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Viisainen K, Baumgart Dos Santos M, Sunderbrink U, Couto A. Gender and stigma in antiretroviral treatment adherence in Mozambique: A qualitative study. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003166. [PMID: 39008454 PMCID: PMC11249256 DOI: 10.1371/journal.pgph.0003166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 05/14/2024] [Indexed: 07/17/2024]
Abstract
Both gender and HIV stigma are known to contribute to poor retention to antiretroviral therapy (ART), but little is known how they interact in decisions about adherence or default by people living with HIV (PLWH). This qualitative study explored HIV stigma and gender interaction in PLWH's care decisions in Mozambique. Transcribed data from semi-structured interviews of 68 men and 71 women living with HIV, were coded and analyzed for themes of HIV stigma, gender norms and treatment continuation and interruption pathways, using both deductive and inductive coding approaches. Stigma experiences were found to be influenced by gender roles. Anticipation of stigma was common across the narratives of PLWH, while women had more experiences of enacted stigma, particularly by their intimate partners. Women's treatment interruptions were influenced by fear of partner's negative reaction. Men's narratives showed internalized stigma and delayed treatment due to anticipated stigma and masculine norm of strength. Severe internalized stigma was found among single mothers, who without economic or moral support defaulted treatment. Women's pathway to adherence was facilitated by their caregiver role and support from partner or kin family. Men's adherence was facilitated by experience of severe symptoms, provider role and by support from their mother or partner. Results indicate that linkage of stigma to gender roles interact in treatment decisions in three main ways. First, HIV stigma and unequal gender norms can work jointly as a barrier to adherence. Secondly, those resisting restrictive gender norms found it easier to manage HIV stigma for the benefit of treatment adherence. Thirdly, some gender norms also facilitated adherence and stigma management. Programs targeted at HIV stigma reduction and improving ART adherence among heterosexual populations should be built on an understanding of the local gender norms and include socially and culturally relevant gender sensitive and transformative activities.
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Affiliation(s)
- Kirsi Viisainen
- Department of Global Health and Social Medicine, King's College, London, United Kingdom
| | | | | | - Aleny Couto
- Directorate of Public Health, Program for Sexually Transmitted Diseases and HIV, Ministry of Health, Maputo, Mozambique
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2
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Frisby MB, Diemer MA, Sack DE, Audet CM. Dyadic Validation of Relational Processes in Seroconcordant Mozambican Couples: Social Support, Physician Trust, and Stigma. AIDS Behav 2022; 26:4135-4143. [PMID: 35689708 PMCID: PMC9940156 DOI: 10.1007/s10461-022-03739-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 11/30/2022]
Abstract
Psychometric instruments can quantify how people living with HIV experience three key barriers to antiretroviral therapy (ART) and retention: partner support, trust in medical professionals, and internalized HIV-related stigma. However, two challenges arise when using these instruments to measure and interpret relational processes among Mozambican couples, especially those participating in a couples intervention. First, relational measures have almost exclusively been developed and normed with Western, middle-class, and/or White adults. Second, traditional measurement approaches neglect the relational processes between partners. Using dyadic modeling, this paper demonstrates metric and scalar invariance for instruments measuring partner support (CFI = 0.964, TLI = 0.965, RMSEA = 0.034, SRMR = 0.052), trust in medical professionals (CFI = 0.978, TLI = 0.980, RMSEA = 0.033, SRMR = 0.039), and internalized HIV-related stigma (CFI = 0.960, TLI = 0.961, RMSEA = 0.050, SRMR = 0.060) within the novel context of seroconcordant HIV+ couples in Zambézia province.
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Affiliation(s)
| | | | - Daniel E Sack
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Carolyn M Audet
- Department of Health Policy and Institute for Global Health, Vanderbilt University, Nashville, TN, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) in affiliation with the School of Public Health at University of the Witwatersrand, Johannesburg, South Africa
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3
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Fabian KE, Muanido A, Cumbe VFJ, Mukunta C, Manaca N, Dorsey S, Hammett WH, Wagenaar BH. Integrating a Transdiagnostic Psychological Intervention Into Routine HIV Care: A Mixed-Methods Evaluation of the Common Elements Treatment Approach in Mozambique. J Acquir Immune Defic Syndr 2022; 89:274-281. [PMID: 35147581 PMCID: PMC8851690 DOI: 10.1097/qai.0000000000002863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/11/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION We integrated a transdiagnostic psychological intervention (Common Elements Treatment Approach [CETA]) into routine HIV care in Sofala, Mozambique. This task-shared program screens and treats newly diagnosed HIV+ patients with comorbid mental health symptoms. METHODS A mixed-methods evaluation included demographics, intake screening scores, mental health symptoms, and barriers/facilitators to implementation examined through interviews. Multilevel models were used to analyze factors associated with symptom improvement and loss to follow-up (LTFU). RESULTS From March 2019 to June 2020, 820 individuals were screened for CETA treatment; 382 (46.6%) showed clinically significant mental health symptoms and attended 1484 CETA sessions. Of CETA patients, 71.5% (n = 273/382) had general mental distress, 7.3% (n = 28) had alcohol abuse/dependence, 12.0% (n = 46) had suicidal ideation, and 3.7% (n = 14) had other violent ideation; 66.2% (n = 253) had experienced at least 1 traumatic event at intake. Mental health symptoms decreased by 74.1% (17.0 to 4.4) after 5 CETA sessions, and 37.4% of patients (n = 143) achieved a ≥50% symptom reduction from intake. LTFU was 29.1% (n = 111), but 59.5% of LTFU patients (n = 66) achieved a ≥50% symptom reduction before LTFU. Facilitators for CETA implementation included readiness for change given the unaddressed burden of mental illness. Barriers included complexity of the intervention and stigma. CONCLUSIONS Approximately 45% of newly diagnosed HIV+ individuals in Mozambique have clinically significant mental health symptoms at diagnosis. Integrating CETA into routine HIV platforms has in-context feasibility. Future implementation studies can optimize strategies for patient retention and scale-up.
