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Reepalu A, Arimide DA, Balcha TT, Yeba H, Zewdu A, Medstrand P, Björkman P. Drug Resistance in HIV-Positive Adults During the Initial Year of Antiretroviral Treatment at Ethiopian Health Centers. Open Forum Infect Dis 2021; 8:ofab106. [PMID: 34805444 PMCID: PMC8597620 DOI: 10.1093/ofid/ofab106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/03/2021] [Indexed: 11/30/2022] Open
Abstract
Background The increasing prevalence of antiretroviral drug resistance in Sub-Saharan
Africa threatens the success of HIV programs. We have characterized patterns
of drug resistance mutations (DRMs) during the initial year of
antiretroviral treatment (ART) in HIV-positive adults receiving care at
Ethiopian health centers and investigated the impact of tuberculosis on DRM
acquisition. Methods Participants were identified from a cohort of ART-naïve individuals aged
≥18 years, all of whom had been investigated for active tuberculosis
at inclusion. Individuals with viral load (VL) data at 6 and/or 12 months
after ART initiation were selected for this study. Genotypic testing was
performed on samples with VLs ≥500 copies/mL obtained on these
occasions and on pre-ART samples from those with detectable DRMs during ART.
Logistic regression analysis was used to investigate the association between
DRM acquisition and tuberculosis. Results Among 621 included individuals (110 [17.5%] with concomitant tuberculosis),
101/621 (16.3%) had a VL ≥500 copies/mL at 6 and/or 12 months. DRMs
were detected in 64/98 cases with successful genotyping (65.3%). DRMs were
detected in 7/56 (12.5%) pre-ART samples from these individuals. High
pre-ART VL and low mid-upper arm circumference were associated with
increased risk of DRM acquisition, whereas no such association was found for
concomitant tuberculosis. Conclusions Among adults receiving health center–based ART in Ethiopia, most
patients without virological suppression during the first year of ART had
detectable DRM. Acquisition of DRM during this period was the dominant cause
of antiretroviral drug resistance in this setting. Tuberculosis did not
increase the risk of DRM acquisition.
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Affiliation(s)
- Anton Reepalu
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Dawit A Arimide
- Clinical Virology, Department of Translational Medicine, Lund University, Malmö, Sweden.,Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Taye T Balcha
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Habtamu Yeba
- Adama Public Health Research and Referral Laboratory Center, Adama, Ethiopia
| | - Adinew Zewdu
- Adama Public Health Research and Referral Laboratory Center, Adama, Ethiopia
| | - Patrik Medstrand
- Clinical Virology, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Per Björkman
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
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2
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Richards L, Spencer DC, Nel JS, Ive P. Infectious disease consultations at a South African academic hospital: A 6-month assessment of inpatient consultations. S Afr J Infect Dis 2021; 35:169. [PMID: 34485477 PMCID: PMC8378114 DOI: 10.4102/sajid.v35i1.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 06/25/2020] [Indexed: 11/01/2022] Open
Abstract
Background Infectious diseases (IDs) dominate the disease profile in South Africa (SA) and the ID department is increasingly valuable. There has been little evaluation of the IDs consultation services in SA hospitals. Methods A qualitative review of ID inpatient consultations was performed over 6 months at a SA tertiary hospital. Prospectively entered data from each consultation were recorded on a computerised database and retrospectively analysed. Results 749 ID consultations were analysed, 4.8% of hospital admissions. Most consultations included initiation of antiretroviral therapy (ART) (27.8%), lipoarabinomannan antigen testing (24.8%) and change of ART (21.6%). Of patients reviewed, 93.3% were human immunodeficiency virus (HIV) positive and the median CD4 count was 52 cells/mm3. The infectious diagnoses (excluding HIV) most frequently encountered were pulmonary and abdominal tuberculosis (TB) and acute gastroenteritis. When all subcategories of TB infection were combined, 42.9% were found to have TB. Patients had predominantly one (45.4%) or two (30.2%) infectious diagnoses in addition to HIV. Some (12%) had three infectious diagnoses during their admission. The number of diagnoses, both infectious (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.11-3.60) and non-infectious (OR 2.27; 95% CI 1.25-4.11), was associated with increased odds of death. Conclusion The IDs department sees a high volume of patients compared to most developed countries. HIV, TB and their management dominate the workload. This study shows that HIV patients still have significant morbidity and mortality. The complexity of these patients indicates that specific expertise is required beyond that of the general physician.
