepted: 09/25/2019] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION In response to suboptimal adherence and retention, South Africa's National Department of Health developed and implemented National Adherence Guidelines for Chronic Diseases. We evaluated the effect of a package of adherence interventions beginning in January 2016 and report on the impact of Fast-Track Treatment Initiation Counselling (FTIC) on ART initiation, adherence and retention. METHODS We conducted a cluster-randomized mixed-methods evaluation in 4 provinces at 12 intervention sites which implemented FTIC and 12 control facilities providing standard of care. Follow-up was by passive surveillance using clinical records. We included data on subjects eligible for FTIC between 08 Jan 2016 and 07 December 2016. We adjusted for pre-intervention differences using difference-in-differences (DiD) analyses controlling for site-level clustering. RESULTS We enrolled 362 intervention and 368 control arm patients. Thirty-day ART initiation was 83% in the intervention and 82% in the control arm (RD 0.5%; 95% CI: -5.0% to 6.0%). After adjusting for baseline ART initiation differences and covariates using DiD we found a 6% increase in ART initiation associated with FTIC (RD 6.3%; 95% CI: -0.6% to 13.3%). We found a small decrease in viral suppression within 18 months (RD -2.8%; 95% CI: -9.8% to 4.2%) with no difference after adjustment (RD: -1.9%; 95% CI: -9.1% to 5.4%) or when considering only those with a viral load recorded (84% intervention vs. 86% control). We found reduced crude 6-month retention in intervention sites (RD -7.2%; 95% CI: -14.0% to -0.4%). However, differences attenuated by 12 months (RD: -3.6%; 95% CI: -11.1% to 3.9%). Qualitative data showed FTIC counselling was perceived as beneficial by patients and providers. CONCLUSIONS We saw a short-term ART-initiation benefit to FTIC (particularly in districts where initiation prior to intervention was lower), with no reductions but also no improvement in longer-term retention and viral suppression. This may be due to lack of fidelity to implementation and delivery of those components that support retention and adherence. FTIC must continue to be implemented alongside other interventions to achieve the 90-90-90 cascade and fidelity to post-initiation counselling sessions must be monitored to determine impact on longer-term outcomes. Understanding the cost-benefit and role of FTIC may then be warranted.
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Affiliation(s)
- Sophie JS Pascoe
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
| | - Amy N Huber
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | | | - Sydney Rosen
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | | | - Yogan Pillay
- National Department of HealthPretoriaSouth Africa
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Rivera VR, Lu L, Ocheretina O, Jean Juste MA, Julma P, Archange D, Moise CG, Homeus F, Phanor PD, Petión S, Cremieux PY, Fitzgerald DW, Pape JW, Koenig SP. Diagnostic yield of active case finding for tuberculosis at human immunodeficiency virus testing in Haiti. Int J Tuberc Lung Dis 2019; 23:1217-1222. [PMID: 31718759 PMCID: PMC7647668 DOI: 10.5588/ijtld.18.0835] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: The Groupe Haïtien d'étude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO) Centres, Port-au-Prince, Haiti, facilitate "test and treat" strategies by screening all patients for tuberculosis (TB) at human immunodeficiency virus (HIV) testing.OBJECTIVE: 1) To determine the proportion of patients with chronic cough at HIV testing diagnosed with TB, stratified by HIV test results; and 2) to evaluate the additional diagnostic yield of Xpert® MTB/RIF vs. sputum microscopy.DESIGN: We conducted a retrospective cohort analysis including all adults tested for HIV at GHESKIO from August 2014 to July 2015.RESULTS: Of 29 233 adult patients tested for HIV, 2953 (10%) were diagnosed as HIV-positive. Chronic cough lasting ≥2 weeks was reported by 1116 (38%) HIV-positive patients; 984 (88%) were tested and 265 (27%) were diagnosed with TB. Chronic cough was reported by 5985 (23%) HIV-negative patients; 5654 (94%) were tested and 1179 (21%) were diagnosed with TB. Of all bacteriologically confirmed cases, 27% were smear-negative and Xpert-positive. Among all TB patients, 81% were HIV-negative.CONCLUSIONS: Screening for TB at HIV testing was high-yield, among both HIV-infected and HIV-negative individuals. Testing for both diseases should be conducted among patients who present with chronic cough at HIV testing.