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Affiliation(s)
- Katrin E Fabian
- University of Washington, Department of Global Health, Seattle, Washington
| | | | - Vasco FJ Cumbe
- Sofala Provincial Health Directorate, Department of Mental Health, Ministry of Health, Beira, Mozambique
- Faculty of Medicine, Eduardo Mondlane University, Mozambique
| | | | - Nelia Manaca
- Health Alliance International, Beira, Mozambique
| | - Shannon Dorsey
- University of Washington, Department of Psychology and Behavioral Sciences, Seattle, Washington
| | - Wilson H Hammett
- University of Washington, Department of Global Health, Seattle, Washington
- Health Alliance International, Seattle, WA, USA
| | - Bradley H Wagenaar
- University of Washington, Department of Global Health, Seattle, Washington
- Health Alliance International, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
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Seekaew P, Phanuphak N, Teeratakulpisarn N, Amatavete S, Lujintanon S, Teeratakulpisarn S, Pankam T, Nampaisan O, Jomja P, Prabjunteuk C, Plodgratoke P, Ramautarsing R, Phanuphak P. Same-day antiretroviral therapy initiation hub model at the Thai Red Cross Anonymous Clinic in Bangkok, Thailand: an observational cohort study. J Int AIDS Soc 2021; 24:e25869. [PMID: 34967504 PMCID: PMC8717692 DOI: 10.1002/jia2.25869] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 12/14/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction WHO has recommended rapid antiretroviral therapy (ART) initiation, including same‐day ART (SDART). However, data on the feasibility in real‐world settings are limited. We implemented a cohort study at a stand‐alone HIV testing centre to examine its applicability and effectiveness. Methods Data were collected from the Thai Red Cross Anonymous Clinic in Bangkok, Thailand, between July 2017 and July 2018 from clients who were ART‐naïve and could return for follow‐up visits. Baseline laboratory tests and chest X‐ray were performed according to national guidelines, and clinical eligibility was determined based on physical examination and chest X‐ray findings. Primary outcomes were retention in care and viral load suppression at 3, 6 and 12 months. Results During the study period, 2427 people tested HIV positive. Of these, 2107 (2207/2427, 86.8%) met logistical criteria, and 1904 (1904/2427, 78.5%) agreed to SDART. One thousand seven hundred and twenty‐nine (1729/2427, 71.2%) were placed on ART, with 1257 received same‐day initiation and 1576 initiated ART within 7 days; 1198 clients were successfully referred to free, sustained ART sites. Retention among eligible clients who accepted SDART service at months 3, 6 and 12 was 79.8%, 75.2% and 75.3%, respectively. Conclusions Same‐day ART initiation hub model at a stand‐alone HIV testing centre in an urban setting in Bangkok, Thailand, is highly feasible and has a potential for scaling up. Clinical Trial Number NCT04032028
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Affiliation(s)
- Pich Seekaew
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA.,Institute of HIV Research and Innovation, Bangkok, Thailand
| | | | | | | | | | | | | | | | - Pintip Jomja
- Thai Red Cross AIDS Research Centre, Bangkok, Thailand
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5
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Coulaud PJ, Protopopescu C, Ndiaye K, Baudoin M, Maradan G, Laurent C, Spire B, Vidal L, Kuaban C, Boyer S. Individual and healthcare supply-related barriers to treatment initiation in HIV-positive patients enrolled in the Cameroonian antiretroviral treatment access programme. Health Policy Plan 2021; 36:137-148. [PMID: 33367696 DOI: 10.1093/heapol/czaa153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2020] [Indexed: 11/14/2022] Open
Abstract
Increasing demand for antiretroviral treatment (ART) together with a reduction in international funding during the last decade may jeopardize access to ART. Using data from a cross-sectional survey conducted in 2014 in 19 HIV services in the Centre and Littoral regions in Cameroon, we investigated the role of healthcare supply-related factors in time to ART initiation in HIV-positive patients eligible for ART at HIV diagnosis. HIV service profiles were built using cluster analysis. Factors associated with time to ART initiation were identified using a multilevel Cox model. The study population included 847 HIV-positive patients (women 72%, median age: 39 years). Median (interquartile range) time to ART initiation was 1.6 (0.5-4.3) months. Four HIV service profiles were identified: (1) small services with a limited staff practising partial task-shifting (n = 4); (2) experienced and well-equipped services practising task-shifting and involving HIV community-based organizations (n = 5); (3) small services with limited resources and activities (n = 6); (4) small services providing a large range of activities using task-shifting and involving HIV community-based organizations (n = 4). The multivariable model showed that HIV-positive patients over 39 years old [hazard ratio: 1.26 (95% confidence interval) (1.09-1.45), P = 0.002], those with disease symptoms [1.21 (1.04-1.41), P = 0.015] and those with hepatitis B co-infection [2.31 (1.15-4.66), P = 0.019] were all more likely to initiate ART early. However, patients in the first profile were less likely to initiate ART early [0.80 (0.65-0.99), P = 0.049] than those in the second profile, as were patients in the third profile [association only significant at the 10% level; 0.86 (0.72-1.02), P = 0.090]. Our findings provide a better understanding of the role played by healthcare supply-related factors in ART initiation. In HIV services with limited capacity, task-shifting and support from community-based organizations may improve treatment access. Additional funding is required to relieve healthcare supply-related barriers and achieve the goal of universal ART access.
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Affiliation(s)
- Pierre-Julien Coulaud
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Faculté de Médecine, 27 Bd Jean Moulin, 13385 Marseille, Cedex 5, France
| | - Camélia Protopopescu
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Faculté de Médecine, 27 Bd Jean Moulin, 13385 Marseille, Cedex 5, France
| | - Khadim Ndiaye
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Faculté de Médecine, 27 Bd Jean Moulin, 13385 Marseille, Cedex 5, France
| | - Maël Baudoin
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Faculté de Médecine, 27 Bd Jean Moulin, 13385 Marseille, Cedex 5, France
| | - Gwenaëlle Maradan
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Faculté de Médecine, 27 Bd Jean Moulin, 13385 Marseille, Cedex 5, France.,ORS PACA, Observatoire régional de la santé Provence-Alpes-Côte d'Azur, Faculté de Médecine, 27 Bd Jean Moulin, 13385 Marseille Cedex 5, France
| | - Christian Laurent
- Institut de Recherche pour le Développement, Inserm, Univ Montpellier, TransVIHMI, 911 avenue Agropolis, BP 64501, 34394 Montpellier, Cedex 5, France
| | - Bruno Spire
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Faculté de Médecine, 27 Bd Jean Moulin, 13385 Marseille, Cedex 5, France
| | - Laurent Vidal
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Faculté de Médecine, 27 Bd Jean Moulin, 13385 Marseille, Cedex 5, France
| | - Christopher Kuaban
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé, Po. Box 1364 Yaoundé, Cameroon
| | - Sylvie Boyer
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Faculté de Médecine, 27 Bd Jean Moulin, 13385 Marseille, Cedex 5, France
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6
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Kamya MR, Petersen ML, Kabami J, Ayieko J, Kwariisima D, Sang N, Clark TD, Schwab J, Charlebois ED, Cohen CR, Bukusi EA, Peng J, Jain V, Chen YH, Chamie G, Balzer LB, Havlir DV. SEARCH Human Immunodeficiency Virus (HIV) Streamlined Treatment Intervention Reduces Mortality at a Population Level in Men With Low CD4 Counts. Clin Infect Dis 2021; 73:e1938-e1945. [PMID: 33783495 DOI: 10.1093/cid/ciaa1782] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We tested the hypothesis that patient-centered, streamlined human immunodeficiency virus (HIV) care would achieve lower mortality than the standard treatment model for persons with HIV and CD4 ≤ 350/uL in the setting of population-wide HIV testing. METHODS In the SEARCH (Sustainable East Africa Research in Community Health) Study (NCT01864603), 32 communities in rural Uganda and Kenya were randomized to country-guided antiretroviral therapy (ART) versus streamlined ART care that included rapid ART start, visit spacing, flexible clinic hours, and welcoming environment. We assessed persons with HIV and CD4 ≤ 350/uL, ART eligible in both arms, and estimated the effect of streamlined care on ART initiation and mortality at 3 years. Comparisons between study arms used a cluster-level analysis with survival estimates from Kaplan-Meier; estimates of ART start among ART-naive persons treated death as a competing risk. RESULTS Among 13 266 adults with HIV, 2973 (22.4%) had CD4 ≤ 350/uL. Of these, 33% were new diagnoses, and 10% were diagnosed but ART-naive. Men with HIV were almost twice as likely as women with HIV to have CD4 ≤ 350/uL and be untreated (15% vs 8%, respectively). Streamlined care reduced mortality by 28% versus control (risk ratio [RR] = 0.72; 95% confidence interval [CI]: .56, .93; P = .02). Despite eligibility in both arms, persons with CD4 ≤ 350/uL started ART faster under streamlined care versus control (76% vs 43% by 12 months, respectively; P < .001). Mortality was reduced substantially more among men (RR = 0.61; 95% CI: .43, .86; P = .01) than among women (RR = 0.90; 95% CI: .62, 1.32; P = .58). CONCLUSIONS After population-based HIV testing, streamlined care reduced population-level mortality among persons with HIV and CD4 ≤ 350/uL, particularly among men. Streamlined HIV care models may play a key role in global efforts to reduce AIDS deaths.
