1
|
Owachi D, Anguzu G, Kigozi J, Cox J, Castelnuovo B, Semitala F, Meya D. Virologic suppression and associated factors in HIV infected Ugandan female sex workers: a cross-sectional study. Afr Health Sci 2021; 21:603-613. [PMID: 34795713 PMCID: PMC8568220 DOI: 10.4314/ahs.v21i2.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Key populations have disproportionately higher HIV prevalence rates than the general population. OBJECTIVE To determine the level of virologic suppression and associated factors in female Commercial Sex Workers (CSW) who completed six months of ART and compare with the female general population (GP). METHODS Clinical records of CSW and GPs who initiated ART between December 2014 to December 2016 from seven urban clinics were analyzed to determine virologic suppression (viral load < 1000 copies/ml) and associated factors. RESULTS We identified 218 CSW and 182 female GPs. CSW had median age of 28 (IQR 25-31) vs 31 (IQR 26-37); median baseline CD4 446 (IQR 308-696) vs 352 (IQR 164-493) cells/microL; and optimal ART adherence levels at 70.6% vs 92.8% respectively, compared to GP. Virologic suppression in CSW and GPs was 85.7% and 89.6% respectively, P=0.28. Overall virologic suppression in CSW was 55% while Retention in care after 6 months of ART was 77.5%. Immediate ART initiation (<2weeks) and tuberculosis independently predicted virologic suppression in CSW with adjusted odds ratios 0.07 (95% C.I. 0.01-0.55, P=0.01) and 0.09 (95% C.I. 0.01-0.96, P=0.046) respectively. CONCLUSION Virologic suppression in both groups is similar, however, intensified follow-up is needed to improve treatment outcomes.
Collapse
Affiliation(s)
- Darius Owachi
- Department of Infectious Diseases, Kiruddu National Referral Hospital, Kampala, Uganda
| | - Godwin Anguzu
- Department of Research, Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joanita Kigozi
- Outreach Department, Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Janneke Cox
- Department of Infectious Diseases and Immunology, Jessa Hospital, Hasselt, Belgium
| | - Barbara Castelnuovo
- Department of Research, Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Fred Semitala
- Department of Medicine, Makerere University, Kampala, Uganda
| | - David Meya
- Department of Research, Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| |
Collapse
|
2
|
Abstract
OBJECTIVE Sub-Saharan Africa faces twin epidemics of HIV and noncommunicable diseases including hypertension. Integrating hypertension care into chronic HIV care is a global priority, but cost estimates are lacking. In the SEARCH Study, we performed population-level HIV/hypertension testing, and offered integrated streamlined chronic care. Here, we estimate costs for integrated hypertension/HIV care for HIV-positive individuals, and costs for hypertension care for HIV-negative individuals in the same clinics. DESIGN Microcosting analysis of healthcare expenditures within Ugandan HIV clinics. METHODS SEARCH (NCT: 01864603) conducted community health campaigns for diagnosis and linkage to care for both HIV and hypertension. HIV-positive patients received hypertension/HIV care jointly including blood pressure monitoring and medications; HIV-negative patients received hypertension care at the same clinics. Within 10 Ugandan study communities during 2015-2016, we estimated incremental annual per-patient hypertension care costs using micro-costing techniques, time-and-motion personnel studies, and administrative/clinical records review. RESULTS Overall, 70 HIV-positive and 2355 HIV-negative participants received hypertension care. For HIV-positive participants, average incremental cost of hypertension care was $6.29 per person per year, a 2.1% marginal increase over prior estimates for HIV care alone. For HIV-negative participants, hypertension care cost $11.39 per person per year, a 3.8% marginal increase over HIV care costs. Key costs for HIV-positive patients included hypertension medications ($6.19 per patient per year; 98% of total) and laboratory testing ($0.10 per patient per year; 2%). Key costs for HIV-negative patients included medications ($5.09 per patient per year; 45%) and clinic staff salaries ($3.66 per patient per year; 32%). CONCLUSION For only 2-4% estimated additional costs, hypertension care was added to HIV care, and also expanded to all HIV-negative patients in prototypic Ugandan clinics, demonstrating substantial synergy. Our results should encourage accelerated scale-up of hypertension care into existing clinics.
Collapse
|
3
|
Chauke P, Huma M, Madiba S. Lost to follow up rate in the first year of ART in adults initiated in a universal test and treat programme: a retrospective cohort study in Ekurhuleni District, South Africa. Pan Afr Med J 2020; 37:198. [PMID: 33505567 PMCID: PMC7813655 DOI: 10.11604/pamj.2020.37.198.25294] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 09/26/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction South Africa adopted and implemented the Universal Test and Treat (UTT) strategy for HIV since 2016. However, the care outcomes for patients initiated antiretroviral therapy (ART) through the UTT strategy have not been established. We determined the rate of lost to follow up (LTFU) and associated factors in patients who were initiated on ART through the UTT and the pre-ART strategy at 12 months post ART initiation. Methods this retrospective study analyzed the records of a cohort of patients at 12 months post the initiation of ART. We extracted data from the TIER.Net electronic database of selected facilities in a sub-district in Gauteng Province, South Africa. Factors associated with LFTU at 12 months of ART were assessed and logistic regression performed to identify predictors of LFTU. Results records of 367 patients were evaluated, and 54% were initiated ART through the UTT strategy. The mean age was 36.3 years, mean CD4 cell count at ART initiation was 341 cells/mm3, and 25% were initiated at CD4 cell count above 500 cells/mm3. LTFU at 12 months was 28%, 50% were LFTU within six months, and 28% within three months of ART. LFTU in the UTT cohort was higher than in the pre-ART cohort, patients initiated through UTT were twice more likely to be LTFU (AOR = 1.84, CI: 1.13-3.00) than pre-ART patients. Conclusion the rate of LTFU at 12 months of ART was 28%, which indicate that the retention in care rate (60%) falls far short of the triple 90 targets required for viral suppression.
Collapse
Affiliation(s)
- Patricia Chauke
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Mmampedi Huma
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Sphiwe Madiba
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| |
Collapse
|
4
|
Courtenay-Quirk C, Geller AL, Duran D, Honwana N. Tracking linkage to care in an anonymous HIV testing context: A field assessment in Mozambique. J Eval Clin Pract 2020; 26:1005-1012. [PMID: 31414555 DOI: 10.1111/jep.13262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/26/2019] [Accepted: 07/29/2019] [Indexed: 11/29/2022]
Abstract
RATIONALE Effective human immunodeficiency virus (HIV) prevention requires a coordinated continuum of services to foster early diagnosis and treatment. Early linkage to care (LTC) is critical, yet programmes differ in strategies to monitor LTC. METHODS In 2014, we visited 23 HIV testing and care service delivery points in Mozambique to assess programme strategies for monitoring LTC. We interviewed key informants, reviewed forms, and matched records across service points to identify successful models and challenges. RESULTS Forms most useful for tracking LTC included individual identifiers, eg, patient name, unique identifier (ie, National Health Identification Number [NID]), sex, and date of birth. The majority (67%) of records matched occurred in the presence of a unique NID. Key informants described challenges related to processes, staffing, and communication between service delivery points to confirm LTC. CONCLUSIONS While tracking clients from HIV testing to care is possible, programmes with insufficient tracking procedures are likely to underreport LTC. Adoption of additional patient identifiers in testing registers and standardized protocols may improve LTC programme monitoring and reduce underreporting.
