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Makonokaya L, Maida A, Kalitera LU, Wang A, Kapanda L, Kayira D, Bottoman M, Nkhoma H, Dunga S, Joaki Z, Chamanga R, Nkanaunena K, Hrapcak S, Nyirenda R, Chiwandira B, Maulidi M, Woelk G, Machekano R, Maphosa T. Early Effects of Scaling Up Dolutegravir-Based ARV Regimens Among Children Living with HIV in Malawi. AIDS Behav 2024; 28:2148-2155. [PMID: 38615099 PMCID: PMC11161418 DOI: 10.1007/s10461-024-04312-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/15/2024]
Abstract
Viral suppression (VS) in children has remained suboptimal compared to that in adults. We evaluated the impact of transitioning children weighing < 20 kg to a pediatric formulation of dolutegravir (pDTG) on VS in Malawi. We analyzed routine retrospective program data from electronic medical record systems pooled across 169 healthcare facilities in Malawi supported by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). We included children who weighed < 20 kg and received antiretroviral therapy (ART) between July 2021-June 2022. Using descriptive statistics, we summarized demographic and clinical characteristics, ART regimens, ART adherence, and VS. We used logistic regression to identify factors associated with post-transition VS. A total of 2468 Children Living with HIV (CLHIV) were included, 55.3% of whom were < 60 months old. Most (83.8%) had initiated on non-DTG-based ART; 71.0% of these had a viral load (VL) test result before transitioning to pDTG, and 62.5% had VS. Nearly all (99.9%) CLHIV transitioned to pDTG-based regimens. Six months after the transition, 52.7% had good ART adherence, and 38.6% had routine VL testing results; 81.7% achieved VS. Post-transition VS was associated with good adherence and pre-transition VS: adjusted odds ratios of 2.79 (95% CI 1.65-4.71), p < 0.001 and 5.32 (95% CI 3.23-9.48), p < 0.001, respectively. After transitioning to pDTG, VS was achieved in most children tested within the first 6 months. However, adherence remained suboptimal post-transition and VL testing at 6 months was limited. Interventions to improve VL testing and enhance ART adherence are still needed in CLHIV on pDTG-based regimens.
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Affiliation(s)
| | - Alice Maida
- U. S. Centers for Disease Control and Prevention, Division of Global HIV and TB, Lilongwe, Malawi
| | | | - Alice Wang
- U. S. Centers for Disease Control and Prevention, Division of Global HIV and TB, Lilongwe, Malawi
| | - Lester Kapanda
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Dumbani Kayira
- U. S. Centers for Disease Control and Prevention, Division of Global HIV and TB, Lilongwe, Malawi
| | | | - Harrid Nkhoma
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Shalom Dunga
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Zuze Joaki
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Rachel Chamanga
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Kondwani Nkanaunena
- U. S. Centers for Disease Control and Prevention, Division of Global HIV and TB, Lilongwe, Malawi
| | - Susan Hrapcak
- U. S. Centers for Disease Control and Prevention, Atlanta, USA
| | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Brown Chiwandira
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Martin Maulidi
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Godfrey Woelk
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | | | - Thulani Maphosa
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
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Gwaza GP, Leqheka M, Mots'oane T, Dittrich S, Kao K. Missed opportunities for integrated testing of HIV and tuberculosis on the GeneXpert platform in Lesotho. Afr J Lab Med 2023; 12:2132. [PMID: 37727530 PMCID: PMC10506622 DOI: 10.4102/ajlm.v12i1.2132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 06/15/2023] [Indexed: 09/21/2023] Open
Abstract
Background Integrated testing, treatment and care are key strategies for addressing the dual burdens of tuberculosis and HIV. The GeneXpert instrument allows simultaneous HIV and tuberculosis testing, but its utilisation for integrated testing remains suboptimal. Objective The study determined the extent to which tuberculosis testing and HIV early infant detection (EID) were integrated on the GeneXpert platform, or the potential for integration at selected health facilities. Methods A mixed methods evaluation was conducted using retrospective secondary data analysis of laboratory records from 2017 to 2019, and semi-structured interviews. Data were collected between January 2020 and March 2020 in Lesotho. Results Forty-four health staff were interviewed across 13 health facilities: one regional, nine district, and three clinic level. Six were government facilities, six were mission hospitals, and one was a non-profit clinic. All facilities selected had at least one GeneXpert instrument used for tuberculosis or HIV testing; none included simultaneous testing for tuberculosis and HIV. In 2017, the average utilisation rate for the GeneXpert instrument for tuberculosis and EID testing was 63% and 24%, while in 2019, the average utilisation rate was 61% for tuberculosis testing and 27% for EID. Conclusion Except for three sites where the testing rates were high, utilisation rates were sufficiently low that all the HIV EID and tuberculosis tests undertaken in 2017 and 2019 could have been performed using only the instruments currently dedicated to tuberculosis testing. There is a missed opportunity for the integration of testing for tuberculosis and HIV on the GeneXpert instrument. What this study adds This study adds to the body of evidence on the need for integration of testing and highlights some practical and technical considerations for successful implementation of integrated tuberculosis and HIV testing.
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Affiliation(s)
- Gamuchirai P Gwaza
- Department of Impact, Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
- Department of Continuing Education, University of Oxford, Oxford, United Kingdom
| | - Monkoe Leqheka
- Department of Research and Laboratory Services, Ministry of Health, Maseru, Lesotho
| | - Tsietso Mots'oane
- Department of Research and Laboratory Services, Ministry of Health, Maseru, Lesotho
| | - Sabine Dittrich
- Department of Global Public Health, Deggendorf Institute of Technology, Deggendorf, Germany
| | - Kekeletso Kao
- Department of Access, Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
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Addisu T, Tilahun M, Wedajo S, Sharew B. Trends Analysis of HIV Infection and Antiretroviral Treatment Outcome in Amhara Regional from 2015 to 2021, Northeast Ethiopia. HIV AIDS (Auckl) 2023; 15:399-410. [PMID: 37426768 PMCID: PMC10329428 DOI: 10.2147/hiv.s411235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/30/2023] [Indexed: 07/11/2023] Open
Abstract
Background The persistent efforts of HIV/AIDS epidemiology remain one of the world's most important community health threats. To avoid becoming an epidemic, UNAIDS has set three 90% fast-track targets for 2020, and Ethiopia has also changed its implementation since 2015. However, the achievement targets in the Amhara region have yet to be evaluated at the end of the programme period. Objective The aim of this study was to assess the Trends of HIV Infection and Antiretroviral Treatment outcome in Eastern Amhara Regional from 2015 to 2021, Northeast Ethiopia. Methods A retrospective study was conducted by reviewing the District Health Information System from 2015 to 2021. The collected data includes the trend of HIV testing services, the trend of HIV positivity, the yield of HIV testing approaches, the number of HIV positive patients linked to HIV care and treatment or access to lifelong antiretroviral therapy, viral load testing coverage, and viral suppression. A descriptive statistic and trend analysis were computed. Results A total of 145,639 people accessed antiretroviral therapy. The trend of HIV test positivity has been declining since 2015, peaking at 0.76% in 2015 and declining to 0.60% in 2020. A high level of positivity was reported in volunteer counselling and testing as compared with provider-initiated testing and counselling services. Following an HIV positive, there was an increase in linkage to HIV care and treatment. High suppression rates of viral load indicate testing coverage grew over time. The viral load monitoring coverage was 70% in 2021, with a viral suppression rate of 94%. Conclusion and Recommendations The trend in achievement in the first 90s was not consistent with predefined goals (90%). On the other hand, there was good achievement in the second and third goals. Hence, intensified case-finding approaches to HIV testing should be strengthened.
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Affiliation(s)
- Tseganew Addisu
- Department of Dental Medicine, School of Medicine, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Mihret Tilahun
- Department of Medical Laboratory Sciences, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Shambel Wedajo
- School of Public Health, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Bekele Sharew
- Department of Medical Laboratory Sciences, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
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Musanhu CCC, Takarinda KC, Shea J, Chitsike I, Eley B. Viral load testing among pregnant women living with HIV in Mutare district of Manicaland province, Zimbabwe. AIDS Res Ther 2022; 19:52. [PMID: 36384677 PMCID: PMC9667426 DOI: 10.1186/s12981-022-00480-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 10/07/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Viral load (VL) monitoring of pregnant women living with HIV (PWLHIV) and antiretroviral therapy (ART) may contribute to lowering the risk of vertical transmission of HIV. The aims of this study were to assess the uptake of HIV VL testing among PWLHIV at entry to the prevention-of-mother-to-child transmission (PMTCT) services and identify facilitatory factors and barriers to HIV VL access. METHODS A retrospective, cross-sectional study was conducted at 15 health facilities in Mutare district, Manicaland Province, Zimbabwe from January to December 2018. This analysis was complemented by prospective interviews with PWLHIV and health care providers between October 2019 and March 2020. Quantitative data were analysed using descriptive and inferential statistical methods. Risk factors were evaluated using multivariate logistic regression. Open-ended questions were analysed and recurring and shared experiences and perceptions of PWLHIV and health care providers identified. RESULTS Among 383 PWLHIV, enrolled in antenatal care (ANC) and receiving ART, only 121 (31.6%) had a VL sample collected and 106 (88%) received their results. Among these 106 women, 93 (87.7%) had a VL < 1000 copies/mL and 77 (73%) a VL < 50 copies/mL. The overall median duration from ANC booking to VL sample collection was 87 (IQR, 7-215) days. The median time interval for the return of VL results from date of sample collection was 14 days (IQR, 7-30). There was no significant difference when this variable was stratified by time of ART initiation. VL samples were significantly less likely to be collected at local authority compared to government facilities (aOR = 0.28; 95% CI 0.16-0.48). Barriers to VL testing included staff shortages, non-availability of consumables and sub-optimal sample transportation. Turnaround time was prolonged by the manual results feedback system. CONCLUSIONS AND RECOMMENDATION The low rate of HIV VL testing among PWLHIV in Mutare district is a cause for concern. To reverse this situation, the Ministry of Health should consider interventions such as disseminating antiretroviral guidelines and policies electronically, conducting regular PMTCT mentorship for clinical staff members, and utilising point of care testing and telecommunication devices like mHealth to increase uptake of VL testing and improve results turnaround time.
