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García-Ruiz de Morales AG, Vivancos MJ, de Lagarde M, Ramírez Schacke M, Del Mar Arcos Rueda M, Orviz E, Curran A, Carmona-Torre F, Moreno S, Pérez-Elías MJ, Martínez-Sanz J. Transition times across the HIV care continuum in Spain from 2005 to 2022: a longitudinal cohort study. Lancet HIV 2024; 11:e470-e478. [PMID: 38824937 DOI: 10.1016/s2352-3018(24)00118-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Ending AIDS by 2030 requires improvements across all stages of the HIV care continuum. We used a longitudinal approach to assess changes in the HIV care continuum in Spain and transition probabilities across different stages. METHODS We used data from the prospective Cohort of the Spanish HIV/AIDS Research Network to analyse the time from diagnosis to linkage to care, linkage to care to antiretroviral therapy (ART), and ART to viral suppression in five calendar periods defined by milestones in ART, from 2005 to 2022. We used the Kaplan-Meier method and Cox proportional hazard models to estimate cumulative probabilities of stage transition within 1, 3, 6, and 12 months of stage eligibility, by period. FINDINGS We included 18 529 participants. Comparing the initial (2005-09) and final (2020-22) periods, time to linkage to care decreased from a median of 6·0 weeks to 1·3 weeks, time to ART initiation from 15·9 weeks to 0·4 weeks, and time to viral suppression from 13·3 weeks to 7·1 weeks. Adjusted hazard ratios for the comparison between the last period and the initial period were 3·1 (95% CI 2·8-3·4) for linkage to care within 1 month, 11·4 (10·1-12·3) for ART initiation within 1 month, and 2·2 (1·2-2·4) for viral suppression within 3 months. The aggregate proportion of late diagnoses was 38·6%, increasing after 2012 to 46·4% in the 2020-22 period. Same-day ART initiation increased from 18% to 39% from 2005 to 2022. The overall incidence rate of virological failure was 1·05 failures per 1000 person-years and showed a non-significant decline throughout the study. INTERPRETATION The great improvement in transition times through the HIV care cascade might put Spain on the verge of achieving the UNAIDS targets for HIV elimination. However, late diagnosis remains a challenge that should be addressed. FUNDING Instituto de Salud Carlos III and Spanish AIDS Research Network.
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Affiliation(s)
- Alejandro G García-Ruiz de Morales
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain; CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; University of Alcalá, Alcalá de Henares, Madrid, Spain
| | - María Jesús Vivancos
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain; CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - María de Lagarde
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Margarita Ramírez Schacke
- Department of Infectious Diseases, Hospital Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | - Eva Orviz
- Centro Sanitario Sandoval, Hospital Clínico San Carlos, Fundación para la Investigación Biomédica del Hospital Clínico San Carlos, Madrid, Spain
| | - Adrian Curran
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Francisco Carmona-Torre
- Biogipuzkoa Health Research Institute, Osakidetza Basque Health Service, Donostia University Hospital, Infectious Diseases Service, San Sebastián, Spain
| | - Santiago Moreno
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain; CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; University of Alcalá, Alcalá de Henares, Madrid, Spain
| | - María Jesús Pérez-Elías
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain; CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Javier Martínez-Sanz
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain; CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain.
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Mulenga LB, Hines JZ, Stafford KA, Dzekedzeke K, Sivile S, Lindsay B, Chola M, Ussery F, Patel HK, Abimiku A, Birhanu S, Minchella PA, Stevens T, Hanunka B, Chisenga T, Shibemba A, Fwoloshi S, Siame M, Mutukwa J, Chirwa L, Siwingwa M, Mulundu G, Agbakwuru C, Mapondera P, Detorio M, Agolory SG, Monze M, Bronson M, Charurat ME. Comparison of HIV prevalence, incidence, and viral load suppression in Zambia population-based HIV impact assessments from 2016 and 2021. AIDS 2024; 38:895-905. [PMID: 38227572 DOI: 10.1097/qad.0000000000003834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND The Zambian government has implemented a public health response to control the HIV epidemic in the country. Zambia conducted a population-based HIV impact assessment (ZAMPHIA) survey in 2021 to assess the status of the HIV epidemic to guide its public health programs. METHODS ZAMPHIA 2021 was a cross-sectional two-stage cluster sample household survey among persons aged ≥15 years conducted in Zambia across all 10 provinces. Consenting participants were administered a standardized questionnaire and whole blood was tested for HIV according to national guidelines. HIV-1 viral load (VL), recent HIV infection, and antiretroviral medications were tested for in HIV-seropositive samples. Viral load suppression (VLS) was defined as <1000 copies/ml. ZAMPHIA 2021 results were compared to ZAMPHIA 2016 for persons aged 15-59 years (i.e., the overlapping age ranges). All estimates were weighted to account for nonresponse and survey design. RESULTS During ZAMPHIA 2021, of 25 483 eligible persons aged ≥15 years, 18 804 (73.8%) were interviewed and tested for HIV. HIV prevalence was 11.0% and VLS prevalence was 86.2% overall, but was <80% among people living with HIV aged 15-24 years and in certain provinces. Among persons aged 15-59 years, from 2016 to 2021, HIV incidence declined from 0.6% to 0.3% ( P -value: 0.07) and VLS prevalence increased from 59.2% to 85.7% ( P -value: <0.01). DISCUSSION Zambia has made substantial progress toward controlling the HIV epidemic from 2016 to 2021. Continued implementation of a test-and-treat strategy, with attention to groups with lower VLS in the ZAMPHIA 2021, could support reductions in HIV incidence and improve overall VLS in Zambia.