Collapse
Affiliation(s)
- Cari Courtenay-Quirk
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Amanda L Geller
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA
| | - Denise Duran
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA
| | - Nely Honwana
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Maputo, Mozambique
| |
Collapse
|
5
|
Determinants of loss to follow-up among HIV positive patients receiving antiretroviral therapy in a test and treat setting: A retrospective cohort study in Masaka, Uganda. PLoS One 2020; 15:e0217606. [PMID: 32255796 PMCID: PMC7138304 DOI: 10.1371/journal.pone.0217606] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 03/15/2020] [Indexed: 12/20/2022] Open
Abstract
Background Retaining patients starting antiretroviral therapy (ART) and ensuring good adherence remain cornerstone of long-term viral suppression. In this era of test and treat (T&T) policy, ensuring that patients starting ART remain connected to HIV clinics is key to achieve the UNAIDS 90-90-90 targets. Currently, limited studies have evaluated the effect of early ART initiation on loss to follow up in a routine health care delivery setting. We studied the cumulative incidence, incidence rate of loss to follow up (LTFU), and factors associated with LTFU in a primary healthcare clinic that has practiced T&T since 2012. Methods We retrospectively analyzed extracted routine program data on patients who started ART from January 2012 to 4th July 2016. We defined LTFU as failure of a patient to return to the HIV clinic for at least 90 days from the date of their last appointment. We calculated cumulative incidence, incidence rate and fitted a multivariable Cox proportion hazards regression model to determine factors associated with LTFU. Results Of the 7,553 patients included in our sample, 3,231 (42.8%) started ART within seven days following HIV diagnosis. There were 1,180 cases of LTFU observed over 15,807.7 person years at risk. The overall incidence rate (IR) of LTFU was 7.5 (95% CI, 7.1–7.9) per 100 person years of observation (pyo). Cumulative incidence of LTFU increased with duration of follow up from 8.9% (95% CI, 8.2–9.6%) at 6 months to 20.2% (95% CI, 19.0–21.4%) at 48 months. Predictors of elevated risk of LTFU were: starting ART within 7 days following HIV diagnosis ((aHR) = 1.69, 95% CI, 1.50–1.91), lack of a telephone set (aHR = 1.52, 95% CI, 1.35–1.71), CD4 cell count of 200–350μ/ml (aHR = 1.21, 95% CI, 1.01–1.45) and baseline WHO clinical stage 3 or 4 (aHR = 1.35, 95% CI, 1.10–1.65). Factors associated with a reduced risk of LTFU were: baseline age ≥25 years (aHR ranging from 0.62, 95% CI, 0.47–0.81 for age group 25–29 years to 0.24, 95% CI, 0.13–0.44 for age group ≥50 years), at least primary education level (aHR ranging from aHR = 0.77, 95% CI, 0.62–0.94 for primary education level to 0.50, 95% CI, 0.34–0.75 for post-secondary education level), and having a BMI ≥ 30 (aHR = 0.28, 95% CI, 0.15–0.51). Conclusion The risk of loss to follow up increased with time and was higher among patients who started ART within seven days following HIV diagnosis, higher among patients without a telephone set, lower among patients aged ≥ 25 years, lower among patients with at least primary education and lower among patients with BMI of ≥ 30. In this era of T&T, it will be important for HIV programs to initiate and continue enhanced therapeutic education programs that target high risk groups, as well as leveraging on mHealth to improve patients’ retention on ART throughout the cascade of care.
Collapse
|
6
|
Byonanebye DM, Semitala FC, Katende J, Bakenga A, Arinaitwe I, Kyambadde P, Musinguzi P, Biraro IA, Byakika-Kibwika P, Kamya MR. High viral suppression and low attrition in healthy HIV-infected patients initiated on ART with CD4 above 500 cells/µL in a program setting in Uganda. Afr Health Sci 2020; 20:132-141. [PMID: 33402901 PMCID: PMC7750048 DOI: 10.4314/ahs.v20i1.18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The World Health Organization recommends antiretroviral therapy (ART) for all HIV-infected patients at all CD4 counts. However, there are concerns that asymptomatic patients may have poorer viral suppression and high attrition. OBJECTIVES We sought to determine attrition and viral suppression among healthy HIV-infected patients initiated on ART in program settings. METHODS This cross-sectional study enrolled ART-experienced patients attending two PEPFAR-supported, high-volume clinics in Kampala, Uganda. Eligible patients were >18 years and had completed at least six months on ART. Participants were interviewed on socio-demographics, ART history and plasma viral load (VL) determined using Abbott Real-time. Predictors of viral suppression (<75 copies/ml) were determined using multivariate logistic regression. RESULTS Overall, 267 participants were screened, 228 were eligible and 203 (89%) retained in care (visit within 90 days). Of the 203 participants, 115 (56.7%) were key-populations. Viral suppression was achieved in 173 patients (85%; 95% CI, 80.3%-90.1%). The factors associated with viral suppression were prior VL tests (AOR 6.98; p-value <0.001) and receiving care from a general clinic (AOR 5.41; p=0.009). CONCLUSION Asymptomatic patients initiated on ART with high baseline CD4 counts, achieve high viral suppression with low risk of attrition. VL monitoring and clinic type are associated with viral suppression.
