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Chabikuli ON, Ditekemena JD, Sigwadhi LN, Mulenga A, Mboyo A, Bidashimwa D, Nachega JB. Advanced HIV Disease at Antiretroviral Therapy Initiation and Treatment Outcomes Among Children and Adolescents Compared to Adults Living With HIV in Kinshasa, Democratic Republic of the Congo. J Int Assoc Provid AIDS Care 2023; 22:23259582231221955. [PMID: 38146172 PMCID: PMC10752042 DOI: 10.1177/23259582231221955] [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: 06/16/2023] [Revised: 11/17/2023] [Accepted: 12/01/2023] [Indexed: 12/27/2023] Open
Abstract
Background: Little is known about advanced HIV disease (AHD) at antiretroviral therapy (ART) initiation among children and adolescents living with HIV (CALHIV) and related age disparities in the Democratic Republic of the Congo (DRC). Methods: We conducted a retrospective cohort analysis of routine program data collected among adults, adolescents, and children living with HIV in 6 health zones in Kinshasa, DRC from 2005 to 2020. Results: Thirty-two percent of those who initiated ART had AHD. Compared to adults, adolescents had a 15% higher risk of AHD (RR: 1.15; 95% CI: 1.08-1.21; P < .001). Despite their higher risk of AHD, adolescents had a lower risk of mortality (aSHR: 0.72; 95% CI: 0.52-0.99; P = .047) and lower cumulative death events versus adults (aSHR: 0.44; 95% CI: 0.34-0.59; P < .001). Conclusions: ADH at ART initiation is highly prevalent in Kinshasa, DRC, and adolescents are disproportionally impacted. There is a need to scale up high-impact HIV interventions targeting CALHIV.
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Affiliation(s)
- Otto Nzapfurundi Chabikuli
- Family Health International (FHI 360), Durham, NC, USA
- Public Health Program, Graduate School, Howard University, Washington, DC, USA
| | - John D. Ditekemena
- Family Health International (FHI 360), Kinshasa, Democratic Republic of the Congo
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Lovemore Nyasha Sigwadhi
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Astrid Mulenga
- Family Health International (FHI 360), Kinshasa, Democratic Republic of the Congo
| | - Aimé Mboyo
- National AIDS Control Program, Kinshasa, Democratic Republic of the Congo
| | | | - Jean B. Nachega
- Departments of Epidemiology, Infectious Diseases and Microbiology and Center for Global Health, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
- Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health; Center for Global Health, Johns Hopkins University Baltimore, MD, USA
- Department of Medicine, Division of Infectious Diseases, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
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Stöger L, Katende A, Mapesi H, Kalinjuma AV, van Essen L, Klimkait T, Battegay M, Weisser M, Letang E. Persistent High Burden and Mortality Associated With Advanced HIV Disease in Rural Tanzania Despite Uptake of World Health Organization "Test and Treat" Guidelines. Open Forum Infect Dis 2022; 9:ofac611. [PMID: 36540386 PMCID: PMC9757676 DOI: 10.1093/ofid/ofac611] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Information about burden, characteristics, predictors, and outcomes of advanced human immunodeficiency virus disease (AHD) is scarce in rural settings of sub-Saharan Africa. Human immunodeficiency virus (HIV) infections and associated deaths remain high despite specific guidelines issued by the World Health Organization (WHO). METHODS Burden of AHD and 6-month death/loss to follow-up (LTFU) were described among 2498 antiretroviral therapy (ART)-naive nonpregnant people with HIV (PWH) aged >15 years enrolled in the Kilombero Ulanga Antiretroviral Cohort in rural Tanzania between 2013 and 2019. Baseline characteristics associated with AHD and predictors of death/LTFU among those with AHD were analyzed using multivariate logistic and Cox regression, respectively. RESULTS Of the PWH, 62.2% had AHD at diagnosis (66.8% before vs 55.7% after national uptake of WHO "test and treat" guidelines in 2016). At baseline, older age, male sex, lower body mass index, elevated aminotransferase aspartate levels, severe anemia, tachycardia, decreased glomerular filtration rate, clinical complaints, impaired functional status, and enrollment into care before 2018 were independently associated with AHD. Among people with AHD, incidence of mortality, and LTFU were 16 and 34 per 100 person-years, respectively. WHO clinical stage 3 or 4, CD4 counts <100 cells/µL, severe anemia, tachypnea, and liver disease were associated with death/LTFU. CONCLUSIONS More than 50% of PWH enrolled in our cohort after test and treat implementation still had AHD at diagnosis. Increasing HIV testing and uptake and implementation of the WHO-specific guidelines on AHD for prevention, diagnosis, treatment of opportunistic infections, and reducing the risks of LTFU are urgently needed to reduce morbidity and mortality.
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Affiliation(s)
- Linda Stöger
- ISGlobal, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | | | - Herry Mapesi
- Ifakara Health Institute, Ifakara, Tanzania,Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Aneth V Kalinjuma
- Ifakara Health Institute, Ifakara, Tanzania,Faculty of Health Sciences, Department of Epidemiology and Biostatistics, University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Liselot van Essen
- Gerion, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Thomas Klimkait
- Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland
| | - Manuel Battegay
- Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Maja Weisser
- Ifakara Health Institute, Ifakara, Tanzania,Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland,Swiss Tropical and Public Health Institute, Basel, Switzerland,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Emilio Letang
- Correspondence: Emilio Letang, MD, MPH, PhD, Barcelona Institute for Global Health, Rosselló 132, 4.1, Barcelona 08036, Spain ()
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Wekesa P, McLigeyo A, Owuor K, Mwangi J, Ngugi E. Survival probability and factors associated with time to loss to follow-up and mortality among patients on antiretroviral treatment in central Kenya. BMC Infect Dis 2022; 22:522. [PMID: 35668350 PMCID: PMC9171980 DOI: 10.1186/s12879-022-07505-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 05/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Retention of patients who are receiving antiretroviral therapy (ART) remains a challenge especially in the setting of rapid expansion of HIV services. Retention in care remains vital to the HIV care continuum, and has been associated with viral suppression and improved survival. This study aimed to ascertain survival rates, time to loss to follow-up (LTFU) or mortality events and factors associated with time to LTFU or mortality among patients enrolled on antiretroviral therapy at health facilities in central Kenya. METHODS This was a retrospective cohort study among patients initiated on ART between 2004 and 2012 in central Kenya. Demographic characteristics, clinical characteristics and outcomes data were analyzed using Stata version 15.1. Competing risks regression analysis and cummulative incidence functions were used to estimate survival. RESULTS A total of 31,346 patients were included, of whom 65.6% were female, 76.0% were aged between 20 and 50 years old, and 38.9% were diagnosed at WHO stage III. At 36 months, overall retention was 68.8%, LTFU was 27.1%, and mortality was 4.1%. The total person-years of follow up was 74,986. The incidence rate of LTFU was 9.99 per 100 person years for a total of 9383.25 person-years of follow up. The mortality rate was 1.25 per 100 person years for a total of 875.5 person-years among those who died. The median time to LTFU was 11 months (IQR 3-22) while median time to death was 3 months (IQR 0-13). Men, unmarried patients, patients presenting with advanced HIV, not on TB treatment, and enrolled into the HIV program in later cohorts, had a shorter time to mortality and LTFU. CONCLUSION Our study demonstrated evidence of scale-up of HIV treatment programs in central Kenya. While most patients were enrolled at an advanced WHO clinical stage, overall 36-month mortality remained low, but occurred earlier during follow-up. Cohort LTFU at 36-months reduced in later years with the losses occurring within the 1st year of follow-up. Predictors of early mortality and LTFU included being male, single, separated or divorced, advanced WHO clinical stage, and among patients not on TB treatment.
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Affiliation(s)
- P Wekesa
- Centre for Health Solutions - Kenya, Nairobi, Kenya.
| | - A McLigeyo
- Centre for Health Solutions - Kenya, Nairobi, Kenya
| | - K Owuor
- Centre for Health Solutions - Kenya, Nairobi, Kenya
| | - J Mwangi
- Division of Global HIV & TB, Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - E Ngugi
- Division of Global HIV & TB, Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
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Jalene Alves M, Sadalla do Nascimento I, Santana Cruz K, Violeta Fernandes Menescal V, Stephanny Fernandes Menescal L, Svetlana Cavalcante Silva L, Bezerra Pinheiro S, Stephanie Pérez Gómez A, Vicente Braga de Souza J, Dos Santos Lazera M, Beatriz Jackisch Matsuura A. Cryptococcosis in HIV/AIDS patients in northern Brazil: clinical aspects, molecular types and isolation of agents from environmental samples associated with patients. Trop Med Int Health 2022; 27:387-396. [PMID: 35178835 DOI: 10.1111/tmi.13737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES In the state of Amazonas, northern Brazil, cryptococcosis is endemic, with a predominance of C. neoformans in individuals with HIV/AIDS, and C. gattii VGII in non-HIV individuals. The present study analyzed the clinical isolates and clinical-epidemiological characteristics of HIV/AIDS patients diagnosed with cryptococcosis in a tertiary healthcare facility in Manaus, Amazonas and investigated the presence of agents of cryptococcosis in environmental samples. METHODS A survey was made of data from HIV/AIDS patients diagnosed with cryptococcosis between January 2017 and December 2019, and environmental samples were collected at the patients' and their neighbors' homes. The isolates were submitted to morphophysiological analysis and PCR-RFLP typing to determine the molecular types. RESULTS Clinical-epidemiological characteristics of 55 patients and 75 clinical isolates were analyzed. Neurocriptococcosis was the clinical form observed in 98.2% (n = 54/55) of patients. A total of 38.1% (n = 21/55) of patients died within 100 weeks, of which 21.8% (n = 12/55) died less than a month after the diagnosis of cryptococcosis. C. neoformans VNI (n = 68/75), C. neoformans VNII (n = 1/75), C. gattii VGI (n = 3/75), C. gattii VGII (n = 3/75) were identified. Mixed infection was observed in two patients, one by C. neoformans VNI and VNII and the other by C. neoformans VNI and C. gattii VGI. Cryptococcus VNI was detected in three (n= 3/51) households, one of a patient (n= 1/17) and two households that neighbor patients' houses (n= 2/34). CONCLUSIONS This study demonstrated the prevalence of C. neoformans VNI, which is a cause of cryptococcosis in patients with HIV/AIDS in the state of Amazonas, and revealed a greater diversity of molecular types affecting these patients in the region than in previous studies. In the studied group, a high mortality rate was observed, which reflects the importance of early diagnosis, and evidences cryptococcosis as an AIDS-defining disease and an important public health problem in the region. The home environment proved to be a potential source of infection/reinfection by C. neoformans VNI.
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Affiliation(s)
- Marla Jalene Alves
- Laboratório de Diversidade Microbiana da Amazônia com Importância para a Saúde, Instituto Leônidas e Maria Deane - FIOCRUZ, Manaus, Brazil.,Programa de Pós-Graduação em Medicina Tropical, Convenio ILMD/IOC - FIOCRUZ, Manaus, Brazil
| | - Izabella Sadalla do Nascimento
- Laboratório de Diversidade Microbiana da Amazônia com Importância para a Saúde, Instituto Leônidas e Maria Deane - FIOCRUZ, Manaus, Brazil
| | - Katia Santana Cruz
- Laboratório de Micologia Médica, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | | | | | | | - Silviane Bezerra Pinheiro
- Laboratório de Micologia, Instituto Nacional de Pesquisas da Amazônia (INPA), Manaus, Brazil.,Pós-Graduação em Genética, Conservação e Biologia Evolutiva, Instituto Nacional de Pesquisas da Amazônia, Manaus, Brazil
| | - Aline Stephanie Pérez Gómez
- Programa de Residência Médica em Medicina Tropical, Fundação de Medicina Tropical Doutor Heitor Viera Dourado, Manaus, Brasil
| | | | - Marcia Dos Santos Lazera
- Programa de Pós-Graduação em Medicina Tropical, Convenio ILMD/IOC - FIOCRUZ, Manaus, Brazil.,Laboratorio de Micologia, Instituto Nacional de Infectologia Evandro Chagas, FIOCRUZ, Rio de Janeiro, Brazil
| | - Ani Beatriz Jackisch Matsuura
- Laboratório de Diversidade Microbiana da Amazônia com Importância para a Saúde, Instituto Leônidas e Maria Deane - FIOCRUZ, Manaus, Brazil
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Longitudinal analysis of sociodemographic, clinical and therapeutic factors of HIV-infected individuals in Kinshasa at antiretroviral therapy initiation during 2006-2017. PLoS One 2021; 16:e0259073. [PMID: 34739506 PMCID: PMC8570501 DOI: 10.1371/journal.pone.0259073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 10/12/2021] [Indexed: 11/22/2022] Open
Abstract
Background The benefits of antiretroviral therapy (ART) underpin the recommendations for the early detection of HIV infection and ART initiation. Late initiation (LI) of antiretroviral therapy compromises the benefits of ART both individually and in the community. Indeed, it promotes the transmission of infection and higher HIV-related morbidity and mortality with complicated and costly clinical management. This study aims to analyze the evolutionary trends in the median CD4 count, the median time to initiation of ART, the proportion of patients with advanced HIV disease at the initiation of ART between 2006 and 2017 and their factors. Methods and findings HIV-positive adults (≥ 16 years old) who initiated ART between January 1, 2006 and December 31, 2017 in 25 HIV care facilities in Kinshasa, the capital of DRC, were eligible. The data were processed anonymously. LI is defined as CD4≤350 cells/μl and/or WHO clinical stage III or IV and advanced HIV disease (AHD), as CD4≤200 cells/μl and/or stage WHO clinic IV. Factors associated with advanced HIV disease at ART initiation were analyzed, irrespective of year of enrollment in HIV care, using logistic regression models. A total of 7278 patients (55% admitted after 2013) with an average age of 40.9 years were included. The majority were composed of women (71%), highly educated women (68%) and married or widowed women (61%). The median CD4 was 213 cells/μl, 76.7% of patients had CD4≤350 cells/μl, 46.1% had CD4≤200 cells/μl, and 59% of patients were at WHO clinical stages 3 or 4. Men had a more advanced clinical stage (p <0.046) and immunosuppression (p<0.0007) than women. Overall, 70% of patients started ART late, and 25% had AHD. Between 2006 and 2017, the median CD4 count increased from 190 cells/μl to 331 cells/μl (p<0.0001), and the proportions of patients with LI and AHD decreased from 76% to 47% (p< 0.0001) and from 18.7% to 8.9% (p<0.0001), respectively. The median time to initiation of ART after screening for HIV infection decreased from 40 to zero months (p<0.0001), and the proportion of time to initiation of ART in the month increased from 39 to 93.3% (p<0.0001) in the same period. The probability of LI of ART was higher in married couples (OR: 1.7; 95% CI: 1.3–2.3) (p<0.0007) and lower in patients with higher education (OR: 0.74; 95% CI: 0.64–0.86) (p<0.0001). Conclusion Despite increasingly rapid treatment, the proportions of LI and AHD remain high. New approaches to early detection, the first condition for early ART and a key to ending the HIV epidemic, such as home and work HIV testing, HIV self-testing and screening at the point of service, must be implemented.