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Affiliation(s)
- V R Rivera
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti, Division of Global Health, Weill Cornell Medical College, New York, NY, USA
| | - L Lu
- Analysis Group, Boston, MA, USA
| | - O Ocheretina
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti, Division of Global Health, Weill Cornell Medical College, New York, NY, USA
| | - M A Jean Juste
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - P Julma
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - D Archange
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - C G Moise
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - F Homeus
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - P D Phanor
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - S Petión
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - D W Fitzgerald
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti, Division of Global Health, Weill Cornell Medical College, New York, NY, USA
| | - J W Pape
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti, Division of Global Health, Weill Cornell Medical College, New York, NY, USA
| | - S P Koenig
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti, Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
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141
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Reflexive Laboratory-Based Cryptococcal Antigen Screening and Preemptive Fluconazole Therapy for Cryptococcal Antigenemia in HIV-Infected Individuals With CD4 <100 Cells/µL: A Stepped-Wedge, Cluster-Randomized Trial. J Acquir Immune Defic Syndr 2019; 80:182-189. [PMID: 30399034 PMCID: PMC6339522 DOI: 10.1097/qai.0000000000001894] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is Available in the Text. Background: HIV-infected persons with cryptococcal antigenemia (CrAg) are at high risk for meningitis or death. We evaluated the effect of CrAg screening and preemptive fluconazole therapy, adjunctive to antiretroviral therapy (ART), on 6-month survival among persons with advanced HIV/AIDS. Methods: We enrolled HIV-infected, ART-naive participants with <100 CD4 cells/µL, in a stepped-wedge, cluster-randomized trial from July 2012 to December 2014 at 17 Ugandan clinics. Clinics participated in a prospective observational phase, followed by an interventional phase with laboratory-based, reflexive CrAg screening of residual CD4 count plasma. Asymptomatic CrAg+ participants received preemptive fluconazole therapy. We assessed 6-month survival using Cox-regression, adjusting for nadir CD4, calendar time, and stepped-wedge steps. Results: We included 1280 observational and 2108 interventional participants, of whom 9.3% (195/2108) were CrAg+. CD4-, time-, and stepped-wedge–adjusted analyses demonstrated no difference in survival in the observational vs the interventional arms (hazard ratio = 1.34; 95% confidence interval: 0.86 to 2.10; P = 0.20). Fewer participants initiated ART in the interventional (73%) versus the observational phase (82%, P < 0.001). When ART initiation was modeled as a time-dependent covariate or confounder, survival did not differ. However, 6-month mortality of participants with CrAg titers <1:160 and CrAg-negative patients did not differ. Patients with CrAg titers ≥1:160 had 2.6-fold higher 6-month mortality than patients with titers <1:160. Conclusions: We observed no overall survival benefit of the CrAg screen-and-treat intervention. However, preemptive antifungal therapy for asymptomatic cryptococcosis seemed to be effective in patients with CrAg titer <1:160. A more aggressive approach is required for persons with CrAg titer ≥1:160.