Collapse
Affiliation(s)
| | - Fred C Semitala
- Makerere University College of Health Sciences, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
| | | | - Alex Bakenga
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Irene Arinaitwe
- Makerere University College of Computing and Information Science
| | | | | | | | | | - Moses R Kamya
- Makerere University College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala Uganda
| |
Collapse
|
7
|
Molemans M, Vernooij E, Dlamini N, Shabalala FS, Khan S, van Leth F, Gomez GB, Reis R. Changes in disclosure, adherence and healthcare interactions after the introduction of immediate ART initiation: an analysis of patient experiences in Swaziland. Trop Med Int Health 2019; 24:563-570. [PMID: 30739385 PMCID: PMC6850272 DOI: 10.1111/tmi.13214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION There are concerns that immediate ART initiation (regardless of CD4 count) negatively affects HIV status disclosure, ART adherence and healthcare interactions. We assessed changes in these factors after the 'Early access to ART for all' intervention, a universal test-and-treat study in Swaziland. METHODS We recruited two samples of participants between 2014 and 2017. The first group was interviewed before the intervention (control); the second group at the implementation and 6 months thereafter (intervention). RESULTS High levels of disclosure to partners (controls and intervention: 94%) and family members (controls: 78%, intervention: 79%) were reported, and high levels of adherence (85% did not miss a dose among the controls, 84% in the intervention group). There were no changes in patients reporting feeling pressured to initiate ART (controls: 10%, intervention: 11%). The quality of interaction with healthcare workers improved after the intervention; healthcare workers explained more often the choice of ART initiation (controls: 88%, intervention: 93%) and the meaning of both CD4 and viral load test results (controls: 15%, intervention: 47%). More patients in the intervention group reported receiving test results (controls: 13%, intervention: 46%). We observed no changes in disclosure, adherence or patient experiences 6 months into the intervention compared to its start. CONCLUSION Our results suggest that both reported adherence and disclosure levels remain high after the introduction of immediate ART in Swaziland. We observed an improvement in the healthcare interactions, possibly due to training at participating facilities, which will be an important element for a successful roll-out of immediate ART.
Collapse
Affiliation(s)
- Marjan Molemans
- Department of Global HealthAcademic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Institute for Global Health and DevelopmentAmsterdamThe Netherlands
| | - Eva Vernooij
- Amsterdam Institute for Social Science ResearchDepartment of AnthropologyUniversity of AmsterdamAmsterdamThe Netherlands
- Social AnthropologySchool of Social and Political ScienceThe University of EdinburghEdinburghUK
| | - Njabuliso Dlamini
- Amsterdam Institute for Social Science ResearchDepartment of AnthropologyUniversity of AmsterdamAmsterdamThe Netherlands
| | - Fortunate S. Shabalala
- Amsterdam Institute for Social Science ResearchDepartment of AnthropologyUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Community Health Nursing SciencesFaculty of Health SciencesUniversity of SwazilandMbabaneSwaziland
| | - Shaukat Khan
- Clinton Health Access InitiativeMbabaneSwaziland
| | - Frank van Leth
- Department of Global HealthAcademic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Institute for Global Health and DevelopmentAmsterdamThe Netherlands
| | - Gabriela B. Gomez
- Amsterdam Institute for Global Health and DevelopmentAmsterdamThe Netherlands
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
| | - Ria Reis
- Amsterdam Institute for Global Health and DevelopmentAmsterdamThe Netherlands
- Amsterdam Institute for Social Science ResearchDepartment of AnthropologyUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Public Health and Primary CareLeiden University Medical CentreLeidenThe Netherlands
- The Children's InstituteSchool of Child and Adolescent HealthUniversity of Cape TownCape TownSouth Africa
| |
Collapse
|
8
|
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.
Collapse
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
| | | |
Collapse
|
9
|
Abstract
Objectives/design: As antiretroviral therapy (ART) rapidly expands in sub-Saharan Africa using new efficient care models, data on costs of these approaches are lacking. We examined costs of a streamlined HIV care delivery model within a large HIV test-and-treat study in Uganda and Kenya. Methods: We calculated observed per-person-per-year (ppy) costs of streamlined care in 17 health facilities in SEARCH Study intervention communities (NCT: 01864603) via micro-costing techniques, time-and-motion studies, staff interviews, and administrative records. Cost categories included salaries, ART, viral load testing, recurring goods/services, and fixed capital/facility costs. We then modeled costs under three increasingly efficient scale-up scenarios: lowest-cost ART, centralized viral load testing, and governmental healthcare worker salaries. We assessed the relationship between community-specific ART delivery costs, retention in care, and viral suppression. Results: Estimated streamlined HIV care delivery costs were $291/ppy. ART ($117/ppy for TDF/3TC/EFV [40%]) and viral load testing ($110/ppy for 2 tests/year [39%]) dominated costs versus salaries ($51/ppy), recurring costs ($5/ppy), and fixed costs ($7/ppy). Optimized ART scale-up with lowest-cost ART ($100/ppy), annual viral load testing ($24/ppy), and governmental healthcare salaries ($27/ppy), lowered streamlined care cost to $163/ppy. We found clinic-to-clinic heterogeneity in retention and viral suppression levels versus streamlined care delivery costs, but no correlation between cost and either retention or viral suppression. Conclusions: In the SEARCH Study, streamlined HIV care delivery costs were similar to or lower than prior estimates despite including viral load testing; further optimizations could substantially reduce costs further. These data can inform global strategies for financing ART expansion to achieve UNAIDS 90–90–90 targets.
Collapse
|
10
|
Predictors of Retention in HIV Care Among Youth (15-24) in a Universal Test-and-Treat Setting in Rural Kenya. J Acquir Immune Defic Syndr 2018; 76:e15-e18. [PMID: 28394821 DOI: 10.1097/qai.0000000000001390] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
11
|
Tymejczyk O, Brazier E, Yiannoutsos C, Wools-Kaloustian K, Althoff K, Crabtree-Ramírez B, Van Nguyen K, Zaniewski E, Dabis F, Sinayobye JD, Anderegg N, Ford N, Wikramanayake R, Nash D. HIV treatment eligibility expansion and timely antiretroviral treatment initiation following enrollment in HIV care: A metaregression analysis of programmatic data from 22 countries. PLoS Med 2018; 15:e1002534. [PMID: 29570723 PMCID: PMC5865713 DOI: 10.1371/journal.pmed.1002534] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 02/14/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The effect of antiretroviral treatment (ART) eligibility expansions on patient outcomes, including rates of timely ART initiation among those enrolling in care, has not been assessed on a large scale. In addition, it is not known whether ART eligibility expansions may lead to "crowding out" of sicker patients. METHODS AND FINDINGS We examined changes in timely ART initiation (within 6 months) at the original site of HIV care enrollment after ART eligibility expansions among 284,740 adult ART-naïve patients at 171 International Epidemiology Databases to Evaluate AIDS (IeDEA) network sites in 22 countries where national policies expanding ART eligibility were introduced between 2007 and 2015. Half of the sites included in this analysis were from Southern Africa, one-third were from East Africa, and the remainder were from the Asia-Pacific, Central Africa, North America, and South and Central America regions. The median age of patients enrolling in care at contributing sites was 33.5 years, and the median percentage of female patients at these clinics was 62.5%. We assessed the 6-month cumulative incidence of timely ART initiation (CI-ART) before and after major expansions of ART eligibility (i.e., expansion to treat persons with CD4 ≤ 350 cells/μL [145 sites in 22 countries] and CD4 ≤ 500 cells/μL [152 sites in 15 countries]). Random effects metaregression models were used to estimate absolute changes in CI-ART at each site before and after guideline expansion. The crude pooled estimate of change in CI-ART was 4.3 percentage points (95% confidence interval [CI] 2.6 to 6.1) after ART eligibility expansion to CD4 ≤ 350, from a baseline median CI-ART of 53%; and 15.9 percentage points (pp) (95% CI 14.3 to 17.4) after ART eligibility expansion to CD4 ≤ 500, from a baseline median CI-ART of 57%. The largest increases in CI-ART were observed among those newly eligible for treatment (18.2 pp after expansion to CD4 ≤ 350 and 47.4 pp after expansion to CD4 ≤ 500), with no change or small increases among those eligible under prior guidelines (CD4 ≤ 350: -0.6 pp, 95% CI -2.0 to 0.7 pp; CD4 ≤ 500: 4.9 pp, 95% CI 3.3 to 6.5 pp). For ART eligibility expansion to CD4 ≤ 500, changes in CI-ART were largest among younger patients (16-24 years: 21.5 pp, 95% CI 18.9 to 24.2 pp). Key limitations include the lack of a counterfactual and difficulty accounting for secular outcome trends, due to universal exposure to guideline changes in each country. CONCLUSIONS These findings underscore the potential of ART eligibility expansion to improve the timeliness of ART initiation globally, particularly for young adults.