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Affiliation(s)
- Moses R Kamya
- Makerere University, Kampala, Uganda.,Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Maya L Petersen
- University of California Berkeley, Berkeley, California, USA
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | | | | | - Tamara D Clark
- University of California San Francisco, San Francisco, California, USA
| | - Joshua Schwab
- University of California Berkeley, Berkeley, California, USA
| | | | - Craig R Cohen
- University of California San Francisco, San Francisco, California, USA
| | | | - James Peng
- University of California San Francisco, San Francisco, California, USA
| | - Vivek Jain
- University of California San Francisco, San Francisco, California, USA
| | - Yea-Hung Chen
- University of California San Francisco, San Francisco, California, USA
| | - Gabriel Chamie
- University of California San Francisco, San Francisco, California, USA
| | - Laura B Balzer
- University of Massachusetts Amherst, Amherst, Massachusetts, USA
| | - Diane V Havlir
- University of California San Francisco, San Francisco, California, USA
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7
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Wagner AD, Gimbel S, Ásbjörnsdóttir KH, Cherutich P, Coutinho J, Crocker J, Cruz E, Cuembelo F, Cumbe V, Eastment M, Einberg J, Floriano F, Gaitho D, Guthrie BL, John-Stewart G, Kral AH, Lambdin BH, Liu S, Maina M, Manaca N, Matsuzaki M, Mattox L, Mburu N, McClelland RS, Micek MA, Mocumbi AO, Muanido A, Nduati R, Njuguna IN, Oluoch G, Oyiengo LB, Ronen K, Soi C, Wagenaar BH, Wanje G, Wenger LD, Sherr K. Cascade Analysis: An Adaptable Implementation Strategy Across HIV and Non-HIV Delivery Platforms. J Acquir Immune Defic Syndr 2019; 82 Suppl 3:S322-S331. [PMID: 31764270 PMCID: PMC6880809 DOI: 10.1097/qai.0000000000002220] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cascades have been used to characterize sequential steps within a complex health system and are used in diverse disease areas and across prevention, testing, and treatment. Routine data have great potential to inform prioritization within a system, but are often inaccessible to frontline health care workers (HCWs) who may have the greatest opportunity to innovate health system improvement. METHODS The cascade analysis tool (CAT) is an Excel-based, simple simulation model with an optimization function. It identifies the step within a cascade that could most improve the system. The original CAT was developed for HIV treatment and the prevention of mother-to-child transmission of HIV. RESULTS CAT has been adapted 7 times: to a mobile application for prevention of mother-to-child transmission; for hypertension screening and management and for mental health outpatient services in Mozambique; for pediatric and adolescent HIV testing and treatment, HIV testing in family planning, and cervical cancer screening and treatment in Kenya; and for naloxone distribution and opioid overdose reversal in the United States. The main domains of adaptation have been technical-estimating denominators and structuring steps to be binary sequential steps-as well as logistical-identifying acceptable approaches for data abstraction and aggregation, and not overburdening HCW. DISCUSSION CAT allows for prompt feedback to HCWs, increases HCW autonomy, and allows managers to allocate resources and time in an equitable manner. CAT is an effective, feasible, and acceptable implementation strategy to prioritize areas most requiring improvement within complex health systems, although adaptations are being currently evaluated.
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Affiliation(s)
| | - Sarah Gimbel
- Child, Family, and Population Health Nursing, University of Washington, Seattle, WA
| | | | | | | | | | - Emilia Cruz
- Health Alliance International, Beira, Mozambique
| | - Fatima Cuembelo
- Community Health Department, Eduardo Mondlane University, Maputo, Mozambique
| | - Vasco Cumbe
- Department of Mental Health, Sofala Provincial Health Directorate, Ministry of Health, Beira, Mozambique
- Psychiatry Department, Paulista School of Medicine, Sao Paulo Federal University, UNIFESP
| | | | | | | | - Douglas Gaitho
- Network of AIDS Researchers of East and Southern Africa, Nairobi, Kenya
| | | | - Grace John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA
- Department of Medicine, University of Washington, Seattle, WA
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Alex H Kral
- Community Health and Implementation Research Program, RTI International, San Francisco, CA
| | - Barrot H Lambdin
- Community Health and Implementation Research Program, RTI International, San Francisco, CA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Shan Liu
- Department of Industrial and Systems Engineering, University of Washington, Seattle, WA
| | - Martin Maina
- Network of AIDS Researchers of East and Southern Africa, Nairobi, Kenya
| | - Nelia Manaca
- Health Alliance International, Beira, Mozambique
| | | | - Loris Mattox
- HIV Education and Prevention Project of Alameda County, Oakland CA
| | - Nancy Mburu
- Network of AIDS Researchers of East and Southern Africa, Nairobi, Kenya
| | - R Scott McClelland
- Department of Epidemiology, University of Washington, Seattle, WA
- Department of Medicine, University of Washington, Seattle, WA
| | - Mark A Micek
- Department of Medicine, University of Wisconsin School of Medicine and Public Health
| | - Ana Olga Mocumbi
- Faculty of Medicine, Universidade Eduardo Mondlane, Division of Non Communicable Diseases, Instituto Nacional de Saúde, Maputo, Mozambique
| | | | - Ruth Nduati
- Network of AIDS Researchers of East and Southern Africa, Nairobi, Kenya
- Department of Pediatrics, University of Nairobi, Nairobi, Kenya
| | - Irene N Njuguna
- Department of Epidemiology, University of Washington, Seattle, WA
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Geoffrey Oluoch
- Network of AIDS Researchers of East and Southern Africa, Nairobi, Kenya
| | | | | | | | | | - George Wanje
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Lynn D Wenger
- Community Health and Implementation Research Program, RTI International, San Francisco, CA
| | - Kenneth Sherr
- Department of Epidemiology, University of Washington, Seattle, WA
- Department of Industrial and Systems Engineering, University of Washington, Seattle, WA
- Health Alliance International, Seattle, WA
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8
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Magaço A, Botão C, Cane RM, Honwana N, Tamele G, Young P, Fagan J, Mbofana F. Qualitative Assessment of Health and Care-Seeking Behaviors among Hiv-Infected Adults and Health Care Providers in Mozambique. CROSS CURRENT INTERNATIONAL JOURNAL OF MEDICAL AND BIOSCIENCES 2019; 1:133-140. [PMID: 39081562 PMCID: PMC11287963 DOI: 10.36344/ccijmb.2019.v01i06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Background From 2009 to 2014, the prevalence of HIV among adults in Mozambique increased from 11.5% to 13.2%. To reduce disease progression and prevent transmission, HIV-infected persons must have access to timely, continuous, high-quality HIV care and treatment services. This study aim to identify the barriers to early diagnosis, access to medical care, ART initiation and adherence. Methods In-depth interviews were conducted with newly diagnosed HIV-positive patients and health providers in Maputo City and Zambézia Province. Participants were recruited into the study at the time of HIV testing. Interviews were obtained at least 45 days after HIV diagnosis and were conducted in the community where the patients resided. Interviews were recorded, transcribed and translated into Portuguese prior to analysis. A framework approach was used for analysis using NVivo 10.0. Results Ninety patients and twelve providers were interviewed. Twenty-nine patients (32%) stated that they were motivated to get tested for HIV because they felt they had an unspecified health problem. Among pregnant women, nineteen (44%) were motivated to enroll in care and initiate ART by nurses during their first prenatal visit. Of the 90 newly diagnosed patients, 80% sought care and treatment for HIV after being diagnosed in a health facility. Conclusions Test-seeking behaviour for persons newly diagnosed with HIV in this study was often influenced by their health status, both for patients accessing voluntarily counselling and testing and for patients who tested in antenatal care settings. Initiation of ART was also strongly influenced by provider recommendation.