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Kim YJ, Kim SW, Kwon KT, Chang HH, Kim SI, Kim YJ, Kim MJ, Choi JY, Kim HY, Kim JM, Choi BY, Park BY, Choi YS, Kee MK, Yoo MS, Lee JG. Significance of Increased Rapid Treatment from HIV Diagnosis to the First Antiretroviral Therapy in the Recent 20 Years and Its Implications: the Korea HIV/AIDS Cohort Study. J Korean Med Sci 2019; 34:e239. [PMID: 31583868 PMCID: PMC6776834 DOI: 10.3346/jkms.2019.34.e239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 08/16/2019] [Indexed: 11/23/2022] Open
Abstract
From December 2006 to December 2016, 1,429 patients enrolled in the Korea human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) Cohort Study were investigated. Based on the year of diagnosis, the time interval between HIV diagnosis and initiation of antiretroviral therapy (ART) was analyzed by dividing it into 2 years. The more recent the diagnosis, the more likely rapid treatment was initiated (P < 0.001) and the proportion of patients starting ART on the same day of HIV diagnosis was increased in 2016 (6.5%) compared to that in 2006 (1.7%). No significant difference in the median values of CD4+ cell counts according to the diagnosis year was observed. In the past 20 years, the time from the HIV diagnosis to the initiation of ART was significantly reduced. Rapid treatment was being implemented at the HIV diagnosis, regardless of CD4+ cell count. Considering the perspective "treatment is prevention," access to more rapid treatment is necessary at the time of HIV diagnosis.
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Affiliation(s)
- Yoon Jung Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Shin Woo Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
| | - Ki Tae Kwon
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyun Ha Chang
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sang Il Kim
- Division of Infectious Disease, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Youn Jeong Kim
- Division of Infectious Disease, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min Ja Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jun Yong Choi
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Youl Kim
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - June Myung Kim
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Bo Youl Choi
- Department of Preventive Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Bo Young Park
- Department of Preventive Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Yun Su Choi
- Department of Preventive Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Mee Kyung Kee
- Division of Viral Disease Research Center for Infectious Disease Research, Korea National Institute of Health, Cheongju, Korea
| | - Myeong Su Yoo
- Division of Viral Disease Research Center for Infectious Disease Research, Korea National Institute of Health, Cheongju, Korea
| | - Jung Gyu Lee
- Division of Viral Disease Research Center for Infectious Disease Research, Korea National Institute of Health, Cheongju, Korea
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Brief Report: A Panel Management and Patient Navigation Intervention Is Associated With Earlier PrEP Initiation in a Safety-Net Primary Care Health System. J Acquir Immune Defic Syndr 2019; 79:347-351. [PMID: 30085955 DOI: 10.1097/qai.0000000000001828] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Timely pre-exposure prophylaxis (PrEP) initiation is critical in at-risk populations, given that HIV acquisition risk persists during delays. Time to treatment initiation, a key metric in HIV care, has not been explored among PrEP users. Interventions that reduce time to PrEP initiation could prevent HIV infections. SETTING Individuals initiating PrEP in a large primary care health network of 15 clinics, the San Francisco Primary Care Clinics (SFPCC), from July 2012 to July 2017 (N = 411). METHODS We examined factors associated with time from first PrEP discussion with a provider to PrEP initiation date using an adjusted Cox proportional-hazards model, with hazard ratios (HRs) >1 indicating earlier initiation. We also examined the relationship between delayed PrEP initiation and PrEP persistence (staying on PrEP) in an adjusted Cox proportional-hazards model. RESULTS PrEP users initiated PrEP after a median of only 7 days. However, there were notable outliers, with 29% waiting >30 days and 12% waiting >90 days. In an adjusted proportional-hazards model, a panel management and patient navigation intervention was associated with earlier PrEP initiation [HR: 1.5; 95% confidence interval (CI): 1.1 to 2.0], whereas only other race/ethnicity compared with white race was associated with delayed PrEP initiation (HR: 0.7; 95% CI: 0.5 to 1.0). Delayed PrEP initiation >30 days was associated with shorter PrEP persistence in an adjusted proportional-hazards model (HR: 1.3; 95% CI: 1.0 to 1.7). CONCLUSIONS PrEP initiation within a week is feasible in a primary care safety-net health system. Setting a goal of rapid PrEP initiation, with the support of panel management and patient navigation, could address delays in at-risk groups.