Collapse
Affiliation(s)
- Olga Tymejczyk
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
- * E-mail:
| | - Ellen Brazier
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
| | - Constantin Yiannoutsos
- R.M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, United States of America
| | - Kara Wools-Kaloustian
- Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Keri Althoff
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | | | - Elizabeth Zaniewski
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | | | | | - Nathan Ford
- World Health Organization, Geneva, Switzerland
| | - Radhika Wikramanayake
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
- Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
| | | |
Collapse
|
12
|
Mujugira A, Baeten J, Kidoguchi L, Haberer J, Celum C, Donnell D, Ngure K, Bukusi E, Mugo N, Asiimwe S, Odoyo J, Tindimwebwa E, Bulya N, Katabira E, Heffron R. High levels of viral suppression among East African HIV-infected women and men in serodiscordant partnerships initiating antiretroviral therapy with high CD4 counts and during pregnancy. AIDS Res Hum Retroviruses 2018; 34:140-147. [PMID: 28899162 PMCID: PMC5806074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024] Open
Abstract
BACKGROUND People who are asymptomatic and feel healthy, including pregnant women, may be less motivated to initiate ART or achieve high adherence. We assessed whether ART initiation, and viral suppression 6, 12 and 24-months after ART initiation, were lower in HIV-infected members of serodiscordant couples who initiated during pregnancy or with higher CD4 counts. METHODS We used data from the Partners Demonstration Project, an open-label study of the delivery of integrated PrEP and ART (at any CD4 count) for HIV prevention among high-risk HIV serodiscordant couples in Kenya and Uganda. Differences in viral suppression (HIV RNA <400 copies/ml) among people initiating ART at different CD4 count levels (≤350, 351-500, and >500 cells/mm3) and during pregnancy were estimated using Poisson regression. RESULTS Of 865 HIV-infected participants retained after becoming eligible for ART during study follow-up, 95% initiated ART. Viral suppression 24-months after ART initiation was high overall (97%), and comparable among those initiating ART at CD4 counts >500, 351-500 and ≤350 cells/mm3 (96% vs 97% vs 97%; relative risk [RR] 0.98; 95% CI: 0.93-1.03 for CD4 >500 vs <350 and RR 0.99; 95% CI: (0.93-1.06) for CD4 351-500 vs ≤350). Viral suppression was as likely among women initiating ART primarily to prevent perinatal transmission as ART initiation for other reasons (p=0.9 at 6 months and p=0.5 at 12 months). CONCLUSIONS Nearly all HIV-infected partners initiating ART were virally suppressed by 24 months, irrespective of CD4 count or pregnancy status. These findings suggest that people initiating ART at high CD4 counts or due to pregnancy can adhere to ART as well as those starting treatment with symptomatic HIV disease or low CD4 counts.
Collapse
Affiliation(s)
- Andrew Mujugira
- University of Washington, Department of Global Health , 901 Boren Ave , Suite 1300 , Seattle, Washington, United States , 98104 ;
| | | | | | | | | | - Deborah Donnell
- Fred Hutchinson Cancer Research Center, SCHARP/VIDI/PHS , 1100 Fairview Ave N , Seattle, Washington, United States , 98109 ;
| | | | | | - Nelly Mugo
- Kenya Medical Research Institute, Nairobi, Kenya ;
| | | | | | | | | | - Elly Katabira
- Makerere University, Infectious Disease Institute, Kampala, Uganda ;
| | - Renee Heffron
- University of Washington, Department of Epidemiology, Seattle, United States ;
| |
Collapse
|
13
|
Kumi Smith M, Jewell BL, Hallett TB, Cohen MS. Treatment of HIV for the Prevention of Transmission in Discordant Couples and at the Population Level. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1075:125-162. [PMID: 30030792 DOI: 10.1007/978-981-13-0484-2_6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The scientific breakthrough proving that antiretroviral therapy (ART) can halt heterosexual HIV transmission came in the form of a landmark clinical trial conducted among serodiscordant couples. Study findings immediately informed global recommendations for the use of treatment as prevention in serodiscordant couples. The extent to which these findings are generalizable to other key populations or to groups exposed to HIV through nonsexual transmission routes (i.e., anal intercourse or unsafe injection of drugs) has since driven a large body of research. This review explores the history of HIV research in serodiscordant couples, the implications for management of couples, subsequent research on treatment as prevention in other key populations, and challenges in community implementation of these strategies.