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Affiliation(s)
- Christine Chiedza Chakanyuka Musanhu
- World Health Organization Country Office, Highlands, P.O.Box HG 430, Harare, Zimbabwe ,grid.415818.1AIDS & TB Department, Ministry of Health and Child Care, Harare, Zimbabwe ,grid.7836.a0000 0004 1937 1151Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | | | - Jawaya Shea
- grid.7836.a0000 0004 1937 1151Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Inam Chitsike
- grid.13001.330000 0004 0572 0760College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Brian Eley
- grid.7836.a0000 0004 1937 1151Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa ,grid.415742.10000 0001 2296 3850Paediatric Infectious Diseases Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
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Lalla-Edward ST, Mashabane N, Stewart-Isherwood L, Scott L, Fyvie K, Duncan D, Haile B, Chugh K, Zhou Y, Reimers J, Pan M, Venkatraman M, Stevens W. Implementation of an mHealth App to Promote Engagement During HIV Care and Viral Load Suppression in Johannesburg, South Africa (iThemba Life): Pilot Technical Feasibility and Acceptability Study. JMIR Form Res 2022; 6:e26033. [PMID: 35107427 PMCID: PMC8851337 DOI: 10.2196/26033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 06/30/2021] [Accepted: 11/23/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND South Africa has the largest HIV treatment program worldwide. Retention in care and medication adherence remain problematic necessitating innovative solutions for improving HIV care. The increasing availability and use of mobile technology can support positive clinical outcomes for persons living with HIV. iThemba Life is a mobile health app designed with input from South African health professionals and patients, promoting engagement with HIV care through access to medical results. OBJECTIVE This study aimed to test the feasibility and acceptability of receiving HIV viral load (VL) results through the app and compare the time to HIV VL result return for study participants before and after app use. METHODS Using convenience sampling, adults having routine VL phlebotomy were recruited from 2 Johannesburg health facilities. After signed consent, the app was downloaded on their Android smartphones, phlebotomy was performed, and the sample barcode was scanned through their phone to link the sample and app. Participants received a notification of the result availability and logged into the app to view results, their explanation and recommended action. RESULTS Overall, 750 people were screened to enroll 500 participants. Of 750, 113 (15.1%) failed eligibility screening. 21.5% (137/637) had smartphone technical limitations preventing enrollment. Results were released to 92.2% (461/500) of participants' phones. App technical issues and laboratory operational issues limited the number of released results. Approximately 78.1% (360/461) results were viewed in the app. Median time from notification of availability to result viewed being 15.5 hours (0.6; range 0-150 days). Turnaround time from phlebotomy to the result being received was 6 (range 1-167) days for users versus 56 days (range 10-430 days; P<.001) before app use. Overall, 4% (20/500) of participants received unsuppressed results (VL>1000 copies/mL). Turnaround time for unsuppressed results was 7 days for participants versus 37.5 days before app use (P<.001). The difference before and after app use in the suppressed and unsuppressed users for time from sample collection to result delivery was statistically significant. Of 20 participants, 12 (60%) returned for a confirmatory VL during the study period. The time from an unsuppressed VL to a confirmatory VL was 106 days for app users versus 203 days before app use (P<.001). Overall, 52.4% (262/500) of participants completed an exit survey; 23.2% (58/250) reported challenges in viewing their VL results. Moreover, 58% (35/60) reported that they overcame challenges with technical assistance from others, and 97.3% (255/262) wanted to continue using the app for VL results. CONCLUSIONS Using iThemba Life for VL results was well-received despite limited smartphone access for some participants. App users received results 10 times sooner than before the app and 5 times sooner if their VL >1000 copies/mL. This increased notification speed led to participants wanting to continue using iThemba Life.
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Affiliation(s)
| | - Nonkululeko Mashabane
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Parktown, South Africa
| | | | - Lesley Scott
- Molecular Medicine & Haematology, University of the Witwatersrand, Parktown, South Africa
| | - Kyle Fyvie
- Molecular Medicine & Haematology, University of the Witwatersrand, Parktown, South Africa
| | - Dana Duncan
- Roche Molecular Systems, Inc, Pleasanton, CA, United States
| | - Betiel Haile
- Roche Molecular Systems, Inc, Pleasanton, CA, United States
| | - Kamal Chugh
- Roche Molecular Systems, Inc, Pleasanton, CA, United States
| | - Yiyong Zhou
- Roche Molecular Systems, Inc, Pleasanton, CA, United States
| | | | - Matteus Pan
- Roche Molecular Systems, Inc, Pleasanton, CA, United States
| | | | - Wendy Stevens
- Molecular Medicine & Haematology, University of the Witwatersrand, Parktown, South Africa.,National Priorities Programme, National Health Laboratory Systems, Parktown, South Africa
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Jani IV, Peter TF. Nucleic Acid Point-of-Care Testing to Improve Diagnostic Preparedness. Clin Infect Dis 2022; 75:723-728. [PMID: 35015842 PMCID: PMC9464067 DOI: 10.1093/cid/ciac013] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Indexed: 01/18/2023] Open
Abstract
Testing programs for severe acute respiratory syndrome coronavirus 2 have relied on high-throughput polymerase chain reaction laboratory tests and rapid antigen assays to meet diagnostic needs. Both technologies are essential; however, issues of cost, accessibility, manufacturing delays, and performance have limited their use in low-resource settings and contributed to the global inequity in coronavirus disease 2019 testing. Emerging low-cost, multidisease point-of-care nucleic acid tests may address these limitations and strengthen pandemic preparedness, especially within primary healthcare where most cases of disease first present. Widespread deployment of these novel technologies will also help close long-standing test access gaps for other diseases, including tuberculosis, human immunodeficiency virus, cervical cancer, viral hepatitis, and sexually transmitted infections. We propose a more optimized testing framework based on greater use of point-of-care nucleic acid tests together with rapid immunologic assays and high-throughput laboratory molecular tests to improve the diagnosis of priority endemic and epidemic diseases, as well as strengthen the overall delivery of primary healthcare services.
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Affiliation(s)
- Ilesh V Jani
- Instituto Nacional da Saúde, Marracuene, Mozambique
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Sharma A, Oda G, Icardi M, Mole L, Holodniy M. Implementation of large-scale laboratory-based detection of COVID-19 in the Veterans Health Administration, March 2020 - February 2021. Diagn Microbiol Infect Dis 2021; 102:115617. [PMID: 35007825 PMCID: PMC8665666 DOI: 10.1016/j.diagmicrobio.2021.115617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 12/09/2021] [Accepted: 12/09/2021] [Indexed: 11/03/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presented numerous operational challenges to healthcare delivery networks responsible for implementing large scale detection of Coronavirus Disease 2019 (COVID-19), the infection caused by SARS-CoV-2. We describe testing performance, review data quality metrics, and summarize experiences during the scale up of laboratory-based detection of COVID-19 in the Veterans Health Administration, the largest healthcare system in the United States. During March 2020 to February 2021, we observed rapid increase in testing volume, decreases in test turnaround time, improvements in testing of hospitalized persons, changes in test positivity, and varying utilization of different tests. Though performance metrics improved over time, surges challenged testing capacity and data quality remained suboptimal. Future planning efforts should focus on fortifying supply chains for consumables and equipment repair, optimizing distribution of testing workload across laboratories, and improving informatics to accurately monitor operations and intent for testing during a public health emergency.
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Affiliation(s)
- Aditya Sharma
- US Department of Veterans Affairs, Public Health Surveillance and Research, Palo Alto, CA, USA.
| | - Gina Oda
- US Department of Veterans Affairs, Public Health Surveillance and Research, Palo Alto, CA, USA
| | - Michael Icardi
- Iowa City Veterans Affairs Medical Center, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Larry Mole
- US Department of Veterans Affairs, Population Health Services, Washington, DC, USA
| | - Mark Holodniy
- US Department of Veterans Affairs, Public Health Surveillance and Research, Palo Alto, CA, USA; Stanford University, Stanford, CA, USA
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Wang M, Boeke CE, Rioja MR, Maparo T, Banda C, Chavula C, Gunda A, Isaac J, Mangwiro A, Mangwendeza PM, Mtaula J, Mwase C, Doi N, Peter T, Kandulu J, Simbi R, Khan S, Sacks JA. Feasibility and impact of near-point-of-care integrated tuberculosis/HIV testing in Malawi and Zimbabwe. AIDS 2021; 35:2531-2537. [PMID: 34310372 DOI: 10.1097/qad.0000000000003031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Near-point-of-care (POC) testing for early infant diagnosis (EID) and viral load expedites clinical action and improves outcomes but requires capital investment. We assessed whether excess capacity on existing near-POC devices used for TB diagnosis could be leveraged to increase near-POC HIV molecular testing, termed integrated testing, without compromising TB services. DESIGN Preimplementation/postimplementation studies in 10 health facilities in Malawi and 8 in Zimbabwe. METHODS Timeliness of EID and viral load test results and clinical action were compared between centralized and near-POC testing using Somers' D tests (continuous indicators) and risk ratios (RR, binary indicators); TB testing/treatment rates and timeliness were analyzed preintegration/postintegration. RESULTS With integration, average device utilization increased but did not exceed 55%. Despite the addition of HIV testing, TB test volumes, timeliness, and treatment initiations were maintained. Although few HIV-positive infants were identified, near-POC EID testing improved treatment initiation within 1 month by 57% compared with centralized EID [Malawi RR: 1.57, 95% confidence interval (CI) 0.98-2.52], and near-POC viral load testing significantly increased the proportion of patients with elevated viral load receiving clinical action within 1 month (Zimbabwe RR: 5.26, 95% CI 3.38-8.20; Malawi RR: 3.90, 95% CI 2.58-5.91). CONCLUSION Integrating TB/HIV testing using existing multidisease platforms is feasible and enables increased access to rapid diagnostics without disrupting existing TB services. Our results serve as an example of a novel, efficient implementation model that can increase access to critical testing services across disease silos and should be considered for additional clinical applications.
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Yee WL, Htay H, Mohamed Y, Nightingale CE, Tin HH, Thein W, Kyaw LL, Yee WW, Aye MM, Badman SG, Vallely AJ, Anderson D, Kelly-Hanku A, Luchters S. Operational experiences associated with the implementation of near point-of-care early infant diagnosis of HIV in Myanmar: a qualitative study. BMC Health Serv Res 2021; 21:863. [PMID: 34425814 PMCID: PMC8383426 DOI: 10.1186/s12913-021-06797-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 07/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background Timely diagnosis and early initiation of life-saving antiretroviral therapy are critical factors in preventing mortality among HIV-infected infants. However, resource-limited settings experience numerous challenges associated with centralised laboratory-based testing, including low rates of testing, complex sample referral pathways and unacceptably long turnaround times for results. Point-of-care (POC) HIV testing for HIV-exposed infants can enable same-day communication of results and early treatment initiation for HIV-infected infants. However, complex operational issues and service integration can limit utility and must be well understood prior to implementation. We explored and documented the challenges and enabling factors in implementing the POC Xpert® HIV-1 Qual test (Cepheid, Sunnyvale, CA, USA) for early infant diagnosis (EID) as part of routine services in four public hospitals in Myanmar. Methods This sub-study was part of a randomised controlled stepped-wedge trial (Australian and New Zealand Clinical Trials Registry, number 12616000734460) designed to investigate the impact of POC testing for EID in Myanmar and Papua New Guinea. Infants recruited during the intervention phase underwent POC testing at the participating hospitals as part of routine care. Semi-structured interviews with 23 caregivers, 12 healthcare providers and 10 key informants were used to explore experiences of POC-EID testing. The research team and hospital staff documented and discussed implementation challenges throughout the study. Results Overall, caregivers and healthcare workers were satisfied with the short turnaround time of the POC test. Occasional delays in POC testing were mostly attributable to late receipt of samples by laboratory technicians and communication constraints among healthcare staff. Hospital staff valued technical assistance from the research group and the National Health Laboratory. Despite staff shortages and infrastructure challenges such as unreliable electricity supply and cramped space, healthcare workers and caregivers found the implementation of the POC test to be feasible at pilot sites. Conclusions As plans for national scale-up evolve, there needs to be a continual focus on staff training, communication pathways and infrastructure. Other models of care, such as allowing non-laboratory-trained personnel to perform POC testing, and cost effectiveness should also be evaluated. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06797-3.