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Affiliation(s)
- Amílcar Magaço
- sistemas de saúde, instituto nacional de saúde, ministério da saúde, moçambique, maputo, Mozambique
| | - Carlos Botão
- sistemas de saúde, instituto nacional de saúde, ministério da saúde, moçambique, maputo, Mozambique
| | - Réka Maulide Cane
- sistemas de saúde, instituto nacional de saúde, ministério da saúde, moçambique, maputo, Mozambique
| | - Nely Honwana
- centers for disease control and prevention, cdc, cgh, dght
| | - Granélio Tamele
- sistemas de saúde, instituto nacional de saúde, ministério da saúde, moçambique, maputo, Mozambique
| | - Peter Young
- centers for disease control and prevention, cdc, cgh, dght
| | - Jennifer Fagan
- centers for disease control and prevention, cdc, oid, nchhstp
| | - Francisco Mbofana
- direcção nacional de saúde pública, ministério da saúde, moçambique, maputo, mozambique
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9
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Continuum of HIV Care in Rural Mozambique: The Implications of HIV Testing Modality on Linkage and Retention. J Acquir Immune Defic Syndr 2019; 78:527-535. [PMID: 29771786 PMCID: PMC6075879 DOI: 10.1097/qai.0000000000001720] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is Available in the Text. Introduction: Context-specific improvements in the continuum of HIV care are needed to achieve the UNAIDS target of 90-90-90. This study aimed to assess the linkage to and retention in HIV care according to different testing modalities in rural southern Mozambique. Methods: Adults newly diagnosed with HIV from voluntary counseling and testing, provider-initiated counseling and testing, and home-based HIV testing services were prospectively enrolled between 2014 and 2015 at the Manhiça District. Patients were passively followed up through chart examination. Tracing was performed at 12 months to ascertain causes of loss to follow-up. Fine and Gray competing risk analysis was performed to determine factors associated with the each step of the cascade. Results: Overall linkage to care as defined by having a CD4 count at 3 months was 43.7% [95% confidence interval (CI): 40.8 to 46.6] and 25.2% of all participants initiated antiretroviral therapy. Factors associated with increased linkage in multivariable analysis included testing at voluntary counseling and testing, older age, having been previously tested for HIV, owning a cell phone, presenting with WHO clinical stages III/IV, self-reported illness-associated disability in the previous month, and later calendar month of participant recruitment. Ascertaining deaths and transfers allowed for adjustment of the rate of 12-month retention in treatment from 75.6% (95% CI: 70.2 to 80.5) to 84.2% (95% CI: 79.2 to 88.5). Conclusions: Home-based HIV testing reached a sociodemographically distinct population from that of clinic-based testing modalities but low linkage to care points to a need for facilitated linkage interventions. Distinguishing between true treatment defaulting and other causes of loss to follow-up can significantly change indicators of retention in care.
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10
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Cleary S, Erasmus E, Gilson L, Michel C, Gremu A, Sherr K, Olivier J. The everyday practice of supporting health system development: learning from how an externally-led intervention was implemented in Mozambique. Health Policy Plan 2018; 33:801-810. [PMID: 30137361 PMCID: PMC6097456 DOI: 10.1093/heapol/czy051] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2018] [Indexed: 11/20/2022] Open
Abstract
Health system strengthening (HSS) has often been undertaken by global health actors working through vertical programmes. However, experience has shown the challenges of this approach, and the need to recognize health systems as open complex adaptive systems—which in turn has implications for the design and implementation approach of more ‘horizontal’ HSS interventions. From 2009 to 2016, the Doris Duke Charitable Foundation supported the African Health Initiative, establishing Population Health Implementation and Training partnerships in five African countries (Ghana, Mozambique, Rwanda, Tanzania and Zambia). Each partnership was designed as a large-scale, long-term, complex health system strengthening intervention, at a primary care or district level—and in each country the intervention was adapted to suit that specific health systems context. In Mozambique, the Population Health Implementation and Training partnership sought to strengthen integrated health systems management at district and provincial levels (through a variety of capacity-development intervention activities, including in-service training and mentoring); to improve the quality of routine data and develop appropriate tools to facilitate decision-making for provincial and district managers; and to build capacity to design and conduct innovative operations research in order to guide integration and system-strengthening efforts. The success of this intervention, as assessed by outcome measures, has been reported elsewhere. In this paper, the implementation practice of this horizontal HSS intervention is assessed, focusing on the key features of how implementation occurred and the implementation approach. A case study focusing on HSS implementation practice was conducted by external researchers from 2014 to 2017. The importance of an accompanying implementation research approach is emphasized—especially for HSS interventions where the ‘complex adaptive system’ (complex and constantly changing context) forces constant adaptations to the intervention design and approach.