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Affiliation(s)
- Lloyd B Mulenga
- Ministry of Health
- University Teaching Hospital
- University of Zambia, School of Medicine
| | - Jonas Z Hines
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Kristen A Stafford
- Center for International Health, Education, and Biosecurity, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kumbutso Dzekedzeke
- Center for International Health, Education, and Biosecurity, Maryland Global Initiatives Corporation-an affiliate of the University of Maryland, Baltimore, Lusaka, Zambia
| | | | - Brianna Lindsay
- Center for International Health, Education, and Biosecurity, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mumbi Chola
- Center for International Health, Education, and Biosecurity, Maryland Global Initiatives Corporation-an affiliate of the University of Maryland, Baltimore, Lusaka, Zambia
| | - Faith Ussery
- U.S. Centers for Disease Control and Prevention, Atlanta, USA
| | - Hetal K Patel
- U.S. Centers for Disease Control and Prevention, Atlanta, USA
| | - Alash'le Abimiku
- Center for International Health, Education, and Biosecurity, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sehin Birhanu
- U.S. Centers for Disease Control and Prevention, Atlanta, USA
| | | | - Thomas Stevens
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Brave Hanunka
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | | | | | | | | | | | | | - Mpanji Siwingwa
- University Teaching Hospital
- University of Zambia, School of Medicine
| | - Gina Mulundu
- University Teaching Hospital
- University of Zambia, School of Medicine
| | - Chinedu Agbakwuru
- Center for International Health, Education, and Biosecurity, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Prichard Mapondera
- Center for International Health, Education, and Biosecurity, Maryland Global Initiatives Corporation-an affiliate of the University of Maryland, Baltimore, Lusaka, Zambia
| | - Mervi Detorio
- U.S. Centers for Disease Control and Prevention, Atlanta, USA
| | - Simon G Agolory
- U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Mwaka Monze
- Ministry of Health
- University Teaching Hospital
| | - Megan Bronson
- U.S. Centers for Disease Control and Prevention, Atlanta, USA
| | - Man E Charurat
- Center for International Health, Education, and Biosecurity, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
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Chen C, Chen H, Wu L, Gong Q, He J. Factors influencing rapid antiretroviral therapy initiation in Jiulongpo, Chongqing, China: a retrospective cohort from 2018 to 2022. AIDS Res Ther 2024; 21:15. [PMID: 38494484 PMCID: PMC10944594 DOI: 10.1186/s12981-024-00601-y] [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] [Received: 11/01/2023] [Accepted: 03/03/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Antiretroviral Therapy (ART) is pivotal in extending the lives of people living with HIV (PLWH) and minimizing transmission. Rapid ART initiation, defined as commencing ART within seven days of HIV diagnosis, is recommended for all PLWH. METHOD A retrospective cohort study was conducted using data from the China Information System for Disease Control and Prevention. This study included PLWH diagnosed between January 2018 and December 2021 and treated by December 2022. Factors influencing rapid ART initiation were examined using univariate and multivariate Cox regression analyses. RESULTS The study analyzed 1310 cases. The majority were male (77.4%), over 50 years old (46.7%), and contracted HIV through heterosexual transmission (70.0%). Rapid ART initiation was observed in 36.6% (n = 479) of cases, with a cumulative treatment rate of 72.9% within 30 days post-diagnosis. Heterosexual contact was associated with longer intervals from diagnosis to treatment initiation compared to homosexual contact (Adjusted Hazard Ratio (HR) = 0.813, 95% Confidence Interval (CI): 0.668-0.988). Individuals older than 50 years (Adjusted HR = 1.852, 95%CI: 1.149-2.985) were more likely to initiate ART rapidly. Conversely, treatment at the Second Public Hospital (Adjusted HR = 0.483, 95% CI: 0.330-0.708) and a CD4 cell counts above 500 (Adjusted HR = 0.553, 95% CI: 0.332-0.921) were associated with a lower likelihood of initiating treatment within seven days. CONCLUSIONS A higher CD4 cell counts and receiving care in local public hospitals may deter rapid ART initiation. Providing CD4 counts results at diagnosis and offering testing and treatment in the same facility could enhance the rate of rapid ART initiation.
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Affiliation(s)
- Cheng Chen
- Center for Disease Control and Prevention of Jiulongpo Distract, Chongqing, China
| | - Hao Chen
- Center for Disease Control and Prevention of Jiulongpo Distract, Chongqing, China
| | - Lingli Wu
- Center for Disease Control and Prevention of Jiulongpo Distract, Chongqing, China
| | - Qin Gong
- Center for Disease Control and Prevention of Jiulongpo Distract, Chongqing, China
| | - Jingchun He
- Center for Disease Control and Prevention of Jiulongpo Distract, Chongqing, China.
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Brazier E, Tymejczyk O, Wools-Kaloustian K, Jiamsakul A, Torres MTL, Lee JS, Abuogi L, Khol V, Mejía Cordero F, Althoff KN, Law MG, Nash D. Long-term HIV care outcomes under universal HIV treatment guidelines: A retrospective cohort study in 25 countries. PLoS Med 2024; 21:e1004367. [PMID: 38498589 PMCID: PMC10962811 DOI: 10.1371/journal.pmed.1004367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 03/25/2024] [Accepted: 02/22/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND While national adoption of universal HIV treatment guidelines has led to improved, timely uptake of antiretroviral therapy (ART), longer-term care outcomes are understudied. There is little data from real-world service delivery settings on patient attrition, viral load (VL) monitoring, and viral suppression (VS) at 24 and 36 months after HIV treatment initiation. METHODS AND FINDINGS For this retrospective cohort analysis, we used observational data from 25 countries in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium's Asia-Pacific, Central Africa, East Africa, Central/South America, and North America regions for patients who were ART naïve and aged ≥15 years at care enrollment between 24 months before and 12 months after national adoption of universal treatment guidelines, occurring 2012 to 2018. We estimated crude cumulative incidence of loss-to-clinic (CI-LTC) at 12, 24, and 36 months after enrollment among patients enrolling in care before and after guideline adoption using competing risks regression. Guideline change-associated hazard ratios of LTC at each time point after enrollment were estimated via cause-specific Cox proportional hazards regression models. Modified Poisson regression was used to estimate relative risks of retention, VL monitoring, and VS at 12, 24, and 36 months after ART initiation. There were 66,963 patients enrolling in HIV care at 109 clinics with ≥12 months of follow-up time after enrollment (46,484 [69.4%] enrolling before guideline adoption and 20,479 [30.6%] enrolling afterwards). More than half (54.9%) were females, and median age was 34 years (interquartile range [IQR]: 27 to 43). Mean follow-up time was 51 months (standard deviation: 17 months; range: 12, 110 months). Among patients enrolling before guideline adoption, crude CI-LTC was 23.8% (95% confidence interval [95% CI] 23.4, 24.2) at 12 months, 31.0% (95% CI [30.6, 31.5]) at 24 months, and 37.2% (95% [CI 36.8, 37.7]) at 36 months after enrollment. Adjusting for sex, age group, enrollment CD4, clinic location and type, and country income level, enrolling in care and initiating ART after guideline adoption was associated with increased hazard of LTC at 12 months (adjusted hazard ratio [aHR] 1.25 [95% CI 1.08, 1.44]; p = 0.003); 24 months (aHR 1.38 [95% CI 1.19, 1.59]; p < .001); and 36 months (aHR 1.34 [95% CI 1.18, 1.53], p < .001) compared with enrollment before guideline adoption, with no before-after differences among patients with no record of ART initiation by end of follow-up. Among patients retained after ART initiation, VL monitoring was low, with marginal improvements associated with guideline adoption only at 12 months after ART initiation. Among those with VL monitoring, VS was high at each time point among patients enrolling before guideline adoption (86.0% to 88.8%) and afterwards (86.2% to 90.3%), with no substantive difference associated with guideline adoption. Study limitations include lags in and potential underascertainment of care outcomes in real-world service delivery data and potential lack of generalizability beyond IeDEA sites and regions included in this analysis. CONCLUSIONS In this study, adoption of universal HIV treatment guidelines was associated with lower retention after ART initiation out to 36 months of follow-up, with little change in VL monitoring or VS among retained patients. Monitoring long-term HIV care outcomes remains critical to identify and address causes of attrition and gaps in HIV care quality.