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Affiliation(s)
- Lauren Richards
- Division of Infectious Diseases, Department of Medicine, Faculty of Health Sciences, Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - David C Spencer
- Division of Infectious Diseases, Department of Medicine, Faculty of Health Sciences, Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa.,Clinical HIV Research Unit (CHRU), University of the Witwatersrand, Johannesburg, South Africa
| | - Jeremy S Nel
- Division of Infectious Diseases, Department of Medicine, Faculty of Health Sciences, Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Prudence Ive
- Division of Infectious Diseases, Department of Medicine, Faculty of Health Sciences, Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
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3
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Rodrigues A, Struchiner CJ, Coelho LE, Veloso VG, Grinsztejn B, Luz PM. Late initiation of antiretroviral therapy: inequalities by educational level despite universal access to care and treatment. BMC Public Health 2021; 21:389. [PMID: 33607975 PMCID: PMC7893724 DOI: 10.1186/s12889-021-10421-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 02/10/2021] [Indexed: 12/27/2022] Open
Abstract
Background Late antiretroviral treatment initiation for HIV disease worsens health outcomes and contributes to ongoing transmission. We investigated whether socioeconomic inequalities exist in access to treatment in a setting with universal access to care and treatment. Methods This study investigated the association of educational level, used as a proxy for socioeconomic status, with late treatment initiation and treatment initiation with advanced disease. Study participants included adults (≥25 years) who started treatment from 2005 to 2018 at Instituto Nacional de Infectologia Evandro Chagas of Fundação Oswaldo Cruz (INI/FIOCRUZ), Rio de Janeiro, Brazil. Educational level was categorized following UNESCO’s International Standard Classification of Education: incomplete basic education, basic education, secondary level, and tertiary level. We defined late treatment initiation as those initiating treatment with a CD4 < 350 cells/mL or an AIDS-defining event, and treatment initiation with advanced disease as those initiating treatment with a CD4 < 200 cells/mL or an AIDS-defining event. A directed acyclic graph (DAG) was constructed to represent the theoretical-operational model and to understand the involvement of covariates. Logistic regression models were used to estimate the adjusted odds ratios (aOR) and 95% confidence intervals (95%CI). Multiple imputation using a chained equations approach was used to treat missing values and non-linear terms for continuous variables were tested. Results In total, 3226 individuals composed the study population: 876 (27.4%) had incomplete basic education, 540 (16.9%) basic, 1251 (39.2%) secondary level, and 525 (16.4%) tertiary level. Late treatment initiation was observed for 2076 (64.4%) while treatment initiation with advanced disease was observed for 1423 (44.1%). Compared to tertiary level of education, incomplete basic, basic and secondary level increased the odds of late treatment initiation by 89% (aOR:1.89 95%CI:1.47–2.43), 61% (aOR:1.61 95%CI:1.23–2.10), and 35% (aOR:1.35 95%CI:1.09–1.67). Likewise, the odds of treatment initiation with advanced disease was 2.5-fold (aOR:2.53 95%CI:1.97–3.26), 2-fold (aOR:2.07 95%CI:1.59–2.71), 1.5-fold (aOR:1.51 95%CI:1.21–1.88) higher for those with incomplete basic, basic and secondary level education compared to tertiary level. Conclusion Despite universal access to HIV care and antiretroviral treatment, late treatment initiation and social inequalities persist. Lower educational level significantly increased the odds of both outcomes, reinforcing the existence of barriers to “universal” antiretroviral treatment.
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Affiliation(s)
- Amanda Rodrigues
- Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Claudio J Struchiner
- Escola de Matemática Aplicada, Fundação Getúlio Vargas, Praia de Botafogo, 190, Rio de Janeiro, Brazil
| | - Lara E Coelho
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Av. Brasil 4365, Manguinhos, Rio de Janeiro, 21040-900, Brazil
| | - Valdilea G Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Av. Brasil 4365, Manguinhos, Rio de Janeiro, 21040-900, Brazil
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Av. Brasil 4365, Manguinhos, Rio de Janeiro, 21040-900, Brazil
| | - Paula M Luz
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Av. Brasil 4365, Manguinhos, Rio de Janeiro, 21040-900, Brazil.
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4
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Nakalema HS, Rajan SS, Morgan RO, Lee M, Gillespie SL, Kekitiinwa A. The effect of antiretroviral therapy guideline change on health outcomes among youth living with HIV in Uganda. AIDS Care 2020; 33:904-913. [PMID: 33021095 DOI: 10.1080/09540121.2020.1829533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ABSTRACTOpportunistic infections (OIs) are the primary cause of HIV-related morbidity and mortality. To reduce the risk, the ART eligibility criteria were revised to start treatment before advanced disease onset. We evaluated the effect of 2014 HIV clinical guideline changes in Uganda on opportunistic infections and survival among Youth Living with HIV (YLWH). This retrospective cohort analysis used administrative data from the District Health Information System (DHIS2) and the national referral hospital, to compare YLWH, 15-24 years old, who started ART pre-guideline (January 2012-June 2014) and post-guideline (July 2014-December 2016). We assessed the effect using multivariable logistic and Cox Proportional Hazards regression models, respectively. Post-guideline youth had 18% and 30% lower adjusted odds of having an OI at 6 (aOR: 0.82, 95%CI: 0.67, 0.99), and 12 months (aOR: 0.70, 95%CI: 0.58, 0.85) after ART initiation, compared to pre-guideline youth. No significant differences were observed in survival probabilities (Z = 2.56, P-value = 0.11) and adjusted hazard ratios (aHR: 1.55, 95%CI: 0.46, 5.28). Early ART initiation reduced the risk of OIs among YLWH. However, given the existence of geographical and clinical variations in the endemicity, morbidity and mortality associated with different OIs, additional research is still needed.