Collapse
Affiliation(s)
- M Kumi Smith
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
| | | | | | - Myron S Cohen
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
14
|
High rates of viral suppression in adults and children with high CD4+ counts using a streamlined ART delivery model in the SEARCH trial in rural Uganda and Kenya. J Int AIDS Soc 2017; 20:21673. [PMID: 28770596 PMCID: PMC5577724 DOI: 10.7448/ias.20.5.21673] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Introduction: The 2015 WHO recommendation of antiretroviral therapy (ART) for all HIV-positive persons calls for treatment initiation in millions of persons newly eligible with high CD4+ counts. Efficient and effective care models are urgently needed for this population. We evaluated clinical outcomes of asymptomatic HIV-positive adults and children starting ART with high CD4+ counts using a novel streamlined care model in rural Uganda and Kenya. Methods: In the 16 intervention communities of the HIV test-and-treat Sustainable East Africa Research for Community Health Study (NCT01864603), all HIV-positive individuals irrespective of CD4 were offered ART (efavirenz [EFV]/tenofovir disoproxil fumarate + emtricitabine (FTC) or lamivudine (3TC). We studied adults (≥fifteen years) with CD4 ≥ 350/μL and children (two to fourteen years) with CD4 > 500/μL otherwise ineligible for ART by country guidelines. Clinics implemented a patient-centred streamlined care model designed to reduce patient-level barriers and maximize health system efficiency. It included (1) nurse-conducted visits with physician referral of complex cases, (2) multi-disease chronic care (including for hypertension/diabetes), (3) patient-centred, friendly staff, (4) viral load (VL) testing and counselling, (5) three-month return visits and ART refills, (6) appointment reminders, (7) tiered tracking for missed appointments, (8) flexible clinic hours (outside routine schedule) and (9) telephone access to clinicians. Primary outcomes were 48-week retention in care, viral suppression (% with measured week 48 VL ≤ 500 copies/mL) and adverse events. Results: Overall, 972 HIV-positive adults with CD4+ ≥ 350/μL initiated ART with streamlined care. Patients were 66% female and had median age thirty-four years (IQR, 28–42), CD4+ 608/μL (IQR, 487–788/μL) and VL 6775 copies/mL (IQR, <500–37,003 c/mL). At week 48, retention was 92% (897/972; 2 died/40 moved/8 withdrew/4 transferred care/21/964 [2%] were lost to follow-up). Viral suppression occurred in 778/838 (93%) and 800/972 (82%) in intention-to-treat analysis. Grade III/IV clinical/laboratory adverse events were rare: 95 occurred in 74/972 patients (7.6%). Only 8/972 adults (0.8%) switched ART from EFV to lopinavir (LPV) (n = 2 for dizziness, n = 2 for gynaecomastia, n = 4 for other reasons). Among 83 children, week 48 retention was 89% (74/83), viral suppression was 92% (65/71) and grade III/IV adverse events occurred in 4/83 (4.8%). Conclusions: Using a streamlined care model, viral suppression, retention and ART safety were high among asymptomatic East African adults and children with high CD4+ counts initiating treatment. Clinical Trial Number: NCT01864603
Collapse
|
15
|
Phased implementation of spaced clinic visits for stable HIV-positive patients in Rwanda to support Treat All. J Int AIDS Soc 2017; 20:21635. [PMID: 28770591 PMCID: PMC5577720 DOI: 10.7448/ias.20.5.21635] [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] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION In 2016, Rwanda implemented "Treat All," requiring the national HIV programme to increase antiretroviral (ART) treatment coverage to all people living with HIV. Approximately half of the 164,262 patients on ART have been on treatment for more than five years, and long-term retention of patients in care is an increasing concern. To address these challenges, the Ministry of Health has introduced a differentiated service delivery approach to reduce the frequency of clinical visits and medication dispensing for eligible patients. This article draws on key policy documents and the views of technical experts involved in policy development to describe the process of implementation of differentiated service delivery in Rwanda. DISCUSSION Implementation of differentiated service delivery followed a phased approach to ensure that all steps are clearly defined and agreed by all partners. Key steps included: definition of scope, including defining which patients were eligible for transition to the new model; definition of the key model components; preparation for patient enrolment; considerations for special patient groups; engagement of implementing partners; securing political and financial support; forecasting drug supply; revision, dissemination and implementation of ART guidelines; and monitoring and evaluation. CONCLUSIONS Based on the outcomes of the evaluation of the new service delivery model, the Ministry of Health will review and strategically reduce costs to the national HIV program and to the patient by exploring and implementing adjustments to the service delivery model.
Collapse
|
16
|
Mujugira A, Baeten JM, Kidoguchi L, Haberer J, Celum C, Donnell D, Ngure K, Bukusi EA, Mugo N, Asiimwe S, Odoyo J, Tindimwebwa E, Bulya N, Katabira E, Heffron R, for the Partners Demonstration Proj. High levels of viral suppression among East African HIV-infected women and men in serodiscordant partnerships initiating antiretroviral therapy with high CD4 counts and during pregnancy. AIDS Res Hum Retroviruses 2017. [PMID: 28899162 DOI: 10.1089/aid.2017.0020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND People who are asymptomatic and feel healthy, including pregnant women, may be less motivated to initiate ART or achieve high adherence. We assessed whether ART initiation, and viral suppression 6, 12 and 24-months after ART initiation, were lower in HIV-infected members of serodiscordant couples who initiated during pregnancy or with higher CD4 counts. METHODS We used data from the Partners Demonstration Project, an open-label study of the delivery of integrated PrEP and ART (at any CD4 count) for HIV prevention among high-risk HIV serodiscordant couples in Kenya and Uganda. Differences in viral suppression (HIV RNA <400 copies/ml) among people initiating ART at different CD4 count levels (≤350, 351-500, and >500 cells/mm3) and during pregnancy were estimated using Poisson regression. RESULTS Of 865 HIV-infected participants retained after becoming eligible for ART during study follow-up, 95% initiated ART. Viral suppression 24-months after ART initiation was high overall (97%), and comparable among those initiating ART at CD4 counts >500, 351-500 and ≤350 cells/mm3 (96% vs 97% vs 97%; relative risk [RR] 0.98; 95% CI: 0.93-1.03 for CD4 >500 vs <350 and RR 0.99; 95% CI: (0.93-1.06) for CD4 351-500 vs ≤350). Viral suppression was as likely among women initiating ART primarily to prevent perinatal transmission as ART initiation for other reasons (p=0.9 at 6 months and p=0.5 at 12 months). CONCLUSIONS Nearly all HIV-infected partners initiating ART were virally suppressed by 24 months, irrespective of CD4 count or pregnancy status. These findings suggest that people initiating ART at high CD4 counts or due to pregnancy can adhere to ART as well as those starting treatment with symptomatic HIV disease or low CD4 counts.
Collapse
Affiliation(s)
- Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, Washington
| | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Lara Kidoguchi
- Department of Global Health, University of Washington, Seattle, Washington
| | | | - Connie Celum
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Deborah Donnell
- Department of Global Health, University of Washington, Seattle, Washington
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, Washington
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | - Elizabeth A. Bukusi
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, Washington
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Josephine Odoyo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Nulu Bulya
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Elly Katabira
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
| | | |
Collapse
|
17
|
Phased implementation of spaced clinic visits for stable HIV-positive patients in Rwanda to support Treat All. J Int AIDS Soc 2017. [DOI: 10.7448/ias.20.1.21635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
|
18
|
Moving toward test and start: learning from the experience of universal antiretroviral therapy programs for HIV-infected pregnant/ breastfeeding women. AIDS 2017; 31:1489-1493. [PMID: 28574966 DOI: 10.1097/qad.0000000000001498] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
: In 2015, the WHO recommended universal antiretroviral therapy (ART) for all people living with HIV after two randomized controlled trials revealed lower rates of mortality and serious illnesses among people living with HIV receiving immediate ART compared with those receiving deferred ART. Many countries in sub-Saharan Africa rapidly adopted this guidance and are implementing 'test and start' programs.As this work begins, lessons learned from prevention of mother-to-child transmission Option B+ programs can inform decisions for new universal HIV treatment programs. The Option B+ approach involved initiation of lifelong treatment for all HIV-infected pregnant and breastfeeding women. Since its inception in Malawi in 2011 and WHO endorsement in 2012, widespread scale-up of Option B+ prevention of mother-to-child transmission programs in most resource-limited countries has resulted in a dramatic increase in ART coverage for HIV-infected pregnant and breastfeeding women.Despite the overall success of the Option B+ universal lifelong treatment approach, program and operational research data highlight the need for additional focus on strategies to retain women in care. In this commentary, we highlight program considerations and lessons learned from Option B+ implementation experience in resource-limited countries, which may help guide decisions and enhance the quality of general 'test and start' programing.