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Affiliation(s)
- Ellen Brazier
- City University of New York, Institute for Implementation Science in Population Health (ISPH), New York, New York, United States of America
- City University of New York, Graduate School of Public Health and Health Policy, New York, New York, United States of America
| | - Olga Tymejczyk
- City University of New York, Institute for Implementation Science in Population Health (ISPH), New York, New York, United States of America
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | | | - Marco Tulio Luque Torres
- Department of Pediatrics, Instituto Hondureño de Seguridad Social and Hospital Escuela Universitario, Tegucigalpa, Honduras
| | - Jennifer S. Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Lisa Abuogi
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado, United States of America
| | - Vohith Khol
- National Center for HIV/AIDS, Dermatology and STDs, Phnom Penh, Cambodia
| | - Fernando Mejía Cordero
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Keri N. Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Matthew G. Law
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Denis Nash
- City University of New York, Institute for Implementation Science in Population Health (ISPH), New York, New York, United States of America
- City University of New York, Graduate School of Public Health and Health Policy, New York, New York, United States of America
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Mody A, Sohn AH, Iwuji C, Tan RKJ, Venter F, Geng EH. HIV epidemiology, prevention, treatment, and implementation strategies for public health. Lancet 2024; 403:471-492. [PMID: 38043552 DOI: 10.1016/s0140-6736(23)01381-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/28/2023] [Accepted: 06/29/2023] [Indexed: 12/05/2023]
Abstract
The global HIV response has made tremendous progress but is entering a new phase with additional challenges. Scientific innovations have led to multiple safe, effective, and durable options for treatment and prevention, and long-acting formulations for 2-monthly and 6-monthly dosing are becoming available with even longer dosing intervals possible on the horizon. The scientific agenda for HIV cure and remission strategies is moving forward but faces uncertain thresholds for success and acceptability. Nonetheless, innovations in prevention and treatment have often failed to reach large segments of the global population (eg, key and marginalised populations), and these major disparities in access and uptake at multiple levels have caused progress to fall short of their potential to affect public health. Moving forward, sharper epidemiologic tools based on longitudinal, person-centred data are needed to more accurately characterise remaining gaps and guide continued progress against the HIV epidemic. We should also increase prioritisation of strategies that address socio-behavioural challenges and can lead to effective and equitable implementation of existing interventions with high levels of quality that better match individual needs. We review HIV epidemiologic trends; advances in HIV prevention, treatment, and care delivery; and discuss emerging challenges for ending the HIV epidemic over the next decade that are relevant for general practitioners and others involved in HIV care.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.
| | - Annette H Sohn
- TREAT Asia, amfAR, The Foundation for AIDS Research, Bangkok, Thailand
| | - Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Rayner K J Tan
- University of North Carolina Project-China, Guangzhou, China; Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
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Mody A, Filiatreau LM, Goss CW, Powell BJ, Geng EH. Instrumental variables for implementation science: exploring context-dependent causal pathways between implementation strategies and evidence-based interventions. Implement Sci Commun 2023; 4:157. [PMID: 38124203 PMCID: PMC10731809 DOI: 10.1186/s43058-023-00536-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND The impact of both implementation strategies (IS) and evidence-based interventions (EBI) can vary across contexts, and a better understanding of how and why this occurs presents fundamental but challenging questions that implementation science as a field will need to grapple with. We use causal epidemiologic methods to explore the mechanisms of why sharp distinctions between implementation strategies (IS) and efficacy of an evidence-based intervention (EBI) may fail to recognize that the effect of an EBI can be deeply intertwined and dependent on the context of the IS leading to its uptake. METHODS We explore the use of instrumental variable (IV) analyses as a critical tool for implementation science methods to isolate three relevant quantities within the same intervention context when exposure to an implementation strategy is random: (1) the effect of an IS on implementation outcomes (e.g., uptake), (2) effect of EBI uptake on patient outcomes, and (3) overall effectiveness of the IS (i.e., ~ implementation*efficacy). We discuss the mechanisms by which an implementation strategy can alter the context, and therefore effect, of an EBI using the underlying IV assumptions. We illustrate these concepts using examples of the implementation of new ART initiation guidelines in Zambia and community-based masking programs in Bangladesh. RESULTS Causal questions relevant to implementation science are answered at each stage of an IV analysis. The first stage assesses the effect of the IS (e.g., new guidelines) on EBI uptake (e.g., same-day treatment initiation). The second stage leverages the IS as an IV to estimate the complier average causal effect (CACE) of the EBI on patient outcomes (e.g., effect of same-day treatment initiation on viral suppression). The underlying assumptions of CACE formalize that the causal effect of EBI may differ in the context of a different IS because (1) the mechanisms by which individuals uptake an intervention may differ and (2) the subgroup of individuals who take up an EBI may differ. IV methods thus provide a conceptual framework for how IS and EBIs are linked and that the IS itself needs to be considered a critical contextual determinant. Moreover, it also provides rigorous methodologic tools to isolate the effect of an IS, EBI, and combined effect of the IS and EBI. DISCUSSION Leveraging IV methods when exposure to an implementation strategy is random helps to conceptualize the context-dependent nature of implementation strategies, EBIs, and patient outcomes. IV methods formalize that the causal effect of an EBI may be specific to the context of the implementation strategy used to promote uptake. This integration of implementation science concepts and theory with rigorous causal epidemiologic methods yields novel insights and provides important tools for exploring the next generation of questions related to mechanisms and context in implementation science.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO, 63110, USA.
| | - Lindsey M Filiatreau
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO, 63110, USA
| | - Charles W Goss
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Byron J Powell
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA
| | - Elvin H Geng
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO, 63110, USA
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Bekolo C, Ndeso S, Gougue C, Moifo L, Mangala N, Tchendjou P, Mboh E, Ateudjieu J, Tendongfor N, Nsagha D, Halle-Ekane G, Choukem S. The effect of the Universal Test and Treat policy uptake on CD4 count testing and incidence of opportunistic infections among people living with HIV infection in Cameroon: a retrospective analysis of routine data. DIALOGUES IN HEALTH 2023; 2:100120. [PMID: 38515498 PMCID: PMC10954022 DOI: 10.1016/j.dialog.2023.100120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/05/2023] [Accepted: 02/23/2023] [Indexed: 03/23/2024]
Abstract
Background Cameroon adopted and started implementing in 2016, the 'universal test and treat' (UTT) guidelines to fast-track progress towards the 95-95-95 ambitious targets to end the HIV epidemic. UTT has shown inconsistent results elsewhere and has not yet been assessed in Cameroon. We aimed to evaluate the effectiveness of this novel approach on the quality of care and health outcomes of people living with HIV (PLHIV). Methods A retrospective cohort design was conducted at The Nkongsamba Regional Hospital, using routine clinical service delivery data to measure uptake levels of UTT and CD4 testing, and to compare the incidence of opportunistic infections (OI) between PLHIV initiated on ART based on the "Universal Test and Treat" strategy and those initiated on ART based on the standard deferred approach between 2002 and 2020. Kaplan Meier plots and log-rank tests were used to compare OI events between the pre-UTT and post-UTT eras. The Cox regression model was used to screen for factors independently associated with the risk of acquisition of OI. Results The uptake of UTT ranged from 39.1% to 92.8% while baseline CD4 count testing reduced drastically from 89.4% to 0.4% between 2016 to 2020 respectively. The median delay in ART initiation declined significantly from 21 days (IQR: 9 - 113) in the pre-UTT era to the same day of diagnosis (IQR: 0 - 2) in the UTT era (p < 0.001). The incidence of all OI events reported was over five times higher during the UTT era than in the pre-UTT era [aHR = 5.55 (95% CI: 3.18 - 9.69), p < 0.001]. Conclusion The UTT policy has been effectively rolled out and has contributed to improved access to rapid and immediate ART initiation, but a higher incidence of OIs was observed with a rollback of baseline CD4 testing. We advocate for a return to routine baseline CD4 measurement to identify PLHIV who should benefit from interventions to prevent OIs for optimal outcomes under the UTT approach.