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Affiliation(s)
| | - Hla Htay
- Burnet Institute, Yangon, Myanmar
| | - Yasmin Mohamed
- Burnet Institute, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Claire E Nightingale
- Burnet Institute, Melbourne, Australia.,Monash Rural Health, Monash University, Bendigo, Australia
| | | | - Win Thein
- National Health Laboratory, Yangon, Myanmar
| | | | | | | | - Steven G Badman
- The Kirby Institute for Infection and Immunity in Society, UNSW Sydney, Sydney, Australia
| | - Andrew J Vallely
- The Kirby Institute for Infection and Immunity in Society, UNSW Sydney, Sydney, Australia
| | | | - Angela Kelly-Hanku
- The Kirby Institute for Infection and Immunity in Society, UNSW Sydney, Sydney, Australia.,Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Stanley Luchters
- Burnet Institute, Melbourne, Australia. .,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia. .,Department of Population Health, Medical College, Aga Khan University, Nairobi, Kenya. .,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
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10
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Gupta-Wright A, Barnabas RV, Ingold H, Duneton P, Abubakar I. HIV self-testing: lessons learnt and priorities for adaptation in a shifting landscape. BMJ Glob Health 2021; 6:bmjgh-2020-004418. [PMID: 34275867 PMCID: PMC8287622 DOI: 10.1136/bmjgh-2020-004418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 01/17/2023] Open
Affiliation(s)
- Ankur Gupta-Wright
- Institute for Global Health, University College London, London, UK .,Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Ruanne V Barnabas
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | | | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK
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11
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Mukonda E, Hsiao NY, Vojnov L, Myer L, Lesosky M. Mixed-method estimation of population-level HIV viral suppression rate in the Western Cape, South Africa. BMJ Glob Health 2021; 5:bmjgh-2020-002522. [PMID: 32816953 PMCID: PMC7437711 DOI: 10.1136/bmjgh-2020-002522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION There are few population-wide data on viral suppression (VS) that can be used to monitor programmatic targets in sub-Saharan Africa. We describe how routinely collected viral load (VL) data from antiretroviral therapy (ART) programmes can be extrapolated to estimate population VS and validate this using a combination of empiric and model-based estimates. METHODS VL test results from were matched using a record linkage algorithm to obtain linked results for individuals. Test-level and individual-level VS rates were based on test VL values <1000 cps/mL, and individual VL <1000 cps/mL in a calendar year, respectively. We calculated population VS among people living with HIV (PLWH) in the province by combining census-derived midyear population estimates, HIV prevalence estimates and individual level VS estimates from routine VL data. RESULTS Approximately 1.9 million VL test results between 2008 and 2018 were analysed. Among individuals in care, VS increased from 85.5% in 2008 to 90% in 2018. Population VS among all PLWH in the province increased from 12.2% in 2008 to 51.0% in 2017. The estimates derived from this method are comparable to those from other published studies. Sensitivity analyses showed that the results are robust to variations in linkage method, but sensitive to the extreme combinations of assumed VL testing coverage and population HIV prevalence. CONCLUSION While validation of this method in other settings is required, this approach provides a simple, robust method for estimating population VS using routine data from ART services that can be employed by national programmes in high-burden settings.
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Affiliation(s)
- Elton Mukonda
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Nei-Yuan Hsiao
- National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa.,Division of Medical Virology, Department of Pathology, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Lara Vojnov
- World Health Organization, Geneva, GE, Switzerland
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Maia Lesosky
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
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Evaluation of a collaborative model for successful implementation of a National CD4 enumeration EQA program in Cameroon. Sci Rep 2021; 11:11536. [PMID: 34078982 PMCID: PMC8172912 DOI: 10.1038/s41598-021-91015-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 05/17/2021] [Indexed: 11/12/2022] Open
Abstract
Participation in an EQA program is critical to the quality assurance process. Reliable and precise CD4 T-cells enumeration are essential to improve the clinical management of patients by evaluating the disease progression and by monitoring the effectiveness of ART in HIV-patients. The CIRCB, CD4 reference laboratory, in collaboration with the Canadian QASI-program, recruited sites, distributed and analyzed CD4-panels in 61 sites across Cameroon. A trend and performance analysis in the pre-analytical, analytical and post-analytical phases was performed. Continuous training and corrective actions carried out from 2014 to 2018 increased the number of participating sites from 15 to 61 sites, the number of unacceptable results decreased from 50 to 10%. Specific challenges included errors in pre analytic (17.5%), analytic (77.0%) and post-analytic (5.5%) phases. This EQA requires the application of good laboratory practices, fluidic communication between all the stakeholders, continuous training, application of specific on-site corrective measures, and timely equipment maintenance in order to avoid repetitive errors and to increase laboratory performance. It could be extended to other HIV-1 testing like viral load and EID point-of-care. Partnership with QASI serve as a model for implementation of a successful EQA model for resource limited countries wanting to implement EQA for HIV testing and monitoring in alignment with 90–90–90 targets.
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Meggi B, Bollinger T, Zitha A, Mudenyanga C, Vubil A, Mutsaka D, Nhachigule C, Mabunda N, Loquiha O, Kroidl A, Jani IV. Performance of a True Point-of-Care Assay for HIV-1/2 Viral Load Measurement at Antenatal and Postpartum Services. J Acquir Immune Defic Syndr 2021; 87:693-699. [PMID: 33399310 DOI: 10.1097/qai.0000000000002621] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Timely viral load (VL) results during pregnancy and the postpartum period are crucial for HIV disease management and for preventing mother-to-child transmission. Point-of-care (POC) VL testing could reduce turnaround times and streamline patient management. We evaluated the diagnostic performance of the novel m-PIMA HIV-1/2 VL assay (Abbott, Chicago, IL) in Mozambique. SETTING The study was conducted in prenatal and postpartum consultation rooms in 2 primary health care clinics. Sample collection and testing on m-PIMA were performed by trained nurses. METHODS HIV-infected pregnant and postpartum women on antiretroviral treatment (ART) or ART naive were tested using both on-site m-PIMA POC and referral laboratory-based real-time VL assays. Linear regression analysis and Bland-Altman plots were used to calculate the agreement between both. FINDINGS Correlation between venous blood plasma POC and plasma laboratory-based VL was strong (r2 = 0.850, P < 0.01), with good agreement between the methods [overall bias 0.202 log copies/mL (95% CI: 0.366 to 0.772 log copies/mL)]. Using the threshold of 1000 copies/mL, which is used to determine ART failure, the sensitivity and specificity of the POC VL assay were 95.0% (95% CI: 91.6% to 97.3%) and 96.5% (95% CI: 94.2% to 98.0%), respectively. The correlation coefficient between the venous and capillary sample types was 0.983 (r2 = 0.966). CONCLUSIONS On-site, nurse-performed POC VL testing is feasible and accurate in resource-limited primary health care settings. The operational challenge of plasma separation within clinics for POC testing was successfully overcome using minicentrifuges. The use of capillary blood could simplify the execution of the assay in a clinical environment.
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Affiliation(s)
- Bindiya Meggi
- Instituto Nacional da Saúde, Marracuene, Mozambique
- CIH LMU Center for International Health, University Hospital, LMU Munich, Munich, Germany
| | | | - Alcina Zitha
- Instituto Nacional da Saúde, Marracuene, Mozambique
| | | | - Adolfo Vubil
- Instituto Nacional da Saúde, Marracuene, Mozambique
| | | | | | | | | | - Arne Kroidl
- CIH LMU Center for International Health, University Hospital, LMU Munich, Munich, Germany
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich (LMU), Munich, Germany ; and
- German Center for Infection Research (DZIF), Partner Site Munich, Germany
| | - Ilesh V Jani
- Instituto Nacional da Saúde, Marracuene, Mozambique
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Ganesh P, Heller T, Chione B, Gumulira J, Gugsa S, Khan S, McGovern S, Nhlema A, Nkhoma L, Sacks JA, Trapence C, Tweya H, Ehrenkranz P, Phiri S. Near Point-of-Care HIV Viral Load: Targeted Testing at Large Facilities. J Acquir Immune Defic Syndr 2021; 86:258-263. [PMID: 33136821 PMCID: PMC7803448 DOI: 10.1097/qai.0000000000002555] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 10/15/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Point-of-care (POC) technologies in resource-limited settings can circumvent challenges of centralized laboratory testing, improving clinical management. However, higher device costs and uncertain indications for use have inhibited scaling up POC modalities. To address this gap, we investigated the feasibility and cost of targeted near-POC viral load (VL) testing in 2 large HIV clinics in Lilongwe, Malawi. METHODS VL testing using GeneXpert was targeted for patients suspected of treatment failure or returning to care after a previously elevated VL (>1000 copies/mL). Descriptive analysis of retrospective clinical and cost data is presented. RESULTS Two thousand eight hundred thirteen near-POC VL tests were conducted. One thousand five hundred eleven (54%) tests were for patients for whom results and reason for the test were documented: 57% (794/1389) of tests were to confirm a previously high VL, and 33% (462/1389) were due to clinical indications. Sixty-one percent (926/1511) of patients had a high VL, of whom 78% (719/926) had a recorded clinical action: 77% (557/719) switched to second line antiretroviral therapy, and 15% (194/719) were referred for intensive adherence counseling. Eighty-two percent (567/687) of patients received a clinical action on the same day as testing. The "all-in" cost was $33.71 for a valid POC VL test, compared with an international benchmark for a centralized VL test of $28.62. CONCLUSION Targeted, near-POC VL testing was feasible and consistently enabled prompt clinical action. The difference between the "all-in" cost of near-POC VL and centralized testing of $5.09 could be further reduced in an optimized national program by combining targeted near-POC testing and centralized testing.
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Affiliation(s)
- Prakash Ganesh
- Lighthouse Trust, Lilongwe, Malawi;
- International Training and Education Center for Health, University of Washington, Seattle, WA
| | | | | | | | - Salem Gugsa
- International Training and Education Center for Health, University of Washington, Seattle, WA
| | | | | | | | | | | | | | | | | | - Sam Phiri
- Lighthouse Trust, Lilongwe, Malawi;
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC;and
- Department of Public Health, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Zomba, Malawi.
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Atuhaire P, Matovu F, Nakalega R, Kataike H, Nabwana M, Lukyamuzi Z, Guwattude D. Time to first viral load testing among pregnant women living with HIV initiated on option B+ at 5 government clinics in Kampala city, Uganda: Retrospective cohort study. Int J Infect Dis 2021; 104:526-531. [PMID: 33434664 DOI: 10.1016/j.ijid.2021.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 01/01/2021] [Accepted: 01/04/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Timely viral load (VL) testing is critical in the care of pregnant women living with HIV and receiving anti-retroviral therapy (ART). There is paucity of data regarding the Time to First Viral Load (TFVL) testing in resource-limited settings. METHODS We extracted clinical and VL test data from records of a cohort of ART-naïve pregnant women living with HIV who initiated Option B + and were retained in care between 01 Jan 2015 and 31 Dec 2015. The data were verified against laboratory VL registers. TFVL (in months) was calculated based on the time difference between the date of ART initiation and FVL test. Descriptive and Cox regression analyses of data up to 30 Sep 2017 (33 months later) were done. RESULTS Of the 622 records retrieved, 424 women were retained in care. Of 424 women retained in care, 182/424 (43%) had at least one VL result post ART initiation while 242/424 (57%) had no VL performed. Only 30/182 (16.5%) had a second VL. At six, nine, and twelve months, only 8/424 (1.9%), 47/424 (11.1%), and 94/424 (22.2%) had VL testing performed respectively post ART initiation. The median TFVL testing was 12.7 months (95 CI 11.6-13.7) post ART initiation. Across the five clinics, patient factors (age, gravidity, gestational age, marital status, and adherence at 12 months) were not significant predictors. CONCLUSION A dismal 1.9% rate of achieving WHO-recommended TFVL testing and a median TFVL testing of twelve months post ART initiation were observed. The non-association of patient factors to these observations may suggest a serious need to review health system factors likely associated with these observations and their effective interventions.
