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Vogt F, Tayler-Smith K, Bernasconi A, Makondo E, Taziwa F, Moyo B, Havazvidi L, Satyanarayana S, Manzi M, Khogali M, Reid A. Access to CD4 Testing for Rural HIV Patients: Findings from a Cohort Study in Zimbabwe. PLoS One 2015; 10:e0129166. [PMID: 26083342 PMCID: PMC4471276 DOI: 10.1371/journal.pone.0129166] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 05/05/2015] [Indexed: 11/19/2022] Open
Abstract
Background CD4 cell count measurement remains an important diagnostic tool for HIV care in developing countries. Insufficient laboratory capacity in rural Sub-Saharan Africa is frequently mentioned but data on the impact at an individual patient level are lacking. Urban-rural discrepancies in CD4 testing have not been quantified to date. Such evidence is crucial for public health planning and to justify new yet more expensive diagnostic procedures that could circumvent access constraints in rural areas. Objective To compare CD4 testing among rural and urban HIV patients during the first year of treatment. Methods Records from 2,145 HIV positive adult patients from a Médecins sans Frontières (Doctors without Borders) HIV project in Beitbridge, Zimbabwe, during 2011 and 2012 were used for a retrospective cohort analysis. Covariate-adjusted risk ratios were calculated to estimate the effects of area of residence on CD4 testing at treatment initiation, six and 12 months among rural and urban patients. Findings While the proportion of HIV patients returning for medical consultations at six and 12 months decreased at a similar rate in both patient groups, CD4 testing during consultations dropped to 21% and 8% for urban, and 2% and 1% for rural patients at six and 12 months, respectively. Risk ratios for missing CD4 testing were 0.8 (95% CI 0.7-0.9), 9.2 (95% CI 5.5-15.3), and 7.6 (95% 3.7-17.1) comparing rural versus urban patients at treatment initiation, six and 12 months, respectively. Conclusions CD4 testing was low overall, and particularly poor in rural patients. Difficulties with specimen transportation were probably a major factor underlying this difference and requires new diagnostic approaches. Our findings point to severe health system constraints in providing CD4 testing overall that need to be addressed if effective monitoring of HIV patients is to be achieved, whether by alternative CD4 diagnostics or newly-recommended routine viral load testing.
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Affiliation(s)
- Florian Vogt
- Operational Centre Barcelona, Médecins sans Frontières/Doctors without Borders, Barcelona, Spain
- * E-mail:
| | - Katie Tayler-Smith
- Operational Research Unit Luxembourg, Médecins sans Frontières/Doctors without Borders, Luxembourg, Luxembourg
| | - Andrea Bernasconi
- Operational Centre Barcelona, Médecins sans Frontières/Doctors without Borders, Barcelona, Spain
- Department of Field Epidemiology and Training, Epicentre, Paris, France
| | - Eliphas Makondo
- Laboratory Department, Beitbridge District Hospital, Ministry of Health and Child Welfare, Beitbridge, Zimbabwe
| | - Fabian Taziwa
- Zimbabwe Mission, Médecins sans Frontières/Doctors without Borders, Harare, Zimbabwe
| | - Buhlebenkosi Moyo
- Beitbridge Project, Médecins sans Frontières/Doctors without Borders, Beitbridge, Zimbabwe
| | - Liberty Havazvidi
- Beitbridge Project, Médecins sans Frontières/Doctors without Borders, Beitbridge, Zimbabwe
| | - Srinath Satyanarayana
- Centre for Operational Research, South-East Asia Regional Office, International Union against Tuberculosis and Lung Disease, New Delhi, India
| | - Marcel Manzi
- Operational Research Unit Luxembourg, Médecins sans Frontières/Doctors without Borders, Luxembourg, Luxembourg
| | - Mohammed Khogali
- Operational Research Unit Luxembourg, Médecins sans Frontières/Doctors without Borders, Luxembourg, Luxembourg
| | - Anthony Reid
- Operational Research Unit Luxembourg, Médecins sans Frontières/Doctors without Borders, Luxembourg, Luxembourg
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Wools-Kaloustian K. Focusing attention on therapy adherence and retention among women diagnosed with HIV during pregnancy. Future Virol 2014. [DOI: 10.2217/fvl.14.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Egan MA. Towards the development of a therapeutic vaccine for the treatment of HIV-1 infection: are we closer than ever? Expert Rev Vaccines 2014; 6:289-91. [PMID: 17542741 DOI: 10.1586/14760584.6.3.289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Martin F, Kiwanuka T, Kawuma R, Zalwango F, Seeley J. Tasks and strategies of self-management of living with antiretroviral therapy in Uganda. AIDS Patient Care STDS 2013; 27:697-706. [PMID: 24219780 DOI: 10.1089/apc.2013.0254] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