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Affiliation(s)
- C.E. Bekolo
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - S.A. Ndeso
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - C.P. Gougue
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - L.L. Moifo
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - N. Mangala
- Department of Gynaecology and Obstetrics, University of Douala, Douala, Cameroon
| | - P. Tchendjou
- Elizabeth Glaser Pediatric AIDS Foundation, EGPAF Yaounde, Yaounde, Cameroon
| | - E. Mboh
- Cameroon Baptist Convention Health Services, Bamenda, Cameroon
| | - J. Ateudjieu
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - N. Tendongfor
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - D.S. Nsagha
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - G.E. Halle-Ekane
- Department of Obstetrics and Gynaecology, University of Buea, Buea, Cameroon
| | - S.P. Choukem
- Department of Internal Medicine and Specialities, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
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Bakari HM, Alo O, Mbwana MS, Salim SM, Ludeman E, Lascko T, Ramadhani HO. Same-day ART initiation, loss to follow-up and viral load suppression among people living with HIV in low- and middle-income countries: systematic review and meta-analysis. Pan Afr Med J 2023; 46:92. [PMID: 38405092 PMCID: PMC10891376 DOI: 10.11604/pamj.2023.46.92.40848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/02/2023] [Indexed: 02/27/2024] Open
Abstract
Introduction in 2015, the World Health Organization recommended early antiretroviral therapy (ART) initiation after HIV diagnosis. Mixed results on the effect of same-day ART initiation (SDI) over non-same-day ART initiation (NSDI) on loss to follow-up (LTFU) and viral load suppression (VLS) necessitate further evaluation. Methods this was a systematic review and meta-analysis of people living with HIV in low- and middle-income countries (LMICs). Multiple databases were searched from January 2016 to December 2022. VLS was defined as HIV RNA <1,000 or <400 cells/ml, depending on the study. Forest plots were used to present the pooled prevalence and 95% confidence intervals (CIs). Heterogeneity was tested by an I2 statistic and a p-value of <0.05 indicated its presence. Analyses were performed in STATA. Results sixteen studies (5 clinical trials, 10 cohorts, and 1 cross-sectional) were included in the final analysis. Nine studies with 157,633 people living with HIV were analyzed for LTFU and the pooled prevalence of LTFU was 22.0% (95%CI; 18.5-25.7). The pooled prevalence of VLS was 72.7% (95%CI; 65.4-79.5%). The I2 statistic had a Q value of 200.62 (p<0.001) and 44.63 (p<0.001) for pooled prevalence of LTFU and VLS, respectively. Overall, compared to those who received NSDI, SDI had a significantly increased risk of LTFU (risk difference (RD)=0.04; 95%CI: 0.01-0.07). Although observational studies showed an increased risk of LTFU among SDI compared to NSDI (RD=0.05, 95%CI: 0.02-0.08), clinical trials did not. There was no statistically significant difference in VLS comparing those who received SDI vs NSDI (RD= 0.02, 95%CI: -0.03 - 0.07). Conclusion nearly two in ten people living with HIV in LMICs who initiated ART were LTFU. SDI was associated with increased risk of LTFU. Efforts to prevent LTFU among those who receive SDI are critical to maximize its potential benefits.
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Affiliation(s)
- Hafidha Mhando Bakari
- President’s Office Regional Administration and Local Government, Ajira Yako, Tanzania
| | - Oluwafemi Alo
- Center for International Health Education and Biosecurity, Maryland Global Initiatives Corporation affiliate of the University of Maryland Baltimore, Abuja, Nigeria
| | | | | | - Emilie Ludeman
- Health Services and Human Services Library, University of Maryland Baltimore, Baltimore, United States
| | - Taylor Lascko
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, United States
- Institute of Human Virology, University of Maryland, School of Medicine, Baltimore, Maryland, United States
| | - Habib Omari Ramadhani
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, United States
- Institute of Human Virology, University of Maryland, School of Medicine, Baltimore, Maryland, United States
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9
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Ye J, Xiong S, Wang T, Li J, Cheng N, Tian M, Yang Y. The Roles of Electronic Health Records for Clinical Trials in Low- and Middle-Income Countries: Scoping Review. JMIR Med Inform 2023; 11:e47052. [PMID: 37991820 DOI: 10.2196/47052] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 09/10/2023] [Accepted: 09/22/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Clinical trials are a crucial element in advancing medical knowledge and developing new treatments by establishing the evidence base for safety and therapeutic efficacy. However, the success of these trials depends on various factors, including trial design, project planning, research staff training, and adequate sample size. It is also crucial to recruit participants efficiently and retain them throughout the trial to ensure timely completion. OBJECTIVE There is an increasing interest in using electronic health records (EHRs)-a widely adopted tool in clinical practice-for clinical trials. This scoping review aims to understand the use of EHR in supporting the conduct of clinical trials in low- and middle-income countries (LMICs) and to identify its strengths and limitations. METHODS A comprehensive search was performed using 5 databases: MEDLINE, Embase, Scopus, Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature. We followed the latest version of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guideline to conduct this review. We included clinical trials that used EHR at any step, conducted a narrative synthesis of the included studies, and mapped the roles of EHRs into the life cycle of a clinical trial. RESULTS A total of 30 studies met the inclusion criteria: 13 were randomized controlled trials, 3 were cluster randomized controlled trials, 12 were quasi-experimental studies, and 2 were feasibility pilot studies. Most of the studies addressed infectious diseases (15/30, 50%), with 80% (12/15) of them about HIV or AIDS and another 40% (12/30) focused on noncommunicable diseases. Our synthesis divided the roles of EHRs into 7 major categories: participant identification and recruitment (12/30, 40%), baseline information collection (6/30, 20%), intervention (8/30, 27%), fidelity assessment (2/30, 7%), primary outcome assessment (24/30, 80%), nonprimary outcome assessment (13/30, 43%), and extended follow-up (2/30, 7%). None of the studies used EHR for participant consent and randomization. CONCLUSIONS Despite the enormous potential of EHRs to increase the effectiveness and efficiency of conducting clinical trials in LMICs, challenges remain. Continued exploration of the appropriate uses of EHRs by navigating their strengths and limitations to ensure fitness for use is necessary to better understand the most optimal uses of EHRs for conducting clinical trials in LMICs.