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Affiliation(s)
- Patience Atuhaire
- Makerere University-Johns Hopkins University Research Collaboration; Makerere University College of Health Sciences - School of Public Health
| | - Flavia Matovu
- Makerere University-Johns Hopkins University Research Collaboration; Makerere University College of Health Sciences - School of Public Health
| | - Rita Nakalega
- Makerere University-Johns Hopkins University Research Collaboration
| | - Hajira Kataike
- Makerere University-Johns Hopkins University Research Collaboration
| | - Martin Nabwana
- Makerere University-Johns Hopkins University Research Collaboration
| | - Zubair Lukyamuzi
- Makerere University-Johns Hopkins University Research Collaboration
| | - David Guwattude
- Makerere University College of Health Sciences - School of Public Health
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Shanmukhappa SC, Abraham RR, Huilgol P, Godbole R, Anand AK, Prasad R, Shridhar V, Bhrushundi M. What influences adherence among HIV patients presenting with first-line antiretroviral therapy failure (ART failure)? A retrospective, cross-sectional study from a private clinic in Nagpur, India. J Family Med Prim Care 2020; 9:6217-6223. [PMID: 33681067 PMCID: PMC7928081 DOI: 10.4103/jfmpc.jfmpc_1155_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/08/2020] [Accepted: 09/25/2020] [Indexed: 12/04/2022] Open
Abstract
Background: Multiple reports show increasing occurrences of ART failure in India. Despite the fact that a significant volume of outpatient and on-going healthcare occurs in private clinics, there are very few studies on adherence from private clinics in India. Objective: To evaluate the factors influencing adherence to ART in patients with first-line ART failure. Materials and Methods: Data were collected from a convenience sample of 139 individuals diagnosed with clinical, immunological or virologic failure from a private HIV clinic in Nagpur, India. A retrospective cross-sectional study was undertaken and data were statistically analysed. Results: Of the 139 patients, 118 (84.9%) were male and 21 (15.1%) were female. 64 (46%) had received pre-treatment and adherence counselling. 81 (58.3%) were not told about the side effects of ART medications and 65 (46.8%) avoided friends and family. Most common reasons for suboptimal adherence by stopping treatment were high cost, alcoholism, choosing non-allopathic medications and depression. Reasons cited for suboptimal adherence due to missed doses included feeling healthy, depression, forgetfulness and busy schedule. A significant association was found between pre-treatment counselling, adherence counselling and being told the importance of lifelong treatment and decreased occurrence of complete stoppage of treatment. Conclusion: This study brings to light some of the predictors of ART failure. Counselling, having a strong support system as well as early identification and tackling of reasons for suboptimal adherence plays an important role in preventing ART failure.
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Affiliation(s)
- Sanjana Chetana Shanmukhappa
- Visiting Research Scholar, AFPI National Center for Primary Care Research and Policy, Bangalore, Karnataka, India
| | - Rahul R Abraham
- Visiting Research Scholar, AFPI National Center for Primary Care Research and Policy, Bangalore, Karnataka, India
| | - Poorva Huilgol
- Laboratory Technician, Molecular Solutions Care Health, Bangalore, Karnataka, India
| | - Rekha Godbole
- Chief of Genotyping Services, Molecular Solutions Care Health, Bangalore, Karnataka, India
| | - Ashoojit K Anand
- Clinical Director, PCMH Restore Health Center, Bangalore, Karnataka, India
| | - Ramakrishna Prasad
- Executive Director, PCMH Restore Health Center, Bangalore, Karnataka, India
| | - Varsha Shridhar
- Director and Co-founder, Molecular Solutions Care Health, Bangalore, Karnataka, India
| | - Milind Bhrushundi
- Central Indian Institute of Infectious Diseases and Lata Mangeshkar Hospital, Nagpur, Maharashtra, India
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Ondoa P, Kim AA, Boender TS, Zhang G, Kroeze S, Wiener J, Botes M, Botes E, Akanmu AS, Akanmu S, Wellington M, Siwale M, Mandaliya K, Kityo C, Labib EE, Adeyemo TA, Rinke de Wit T, Nkengasong J. Access to HIV Viral Load Testing and Antiretroviral Therapy Switch Practices: A Multicountry Prospective Cohort Study in Sub-Saharan Africa. AIDS Res Hum Retroviruses 2020; 36:918-926. [PMID: 32722958 DOI: 10.1089/aid.2020.0049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Poor access to HIV viral load (VL) testing prevents the timely monitoring of HIV treatment adherence and efficacy. Factors enabling clinical benefits of VL testing when added to local standards of care, can inform the development of more cost-effective routine VL scale-up plans. We compared antiretroviral therapy (ART) switch practices in 13 clinics across 6 countries, with full (N = 8), phasing-in (N = 3) or no onsite access (N = 2) to VL. The analysis used data from the Pan-African Studies to Evaluate Resistance (PASER), observing virological and drug resistance outcomes among adults receiving first- or second-line ART between 2008 and 2015. Study plasma viral load (sVL) determined at baseline, every 12 months thereafter and at the time of switch served for retrospectively validating switch decisions, categorized into "necessary," "unnecessary," and "missed." Virological failure was defined as two consecutive sVL ≥1,000 HIV-RNA copies/mL. One thousand nine hundred ninety-five of the 2,420 (82.4%) study participants had continuous virological suppression during the median 30 months of follow-up. Among the 266 virological failures (11.0%), the proportion of necessary switches were similar in clinics with full (37%), phasing-in (25%), or no access (39%) to local VL testing. Documented utilization of local VL results for the switch decision was associated with higher percentage of necessary switch (87.6% vs. 67.9%). Shorter time to necessary switch was associated with higher rates of long-term virological suppression, regardless of access to local viral load. Availability of HIV VL testing capacity does not systematically result in adequate switch practices or better virological outcomes. Systems supporting sufficient test demand execution, and actual utilization of results for patient management need strengthening.
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Affiliation(s)
- Pascale Ondoa
- African Society for Laboratory Medicine, Addis Ababa, Ethiopia
- Amsterdam Institute for Global Health and Development, Academic Medical Center, Department of Global Health, University of Amsterdam, the Netherlands
| | - Andrea A. Kim
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Los Angeles County Public Health Department, Los Angeles, California, USA
| | - T. Sonia Boender
- Amsterdam Institute for Global Health and Development, Academic Medical Center, Department of Global Health, University of Amsterdam, the Netherlands
| | - Guoqing Zhang
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Stefanie Kroeze
- Amsterdam Institute for Global Health and Development, Academic Medical Center, Department of Global Health, University of Amsterdam, the Netherlands
| | - Jeffrey Wiener
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | | | | | | | | | | | | | | | | | - Tobias Rinke de Wit
- Amsterdam Institute for Global Health and Development, Academic Medical Center, Department of Global Health, University of Amsterdam, the Netherlands
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Haas AD, Radin E, Hakim AJ, Jahn A, Philip NM, Jonnalagadda S, Saito S, Low A, Patel H, Schwitters AM, Rogers JH, Frederix K, Kim E, Bello G, Williams DB, Parekh B, Sachathep K, Barradas DT, Kalua T, Birhanu S, Musuka G, Mugurungi O, Tippett Barr BA, Sleeman K, Mulenga LB, Thin K, Ao TT, Brown K, Voetsch AC, Justman JE. Prevalence of nonsuppressed viral load and associated factors among HIV-positive adults receiving antiretroviral therapy in Eswatini, Lesotho, Malawi, Zambia and Zimbabwe (2015 to 2017): results from population-based nationally representative surveys. J Int AIDS Soc 2020; 23:e25631. [PMID: 33225559 PMCID: PMC7680921 DOI: 10.1002/jia2.25631] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/28/2020] [Accepted: 10/02/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION The global target for 2020 is that ≥90% of people living with HIV (PLHIV) receiving antiretroviral therapy (ART) will achieve viral load suppression (VLS). We examined VLS and its determinants among adults receiving ART for at least four months. METHODS We analysed data from the population-based HIV impact assessment (PHIA) surveys in Eswatini, Lesotho, Malawi, Zambia and Zimbabwe (2015 to 2017). PHIA surveys are nationally representative, cross-sectional household surveys. Data collection included structured interviews, home-based HIV testing and laboratory testing. Blood samples from PLHIV were analysed for HIV RNA, CD4 counts and recent exposure to antiretroviral drugs (ARVs). We calculated representative estimates for the prevalence of VLS (viral load <1000 copies/mL), nonsuppressed viral load (NVL; viral load ≥1000 copies/mL), virologic failure (VF; ARVs present and viral load ≥1000 copies/mL), interrupted ART (ARVs absent and viral load ≥1000 copies/mL) and rates of switching to second-line ART (protease inhibitors present) among PLHIV aged 15 to 59 years who participated in the PHIA surveys in Eswatini, Lesotho, Malawi, Zambia and Zimbabwe, initiated ART at least four months before the survey and were receiving ART at the time of the survey (according to self-report or ARV testing). We calculated odds ratios and incidence rate ratios for factors associated with NVL, VF, interrupted ART, and switching to second-line ART. RESULTS We included 9200 adults receiving ART of whom 88.8% had VLS and 11.2% had NVL including 8.2% who experienced VF and 3.0% who interrupted ART. Younger age, male sex, less education, suboptimal adherence, receiving nevirapine, HIV non-disclosure, never having married and residing in Zimbabwe, Lesotho or Zambia were associated with higher odds of NVL. Among people with NVL, marriage, female sex, shorter ART duration, higher CD4 count and alcohol use were associated with lower odds for VF and higher odds for interrupted ART. Many people with VF (44.8%) had CD4 counts <200 cells/µL, but few (0.31% per year) switched to second-line ART. CONCLUSIONS Countries are approaching global VLS targets for adults. Treatment support, in particular for younger adults, and people with higher CD4 counts, and switching of people to protease inhibitor- or integrase inhibitor-based regimens may further reduce NVL prevalence.