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Wekesa P, McLigeyo A, Owuor K, Mwangi J, Isavwa L, Katana A. Temporal trends in pre-ART patient characteristics and outcomes before the test and treat era in Central Kenya. BMC Infect Dis 2021; 21:1007. [PMID: 34565337 PMCID: PMC8474838 DOI: 10.1186/s12879-021-06706-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/16/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Retention of patients who did not initiate antiretroviral therapy (ART) has been persistently low compared to those who initiated ART. Understanding the temporal trends in clinical outcomes prior to ART initiation may inform interventions targeting patients who do not initiate ART immediately after diagnosis. METHODS A retrospective cohort analysis of known HIV-infected patients who did not initiate ART from healthcare facilities in Central Kenya was done to investigate temporal trends in characteristics, retention, and mortality outcomes. The data were sourced from the Comprehensive Care Clinic Patient Application Database (CPAD) and IQ care electronic patient-level databases for those enrolled between 2004 and 2014. RESULTS A total of 13,779 HIV-infected patients were assessed, of whom 30.7% were men.There were statisitically significant differences in temporal trends relating to marital status, WHO clinical stage, and tuberculosis (TB) status from 2004 to 2014. The proportion of widowed patients decreased from 9.1 to 6.0%. By WHO clinical stage at enrollment in program, those in WHO stage I increased over time from 8.7 to 43.1%, while those in WHO stage III and IV reduced from 28.5 to 10.8% and 4.0 to 1.1% respectively. Those on TB treatment during their last known visit reduced from 8.3 to 3.9% while those with no TB signs increased from 58.5 to 86.8%. Trends in 6 and 12 month retention in the program, loss to follow-up (LTFU) and mortality were statistically significant. At 6 months, program retention ranged between 36.0% in 2004 to a high of 54.1% in 2013. LTFU at 6 months remained around 50.0% for most of the cohorts, while mortality at 6 months was 7.5% in 2004 but reduced to 3.8% in 2014. At 12 months, LTFU was above 50.0% across all the cohorts while mortality rate reached 3.9% in 2014. CONCLUSION Trends in pre ART enrollment suggested higher enrollment among patients who were women and at earlier WHO clinical stages. Retention and mortality outcomes at 6 and 12 months generally improved over the 11 year follow-up period, though dipped as enrollment in asymptomatic disease stage increased.
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Affiliation(s)
- P Wekesa
- Centre for Health Solutions - Kenya, Nairobi, Kenya.
| | - A McLigeyo
- Centre for Health Solutions - Kenya, Nairobi, Kenya.
| | - K Owuor
- Centre for Health Solutions - Kenya, Nairobi, Kenya
| | - J Mwangi
- Division of Global HIV & TB, Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - L Isavwa
- Centre for Health Solutions - Kenya, Nairobi, Kenya
| | - A Katana
- Division of Global HIV & TB, Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
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Raichur P, Salvi SP, Sangle S, Chavan A, Nimkar S, Gawande G, Rewari B, Mathad J, Mcintire K, Gupta A, Marbaniang I, Mave V. Trends and Sex Differences in Access to HIV Care with Scale Up of National HIV Treatment Guidelines in Pune, India. J Int Assoc Provid AIDS Care 2021; 19:2325958220931735. [PMID: 32573318 PMCID: PMC7313325 DOI: 10.1177/2325958220931735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Test and treat is the current global standard, yet sex differences persist in access to HIV care. We assessed the differences in presentation and antiretroviral therapy (ART) uptake by sex and ART-eligibility period among ART-naive adults registered at a public ART center in India. Four ART eligibility periods were defined by programmatically determined CD4 criteria (periods I-IV: CD4 <200, <350, ≤500 cells/μL, and any CD4) between January 2005 and December 2017. Of 23 957 participants, 12 510 were male. Men consistently presented with lower median CD4 count (period I-IV, P < .05) and higher median age (period I-III, P < .001) than women. From period I to IV, median age increased in women (P < .0001), ART initiation time decreased in both sexes (P < .001), and median CD4 remained <200 cells/µL in men. Advanced HIV disease and increasing age at presentation are persistent sex-specific trends which warrant innovative HIV testing strategies in both sexes.
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Affiliation(s)
- Priyanka Raichur
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Sonali Pankaj Salvi
- Department of Medicine, BJ Government Medical College and Sassoon General Hospitals, Pune, Maharashtra, India
| | - Shashikala Sangle
- Department of Medicine, BJ Government Medical College and Sassoon General Hospitals, Pune, Maharashtra, India
| | - Amol Chavan
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Smita Nimkar
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Gajanan Gawande
- Department of Medicine, BJ Government Medical College and Sassoon General Hospitals, Pune, Maharashtra, India
| | - Bharat Rewari
- National AIDS Control Organisation, New Delhi, New Delhi, India
| | - Jyoti Mathad
- Department of Medicine, Center for Global Health, Weill Cornell Medicine, New York, NY, USA
| | - Katherine Mcintire
- Department of Medicine and Infectious Diseases, Johns Hopkins University, Baltimore, MD, USA
| | - Amita Gupta
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India.,Department of Medicine and Infectious Diseases, Johns Hopkins University, Baltimore, MD, USA
| | - Ivan Marbaniang
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India.,Department of Epidemiology, McGill University, Montreal, Quebec, Canada
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India.,Department of Medicine and Infectious Diseases, Johns Hopkins University, Baltimore, MD, USA
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A Rapid Screening Program for Histoplasmosis, Tuberculosis, and Cryptococcosis Reduces Mortality in HIV Patients from Guatemala. J Fungi (Basel) 2021; 7:jof7040268. [PMID: 33916153 PMCID: PMC8065950 DOI: 10.3390/jof7040268] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 01/15/2023] Open
Abstract
Opportunistic infections (OIs) and advanced HIV disease (AHD) contribute to HIV-related mortality. Here, we analyzed the situation of AHD and OIs in a cohort of newly diagnosed HIV patients from Guatemala. We included 2127 adult patients from 13 facilities across the country during 2017 to 2018. Patients were screened for tuberculosis (TB), nontuberculous mycobacteria (NTM), histoplasmosis, and cryptococcal disease, independently of their CD4 cell count. Of the 2127 enrolled patients, 1682 (79.1%) had a CD4 cell count available; of which 52% presented with AHD. Of the Mayan population, 65% had AHD. The overall OI incidence was 21%. Histoplasmosis was the most frequent OI (7.9%), followed by TB (7.1%); 94.4% of these infections occurred in patients with a CD4 < 350 cells/mm3. Mortality at 180 days was significantly higher in those with OIs than without OIs (29.7% vs. 5.9%, p < 0.0001). In one year, this program decreased the OI mortality by 7% and increased the OI treatment by 5.1%. Early OI diagnosis and appropriate therapy reduced OI mortality among newly diagnosed HIV patients in Guatemala. Screening for OIs should be considered in all newly diagnosed HIV patients who have a CD4 cell count < 350 cells/mm3 or those without a CD4 cell count available. To improve results, interventions such as early HIV detection and access to flucytosine and liposomal amphotericin B are required.
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Lopez-Varela E, Augusto O, Fuente-Soro L, Sacoor C, Nhacolo A, Casavant I, Karajeanes E, Vaz P, Naniche D. Quantifying the gender gap in the HIV care cascade in southern Mozambique: We are missing the men. PLoS One 2021; 16:e0245461. [PMID: 33577559 PMCID: PMC7880488 DOI: 10.1371/journal.pone.0245461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 01/04/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND HIV-infected men have higher rates of delayed diagnosis, reduced antiretroviral treatment (ART) retention and mortality than women. We aimed to assess, by gender, the first two UNAIDS 90 targets in rural southern Mozambique. METHODS This analysis was embedded in a larger prospective cohort enrolling individuals with new HIV diagnosis between May 2014-June 2015 from clinic and home-based testing (HBT). We assessed gender differences between steps of the HIV-cascade. Adjusted HIV-community prevalence was estimated using multiple imputation (MI). RESULTS Among 11,773 adults randomized in HBT (7084 female and 4689 male), the response rate before HIV testing was 48.7% among eligible men and 62.0% among women (p<0.001). MI did not significantly modify all-age HIV-prevalence for men but did decrease prevalence estimates in women from 36.4%to 33.0%. Estimated proportion of HIV-infected individuals aware of their status was 75.9% for men and 88.9% for women. In individuals <25 years, we observed up to 22.2% disparity in awareness of serostatus between genders. Among individuals eligible for ART, similar proportions of men and women initiated treatment (81.2% and 85.9%, respectively). Fourfold more men than womenwere in WHO stage III/IV AIDS at first clinical visit. Once on ART, men had a twofold higher 18-month loss to follow-up rate than women. CONCLUSION The contribution of missing HIV-serostatus data differentially impacted indicators of HIV prevalence and of achievement of UNAIDS targets by age and gender and men were missing long before the second 90. Increased efforts to characterize missing men and their needs will and their needs will allow us to urgently address the barriers to men accessing care and ensure men are not left behind in the UNAIDS 90-90-90 targets achievement.
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Affiliation(s)
- Elisa Lopez-Varela
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Instituto de Salud Global de Barcelona, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Orvalho Augusto
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Facultade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Laura Fuente-Soro
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Instituto de Salud Global de Barcelona, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Charfudin Sacoor
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Ariel Nhacolo
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | | | | | - Paula Vaz
- Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo, Mozambique
| | - Denise Naniche
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Instituto de Salud Global de Barcelona, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
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10
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De Anda S, Njoroge A, Njuguna I, Dunbar MD, Abuna F, Macharia P, Betz B, Cherutich P, Bukusi D, Farquhar C, Katz DA. Predictors of First-Time and Repeat HIV Testing Among HIV-Positive Individuals in Kenya. J Acquir Immune Defic Syndr 2020; 85:399-407. [PMID: 33136736 DOI: 10.1097/qai.0000000000002469] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite a doubling of HIV testing coverage in Kenya over the past decade, approximately 2 in 10 people with HIV remained unaware of their infection in 2018. HIV testing is most effective in identifying people with undiagnosed HIV through frequent and strategic testing in populations at high risk. An assessment of testing frequency and predictors of first-time and repeat testing is critical for monitoring effectiveness of testing strategies. METHODS We conducted a cross-sectional analysis of adults aged ≥18 years who tested HIV-positive at 4 HIV testing and counseling clinics in Kenya from February 2015 to February 2016. We categorized individuals based on testing history, used Wilcoxon rank-sum tests to assess differences in intervals between the most recent and current HIV test, and used log-binomial regression to determine characteristics associated with first-time and repeat testing. RESULTS Among 1136 people testing HIV-positive, 336 (30%) had never tested before and 800 (70%) had, of whom 208 (26%) had previously tested positive. Among previously negative repeat testers, the median intertest interval was 414 days in key/priority populations (interquartile range = 179-1072) vs. 538 in the general population (interquartile range = 228-1299) (P = 0.09). Compared with previously negative repeat testers, being a first-time tester was associated with being age ≥40 years [vs. 18-24; adjusted risk ratio = 1.67, 95% confidence interval (CI): 1.23 to 2.26], men (vs. women; adjusted risk ratio = 1.45, 95% CI: 1.21 to 1.71), and testing through provider-initiated testing and counseling (vs. client initiated; 1.19, 95% CI: 1.00 to 1.40). CONCLUSIONS There is a need to increase HIV testing among older individuals and men, increase testing frequency in key/priority populations, and maintain provider-initiated and facility-based testing to reach first-time testers.
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Affiliation(s)
- Sofia De Anda
- Department of Global Health, University of Washington, Seattle, WA
| | - Anne Njoroge
- Department of Global Health, University of Washington, Seattle, WA
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Irene Njuguna
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Matthew D Dunbar
- Center for Demography and Ecology, University of Washington, Seattle, WA
| | - Felix Abuna
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Bourke Betz
- Department of Global Health, University of Washington, Seattle, WA
| | | | - David Bukusi
- Voluntary Counseling and Testing (VCT) and HIV Prevention Unit, Kenyatta National Hospital, Nairobi, Kenya; and
| | - Carey Farquhar
- Department of Global Health, University of Washington, Seattle, WA
- Department of Epidemiology, University of Washington, Seattle, WA
- Departments of Medicine University of Washington, Seattle, WA
| | - David A Katz
- Departments of Medicine University of Washington, Seattle, WA
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11
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Hannaford A, Moll AP, Madondo T, Khoza B, Shenoi SV. Mobility and structural barriers in rural South Africa contribute to loss to follow up from HIV care. AIDS Care 2020; 33:1436-1444. [PMID: 32856470 DOI: 10.1080/09540121.2020.1808567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Retention in HIV care is crucial to sustaining viral load suppression, and reducing HIV transmission, yet loss to follow-up (LTFU) in South Africa remains substantial. We conducted a mixed methods evaluation in rural South Africa to characterize ART disengagement in neglected rural settings. Using convenience sampling, surveys were completed by 102 PLWH who disengaged from ART (minimum 90 days) and subsequently resumed care. A subset (n = 60) completed individual in-depth interviews. Median duration of ART discontinuation was 9 months (IQR 4-22). Participants had HIV knowledge gaps regarding HIV transmission and increased risk of tuberculosis. The major contributors to LTFU were mobility and structural barriers. PLWH traveled for an urgent family need or employment, and were not able to collect ART while away. Structural barriers included inability to access care, due to lack of financial resources to reach distant clinics. Other factors included dissatisfaction with care, pill fatigue, lack of social support, and stigma. Illness was the major precipitant of returning to care. Mobility and structural barriers impede longitudinal HIV care in rural South Africa, threatening the gains made from expanded ART access. To achieve 90-90-90, future interventions, including emphasis on patient centered care, must address barriers relevant to rural settings.
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Affiliation(s)
- Alisse Hannaford
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anthony P Moll
- Church of Scotland Hospital, Tugela Ferry, South Africa.,Philanjalo NGO, Tugela Ferry, South Africa
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12
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Mark J, Kinuthia J, Osoti AO, Gone MA, Asila V, Krakowiak D, Sharma M, Parikh S, Ton QT, Richardson BA, Farquhar C, Roxby AC. Male Partner Linkage to Clinic-Based Services for Sexually Transmitted Infections and Human Immunodeficiency Virus Services Following Couple Home-Based Education and Testing. Sex Transm Dis 2020; 46:716-721. [PMID: 31644499 DOI: 10.1097/olq.0000000000001057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Home-based human immunodeficiency virus (HIV) testing and education has increased HIV test uptake and access to health services among men. We studied how a home-based antenatal intervention influenced male partner utilization of clinic-based HIV and sexually transmitted infection (STI) services, linkage to HIV care and medical circumcision. METHODS We conducted a secondary analysis within a randomized controlled trial of pregnant women attending antenatal care in Kenya. Women and their male partners received either a home-based couple intervention or an invitation letter for clinic-based couple HIV testing. The home-based intervention included education on STI symptoms, STI and HIV treatment and male circumcision for HIV prevention. Male self-reported outcomes were compared using relative risks at 6 months postpartum. RESULTS Among 525 women, we reached 487 (93%) of their male partners; 247 men in the intervention arm and 240 men in the control arm. Men who received the intervention were more likely to report an STI consultation (n = 47 vs. 16; relative risk, 1.59; 95% confidence interval, 1.33-1.89). Among 23 men with newly diagnosed HIV, linkage to HIV care was reported by 4 of 15 in the intervention (3 men had missing linkage data) and 3 of 5 men in the control arms (relative risk, 0.66; 95% confidence interval, 0.34-1.29). Although the intervention identified 3 times more men with new HIV infection, the study lacked power to find significant differences in linkage to HIV care. Few eligible men sought medical circumcision (4 of 72 intervention and 2 of 88 control). CONCLUSIONS Home-based couple education and testing increased STI consultations among male partners of pregnant women, but appeared insufficient to overcome the barriers involved in linkage to HIV care and medical circumcision.