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Affiliation(s)
- Hilda Sekabira Nakalema
- Department of Management, Policy and Community Health, University of Texas Health Science Center, Houston, TX, USA.,Baylor College of Medicine Children's Foundation Uganda, Kampala, Uganda.,Department of Retrovirology, Baylor College of Medicine, Houston, TX, USA
| | - Suja S Rajan
- Department of Management, Policy and Community Health, University of Texas Health Science Center, Houston, TX, USA.,Department of Biostatistics & Data Science, University of Texas Health Science Center, Houston, TX, USA
| | - Robert O Morgan
- Department of Management, Policy and Community Health, University of Texas Health Science Center, Houston, TX, USA
| | - Minjae Lee
- Department of Epidemiology, Human Genetics & Environmental Health, University of Texas Health Science Center, Houston, TX, USA.,Department of Biostatistics & Data Science, University of Texas Health Science Center, Houston, TX, USA
| | - Susan L Gillespie
- Department of Retrovirology, Baylor College of Medicine, Houston, TX, USA
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5
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Abstract
Purpose of review To describe how countries in Latin America and the Caribbean are (or are not) meeting 2016 WHO guidelines on the use of antiretroviral drugs for treating and preventing HIV infection, that is, their progress on the adoption of ‘Treat All’ and of preexposure prophylaxis (PrEP) as an additional prevention tool for people at substantial risk of HIV infection. Recent findings The HIV epidemic in the region continues largely concentrated in vulnerable populations with MSM and transgender women (TGW) suffering the highest burden. On treatment, the challenges of late initiation as well as suboptimal adherence persist. On prevention, recent studies on PrEP willingness in key populations show promising results, meanwhile PrEP implementation projects as well as actual PrEP adoption by national health systems is expanding. A glimpse of real-world PrEP uptake is shown through Brazil's first-year experience of offering PrEP in multiple cities in all regions of the country. Summary In conclusion, accomplishments have been made though challenges for fully addressing the HIV epidemic persist. The impact of both treatment and PrEP will be limited by the availability and prompt use of all services, including HIV testing.
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6
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Zhao Y, Wu Z, McGoogan JM, Sha Y, Zhao D, Ma Y, Brookmeyer R, Detels R, Montaner JSG. Nationwide Cohort Study of Antiretroviral Therapy Timing: Treatment Dropout and Virological Failure in China, 2011-2015. Clin Infect Dis 2020; 68:43-50. [PMID: 29771296 PMCID: PMC6293037 DOI: 10.1093/cid/ciy400] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/04/2018] [Indexed: 12/21/2022] Open
Abstract
Background People living with human immunodeficiency virus (PLWH) are still being diagnosed late, rendering the benefits of "early" antiretroviral therapy (ART) unattainable. Therefore, we aimed to evaluate the benefits of "immediate" ART. Methods A nationwide cohort of PLWH in China who initiated ART January 1, 2011, to December 31, 2014 and had baseline CD4 results >200 cells/μL were censored at 12 months, dropout, or death, whichever came first. Treatment dropout and virological failure (viral load ≥400 copies/mL) were measured. Determinants were assessed by Cox and log-binomial regression. Results The cohort included 123605 PLWH. The ≤30 days group had a significantly lower treatment dropout rate of 6.72%, compared to 8.91% for the 91-365 days group and to 12.64% for the >365 days group. The ≤30 days group also had a significantly lower virological failure rate of 5.45% (31-90 days: 7.39%; 91-365 days: 9.64%; >365 days: 12.67%). Greater risk of dropout (91-365 days: adjusted hazard ratio [aHR] = 1.33, 95% confidence interval [CI] = 1.25-1.42; >365 days: aHR = 1.55, CI = 1.47-1.54), and virological failure (31-90 days: adjusted risk ratio [aRR] = 1.35, CI = 1.26-1.45; 91-365 days: aRR = 1.66, CI = 1.55-1.78; >365 days: aRR = 1.85, CI = 1.74-1.97) were observed for those who delayed treatment. Conclusions ART within 30 days of HIV diagnosis was associated with significantly reduced risk of treatment failure, highlighting the need to implement test-and-immediately-treat policies.