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Affiliation(s)
- Jiancheng Ye
- Weill Cornell Medicine, New York, NY, United States
- Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Shangzhi Xiong
- The George Institute for Global Health, Faulty of Medicine and Health, University of New South Wales, Sydney, Australia
- Global Health Research Centre, Duke Kunshan University, Kunshan, China
| | - Tengyi Wang
- School of Public Health, Harbin Medical University, Harbin, China
| | - Jingyi Li
- School of Basic Medicine, Harbin Medical University, Harbin, China
| | - Nan Cheng
- The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Maoyi Tian
- The George Institute for Global Health, Faulty of Medicine and Health, University of New South Wales, Sydney, Australia
- School of Public Health, Harbin Medical University, Harbin, China
| | - Yang Yang
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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10
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Tao Y, Xiao X, Zhang C, Xie Y, Wang H. Prevalence of delayed antiretroviral therapy initiation among people living with HIV: A systematic review and meta-analysis. PLoS One 2023; 18:e0286476. [PMID: 37874794 PMCID: PMC10597480 DOI: 10.1371/journal.pone.0286476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 05/16/2023] [Indexed: 10/26/2023] Open
Abstract
OBJECTIVE HIV continues to be a global challenge. Key recommendations for HIV prevention and treatment are presented on rapid antiretroviral therapy (ART) initiation. However, several studies showed a high prevalence of delayed ART initiation. The aim of this systematic review and meta-analysis was to assess the prevalence of delayed ART initiation among HIV-infected patients globally. METHODS This review summarised eligible studies conducted between January 2015 and August 2022 on the prevalence of delayed ART initiation in HIV-infected adults (age ≥ 15). Relevant studies were systematic searched through PubMed/Medline, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang, and Chongqing VIP databases. Random-effects models were used to calculate pooled prevalence estimates. The heterogeneity was evaluated using Cochran's Q test and I2 statistics. Moreover, potential sources of heterogeneity were explored using univariate subgroup analysis. RESULTS Data on the prevalence of delayed ART initiation was pooled across 29 studies involving 34,937 participants from 15 countries. The overall pooled prevalence of delayed ART initiation was 36.1% [95% confidence interval (CI), 29.7-42.5%]. In subgroup analysis, the estimated pooled prevalence decreased with age. By sex, the prevalence was higher among male patients (39.3%, 95% CI: 32.2-46.4%) than female (36.5%, 95% CI: 26.9-50.7%). Patients with high CD4 cell count were more likely to delay ART initiation than those with low CD4 cell count (>500cells/mm3: 40.3%; 201-500cells/mm3: 33.4%; and ≤200cells/mm3: 25.3%). CONCLUSIONS Our systematic review and meta-analysis identified a high prevalence of delayed ART initiation. The prolonged time interval between diagnosis and treatment is a prevalent and unaddressed problem that should spur initiatives from countries globally. Further research is urgently needed to identify effective strategies for promoting the early ART initiation.
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Affiliation(s)
- Yan Tao
- Xiangya Nursing School, Central South University, Changsha, Hunan Province, People's Republic of China
| | - Xueling Xiao
- Xiangya Nursing School, Central South University, Changsha, Hunan Province, People's Republic of China
| | - Ci Zhang
- Xiangya Nursing School, Central South University, Changsha, Hunan Province, People's Republic of China
| | - Ying Xie
- Xiangya Nursing School, Central South University, Changsha, Hunan Province, People's Republic of China
| | - Honghong Wang
- Xiangya Nursing School, Central South University, Changsha, Hunan Province, People's Republic of China
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11
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Labhardt ND, Brown JA, Sass N, Ford N, Rosen S. Treatment Outcomes After Offering Same-Day Initiation of Human Immunodeficiency Virus Treatment-How to Interpret Discrepancies Between Different Studies. Clin Infect Dis 2023; 77:1176-1184. [PMID: 37229594 PMCID: PMC10573746 DOI: 10.1093/cid/ciad317] [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] [Received: 03/16/2023] [Revised: 05/18/2023] [Accepted: 05/23/2023] [Indexed: 05/27/2023] Open
Abstract
The World Health Organization recommends same-day initiation of antiretroviral therapy (ART) for all persons diagnosed with HIV and ready to start treatment. Evidence, mainly from randomized trials, indicates offering same-day ART increases engagement in care and viral suppression during the first year. In contrast, most observational studies using routine data find same-day ART to be associated with lower engagement in care. We argue that this discrepancy is mainly driven by different time points of enrollment, leading to different denominators. While randomized trials enroll individuals when tested positive, most observational studies start at the time point when ART is initiated. Thus, most observational studies omit those who are lost between diagnosis and treatment, thereby introducing a selection bias in the group with delayed ART. This viewpoint article summarizes the available evidence and argues that the benefits of same-day ART outweigh a potential higher risk of attrition from care after ART initiation.
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Affiliation(s)
- Niklaus Daniel Labhardt
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Jennifer Anne Brown
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Nikita Sass
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Nathan Ford
- Department of HIV, Hepatitis, and Sexually Transmitted Infections, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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12
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Hamooya BM, Mutembo S, Muyunda B, Mweebo K, Kancheya N, Sikazwe L, Sakala M, Mvula J, Kunda S, Kabesha S, Cheelo C, Fwemba I, Banda C, Masenga SK. HIV test-and-treat policy improves clinical outcomes in Zambian adults from Southern Province: a multicenter retrospective cohort study. Front Public Health 2023; 11:1244125. [PMID: 37900026 PMCID: PMC10600392 DOI: 10.3389/fpubh.2023.1244125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/11/2023] [Indexed: 10/31/2023] Open
Abstract
Background Globally, most countries have implemented a test-and-treat policy to reduce morbidity and mortality associated with HIV infection. However, the impact of this strategy has not been critically appraised in many settings, including Zambia. We evaluated the retention and clinical outcomes of adults enrolled in antiretroviral therapy (ART) and assessed the impact of the test-and-treat policy. Methods We conducted a retrospective cohort study among 6,640 individuals who initiated ART between January 1, 2014 and July 31, 2016 [before test-and-treat cohort (BTT), n = 2,991] and between August 1, 2016 and October 1, 2020 [after test-and-treat cohort (ATT), n = 3,649] in 12 districts of the Southern province. To assess factors associated with retention, we used logistic regression (xtlogit model). Results The median age [interquartile range (IQR)] was 34.8 years (28.0, 42.1), and 60.2% (n = 3,995) were women. The overall retention was 83.4% [95% confidence interval (CI) 82.6, 84.4], and it was significantly higher among the ATT cohort, 90.6 vs. 74.8%, p < 0.001. The reasons for attrition were higher in the BTT compared to the ATT cohorts: stopped treatment (0.3 vs. 0.1%), transferred out (9.3 vs. 3.2%), lost to follow-up (13.5 vs. 5.9%), and death (1.4 vs. 0.2%). Retention in care was significantly associated with the ATT cohort, increasing age and baseline body mass index (BMI), rural residence, and WHO stage 2, while non-retention was associated with never being married, divorced, and being in WHO stage 3. Conclusion The retention rate and attrition factors improved in the ATT compared to the BTT cohorts. Drivers of retention were test-and-treat policy, older age, high BMI, rural residence, marital status, and WHO stage 1. Therefore, there is need for interventions targeting young people, urban residents, non-married people, and those in the symptomatic WHO stages and with low BMI. Our findings highlight improved ART retention after the implementation of the test-and-treat policy.