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Affiliation(s)
- Susan Cleary
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Ermin Erasmus
- Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Lucy Gilson
- Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, United Kingdom
| | | | - Artur Gremu
- Health Alliance International, Beira, Mozambique
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA.,Health Alliance International, Seattle, WA, USA
| | - Jill Olivier
- Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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11
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Abongomera G, Chiwaula L, Revill P, Mabugu T, Tumwesige E, Nkhata M, Cataldo F, van Oosterhout J, Colebunders R, Chan AK, Kityo C, Gilks C, Hakim J, Seeley J, Gibb DM, Ford D. Patient-level benefits associated with decentralization of antiretroviral therapy services to primary health facilities in Malawi and Uganda. Int Health 2018; 10:8-19. [PMID: 29329396 DOI: 10.1093/inthealth/ihx061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 11/28/2017] [Indexed: 11/14/2022] Open
Abstract
Background The Lablite project captured information on access to antiretroviral therapy (ART) at larger health facilities ('hubs') and lower-level health facilities ('spokes') in Phalombe district, Malawi and in Kalungu district, Uganda. Methods We conducted a cross-sectional survey among patients who had transferred to a spoke after treatment initiation (Malawi, n=54; Uganda, n=33), patients who initiated treatment at a spoke (Malawi, n=50; Uganda, n=44) and patients receiving treatment at a hub (Malawi, n=44; Uganda, n=46). Results In Malawi, 47% of patients mapped to the two lowest wealth quintiles (Q1-Q2); patients at spokes were poorer than at a hub (57% vs 23% in Q1-Q2; p<0.001). In Uganda, 7% of patients mapped to Q1-Q2; patients at the rural spoke were poorer than at the two peri-urban facilities (15% vs 4% in Q1-Q2; p<0.001). The median travel time one way to a current ART facility was 60 min (IQR 30-120) in Malawi and 30 min (IQR 20-60) in Uganda. Patients who had transferred to the spokes reported a median reduction in travel time of 90 min in Malawi and 30 min in Uganda, with reductions in distance and food costs. Conclusions Decentralizing ART improves access to treatment. Community-level access to treatment should be considered to further minimize costs and time.
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Affiliation(s)
- George Abongomera
- Department of Research, Joint Clinical Research Centre, Kampala, Uganda.,Faculty of Medicine, University of Antwerp, Antwerp, Belgium
| | - Levison Chiwaula
- Medical and Research Department, Dignitas International, Zomba, Malawi.,Department of Economics, University of Malawi, Zomba, Malawi
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Travor Mabugu
- Clinical Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Edward Tumwesige
- Department of Social Sciences, Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - Misheck Nkhata
- Medical and Research Department, Dignitas International, Zomba, Malawi
| | - Fabian Cataldo
- Medical and Research Department, Dignitas International, Zomba, Malawi
| | - J van Oosterhout
- Medical and Research Department, Dignitas International, Zomba, Malawi.,Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Adrienne K Chan
- Medical and Research Department, Dignitas International, Zomba, Malawi.,Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Cissy Kityo
- Department of Research, Joint Clinical Research Centre, Kampala, Uganda
| | - Charles Gilks
- Faculty of Medicine, Imperial College London, London, UK.,School of Population Health, University of Queensland, Brisbane, Queensland, Australia
| | - James Hakim
- Clinical Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Janet Seeley
- Department of Social Sciences, Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda.,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Diana M Gibb
- Medical Research CouncilClinical Trials Unit at University College London, London, UK
| | - Deborah Ford
- Medical Research CouncilClinical Trials Unit at University College London, London, UK
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12
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Guiteau Moise C, Rivera VR, Hennessey KA, Bellot C, Nicholas C, Fang AP, Verdier RI, Severe P, Sainvil A, Charles B, Dorval D, St Amour J, Pape JW, Koenig SP. A Successful Model of Expedited Antiretroviral Therapy for Clinically Stable Patients Living With HIV in Haiti. J Acquir Immune Defic Syndr 2018; 79:70-76. [PMID: 29771791 PMCID: PMC6092230 DOI: 10.1097/qai.0000000000001725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recommendations for universal antiretroviral therapy have greatly increased the number of HIV-infected patients who qualify for treatment, particularly with early clinical disease. Less intensive models of care are needed for clinically stable patients. SETTING A rapid pathway (RP) model of expedited outpatient care for clinically stable patients was implemented at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) Center, Port-au-Prince, Haiti. Expedited visits included nurse-led assessments and point-of-service antiretroviral therapy dispensing. METHODS We conducted a retrospective analysis including patients who initiated RP care between June 1, 2014, and September 30, 2015, comparing outcomes of patients with timely visit attendance (never >3 days late) with patients with ≥1 nontimely visit within 6 months before RP enrollment. We calculated retention in care and adherence at 12 months, and assessed predictors of both outcomes. RESULTS Of the 2361 patients who initiated RP care during the study period, 1429 (61%) had timely visit attendance and 932 (39%) had ≥1 nontimely visit before RP enrollment. Among RP-enrolled patients, 94% were retained at 12 months and 75% had ≥90% adherence, with higher proportions in those with timely pre-RP visits (95% vs. 92%; 87% vs. 55%). In multivariable analysis, pre-RP visit timeliness was associated with both retention (adjusted odds ratio: 1.67; 95% confidence interval: 1.08 to 2.59) and adherence (adjusted odds ratio: 4.53; 95% confidence interval: 3.58 to 5.72). CONCLUSIONS RP care was associated with high levels of retention and adherence for clinically stable patients. Timeliness of pre-RP visits was predictive of outcomes after RP initiation.
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Affiliation(s)
- Colette Guiteau Moise
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Vanessa R Rivera
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health, Weill Cornell Medical College, New York, NY
| | - Kelly A Hennessey
- Analysis Group, Boston, MA
- University of Washington School of Medicine, Seattle, WA
| | - Clovy Bellot
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Chris Nicholas
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Anna P Fang
- Analysis Group, Boston, MA
- Harvard Medical School, Boston, MA
| | - Rose Irène Verdier
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Patrice Severe
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Alix Sainvil
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Benedict Charles
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Derothy Dorval
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Juseline St Amour
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jean W Pape
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health, Weill Cornell Medical College, New York, NY
| | - Serena P Koenig
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA
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13
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Time taken to link newly identified HIV positive clients to care following a home-base index case HIV testing: Experience from two provinces in Zimbabwe. PLoS One 2018; 13:e0201018. [PMID: 30133526 PMCID: PMC6104920 DOI: 10.1371/journal.pone.0201018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 07/07/2018] [Indexed: 12/21/2022] Open
Abstract
Background Homebased index case HIV testing (HHTC) has shown higher uptake and good yield than traditional HIV testing methods. World Health Organization has called for increased operational research to evaluate HIV care processes particularly linkage to care. In this paper, we present project results of the time taken to link newly identified PLHIV to care after HHTC in the Manicaland and Midlands provinces of Zimbabwe. Methods We retrospectively reviewed community-facility referral data from the Zimbabwe HIV Care and Treatment project for newly diagnosed PLHIV for the period March–September 2016. A referral slip was given to a client after receiving a positive HIV results and was presented and filed upon reaching a health facility. In July 2016, the project started working with trained expert clients to assist with linkage to care. Data was entered in a spreadsheet and then imported for descriptive statistical analysis with EpiInfoTM Version 7.2.0.1. Odd ratios were used to identify factors associated with linkage to care within seven days. Results Out of 1004 newly identified PLHIV between March and September 2016, 650 (64.7%) were linked to care. The median time taken to be linked to care was four days (Interquartile range 19 days). Overall, 63.1% (410) of PLHIV were linked to care within seven days of diagnosis and 85% within 30 days. PLHIV were more likely to be linked to care within seven days of diagnosis between July and September 2016 (OR = 4.1; p< 0.001), a period when ZHCT started working with expert clients to support linkage to care. Conclusion HHTC resulted in almost 63% of newly diagnosed PLHIV being linked into care within seven days, and 85% within 30 days. Linkage to care within seven days was significantly associated with the period of engaging expert clients in the project. We recommend community based HIV testing programs to work with expert clients to ensure timely linkages of new PLHIV.