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Affiliation(s)
- Yan Zhao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zunyou Wu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.,Department of Epidemiology, University of California, Los Angeles (UCLA) Fielding School of Public Health
| | - Jennifer M McGoogan
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yiyi Sha
- Tsinghua University, Beijing, China
| | - Decai Zhao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Ye Ma
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Ron Brookmeyer
- Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles, California
| | - Roger Detels
- Department of Epidemiology, University of California, Los Angeles (UCLA) Fielding School of Public Health
| | - Julio S G Montaner
- British Columbia Center for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada
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7
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Dekkers OM, Vandenbroucke JP, Cevallos M, Renehan AG, Altman DG, Egger M. COSMOS-E: Guidance on conducting systematic reviews and meta-analyses of observational studies of etiology. PLoS Med 2019; 16:e1002742. [PMID: 30789892 PMCID: PMC6383865 DOI: 10.1371/journal.pmed.1002742] [Citation(s) in RCA: 283] [Impact Index Per Article: 56.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND To our knowledge, no publication providing overarching guidance on the conduct of systematic reviews of observational studies of etiology exists. METHODS AND FINDINGS Conducting Systematic Reviews and Meta-Analyses of Observational Studies of Etiology (COSMOS-E) provides guidance on all steps in systematic reviews of observational studies of etiology, from shaping the research question, defining exposure and outcomes, to assessing the risk of bias and statistical analysis. The writing group included researchers experienced in meta-analyses and observational studies of etiology. Standard peer-review was performed. While the structure of systematic reviews of observational studies on etiology may be similar to that for systematic reviews of randomised controlled trials, there are specific tasks within each component that differ. Examples include assessment for confounding, selection bias, and information bias. In systematic reviews of observational studies of etiology, combining studies in meta-analysis may lead to more precise estimates, but such greater precision does not automatically remedy potential bias. Thorough exploration of sources of heterogeneity is key when assessing the validity of estimates and causality. CONCLUSION As many reviews of observational studies on etiology are being performed, this document may provide researchers with guidance on how to conduct and analyse such reviews.
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Affiliation(s)
- Olaf M. Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jan P. Vandenbroucke
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Myriam Cevallos
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Andrew G. Renehan
- Manchester Cancer Research Centre, NIHR Manchester Biomedical Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Douglas G. Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Matthias Egger
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
- Centre for Infectious Diseases Epidemiology and Research (CIDER), School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Luchters S, Technau K, Mohamed Y, Chersich MF, Agius PA, Pham MD, Garcia ML, Forbes J, Shepherd A, Coovadia A, Crowe SM, Anderson DA. Field Performance and Diagnostic Accuracy of a Low-Cost Instrument-Free Point-of-Care CD4 Test (Visitect CD4) Performed by Different Health Worker Cadres among Pregnant Women. J Clin Microbiol 2019; 57:e01277-18. [PMID: 30463898 PMCID: PMC6355532 DOI: 10.1128/jcm.01277-18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 11/12/2018] [Indexed: 12/27/2022] Open
Abstract
Measuring CD4 counts remains an important component of HIV care. The Visitect CD4 is the first instrument-free low-cost point-of-care CD4 test with results interpreted visually after 40 min, providing a result of ≥350 CD4 cells/mm3 The field performance and diagnostic accuracy of the test was assessed among HIV-infected pregnant women in South Africa. A nurse performed testing at the point-of-care using both venous and finger-prick blood, and a counselor and laboratory staff tested venous blood in the clinic laboratory (four Visitect CD4 tests/participant). Performance was compared to the mean CD4 count from duplicate flow cytometry tests on venous blood (FACSCalibur Trucount). In 2017, 156 patients were enrolled, providing a total of 624 Visitect CD4 tests (468 venous and 156 finger-prick samples). Of 624 tests, 28 (4.5%) were inconclusive. Generalized linear mixed modeling showed better performance of the test on venous blood (sensitivity = 81.7%; 95% confidence interval [CI] = 72.3 to 91.1]; specificity = 82.6%, 95% CI = 77.1 to 88.1) than on finger-prick specimens (sensitivity = 60.7%; 95% CI = 45.0 to 76.3; specificity = 89.5%, 95% CI = 83.2 to 95.8; P = 0.001). No difference in performance was detected by cadre of health worker (P = 0.113) or between point-of-care versus laboratory-based testing (P = 0.108). Adequate performance of Visitect CD4 with different operators and at the point of care, with no need of electricity or instrument, shows the potential utility of this device, especially for facilitating decentralization of CD4 testing services in rural areas.