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Affiliation(s)
- Andreas D Haas
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Elizabeth Radin
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Avi J Hakim
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | | | - Neena M Philip
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Sasi Jonnalagadda
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | - Suzue Saito
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Andrea Low
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Hetal Patel
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | - Amee M Schwitters
- Division of Global HIV and TB, Center for Global Health, CDC Lesotho, Maseru, Lesotho
| | - John H Rogers
- Division of Global HIV and TB, Center for Global Health, CDC Zimbabwe, Harare, Zimbabwe
| | - Koen Frederix
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Evelyn Kim
- Division of Global HIV and TB, Center for Global Health, CDC Malawi, Lilongwe, Malawi
| | | | - Daniel B Williams
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | - Bharat Parekh
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | - Karampreet Sachathep
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Danielle T Barradas
- Division of Global HIV and TB, Center for Global Health, CDC Zambia, Lusaka, Zambia
| | | | - Sehin Birhanu
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | - Godfrey Musuka
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | - Beth A Tippett Barr
- Division of Global HIV and TB, Center for Global Health, CDC Zimbabwe, Harare, Zimbabwe
| | - Katrina Sleeman
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | | | - Kyaw Thin
- Research Coordination Unit, Ministry of Health, Maseru, Lesotho
| | - Trong T Ao
- Division of Global HIV and TB, Center for Global Health, CDC Eswatini, Mbabane, Swaziland
| | - Kristin Brown
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | - Andrew C Voetsch
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA, USA
| | - Jessica E Justman
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA
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Bien-Gund CH, Zhao P, Cao B, Tang W, Ong JJ, Baral SD, Bauermeister JA, Yang LG, Luo Z, Tucker JD. Providing competent, comprehensive and inclusive sexual health services for men who have sex with men in low- and middle-income countries: a scoping review. Sex Health 2020; 16:320-331. [PMID: 31213225 DOI: 10.1071/sh18191] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 03/07/2019] [Indexed: 12/20/2022]
Abstract
Although men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmissible infections, sexual health services for MSM in low- and middle-income countries (LMIC) remain under-resourced and are poorly understood. A scoping review of literature on MSM sexual health in LMIC was conducted in order to identify key clinical services and gaps in knowledge. Three databases were searched, in addition to hand-reviewing key journals and bulletins, to identify literature with a focus on MSM sexual health. Key services related to providing care to MSM in LMIC that emerged from our review are described. These services include creation of safe and confidential clinic environments, HIV testing services, behavioural interventions, HIV pre-exposure prophylaxis (PrEP), rapid antiretroviral therapy (ART) initiation and STI services. Compared with high-income settings, major differences in LMIC include lack of diagnostic technology, unfavourable legal environments and lack of funding for MSM health. Innovative approaches to healthcare delivery, such as harnessing mobile technology, self-testing and crowdsourcing interventions, can improve health services among MSM in LMIC. There are gaps in the evidence about how best to provide sexual health services for MSM in LMIC settings. Implementation research and scale-up of existing biomedical and behavioural interventions, such as HIV/STI testing services, PrEP and early antiretroviral initiation are urgently needed in LMIC.
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Affiliation(s)
- Cedric H Bien-Gund
- University of North Carolina Project-China, No. 2 Lujing Road, Guangzhou 510095, China; and Division of Infectious Diseases, Department of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Peipei Zhao
- Shenzhen Nanshan Center for Chronic Disease Control, No. 8 Longyuan Road, Shenzhen 510855, China
| | - Bolin Cao
- School of Media and Communication, Shenzhen University, 3688 Nanhai Avenue, Shenzhen 518060, China
| | - Weiming Tang
- University of North Carolina Project-China, No. 2 Lujing Road, Guangzhou 510095, China; and Social Entrepreneurship to Spur Health, No. 2 Lujing Road, Guangzhou 510095, China; and School of Medicine, University of North Carolina at Chapel Hill, 321 S. Columbia Street, Chapel Hill, NC 27516, USA
| | - Jason J Ong
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Stefan D Baral
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - José A Bauermeister
- Department of Family and Community Health, School of Nursing, 418 Curie Boulevard, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Li-Gang Yang
- Guangdong Provincial STD Control Center, No. 2 Lujing Road, Guangzhou 510095, China
| | - Zhenzhou Luo
- Shenzhen Nanshan Center for Chronic Disease Control, No. 8 Longyuan Road, Shenzhen 510855, China
| | - Joseph D Tucker
- University of North Carolina Project-China, No. 2 Lujing Road, Guangzhou 510095, China; and Social Entrepreneurship to Spur Health, No. 2 Lujing Road, Guangzhou 510095, China; and Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; and Institute of Global Health and Infectious Diseases, University of North Carolina, 130 Mason Farm Road, Chapel Hill, NC 27599, USA; and Corresponding author.
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20
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Terris-Prestholt F, Boeras D, Ong JJ, Torres-Rueda S, Cassim N, Mbengue MAS, Mboup S, Mwau M, Munemo E, Nyegenye W, Odhiambo CO, Dabula P, Sandstrom P, Sarr M, Simbi R, Stevens W, Tucker JD, Vickerman P, Ciaranello A, Peeling RW. The potential for quality assurance systems to save costs and lives: the case of early infant diagnosis of HIV. Trop Med Int Health 2020; 25:1235-1245. [PMID: 32737914 DOI: 10.1111/tmi.13472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Scaling up of point-of-care testing (POCT) for early infant diagnosis of HIV (EID) could reduce the large gap in infant testing. However, suboptimal POCT EID could have limited impact and potentially high avoidable costs. This study models the cost-effectiveness of a quality assurance system to address testing performance and screening interruptions, due to, for example, supply stockouts, in Kenya, Senegal, South Africa, Uganda and Zimbabwe, with varying HIV epidemics and different health systems. METHODS We modelled a quality assurance system-raised EID quality from suboptimal levels: that is, from misdiagnosis rates of 5%, 10% and 20% and EID testing interruptions in months, to uninterrupted optimal performance (98.5% sensitivity, 99.9% specificity). For each country, we estimated the 1-year impact and cost-effectiveness (US$/DALY averted) of improved scenarios in averting missed HIV infections and unneeded HIV treatment costs for false-positive diagnoses. RESULTS The modelled 1-year costs of a national POCT quality assurance system range from US$ 69 359 in South Africa to US$ 334 341 in Zimbabwe. At the country level, quality assurance systems could potentially avert between 36 and 711 missed infections (i.e. false negatives) per year and unneeded treatment costs between US$ 5808 and US$ 739 030. CONCLUSIONS The model estimates adding effective quality assurance systems are cost-saving in four of the five countries within the first year. Starting EQA requires an initial investment but will provide a positive return on investment within five years by averting the costs of misdiagnoses and would be even more efficient if implemented across multiple applications of POCT.
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Affiliation(s)
| | - D Boeras
- London School of Hygiene and Tropical Medicine, London, UK.,Global Health Impact Group, Atlanta, GA, USA
| | - J J Ong
- London School of Hygiene and Tropical Medicine, London, UK.,Central Clinical School, Monash University, Clayton, Vic, Australia
| | - S Torres-Rueda
- London School of Hygiene and Tropical Medicine, London, UK
| | - N Cassim
- National Health Laboratory Service, National Priority Programmes, Johannesburg, South Africa.,Department of Molecular Medicine and Haematology, University of Witwatersrand, Johannesburg, South Africa
| | - M A S Mbengue
- Institut de Recherche en Santé, de Surveillance Epidémiologique et de Formations, Dakar, Sénégal.,Department of Epidemiology and Biostatistics, University of the Witwatersrand, Johannesburg, South Africa
| | - S Mboup
- Institut de Recherche en Santé, de Surveillance Epidémiologique et de Formations, Dakar, Sénégal
| | - M Mwau
- Kenya Medical Research Institute, Nairobi, Kenya
| | - E Munemo
- Ministry of Health and Child Care, National Microbiology Reference Laboratory, Harare Central Hospital, Harare, Zimbabwe
| | - W Nyegenye
- Ministry of Health Uganda, Kampala, Uganda
| | | | - P Dabula
- National Health Laboratory Service, National Priority Programmes, Johannesburg, South Africa
| | - P Sandstrom
- National HIV & Retrovirology Laboratories, Public Health Agency of Canada, Winnipeg, Canada
| | - M Sarr
- Westat, Inc., Rockville, MD, USA
| | - R Simbi
- Ministry of Health and Child Care, National Microbiology Reference Laboratory, Harare Central Hospital, Harare, Zimbabwe
| | - W Stevens
- National Health Laboratory Service, National Priority Programmes, Johannesburg, South Africa
| | - J D Tucker
- London School of Hygiene and Tropical Medicine, London, UK.,University of North Carolina, Chapel Hill, NC, USA
| | - P Vickerman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - A Ciaranello
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - R W Peeling
- London School of Hygiene and Tropical Medicine, London, UK
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21
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Williams J, Edgil D, Wattleworth M, Ndongmo C, Kuritsky J. The network approach to laboratory procurement and supply chain management: Addressing the system issues to enhance HIV viral load scale-up. Afr J Lab Med 2020; 9:1022. [PMID: 38361786 PMCID: PMC10867671 DOI: 10.4102/ajlm.v9i1.1022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 05/15/2020] [Indexed: 02/17/2024] Open
Abstract
Investment in viral load scale-up in order to control the HIV epidemic and meet the Joint United Nations Programme on HIV and AIDS (UNAIDS) '90-90-90' goals has prompted the President's Emergency Plan for AIDS Relief and countries to increase their investment in viral load and infant virological testing. This has resulted in the increased procurement of molecular-based instruments, with many countries having challenges to effectively procure and place these products. In response to these challenges, the global laboratory stakeholder community has developed an informed 'network approach' to guide placement strategies. This article defines and describes the 'network approach' for laboratory procurement and supply chain management to assist countries in developing a strategic instrument procurement and placement strategy. The four key pillars of the approach should be performed in a stepwise fashion, with regular reviews. The approach is comprised of (1) laboratory network optimisation, (2) forecasting and supply planning, (3) the development of effective procurement and strategic sourcing to develop 'all-inclusive' contracts that provide transparent pricing, and the establishment of clear service and maintenance expectations and key performance indicators and (4) performance management to increase communication and planning, and promote issue resolution. Investments in the network approach will enable countries to strengthen laboratory systems and ready them for future laboratory needs. These disease-agnostic networks will be poised to improve overall national disease surveillance and assist countries in responding to disease outbreaks and other chronic diseases.