There is increasing interest in promoting and supporting self-management of HIV and antiretroviral treatment (ART), including in resource-limited settings. Although the impact of HIV and ART on people in Uganda has been explored, little attention has been paid to how people self-manage. This qualitative study collected data from 20 participants on ART in Wakiso district, Uganda, using in-depth interviews, life histories, and observations to explore the tasks and strategies of living with ART. The identified strategies were compared to two existing self-management frameworks. Results highlighted a range of tasks including obtaining, taking, and adhering to ART medication, monitoring their condition, living with stigma and managing disclosure, maintaining general health, and adjusting to new roles. Participants described a range of strategies or behaviors to manage, which they actively created and used, tailored to their needs and environment. Comparison with existing frameworks revealed many similarities, with some local differences in enactment, and greater emphasis in our sample on obtaining the medication. Interventions to support people with self-management in Uganda, and possibly other resource-limited settings, require careful adaptation to local settings. The degree to which each of these strategies may improve health and quality of life requires further investigation.
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Affiliation(s)
- Faith Martin
- School of International Development, University of East Anglia, Norwich Research Park, Norwich, United Kingdom
| | - Thadeus Kiwanuka
- Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - Rachel Kawuma
- Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - Flavia Zalwango
- Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - Janet Seeley
- School of International Development, University of East Anglia, Norwich Research Park, Norwich, United Kingdom
- Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
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Etienne M, Burrows L, Osotimehin B, Macharia T, Hossain B, Redfield RR, Amoroso A. Situational analysis of varying models of adherence support and loss to follow up rates; findings from 27 treatment facilities in eight resource limited countries. Trop Med Int Health 2011; 15 Suppl 1:76-81. [PMID: 20586964 DOI: 10.1111/j.1365-3156.2010.02513.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Large-scale provision of ART in the absence of viral load monitoring, resistance testing, and limited second-line treatment options places adherence support as a vital therapeutic intervention. We aimed to compare patient loss to follow up rates with the degree of adherence support through a retrospective review of patients enrolled in the AIDSRelief program between August 2004 and June 2005. METHODS Loss to follow up data were analysed and programs were categorised into one of four tiered levels of adherence support models: Tier I, II, III, and IV which increase from lowest to highest support. Bivariate and t-test analyses were used to test for significant differences between the models. RESULTS 13,391 patients at 27 treatment facilities from six African and two Caribbean countries began antiretroviral therapy within the first year of the AIDSRelief program. The mean loss to follow up within the first year was 7.5%. Eight facilities were Tier I, three (Tier II), nine (Tier III), and seven (Tier IV). Facilities in Tier I had a loss to follow up rate of 14%, Tier II (10%), Tier III (5%), and Tier IV (1%). The proportion of loss to follow up for Tier I and Tier III were significantly different from each other (P < 0.02), as were Tier I and Tier IV (P < 0.006). There were differences between Tier II and Tier IV (P < 0.009) as well as Tier III and Tier IV (P < 0.017). CONCLUSION These data strongly support the use of proactive adherence support programs, beyond routine patient counselling and defaulter tracking to support the'public health approach'to ART.
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Affiliation(s)
- M Etienne
- Institute of Human Virology of the University of Maryland School of Medicine, Baltimore, MD, USA.