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Affiliation(s)
- Stanley Luchters
- Burnet Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- International Centre for Reproductive Health, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Karl Technau
- Empilweni Services and Research Unit, Department of Paediatrics & Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yasmin Mohamed
- Burnet Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Matthew F Chersich
- International Centre for Reproductive Health, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Paul A Agius
- Burnet Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Minh D Pham
- Burnet Institute, Melbourne, Victoria, Australia
| | | | - James Forbes
- Omega Diagnostics, Ltd., Omega House, Alva, Scotland
| | | | - Ashraf Coovadia
- Empilweni Services and Research Unit, Department of Paediatrics & Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Suzanne M Crowe
- Burnet Institute, Melbourne, Victoria, Australia
- The Alfred Hospital and Department of Infectious Diseases, Monash University, Melbourne, Victoria, Australia
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9
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Hechter RC, Bider-Canfield Z, Towner W. Effect of an Electronic Alert on Targeted HIV Testing Among High-Risk Populations. Perm J 2019; 22:18-015. [PMID: 30285916 DOI: 10.7812/tpp/18-015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Screening for HIV infection in medical settings remains suboptimal. OBJECTIVE To examine the real-world effectiveness of an electronic clinician alert on the same-day HIV testing rate and early diagnosis in high-risk populations. DESIGN We identified Kaiser Permanente Southern California Health Plan members aged 14 years or older who received tests for sexually transmitted infections. MAIN OUTCOME MEASURES Encounter-based same-day HIV testing rate, positive test result rate, and CD4+ cell count and HIV viral load at diagnosis. RESULTS We identified 1,800,948 patients who made 2,326,701 health care encounters eligible for HIV testing before implementation (January 1, 2008 - June 30, 2012) and 1,362,479 eligible encounters after implementation (January 1, 2013 - June 30, 2015). The same-day HIV testing rate increased from 36.7% to 44.1% (standardized mean difference = 0.15, significant difference). The alert was associated with a moderate difference and statistically significant increase in the HIV testing rate (adjusted odds ratio = 1.17, 95% confidence interval = 1.16-1.18). The positive test result rate increased from 0.02% to 0.04% (p < 0.001). During the postimplementation period, fewer HIV-infected patients had a CD4+ cell count below 200 and/or an HIV viral load of 10,000 copies/mL or higher at diagnosis. CONCLUSION Implementation of a targeted electronic alert embedded in the electronic medical record improved same-day HIV screening rate and positive test result rates among patients receiving tests for sexually transmitted infections in a large health organization. This intervention has potential for facilitating frequent screening and early identification of HIV infection in high-risk populations.
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Affiliation(s)
- Rulin C Hechter
- Research Scientist and Epidemiologist at the Kaiser Permanente Southern California Department of Research and Evaluation in Pasadena
| | - Zoe Bider-Canfield
- Biostatistician at the Kaiser Permanente Southern California Department of Research and Evaluation in Pasadena
| | - William Towner
- Regional Physician Director for Clinical Trials at the Kaiser Permanente Southern California Department of Research and Evaluation in Pasadena
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10
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Li AH, Wu ZY, Jiang Z, McGoogan JM, Zhao Y, Duan S. Duration of Human Immunodef iciency Virus Infection at Diagnosis among New Human Immunodef iciency Virus Cases in Dehong, Yunnan, China, 2008-2015. Chin Med J (Engl) 2018; 131:1936-1943. [PMID: 30082524 PMCID: PMC6085858 DOI: 10.4103/0366-6999.238152] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: On diagnosis of human immunodeficiency virus (HIV) infection, a person may have been infected already for many years. This study aimed to estimate the duration of HIV infection at the time of diagnosis. Methods: Newly diagnosed HIV cases in Dehong, China, from 2008 to 2015 were studied. Duration of infection at the time of diagnosis was calculated using the first CD4 cell count result after diagnosis and a CD4 depletion model of disease progression. Multiple linear regression analysis was used to investigate the associated risk factors. Results: A total of 5867 new HIV cases were enrolled. Overall, mean duration of infection was 6.3 years (95% confidence interval [CI]: 6.2, 6.5). After adjusting for confounding, significantly shorter durations of infection were observed among participants who were female (beta: −0.37, 95% CI: −0.64, −0.09), Dai ethnicity (beta: −0.28, 95% CI: −0.57, 0.01), and infected through injecting drug use (beta: −1.82, 95% CI: −2.25, −1.39). Compared to the hospital setting, durations were shorter for those diagnosed in any other settings, and compared to 2008, durations were shorter for those diagnosed all years after 2010. Results: A total of 5867 new HIV cases were enrolled. Overall, mean duration of infection was 6.3 years (95% confidence interval [CI]: 6.2, 6.5). After adjusting for confounding, significantly shorter durations of infection were observed among participants who were female (beta: −0.37, 95% CI: −0.64, −0.09), Dai ethnicity (beta: −0.28, 95% CI: −0.57, 0.01), and infected through injecting drug use (beta: −1.82, 95% CI: −2.25, −1.39). Compared to the hospital setting, durations were shorter for those diagnosed in any other settings, and compared to 2008, durations were shorter for those diagnosed all years after 2010. Conclusion: Although the reduction in duration of infection at the time of diagnosis observed in Dehong was significant, it may not have had a meaningful impact.
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Affiliation(s)
- Ai-Hua Li
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China
| | - Zun-You Wu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China; Department of Epidemiology, University of California, Los Angeles, California, USA
| | - Zhen Jiang
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China
| | - Jennifer M McGoogan
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China
| | - Yan Zhao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China
| | - Song Duan
- Dehong Prefecture Center for Disease Control and Prevention, Mangshi, Yunnan 678400, China
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11
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Abstract
INTRODUCTION HIV eradication and remission research has largely taken place in high-income countries. In low- and middle-income countries (LMIC), there may be factors that have a substantial impact on the size of the latent HIV reservoir and the immunological response to infection. If a curative strategy is to be available to all HIV-infected individuals, these factors must be understood. METHODS We use a scoping review to examine the literature on biological factors that may have an impact on HIV persistence in LMIC. Three databases were searched without date restrictions. RESULTS Uncontrolled viral replication and higher coinfection prevalence may alter the immunological milieu of individuals in LMIC and increase the size of the HIV reservoir. Differences in HIV subtype could also influence the measurement and size of the HIV reservoir. Immune activation may differ due to late presentation to care, presence of chronic infections, increased gut translocation of bacterial products and poor nutrition. CONCLUSIONS Research on HIV remission is urgently needed in LMIC. Research into chronic immune activation in resource poor environments, the immune response to infection, the mechanisms of HIV persistence and latency in different viral clades and the effect of the microbiological milieu must be performed. Geographic differences, which may be substantial and may delay access to curative strategies, should be identified.