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Rodriguez AE, Wawrzyniak AJ, Tookes HE, Vidal MG, Soni M, Nwanyanwu R, Goldberg D, Freeman R, Villamizar K, Alcaide ML, Kolber MA. Implementation of an Immediate HIV Treatment Initiation Program in a Public/Academic Medical Center in the U.S. South: The Miami Test and Treat Rapid Response Program. AIDS Behav 2019; 23:287-295. [PMID: 31520241 DOI: 10.1007/s10461-019-02655-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Test and Rapid Response Treatment (TRRT) linkage programs have demonstrated improved HIV suppression rates. This paper describes the design and implementation of the Miami TRRT initiative and its clinical impact. Assisted by a dedicated care navigator, patients receiving a reactive HIV rapid test at the Florida Department of Health STD Clinic were offered same-day HIV care at the University of Miami/Jackson Memorial Medical Center Adult HIV Outpatient Clinic. Patient retention and labs were tracked for 12 months. Of the 2337 individuals tested, 46 had a reactive HIV test; 41 (89%) consented to participate. For the 36 patients in continued care for a year, 33 (91.7%) achieved virological suppression (< 200 copies/mL) within 70 days of their reactive HIV rapid test; at 12 months, 35 (97.2%) remained suppressed, and mean CD4 T cell counts increased from 452 ± 266 to 597 ± 322 cells/mm3. The Miami TRRT initiative demonstrated that immediate linkage to care is feasible and improves retention and suppression in a public/academic medical center in the U.S. South.
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Affiliation(s)
- Allan E Rodriguez
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 856, Miami, FL, 33136, USA.
| | - Andrew J Wawrzyniak
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hansel E Tookes
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 856, Miami, FL, 33136, USA
| | - Marcia G Vidal
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 856, Miami, FL, 33136, USA
| | - Manasi Soni
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 856, Miami, FL, 33136, USA
| | | | - David Goldberg
- Florida Department of Health in Miami-Dade County, Miami, FL, USA
| | | | - Kira Villamizar
- Florida Department of Health in Miami-Dade County, Miami, FL, USA
| | - Maria L Alcaide
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 856, Miami, FL, 33136, USA
| | - Michael A Kolber
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 856, Miami, FL, 33136, USA
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Mussini C, Roncaglia E, Borghi V, Rusconi S, Nozza S, Cattelan AM, Segala D, Bonfanti P, Di Biagio A, Barchi E, Focà E, Degli Antoni A, Bonora S, Francisci D, Limonta S, Antinori A, D’Ettorre G, Maggiolo F. A prospective randomized trial on abacavir/lamivudine plus darunavir/ritonavir or raltegravir in HIV-positive drug-naïve patients with CD4<200 cells/uL (the PRADAR study). PLoS One 2019; 14:e0222650. [PMID: 31560700 PMCID: PMC6764686 DOI: 10.1371/journal.pone.0222650] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 09/02/2019] [Indexed: 01/11/2023] Open
Abstract
Background Very few data are available on treatment in HIV Late presenter population that still represents a clinical challenge. Methods Prospective, multicenter, randomized open-label, 2 arm, phase-3 trial comparing the 48-week virological response of two different regimens: abacavir/lamivudine + darunavir/r vs abacavir/lamivudine + raltegravir in antiretroviral naive with CD4+ counts < 200/mm3 and a viral load (VL)<500,000 copies/mL. The primary Endpoint was the proportion of patients with undetectable viremia (VL<50 copies/mL) after 48 weeks. The planned sample size for this trial was 350 patients. Results In 3 years, 53 patients were screened and 46 enrolled: 22 randomized to raltegravir and 24 to darunavir/r; 7 patients were excluded, 4 because of a VL >500,000 copies/mL and 3 for HLAB5701 positivity. The snapshot analysis at 48 weeks showed a virologic success of 77.3% in raltegravir and 66.7% in darunavir/r. Time to starting treatment was 34.5 days in raltegravir and 53 days in darunavir/r. At the as treated analysis, the median CD4 counts at 48 weeks was 297 cells/μL in raltegravir and 239 cells/μL in darunavir/r. No difference in total cholesterol, while triglycerides were higher in the darunavir/r arm. No statistical analyses were performed due to the low number of patients enrolled. Conclusions Late presenter patients are frequent but very difficult to enroll in clinical trials, especially in western countries. These regimens and the conditions of many patients could not allow the test and treat strategy. The rate of virologic success was higher than 65% in both arms with a median CD4 cell count >200/μL at week 48. Trial registration EUDRACT number: 2011-005973-21