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Affiliation(s)
- Jennifer Mark
- From the Department of Epidemiology, University of Washington, Seattle, WA
| | - John Kinuthia
- Department of Research and Programs.,Department of Reproductive Health, Kenyatta National Hospital.,Department of Obstetrics and Gynaecology, University of Nairobi
| | - Alfred O Osoti
- From the Department of Epidemiology, University of Washington, Seattle, WA.,Department of Reproductive Health, Kenyatta National Hospital.,Department of Obstetrics and Gynaecology, University of Nairobi
| | - Molly A Gone
- Department of Obstetrics and Gynaecology, University of Nairobi
| | - Victor Asila
- Department of Obstetrics and Gynaecology, University of Nairobi
| | - Daisy Krakowiak
- From the Department of Epidemiology, University of Washington, Seattle, WA
| | - Monisha Sharma
- From the Department of Epidemiology, University of Washington, Seattle, WA
| | - Saloni Parikh
- Computer Science and Engineering and Public Health.,Department of Public, Health University of Washington, Seattle, WA
| | | | | | - Carey Farquhar
- From the Department of Epidemiology, University of Washington, Seattle, WA.,Department of Global Health.,Department of Medicine, University of Washington, Seattle, WA
| | - Alison C Roxby
- Department of Medicine, University of Washington, Seattle, WA
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13
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Lifson AR, Workneh S, Hailemichael A, MacLehose RF, Horvath KJ, Hilk R, Sites AR, Shenie T. Advanced HIV Disease among Males and Females Initiating HIV Care in Rural Ethiopia. J Int Assoc Provid AIDS Care 2020; 18:2325958219847199. [PMID: 31104543 PMCID: PMC6748532 DOI: 10.1177/2325958219847199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Despite recommendations for rapidly initiating HIV treatment, many persons in sub-Saharan
Africa present to care with advanced HIV disease. Baseline survey and clinical data were
collected on 1799 adults newly enrolling at 32 district hospitals and local health HIV
clinics in rural Ethiopia. Among those with complete HIV disease information, advanced HIV
disease (defined as CD4 count <200 cells/mm3 or World Health Organization
[WHO] HIV clinical stage III or IV disease) was present in 66% of males and 56% of females
(P < .001). Males (compared to females) had lower CD4 counts (287
cells/mm3 versus 345 cells/mm3), lower body mass index (19.3
kg/m2 versus 20.2 kg/m2), and more WHO stage III or IV disease
(46% versus 37%), (P < .001). Men reported more chronic diarrhea,
fevers, cough, pain, fatigue, and weight loss (P < .05). Most
initiating care in this resource-limited setting had advanced HIV disease. Men had poorer
health status, supporting the importance of earlier diagnosis, linkage to care, and
initiation of antiretroviral therapy.
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Affiliation(s)
- Alan Raymond Lifson
- 1 Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Sale Workneh
- 2 National Alliance of State and Territorial AIDS Directors, Ethiopian Office, Addis Ababa, Ethiopia
| | - Abera Hailemichael
- 2 National Alliance of State and Territorial AIDS Directors, Ethiopian Office, Addis Ababa, Ethiopia
| | | | - Keith Joseph Horvath
- 1 Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Rose Hilk
- 1 Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Anne Redmond Sites
- 3 National Alliance of State and Territorial AIDS Directors, Global Program, Washington, DC, USA
| | - Tibebe Shenie
- 2 National Alliance of State and Territorial AIDS Directors, Ethiopian Office, Addis Ababa, Ethiopia
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14
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Schaffer EM, Gonzalez JM, Wheeler SB, Kwarisiima D, Chamie G, Thirumurthy H. Promoting HIV Testing by Men: A Discrete Choice Experiment to Elicit Preferences and Predict Uptake of Community-based Testing in Uganda. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:413-432. [PMID: 31981135 PMCID: PMC7255957 DOI: 10.1007/s40258-019-00549-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND AND OBJECTIVES HIV testing is essential to access HIV treatment and care and plays a critical role in preventing transmission. Despite this, testing coverage is low among men in sub-Saharan Africa. Community-based testing has demonstrated potential to expand male testing coverage, yet scant evidence reveals how community-based services can be designed to optimize testing uptake. We conducted a discrete choice experiment (DCE) to elicit preferences and predict uptake of community-based testing by men in Uganda. METHODS Hypothetical choices between alternative community-based testing services and the option to opt-out of testing were presented to a random, population-based sample of 203 adult male residents. The testing alternatives varied by service delivery model (community health campaign, counselor-administered home-based testing, distribution of HIV self-test kits at local pharmacies), availability of multi-disease testing, access to antiretroviral therapy (ART), and provision of a US$0.85 incentive. We estimated preferences using a random parameters logit model and explored whether preferences varied by participant characteristics through subgroup analyses. We simulated uptake when a single and when two community-based testing services are made available, using reference values of observed uptake to calibrate predictions. RESULTS The share of the adult male population predicted to test for HIV ranged from 0.15 to 0.91 when a single community-based testing service is made available and from 0.50 to 0.96 when two community-based services are provided concurrently. ART access was the strongest driver of choices (relative importance [RI] = 3.01, 95% confidence interval [CI]: 1.74-4.29), followed by the service delivery model (RI = 1.27, 95% CI 0.72-1.82) and availability of multi-disease testing (RI = 1.27, 95% CI 0.09-2.45). A US$0.85 incentive had the least yet still significant influence on choices (RI = 0.77, 95% CI 0.06-1.49). Men who perceived their risk of having HIV to be relatively elevated had higher predicted uptake of HIV self-test kits at local pharmacies, as did young adult men compared to men aged ≥ 30 years. Men who earned ≤ the daily median income had higher predicted uptake of all community-based testing services versus men who earned above the daily median income. CONCLUSION Substantial opportunity exists to optimize the delivery of HIV testing to expand uptake by men; using an innovative DCE, we deliver timely, actionable guidance for promoting community-based testing by men in Uganda. We advance the stated preference literature methodologically by describing how we constructed and evaluated a pragmatic experimental design, used interaction terms to conduct subgroup analyses, and harnessed participant-specific preference estimates to predict and calibrate testing uptake.
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Affiliation(s)
- Elisabeth M Schaffer
- Data Science to Patient Value, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Harsha Thirumurthy
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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15
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Maughan-Brown B, Beckett S, Kharsany ABM, Cawood C, Khanyile D, Lewis L, Venkataramani A, George G. Poor rates of linkage to HIV care and uptake of treatment after home-based HIV testing among newly diagnosed 15-to-49 year-old men and women in a high HIV prevalence setting in South Africa. AIDS Care 2020; 33:70-79. [DOI: 10.1080/09540121.2020.1719025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Brendan Maughan-Brown
- Southern Africa Labour and Development Research Unit (SALDRU), University of Cape Town, Rondebosch, South Africa
| | - Sean Beckett
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Ayesha B. M. Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | | | | | - Lara Lewis
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Atheendar Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gavin George
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
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16
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Trends Over Time for Adolescents Enrolling in HIV Care in Kenya, Tanzania, and Uganda From 2001-2014. J Acquir Immune Defic Syndr 2019; 79:164-172. [PMID: 29985263 DOI: 10.1097/qai.0000000000001796] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The data needed to understand the characteristics and outcomes, over time, of adolescents enrolling in HIV care in East Africa are limited. SETTING Six HIV care programs in Kenya, Tanzania, and Uganda. METHODS This retrospective cohort study included individuals enrolling in HIV care as younger adolescents (10-14 years) and older adolescents (15-19 years) from 2001-2014. Descriptive statistics were used to compare groups at enrollment and antiretroviral therapy (ART) initiation over time. The proportion of adolescents was compared with the total number of individuals aged 10 years and older enrolling over time. Competing-risk analysis was used to estimate 12-month attrition after enrollment/pre-ART initiation; post-ART attrition was estimated by Kaplan-Meier method. RESULTS A total of 6344 adolescents enrolled between 2001 and 2014. The proportion of adolescents enrolling among all individuals increased from 2.5% (2001-2004) to 3.9% (2013-2014, P < 0.0001). At enrollment, median CD4 counts in 2001-2004 compared with 2013-2014 increased for younger (188 vs. 379 cells/mm, P < 0.0001) and older (225 vs. 427 cells/mm, P < 0.0001) adolescents. At ART initiation, CD4 counts increased for younger (140 vs. 233 cells/mm, P < 0.0001) and older (64 vs. 323 cells/mm, P < 0.0001) adolescents. Twelve-month attrition also increased for all adolescents both after enrollment/pre-ART initiation (4.7% vs. 12.0%, P < 0.001) and post-ART initiation (18.7% vs. 31.2%, P < 0.001). CONCLUSIONS Expanding HIV services and ART coverage was likely associated with earlier adolescent enrollment and ART initiation but also with higher attrition rates before and after ART initiation. Interventions are needed to promote retention in care among adolescents.
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17
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Anlay DZ, Tiruneh BT, Dachew BA. Late ART Initiation among adult HIV patients at university of Gondar Hospital, NorthWest Ethiopia. Afr Health Sci 2019; 19:2324-2334. [PMID: 32127801 PMCID: PMC7040303 DOI: 10.4314/ahs.v19i3.4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction Late initiation of anti-retroviral therapy (ART) is associated with low immunologic response, increase morbidity, mortality and hospitalization. Therefore, this study aimed to assess the prevalence and factors associated with late ART initiation among adult HIV patients in NorthWest Ethiopia. Methods Retrospective cross-sectional study was conducted among 412 HIV patients who started ART between January/2009 and December/2014. Simple random sampling technique was used to select patient records. Data were collected by using pretested and structured extraction tool. Binary logistic regression model was fitted to identify factors associated with late ART initiation. Result A total of 410 participants were included for analysis after excluding 2 participants with incomplete data. The prevalence of late ART initiation was 67.3%. Age between 35–44 years(AOR=3.85; 95%CI:1.68–8.82), duration between testing and enrollment to care<1year (AOR=2.19;95%CI:1.30–3.69), secondary education (AOR=2.59; 95%CI 1.36–4.94), teritary education(AOR=3.28; 95%CI 1.25–8.64), being unmarried(AOR=1.88; 95%CI 1.13–3.03), bedridden and ambulatory patients (AOR=4.68 95%CI:1.49–14.68), other medication use before ART initiation(AOR=2.18; 95%CI 1.07–4.44), starting ART between 2009–2010 (AOR=5.94; 95%CI 2.74–12.87) and 2011–2012(AOR=2.80; 95%CI 1.31–5.96) were significantly associated with late ART initation at p-value <0.05. Conclusion The prevalence of late ART initiation was high. Strengthening the mechanisms of early HIV testing and linkage to care are recommended to initiate treatment earlier.
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Affiliation(s)
| | | | - Berihun Assefa Dachew
- University of Gondar, College of Medicine and Health Science, Institute of Public Health, Department of Epidemiology and Biostatistics, Gondar, Ethiopia. Mobile: +251911-54-23-48
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18
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Osingada CP, Siu G, Amollo M, Muwanguzi P, Sewankambo N, Kiwanuka N. Acceptability of HIV testing for men attending televised football venues in Uganda. BMC Public Health 2019; 19:1136. [PMID: 31426776 PMCID: PMC6700992 DOI: 10.1186/s12889-019-7478-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 08/12/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Worldwide, HIV remains a major public health challenge, especially in Sub-Saharan Africa. Literature indicates that men's involvement in HIV testing, care, and treatment services is lower compared to women, therefore novel approaches are required to engage men in the cascade of HIV care. This study aimed to explore men's perception on the provision of HIV testing services in venues where English Premier League football games are televised. METHODS An exploratory qualitative study was conducted between February and May 2018. Six focus group discussions were conducted with 50 conveniently selected men aged 18 years and older using a pre-tested discussion guide. All focus group discussions were audio recorded, transcribed verbatim, and analyzed thematically. RESULTS Overall, HIV testing at venues telecasting English Premier League football games was acceptable to men. There was a very strong preference for health workers providing testing and counseling services be external or unknown in the local community. Possible motivators for testing services provided in these settings include subsidizing or eliminating entrance fee to venues telecasting games, integrating testing and counseling with health promotion or screening for other diseases, use of local football games as mobilization tools and use of expert clients as role models. CONCLUSIONS This study suggests that HIV testing services at venues where EPL football games are televised is generally acceptable to men. In implementing such services, consideration should be given to preferences for external or unknown health workers and the motivating factors contributing to the use of these services. Given that HIV testing is currently not conducted in these settings, further research should be conducted to evaluate the feasibility of this approach as a means of enhancing HIV testing among Ugandan men.
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Affiliation(s)
- Charles Peter Osingada
- Department of Nursing, Makerere University College of Health Sciences, School of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Godfrey Siu
- Makerere University Child Health and Development Centre, P.O Box 7072, Kampala, Uganda
| | - Mathew Amollo
- Department of Community and Environmental Health, Makerere University College of Health Sciences, School of Public Health, P.O Box 7072, Kampala, Uganda
| | - Patience Muwanguzi
- Department of Nursing, Makerere University College of Health Sciences, School of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Nelson Sewankambo
- Department of Internal Medicine, School of Medicine, Makerere College of Health Sciences, P.O Box 7072, Kampala, Uganda
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, P.O Box 7072, Kampala, Uganda
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19
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Nash D, Robertson M. How to Evolve the Response to the Global HIV Epidemic With New Metrics and Targets Based on Pre-Treatment CD4 Counts. Curr HIV/AIDS Rep 2019; 16:304-313. [PMID: 31278620 PMCID: PMC10938289 DOI: 10.1007/s11904-019-00452-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF THE REVIEW Early diagnosis and treatment of HIV following seroconversion improves individual and population health. Using published data on pre-treatment CD4 cell counts, we benchmarked the level of immunodeficiency at HIV diagnosis and ART initiation in the "real world" against those of the treatment and control arms of landmark controlled trials that successfully reduced HIV-related deaths (INSIGHT/START) and onward HIV transmission (HPTN 052). RECENT FINDINGS The median CD4 count in the treatment vs. control arms of the INSIGHT/START trial and HPTN 052 were 650 vs. 408 cells/μL and 442 vs. 221 cells/μL, respectively. In the real world, recent global estimates of the median CD4 count at start of ART range from 234 to 350 cells/μL, and only 25% of those initiating ART do so early (i.e., with CD4 > 500 cells/μL). Recent global data on trends in the median CD4 count at diagnosis and ART initiation are not encouraging. We identify a critical need for new targets and metrics for persons newly diagnosed with HIV, newly enrolling in HIV care, and newly initiating ART, based on pre-treatment CD4 counts, to help increase the focus of implementation efforts on achieving earlier diagnosis, linkage to care, and ART initiation.
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Affiliation(s)
- Denis Nash
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, NY, USA.
- Department of Epidemiology and Biostatistics, CUNY School of Public Health, New York, NY, USA.