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14
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Koesoema AP, Ariani A, Irawan YS, Soegijoko S. Design of an mHealth System for Maternal and Children HIV care. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2018; 2017:2630-2633. [PMID: 29060439 DOI: 10.1109/embc.2017.8037397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
While progress has been made to slow down its spread and increase uptake of treatment, human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) is still a highly significant health problem for many low- and middle-income countries (LMICs). Specifically, almost half of new HIV patients in Asia Pacific were children. The prevention of mother-to-child transmission faces complex socioeconomic and other problems. With the increasing growth of mobile technologies in LMICs, especially in Asia Pacific, mHealth, the application of mobile technology for health applications, has a significant potential to help alleviate these problems. In this paper, we propose the design of an mHealth System for Maternal and Children HIV care. It includes specialized portals for patients, family/community members, healthcare providers, healthcare referral system, payers and drug supply chain. While each portal is customized towards the needs of a particular actor, such as treatment scheduling and education for patients, and epidemiological data management for healthcare referrals, all the different elements are integrated through a central server to form an integrated system with a secured data exchange environment. This proposed integrative design is aimed to facilitate efficient, timely and coordinated information dissemination, analysis, and care across the healthcare system, and is intended for application in developing countries, especially in the Asia Pacific region.
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15
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Audet CM, Graves E, Barreto E, De Schacht C, Gong W, Shepherd BE, Aboobacar A, Gonzalez-Calvo L, Alvim MF, Aliyu MH, Kipp AM, Jordan H, Amico KR, Diemer M, Ciaranello A, Dugdale C, Vermund SH, Van Rompaey S. Partners-based HIV treatment for seroconcordant couples attending antenatal and postnatal care in rural Mozambique: A cluster randomized trial protocol. Contemp Clin Trials 2018; 71:63-69. [PMID: 29879469 PMCID: PMC6067957 DOI: 10.1016/j.cct.2018.05.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/26/2018] [Accepted: 05/31/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND In resource-limited rural settings, scale-up of services to eliminate mother-to-child transmission of HIV has not been as effective as in better resourced urban settings. In sub-Saharan Africa, women often require male partner approval to access and remain engaged in HIV care. Our study will evaluate a promising male engagement intervention ("Homens para Saúde Mais" (HoPS+) [Men for Health Plus]) targeting the elimination of mother-to-child transmission in rural Mozambique. DESIGN We will use a cluster randomized clinical trial design to engage 24 health facilities (12 intervention and 12 standard of care), with 45 HIV-infected seroconcordant couples per clinic. The planned intervention will engage male partners to address social-structural and cultural factors influencing eMTCT based on new couple-centered integrated HIV services. CONCLUSIONS The HoPS+ study will evaluate the effectiveness of engaging male partners in antenatal care to improve outcomes among HIV-infected pregnant women, their HIV-infected male partners, and their newborn children. Our objectives are to: (1) Implement and evaluate the impact of male-engaged, couple-centered services on partners' retention in care, adherence to antiretroviral therapy, early infant diagnosis uptake, and mother-to-child transmission throughout pregnancy and breastfeeding; (2) Investigate the impact of HoPS+ intervention on hypothesized mechanisms of change; and (3) Use validated simulation models to evaluate the cost-effectiveness of the HoPS+ intervention with the use of routine clinical data from our trial. We expect the intervention to lead to strategies that can improve outcomes related to partners' retention in care, uptake of services for HIV-exposed infants, and reduced MTCT.
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Affiliation(s)
- Carolyn M Audet
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37203, USA; Vanderbilt University Medical Center, Department of Health Policy, 2525 West End Ave, Suite 1200, Nashville, TN 37203, USA.
| | - Erin Graves
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37203, USA
| | - Ezequiel Barreto
- Friends in Global Health, Avenida Maguiguana, 32 R/C, Maputo, CP 604, Mozambique
| | - Caroline De Schacht
- Friends in Global Health, Avenida Maguiguana, 32 R/C, Maputo, CP 604, Mozambique
| | - Wu Gong
- Vanderbilt University School of Medicine, Department of Biostatistics, 2525 West End Ave, Suite 11000, Nashville, TN 37203, USA
| | - Bryan E Shepherd
- Vanderbilt University School of Medicine, Department of Biostatistics, 2525 West End Ave, Suite 11000, Nashville, TN 37203, USA
| | | | - Lazaro Gonzalez-Calvo
- Friends in Global Health, Avenida Maguiguana, 32 R/C, Maputo, CP 604, Mozambique; Vanderbilt University Medical Center, Department of Pediatrics, 2200 Children's Way, Nashville, TN 37232, USA
| | - Maria Fernanda Alvim
- Friends in Global Health, Avenida Maguiguana, 32 R/C, Maputo, CP 604, Mozambique
| | - Muktar H Aliyu
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37203, USA; Vanderbilt University Medical Center, Department of Health Policy, 2525 West End Ave, Suite 1200, Nashville, TN 37203, USA
| | - Aaron M Kipp
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37203, USA; Vanderbilt University Medical Center, Division of Epidemiology, Nashville, TN 37203, USA
| | - Heather Jordan
- Vanderbilt University Medical Center, Vanderbilt Institute for Global Health, 2525 West End Ave, Suite 750, Nashville, TN 37203, USA
| | - K Rivet Amico
- University of Michigan, Department of Health Behavior and Health Education, School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
| | - Matthew Diemer
- University of Michigan, Combined Program in Education and Psychology & Educational Studies, School of Education, Room 4120, Ann Arbor, MI 48109, USA
| | - Andrea Ciaranello
- Division of Infectious Diseases, 100 Cambridge St, Room 1670, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Harvard University, 25 Shattuck St, Boston 02115, MA, USA
| | - Caitlin Dugdale
- Harvard Medical School, Harvard University, 25 Shattuck St, Boston 02115, MA, USA
| | - Sten H Vermund
- Yale School of Public Health, 60 College St., Suite 212, New Haven, CT, USA
| | - Sara Van Rompaey
- Friends in Global Health, Avenida Maguiguana, 32 R/C, Maputo, CP 604, Mozambique
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16
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Bor J, Chiu C, Ahmed S, Katz I, Fox MP, Rosen S, Yapa M, Tanser F, Pillay D, Bärnighausen T. Failure to initiate HIV treatment in patients with high CD4 counts: evidence from demographic surveillance in rural South Africa. Trop Med Int Health 2018; 23:206-220. [PMID: 29160949 PMCID: PMC5829292 DOI: 10.1111/tmi.13013] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To assess the relationship between CD4 count at presentation and ART uptake and assess predictors of timely treatment initiation in rural KwaZulu-Natal, South Africa. METHODS We used Kaplan-Meier and Cox proportional hazards models to assess the association between first CD4 count and time from first CD4 to ART initiation among all adults presenting to the Hlabisa HIV Treatment and Care Programme between August 2011 and December 2012 with treatment-eligible CD4 counts (≤ 350 cells/mm3 ). For a subset of healthier patients (200 < CD4 ≤ 350 cells) residing within the population surveillance of the Africa Health Research Institute, we assessed sociodemographic, economic and geographic predictors hypothesised to influence ART uptake. RESULTS A total of 4739 patients presented for care with eligible CD4 counts. The proportion initiating ART within six months of diagnosis was 67% (95% CI 63, 71) in patients with CD4 ≤ 50, 59% (0.55, 0.63) in patients with CD4 151-200 and 48% (95% CI 44, 51) in patients with CD4 301-350. The hazard of starting ART fell by 17% (95% CI 14, 20) for every 100-cell increase in baseline CD4 count. Among healthier patients under demographic surveillance (n = 193), observable sociodemographic, economic and geographic predictors did not add discriminatory power beyond CD4 count, age and sex to identify patients at high risk of non-initiation. CONCLUSIONS Individuals presenting for HIV care at higher CD4 counts were less likely to initiate ART than patients presenting at low CD4 counts. Overall, ART uptake was low. Under new guidelines that establish ART eligibility regardless of CD4 count, patients with high CD4 counts may require additional interventions to encourage treatment initiation.