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Affiliation(s)
- Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
- * E-mail:
| | - Enrica Roncaglia
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Vanni Borghi
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Rusconi
- Clinic of Infectious Diseases, DIBIC Luigi Sacco, University of Milan, Milan, Italy
| | - Silvia Nozza
- Clinic of Infectious Diseases, University Vita e Salute, San Raffaele Hospital, Milan, Italy
| | | | - Daniela Segala
- Clinic of Infectious Diseases, Sant’Anna Hospital, Ferrara, Italy
| | - Paolo Bonfanti
- Department of Infectious Diseases, Lecco Hospital, Lecco, Italy
| | | | - Enrico Barchi
- Department of Infectious Diseases, Santa Maria Nuova Hospital, Reggio Emilia, Italy
| | - Emanuele Focà
- Clinic of Infectious Diseases, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | | | - Stefano Bonora
- Clinic of Infectious Diseases, University of Torino, Torino, Italy
| | - Daniela Francisci
- Clinic of Infectious Diseases, University of Perugia, Perugia, Italy
| | - Silvia Limonta
- Clinic of Infectious Diseases, DIBIC Luigi Sacco, University of Milan, Milan, Italy
| | - Andrea Antinori
- National Institute for Infectious Diseases L. Spallanzani, Rome, Italy
| | | | - Franco Maggiolo
- Department of Infectious Diseases, Bergamo Hospital, Bergamo, Italy
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Huang YC, Sun HY, Chuang YC, Huang YS, Lin KY, Huang SH, Chen GJ, Luo YZ, Wu PY, Liu WC, Hung CC, Chang SC. Short-term outcomes of rapid initiation of antiretroviral therapy among HIV-positive patients: real-world experience from a single-centre retrospective cohort in Taiwan. BMJ Open 2019; 9:e033246. [PMID: 31542770 PMCID: PMC6756335 DOI: 10.1136/bmjopen-2019-033246] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES Rapid initiation of antiretroviral therapy (ART) engenders faster viral suppression but with suboptimal rates of durable viral suppression and engagement in care, as reported by clinical trials in resource-limited settings. Real-world experience with rapid ART initiation remains limited in resource-rich settings. DESIGN Retrospective cohort study. SETTING A tertiary hospital in metropolitan Taipei, Taiwan. PARTICIPANTS We included 631 patients newly diagnosed as having HIV infection between March 2014 and July 2018. MAIN OUTCOME MEASURES Rapid ART initiation was defined as starting ART within 7 days after HIV diagnosis confirmation. HIV diagnosis, ART initiation and viral suppression dates and clinical outcome data were collected by reviewing medical records. The rates of loss to follow-up (LTFU), engagement in care and virological rebound at 12 months were compared between patients with rapid ART initiation and those with standard initiation. RESULTS Rapid ART initiation increased from 33.8% in 2014 to 68.3% in 2017, and the median interval between HIV diagnosis and viral suppression (HIV RNA load <200 copies/mL) decreased from 138 to 47 days. Patients with rapid ART initiation had a significantly higher rate of engagement in care at 12 months than did those with standard initiation (88.3% vs 79.0%; p=0.002). Patients aged <30 years had a higher risk of LTFU (HR: 2.19; 95% CI 1.20 to 3.98); and rapid ART initiation was associated with a lower risk of LTFU (HR: 0.41; 95% CI 0.24 to 0.83). Patients aged <30 years were more likely to acquire incident sexually transmitted infections (STIs) before achieving viral suppression. CONCLUSIONS Rapid ART initiation was associated with a higher rate of engagement in care at 12 months and shortened interval from diagnosis to HIV suppression. Delayed ART initiation may increase onwards HIV transmission considering the high rates of STIs. ETHICS APPROVAL The study was approved by the Research Ethics Committee of National Taiwan University Hospital (Registration No. 201003112R).