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Affiliation(s)
- Jason Williams
- Supply Chain Division, United States Agency for International Development (USAID), Crystal City, Virginia, United States
| | - Dianna Edgil
- Supply Chain Division, United States Agency for International Development (USAID), Crystal City, Virginia, United States
| | - Matthew Wattleworth
- Global Health Supply Chain Program, Procurement and Supply Management (GHSC-PSM), Arlington, Virginia, United States
| | - Clement Ndongmo
- Global Health Supply Chain Program, Procurement and Supply Management (GHSC-PSM), Arlington, Virginia, United States
| | - Joel Kuritsky
- Supply Chain Division, United States Agency for International Development (USAID), Crystal City, Virginia, United States
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22
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Nicholas S, Poulet E, Wolters L, Wapling J, Rakesh A, Amoros I, Szumilin E, Gueguen M, Schramm B. Point-of-care viral load monitoring: outcomes from a decentralized HIV programme in Malawi. J Int AIDS Soc 2020; 22:e25387. [PMID: 31441242 PMCID: PMC6706700 DOI: 10.1002/jia2.25387] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 07/31/2019] [Indexed: 11/16/2022] Open
Abstract
Introduction Routinely monitoring the HIV viral load (VL) of people living with HIV (PLHIV) on anti‐retroviral therapy (ART) facilitates intensive adherence counselling and faster ART regimen switch when treatment failure is indicated. Yet standard VL‐testing in centralized laboratories can be time‐intensive and logistically difficult in low‐resource settings. This paper evaluates the outcomes of the first four years of routine VL‐monitoring using Point‐of‐Care technology, implemented by Médecins Sans Frontières (MSF) in rural clinics in Malawi. Methods We conducted a retrospective cohort analysis of patients eligible for routine VL‐ testing between 2013 and 2017 in four decentralized ART‐clinics and the district hospital in Chiradzulu, Malawi. We assessed VL‐testing coverage and the treatment failure cascade (from suspected failure (first VL>1000 copies/mL) to VL suppression post regimen switch). We used descriptive statistics and multivariate logistic regression to assess factors associated with suspected failure. Results and Discussion Among 21,400 eligible patients, VL‐testing coverage was 85% and VL suppression was found in 89% of those tested. In the decentralized clinics, 88% of test results were reviewed on the same day as blood collection, whereas in the district hospital the median turnaround‐time for results was 85 days. Among first‐line ART patients with suspected failure (N = 1544), 30% suppressed (VL<1000 copies/mL), 35% were treatment failures (confirmed by subsequent VL‐testing) and 35% had incomplete VL follow‐up. Among treatment failures, 80% (N = 540) were switched to a second‐line regimen, with a higher switching rate in the decentralized clinics than in the district hospital (86% vs. 67%, p < 0.01) and a shorter median time‐to‐switch (6.8 months vs. 9.7 months, p < 0.01). Similarly, the post‐switch VL‐testing rate was markedly higher in the decentralized clinics (61% vs. 26%, p < 0.01). Overall, 79% of patients with a post‐switch VL‐test were suppressed. Conclusions Viral load testing at the point‐of‐care in Chiradzulu, Malawi achieved high coverage and good drug regimen switch rates among those identified as treatment failures. In decentralized clinics, same‐day test results and shorter time‐to‐switch illustrated the game‐changing potential of POC‐based VL‐testing. Nevertheless, gaps were identified along all steps of the failure cascade. Regular staff training, continuous monitoring and creating demand are essential to the success of routine VL‐testing.
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23
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Drain PK, Dorward J, Violette LR, Quame-Amaglo J, Thomas KK, Samsunder N, Ngobese H, Mlisana K, Moodley P, Donnell D, Barnabas RV, Naidoo K, Abdool Karim SS, Celum C, Garrett N. Point-of-care HIV viral load testing combined with task shifting to improve treatment outcomes (STREAM): findings from an open-label, non-inferiority, randomised controlled trial. Lancet HIV 2020; 7:e229-e237. [PMID: 32105625 DOI: 10.1016/s2352-3018(19)30402-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/27/2019] [Accepted: 11/15/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Monitoring HIV treatment with laboratory testing introduces delays for providing appropriate care in resource-limited settings. The aim of our study was to determine whether point-of-care HIV viral load testing with task shifting changed treatment and care outcomes for adults on antiretroviral therapy (ART) when compared with standard laboratory viral load testing. METHODS We did an open-label, non-inferiority, randomised controlled trial in a public clinic in Durban, South Africa. We enrolled HIV-positive adults (aged ≥18 years) who presented for their first routine HIV viral load test 6 months after ART initiation. Individuals were randomly assigned by a random number allocation sequence to receive either point-of-care viral load testing at enrolment and after 6 months with task shifting to enrolled nurses (intervention group), or laboratory viral load testing (standard-of-care group). The primary outcome was combined viral suppression (<200 copies per mL) and retention at 12 months after enrolment. A non-inferiority margin of 10% was used. Analysis was done by intention to treat. This study was registered with ClinicalTrials.gov, NCT03066128. FINDINGS Between Feb 24, 2017, and Aug 23, 2017, we screened 657 participants, and 390 were enrolled and randomly assigned to either the intervention group (n=195) or standard-of-care group (n=195). 175 (90%) individuals in the intervention group and 148 (76%) individuals in the standard-of-care group had the primary outcome of retention with viral suppression, a difference of 13·9% (95% CI 6·4-21·2; p<0·00040). 182 participants (93%) in the intervention group had viral suppression compared with 162 (83%) in the standard-of-care group (difference 10·3%, 3·9-16·8; p=0·0025); 180 (92%) and 162 (85%) were retained in care (7·7%, 1·3-14·2; p=0·026). There were no adverse events related to point-of-care HIV viral load testing or task shifting. INTERPRETATION Point-of-care viral load testing combined with task shifting significantly improved viral suppression and retention in HIV care. Point-of-care testing can simplify treatment and improve outcomes for HIV-positive adults receiving ART in resource-limited settings. FUNDING National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Paul K Drain
- Department of Global Health, School of Public Health and School of Medicine, University of Washington, Seattle, WA, USA; Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA; Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA.
| | - Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Lauren R Violette
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Justice Quame-Amaglo
- Department of Global Health, School of Public Health and School of Medicine, University of Washington, Seattle, WA, USA
| | - Katherine K Thomas
- Department of Global Health, School of Public Health and School of Medicine, University of Washington, Seattle, WA, USA
| | - Natasha Samsunder
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Hope Ngobese
- Prince Cyril Zulu Communicable Disease Clinic, Durban Municipality, Durban, South Africa
| | - Koleka Mlisana
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa; National Health Laboratory Service, Durban, South Africa
| | - Pravikrishnen Moodley
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa; National Health Laboratory Service, Durban, South Africa; Department of Virology, Inkosi Albert Luthuli Central Hospital, Cato Manor, South Africa
| | - Deborah Donnell
- Department of Global Health, School of Public Health and School of Medicine, University of Washington, Seattle, WA, USA
| | - Ruanne V Barnabas
- Department of Global Health, School of Public Health and School of Medicine, University of Washington, Seattle, WA, USA; Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa; School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; CAPRISA-MRC HIV-TB Pathogenesis and Treatment Research Unit, and Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Salim S Abdool Karim
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa; School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; Department of Epidemiology, Columbia University, New York, NY, USA
| | - Connie Celum
- Department of Global Health, School of Public Health and School of Medicine, University of Washington, Seattle, WA, USA; Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa; School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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24
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Jespersen S, Månsson F, Lindman J, Wejse C, Medina C, da Silva ZJ, Te D, Medstrand P, Esbjörnsson J, Hønge BL. HIV treatment in Guinea-Bissau: room for improvement and time for new treatment options. AIDS Res Ther 2020; 17:3. [PMID: 32019545 PMCID: PMC6998355 DOI: 10.1186/s12981-020-0259-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 01/21/2020] [Indexed: 11/10/2022] Open
Abstract
Despite advances in the treatment quality of HIV throughout the world, several countries are still facing numerous obstacles in delivering HIV treatment at a sufficiently high quality, putting patients' lives in jeopardy. The aim of this status article is to give an overview of HIV treatment outcomes in the West African country, Guinea-Bissau, and to assess how newer treatment strategies such as long-acting injectable drugs or an HIV cure may limit or stop the HIV epidemic in this politically unstable and low-resource setting. Several HIV cohorts in Guinea-Bissau have been established and are used as platforms for epidemiological, virological, immunological and clinical studies often with a special focus on HIV-2, which is prevalent in the country. The Bandim Health Project, a demographic surveillance site, has performed epidemiological HIV surveys since 1987 among an urban population in the capital Bissau. The Police cohort, an occupational cohort of police officers, has enabled analyses of persons seroconverting with estimated times of seroconversion among HIV-1 and HIV-2-infected individuals, allowing incidence measurements while the Bissau HIV Cohort and a newer Nationwide HIV Cohort have provided clinical data on large numbers of HIV-infected patients. The HIV cohorts in Guinea-Bissau are unique platforms for research and represent real life in many African countries. Poor adherence, lack of HIV viral load measurements, inadequate laboratory facilities, high rates of loss to follow-up, mortality, treatment failure and resistance development, are just some of the challenges faced putting the goal of "90-90-90″ for Guinea-Bissau well out of reach by 2020. Maintaining undetectable viral loads on treatment as a prerequisite of a cure strategy seems not possible at the moment. Thinking beyond one-pill-once-a-day, long-acting antiretroviral treatment options such as injectable drugs or implants may be a better treatment option in settings like Guinea-Bissau and may even pave the way for an HIV cure. If the delivery of antiretroviral treatment in sub-Saharan Africa in a sustainable way for the future should be improved by focusing on existing treatment options or through focusing on new treatment options remains to be determined.
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25
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Nyagadza B, Kudya N, Mbofana E, Masaka S, Garone D, Chen CY, Mulingwa A, Uzande C, Isaakidis P, Ndlovu Z. Scaling up HIV viral load monitoring in Manicaland, Zimbabwe: challenges and opportunities from the field. Public Health Action 2019; 9:177-181. [PMID: 32042612 DOI: 10.5588/pha.19.0024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/19/2019] [Indexed: 11/10/2022] Open
Abstract
Background Demand for viral load (VL) monitoring is expected to increase; however, implementation of the multifaceted VL testing poses numerous challenges. We report experiences from Médecins Sans Frontiéres (MSF) and partners in the scale-up of HIV VL in collaboration with the Ministry of Health and Child Care (MoHCC) of Zimbabwe. Methods A retrospective data review of routine reports from MSF-supported health facilities in Manicaland Province (Zimbabwe) was conducted. These secondary aggregate data were triangulated, and emerging themes of lessons learnt from VL monitoring were shared. Results A VL testing coverage of 63% (5966/9456) was achieved among the 40 health facilities, together with a switch rate to second-line antiretroviral therapy (ART) of 46.4% (108/233). The key enablers to scaling-up the VL monitoring were well-equipped and supported VL laboratories, the operationalisation of the on-the-job clinical mentoring and systematic weaning off of better performing health facilities. Concerted efforts from different implementing partners and funders in the HIV programme, and close collaboration with MoHCC were pivotal. Conclusion Our experience indicates that clinical mentoring is effective, and resulted in high VL testing coverage and up-skilling primary health care workers in VL monitoring. Attention must be focused on innovations for improving VL result utilisation, especially the identification and management of patients who fail ART.
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Affiliation(s)
- B Nyagadza
- Médecins Sans Frontières (MSF), Mutare, Zimbabwe
| | - N Kudya
- Médecins Sans Frontières (MSF), Mutare, Zimbabwe
| | - E Mbofana
- Médecins Sans Frontières (MSF), Mutare, Zimbabwe
| | - S Masaka
- Médecins Sans Frontières (MSF), Mutare, Zimbabwe
| | | | | | - A Mulingwa
- Ministry of Health and Child Care, Zimbabwe
| | - C Uzande
- Ministry of Health and Child Care, Zimbabwe
| | - P Isaakidis
- MSF, Southern Africa Medical Unit, Cape Town, South Africa
| | - Z Ndlovu
- MSF, Southern Africa Medical Unit, Cape Town, South Africa
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26
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Hubbard J, Kakwesa G, Nyirenda M, Mwambene J, Bardon A, Balakasi K, Dovel K, Kalua T, Hoffman RM. Towards the third 90: improving viral load testing with a simple quality improvement program in health facilities in Malawi. Int Health 2019; 11:215-220. [PMID: 30383224 DOI: 10.1093/inthealth/ihy083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/31/2018] [Accepted: 09/18/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Viral load (VL) scale-up efforts have largely focused on laboratory systems, with less attention on facility-level strengthening of staff who facilitate VL testing. To address this gap we implemented a quality improvement (QI) program at 13 health facilities in central and southern Malawi. METHODS QI program tools focused on patient and provider VL knowledge and clarification of site-level roles and responsibilities, including the designation of a VL 'focal person' to oversee all VL activities. T-tests were used to compare differences in VL testing before (November 2016-April 2017) and after (May 2017-November 2017) the intervention. RESULTS The mean number of VL tests performed significantly increased after implementation of the QI program. Overall there was a 164% increase in the mean number of routine VL tests performed per month (p<0.001). Increased VL testing was sustained during the 6 months of follow-up. CONCLUSIONS A simple QI program focused on improving VL knowledge among patients and providers, and clarifying staff roles at a facility level increased VL testing over a 6-month period. Further investigation is needed on whether this program can be scaled in different settings across sub-Saharan Africa and on the duration of follow-up required for sustained improvements in VL testing.