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12
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Trends and outcomes of late initiation of combination antiretroviral therapy driven by late presentation among HIV-positive Taiwanese patients in the era of treatment scale-up. PLoS One 2017; 12:e0179870. [PMID: 28665938 PMCID: PMC5493332 DOI: 10.1371/journal.pone.0179870] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 06/06/2017] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES The international and national HIV treatment guidelines in 2016 have focused on scaling up access to combination antiretroviral therapy (cART). We aimed to assess the trends and treatment outcomes of late cART initiation in Taiwan. METHODS Between June 2012 and May 2016, we retrospectively included antiretroviral-naive HIV-positive adults who initiated cART. Late initiation was defined as when cART was initiated in patients with a CD4 count <200 cells/mm3 or having experienced AIDS-defining illnesses. The treatment outcomes were assessed up to 6 months after starting cART. RESULTS We included 3655 HIV-positive patients, and the majority of the patients were male (95.4%) with a median age of 31 years and initiated non-nucleoside reverse-transcriptase inhibitor-containing regimens (87.0%). The median CD4 count at cART initiation increased from 207 cells/mm3 in 2012 to 298 cells/mm3 in 2016, and the overall proportion of late cART initiation decreased from 49.1% in 2012 to 29.0% in 2016 (P for trend <0.001). Late cART initiation mainly resulted from late presentation for HIV care and was associated with older age (per 1-year increase, adjusted odds ratio [AOR], 1.05; 95% CI, 1.04-1.06), HBsAg seropositivity (AOR, 1.31; 95% CI, 1.04-1.64), HIV care in central and southern Taiwan, initiating cART in earlier year, non-intravenous drug users (AOR, 1.96; 95% CI, 1.33-2.86), and negative hepatitis C serostatus (AOR, 1.47; 95% CI, 1.04-2.08). Compared with non-late initiators, late initiators had a higher rate of all-cause mortality (1.7% vs. 0.3%) and regimen modification due to virological failure (7.1% vs. 2.6%). The predicting factors of all-cause mortality were late cART initiation (adjusted hazard ratio [AHR], 5.40; 95% CI, 2.14-13.65) and older age (AHR, 1.06; 95% CI, 1.03-1.10). CONCLUSIONS While the proportion of late cART initiation decreased over time in Taiwan, late initiation remained in a substantial proportion of HIV-positive patients. The late initiators had higher risk for poor outcomes. The need for strategies to earlier detection of HIV infection and expediting cART initiation should be highlighted, especially among the older population.
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Reniers G, Blom S, Calvert C, Martin-Onraet A, Herbst AJ, Eaton JW, Bor J, Slaymaker E, Li ZR, Clark SJ, Bärnighausen T, Zaba B, Hosegood V. Trends in the burden of HIV mortality after roll-out of antiretroviral therapy in KwaZulu-Natal, South Africa: an observational community cohort study. Lancet HIV 2017; 4:e113-e121. [PMID: 27956187 PMCID: PMC5405557 DOI: 10.1016/s2352-3018(16)30225-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 10/13/2016] [Accepted: 10/24/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Antiretroviral therapy (ART) substantially decreases morbidity and mortality in people living with HIV. In this study, we describe population-level trends in the adult life expectancy and trends in the residual burden of HIV mortality after the roll-out of a public sector ART programme in KwaZulu-Natal, South Africa, one of the populations with the most severe HIV epidemics in the world. METHODS Data come from the Africa Centre Demographic Information System (ACDIS), an observational community cohort study in the uMkhanyakude district in northern KwaZulu-Natal, South Africa. We used non-parametric survival analysis methods to estimate gains in the population-wide life expectancy at age 15 years since the introduction of ART, and the shortfall of the population-wide adult life expectancy compared with that of the HIV-negative population (ie, the life expectancy deficit). Life expectancy gains and deficits were further disaggregated by age and cause of death with demographic decomposition methods. FINDINGS Covering the calendar years 2001 through to 2014, we obtained information on 93 903 adults who jointly contribute 535 42 8 person-years of observation to the analyses and 9992 deaths. Since the roll-out of ART in 2004, adult life expectancy increased by 15·2 years for men (95% CI 12·4-17·8) and 17·2 years for women (14·5-20·2). Reductions in pulmonary tuberculosis and HIV-related mortality account for 79·7% of the total life expectancy gains in men (8·4 adult life-years), and 90·7% in women (12·8 adult life-years). For men, 9·5% is the result of a decline in external injuries. By 2014, the life expectancy deficit had decreased to 1·2 years for men (-2·9 to 5·8) and to 5·3 years for women (2·6-7·8). In 2011-14, pulmonary tuberculosis and HIV were responsible for 84·9% of the life expectancy deficit in men and 80·8% in women. INTERPRETATION The burden of HIV on adult mortality in this population is rapidly shrinking, but remains large for women, despite their better engagement with HIV-care services. Gains in adult life-years lived as well as the present life expectancy deficit are almost exclusively due to differences in mortality attributed to HIV and pulmonary tuberculosis. FUNDING Wellcome Trust, the Bill & Melinda Gates Foundation, and the National Institutes of Health.