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Affiliation(s)
- Yi-Chia Huang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Shan Huang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kuan-Yin Lin
- Department of Medicine, National Taiwan University Hospital Jin-Shan Branch, New Taipei City, Taiwan
| | - Sung-Hsi Huang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Guan-Jhou Chen
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Yu-Zheng Luo
- Center of Infection Control, National Taiwan University Hospital, Taipei, Taiwan
| | - Pei-Ying Wu
- Center of Infection Control, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Chun Liu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chien-Ching Hung
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
- China Medical University, Taichung, Taiwan
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Slow Acceptance of Universal Antiretroviral Therapy (ART) Among Mothers Enrolled in IMPAACT PROMISE Studies Across the Globe. AIDS Behav 2019; 23:2522-2531. [PMID: 31399793 PMCID: PMC6766470 DOI: 10.1007/s10461-019-02624-3] [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] [Indexed: 10/29/2022]
Abstract
The PROMISE trial enrolled asymptomatic HIV-infected pregnant and postpartum women not eligible for antiretroviral treatment (ART) per local guidelines and randomly assigned proven antiretroviral strategies to assess relative efficacy for perinatal prevention plus maternal/infant safety and maternal health. The START study subsequently demonstrated clear benefit in initiating ART regardless of CD4 count. Active PROMISE participants were informed of results and women not receiving ART were strongly recommended to immediately initiate treatment to optimize their own health. We recorded their decision and the primary reason given for accepting or rejecting the universal ART offer after receiving the START information. One-third of participants did not initiate ART after the initial session, wanting more time to consider. Six sessions were required to attain 95% uptake. The slow uptake of universal ART highlights the need to prepare individuals and sensitize communities regarding the personal and population benefits of the "Treat All" strategy.
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Re-thinking Linkage to Care in the Era of Universal Test and Treat: Insights from Implementation and Behavioral Science for Achieving the Second 90. AIDS Behav 2019; 23:120-128. [PMID: 31161462 PMCID: PMC6773672 DOI: 10.1007/s10461-019-02541-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
To successfully link to care, persons living with HIV must negotiate a complex series of processes from HIV diagnosis through initial engagement with HIV care systems and providers. Despite the complexity involved, linkage to care is often oversimplified and portrayed as a single referral step. In this article, we offer a new conceptual framework for linkage to care, tailored to the current universal test and treat era that presents linkage to care as its own nuanced pathway within the larger HIV care cascade. Conceptualizing linkage to care in this way may help better identify and specify processes posing a barrier to linkage, and allow for the development of targeted implementation and behavioral science-based approaches to address them. Such approaches are likely to be most relevant to programmatic and clinical settings with limited resources and high HIV burden.