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Affiliation(s)
- Julie Hubbard
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at the University of California Los Angeles, 10833 Le Conte Avenue, 37-121 CHS, Los Angeles, CA, USA.,Partners in Hope/EQUIP
| | | | | | | | - Ashley Bardon
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at the University of California Los Angeles, 10833 Le Conte Avenue, 37-121 CHS, Los Angeles, CA, USA.,Partners in Hope/EQUIP
| | | | - Kathryn Dovel
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at the University of California Los Angeles, 10833 Le Conte Avenue, 37-121 CHS, Los Angeles, CA, USA.,Partners in Hope/EQUIP
| | - Thokozani Kalua
- Ministry of Health, Department of HIV and AIDS, Area 3, Lilongwe, Malawi
| | - Risa M Hoffman
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at the University of California Los Angeles, 10833 Le Conte Avenue, 37-121 CHS, Los Angeles, CA, USA
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27
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Simeon K, Sharma M, Dorward J, Naidoo J, Dlamini N, Moodley P, Samsunder N, Barnabas RV, Garrett N, Drain PK. Comparative cost analysis of point-of-care versus laboratory-based testing to initiate and monitor HIV treatment in South Africa. PLoS One 2019; 14:e0223669. [PMID: 31618220 PMCID: PMC6795460 DOI: 10.1371/journal.pone.0223669] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 09/25/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The number of people living with HIV (PLHIV) in need of treatment monitoring in low-and-middle-income countries has been rapidly expanding, placing an increasing burden on laboratories. Promising new point-of-care (POC) test have the potential to reduce laboratory workloads, but the implementation cost is uncertain. We sought to estimate the costs of decentralized POC testing compared to centralized laboratory testing for PLHIV initiating treatment in South Africa. METHODS We conducted a microcosting analyses comparing clinic-based POC testing to centralized laboratory testing for HIV viral load, creatinine, and CD4 count monitoring. We completed time-and-motion studies to assess staff time for sample collection and processing. Instrument costs were estimated assuming five-year lifespans and we applied a 3% annual discount rate. Total costs and cost per patient were estimated over a five-year period: the first year of ART initiation and four years of routine HIV monitoring, following World Health Organization ART monitoring guidelines. RESULTS We estimated that per-patient costs of POC HIV viral load, CD4, and creatinine tests were USD $25, $11, and $9, respectively, assuming a clinic volume of 50 patients initiated per month. At centralized laboratories, per-patient costs of POC HIV viral load, CD4, and creatinine tests were USD $26, $6, $3. Total monitoring costs of all testing over a 5-year period was $45 higher for POC testing compared to centralized laboratory testing ($210 vs $166). CONCLUSIONS POC testing for HIV care and treatment can be feasibly implemented within clinics in South Africa, particularly those with larger patient volumes. POC HIV viral load costs are similar to lab-based testing while CD4 count and creatinine testing are more costly as POC tests. Our cost estimates are useful to policymakers in planning resource allocation and can inform cost-effectiveness analyses of POC testing.
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Affiliation(s)
- Kate Simeon
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Monisha Sharma
- Department of Global Health, Schools of Public Health and Medicine, University of Washington, Seattle, Washington, United States of America
| | - Jienchi Dorward
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu–Natal, Durban, South Africa
| | - Jessica Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu–Natal, Durban, South Africa
| | - Ntuthu Dlamini
- Prince Cyril Zulu Communicable Disease Clinic, Ethekwini Municipality, Durban, South Africa
| | - Pravikrishnen Moodley
- Department of Virology, National Health Laboratory Service and University of KwaZulu-Natal, Durban, South Africa
| | - Natasha Samsunder
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu–Natal, Durban, South Africa
| | - Ruanne V. Barnabas
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, Schools of Public Health and Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu–Natal, Durban, South Africa
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Paul K. Drain
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, Schools of Public Health and Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, United States of America
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28
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Haas AD, Johnson LF, Grimsrud A, Ford N, Mugglin C, Fox MP, Euvrard J, van Lettow M, Prozesky H, Sikazwe I, Chimbetete C, Hobbins M, Kunzekwenyika C, Egger M. Extending Visit Intervals for Clinically Stable Patients on Antiretroviral Therapy: Multicohort Analysis of HIV Programs in Southern Africa. J Acquir Immune Defic Syndr 2019; 81:439-447. [PMID: 31242142 PMCID: PMC6597180 DOI: 10.1097/qai.0000000000002060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The World Health Organization recommends differentiated antiretroviral therapy (ART) delivery with longer visit intervals for clinically stable patients. We examined time trends in visit frequency and associations between criteria for clinical stability and visit frequency in ART programs in Southern Africa. METHODS We included adults on ART from 4 programs with viral-load monitoring, 2 programs with CD4 monitoring, and 4 programs with clinical monitoring of ART. We classified patients as clinically stable based on virological (viral load <1000 copies/mL), immunological (CD4 >200 cells/µL), or clinical (no current tuberculosis) criteria. We used Poisson regression and survival models to examine associations between criteria for clinical stability and the rate of clinic visits. RESULTS We included 180,837 patients. There were trends toward fewer visits in more recent years and with longer ART duration. In all ART programs, clinically stable patients were seen less frequently than patients receiving failing ART, but the strength of the association varied. Adjusted incidence rate ratios comparing visit rates for stable patients with patients on failing ART were 0.82 (95% confidence interval: 0.73 to 0.90) for patients classified based on the virological criterion, 0.81 (0.69 to 0.93) for patients classified based on the clinical criterion, and 0.90 (0.85 to 0.96) for patients classified based on the immunological criterion for stability. CONCLUSION Differences in visit rates between stable patients and patients failing ART were variable and modest overall. Larger differences were seen in programs using virological criteria for clinical stability than in programs using immunological criteria. Greater access to routine viral-load monitoring may increase scale-up of differentiated ART delivery.
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Affiliation(s)
- Andreas D. Haas
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Nathan Ford
- World Health Organization, Geneva, Switzerland
| | - Catarina Mugglin
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland
| | - 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 Epidemiology, Boston University School of Public Health, Boston, MA, USA
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Monique van Lettow
- Dignitas International, Zomba, Malawi
- Dalla Lana School of Public Health, University of Toronto, Canada
| | - Hans Prozesky
- Division of Infectious Diseases, Department of Medicine, University of Stellenbosch and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Izukanji Sikazwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | | | | | | | - Matthias Egger
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Brazier E, Maruri F, Duda SN, Tymejczyk O, Wester CW, Somi G, Ross J, Freeman A, Cornell M, Poda A, Musick BS, Zhang F, Althoff KN, Mugglin C, Kimmel AD, Yotebieng M, Nash D. Implementation of "Treat-all" at adult HIV care and treatment sites in the Global IeDEA Consortium: results from the Site Assessment Survey. J Int AIDS Soc 2019; 22:e25331. [PMID: 31623428 PMCID: PMC6625339 DOI: 10.1002/jia2.25331] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 05/29/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Since 2015, the World Health Organization (WHO) has recommended that all people living with HIV (PLHIV) initiate antiretroviral treatment (ART), irrespective of CD4+ count or clinical stage. National adoption of universal treatment has accelerated since WHO's 2015 "Treat All" recommendation; however, little is known about the translation of this guidance into practice. This study aimed to assess the status of Treat All implementation across regions, countries, and levels of the health care delivery system. METHODS Between June and December 2017, 201/221 (91%) adult HIV treatment sites that participate in the global IeDEA research consortium completed a survey on capacity and practices related to HIV care. Located in 41 countries across seven geographic regions, sites provided information on the status and timing of site-level introduction of Treat All, as well as site-level practices related to ART initiation. RESULTS Almost all sites (93%) reported that they had begun implementing Treat All, and there were no statistically significant differences in site-level Treat All introduction by health facility type, urban/rural location, sector (public/private) or country income level. The median time between national policy adoption and site-level introduction was one month. In countries where Treat All was not yet adopted in national guidelines, 69% of sites reported initiating all patients on ART, regardless of clinical criteria, and these sites had been implementing Treat All for a median period of seven months at the time of the survey. The majority of sites (77%) reported typically initiating patients on ART within 14 days of confirming diagnosis, with 60% to 62% of sites implementing Treat All in East, Southern and West Africa reporting same-day ART initiation for most patients. CONCLUSIONS By mid- to late-2017, the Treat All strategy was the standard of care at almost all IeDEA sites, including rural, primary-level health facilities in low-resource settings. While further assessments of site-level capacity to provide high-quality HIV care under Treat All and to support sustained viral suppression after ART initiation are needed, the widespread introduction of Treat All at the service delivery level is a critical step towards global targets for ending the HIV epidemic as a public health threat.