- CUNY Institute for Implementation Science in Population Health, 55 W. 125th St., 6th Floor, New York, NY, USA.
| | - McKaylee Robertson
- Institute for Implementation Science in Population Health (ISPH), City University of New York (CUNY), New York, NY, USA
- Department of Epidemiology and Biostatistics, CUNY School of Public Health, New York, NY, USA
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20
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Lilian RR, Rees K, Mabitsi M, McIntyre JA, Struthers HE, Peters RPH. Baseline CD4 and mortality trends in the South African human immunodeficiency virus programme: Analysis of routine data. South Afr J HIV Med 2019; 20:963. [PMID: 31392037 PMCID: PMC6676982 DOI: 10.4102/sajhivmed.v20i1.963] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 04/11/2019] [Indexed: 01/08/2023] Open
Abstract
Background Despite widespread availability of antiretroviral therapy (ART) in South Africa, there remains a considerable burden of human immunodeficiency virus (HIV)-related morbidity and mortality. Objectives To describe ART initiation and outcome trends over time, with a focus on clients presenting with advanced HIV-infection, so as to identify interventions to reduce morbidity and mortality. Methods Routine TIER.Net data from HIV-infected adults who had a documented baseline CD4 count and were newly initiating ART in Johannesburg or Mopani districts from 2004 to 2017 were analysed. Trends in baseline CD4 count and 5-year mortality were investigated and the population initiating ART with CD4 < 200 cells/mm3 was described. Results The Johannesburg and Mopani data sets comprised 203 131 and 101 814 records, respectively. Although median CD4 count increased over time, the proportion of initiations at CD4 < 200 cells/mm3 in 2017 remained high (Johannesburg 39%, Mopani 35%). Mortality was significantly increased among clients with CD4 < 200 compared to those with higher baseline counts (p < 0.001). Even though mortality among clients with low CD4 declined over time, likely because of improved drug regimens, in 2016-2017 mortality was still significantly increased among these clients (p < 0.001). Delivery of cotrimoxazole prophylaxis to clients with low CD4 declined over time to < 30% in 2017 and was associated with clinical stage. Presentation with CD4 < 200 cells/mm3 was associated with older age, male gender and hospitalisation. Conclusion A concerningly large proportion of South Africans still initiate ART at low CD4 counts. This is associated with increased mortality and requires targeted interventions to improve delivery of prophylactic regimens and early engagement in care.
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Affiliation(s)
| | - Kate Rees
- Anova Health Institute, Johannesburg, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - James A McIntyre
- Anova Health Institute, Johannesburg, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen E Struthers
- Anova Health Institute, Johannesburg, South Africa.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Remco P H Peters
- Anova Health Institute, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Department of Medical Microbiology, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, Maastricht, the Netherlands
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21
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Traditional healers, HIV outcomes, and mortality among people living with HIV in Senegal, West Africa. AIDS 2019; 33:1521-1526. [PMID: 31008800 DOI: 10.1097/qad.0000000000002232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The goals of this study were to determine the frequency of traditional healer use among people living with HIV in Senegal, to identify predictors of traditional healer use, and to determine if traditional healer use is associated with HIV outcomes. DESIGN Prospective longitudinal study. METHODS Participants were enrolled from April 2017 to April 2018 in Dakar and Ziguinchor, Senegal. Interviews, clinical evaluations, laboratory analyses, and chart review were conducted. Logistic regression was used to identify sociodemographic predictors of traditional healer use and to determine the associations between HIV-outcomes and use of a traditional healer. Survival analysis was conducted using the Kaplan-Meier method. RESULTS Data from 157 HIV-positive individuals were included; 34% reported seeking care from a traditional healer. Median follow-up was 224 days (interquartile range 118-339.5). Predictors of traditional healer use included age greater than or equal to 35 years and residence in the Casamance region. HIV-1-infected participants who sought care from a traditional healer had lower baseline CD4 cell counts compared with those who did not (104 versus 208; P = 0.02), and a greater percentage presented with advanced disease (85% versus 62%; P = 0.01). A greater percentage of those who sought care from a traditional healer died (13.2 versus 2.9%; P = 0.03). HIV-1-infected individuals with advanced disease [odds ratio (OR) 3.58, 95% confidence interval (CI) 1.18-10.82], those who were malnourished (OR 3.79, 95% CI 1.63-8.83), and those who died during follow-up (OR 7.26, 95% CI 1.34-39.37) were more likely to have sought care from a traditional healer. CONCLUSION Traditional healer use is common among people living with HIV in Senegal and is associated with advanced disease and increased mortality. Partnering with traditional healers may be an effective strategy to improve the HIV care cascade and decrease mortality in the region.
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Colombe S, Machemba R, Mtenga B, Lutonja P, Safari W, Beard J, Downs JA, Urassa M, Todd J, Changalucha J. Cascade of care for HIV-seroconverters in rural Tanzania: a longitudinal study. AIDS Care 2019; 32:666-671. [PMID: 31288545 DOI: 10.1080/09540121.2019.1640842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We examined the HIV care cascade in a community-based cohort study in Kisesa, Magu, Tanzania. We analyzed the proportion achieving each stage of the cascade - Seroconversion, Awareness of HIV status, Enrollment in Care and Antiretroviral therapy (ART) initiation - and estimated the median and interquartile range for the time for progression to the next stage. Modified Poisson regression was used to estimate prevalence risk ratios for enrollment in care and initiation of ART. From 2006 to 2017, 175 HIV-seroconverters were identified. 140 (80%) knew their HIV status, of whom 97 (69.3%) were enrolled in HIV care, and 87 (49.7%) had initiated ART. Time from seroconversion to awareness of HIV status was 731.3 [475.5-1345.8] days. Time from awareness to enrollment was 7 [0-64] days, and from enrollment to ART initiation was 19 [3-248] days. There were no demographic differences in enrollment in care or ART initiation. Efforts have been focusing on shortening time from seroconversion to diagnosis, mostly by increasing the number of testing clinics available. We recommend increased systematic testing to reduce time from seroconversion to awareness of status, and by doing so speed up enrollment into care. Interventions that increase enrollment are likely to have the most impact in achieving UNAIDS targets.
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Affiliation(s)
| | - Richard Machemba
- National Institute for Medical Research, Mwanza Research Centre, Mwanza, Tanzania
| | - Baltazar Mtenga
- National Institute for Medical Research, Mwanza Research Centre, Mwanza, Tanzania
| | - Peter Lutonja
- National Institute for Medical Research, Mwanza Research Centre, Mwanza, Tanzania
| | - Wende Safari
- National Institute for Medical Research, Mwanza Research Centre, Mwanza, Tanzania
| | - James Beard
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jennifer A Downs
- Weill Cornell Medicine, New York, NY, USA.,Department of Medicine, Bugando Medical Centre, Mwanza, Tanzania
| | - Mark Urassa
- National Institute for Medical Research, Mwanza Research Centre, Mwanza, Tanzania
| | - Jim Todd
- National Institute for Medical Research, Mwanza Research Centre, Mwanza, Tanzania.,Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - John Changalucha
- National Institute for Medical Research, Mwanza Research Centre, Mwanza, Tanzania
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23
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Prabhu S, Harwell JI, Kumarasamy N. Advanced HIV: diagnosis, treatment, and prevention. Lancet HIV 2019; 6:e540-e551. [PMID: 31285181 DOI: 10.1016/s2352-3018(19)30189-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 05/06/2019] [Accepted: 05/17/2019] [Indexed: 11/25/2022]
Abstract
Substantial progress has been made this century in bringing millions of people living with HIV into care, but progress for early HIV diagnosis has stalled. Individuals first diagnosed with advanced HIV have higher rates of mortality than those diagnosed at an earlier stage even after starting antiretroviral therapy (ART), resulting in substantial costs to health systems. Diagnosis of these individuals is hindered because many patients are asymptomatic, despite being severely immunosuppressed. Baseline CD4 counts and screening for opportunistic infections, such as tuberculosis and cryptococcus, is crucial because of the high mortality associated with these co-infections. Individuals with advanced HIV should have rapid ART initiation (except when found to have symptoms, signs, or a diagnosis of cryptococcal meningitis) and those in treatment failure should switch treatment. Overcoming barriers to testing and adherence through the development of differentiated care models and providing psychosocial support will be key in reaching populations at high risk of presenting with advanced HIV.
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Affiliation(s)
- Sandeep Prabhu
- University of California, San Diego School of Medicine, La Jolla, CA, USA
| | | | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site, Voluntary Health Services, Chennai, India.
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24
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Fiori KP, Belli HM, Lauria ME, Hirschhorn LR, Schechter J, Hansman E, Rajshekhar N, Katin V, Gbeleou S, Grunitsky-Bekele M, Pitche VP. Implementing an integrated community based health systems strengthening approach to improve HIV survival in Northern Togo. AIDS Care 2019; 32:705-713. [PMID: 31170827 DOI: 10.1080/09540121.2019.1626342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To disseminate lessons learned from the implementation experience of a public-private sector partnership, we describe a comprehensive HIV/AIDS program including 5-year survival outcomes for individuals who initiated antiretroviral therapy (ART) treatment in Togo from 2010 to 2015. A retrospective case study analysis was conducted from a cohort of patients receiving ART at an HIV/AIDS care clinic in Kara Region, Togo. Kaplan-Meier curves with Log rank tests were used to compare estimated survival curves by demographic and clinical characteristics. Associations were described between survival probability and age, gender, World Health Organization (WHO) disease stage, and timing of ART initiation. Cox proportional hazard model was used to determine predictors of mortality. After approximately five-years since ART initiation (1780 days), there were 114 deaths, with a survival probability of 75.3% (95% CI: 70.3-80.6%). Participants with advanced WHO disease stage were more likely at risk of death relative to patients categorized as WHO Stage 1, with Stage 4 approximately 9 times more likely (aHR 9.22, 95% CI 4.29-19.84). Our study suggests that delivering comprehensive HIV care through a private-public partnership may serve as a model to expand and improve HIV/AIDS care as well as high quality primary care.
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Affiliation(s)
- Kevin P Fiori
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.,Community Health Systems Lab, Integrate Health/Santé Intégrée, Kara, Togo and New York, NY, USA
| | - Hayley M Belli
- New York University School of Medicine, New York, NY, USA
| | - Molly E Lauria
- Community Health Systems Lab, Integrate Health/Santé Intégrée, Kara, Togo and New York, NY, USA
| | - Lisa R Hirschhorn
- Community Health Systems Lab, Integrate Health/Santé Intégrée, Kara, Togo and New York, NY, USA.,Northwestern University Feinberg School of Medicine, Chicago, USA
| | | | - Emily Hansman
- Integrate Health/Santé Intégrée, Kara, Togo and New York, NY, USA
| | | | - Venance Katin
- Integrate Health/Santé Intégrée, Kara, Togo and New York, NY, USA.,Service de dermatologie et IST, Centre Hospitalier Universitaire (CHU) Kara, Kara, Togo
| | - Sesso Gbeleou
- Integrate Health/Santé Intégrée, Kara, Togo and New York, NY, USA
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25
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Blankley S, Gashu T, Ahmad B, Belaye AK, Ringtho L, Mesic A, Zizhou S, Casas EC. Lessons learned: Retrospective assessment of outcomes and management of patients with advanced HIV disease in a semi-urban polyclinic in Epworth, Zimbabwe. PLoS One 2019; 14:e0214739. [PMID: 30969987 PMCID: PMC6457534 DOI: 10.1371/journal.pone.0214739] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 03/19/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION HIV continues to be one of the leading causes of infectious death worldwide and presentation with advanced HIV disease is associated with increased morbidity and mortality. Recommendations for the management of advanced HIV disease include prompt screening and treatment of opportunistic infections, rapid initiation of ART and intensified adherence support. We present treatment outcomes of a cohort of patients presenting with advanced HIV disease in a semi-urban Zimbabwean polyclinic. METHODS Retrospective cohort analysis of adult patients enrolled for care at Epworth polyclinic, Zimbabwe between 2007 and end June 2016. Treatment outcomes at 6 and 12 months were recorded. Multivariate logistical regression analysis was undertaken to identify risk factors for presentation with advanced HIV Disease (CD4 count less than 200 cells/mm3 or WHO stage 3 or 4) and risks for attrition at 12 months. RESULTS 16,007 anti-retroviral therapy naive adult patients were included in the final analysis, 47.4% of whom presented with advanced HIV disease. Patients presenting with advanced HIV disease had a higher mortality rate at 12 months following enrollment compared to early stage patients (5.11% vs 0.45%). Introduction of a package of differentiated care for patients with a CD4 count of less than 100 cells/mm3 resulted in diagnosis of cryptococcal antigenaemia in 7% of patients and a significant increase in the diagnosis of TB, although there was no significant difference in attrition at 6 or 12 months for these patients compared to those enrolled prior to the introduction of the differentiated care. CONCLUSIONS The burden of advanced HIV disease remained high over the study period in this semi-urban polyclinic in Zimbabwe. Introduction of a package of differentiated care for those with advanced HIV disease increased the diagnosis of opportunistic infections and represents a model of care which can be replicated in other polyclinics in the resource constrained Zimbabwean context.
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Affiliation(s)
- Simon Blankley
- Médecins Sans Frontières/Doctors Without Borders, Harare, Zimbabwe
- * E-mail:
| | - Tadele Gashu
- Médecins Sans Frontières/Doctors Without Borders, Harare, Zimbabwe
| | - Bilal Ahmad
- Médecins Sans Frontières/Doctors Without Borders, Harare, Zimbabwe
| | - Abi kebra Belaye
- Médecins Sans Frontières/Doctors Without Borders, Harare, Zimbabwe
| | - Lucia Ringtho
- Médecins Sans Frontières/Doctors Without Borders, Berlin, Germany
| | - Anita Mesic
- Médecins Sans Frontières/Doctors Without Borders, Amsterdam, Netherlands
| | - Simukai Zizhou
- Provincial Medical Directorate, Ministry of Health and Child Care, Marondera, Zimbabwe
| | - Esther C. Casas
- Médecins Sans Frontières/Doctors Without Borders, Amsterdam, Netherlands
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26
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Ross J, Sinayobye JD, Yotebieng M, Hoover DR, Shi Q, Ribakare M, Remera E, Bachhuber MA, Murenzi G, Sugira V, Nash D, Anastos K. Early outcomes after implementation of treat all in Rwanda: an interrupted time series study. J Int AIDS Soc 2019; 22:e25279. [PMID: 30993854 PMCID: PMC6468264 DOI: 10.1002/jia2.25279] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 03/29/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Nearly all countries in sub-Saharan Africa have adopted policies to provide antiretroviral therapy (ART) to all persons living with HIV (Treat All), though HIV care outcomes of these programmes are not well-described. We estimated changes in ART initiation and retention in care following Treat All implementation in Rwanda in July 2016. METHODS We conducted an interrupted time series analysis of adults enrolling in HIV care at ten Rwandan health centres from July 2014 to September 2017. Using segmented linear regression, we assessed changes in levels and trends of 30-day ART initiation and six-month retention in care before and after Treat All implementation. We compared modelled outcomes with counterfactual estimates calculated by extrapolating baseline trends. Modified Poisson regression models identified predictors of outcomes among patients enrolling after Treat All implementation. RESULTS Among 2885 patients, 1803 (62.5%) enrolled in care before and 1082 (37.5%) after Treat All implementation. Immediately after Treat All implementation, there was a 31.3 percentage point increase in the predicted probability of 30-day ART initiation (95% CI 15.5, 47.2), with a subsequent increase of 1.1 percentage points per month (95% CI 0.1, 2.1). At the end of the study period, 30-day ART initiation was 47.8 percentage points (95% CI 8.1, 87.8) above what would have been expected under the pre-Treat All trend. For six-month retention, neither the immediate change nor monthly trend after Treat All were statistically significant. While 30-day ART initiation and six-month retention were less likely among patients 15 to 24 versus >24 years, the predicted probability of both outcomes increased significantly for younger patients in each month after Treat All implementation. CONCLUSIONS Implementation of Treat All in Rwanda was associated with a substantial increase in timely ART initiation without negatively impacting care retention. These early findings support Treat All as a strategy to help achieve global HIV targets.