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Differences in presentation, treatment initiation, and response among children infected with human immunodeficiency virus in urban and rural Zambia. Pediatr Infect Dis J 2010; 29:849-54. [PMID: 20526227 DOI: 10.1097/inf.0b013e3181e753a8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Access to pediatric antiretroviral therapy (ART) in rural areas remains limited due to the unique challenges faced by providers and patients. Few rural ART programs have been evaluated to determine whether these challenges affect care and treatment response. METHODS Routinely collected data from 3 pediatric ART programs in rural and urban Zambia were obtained from medical records. Participants included human immunodeficiency virus-infected children <15 years of age presenting for care between August 2004 and July 2008. Characteristics at presentation, time to ART initiation, and treatment response were compared between urban and rural children. RESULTS A total of 863 children were enrolled (562 urban and 301 rural). At presentation, children in rural clinics were significantly younger (3.4 vs. 6.5 years), had higher CD4 T-cell percentages (18.0% vs. 12.8%), less advanced disease (47.5% vs. 62.3% in World Health Organization stage 3/4), lower weight-for-age Z-scores (-2.8 vs. -2.3), and traveled greater distances (29 vs. 2 km). Rural children eligible for ART at presentation took longer to initiate treatment (3.6 vs. 0.9 months); no differences were found in time to ART initiation among children ineligible at presentation (15.4 vs. 12.1 months). For the 607 children initiating ART, clinical and immunologic status improved in both urban and rural clinics. Mortality was highest in the first 90 days of treatment and was higher at all times in rural clinics. CONCLUSIONS The findings support expansion of ART programs into rural areas to increase access to treatment services and reduce inequities.
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Portelinha Filho AM, Nascimento CUD, Tannouri TN, Troiani C, Ascêncio EL, Bonfim R, D'Andrea LAZ, Prestes-Carneiro LE. Seroprevalence of HBV, HCV and HIV co-infection in selected individuals from state of São Paulo, Brazil. Mem Inst Oswaldo Cruz 2009; 104:960-3. [DOI: 10.1590/s0074-02762009000700003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Accepted: 09/02/2009] [Indexed: 11/21/2022] Open
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van Dijk JH, Sutcliffe CG, Munsanje B, Hamangaba F, Thuma PE, Moss WJ. Barriers to the care of HIV-infected children in rural Zambia: a cross-sectional analysis. BMC Infect Dis 2009; 9:169. [PMID: 19835604 PMCID: PMC2767351 DOI: 10.1186/1471-2334-9-169] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 10/16/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Successful antiretroviral treatment programs in rural sub-Saharan Africa may face different challenges than programs in urban areas. The objective of this study was to identify patient characteristics, barriers to care, and treatment responses of HIV-infected children seeking care in rural Zambia. METHODS Cross-sectional analysis of HIV-infected children seeking care at Macha Hospital in rural southern Zambia. Information was collected from caretakers and medical records. RESULTS 192 HIV-infected children were enrolled from September 2007 through September 2008, 28% of whom were receiving antiretroviral therapy (ART) at enrollment. The median age was 3.3 years for children not receiving ART (IQR 1.8, 6.7) and 4.5 years for children receiving ART (IQR 2.7, 8.6). 91% travelled more than one hour to the clinic and 26% travelled more than 5 hours. Most participants (73%) reported difficulties accessing the clinic, including insufficient money (60%), lack of transportation (54%) and roads in poor condition (32%). The 54 children who were receiving ART at study enrollment had been on ART a median of 8.6 months (IQR: 2.7, 19.5). The median percentage of CD4+ T cells was 12.4 (IQR: 9.2, 18.6) at the start of ART, and increased to 28.6 (IQR: 23.5, 36.1) at the initial study visit. However, the proportion of children who were underweight decreased only slightly, from 70% at initiation of ART to 61% at the initial study visit. CONCLUSION HIV-infected children in rural southern Zambia have long travel times to access care and may have poorer weight gain on ART than children in urban areas. Despite these barriers, these children had a substantial rise in CD4+ T cell counts in the first year of ART although longer follow-up may indicate these gains are not sustained.