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Affiliation(s)
- Benson M. Hamooya
- School of Medicine and Health Sciences, Mulungushi University, Livingstone, Zambia
| | - Simon Mutembo
- International Vaccine Access Center, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Brian Muyunda
- Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Keith Mweebo
- Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Nzali Kancheya
- Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Lyapa Sikazwe
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Morgan Sakala
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Johanzi Mvula
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Salazeh Kunda
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Shem Kabesha
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Chilala Cheelo
- School of Medicine and Health Sciences, Mulungushi University, Livingstone, Zambia
| | - Isaac Fwemba
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Clive Banda
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Sepiso K. Masenga
- School of Medicine and Health Sciences, Mulungushi University, Livingstone, Zambia
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13
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Knox J, Schwartz S, Duncan DT, Curran G, Schneider J, Stephenson R, Wilson P, Nash D, Sullivan P, Geng E. Proposing the observational-implementation hybrid approach: designing observational research for rapid translation. Ann Epidemiol 2023; 85:45-50. [PMID: 37015306 DOI: 10.1016/j.annepidem.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/01/2023] [Accepted: 03/24/2023] [Indexed: 04/04/2023]
Abstract
We propose the observational-implementation hybrid approach-the incorporation of implementation science methods and measures into observational studies to collect information that would allow researchers to anticipate, estimate, or infer the effects of interventions and implementation strategies. Essentially, we propose that researchers collect implementation data early in the research pipeline, in situations where they might not typically be thinking about implementation science. We describe three broad contextual scenarios through which the observational-implementation hybrid approach would most productively be applied. The first application is for observational cohorts that individually enroll participants-either for existing (to which implementation concepts could be added) or for newly planned studies. The second application is with routinely collected program data, at either the individual or aggregate levels. The third application is to the collection of data from study participants enrolled in an observational cohort study who are also involved in interventions linked to that study (e.g., collecting data about their experiences with those interventions). Examples of relevant implementation data that could be collected as part of observational studies include factors relevant to transportability, participant preferences, and participant/provider perspectives regarding interventions and implementation strategies. The observational-implementation hybrid model provides a practical approach to make the research pipeline more efficient and to decrease the time from observational research to health impact. If this approach is widely adopted, observational and implementation science studies will become more integrated; this will likely lead to new collaborations, will encourage the expansion of epidemiological training, and, we hope, will push both epidemiologists and implementation scientists to increase the public health impact of their work.
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Affiliation(s)
- Justin Knox
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY; HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York; Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY.
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Dustin T Duncan
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | - Geoff Curran
- Center for Implementation Research, University of Arkansas for Medical Sciences, Little Rock
| | - John Schneider
- Department of Medicine, University of Chicago, Chicago, IL
| | - Rob Stephenson
- The Center for Sexuality and Health Disparities, University of Michigan, Ann Arbor
| | - Patrick Wilson
- Department of Psychology, University of California, Los Angeles
| | - Denis Nash
- Department of Epidemiology, School of Public Health, City University of New York, New York
| | - Patrick Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Elvin Geng
- Washington University School of Medicine, St. Louis, MO
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14
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Bekolo CE, Ndeso SA, Moifo LL, Mangala N, Yimdjo TD, Ateudjieu J, Kouanfack C, Djam A, Tabah EN, Whegang S, Mapa-Tassou C, Tendongfor N, Nsagha DS, Choukem SP. Universal test and treat in Cameroon: a comparative retrospective analysis of mortality and loss to follow-up before and after a strategic change in approach to HIV care. Pan Afr Med J 2023; 45:191. [PMID: 38020352 PMCID: PMC10656581 DOI: 10.11604/pamj.2023.45.191.40448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/09/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction an increasing number of persons living with HIV (PLHIV) are accessing antiretroviral therapy (ART) since the adoption of the universal test and treat (UTT) policy by Cameroon in 2016. We sought to evaluate the effectiveness of the UTT approach to keep this growing number of PLHIV on a lifelong treatment. Methods a retrospective cohort analysis was conducted at the Nkongsamba Regional Hospital between 2002 and 2020, using routine data to compare the cumulative incidence of loss to follow-up (LTFU) and mortality between PLHIV initiated on ART under UTT guidelines and those initiated under the standard deferred approach. Chi-squared test was used to compare the risk of attrition between the guideline periods while multiple logistic regression modelling was used to adjust for confounders. Results of 1627 PLHIV included for analysis, 756 (46.47%) were enrolled during the era of UTT with 545 (33.54%) initiated on ART on the same day of HIV diagnosis. The transition to the UTT era was associated with an overall reduction in the risk of LTFU by 73% (aOR = 0.27, 95%CI: 0.17 - 0.45). There was modest evidence that the odds of mortality had increased under the UTT policy by about 3-fold (aOR = 2.86, 95%CI: 0.91-8.94). Same-day initiation had no overall effect on LTFU or mortality. LTFU was lower among the same-day initiators in the first 24 months but increased thereafter above the rate among late initiators. Conclusion overall ART programme implementation under the UTT has led to a significant decline in LTFU though mortality appeared to have increased. Ongoing efforts to keep patients on long-term treatment should be sustained while other innovative schemes are sought.
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Affiliation(s)
- Cavin Epie Bekolo
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Sylvester Atanga Ndeso
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Linda Lucienne Moifo
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Nkwele Mangala
- Department of Gynaecology and Obstetrics, University of Douala, Douala, Cameroon
| | | | - Jerome Ateudjieu
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Charles Kouanfack
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Alain Djam
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Earnest Njih Tabah
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Solange Whegang
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Clarisse Mapa-Tassou
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Nicolas Tendongfor
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Dickson Shey Nsagha
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Siméon-Pierre Choukem
- Department of Internal Medicine and Specialities, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
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15
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Rosen JG, Muraleetharan O, Walker A, Srivastava M. Pediatric Antiretroviral Therapy Coverage and AIDS Deaths in the "Treat All" Era. Pediatrics 2023; 151:e2022059013. [PMID: 37194480 PMCID: PMC10829847 DOI: 10.1542/peds.2022-059013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 05/18/2023] Open
Abstract
OBJECTIVES In 2015, CD4-based clinical staging criteria for antiretroviral therapy (ART) initiation were removed, expanding ART eligibility ("Treat All") for children, who shoulder an outsized burden of HIV-related deaths. To quantify the impact of "Treat All" on pediatric HIV outcomes, we examined shifts in pediatric ART coverage and AIDS mortality before and after "Treat All" implementation. METHODS We abstracted country-level ART coverage (proportion of children <15 years on ART) and AIDS mortality (deaths per 100 000 population) estimates over 11 years. For 91 countries, we also abstracted the year "Treat All" was incorporated into national guidelines. We used multivariable 2-way fixed effects negative binomial regression to estimate changes in pediatric ART coverage and AIDS mortality potentially attributable to "Treat All" expansion, reported as adjusted incidence rate ratios (adj.IRR) with 95% confidence intervals (95% CI). RESULTS From 2010 to 2020, pediatric ART coverage tripled (16% to 54%), and AIDS-related deaths were halved (240 000 to 99 000). Compared with the pre-implementation period, observed ART coverage continued increasing after "Treat All" adoption, but this rate of increase declined by 6% (adj.IRR = 0.94, 95% CI: 0.91-0.98). AIDS mortality continued declining after "Treat All" adoption, but this rate of decline decreased by 8% (adj.IRR = 1.08, 95% CI: 1.05-1.11) in the post-implementation period. CONCLUSIONS Although "Treat All" called for increased HIV treatment equity, ART coverage continues lagging in children and comprehensive approaches that address structural issues, including family-based services and intensified case-finding, are needed to close pediatric HIV treatment gaps.