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Affiliation(s)
- Jonathan Ross
- Department of MedicineMontefiore Medical Center/Albert Einstein College of MedicineBronxNYUSA
| | | | - Marcel Yotebieng
- Division of EpidemiologyCollege of Public HealthOhio State UniversityColumbusOHUSA
| | - Donald R Hoover
- Department of Statistics and Biostatistics and Institute for HealthHealth Care Policy and Aging ResearchRutgers the State University of New JerseyPiscatawayNJUSA
| | - Qiuhu Shi
- Department of Epidemiology and Community HealthNew York Medical CollegeValhallaNYUSA
| | | | | | - Marcus A Bachhuber
- Department of MedicineMontefiore Medical Center/Albert Einstein College of MedicineBronxNYUSA
| | - Gad Murenzi
- Research DivisionRwanda Military HospitalKigaliRwanda
| | | | - Denis Nash
- Institute for Implementation Science in Population HealthCity University of New YorkNew YorkNYUSA
| | - Kathryn Anastos
- Department of MedicineMontefiore Medical Center/Albert Einstein College of MedicineBronxNYUSA
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Benzekri NA, Sambou JF, Ndong S, Tamba IT, Faye D, Diallo MB, Diatta JP, Faye K, Sall I, Sall F, Manga NM, Malomar JJ, Ndour CT, Hawes SE, Seydi M, Gottlieb GS. Prevalence, predictors, and management of advanced HIV disease among individuals initiating ART in Senegal, West Africa. BMC Infect Dis 2019; 19:261. [PMID: 30876400 PMCID: PMC6420737 DOI: 10.1186/s12879-019-3826-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 02/15/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The WHO guidelines for the management of advanced HIV disease recommend a package of care consisting of rapid initiation of antiretroviral therapy (ART), enhanced screening and diagnosis of tuberculosis (TB) and cryptococcal meningitis, co-trimoxazole prophylaxis, isoniazid preventive therapy (IPT), fluconazole pre-emptive therapy, and adherence support. The goals of this study were to determine the prevalence of advanced HIV disease among individuals initiating ART in Senegal, to identify predictors of advanced disease, and to evaluate adherence to the WHO guidelines. METHODS This study was conducted among HIV-positive individuals initiating ART in Dakar and Ziguinchor, Senegal. Clinical evaluations, laboratory analyses, questionnaires and chart review were conducted. Logistic regression was used to identify predictors of advanced disease. RESULTS A total of 198 subjects were enrolled; 70% were female. The majority of subjects (71%) had advanced HIV disease, defined by the WHO as a CD4 count < 200 cells/mm3 or clinical stage 3 or 4. The median CD4 count was 185 cells/mm3. The strongest predictors of advanced disease were age ≥ 35 (OR 5.80, 95%CI 2.35-14.30) and having sought care from a traditional healer (OR 3.86, 95%CI 1.17-12.78). Approximately one third of subjects initiated ART within 7 days of diagnosis. Co-trimoxazole prophylaxis was provided to 65% of subjects with CD4 counts ≤350 cells/mm3 or stage 3 or 4 disease. TB symptom screening was available for 166 subjects; 54% reported TB symptoms. Among those with TB symptoms, 39% underwent diagnostic evaluation. Among those eligible for IPT, one subject received isoniazid. No subjects underwent CrAg screening or received fluconazole to prevent cryptococcal meningitis. CONCLUSIONS This is the first study to report an association between seeking care from a traditional healer and presentation with WHO defined advanced disease in sub-Saharan Africa. Given the widespread use of traditional healers in sub-Saharan Africa, future studies to further explore this finding are indicated. Although the majority of individuals in this study presented with advanced disease and warranted management according to WHO guidelines, there were numerous missed opportunities to prevent HIV-associated morbidity and mortality. Programmatic evaluation is needed to identify barriers to implementation of the WHO guidelines and enhanced funding for operational research is indicated.
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Affiliation(s)
- Noelle A Benzekri
- Department of Medicine, University of Washington, Box 358061, 750 Republican St, Seattle, WA, 98109-4725, USA.
| | | | - Sanou Ndong
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier National Universitaire (CHNU) de Fann, Dakar, Senegal
| | | | | | - Mouhamadou Baïla Diallo
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier National Universitaire (CHNU) de Fann, Dakar, Senegal
| | | | - Khadim Faye
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier National Universitaire (CHNU) de Fann, Dakar, Senegal
| | | | - Fatima Sall
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier National Universitaire (CHNU) de Fann, Dakar, Senegal
| | | | | | - Cheikh T Ndour
- Division de Lutte contre le Sida et les IST, Ministère de la Santé et de l'Action Sociale, Dakar, Sénégal
| | - Stephen E Hawes
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Moussa Seydi
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier National Universitaire (CHNU) de Fann, Dakar, Senegal
| | - Geoffrey S Gottlieb
- Department of Medicine, University of Washington, Box 358061, 750 Republican St, Seattle, WA, 98109-4725, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
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Nash D, Yotebieng M, Sohn AH. Treating all people living with HIV in sub-Saharan Africa: a new era calling for new approaches. J Virus Erad 2018; 4:1-4. [PMID: 30515307 PMCID: PMC6248848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Nearly all countries in sub-Saharan Africa (SSA) have adopted national policies to treat all persons with HIV, regardless of CD4 cell count or clinical stage ('treat all'). With 10.3 million people untreated and a projected 1.2 million new infections per year in SSA, the current and anticipated unmet need for HIV treatment in SSA is substantial. Evidence to date from SSA suggests that, once linked to care, timely ART initiation with retention and viral suppression is the norm. However, ART initiation in SSA usually occurs late in the course of infection, driving high mortality and incidence rates. The 'treat all' era presents strategic opportunities for health systems to substantially reduce AIDS-related mortality and HIV incidence. This special issue of the Journal of Virus Eradication contains eight articles focused on issues critical to ensuring the success and impact of 'treat all' implementation in SSA.
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Affiliation(s)
- Denis Nash
- Corresponding author: Denis Nash,
City University of New York,
Institute for Implementation Science in Population Health,
55 W 125th Street, 6th Floor,
New York,
NY10027,
USA
| | - Marcel Yotebieng
- College of Public Health, Division of Epidemiology, Ohio State University,
Columbus, OH,
USA
| | - Annette H Sohn
- TREAT Asia, amfAR – Foundation for AIDS Research,
Bangkok,
Thailand
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29
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Nash D, Yotebieng M, Sohn AH. Treating all people living with HIV in sub-Saharan Africa: a new era calling for new approaches. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30340-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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30
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ART initiation in an outpatient treatment center in Dakar, Senegal: A retrospective cohort analysis (1998-2015). PLoS One 2018; 13:e0202984. [PMID: 30231075 PMCID: PMC6145516 DOI: 10.1371/journal.pone.0202984] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 08/12/2018] [Indexed: 11/27/2022] Open
Abstract
Objective To examine how patient characteristics combined with ART eligibility expansions affect the initiation of antiretroviral therapy (ART) among eligible patients attending a referral center in Senegal from 1998 to 2015. Methods This is a retrospective observational study carried out at the outpatient treatment Centre (Centre de Traitement Ambulatoire) in Dakar, Senegal, based on computerized medical records, gathered from 1998 to 2015, of ART-naïve patients over 15 years of age. ART eligibility was defined as (CD4 count below 200) or as (WHO stage 4) or as (WHO stage 3 with (CD4 count below 350 or with unavailable CD4 count)) in 1998–2010; as (CD4 count below 350) or as (WHO stage 3 or 4) in 2011–2013; as (CD4 count below 500) or as (WHO stage 3 or 4) in 2014–2015. Four periods were defined according to ART eligibility expansions and Senegal’s HIV care history: 1998–2003 (P 1), 2004–2010 (P 2), 2011–2013 (P3), and 2014–2015 (P4). Patients were expected to participate financially in their treatment during the first period (P1). Results A total of 3651 patient records were included. The median patient age was 40 years (IQR: 32–48). Women represented 56% of the population. The median CD4 count was 183 cells/mm3. Overall, 53% of patients had CD4 < 200 cells/mm3 at entry. This proportion reached 45% in 2014–2015. 2535 patients (69%) were eligible for therapy, including 1503 (41%) who started ART. The proportion of treated patients among those who were eligible at entry or later increased steadily from 25%, 47%, 75% to 82% in the four periods, respectively. The median time to treatment decreased from 5.6 months (IQR: 3–11) in P1 to 0.8 months (IQR: 0–2) in P4. Eligible patients with more advanced disease (CD4<200 cells/mm3 and/or clinical stage 3 or 4) were more likely to be ART initiated than those with CD4≥200 cells/mm3 and/or clinical stage 1 or 2 at each stage of ART eligibility expansion. Conclusion ART eligibility expansions were marked by a sharp increase in the proportion of eligible patients initiating treatment. These results show that in terms of management, the target of "Test and Treat" can be easily reached but that HIV testing will remain a key element to improve treatment success, as illustrated by the high proportion of people with advanced stage of infection at the time of ART initiation.
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Mecha JO, Kubo EN, Nganga LW, Muiruri PN, Njagi LN, Ilovi S, Ngethe R, Mutisya I, Ngugi EW, Maleche-Obimbo E. Trends, treatment outcomes, and determinants for attrition among adult patients in care at a large tertiary HIV clinic in Nairobi, Kenya: a 2004-2015 retrospective cohort study. HIV AIDS (Auckl) 2018; 10:103-114. [PMID: 29988689 PMCID: PMC6029585 DOI: 10.2147/hiv.s153185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Understanding trends in patient profiles and identifying predictors for adverse outcomes are key to improving the effectiveness of HIV care and treatment programs. Previous work in Kenya has documented findings from a rural setting. This paper describes trends in demographic and clinical characteristics of antiretroviral therapy (ART) treatment cohorts at a large urban, referral HIV clinic and explores treatment outcomes and factors associated with attrition during 12 years of follow-up. Methods This was a retrospective cohort analysis of HIV-infected adults who started ART between January 1, 2004, and September 30, 2015. ART-experienced patients and those with missing data were excluded. The Cochran–Armitage test was used to determine trends in baseline characteristics over time. Cox proportional hazards models were used to determine the effect of baseline characteristics on attrition. Results ART uptake among older adolescents (15–19 years), youth, and young adults increased over time (p=0.0001). Independent predictors for attrition included (adjusted hazard ratio [95% CI]) male sex: 1.30 (1.16–1.45), p=0.0001; age: 15–19 years: 1.83 (1.26–2.66), p=0.0014; 20–24 years: 1.93 (1.52–2.44), p=0.0001; and 25–29 years: 1.31 (1.11–1.54), p=0.0012; marital status – single: 1.27 (1.11–1.44), p=0.0005; and divorced/separated: 1.56 (1.30–1.87), p=0.0001; urban residence: 1.40 (1.20–1.64), p=0.0001; entry into HIV care following hospitalization: 1.31 (1.10–1.57), p=0.0026, or transfer from another facility: 1.60 (1.26–2.04), p=0.0001; initiation of ART more than 12 months after the date of HIV diagnosis: 1.36 (1.19–1.55), p=0.0001, and history of a current or past opportunistic infection (OI): 1.15 (1.02–1.30), p=0.0284. Conclusion Although ART uptake among adolescents and young people increased over time, this group was at increased risk for attrition. Single marital status, urban residence, history of hospitalization or OI, and delayed initiation of ART also predicted attrition. This calls for focused evidence-informed strategies to address attrition and improve outcomes.
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Affiliation(s)
- Jared O Mecha
- Department of Clinical Medicine & Therapeutics, University of Nairobi School of Medicine, Nairobi, Kenya,
| | - Elizabeth N Kubo
- Department of Clinical Medicine & Therapeutics, University of Nairobi School of Medicine, Nairobi, Kenya,
| | | | | | - Lilian N Njagi
- Department of Clinical Medicine & Therapeutics, University of Nairobi School of Medicine, Nairobi, Kenya,
| | - Syokau Ilovi
- Department of Clinical Medicine & Therapeutics, University of Nairobi School of Medicine, Nairobi, Kenya,
| | | | - Immaculate Mutisya
- Division of Global HIV and TB (DGHT), US Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Evelyn W Ngugi
- Division of Global HIV and TB (DGHT), US Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Elizabeth Maleche-Obimbo
- Department of Clinical Medicine & Therapeutics, University of Nairobi School of Medicine, Nairobi, Kenya,
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Supervie V, Assoumou L, Breban R, Lert F, Costagliola D, Pialoux G, Landman R, Girard PM, Slama L. Risk of HIV transmission during combined ART initiation for HIV-infected persons with severe immunosuppression. J Antimicrob Chemother 2018; 72:3172-3176. [PMID: 28961977 DOI: 10.1093/jac/dkx276] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 07/07/2017] [Indexed: 11/13/2022] Open
Abstract
Background Individuals presenting for care with severe immunosuppression typically have high plasma HIV viral load (pVL) and may transmit HIV before and after initiation of combination antiretroviral therapies (cART). Patients and methods Using risk equations and data collected in the IMEA 040 DATA trial on sexual behaviour and pVL level of 84 HIV-infected patients (23 women), we estimated monthly rates of HIV transmission for each virologically unsuppressed participant (pVL >50 copies/mL) who reported sex with HIV-negative or unknown serostatus (HNUS) partners at cART initiation, 24 weeks (W24) and W48 after; rates were considered negligible for other participants. Results At cART initiation, median pVL was 5.4 log10 copies/mL. The percentage of virologically unsuppressed patients decreased, from 100% at cART initiation to 27% (95% CI 16%-43%) for heterosexuals and 8% (95% CI 2%-22%) for MSM at W48 (P < 0.001). The percentage of patients reporting sex with HNUS partners increased between cART initiation and W48, from 23% (95% CI 10%-42%) to 42% (95% CI 25%-61%) for heterosexuals (P = 0.042) and from 41% (95% CI 21%-64%) to 73% (95% CI 52%-88%) for MSM (P = 0.004). Median monthly HIV transmission rates were 0.0540 (IQR 0.0339-0.0742) for MSM and 0.0018 (IQR 0.0014-0.0191) for heterosexuals at cART initiation, and were reduced by 95% (95% CI 87%-100%) for heterosexuals and 98% (95% CI 95%-100%) for MSM as early as W24. Conclusions Risk of onward transmission for severely immunosuppressed individuals is high before and within the first weeks of cART, and persists, at a substantially reduced level, beyond 24 weeks of cART for some individuals. Earlier cART and protecting HIV-negative partners until full viral suppression is achieved could reduce HIV transmission.