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Affiliation(s)
- Jacob Bor
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Calvin Chiu
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shahira Ahmed
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Ingrid Katz
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA
- Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Manisha Yapa
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Frank Tanser
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - Deenan Pillay
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Virology, University College London, London, United Kingdom
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Research Department of Infection & Population Health, University College London, London, United Kingdom
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
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17
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Gimbel S, Mwanza M, Nisingizwe MP, Michel C, Hirschhorn L. Improving data quality across 3 sub-Saharan African countries using the Consolidated Framework for Implementation Research (CFIR): results from the African Health Initiative. BMC Health Serv Res 2017; 17:828. [PMID: 29297401 PMCID: PMC5763292 DOI: 10.1186/s12913-017-2660-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background High-quality data are critical to inform, monitor and manage health programs. Over the seven-year African Health Initiative of the Doris Duke Charitable Foundation, three of the five Population Health Implementation and Training (PHIT) partnership projects in Mozambique, Rwanda, and Zambia introduced strategies to improve the quality and evaluation of routinely-collected data at the primary health care level, and stimulate its use in evidence-based decision-making. Using the Consolidated Framework for Implementation Research (CFIR) as a guide, this paper: 1) describes and categorizes data quality assessment and improvement activities of the projects, and 2) identifies core intervention components and implementation strategy adaptations introduced to improve data quality in each setting. Methods The CFIR was adapted through a qualitative theme reduction process involving discussions with key informants from each project, who identified two domains and ten constructs most relevant to the study aim of describing and comparing each country’s data quality assessment approach and implementation process. Data were collected on each project’s data quality improvement strategies, activities implemented, and results via a semi-structured questionnaire with closed and open-ended items administered to health management information systems leads in each country, with complementary data abstraction from project reports. Results Across the three projects, intervention components that aligned with user priorities and government systems were perceived to be relatively advantageous, and more readily adapted and adopted. Activities that both assessed and improved data quality (including data quality assessments, mentorship and supportive supervision, establishment and/or strengthening of electronic medical record systems), received higher ranking scores from respondents. Conclusion Our findings suggest that, at a minimum, successful data quality improvement efforts should include routine audits linked to ongoing, on-the-job mentoring at the point of service. This pairing of interventions engages health workers in data collection, cleaning, and analysis of real-world data, and thus provides important skills building with on-site mentoring. The effect of these core components is strengthened by performance review meetings that unify multiple health system levels (provincial, district, facility, and community) to assess data quality, highlight areas of weakness, and plan improvements.
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Affiliation(s)
- Sarah Gimbel
- School of Nursing, University of Washington, Magnuson Health Sciences Building, Box 357262, Seattle, WA, 98195-7262, USA. .,Department of Global Health, University of Washington, Seattle, WA, USA. .,Health Alliance International, Seattle, WA, USA.
| | - Moses Mwanza
- Centre of Infectious Diseases in Zambia, Lusaka, Zambia
| | | | - Cathy Michel
- Health Alliance International, Beira, Mozambique
| | - Lisa Hirschhorn
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.,University of Global Health Equity, Kigali, Rwanda.,Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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18
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Kaindjee-Tjituka F, Sawadogo S, Mutandi G, Maher AD, Salomo N, Mbapaha C, Neo M, Beukes A, Gweshe J, Muadinohamba A, Lowrance DW. Task-shifting point-of-care CD4+ testing to lay health workers in HIV care and treatment services in Namibia. Afr J Lab Med 2017; 6:643. [PMID: 29159139 PMCID: PMC5684646 DOI: 10.4102/ajlm.v6i1.643] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/02/2017] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Access to CD4+ testing remains a common barrier to early initiation of antiretroviral therapy among persons living with HIV/AIDS in low- and middle-income countries. The feasibility of task-shifting of point-of-care (POC) CD4+ testing to lay health workers in Namibia has not been evaluated. METHODS From July to August 2011, Pima CD4+ analysers were used to improve access to CD4+ testing at 10 selected public health facilities in Namibia. POC Pima CD4+ testing was performed by nurses or lay health workers. Venous blood samples were collected from 10% of patients and sent to centralised laboratories for CD4+ testing with standard methods. Outcomes for POC Pima CD4+ testing and patient receipt of results were compared between nurses and lay health workers and between the POC method and standard laboratory CD4+ testing methods. RESULTS Overall, 1429 patients received a Pima CD4+ test; 500 (35.0%) tests were performed by nurses and 929 (65.0%) were performed by lay health workers. When Pima CD4+ testing was performed by a nurse or a lay health worker, 93.2% and 95.2% of results were valid (p = 0.1); 95.6% and 98.1% of results were received by the patient (p = 0.007); 96.2% and 94.0% of results were received by the patient on the same day (p = 0.08). Overall, 97.2% of Pima CD4+ results were received by patients, compared to 55.4% of standard laboratory CD4+ results (p < 0.001). CONCLUSIONS POC CD4+ testing was feasible and effective when task-shifted to lay health workers. Rollout of POC CD4+ testing via task-shifting can improve access to CD4+ testing and retention in care between HIV diagnosis and antiretroviral therapy initiation in low- and middle-income countries.