Collapse
|
19
|
Taieb F, Madec Y, Cournil A, Delaporte E. Virological success after 12 and 24 months of antiretroviral therapy in sub-Saharan Africa: Comparing results of trials, cohorts and cross-sectional studies using a systematic review and meta-analysis. PLoS One 2017; 12:e0174767. [PMID: 28426819 PMCID: PMC5398519 DOI: 10.1371/journal.pone.0174767] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 03/15/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND UNAIDS recently defined the 90-90-90 target as a way to end the HIV epidemic. However, the proportion of virological success following antiretroviral therapy (ART) may not be as high as the anticipated 90%, and may in fact be highly heterogeneous. We aimed to describe the proportion of virological success in sub-Saharan Africa and to identify factors associated with the proportion of virological success. METHODS We performed a systematic review and meta-analysis focusing on the proportion of patients in sub-Saharan Africa who demonstrate virological success at 12 and 24 months since ART initiation, as well as at 6 and 36 months, where possible. Programme factors associated with the proportion of virological success were identified using meta-regression. Analyses were conducted using both on-treatment (OT) and intention-to-treat (ITT) approaches. RESULTS Eighty-five articles were included in the meta-analysis, corresponding to 125 independent study populations. Using an on-treatment approach, the proportions (95% confidence interval (CI)) of virological success at 12 (n = 64) and at 24 (n = 32) months since ART initiation were 87.7% (81.3-91.0) and 83.7% (79.8-87.6), respectively. Univariate analysis indicated that the proportion of virological success was not different by study design. Multivariate analysis at 24 months showed that the proportion of virological success was significantly larger in studies conducted in public sector sites than in other sites (p = 0.045). Using an ITT approach, the proportions (95% CI) of virological success at 12 (n = 50) and at 24 (n = 20) months were 65.4% (61.8-69.1) and 56.8% (51.3-62.4), respectively. At 12 months, multivariate analysis showed that the proportion of success was significantly lower in cohort studies than in trials (63.0% vs. 71.1%; p = 0.017). At 24 months, univariate analysis demonstrated that the proportion of success was also lower in cohorts. DISCUSSION Regardless of the time following ART initiation, and of the threshold, proportions of virological success were highly variable. Evidence from this review suggests that the new international target of 90% of patients controlled is not yet being achieved, and that in order to improve the virological outcome, efforts should be made to improve retention in care.
Collapse
Affiliation(s)
- Fabien Taieb
- Emerging Diseases Epidemiology Unit-Institut Pasteur, Paris, France
- IRD UMI 233 INSERM U1175 Université de Montpellier, Unité TransVIHMI, Montpellier, France
- Direction de la Recherche Clinique et du Développement-Assistance Publique des Hôpitaux de Paris-Hôpital Saint-Louis, Paris, France
- * E-mail:
| | - Yoann Madec
- Emerging Diseases Epidemiology Unit-Institut Pasteur, Paris, France
| | - Amandine Cournil
- IRD UMI 233 INSERM U1175 Université de Montpellier, Unité TransVIHMI, Montpellier, France
| | - Eric Delaporte
- IRD UMI 233 INSERM U1175 Université de Montpellier, Unité TransVIHMI, Montpellier, France
| |
Collapse
|
20
|
Haberer JE, Sabin L, Amico KR, Orrell C, Galárraga O, Tsai AC, Vreeman RC, Wilson I, Sam‐Agudu NA, Blaschke TF, Vrijens B, Mellins CA, Remien RH, Weiser SD, Lowenthal E, Stirratt MJ, Sow PS, Thomas B, Ford N, Mills E, Lester R, Nachega JB, Bwana BM, Ssewamala F, Mbuagbaw L, Munderi P, Geng E, Bangsberg DR. Improving antiretroviral therapy adherence in resource-limited settings at scale: a discussion of interventions and recommendations. J Int AIDS Soc 2017; 20:21371. [PMID: 28630651 PMCID: PMC5467606 DOI: 10.7448/ias.20.1.21371] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 02/24/2017] [Indexed: 01/01/2023] Open
Abstract
Introduction: Successful population-level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale-up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource-limited settings. Methods: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource-limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta-analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low- and middle-income countries. Interventions are categorized broadly as education and counselling; information and communication technology-enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described. Results and discussion: The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource-limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi-media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement. Conclusions: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS.