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Affiliation(s)
- Georges Reniers
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Sylvia Blom
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Clara Calvert
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jacob Bor
- Department of Global Health, Boston University, Boston, MA, USA
| | - Emma Slaymaker
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Zehang R Li
- Department of Statistics, University of Washington, Seattle, WA, USA
| | - Samuel J Clark
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Department of Sociology, The Ohio State University, Columbus, OH, USA
| | - Till Bärnighausen
- Africa Health Research Institute, Durban, South Africa; Institute of Public Health, University of Heidelberg, Heidelberg, Germany; Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Basia Zaba
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Victoria Hosegood
- Africa Health Research Institute, Durban, South Africa; Social Statistics and Demography, University of Southampton, Southampton, UK
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Mayston R, Lazarus A, Patel V, Abas M, Korgaonkar P, Paranjape R, Rodrigues S, Prince M. Pathways to HIV testing and care in Goa, India: exploring psychosocial barriers and facilitators using mixed methods. BMC Public Health 2016; 16:765. [PMID: 27516106 PMCID: PMC4982414 DOI: 10.1186/s12889-016-3456-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 08/05/2016] [Indexed: 01/12/2023] Open
Abstract
Background Despite recognition of the importance of timely presentation to HIV care, research on pathways to care is lacking. The adverse impact of depression upon adherence to antiretroviral therapy is established. There is emerging evidence to suggest depression may inhibit initial engagement with care. However, the effect of depression and other psychosocial factors upon the pathway to care is unknown. Methods We used mixed methods to explore pathways to care of people accessing testing and treatment in Goa, India. Questionnaires including measures of common mental disorder, hazardous alcohol use, cognition and assessment of pathways to care (motivations for testing, time since they were first aware of this reason for testing, whether they had been advised to test, who had given this advice, time elapsed since this advice was given) were administered to 1934 participants at the time of HIV testing. Qualitative interviews were carried out with 15 study participants who attended the antiretroviral therapy treatment centre. Interview topic guides were designed to elicit responses that discussed barriers and facilitators of accessing testing and care. Results Pathways were often long and complex. Quantitative findings revealed that Common Mental Disorder was associated with delayed testing when advised by a Doctor (the most common pathway to testing) (AOR = 6.18, 2.16–17.70). Qualitative results showed that triggers for testing (symptoms believed to be due to HIV, and for women, illness or death of their husband) suggested that poor health, rather than awareness of risk was a key stimulus for testing. The period immediately before and after diagnosis was characterised by distress and fear. Stigma was a prominent backdrop to narratives. However, once participants had made contact with care and support (HIV services and non-governmental organisations), these systems were often effective in alleviating fear and promoting confidence in treatment and self-efficacy. Conclusion The effectiveness of formal and informal systems of support around the time of diagnosis in supporting people with mental disorder is unclear. Ways of enhancing these systems should be explored, with the aim of achieving timely presentation at HIV care for all those diagnosed with the disease.
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Affiliation(s)
- Rosie Mayston
- Health Service & Population Research Department, Kings College London, London, SE5 8AF, UK.
| | - Anisha Lazarus
- Centre for Global Mental Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Vikram Patel
- Centre for Global Mental Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.,Sangath, H No 451 (168), Bhatkar Waddo, Socorro, Porvorim, Bardez, Goa, 403501, India
| | - Melanie Abas
- Health Service & Population Research Department, Kings College London, London, SE5 8AF, UK
| | - Priya Korgaonkar
- Sangath, H No 451 (168), Bhatkar Waddo, Socorro, Porvorim, Bardez, Goa, 403501, India
| | - Ramesh Paranjape
- National AIDS Research Institute, 73, 'G'-Block, MIDC, Bhosari, Pune, 411 026, India
| | - Savio Rodrigues
- Department of Microbiology, Goa Medical College and Hospital, Bambolim, Tiswadi, Goa, India
| | - Martin Prince
- Health Service & Population Research Department, Kings College London, London, SE5 8AF, UK
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15
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Tenforde MW, Wake R, Leeme T, Jarvis JN. HIV-Associated Cryptococcal Meningitis: Bridging the Gap Between Developed and Resource-Limited Settings. CURRENT CLINICAL MICROBIOLOGY REPORTS 2016; 3:92-102. [PMID: 27257597 PMCID: PMC4845086 DOI: 10.1007/s40588-016-0035-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Cryptococcal meningitis is a major cause of HIV-associated morbidity and mortality worldwide. Most cases occur in low-income countries, where over half of patients die within 10 weeks of diagnosis compared to as few as 10 % of patients from developed countries. A host of factors, spanning the HIV care continuum, are responsible for this gap in treatment outcomes between developed and resource-limited settings. We explore factors responsible for this outcomes gap and describe low-cost, highly effective measures that can be implemented immediately to improve outcomes in resource-limited settings. We also explore health-system challenges that must be addressed to reduce mortality further, recent research in disease prevention, and novel short-course treatment regimens that, if efficacious, could be implemented in resource-limited settings where the cost of standard treatment regimens is currently prohibitive.