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Affiliation(s)
- Joseph G. Rosen
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ohvia Muraleetharan
- Office of HIV/AIDS, United States Agency for International Development, Washington, District of Columbia
| | - Allison Walker
- Office of HIV/AIDS, United States Agency for International Development, Washington, District of Columbia
| | - Meena Srivastava
- Office of HIV/AIDS, United States Agency for International Development, Washington, District of Columbia
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16
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Dovel KL, Hariprasad S, Hubbard J, Cornell M, Phiri K, Choko A, Abbott R, Hoffman R, Nichols B, Gupta S, Long L. Strategies to improve antiretroviral therapy (ART) initiation and early engagement among men in sub-Saharan Africa: A scoping review of interventions in the era of universal treatment. Trop Med Int Health 2023; 28:454-465. [PMID: 37132119 PMCID: PMC10354296 DOI: 10.1111/tmi.13880] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVES Men in sub-Saharan Africa (SSA) have lower rates of antiretroviral therapy (ART) initiation and higher rates of early default than women. Little is known about effective interventions to improve men's outcomes. We conducted a scoping review of interventions aimed to increase ART initiation and/or early retention among men in SSA since universal treatment policies were implemented. METHODS Three databases, HIV conference databases and grey literature were searched for studies published between January 2016 to May 2021 that reported on initiation and/or early retention among men. Eligibility criteria included: participants in SSA, data collected after universal treatment policies were implemented (2016-2021), quantitative data on ART initiation and/or early retention for males, general male population (not exclusively focused on key populations), intervention study (report outcomes for at least one non-standard service delivery strategy), and written in English. RESULTS Of the 4351 sources retrieved, 15 (reporting on 16 interventions) met inclusion criteria. Of the 16 interventions, only two (2/16, 13%) exclusively focused on men. Five (5/16, 31%) were randomised control trials (RCT), one (1/16, 6%) was a retrospective cohort study, and 10 (10/16, 63%) did not have comparison groups. Thirteen (13/16, 81%) interventions measured ART initiation and six (6/16, 37%) measured early retention. Outcome definitions and time frames varied greatly, with seven (7/16, 44%) not specifying time frames at all. Five types of interventions were represented: optimising ART services at health facilities, community-based ART services, outreach support (such as reminders and facility escort), counselling and/or peer support, and conditional incentives. Across all intervention types, ART initiation rates ranged from 27% to 97% and early retention from 47% to 95%. CONCLUSIONS Despite years of data of men's suboptimal ART outcomes, there is little high-quality evidence on interventions to increase men's ART initiation or early retention in SSA. Additional randomised or quasi-experimental studies are urgently needed.
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Affiliation(s)
- Kathryn L Dovel
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
- Partners in Hope Medical Center, Lilongwe, Malawi
| | - Santhi Hariprasad
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Julie Hubbard
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
- Partners in Hope Medical Center, Lilongwe, Malawi
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Khumbo Phiri
- Partners in Hope Medical Center, Lilongwe, Malawi
| | | | - Rachel Abbott
- Division of HIV, Infections Diseases & Global Medicine, University of California San Francisco, San Francisco, California, USA
| | - Risa Hoffman
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Brooke Nichols
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Sundeep Gupta
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Lawrence Long
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Huber A, Hirasen K, Brennan AT, Phiri B, Tcherini T, Mulenga L, Haimbe P, Shakwelele H, Nyirenda R, Wilson Matola B, Gunda A, Rosen S. Uptake of same-day initiation of HIV treatment in Malawi, South Africa, and Zambia as reported in routinely collected data: the SPRINT retrospective cohort study. Gates Open Res 2023; 7:42. [PMID: 37153118 PMCID: PMC10160348 DOI: 10.12688/gatesopenres.14424.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 05/11/2023] Open
Abstract
Background: Since 2017 global guidelines have recommended "same-day initiation" (SDI) of antiretroviral treatment (ART) for patients considered ready for treatment on the day of HIV diagnosis. Many countries have incorporated a SDI option into national guidelines, but SDI uptake is not well documented. We estimated average time to ART initiation at 12 public healthcare facilities in Malawi, five in South Africa, and 12 in Zambia. Methods: We identified patients eligible to start ART between January 2018 and June 2019 from facility testing registers and reviewed their medical records from HIV diagnosis to the earlier date of treatment initiation or 6 months. We estimated the proportion of patients initiating ART on the same day or within 7, 14, 30, or 180 days of baseline. Results: We enrolled 825 patients in Malawi, 534 in South Africa, and 1,984 in Zambia. Overall, 88% of patients in Malawi, 57% in South Africa, and 91% in Zambia received SDI. In Malawi, most who did not receive SDI had not initiated ART ≤6 months. In South Africa, an additional 13% initiated ≤1 week, but 21% had no record of initiation ≤6 months. Among those who did initiate within 6 months in Zambia, most started ≤1 week. There were no major differences by sex. WHO Stage III/IV and tuberculosis symptoms were associated with delays in ART initiation; clinic size and having a CD4 count done were associated with an increased likelihood of SDI. Conclusions: As of 2020, SDI of ART was widespread, if not nearly universal, in Malawi and Zambia but considerably less common in South Africa. Limitations of the study include pre-COVID-19 data that do not reflect pandemic adaptations and potentially missing data for Zambia. South Africa may be able to increase overall ART coverage by reducing numbers of patients who do not initiate ≤6 months.