Collapse
Affiliation(s)
- Jessica E. Haberer
- Massachusetts General Hospital Global Health, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lora Sabin
- Department of Global Health, Center for Global Health and Department, Boston University School of Public Health, Boston, MA, USA
| | - K. Rivet Amico
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Omar Galárraga
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Alexander C. Tsai
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Rachel C. Vreeman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ira Wilson
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Nadia A. Sam‐Agudu
- Clinical Department, Institute of Human Virology Nigeria, Abuja, Nigeria
- Institute of Human Virology and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Terrence F. Blaschke
- Department of Medicine and Clinical Pharmacology, Stanford University School of Medicine, Stanford, CA, USA
| | - Bernard Vrijens
- Department of Biostatistics, University of Liège, Liège, Wallonia, Belgium
- WestRock Healthcare, Sion, Switzerland
| | - Claude A. Mellins
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Robert H. Remien
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Sheri D. Weiser
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Elizabeth Lowenthal
- Departments of Pediatrics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael J. Stirratt
- Division of AIDS Research, National Institute of Mental Health, Bethesda, MD, USA
| | - Papa Salif Sow
- Bill and Melinda Gates Foundation, Seattle, WA, USA
- Department of Infectious diseases, University of Dakar, Dakar, Sénégal
| | | | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Edward Mills
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard Lester
- Division of Infectious Diseases, Department of Medicine, University of British Columbia
| | - Jean B. Nachega
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Bosco Mwebesa Bwana
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Fred Ssewamala
- Columbia University School of Social Work & School of International and Public Affairs, New York, NY, USA
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Paula Munderi
- HIV Care Research Program, Medical Research Council, Uganda Virus Research Institute, Entebbe, Uganda
| | - Elvin Geng
- Division of HIV, Infectious Disease and Global Medicine, San Francisco General Hospital, Department of Medicine, University of California, San Francisco, CA, USA
| | - David R. Bangsberg
- Oregon Health & Sciences University‐Portland State University School of Public Health, Portland, OR, USA
| |
Collapse
|
21
|
From policy to action: how to operationalize the treatment for all agenda. J Int AIDS Soc 2016; 19:21185. [PMID: 27989270 PMCID: PMC5165084 DOI: 10.7448/ias.19.1.21185] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 09/09/2016] [Accepted: 11/14/2016] [Indexed: 12/30/2022] Open
|
22
|
High levels of retention in care with streamlined care and universal test and treat in East Africa. AIDS 2016; 30:2855-2864. [PMID: 27603290 DOI: 10.1097/qad.0000000000001250] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to measure retention in care and identify predictors of nonretention among patients receiving antiretroviral therapy (ART) with streamlined delivery during the first year of the ongoing Sustainable East Africa Research on Community Health (SEARCH) 'test-and-treat' trial (NCT 01864603) in rural Uganda and Kenya. DESIGN Prospective cohort of patients in the intervention arm of the SEARCH study. METHODS We measured retention in care at 12 months among HIV-infected adults who linked to care and were offered ART regardless of CD4 cell count, following community-wide HIV-testing. Kaplan-Meier estimates and Cox proportional hazards modeling were used to calculate the probability of retention at 1 year and identify predictors of nonretention. RESULTS Among 5683 adults (age ≥15) who linked to care, 95.5% [95% confidence interval (CI): 92.9-98.1%] were retained in care at 12 months. The overall probability of retention at 1 year was 89.3% (95% CI: 87.6-90.7%) among patients newly linking to care and 96.4% (95% CI: 95.8-97.0%) among patients previously in care. Younger age and pre-ART CD4 cell count below country treatment initiation guidelines were predictors of nonretention among all patients. Among those newly linking, taking more than 30 days to link to care after HIV diagnosis was additionally associated with nonretention at 1 year. HIV viral load suppression at 12 months was observed in 4227 of 4736 (89%) of patients retained with valid viral load results. CONCLUSION High retention in care and viral suppression after 1 year were achieved in a streamlined HIV care delivery system in the context of a universal test-and-treat intervention.
Collapse
|
23
|
Bock NN, Emerson RC, Reed JB, Nkambule R, Donnell DJ, Bicego GT, Okello V, Philip NM, Ehrenkranz PD, Duong YT, Moore JS, Justman JE. Changing Antiretroviral Eligibility Criteria: Impact on the Number and Proportion of Adults Requiring Treatment in Swaziland. J Acquir Immune Defic Syndr 2016; 71:338-44. [PMID: 26361174 PMCID: PMC4752404 DOI: 10.1097/qai.0000000000000846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 08/21/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Early initiation of antiretroviral treatment (ART) at CD4 cell count ≥ 500 cells per microliter reduces morbidity and mortality in HIV-infected adults. We determined the proportion of HIV-infected people with high viral load (VL) for whom transmission prevention would be an additional benefit of early treatment. DESIGN A randomly selected subset of a nationally representative sample of HIV-infected adults in Swaziland in 2012. METHODS Eight to 12 months after a national survey to determine adult HIV prevalence, 1067 of 5802 individuals identified as HIV-infected were asked to participate in a follow-up cross-sectional assessment. CD4 cell enumeration, VL measurements, and ART status were obtained to estimate the proportion of currently untreated adults and of the entire HIV-infected population with high VL (≥ 1000 copies/mL) whose treatment under a test-and-treat or VL threshold eligibility strategy would reduce HIV transmission. RESULTS Of the 927 (87% of 1067) participants enrolled, 466 (50%) reported no ART use. Among them, 424 (91%) had VL ≥ 1000 copies per milliliter; of these, 148 (35%) were eligible for ART at the then existing CD4 count threshold of <350 cells per microliter; an additional 107 (25%) were eligible with expanded CD4 criterion of <500 cells per microliter; and 169 (40%) remained ART ineligible. Thus, 36% of the 466 currently untreated and 18% of the total 927 had high VL yet remained ART ineligible under a CD4 criterion of <500 cells per microliter. CONCLUSIONS A test-and-treat or VL threshold for treatment eligibility is necessary to maximize the HIV transmission prevention benefits of ART.
Collapse
Affiliation(s)
- Naomi N. Bock
- Centers for Disease Control and Prevention, Center for Global Health, Division of HIV/AIDS, Atlanta, GA
| | - Ruth C. Emerson
- Statistical Center for HIV/AIDS Research and Prevention and the Vaccine and Infectious Disease Institute, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jason B. Reed
- Centers for Disease Control and Prevention, Center for Global Health, Division of HIV/AIDS, Atlanta, GA
| | | | - Deborah J. Donnell
- Statistical Center for HIV/AIDS Research and Prevention and the Vaccine and Infectious Disease Institute, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - George T. Bicego
- Centers for Disease Control and Prevention, Center for Global Health, Division of HIV/AIDS, Atlanta, GA
| | | | - Neena M. Philip
- ICAP-Columbia, Mailman School of Public Health, Columbia University, New York, NY; and
| | | | - Yen T. Duong
- Centers for Disease Control and Prevention, Center for Global Health, Division of HIV/AIDS, Atlanta, GA
| | - Janet S. Moore
- Centers for Disease Control and Prevention, Center for Global Health, Division of HIV/AIDS, Atlanta, GA
| | - Jessica E. Justman
- ICAP-Columbia, Mailman School of Public Health, Columbia University, New York, NY; and
| |
Collapse
|
24
|
Jain V, Chang W, Byonanebye DM, Owaraganise A, Twinomuhwezi E, Amanyire G, Black D, Marseille E, Kamya MR, Havlir DV, Kahn JG. Estimated Costs for Delivery of HIV Antiretroviral Therapy to Individuals with CD4+ T-Cell Counts >350 cells/uL in Rural Uganda. PLoS One 2015; 10:e0143433. [PMID: 26632823 PMCID: PMC4669141 DOI: 10.1371/journal.pone.0143433] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 11/04/2015] [Indexed: 12/22/2022] Open
Abstract
Background Evidence favoring earlier HIV ART initiation at high CD4+ T-cell counts (CD4>350/uL) has grown, and guidelines now recommend earlier HIV treatment. However, the cost of providing ART to individuals with CD4>350 in Sub-Saharan Africa has not been well estimated. This remains a major barrier to optimal global cost projections for accelerating the scale-up of ART. Our objective was to compute costs of ART delivery to high CD4+count individuals in a typical rural Ugandan health center-based HIV clinic, and use these data to construct scenarios of efficient ART scale-up. Methods Within a clinical study evaluating streamlined ART delivery to 197 individuals with CD4+ cell counts >350 cells/uL (EARLI Study: NCT01479634) in Mbarara, Uganda, we performed a micro-costing analysis of administrative records, ART prices, and time-and-motion analysis of staff work patterns. We computed observed per-person-per-year (ppy) costs, and constructed models estimating costs under several increasingly efficient ART scale-up scenarios using local salaries, lowest drug prices, optimized patient loads, and inclusion of viral load (VL) testing. Findings Among 197 individuals enrolled in the EARLI Study, median pre-ART CD4+ cell count was 569/uL (IQR 451–716). Observed ART delivery cost was $628 ppy at steady state. Models using local salaries and only core laboratory tests estimated costs of $529/$445 ppy (+/-VL testing, respectively). Models with lower salaries, lowest ART prices, and optimized healthcare worker schedules reduced costs by $100–200 ppy. Costs in a maximally efficient scale-up model were $320/$236 ppy (+/- VL testing). This included $39 for personnel, $106 for ART, $130/$46 for laboratory tests, and $46 for administrative/other costs. A key limitation of this study is its derivation and extrapolation of costs from one large rural treatment program of high CD4+ count individuals. Conclusions In a Ugandan HIV clinic, ART delivery costs—including VL testing—for individuals with CD4>350 were similar to estimates from high-efficiency programs. In higher efficiency scale-up models, costs were substantially lower. These favorable costs may be achieved because high CD4+ count patients are often asymptomatic, facilitating more efficient streamlined ART delivery. Our work provides a framework for calculating costs of efficient ART scale-up models using accessible data from specific programs and regions.