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Affiliation(s)
- Ellen Brazier
- Institute for Implementation Science in Population HealthCity University of New YorkNew YorkNYUSA
- Graduate School of Public Health and Health Policy (GSPHHP)City University of New YorkNew YorkNYUSA
| | - Fernanda Maruri
- Department of MedicineDivision of Infectious DiseasesVanderbilt University Medical CenterNashvilleTNUSA
| | - Stephany N Duda
- Department of Biomedical InformaticsVanderbilt University School of MedicineNashvilleTNUSA
| | - Olga Tymejczyk
- Institute for Implementation Science in Population HealthCity University of New YorkNew YorkNYUSA
- Graduate School of Public Health and Health Policy (GSPHHP)City University of New YorkNew YorkNYUSA
| | - C William Wester
- Department of MedicineDivision of Infectious DiseasesVanderbilt University Medical CenterNashvilleTNUSA
- Vanderbilt Institute for Global Health (VIGH)NashvilleTNUSA
| | - Geoffrey Somi
- National AIDS Control ProgrammeDar es SalaamTanzania
| | - Jeremy Ross
- TREAT Asia, amfARThe Foundation for AIDS ResearchBangkokThailand
| | - Aimee Freeman
- Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMDUSA
| | - Morna Cornell
- School of Public Health and Family MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Armel Poda
- Hôpital de Jour, Service des Maladies Infectieuses, CHU Souro SanouBobo‐DioulassoBurkina Faso
- Institut Supérieur des Sciences de la Santé (INSSA)Université Nazi BoniBobo‐DioulassoBurkina Faso
| | | | - Fujie Zhang
- Clinical and Research Center of Infectious DiseasesBeijing Ditan HospitalCapital Medical UniversityBeijingChina
| | - Keri N Althoff
- Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMDUSA
| | - Catrina Mugglin
- Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
| | - April D Kimmel
- School of MedicineVirginia Commonwealth UniversityRichmondVAUSA
| | | | - Denis Nash
- Institute for Implementation Science in Population HealthCity University of New YorkNew YorkNYUSA
- Graduate School of Public Health and Health Policy (GSPHHP)City University of New YorkNew YorkNYUSA
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Agutu CA, Ngetsa CJ, Price MA, Rinke de Wit TF, Omosa-Manyonyi G, Sanders EJ, Graham SM. Systematic review of the performance and clinical utility of point of care HIV-1 RNA testing for diagnosis and care. PLoS One 2019; 14:e0218369. [PMID: 31246963 PMCID: PMC6597060 DOI: 10.1371/journal.pone.0218369] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 05/31/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Point of-care (POC) HIV-1 RNA tests which are accurate and easy to use with limited infrastructure are needed in resource-limited settings (RLS). We systematically reviewed evidence of POC test performance compared to laboratory-based HIV-1 RNA assays and the potential utility of these tests for diagnosis and care in RLS. METHODS Studies published up to July 2018 were identified by a search of PUBMED, EMBASE, Web of Science, CINAHL and Cochrane Central Register of Controlled Trials. Studies evaluating the use of POC HIV-1 RNA testing for early infant diagnosis (EID), acute HIV infection (AHI) diagnosis, or viral load monitoring (VL), compared to centralized testing, were included. Separate search strategies were used for each testing objective. RESULTS 197 abstracts were screened and 34 full-text articles were assessed, of which 32 met inclusion criteria. Thirty studies evaluated performance and diagnostic accuracy of POC tests compared to standard reference tests. Two of the thirty and two additional studies with no comparative testing reported on clinical utility of POC results. Five different POC tests (Cepheid GeneXpert HIV-1 Quantitative and Qualitative assays, Alere q HIV-1/2 Detect, SAMBA, Liat HIV Quant and Aptima HIV-1 Quant) were used in 21 studies of VL, 11 of EID and 2 of AHI. POC tests were easy to use, had rapid turnaround times, and comparable accuracy and precision to reference technologies. Sensitivity and specificity were high for EID and AHI but lower for VL. For VL, lower sensitivity was reported for whole blood and dried blood spots compared to plasma samples. Reported error rates for Cepheid GeneXpert Qual (2.0%-5.0%), GeneXpert Quant (2.5%-17.0%) and Alere q HIV-1/2 Detect (3.1%-11.0%) were higher than in WHO prequalification reports. Most errors resolved with retesting; however, inadequate sample volumes often precluded repeat testing. Only two studies used POC results for clinical management, one for EID and another for VL. POC EID resulted in shorter time-to-result, rapid ART initiation, and better retention in care compared to centralised testing. CONCLUSIONS Performance of POC HIV-1 RNA tests is comparable to reference assays, and have potential to improve patient outcomes. Additional studies on implementation in limited-resources settings are needed.
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Affiliation(s)
- Clara A. Agutu
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Caroline J. Ngetsa
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Matt A. Price
- International AIDS Vaccine Initiative (IAVI), Department of Medical Affairs, New York, New York, United States of America
| | - Tobias F. Rinke de Wit
- Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Gloria Omosa-Manyonyi
- School of Medicine, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Eduard J. Sanders
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Susan M. Graham
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, United States of America
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Point-of-Care HIV Viral Load Testing: an Essential Tool for a Sustainable Global HIV/AIDS Response. Clin Microbiol Rev 2019; 32:32/3/e00097-18. [PMID: 31092508 DOI: 10.1128/cmr.00097-18] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The global public health community has set ambitious treatment targets to end the HIV/AIDS pandemic. With the notable absence of a cure, the goal of HIV treatment is to achieve sustained suppression of an HIV viral load, which allows for immunological recovery and reduces the risk of onward HIV transmission. Monitoring HIV viral load in people living with HIV is therefore central to maintaining effective individual antiretroviral therapy as well as monitoring progress toward achieving population targets for viral suppression. The capacity for laboratory-based HIV viral load testing has increased rapidly in low- and middle-income countries, but implementation of universal viral load monitoring is still hindered by several barriers and delays. New devices for point-of-care HIV viral load testing may be used near patients to improve HIV management by reducing the turnaround time for clinical test results. The implementation of near-patient testing using these new and emerging technologies may be an essential tool for ensuring a sustainable response that will ultimately enable an end to the HIV/AIDS pandemic. In this report, we review the current and emerging technology, the evidence for decentralized viral load monitoring by non-laboratory health care workers, and the additional considerations for expanding point-of-care HIV viral load testing.
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Nsabimana AP, Uzabakiriho B, Kagabo DM, Nduwayo J, Fu Q, Eng A, Hughes J, Sia SK. Bringing Real-Time Geospatial Precision to HIV Surveillance Through Smartphones: Feasibility Study. JMIR Public Health Surveill 2018; 4:e11203. [PMID: 30087088 PMCID: PMC6103996 DOI: 10.2196/11203] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/01/2018] [Accepted: 07/17/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Precise measurements of HIV incidences at community level can help mount a more effective public health response, but the most reliable methods currently require labor-intensive population surveys. Novel mobile phone technologies are being tested for adherence to medical appointments and antiretroviral therapy, but using them to track HIV test results with automatically generated geospatial coordinates has not been widely tested. OBJECTIVE We customized a portable reader for interpreting the results of HIV lateral flow tests and developed a mobile phone app to track HIV test results in urban and rural locations in Rwanda. The objective was to assess the feasibility of this technology to collect front line HIV test results in real time and with geospatial context to help measure HIV incidences and improve epidemiological surveillance. METHODS Twenty health care workers used the technology to track the test results of 2190 patients across 3 hospital sites (2 urban sites in Kigali and a rural site in the Western Province of Rwanda). Mobile phones for less than US $70 each were used. The mobile phone app to record HIV test results could take place without internet connectivity with uploading of results to the cloud taking place later with internet. RESULTS A total of 91.51% (2004/2190) of HIV test results could be tracked in real time on an online dashboard with geographical resolution down to street level. Out of the 20 health care workers, 14 (70%) would recommend the lateral flow reader, and 100% would recommend the mobile phone app. CONCLUSIONS Smartphones have the potential to simplify the input of HIV test results with geospatial context and in real time to improve public health surveillance of HIV.
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Gous N, Boeras DI, Cheng B, Takle J, Cunningham B, Peeling RW. The impact of digital technologies on point-of-care diagnostics in resource-limited settings. Expert Rev Mol Diagn 2018; 18:385-397. [PMID: 29658382 DOI: 10.1080/14737159.2018.1460205] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Simple, rapid tests that can be used at the point-of-care (POC) can improve access to diagnostic services and overall patient management in resource-limited settings where laboratory infrastructure is limited. Implementation of POC tests places tremendous strain on already fragile health systems as the demand for training, supply management and quality assurance are amplified. Digital health has a major role to play in ensuring effective delivery and management of POC testing services. Area covered: The ability to digitise laboratory and POC platforms, including lateral flow rapid diagnostic test results, can standardize the interpretation of results and allows data to be linked to proficiency testing to ensure testing quality, reducing interpretation and transcription errors. Remote monitoring of POC instrument functionality and utilization through connectivity, allows programs to optimize instrument placement, algorithm adoption and supply management. Alerts can be built into the system to raise alarm at unusual trends such as outbreaks. Expert commentary: Digital technology has had a powerful impact on POC testing in resource limited settings. Technology, markets, and medical devices have matured to enable connected diagnostics to become a useful tool for epidemiology, patient care and tracking, research, and antimicrobial resistance and outbreak surveillance. However, to unlock this potential, digital tools must first add value at the point of patient care. The global health community need to propose models for protecting intellectual property to foster innovation and for safeguarding data confidentiality.
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Affiliation(s)
- Natasha Gous
- a Global Health Department , SystemOne LLC , Johannesburg , South Africa
| | - Debrah I Boeras
- b Global Health Impact Group , Atlanta , GA , USA.,c International Diagnostics Centre , London , UK
| | - Ben Cheng
- c International Diagnostics Centre , London , UK
| | - Jeff Takle
- d Global Health Department , SystemOne LLC , Springfield , MA , USA
| | - Brad Cunningham
- a Global Health Department , SystemOne LLC , Johannesburg , South Africa
| | - Rosanna W Peeling
- e Department of Clinical Research , London School of Hygiene and Tropical Medicine , London , UK
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Peter T, Zeh C, Katz Z, Elbireer A, Alemayehu B, Vojnov L, Costa A, Doi N, Jani I. Scaling up HIV viral load - lessons from the large-scale implementation of HIV early infant diagnosis and CD4 testing. J Int AIDS Soc 2018; 20 Suppl 7. [PMID: 29130601 PMCID: PMC5978645 DOI: 10.1002/jia2.25008] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 08/21/2017] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION The scale-up of effective HIV viral load (VL) testing is an urgent public health priority. Implementation of testing is supported by the availability of accurate, nucleic acid based laboratory and point-of-care (POC) VL technologies and strong WHO guidance recommending routine testing to identify treatment failure. However, test implementation faces challenges related to the developing health systems in many low-resource countries. The purpose of this commentary is to review the challenges and solutions from the large-scale implementation of other diagnostic tests, namely nucleic-acid based early infant HIV diagnosis (EID) and CD4 testing, and identify key lessons to inform the scale-up of VL. DISCUSSION Experience with EID and CD4 testing provides many key lessons to inform VL implementation and may enable more effective and rapid scale-up. The primary lessons from earlier implementation efforts are to strengthen linkage to clinical care after testing, and to improve the efficiency of testing. Opportunities to improve linkage include data systems to support the follow-up of patients through the cascade of care and test delivery, rapid sample referral networks, and POC tests. Opportunities to increase testing efficiency include improvements to procurement and supply chain practices, well connected tiered laboratory networks with rational deployment of test capacity across different levels of health services, routine resource mapping and mobilization to ensure adequate resources for testing programs, and improved operational and quality management of testing services. If applied to VL testing programs, these approaches could help improve the impact of VL on ART failure management and patient outcomes, reduce overall costs and help ensure the sustainable access to reduced pricing for test commodities, as well as improve supportive health systems such as efficient, and more rigorous quality assurance. These lessons draw from traditional laboratory practices as well as fields such as logistics, operations management and business. CONCLUSIONS The lessons and innovations from large-scale EID and CD4 programs described here can be adapted to inform more effective scale-up approaches for VL. They demonstrate that an integrated approach to health system strengthening focusing on key levers for test access such as data systems, supply efficiencies and network management. They also highlight the challenges with implementation and the need for more innovative approaches and effective partnerships to achieve equitable and cost-effective test access.
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Affiliation(s)
- Trevor Peter
- Clinton Health Access Initiative, Gaborone, Botswana
| | - Clement Zeh
- United States Centers for Disease Control, Addis Ababa, Ethiopia
| | - Zachary Katz
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Ali Elbireer
- African Society for Laboratory Medicine, Addid Ababa, Ethiopia
| | | | - Lara Vojnov
- World Health Organization, Geneva, Switzerland
| | | | - Naoko Doi
- Clinton Health Access Initiative, Gaborone, Botswana
| | - Ilesh Jani
- Institut Nacional Da Saude, Maputo, Mozambique
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El-Sadr WM, Rabkin M, Nkengasong J, Birx DL. Realizing the potential of routine viral load testing in sub-Saharan Africa. J Int AIDS Soc 2017; 20 Suppl 7. [PMID: 29130621 PMCID: PMC5978658 DOI: 10.1002/jia2.25010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 12/11/2022] Open
Affiliation(s)
| | | | - John Nkengasong
- Africa Centres for Disease Control and Prevention, Addis Ababa, Ethiopia
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