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Affiliation(s)
- V Supervie
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), 56 bd Vincent Auriol, F75013 Paris, France
| | - L Assoumou
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), 56 bd Vincent Auriol, F75013 Paris, France
| | - R Breban
- Institut Pasteur, UEME, F75015 Paris, France
| | - F Lert
- INSERM CESP U1018, Hôpital Paul-Brousse, 94800 Villejuif, France
| | - D Costagliola
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), 56 bd Vincent Auriol, F75013 Paris, France
| | - G Pialoux
- Hôpital Tenon, APHP, Service des Maladies Infectieuses et Tropicales, F75020 Paris, France
| | - R Landman
- Bichat Claude Bernard, APHP, Maladies Infectieuses, F75018 Paris, France.,Institut de Médecine et d'Epidémiologie Appliquées, UMR 1137, Univ Paris Diderot, Sorbonne Paris Cité, F75018 Paris, France.,Institut de Médecine et d'Epidémiologie Appliquées, UMR 1137, INSERM, F75018 Paris, France
| | - P M Girard
- Institut de Médecine et d'Epidémiologie Appliquées, UMR 1137, INSERM, F75018 Paris, France.,Saint Antoine, APHP, Maladies Infectieuses, F75012 Paris, France
| | - L Slama
- Hôpital Tenon, APHP, Service des Maladies Infectieuses et Tropicales, F75020 Paris, France.,Hôtel Dieu, APHP, Service de thérapeutique en immuno-infectiologie, F75004 Paris, France
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Anderegg N, Panayidou K, Abo Y, Alejos B, Althoff KN, Anastos K, Antinori A, Balestre E, Becquet R, Castagna A, Castelnuovo B, Chêne G, Coelho L, Collins IJ, Costagliola D, Crabtree-Ramírez B, Dabis F, d’Arminio Monforte A, Davies MA, De Wit S, Delpech V, De La Mata NL, Duda S, Freeman A, Gange SJ, Grabmeier-Pfistershammer K, Gunsenheimer-Bartmeyer B, Jiamsakul A, Kitahata MM, Law M, Manzardo C, McGowan C, Meyer L, Moore R, Mussini C, Nakigoz G, Nash D, Tek Ng O, Obel N, Pantazis N, Poda A, Raben D, Reiss P, Riggen L, Sabin C, d’Amour Sinayobye J, Sönnerborg A, Stoeckle M, Thorne C, Torti C, Twizere C, Wasmuth JC, Wittkop L, Wools-Kaloustian K, Yotebieng M, Kirk O, Egger M. Global Trends in CD4 Cell Count at the Start of Antiretroviral Therapy: Collaborative Study of Treatment Programs. Clin Infect Dis 2018; 66:893-903. [PMID: 29373672 PMCID: PMC5848308 DOI: 10.1093/cid/cix915] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 11/21/2017] [Indexed: 11/14/2022] Open
Abstract
Background Early initiation of combination antiretroviral therapy (cART), at higher CD4 cell counts, prevents disease progression and reduces sexual transmission of human immunodeficiency virus (HIV). We describe the temporal trends in CD4 cell counts at the start of cART in adults from low-income, lower-middle-income, upper-middle-income, and high-income countries (LICs, LMICs, UMICs, and HICs, respectively). Methods We included HIV-infected individuals aged ≥16 years who started cART between 2002 and 2015 in a clinic participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) or the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE). Missing CD4 cell counts at the start of cART were estimated through multiple imputation. Weighted mixed-effect models were used to smooth trends in median CD4 cell counts. Results A total of 951855 adults from 16 LICs, 11 LMICs, 9 UMICs, and 19 HICs were included. Overall, the modeled median CD4 cell count at the start of cART increased from 2002 to 2015, from 78/µL (95% confidence interval, 58-104/µL) to 287/µL (250-328/µL) in LICs, from 99/µL (71-140/µL) to 234/µL (192-285/µL) in LMICs, from 71/µL (49-104/µL) to 311/µL (255-379/µL) in UMICs, and from 161/µL (143-181/µL) to 327/µL (286-372/µL) in HICs. In LICs, LMICs, and UMICs, the increase was more pronounced in women; in HICs, the opposite was observed. Conclusions Median CD4 cell counts at the start of cART increased in all income groups, but generally remained below 350/μL in 2015. Substantial additional efforts and resources are required to achieve earlier diagnosis, linkage to care, and initiation of cART.
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Carmona S, Bor J, Nattey C, Maughan-Brown B, Maskew M, Fox MP, Glencross DK, Ford N, MacLeod WB. Persistent High Burden of Advanced HIV Disease Among Patients Seeking Care in South Africa's National HIV Program: Data From a Nationwide Laboratory Cohort. Clin Infect Dis 2018; 66:S111-S117. [PMID: 29514238 PMCID: PMC5850436 DOI: 10.1093/cid/ciy045] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background The South African national HIV program has increased antiretroviral therapy (ART) coverage over the last decade, supported by policy changes allowing for earlier ART initiation. However, many patients still enter care with advanced (<200 cells/μL) and very advanced (<100 cells/μL) HIV disease. We assessed disease progression at entry to care using nationwide laboratory data. Methods We constructed a national HIV cohort using laboratory records containing HIV RNA loads and CD4 counts from 2004 to 2016 to determine entry into care. We estimated numbers and proportions of adults with the first CD4 count <100 cells/ μL or 100-199 cells/μL. We calculated relative risks of presenting with advanced disease associated with male sex. Results 8.04 million first CD4 results were identified. From 2005 to 2011, the proportion of patients entering into care with CD4 count <200 cells/μL declined from 46.8% to 35.6%. From 2011 onward, the proportion of patients entering ART with advanced HIV disease has remained relatively unchanged. In 2016, we estimated that of 654 868 patients entering care, 32.9% had advanced HIV disease, and 16.8% had very advanced HIV disease. Men were almost twice as likely as women (23.1% vs 12.6% ) to enter care with very advanced HIV disease. Conclusions The proportion of patients presenting with advanced HIV disease in South Africa remains consistently high despite ART scale-up, representing a large and avoidable burden of morbidity. Early HIV diagnosis, rapid linkage to ART and approaches to attract men into early ART initiation should be prioritized.
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Affiliation(s)
- Sergio Carmona
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
- National Health Laboratory Service, Johannesburg
| | - Jacob Bor
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Massachusetts
- Department of Epidemiology, Boston University School of Public Health, Massachusetts
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Brendan Maughan-Brown
- Southern Africa Labour and Development Research Unit, University of Cape Town, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Massachusetts
- Department of Epidemiology, Boston University School of Public Health, Massachusetts
| | - Deborah K Glencross
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
- National Health Laboratory Service, Johannesburg
| | - Nathan Ford
- World Health Organization, HIV/AIDS, Geneva, Switzerland
| | - William B MacLeod
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Massachusetts
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Maughan-Brown B, Smith P, Kuo C, Harrison A, Lurie MN, Bekker LG, Galárraga O. A Conditional Economic Incentive Fails to Improve Linkage to Care and Antiretroviral Therapy Initiation Among HIV-Positive Adults in Cape Town, South Africa. AIDS Patient Care STDS 2018; 32:70-78. [PMID: 29432045 PMCID: PMC5808383 DOI: 10.1089/apc.2017.0238] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Interventions to improve antiretroviral therapy (ART) access are urgently needed to maximize the multiple benefits from ART. This pilot study examined the effect of a conditional economic incentive on linkage to care and uptake of treatment following ART referral by a mobile health clinic. Between April 2015 and May 2016, 86 individuals (≥18 years old) referred for ART in a resource-limited setting were randomized (1:1) to a control group or to an incentive: R300 cash (∼$23, or 3.5 days minimum wage in the domestic worker sector), conditional upon starting ART within 3 months. Outcome data were obtained from clinic records. The incentive effects on linkage to care (first clinic visit within 3 months) and ART initiation (treatment uptake within 3 months) were assessed using logistic regression. Overall, 67% linked to care and 42% initiated ART within 3 months after referral. No significant differences were found between the incentive and non-incentive group in terms of linkage to care [adjusted odds ratio (aOR): 0.70, 95% confidence interval (CI): 0.26-1.91] and initiation of ART (aOR: 0.67, 95% CI: 0.26-1.78). Ordinary least-squares regression analysis showed that incentivized individuals linked to care in fewer days (-7.9, 95% CI: -18.09 to 2.26) and started treatment in fewer days (-7.3, 95% CI: -27.01 to 12.38), but neither result was statistically significant. Our findings demonstrate poor treatment uptake by both the intervention and control participants and further highlight the challenge in achieving universal early treatment access. Further research is required to understand how economic incentives, which have been shown to have many benefits, can be applied to improve linkage to HIV care and treatment.
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Affiliation(s)
- Brendan Maughan-Brown
- Southern Africa Labour and Development Research Unit (SALDRU), University of Cape Town, Cape Town, South Africa
| | - Philip Smith
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Caroline Kuo
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Abigail Harrison
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island
| | - Mark N. Lurie
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Omar Galárraga
- Department of Health Services, Policy and Practice (HSPP), Brown University School of Public Health, Providence, Rhode Island
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Elul B, Saito S, Chung H, Hoos D, El-Sadr W. Attrition From Human Immunodeficiency Virus Treatment Programs in Africa: A Longitudinal Ecological Analysis Using Data From 307 144 Patients Initiating Antiretroviral Therapy Between 2005 and 2010. Clin Infect Dis 2018; 64:1309-1316. [PMID: 28329244 DOI: 10.1093/cid/cix162] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 02/15/2017] [Indexed: 11/14/2022] Open
Abstract
Background As access to antiretroviral therapy (ART) in Africa has increased dramatically, concerns have been raised regarding patient attrition, an important measure of program quality. Methods We examined aggregate data from 307144 patients initiating ART in 5638 successive cohorts at 638 facilities in 9 African countries from 2005 to 2010, a period characterized by massive treatment expansion. Poisson regression assessed trends in 6- and 12-month cohort attrition (ie, the proportion of patients in each cohort no longer receiving ART at their initiating facility) over calendar time and as ART services matured, and identified factors associated with attrition. Results Across all 9 countries, 6- and 12-month cohort attrition was 21% and 29%, respectively, with no decrease over calendar time (6-month P = .8735; 12-month P = .5717) or as ART services matured (6-month P = .3005; 12-month P = .2277). Additionally, attrition remained stable or decreased across both measures in nearly all countries. Initiating ART in facilities with more documented transfers and fewer women on ART, and in cohorts with poor CD4 count documentation and lower median CD4 count at ART initiation was associated with increased 6-month attrition. Increased 12-month attrition was observed in semiurban facilities and those with more documented transfers, and in cohorts with poor CD4 count documentation, whereas higher patient load was associated with decreased attrition. Conclusions Stable or decreasing trends in attrition for ART patients were observed in most countries, suggesting programs can be expanded without compromising quality. However, further reductions in attrition are needed to maximize individual and population benefits of ART.
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Affiliation(s)
- Batya Elul
- Department of Epidemiology, and.,ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York
| | - Suzue Saito
- Department of Epidemiology, and.,ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York
| | - Hannah Chung
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York
| | - David Hoos
- Department of Epidemiology, and.,ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York
| | - Wafaa El-Sadr
- Department of Epidemiology, and.,ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York
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Tariq S, Hoffman S, Ramjee G, Mantell JE, Phillip JL, Blanchard K, Lince-Deroche N, Exner TM. "I did not see a need to get tested before, everything was going well with my health": a qualitative study of HIV-testing decision-making in KwaZulu-Natal, South Africa. AIDS Care 2018; 30:32-39. [PMID: 28695750 PMCID: PMC5699939 DOI: 10.1080/09540121.2017.1349277] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 06/26/2017] [Indexed: 01/15/2023]
Abstract
Few studies have examined HIV-testing decision-making since the South African national HIV counseling and testing campaign in 2010-2011 and subsequent expansion in antiretroviral therapy (ART) eligibility in 2012. We describe HIV-testing decision-making and pathways to testing among participants in Pathways to Care, a cohort study of newly-diagnosed HIV-positive adults in KwaZulu-Natal. Our analysis is embedded within a theoretical framework informed by Arthur Kleinman's work on pluralistic healthcare systems, and the concept of diagnostic itineraries (i.e., the route taken to HIV testing). We conducted 26 semi-structured interviews in 2012, within one month of participants' diagnosis. Most (n = 22) deferred testing until they had developed symptoms, and then often sought recourse in non-biomedical settings. Of the eleven symptomatic participants who accessed professional medical services prior to testing, only three reported that a healthcare professional had offered or recommended an HIV test. Although ART emerged as an important motivator, offering hope of health and normalcy, fear of death and HIV-related stigma remained key barriers. Despite national policy changes in testing and treatment, health system and individual factors contributed to ongoing high levels of late diagnosis of HIV in this study population. Encouraging local health systems to direct clients toward HIV testing, and continuing to raise awareness of the benefits of routine testing remain important strategies to reduce delayed diagnoses.
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Affiliation(s)
- Shema Tariq
- a HIV Center for Clinical and Behavioral Studies , NYS Psychiatric Institute and Columbia University , New York , NY , USA
| | - Susie Hoffman
- a HIV Center for Clinical and Behavioral Studies , NYS Psychiatric Institute and Columbia University , New York , NY , USA
- b Department of Epidemiology, Mailman School of Public Health , Columbia University , New York , NY , USA
| | - Gita Ramjee
- c South African Medical Research Council , HIV Prevention Research Unit , Durban , South Africa
- d Department of Global Health, School of Medicine , University of Washington , Seattle , WA , USA
| | - Joanne E Mantell
- a HIV Center for Clinical and Behavioral Studies , NYS Psychiatric Institute and Columbia University , New York , NY , USA
| | - Jessica L Phillip
- c South African Medical Research Council , HIV Prevention Research Unit , Durban , South Africa
| | - Kelly Blanchard
- e Ibis Reproductive Health , Cambridge , MA , USA
- f Ibis Reproductive Health , Johannesburg , South Africa
| | - Naomi Lince-Deroche
- e Ibis Reproductive Health , Cambridge , MA , USA
- f Ibis Reproductive Health , Johannesburg , South Africa
| | - Theresa M Exner
- a HIV Center for Clinical and Behavioral Studies , NYS Psychiatric Institute and Columbia University , New York , NY , USA
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Abstract
Background Many people living with HIV in South Africa (SA) are not aware of their seropositive status and are diagnosed late during the course of HIV infection. These individuals do not obtain the full benefit from available HIV care and treatment services. Objectives To describe the prevalence of late presentation for HIV care among newly diagnosed HIV-positive individuals and evaluate sociodemographic variables associated with late presentation for HIV care in three high-burden districts of SA. Methods We used data abstracted from records of 8 138 newly diagnosed HIV-positive individuals in 35 clinics between 1 June 2014 and 31 March 2015 to determine the prevalence of late presentation among newly diagnosed HIV-positive individuals in selected high-prevalence health districts. Individuals were categorised as ‘moderately late’, ‘very late’ or ‘extremely late’ presenters based on specified criteria. Descriptive analysis was performed to measure the prevalence of late presentation, and multivariate regression analysis was conducted to identify variables independently associated with extremely late presentation. Results Overall, 79% of the newly diagnosed cases presented for HIV care late in the course of HIV infection (CD4+ count ≤500 cells/ μL and/or AIDS-defining illness in World Health Organization (WHO) stage III/IV), 19% presented moderately late (CD4+ count 351 – 500 cells/μL and WHO clinical stage I or II), 27% presented very late (CD4+ count 201 – 350 cells/μL or WHO clinical stage III), and 33% presented extremely late (CD4+ count ≤200 cells/μL and/or WHO clinical stage IV) for HIV care. Multivariate regression analysis indicated that males, non-pregnant women, individuals aged >30 years, and those accessing care in facilities located in townships and inner cities were more likely to present late for HIV care. Conclusions The majority of newly diagnosed HIV-positive individuals in the three high-burden districts (Gert Sibande, uThukela and City of Johannesburg) presented for HIV care late in the course of HIV infection. Interventions that encourage early presentation for HIV care should be prioritised in SA and should target males, non-pregnant women, individuals aged >30 years and those accessing care in facilities located in inner cities and urban townships.