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Affiliation(s)
- Amy Huber
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
| | - Kamban Hirasen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
| | - Alana T. Brennan
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
- Department Epidemiology, Boston University School of Public Health, Boston, MA, 02118, USA
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
| | - Bevis Phiri
- Clinton Health Access Institute-Zambia, Lusaka, Zambia
| | | | | | | | | | | | | | - Andrews Gunda
- Clinton Health Access Institute-Malawi, Lilongwe, Malawi
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
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18
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Huber A, Hirasen K, Brennan AT, Phiri B, Tcherini T, Mulenga L, Haimbe P, Shakwelele H, Nyirenda R, Wilson Matola B, Gunda A, Rosen S. Uptake of same-day initiation of HIV treatment among adult men and women in Malawi, South Africa, and Zambia: the SPRINT retrospective cohort study. Gates Open Res 2023; 7:42. [PMID: 37153118 PMCID: PMC10160348 DOI: 10.12688/gatesopenres.14424.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 02/24/2023] Open
Abstract
Background: Since 2017 global guidelines have recommended "same-day initiation" (SDI) of antiretroviral treatment (ART) for patients considered ready for treatment on the day of HIV diagnosis. Many countries have incorporated a SDI option into national guidelines, but SDI uptake is not well documented. We estimated average time to ART initiation at 12 public healthcare facilities in Malawi, five in South Africa, and 12 in Zambia. Methods: We sequentially enrolled patients eligible to start ART between January 2018 and June 2019 and reviewed their medical records from the point of HIV diagnosis or first HIV-related interaction with the clinic to the earlier date of treatment initiation or 6 months. We estimated the proportion of patients initiating ART on the same day or within 7, 14, 30, or 180 days of baseline. Results: We enrolled 826 patients in Malawi, 534 in South Africa, and 1,984 in Zambia. Overall, 88% of patients in Malawi, 57% in South Africa, and 91% in Zambia were offered and accepted SDI. In Malawi, most who did not receive SDI had not initiated ART ≤6 months. In South Africa, an additional 13% initiated ≤1 week, but 21% had no record of initiation ≤6 months. Among those who did initiate within 6 months in Zambia, most started ≤1 week. There were no major differences by sex. WHO Stage III/IV and tuberculosis symptoms were associated with delays in ART initiation. Conclusions: As of 2020, SDI of ART was widespread, if not nearly universal, in Malawi and Zambia but considerably less common in South Africa. Limitations of the study include pre-COVID-19 data that do not reflect pandemic adaptations and potentially missing data for Zambia. South Africa may be able to increase overall ART coverage by reducing numbers of patients who do not initiate ≤6 months. Registration: Clinicaltrials.gov ( NCT04468399; NCT04170374; NCT04470011).
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Affiliation(s)
- Amy Huber
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
| | - Kamban Hirasen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
| | - Alana T. Brennan
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
- Department Epidemiology, Boston University School of Public Health, Boston, MA, 02118, USA
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
| | - Bevis Phiri
- Clinton Health Access Institute-Zambia, Lusaka, Zambia
| | | | | | | | | | | | | | - Andrews Gunda
- Clinton Health Access Institute-Malawi, Lilongwe, Malawi
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
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Ross J, Brazier E, Fatti G, Jaquet A, Tanon A, Haas AD, Diero L, Castelnuovo B, Yiannoutsos CT, Nash D, Anastos KM, Yotebieng M. Same-Day Antiretroviral Therapy Initiation as a Predictor of Loss to Follow-up and Viral Suppression Among People With Human Immunodeficiency Virus in Sub-Saharan Africa. Clin Infect Dis 2023; 76:39-47. [PMID: 36097726 PMCID: PMC10202422 DOI: 10.1093/cid/ciac759] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/31/2022] [Accepted: 09/08/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Treat-All guidelines recommend initiation of antiretroviral therapy (ART) for all people with HIV (PWH) on the day of diagnosis when possible, yet uncertainty exists about the impact of same-day ART initiation on subsequent care engagement. We examined the association of same-day ART initiation with loss to follow-up and viral suppression among patients in 11 sub-Saharan African countries. METHODS We included ART-naive adult PWH from sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium who enrolled in care after Treat-All implementation and prior to January 2019. We used multivariable Cox regression to estimate the association between same-day ART initiation and loss to follow-up and Poisson regression to estimate the association between same-day ART initiation and 6-month viral suppression. RESULTS Among 29 017 patients from 63 sites, 18 584 (64.0%) initiated ART on the day of enrollment. Same-day ART initiation was less likely among those with advanced HIV disease versus early-stage disease. Loss to follow-up was significantly lower among those initiating ART ≥1 day of enrollment, compared with same-day ART initiators (20.6% vs 27.7%; adjusted hazard ratio: .66; 95% CI .57-.76). No difference in viral suppression was observed by time to ART initiation (adjusted rate ratio: 1.00; 95% CI: .98-1.02). CONCLUSIONS Patients initiating ART on the day of enrollment were more frequently lost to follow-up than those initiating later but were equally likely to be virally suppressed. Our findings support recent World Health Organization recommendations for providing tailored counseling and support to patients who accept an offer of same-day ART.
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Affiliation(s)
- Jonathan Ross
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
- Montefiore Health System, Bronx, New York, USA
| | - Ellen Brazier
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, USA
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | - Geoffrey Fatti
- Kheth’Impilo AIDS Free Living, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Antoine Jaquet
- University of Bordeaux, National Institute for Health and Medical Research (INSERM), UMR 1219, Research Institute for Sustainable Development (IRD), EMR 271, Bordeaux Population Health Centre, Bordeaux, France
| | - Aristophane Tanon
- Service de Maladies Infectieuses et Tropicales (SMIT), Treichville Teaching Hospital, Abidjan, Côte d’Ivoire
| | - Andreas D Haas
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Lameck Diero
- Department of Medicine, Moi University School of Medicine and Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Barbara Castelnuovo
- Department of Medicine, Moi University School of Medicine and Moi Teaching and Referral Hospital, Eldoret, Kenya
| | | | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, USA
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | - Kathryn M Anastos
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
- Montefiore Health System, Bronx, New York, USA
| | - Marcel Yotebieng
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
- Montefiore Health System, Bronx, New York, USA
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Sikazwe I, Bolton-Moore C, Herce MB. Nongovernmental organizations supporting the HIV service delivery response in Africa - an engine for innovation. Curr Opin HIV AIDS 2023; 18:52-56. [PMID: 36503879 DOI: 10.1097/coh.0000000000000774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Nongovernmental organizations (NGOs) are pivotal to the HIV response, supporting access to HIV services since the start of the epidemic. Against the backdrop of the impact of NGOs, is the recognition of the unique role that local NGOs bring to the HIV response, drawing from their deep understanding of the context and knowledge of local health problems. RECENT FINDINGS The Centre for Infectious Disease Research in Zambia (CIDRZ) is one such NGO. Through various implementation science research and programs, CIDRZ has supported the Zambian government's HIV response. As Zambia moves closer to epidemic control, understanding reasons for patient disengagement from care and patient preferences for HIV care demonstrated by CIDRZ have contributed to global and national HIV treatment and care guidelines. SUMMARY This paper offers a case study for how NGOs like CIDRZ can serve as health system-wide catalyst to identify, integrate, and scale up evidence-based practices for HIV prevention, care, and treatment. It draws from the public health literature, CIDRZ extensive program and research experience and implementation science theory, to illustrate key strategies that can be deployed by local NGOs to spark innovation, quality improvement, and support governments to achieve and sustain HIV epidemic control.
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Affiliation(s)
- Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- University of Alabama at Birmingham (UAB), Birmingham, Alabama
| | - Michael B Herce
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- University of North Carolina at Chapel Hill (UNC), Chapel Hill, North Carolina, USA
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