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Affiliation(s)
| | - Catherine G Sutcliffe
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Philip E Thuma
- Medical/Malaria Institute at Macha, Macha Hospital, Choma, Zambia
| | - William J Moss
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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The impact of the President's Emergency Plan for AIDS Relief on expansion of HIV care services for adult patients in western Kenya. AIDS 2009; 23:195-201. [PMID: 19098489 DOI: 10.1097/qad.0b013e32831cc0e6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The President's Emergency Plan for AIDS Relief committed $15 billion to addressing HIV in resource-poor settings. OBJECTIVE To assess the impact of The President's Emergency Plan for AIDS Relief on the treatment services of an HIV care program. DESIGN, SETTING, AND PATIENTS Cohort study utilizing computerized medical records of nonpregnant adults enrolled into the Academic Model for the Prevention and Treatment of HIV/AIDS system, in western Kenya between 27 November 2001 and 24 July 2006. MAIN OUTCOMES MEASURES Number of clinics and patients enrolled in Academic Model for the Prevention and Treatment of HIV/AIDS, as well as patient demographics, immunologic, and clinical characteristics during three periods defined by the availability of combination antiretroviral therapy (cART). RESULTS Enrollment as of May 2006 was 23,539. Mean monthly enrollment increased from 64 to 815 between periods 1 and 3. The median CD4 cell count at enrollment during period 3 (172 cells/microl) was significantly higher than for period 2 (119 cells/microl; P < 0.001). World Health Organization stage at enrollment differed significantly between periods with 6.7% having stage 4 disease in period 3 compared with 13.8% during period 1 (P < 0.001). Significantly more patients had complete documentation of cART eligibility, during period 3 as compared with the previous periods. Time from enrollment to cART initiation decreased from a median of 64 weeks in period 1 to 12 weeks during period 3 (P < 0.001). CONCLUSION The President's Emergency Plan for AIDS Relief funding has allowed Academic Model for the Prevention and Treatment of HIV/AIDS to significantly increase the number of individuals receiving HIV care and provided the ability to expand services allowing for identification of patients earlier in their disease process.
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Larsen CH. The fragile environments of inexpensive CD4+ T-cell enumeration in the least developed countries: Strategies for accessible support. CYTOMETRY PART B-CLINICAL CYTOMETRY 2008; 74 Suppl 1:S107-16. [DOI: 10.1002/cyto.b.20386] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Kiguba R, Byakika-Tusiime J, Karamagi C, Ssali F, Mugyenyi P, Katabira E. Discontinuation and Modification of Highly Active Antiretroviral Therapy in HIV-Infected Ugandans. J Acquir Immune Defic Syndr 2007; 45:218-23. [PMID: 17438478 DOI: 10.1097/qai.0b013e31805d8ae3] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Data on discontinuation and modification of highly active antiretroviral therapy (HAART) are scarce among sub-Saharan African populations. We sought to estimate the prevalence and to identify factors associated with these phenomena in our resource-limited setting. METHODS Patients were recruited into this cross-sectional study from 2 treatment centers in Kampala, Uganda. Discontinuation and modification were assessed by self-report using semistructured quantitative and unstructured qualitative interviews. Discontinuation was defined as the simultaneous stopping of all antiretrovirals for at least 1 month, and modification as the changing of at least 1 antiretroviral used in an initial HAART regimen. Factors independently associated with each outcome were assessed using multivariate logistic regression. RESULTS Of 686 subjects evaluated, 94 (13.7%) had ever discontinued therapy, whereas 175 (25.5%) had ever modified their regimen. The median CD4 count was 175 (interquartile range: 66-297) cells/microL. Factors associated with discontinuation were HAART experience before starting the current regimen (odds ratio [OR] = 3.70, 95% confidence interval [CI]: 2.13 to 6.25), use of alternative medicines (OR = 2.18, 95% CI: 1.06 to 4.47), hospitalization (OR = 2.36, 95% CI: 1.32 to 4.20), and 1 year or less on HAART (OR = 11.11, 95% CI: 5.00 to 25.00). Modification was associated with more than 3 months' duration on HAART (OR = 3.13, 95% CI: 1.16 to 8.33) and being unmarried (OR = 1.64, 95% CI: 1.02 to 2.70). CONCLUSIONS The proportions of discontinuation and modification of antiretroviral therapy (ART) observed in our resource-poor setting pose a challenge to the limited treatment options presently available. Drug cost as a major reason for discontinuation of HAART has major implications for ART programs that charge fees in resource-limited settings.
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Affiliation(s)
- Ronald Kiguba
- Makerere University Medical School, Kampala, Uganda.
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