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Lay P, An S, Soeung S, Srey PS, Thai S, Lynen L, van Griensven J. Ten year experience with antiretroviral treatment in Cambodia: Trends in patient characteristics and treatment outcomes. PLoS One 2017; 12:e0185348. [PMID: 29136011 PMCID: PMC5685593 DOI: 10.1371/journal.pone.0185348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 09/11/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Although HIV disease stage at ART initiation critically determines ART outcomes, few reports have longitudinally monitored this within Asia. Using prospectively collected data from a large ART program at Sihanouk Hospital Center of Hope in Cambodia, we report on the change in patient characteristics and outcomes over a ten-year period. METHODS We conducted a retrospective analysis including all adults (≥ 18 years old) starting ART from March 2003-March 2013 in a non-governmental hospital in Phnom Penh, Cambodia. The cumulative incidence of death, lost to follow-up (LTFU), attrition (death or LTFU) and first line treatment failure were calculated using Kaplan-Meier methods. Independent risk factors for these outcomes were determined using Cox regression modeling. RESULTS Over the ten-year period, 3581 patients initiated ART with a median follow-up time of 4.8 years (IQR 2.8-7.2). The median age was 35 years (IQR 30-41), 54% were female. The median CD4 count at ART initiation increased from 22 cells/μL (IQR 4-129) in 2003 to 218 (IQR 57-302) in 2013. Over the 10 year period, a total of 282 (7.9%) individuals died and 433 (12.1%) were defined LTFU. Program attrition (died or LTFU) was 11.1% (95% CI: 10.1%- 12.4%) at one year, 16.3% (95% CI: 15.1%-17.6%) at three years, 19.8% (95% CI: 18.5%-21.2%) at five years and 23.3% (95% CI: 21.6-25.1) at ten years. Male sex and low baseline body mass index (BMI) were associated with increased attrition. Factors independently associated with mortality included a low baseline CD4 count, older age, male sex, low baseline BMI and hepatitis B co-infection. Individuals aged above 40 years old had an increased risk of mortality but were less likely to LTFU. There were a total of 137 individuals with first line ART failure starting second line treatment. The probability of first line failure was estimated at 2.8% (95% CI: 2.3%-3.4%) at 3 years, 4.6% (95% CI: 3.9%-5.5%) at 5 years and 7.8% (95% CI 4.8%-12.5%) at ten years of ART. The probability was particularly high in the first few program years. A lower risk was observed among individuals starting ART during the 2006-2008 period. Factors independently associated with an increased risk of treatment failure included ART-experience, NVP-based ART and a baseline CD4 count below 200 cells/μL. CONCLUSIONS Overall program outcomes were fair, and generally compare well to other reports from the region. Despite gradually earlier initiation of ART over the ten year period, ART is still initiated at too low CD4 count levels, warranting increased efforts for early HIV diagnosis and enrolment/retention into HIV care. Tailored strategies for poor prognostic groups (older age, male, low BMI) should be designed and evaluated.
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Affiliation(s)
- Phirum Lay
- Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
| | - Sokkab An
- Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
| | | | | | - Sopheak Thai
- Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
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Kulkarni S, Tymejczyk O, Gadisa T, Lahuerta M, Remien RH, Melaku Z, El-Sadr W, Elul B, Nash D, Hoffman S. "Testing, Testing": Multiple HIV-Positive Tests among Patients Initiating Antiretroviral Therapy in Ethiopia. J Int Assoc Provid AIDS Care 2017; 16:546-554. [PMID: 29117777 DOI: 10.1177/2325957417737840] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Repeat HIV testing after receiving a positive result has never been studied systematically and may give insight into reasons for delayed linkage to care. Among 831 adults in 6 secondary facilities in Oromia, Ethiopia, who completed an interviewer-administered structured questionnaire within 2 weeks of initiating antiretroviral therapy in 2012 to 2013, 110 (13.2%) reported having retested after an HIV-positive result. The odds of repeat (versus single) HIV-positive testing were higher among those who had doubted their HIV status (adjusted odds ratio [AOR]ref=nodoubt = 6.5; 95% confidence interval [CI]: 3.7-11.4) and those who initially tested at another facility, whether another secondary facility (AOR ref=studyfacility = 22.7; 95% CI: 11.0-46.9) or a lower-level facility (AORref=studyfacility = 19.1; 95% CI: 10.5-34.5). The odds of repeat (versus single) HIV-positive testing were lower among those who initially tested because of symptoms (AORref=not a reason = 0.40; 95% CI: 0.24-0.66). Median time between initial diagnosis and enrollment in care was 12.3 versus 1.0 month for repeat and single HIV-positive testers, respectively ( P < .001). Repeat HIV-positive testing-not a rare occurrence-appears to stem from doubt, seeking care at a facility other than where diagnosed, and testing for a reason other than having symptoms. Because repeat HIV-positive testing is associated with delay in linkage to care, providers should be aware of this potential when counseling those who test HIV positive.
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Affiliation(s)
- Sarah Kulkarni
- 1 CUNY Graduate School of Public Health and Health Policy, New York, NY, USA.,2 CUNY Institute of Implementation Science in Population Health, New York, NY, USA
| | - Olga Tymejczyk
- 1 CUNY Graduate School of Public Health and Health Policy, New York, NY, USA.,2 CUNY Institute of Implementation Science in Population Health, New York, NY, USA
| | - Tsigereda Gadisa
- 3 ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Maria Lahuerta
- 3 ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Robert H Remien
- 4 HIV Center for Clinical and Behavioral Studies, New York, NY, USA
| | - Zenebe Melaku
- 3 ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Wafaa El-Sadr
- 3 ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA.,5 Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Batya Elul
- 3 ICAP-Columbia University, Mailman School of Public Health, New York, NY, USA.,5 Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Denis Nash
- 1 CUNY Graduate School of Public Health and Health Policy, New York, NY, USA.,2 CUNY Institute of Implementation Science in Population Health, New York, NY, USA.,4 HIV Center for Clinical and Behavioral Studies, New York, NY, USA.,5 Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Susie Hoffman
- 4 HIV Center for Clinical and Behavioral Studies, New York, NY, USA.,5 Mailman School of Public Health, Columbia University, New York, NY, USA
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Rick F, Niyibizi AA, Shroufi A, Onami K, Steele SJ, Kuleile M, Muleya I, Chiller T, Walker T, Van Cutsem G. Cryptococcal antigen screening by lay cadres using a rapid test at the point of care: A feasibility study in rural Lesotho. PLoS One 2017; 12:e0183656. [PMID: 28877182 PMCID: PMC5587318 DOI: 10.1371/journal.pone.0183656] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 08/08/2017] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Cryptococcal meningitis is one of the leading causes of death among people with HIV in Africa, primarily due to delayed presentation, poor availability and high cost of treatment. Routine cryptococcal antigen (CrAg) screening of patients with a CD4 count less than 100 cells/mm3, followed by pre-emptive therapy if positive, might reduce mortality in high prevalence settings. Using the cryptococcal antigen (CrAg) lateral flow assay (LFA), screening is possible at the point of care (POC). However, critical shortages of health staff may limit adoption. This study investigates the feasibility of lay counsellors conducting CrAg LFA screening in rural primary care clinics in Lesotho. METHODS From May 2014 to June 2015, individuals who tested positive for HIV were tested for CD4 count and those with CD4 <100 cells/mm3 were screened with CrAg LFA. All tests were performed by lay counsellors. CrAg-positive asymptomatic patients received fluconazole, while symptomatic patients were referred to hospital. Lay counsellors were trained and supervised by a laboratory technician and counsellor activity supervisor. Additionally, nurses and doctors were trained on CrAg screening and appropriate treatment. RESULTS During the study period, 1,388 people were newly diagnosed with HIV, of whom 129 (9%) presented with a CD4 count <100 cells/mm3. Of these, 128 (99%) were screened with CrAg LFA and 14/128 (11%) tested positive. Twelve of the 14 (86%) were asymptomatic, and received outpatient fluconazole. All commenced ART with a median time to initiation of 15.5 days [IQR: 14-22]. Of the asymptomatic patients, nine (75%) remained asymptomatic after a median time of 5 months [IQR; 3-6] of follow up. One (8%) became co-infected with tuberculosis and died and two were transferred out. The two patients with symptomatic cryptococcal meningitis (CM) were referred to hospital, where they later died. CONCLUSIONS CrAg LFA screening by lay counsellors followed by pre-emptive fluconazole treatment for asymptomatic cases, or referral to hospital for symptomatic cases, proved feasible. However, regular follow-up to ensure proper management of cryptococcal disease was needed. These early results support the wider use of CrAg LFA screening in remote primary care settings where upper cadres of healthcare staff may be in short supply.
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Affiliation(s)
| | | | - Amir Shroufi
- Médecins Sans Frontières, Cape Town, South Africa
- * E-mail:
| | | | | | | | | | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Tiffany Walker
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Epidemic Intelligence Service, Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States of America
| | - Gilles Van Cutsem
- Médecins Sans Frontières, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
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Kujawski SA, Lamb MR, Lahuerta M, McNairy ML, Ahoua L, Abacassamo F, Nuwagaba-Biribonwoha H, Gachuhi A, El-Sadr WM, Elul B. Advanced Human Immunodeficiency Virus Disease at Diagnosis in Mozambique and Swaziland. Open Forum Infect Dis 2017; 4:ofx156. [PMID: 28959700 PMCID: PMC5610724 DOI: 10.1093/ofid/ofx156] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 07/17/2017] [Indexed: 11/14/2022] Open
Abstract
Background Early diagnosis of human immunodeficiency virus (HIV) is a prerequisite to maximizing individual and societal benefits of antiretroviral therapy. Methods Adults ≥18 years of age testing HIV positive at 10 health facilities in Mozambique and Swaziland received point-of-care CD4+ cell count testing immediately after diagnosis. We examined median CD4+ cell count at diagnosis, the proportion diagnosed with advanced HIV disease (CD4+ cell count ≤350 cells/μL) and severe immunosuppression (CD4+ cell count ≤100 cells/μL), and determinants of the latter 2 measures. Results Among 2333 participants, the median CD4+ cell count at diagnosis was 313 cells/μL (interquartile range, 164–484), more than half (56.5%) had CD4+ ≤350 cells/μL, and 13.9% had CD4+ ≤100 cells/μL. The adjusted relative risk (aRR) of both advanced HIV disease and severe immunosuppression at diagnosis was higher in men versus women (advanced disease aRR = 1.31; 95% confidence interval [CI] = 1.16–1.48; severe immunosuppression aRR = 1.54, 95% CI = 1.17–2.02) and among those who sought HIV testing because they felt ill (advanced disease aRR = 1.30, 95% CI = 1.08–1.55; severe immunosuppression aRR = 2.10, 95% CI = 1.35–2.26). Age 18–24 versus 25–39 was associated with a lower risk of both outcomes (advanced disease aRR = 0.70, 95% CI = 0.59–0.84; severe immunosuppression aRR = 0.62, 95% CI = 0.41–0.95). Conclusions More than 10 years into the global scale up of comprehensive HIV services, the majority of adults diagnosed with HIV at health facilities in 2 high-prevalence countries presented with advanced disease and 1 in 7 had severe immunosuppression. Innovative strategies for early identification of HIV-positive individuals are urgently needed.
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Affiliation(s)
- Stephanie A Kujawski
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Matthew R Lamb
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York.,ICAP at Columbia University Mailman School of Public Health, New York, New York
| | - Maria Lahuerta
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York.,ICAP at Columbia University Mailman School of Public Health, New York, New York
| | | | - Laurence Ahoua
- ICAP at Columbia University Mailman School of Public Health, New York, New York
| | | | - Harriet Nuwagaba-Biribonwoha
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York.,ICAP at Columbia University Mailman School of Public Health, New York, New York
| | - Averie Gachuhi
- ICAP at Columbia University Mailman School of Public Health, New York, New York
| | - Wafaa M El-Sadr
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York.,ICAP at Columbia University Mailman School of Public Health, New York, New York
| | - Batya Elul
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
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Molloy SF, Chiller T, Greene GS, Burry J, Govender NP, Kanyama C, Mfinanga S, Lesikari S, Mapoure YN, Kouanfack C, Sini V, Temfack E, Boulware DR, Dromer F, Denning DW, Day J, Stone NRH, Bicanic T, Jarvis JN, Lortholary O, Harrison TS, Jaffar S, Loyse A. Cryptococcal meningitis: A neglected NTD? PLoS Negl Trop Dis 2017; 11:e0005575. [PMID: 28662028 PMCID: PMC5490932 DOI: 10.1371/journal.pntd.0005575] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Síle F. Molloy
- Centre for Global Health, Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
- * E-mail:
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Gregory S. Greene
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Jessica Burry
- Medecins Sans Frontières Access Campaign, Médecins Sans Frontières, Geneva, Switzerland
| | - Nelesh P. Govender
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), Johannesburg, South Africa
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Sayoki Mfinanga
- National Institute of Medial Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania
| | - Sokoine Lesikari
- National Institute of Medial Research, Muhimbili Medical Research Centre, Dar Es Salaam, Tanzania
| | | | - Charles Kouanfack
- Department of Internal Medicine, Douala General Hospital, Douala, Cameroon
| | - Victor Sini
- Department of Internal Medicine, Douala General Hospital, Douala, Cameroon
| | | | - David R. Boulware
- Division of Infectious Disease and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Francoise Dromer
- Institut Pasteur, Molecular Mycology—CNRS URA3012, Department of Mycology, Paris, France
| | - David W. Denning
- Global Action Fund for Fungal Infections (GAFFI), Geneva, Switzerland
| | - Jeremy Day
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Vietnam, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Neil R. H. Stone
- Centre for Global Health, Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
| | - Tihana Bicanic
- Centre for Global Health, Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
| | - Joseph N. Jarvis
- Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Olivier Lortholary
- Institut Pasteur, Molecular Mycology—CNRS URA3012, Department of Mycology, Paris, France
| | - Thomas S. Harrison
- Centre for Global Health, Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Angela Loyse
- Centre for Global Health, Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
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Implementation and Operational Research: An Integrated and Comprehensive Service Delivery Model to Improve Pediatric and Maternal HIV Care in Rural Africa. J Acquir Immune Defic Syndr 2017; 73:e67-e75. [PMID: 27846070 PMCID: PMC5172808 DOI: 10.1097/qai.0000000000001178] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Strategies to improve HIV diagnosis and linkage into care, antiretroviral treatment coverage, and treatment outcomes of mothers and children are urgently needed in sub-Saharan Africa. METHODS From December 2012, we implemented an intervention package to improve prevention of mother-to-child transmission (PMTCT) and pediatric HIV care in our rural Tanzanian clinic, consisting of: (1) creation of a PMTCT and pediatric unit integrated within the reproductive and child health clinic; (2) implementation of electronic medical records; (3) provider-initiated HIV testing and counseling in the hospital wards; and (4) early infant diagnosis test performed locally. To assess the impact of this strategy, clinical characteristics and outcomes were compared between the period before (2008-2012) and during/after the implementation (2013-2014). RESULTS After the intervention, the number of mothers and children enrolled into care almost doubled. Compared with the pre-intervention period (2008-2012), in 2013-2014, children presented lower CD4% (16 vs. 16.8, P = 0.08) and more advanced disease (World Health Organization stage 3/4 72% vs. 35%, P < 0.001). The antiretroviral treatment coverage rose from 80% to 98% (P < 0.001), the lost-to-follow-up rate decreased from 20% to 11% (P = 0.002), and mortality ascertainment improved. During 2013-2014, 261 HIV-exposed infants were enrolled, and the early mother-to-child transmission rate among mother-infant pairs accessing PMTCT was 2%. CONCLUSIONS This strategy resulted in an increased number of mothers and children diagnosed and linked into care, a higher detection of children with AIDS, universal treatment coverage, lower loss to follow-up, and an early mother-to-child transmission rate below the threshold of elimination. This study documents a feasible and scalable model for family-centered HIV care in sub-Saharan Africa.