Collapse
Affiliation(s)
- Vivek Jain
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco (UCSF), San Francisco, CA, United States of America
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
- * E-mail:
| | - Wei Chang
- Philip R. Lee Institute for Health Policy Studies, UCSF, San Francisco, CA, United States of America
| | | | | | - Ellon Twinomuhwezi
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
| | - Gideon Amanyire
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Douglas Black
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco (UCSF), San Francisco, CA, United States of America
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
| | - Elliot Marseille
- Health Strategies International, Oakland, CA, United States of America
| | - Moses R. Kamya
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane V. Havlir
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco (UCSF), San Francisco, CA, United States of America
- Makerere University-UCSF (MU-UCSF) Research Collaboration, Kampala, Uganda
| | - James G. Kahn
- Philip R. Lee Institute for Health Policy Studies, UCSF, San Francisco, CA, United States of America
| |
Collapse
|
25
|
Okoboi S, Ding E, Persuad S, Wangisi J, Birungi J, Shurgold S, Kato D, Nyonyintono M, Egessa A, Bakanda C, Munderi P, Kaleebu P, Moore DM. Community-based ART distribution system can effectively facilitate long-term program retention and low-rates of death and virologic failure in rural Uganda. AIDS Res Ther 2015; 12:37. [PMID: 26566390 PMCID: PMC4642676 DOI: 10.1186/s12981-015-0077-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 10/26/2015] [Indexed: 11/11/2022] Open
Abstract
Background Community-drug distribution point is a care model for stable patients in the community designed to make ART delivery more efficient for the health system and provide appropriate support to encourage long-term retention of patients. We examined program retention among ART program participants in rural Uganda, which has used a community-based distribution model of ART delivery since 2004. Methods We analyzed data of all patients >18 years who initiated ART in Jinja, Ugandan site of The AIDS Support Organization between January 1, 2004 and July 31, 2009. Participants attended clinic or outreach visits every 2–3 months and had CD4 cell counts measured every 6 months. Retention to care was defined as any patient with at least one visit in the 6 months before June 1, 2013. We then identified participants with at least one visit in the 6 months before June 1, 2013 and examined associations with mortality and lost-to-follow-up (LTFU). Participants with >4 years of follow up during August, 2012 to May, 2013 had viral load conducted, since no routine viral load testing was available. Results A total of 3345 participants began ART during 2004–2009. The median time on ART in June 2013 was 5.69 years. A total of 1335 (40 %) were residents of Jinja district and 2005 (60 %) resided in outlying districts. Of these, 2322 (69 %) were retained in care, 577 (17 %) died, 161 (5 %) transferred out and 285 (9 %) were LTFU. Factors associated with mortality or LTFU included male gender, [Adjusted Hazard Ratio (AHR) = 1.56; 95 % CI 1.28–1.9], CD4 cell count <50 cells/μL (AHR = 4.09; 95 % CI 3.13–5.36) or 50–199 cells/μL (AHR = 1.86; 95 % CI 1.46–2.37); ART initiation and WHO stages 3 (AHR = 1.35; 95 % CI 1.1–1.66) or 4 (AHR = 1.74; 95 % CI 1.23–2.45). Residence outside of Jinja district was not associated with mortality/LTFU (p value = 0.562). Of 870 participants who had VL tests, 756 (87 %) had VLs <50 copies/mL. Conclusion Community-based ART distribution systems can effectively mitigate the barriers to program retention and result in good rates of virologic suppression.
Collapse
|
26
|
Beyrer C, Birx DL, Bekker LG, Barré-Sinoussi F, Cahn P, Dybul MR, Eholié SP, Kavanagh MM, Katabira ET, Lundgren JD, Mworeko L, Pala M, Puttanakit T, Ryan O, Sidibé M, Montaner JSG. The Vancouver Consensus: antiretroviral medicines, medical evidence, and political will. Lancet 2015; 386:505-7. [PMID: 26293427 DOI: 10.1016/s0140-6736(15)61458-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Chris Beyrer
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; International AIDS Society, Geneva, Switzerland
| | - Deborah L Birx
- US President's Emergency Plan for AIDS Relief, Washington, DC, USA
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | | | - Pedro Cahn
- Buenos Aires University Medical School, Buenos Aires, Argentina
| | - Mark R Dybul
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
| | - Serge P Eholié
- Medical School of University Félix Houphouet-Boigny, Abidjan, Côte d'Ivoire; International Association of Providers of AIDS Care, Washington, DC, USA
| | - Matthew M Kavanagh
- Health Global Access Project, New York, USA; Department of Political Science and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Elly T Katabira
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Lilian Mworeko
- International Community of Women Living with HIV East Africa, Uganda
| | - Marama Pala
- International Indigenous Working Group on HIV and AIDS, Waikato, New Zealand
| | | | - Owen Ryan
- International AIDS Society, Geneva, Switzerland
| | | | | |
Collapse
|
27
|
Ciaranello AL, Matthews LT. Safer Conception Strategies for HIV-Serodiscordant Couples: How Safe Is Safe Enough? J Infect Dis 2015; 212:1525-8. [PMID: 26092857 PMCID: PMC4621252 DOI: 10.1093/infdis/jiv275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 05/05/2015] [Indexed: 01/01/2023] Open
Affiliation(s)
- Andrea L Ciaranello
- Division of Infectious Disease, Department of Medicine Medical Practice Evaluation Center
| | - Lynn T Matthews
- Division of Infectious Disease, Department of Medicine Center for Global Health, Massachusetts General Hospital, Boston
| |
Collapse
|