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Affiliation(s)
- Mark W. Tenforde
- />Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, WA USA
- />University of Washington Medical Center, 1959 NE Pacific Street, Health Sciences Division #356423, Seattle, WA 98195 USA
| | - Rae Wake
- />Institute of Infection and Immunity, St. George’s University of London, London, UK
- />Centre for Opportunistic, Tropical and Hospital Infections, National Institute for Communicable Diseases, Johannesburg, South Africa
- />National Institute for Communicable Diseases, 1 Modderfontein Road, Sandringham, Johannesburg, 2131 South Africa
| | - Tshepo Leeme
- />Botswana-UPenn Partnership, Gaborone, Botswana
| | - Joseph N. Jarvis
- />Botswana-UPenn Partnership, Gaborone, Botswana
- />Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
- />Department of Clinical Research, Faculty of Infectious Diseases and Tropical Medicine, London School of Hygiene and Tropical Medicine, London, UK
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16
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Siedner MJ, Bassett IV, Katz IT, Ng CK, Bangsberg DR, Tsai AC. Reply to Okatch et al. Clin Infect Dis 2016; 62:670-1. [PMID: 26668342 PMCID: PMC4741363 DOI: 10.1093/cid/civ969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024] Open
Affiliation(s)
- Mark J Siedner
- Center for Global Health Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital Harvard Medical School
| | - Ingrid V Bassett
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital Harvard Medical School Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital
| | - Ingrid T Katz
- Center for Global Health Harvard Medical School Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - David R Bangsberg
- Center for Global Health Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital Harvard Medical School Mbarara University of Science and Technology, Uganda
| | - Alexander C Tsai
- Center for Global Health Harvard Medical School Mbarara University of Science and Technology, Uganda Department of Psychiatry, Massachusetts General Hospital, Boston
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17
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Okatch H, Bellamy SL, Han X, Ratshaa B, Steenhoff AP, Mosepele M, Bisson GP, Gross R. CD4 Cell Counts at Antiretroviral Therapy Initiation in Botswana Have Been Increasing. Clin Infect Dis 2015; 62:669-70. [PMID: 26668340 DOI: 10.1093/cid/civ965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Harriet Okatch
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania Chemistry Department, University of Botswana, Gaborone, Botswana
| | - Scarlett L Bellamy
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xiaoyan Han
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Andrew P Steenhoff
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania Botswana-UPenn Partnership, Gaborone, Botswana Children's Hospital of Philadelphia, Pennsylvania
| | | | - Gregory P Bisson
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania Botswana-UPenn Partnership, Gaborone, Botswana
| | - Robert Gross
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania Botswana-UPenn Partnership, Gaborone, Botswana
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18
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Koller M, Patel K, Chi BH, Wools-Kaloustian K, Dicko F, Chokephaibulkit K, Chimbetete C, Hazra R, Ayaya S, Leroy V, Trong HK, Egger HK, Davies MA. Authors' Reply: Early Initiation of Antiretroviral Therapy Among Young Children: A Long Way to Go. J Acquir Immune Defic Syndr 2015; 70:e71-2. [PMID: 26218412 PMCID: PMC5339440 DOI: 10.1097/qai.0000000000000773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Manuel Koller
- Institute of Social & Preventive Medicine (ISPM),
University of Bern, Switzerland
| | - Kunjal Patel
- Department of Epidemiology, Harvard School of Public
Health, Boston, USA
| | - Benjamin H. Chi
- Centre for Infectious Disease Research in Zambia, Lusaka,
Zambia
| | | | - Fatoumata Dicko
- Department of Pediatrics, Gabriel Toure Hospital, Bamako,
Mali
| | | | | | - Rohan Hazra
- Maternal and Pediatric Infectious Disease Branch, Eunice
Kennedy Shriver National Institute of Child Health and Human Development (NICHD),
Bethesda, USA
| | - Samual Ayaya
- Department of Pediatrics, College of Health Sciences, Moi
University, Kenya
| | - Valeriane Leroy
- INSERM, French National Institute for Health and Medical
Research, U897, Bordeaux, France
| | | | - Huu Khanh Egger
- Institute of Social & Preventive Medicine (ISPM),
University of Bern, Switzerland
- School of Public Health and Family Medicine, University
of Cape Town, South Africa
| | - Mary-Ann Davies
- School of Public Health and Family Medicine, University
of Cape Town, South Africa
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