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Billioux VG, Chang LW, Reynolds SJ, Nakigozi G, Ssekasanvu J, Grabowski MK, Ssekubugu R, Nalugoda F, Kigozi G, Kagaayi J, Serwadda D, Gray RH, Wawer MJ. Human immunodeficiency virus care cascade among sub-populations in Rakai, Uganda: an observational study. J Int AIDS Soc 2017; 20:21590. [PMID: 28605171 PMCID: PMC5515027 DOI: 10.7448/ias.20.1.21590] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 05/18/2017] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION To assess progress towards the UNAIDS 90-90-90 initiative targets, we examined the HIV care cascade in the population-based Rakai Community Cohort Study (RCCS) in rural Uganda and examined differences between sub-groups. METHODS Self-reports and clinical records were used to assess the proportion achieving each stage in the cascade. Statistical inference based on a χ2 test for categorical variables and modified Poisson regression were used to estimate prevalence risk ratios (PRRs) and 95% confidence intervals (CI) for enrolment into care and initiating antiretroviral therapy (ART). RESULTS From September 2013 through December 2015, 3,666 HIV-positive participants were identified in the RCCS. As of December 2015, 98% had received HIV Counseling and Testing (HCT), 74% were enrolled in HIV care, and 63% had initiated ART of whom 92% were virally suppressed after 12 months on ART. Engagement in care was lower among men than women (enrolment in care: adjPRR 0.84, 95% CI 0.77-0.91; ART initiation: adjPRR 0.75, 95% CI 0.69-0.82), persons aged 15-24 compared to those aged 30-39 (enrolment: adjPRR 0.72, 95% CI 0.63-0.82; ART: adjPRR 0.69, 95%CI 0.60-0.80), unmarried persons (enrolment: adjPRR 0.84, 95% CI 0.71-0.99; ART adjPRR 0.80, 95% CI 0.66-0.95), and new in-migrants (enrolment: adjPRR 0.75, 95% CI 0.67-0.83; ART: adjPRR 0.76, 95% CI 0.67-0.85). This cohort achieved 98-65-92 towards the UNAIDS "90-90-90" targets with an estimated 58% of the entire HIV-positive RCCS population virally suppressed. CONCLUSIONS This cohort achieved over 90% in both HCT and viral suppression among ART users, but only 65% in initiating ART, likely due to both an ART eligibility criterion of <500 CD4 cells/mL and suboptimal entry into care among men, younger individuals, and in-migrants. Interventions are needed to promote enrolment in HIV care, particular for hard-to-reach sub-populations.
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Affiliation(s)
- Veena G. Billioux
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Larry W. Chang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Rakai Community Cohort Study, Rakai Health Sciences Program, Kalisizo, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Steven J. Reynolds
- Department of Rakai Community Cohort Study, Rakai Health Sciences Program, Kalisizo, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Gertrude Nakigozi
- Department of Rakai Community Cohort Study, Rakai Health Sciences Program, Kalisizo, Uganda
| | - Joseph Ssekasanvu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Rakai Community Cohort Study, Rakai Health Sciences Program, Kalisizo, Uganda
| | - Mary K. Grabowski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Rakai Community Cohort Study, Rakai Health Sciences Program, Kalisizo, Uganda
| | - Robert Ssekubugu
- Department of Rakai Community Cohort Study, Rakai Health Sciences Program, Kalisizo, Uganda
| | - Fred Nalugoda
- Department of Rakai Community Cohort Study, Rakai Health Sciences Program, Kalisizo, Uganda
| | - Godfrey Kigozi
- Department of Rakai Community Cohort Study, Rakai Health Sciences Program, Kalisizo, Uganda
| | - Joseph Kagaayi
- Department of Rakai Community Cohort Study, Rakai Health Sciences Program, Kalisizo, Uganda
| | - David Serwadda
- Department of Rakai Community Cohort Study, Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Disease Control & Environmental Health, School of Public Health, Makerere University, Kampala, Uganda
| | - Ronald H. Gray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Rakai Community Cohort Study, Rakai Health Sciences Program, Kalisizo, Uganda
| | - Maria J. Wawer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Rakai Community Cohort Study, Rakai Health Sciences Program, Kalisizo, Uganda
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A Decade of Antiretroviral Therapy Scale-up in Mozambique: Evaluation of Outcome Trends and New Models of Service Delivery Among More Than 300,000 Patients Enrolled During 2004-2013. J Acquir Immune Defic Syndr 2017; 73:e11-22. [PMID: 27454248 DOI: 10.1097/qai.0000000000001137] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND During 2004-2013 in Mozambique, 455,600 HIV-positive adults (≥15 years old) initiated antiretroviral therapy (ART). We evaluated trends in patient characteristics and outcomes during 2004-2013, outcomes of universal treatment for pregnant women (Option B+) implemented since 2013, and effect on outcomes of distributing ART to stable patients through Community ART Support Groups (CASG) since 2010. METHODS Data for 306,335 adults starting ART during 2004-2013 at 170 ART facilities were analyzed. Mortality and loss to follow-up (LTFU) were estimated using competing risks models. Outcome determinants were estimated using proportional hazards models, including CASG participation as a time-varying covariate. RESULTS Compared with ART enrollees in 2004, enrollees in 2013 were more commonly female (55% vs. 73%), more commonly pregnant if female (<1% vs. 30%), and had a higher median baseline CD4 count (139 vs. 235/μL). During 2004-2013, observed 6-month mortality declined from 7% to 2% but LTFU increased from 24% to 30%. Pregnant women starting ART with CD4 count >350/μL and WHO stage I/II under Option B+ guidelines in 2013 had low 6-month mortality (0.1%) but high 6-month LTFU (38%). During 2010-2013, 6766 patients joined CASGs. In multivariable analysis, compared with nonparticipation in CASG, CASG participation was associated with 35% lower LTFU but similar mortality. CONCLUSIONS Initiation of ART at earlier disease stages in later calendar years might explain observed declines in mortality. Retention interventions are needed to address trends of increasing LTFU overall and the high LTFU among Option B+ pregnant women specifically. Further expansion of CASG could help reduce LTFU.
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Rajasingham R, Smith RM, Park BJ, Jarvis JN, Govender NP, Chiller TM, Denning DW, Loyse A, Boulware DR. Global burden of disease of HIV-associated cryptococcal meningitis: an updated analysis. THE LANCET. INFECTIOUS DISEASES 2017; 17:873-881. [PMID: 28483415 DOI: 10.1016/s1473-3099(17)30243-8] [Citation(s) in RCA: 1270] [Impact Index Per Article: 181.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/23/2017] [Accepted: 03/24/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cryptococcus is the most common cause of meningitis in adults living with HIV in sub-Saharan Africa. Global burden estimates are crucial to guide prevention strategies and to determine treatment needs, and we aimed to provide an updated estimate of global incidence of HIV-associated cryptococcal disease. METHODS We used 2014 Joint UN Programme on HIV and AIDS estimates of adults (aged >15 years) with HIV and antiretroviral therapy (ART) coverage. Estimates of CD4 less than 100 cells per μL, virological failure incidence, and loss to follow-up were from published multinational cohorts in low-income and middle-income countries. We calculated those at risk for cryptococcal infection, specifically those with CD4 less than 100 cells/μL not on ART, and those with CD4 less than 100 cells per μL on ART but lost to follow-up or with virological failure. Cryptococcal antigenaemia prevalence by country was derived from 46 studies globally. Based on cryptococcal antigenaemia prevalence in each country and region, we estimated the annual numbers of people who are developing and dying from cryptococcal meningitis. FINDINGS We estimated an average global cryptococcal antigenaemia prevalence of 6·0% (95% CI 5·8-6·2) among people with a CD4 cell count of less than 100 cells per μL, with 278 000 (95% CI 195 500-340 600) people positive for cryptococcal antigen globally and 223 100 (95% CI 150 600-282 400) incident cases of cryptococcal meningitis globally in 2014. Sub-Saharan Africa accounted for 73% of the estimated cryptococcal meningitis cases in 2014 (162 500 cases [95% CI 113 600-193 900]). Annual global deaths from cryptococcal meningitis were estimated at 181 100 (95% CI 119 400-234 300), with 135 900 (75%; [95% CI 93 900-163 900]) deaths in sub-Saharan Africa. Globally, cryptococcal meningitis was responsible for 15% of AIDS-related deaths (95% CI 10-19). INTERPRETATION Our analysis highlights the substantial ongoing burden of HIV-associated cryptococcal disease, primarily in sub-Saharan Africa. Cryptococcal meningitis is a metric of HIV treatment programme failure; timely HIV testing and rapid linkage to care remain an urgent priority. FUNDING None.
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Affiliation(s)
- Radha Rajasingham
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - Rachel M Smith
- Mycotic Diseases Branch, Centers for Disease Control, Atlanta, GA, USA
| | - Benjamin J Park
- Mycotic Diseases Branch, Centers for Disease Control, Atlanta, GA, USA
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Botswana-University of Pennsylvania Partnership, Gaborone, Botswana; Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, PA, USA; Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Nelesh P Govender
- National Institute for Communicable Diseases, Center for Healthcare-associated Infections, Antimicrobial Resistance and Mycoses, Johannesburg, South Africa; Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Tom M Chiller
- Mycotic Diseases Branch, Centers for Disease Control, Atlanta, GA, USA
| | - David W Denning
- University of Manchester, Manchester Academic Health Science Centre and the National Aspergillosis Centre, University Hospital of South Manchester, Manchester, UK
| | - Angela Loyse
- Cryptococcal Meningitis Group, Research Centre for Infection and Immunity, Division of Clinical Sciences, St George's University of London, London, UK
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Sun J, Liu L, Shen J, Chen P, Lu H. Trends in baseline CD4 cell counts and risk factors for late antiretroviral therapy initiation among HIV-positive patients in Shanghai, a retrospective cross-sectional study. BMC Infect Dis 2017; 17:285. [PMID: 28420350 PMCID: PMC5395868 DOI: 10.1186/s12879-017-2398-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 04/11/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUNDS There are few studies focus on the factors underlying the late initiation of ART in China. We analyzed the trends in the median CD4 cell counts among different patient groups over time and the risk factors for the late initiation of ART in Shanghai, China. METHODS A retrospective cross-sectional survey was made in the Department of Infectious Disease of Shanghai Public Health Clinical Center which is a designated diagnosis and treatment center for HIV-positive patients in Shanghai during the period of January 1st, 2008--June 30th, 2014. Late ART initiation was defined as a CD4 cell count <200 cells/mm3 or having a clinical AIDS diagnosis prior to ART initiation. Trends in the median CD4 cell count at ART initiation and the proportion of late ART initiation by year were evaluated using Spearman's correlations and Chi-squared methods, respectively. We used a logistic regression model to analyze the risk factors for late ART initiation. The related factors collected in the multivariate model were the patient's age, gender, infection routes and marital status. RESULTS A total of 3796 patients were analyzed in this study, with a median baseline CD4 cell count of 205 cells/mm3 [interquartile range: 75-287]. The median CD4 cell counts of patients initiating ART late increased from 76 cells/mm3 in 2008 to 103 cells/mm3 in 2014 (p < 0.001), and the proportion of late ART initiation decreased from 80% to 45% (p < 0.001). The risk factors for late ART initiation were male gender, heterosexual transmission and older age (>30 years) (p < 0.001). CONCLUSIONS Notable improvements were made in the median CD4 cell count at ART initiation and the proportion of late ART initiation from 2008 to 2014. However, persons with high risk of HIV exposure who are male, older even heterosexual orientation should be given more opportunities to receive frequently screening, earlier diagnoses and timely treatment.
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Affiliation(s)
- Jianjun Sun
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Fudan University, Shanghai, 201508, China
| | - Li Liu
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Fudan University, Shanghai, 201508, China
| | - Jiayin Shen
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Fudan University, Shanghai, 201508, China
| | - Panpan Chen
- Pudong New Area Center for Disease Control and Prevention, Shanghai, 200136, China
| | - Hongzhou Lu
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Fudan University, Shanghai, 201508, China. .,Department of Infectious Diseases, Huashan Hospital Affiliated to Fudan University, Shanghai, 200040, China. .,Department of Internal Medicine, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
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McNairy ML, Abrams EJ, Rabkin M, El-Sadr WM. Clinical decision tools are needed to identify HIV-positive patients at high risk for poor outcomes after initiation of antiretroviral therapy. PLoS Med 2017; 14:e1002278. [PMID: 28419097 PMCID: PMC5395167 DOI: 10.1371/journal.pmed.1002278] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Margaret McNairy and colleagues highlight the need for clinical decision tools to help identify HIV patients who would benefit from tailored services to avoid poor outcomes such as death and loss to follow-up.
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Affiliation(s)
- Margaret L. McNairy
- ICAP, Columbia University, New York, New York, United States of America
- Department of Medicine, Cornell Medical College, New York, New York, United States of America
| | - Elaine J. Abrams
- ICAP, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Miriam Rabkin
- ICAP, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Wafaa M. El-Sadr
- ICAP, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
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50
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Melaku Z, Lulseged S, Wang C, Lamb MR, Gutema Y, Teasdale CA, Ahmed S, Gadisa T, Habtamu Z, Bedri A, Fayorsey R, Abrams EJ. Outcomes among HIV-infected children initiating HIV care and antiretroviral treatment in Ethiopia. Trop Med Int Health 2017; 22:474-484. [PMID: 28066962 DOI: 10.1111/tmi.12834] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe pediatric ART scale-up in Ethiopia, one of the 21 global priority countries for elimination of pediatric HIV infection. METHODS A descriptive analysis of routinely collected HIV care and treatment data on HIV-infected children (<15 years) enrolled at 70 health facilities in four regions in Ethiopia, January 2006-September 2013. Characteristics at enrollment and ART initiation are described along with outcomes at 1 year after enrollment. Among children who initiated ART, cumulative incidence of death and loss to follow-up (LTF) were estimated using survival analysis. RESULTS 11 695 children 0-14 years were enrolled in HIV care and 6815 (58.3%) initiated ART. At enrollment, 31.2% were WHO stage III and 6.3% stage IV. The majority (87.9%) were enrolled in secondary or tertiary facilities. At 1 year after enrollment, 17.9% of children were LTF prior to ART initiation. Among children initiating ART, cumulative incidence of death was 3.4%, 4.1% and 4.8%, and cumulative incidence of LTF was 7.7%, 11.8% and 16.6% at 6, 12 and 24 months, respectively. Children <2 years had higher risk of LTF and death than older children (P < 0.0001). Children with more advanced disease and those enrolled in rural settings were more likely to die. Children enrolled in more recent years were less likely to die but more likely to be LTF. CONCLUSIONS Over the last decade large numbers of HIV-infected children have been successfully enrolled in HIV care and initiated on ART in Ethiopia. Retention prior to and after ART initiation remains a major challenge.
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Affiliation(s)
| | | | - Chunhui Wang
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Matthew R Lamb
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | - Chloe A Teasdale
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Solomon Ahmed
- Centers for Disease Control and Prevention, Addis Ababa, Ethiopia
| | | | | | - Abubaker Bedri
- Centers for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Ruby Fayorsey
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Elaine J Abrams
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.,College of Physicians & Surgeons, Columbia University, New York, NY, USA
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