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Rosen S, Maskew M, Larson BA, Brennan AT, Tsikhutsu I, Fox MP, Vezi L, Bii M, Venter WDF. Simplified clinical algorithm for identifying patients eligible for same-day HIV treatment initiation (SLATE): Results from an individually randomized trial in South Africa and Kenya. PLoS Med 2019; 16:e1002912. [PMID: 31525187 PMCID: PMC6746347 DOI: 10.1371/journal.pmed.1002912] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 08/14/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The World Health Organization recommends "same-day" initiation of antiretroviral therapy (ART) for HIV patients who are eligible and ready. Identifying efficient, safe, and feasible procedures for determining same-day eligibility and readiness is now a priority. The Simplified Algorithm for Treatment Eligibility (SLATE) study evaluated a clinical algorithm that allows healthcare workers to determine eligibility for same-day treatment and to initiate ART at the patient's first clinic visit. METHODS AND FINDINGS SLATE was an individually randomized trial at three outpatient clinics in urban settlements in Johannesburg, South Africa and three hospital clinics in western Kenya. Adult, nonpregnant, HIV-positive, ambulatory patients presenting for any HIV care, including HIV testing, but not yet on ART were enrolled and randomized to the SLATE algorithm arm or standard care. The SLATE algorithm used four screening tools-a symptom self-report, medical history questionnaire, physical examination, and readiness assessment-to ascertain eligibility for same-day initiation or refer for further care. Follow-up was by record review, and analysis was conducted by country. We report primary outcomes of 1) ART initiation ≤28 days and 2) initiation ≤28 days and retention in care ≤8 months of enrollment. From March 7, 2017 to April 17, 2018, we enrolled 600 patients (median [IQR] age 34 [29-40] and CD4 count 286 [128-490]; 63% female) in South Africa and 477 patients in Kenya (median [IQR] age 35 [29-43] and CD4 count 283 [117-541]; 58% female). In the intervention arm, 78% of patients initiated ≤28 days in South Africa, compared to 68% in the standard arm (risk difference [RD] [95% confidence interval (CI)] 10% [3%-17%]); in Kenya, 94% of intervention-arm patients initiated ≤28 days compared to 89% in the standard arm (6% [0.5%-11%]). By 8 months in South Africa, 161/298 (54%) intervention-arm patients had initiated and were retained, compared to 146/302 (48%) in the standard arm (6% [(2% to 14%]). By 8 months in Kenya, the corresponding retention outcomes were identical in both arms (137/240 [57%] of intervention-arm patients and 136/237 [57%] of standard-arm patients). Limitations of the trial included limited geographic representativeness, exclusion of patients too ill to participate, missing viral load data, greater study fidelity to the algorithm than might be achieved in standard care, and secular changes in standard care over the course of the study. CONCLUSIONS In South Africa, the SLATE algorithm increased uptake of ART within 28 days by 10% and showed a numerical increase (6%) in retention at 8 months. In Kenya, the algorithm increased uptake of ART within 28 days by 6% but found no difference in retention at 8 months. Eight-month retention was poor in both arms and both countries. These results suggest that a simple structured algorithm for same-day treatment initiation procedures is feasible and can increase and accelerate ART uptake but that early retention on treatment remains problematic. TRIAL REGISTRATION Clinicaltrials.gov NCT02891135, registered September 1, 2016. First participant enrolled March 6, 2017 in South Africa and July 13, 2017 in Kenya.
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Affiliation(s)
- Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Mhairi Maskew
- 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
| | - Bruce A. Larson
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Alana T. Brennan
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute, Kericho, Kenya
- Henry M. Jackson Foundation Medical Research International, Inc., Nairobi, Kenya
| | - Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Lungisile Vezi
- 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
| | - Margaret Bii
- Kenya Medical Research Institute, Kericho, Kenya
- Henry M. Jackson Foundation Medical Research International, Inc., Nairobi, Kenya
| | - Willem D. F. Venter
- Ezintsha, Wits Reproductive Health and HIV Institute, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Abstract
Because lifelong therapy is needed in HIV infection, high long-term adherence is necessary. Darunavir/co-bicistat/emtricitabina/tenofovir alafenamide (Symtuza®) is the first triple therapy combining a protease inhibitor (PI) in a single tablet regimen. This drug combines the potency and high genetic barrier of the most effective PI, darunavir, with the renal and bone safety of tenofovir alafenamide. Phase 3 studies have demonstrated its non-inferiority in achieving virologic suppression and maintaining efficacy in virological-ly suppressed patients, even in those with previous failure. Although long-term data are needed, Symtuza® has become a preferred option in most patients. The drug is especially useful in patients with suspected poor adherence, those requiring rapid treatment initiation because of late presentation or opportunistic infection, patients with limitations for other alternatives, and those with a history of previous failure or resistance to other classes of drugs. Supplement information: This article is part of a supplement entitled "Co-formulated cobicistat-boosted darunavir, emtricitabine, and tenofovir alafenamide for the treatment of HIV infection", which is sponsored by Janssen.
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