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Affiliation(s)
| | | | - Graham Mutandi
- US Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Andrew D. Maher
- US Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Natanael Salomo
- US Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Claudia Mbapaha
- US Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Marytha Neo
- US Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Anita Beukes
- US Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Justice Gweshe
- Directorate of Special Programs, Ministry of Health and Social Services, Windhoek, Namibia
| | - Alexinah Muadinohamba
- Directorate of Special Programs, Ministry of Health and Social Services, Windhoek, Namibia
| | - David W. Lowrance
- Directorate of Special Programs, Ministry of Health and Social Services, Windhoek, Namibia
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Feasibility and Acceptability of Health Communication Interventions Within a Combination Intervention Strategy for Improving Linkage and Retention in HIV Care in Mozambique. J Acquir Immune Defic Syndr 2017; 74 Suppl 1:S29-S36. [PMID: 27930609 PMCID: PMC5147034 DOI: 10.1097/qai.0000000000001208] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Challenges to ensuring timely linkage to and retention in HIV care are well documented. Combination intervention strategies can be effective in improving the HIV care continuum. Data on feasibility and acceptability of intervention types within intervention packages are limited. METHODS The Engage4Health study assessed the effectiveness of a combination intervention strategy to increase linkage and retention among adults newly diagnosed with HIV in Mozambique. The study included 2 health communication interventions-modified delivery of pre-antiretroviral therapy (pre-ART) counseling sessions and SMS reminders-and 3 structural interventions-point-of-care CD4 testing after diagnosis, accelerated ART initiation, and noncash financial incentives. We used a process evaluation framework to assess dose delivered-extent each intervention was delivered as planned-and dose received-participant acceptability-of health communication versus structural interventions in the effectiveness study to understand associated benefits and challenges. Data sources included study records, participant interviews, and clinical data. RESULTS For dose delivered of health communication interventions, 98% of eligible clients received pre-ART counseling and 90% of participants received at least one SMS reminder. For structural interventions, 74% of clients received CD4 testing and 53% of eligible participants initiated ART within 1 month. Challenges for structural interventions included facility-level barriers, staffing limitations, and machine malfunctions. For dose received, participants reported pre-ART counseling and CD4 testing as the most useful interventions for linkage and financial incentives as the least useful for linkage and retention. DISCUSSION Findings demonstrate that health communication interventions can be feasibly and acceptably integrated with structural interventions to create combination intervention strategies.
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HEIMER R, USACHEVA N, BARBOUR R, NICCOLAI LM, UUSKÜLA A, LEVINA OS. Engagement in HIV care and its correlates among people who inject drugs in St Petersburg, Russian Federation and Kohtla-Järve, Estonia. Addiction 2017; 112:1421-1431. [PMID: 28233356 PMCID: PMC5526080 DOI: 10.1111/add.13798] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 10/18/2016] [Accepted: 02/16/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS HIV infection and mortality in Eastern Europe are driven by unsafe injection drug use. We sought to compare engagement in care from HIV testing through receipt of antiretroviral treatment among HIV-positive people who inject drugs (PWID) in St Petersburg, Russian Federation (RF) and Kohtla-Järve, Estonia and identify factors associated significantly with failure to progress at each stage of the HIV treatment cascade. DESIGN Cross-sectional biobehavioral surveys of PWID with an analysis stratified by location-two Russian-speaking regions with similar HIV epidemic histories and current prevalence. SETTING Field-based surveys conducted in St Petersburg, RF and Kohtla-Järve, Estonia. PARTICIPANTS We recruited 452 HIV-positive PWID in St Petersburg (November 2012 to June 2013) and 370 HIV-positive PWID in Kohtla-Järve (June-August 2012) using respondent-driven sampling. MEASUREMENTS Participants were tested for antibodies to HIV, and administered a questionnaire focusing on participants' medical care histories. Engagement in care was categorized as a cascade of five transitional steps through six stages, ranging from HIV testing to current receipt of antiretroviral medications. FINDINGS Progress along the cascade was greater in Kohtla Järve (32.7% were receiving antiretroviral medications) than in St Petersburg (9.7%). In both locations, we found the steps with high failure rates were the transitions from being aware of one's HIV diagnosis to being in regular care and initiation of highly active antiretroviral therapy (HAART). Factors associated significantly with transition failure in both locations and across steps included high alcohol consumption, variables associated with drug choice and injection frequency and lack of basic medical insurance. CONCLUSION The two steps in treatment cascade for HIV-positive PWID in St Petersburg, RF and Kohtla-Järve, Estonia requiring greatest improvement are retention in regular care and initiation of HAART. Both individual behavioral and structural factors are associated with failure to transition along the cascade.
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Affiliation(s)
- Robert HEIMER
- Department of the Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA,Center for Interdisciplinary Research at Yale University, New Haven, CT, USA
| | | | - Russell BARBOUR
- Department of the Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA,Center for Interdisciplinary Research at Yale University, New Haven, CT, USA
| | - Linda M. NICCOLAI
- Department of the Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA,Center for Interdisciplinary Research at Yale University, New Haven, CT, USA
| | - Anneli UUSKÜLA
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
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Relationship Between Time to Initiation of Antiretroviral Therapy and Treatment Outcomes: A Cohort Analysis of ART Eligible Adolescents in Zimbabwe. J Acquir Immune Defic Syndr 2017; 74:390-398. [PMID: 28002183 PMCID: PMC5321111 DOI: 10.1097/qai.0000000000001274] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is Available in the Text. Background: Age-specific retention challenges make antiretroviral therapy (ART) initiation in adolescents difficult, often requiring a lengthy preparation process. This needs to be balanced against the benefits of starting treatment quickly. The optimal time to initiation duration in adolescents is currently unknown. Objective: To assess the effect of time to ART initiation on mortality and loss to follow-up (LTFU) among treatment eligible adolescents. Methods: We conducted a retrospective cohort analysis among 1499 ART eligible adolescents aged ≥10 to <19 years registered in a public sector HIV program in Bulawayo, Zimbabwe, between 2004 and 2011. Hazard ratios (HR) for mortality and LTFU were calculated for different time to ART durations using multivariate Cox regression models. Results: Median follow-up duration was 1.6 years. Mortality HRs of patients who initiated at 0 to ≤7 days, >14 days to ≤1 month, >1 to ≤2 months, >2 months, and before initiation were 1.59, 1.19, 1.56, 1.08, and 0.94, respectively, compared with the reference group of >7 to ≤14 days. LTFU HRs were 1.02, 1.07, 0.85, 0.97, and 3.96, respectively. Among patients not on ART, 88% of deaths and 85% of LTFU occurred during the first 3 months after becoming ART eligible, but only 37% and 29% among adolescents on ART, respectively. Conclusions: Neither mortality or LTFU was associated with varying time to ART. The initiation process can be tailored to the adolescents' needs and individual life situations without risking to increase poor treatment outcomes. Early mortality was high despite rapid ART initiation, calling for earlier rather than faster initiation through HIV testing scale-up.
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Rosen S, Fox MP, Larson BA, Brennan AT, Maskew M, Tsikhutsu I, Bii M, Ehrenkranz PD, Venter WDF. Simplified clinical algorithm for identifying patients eligible for immediate initiation of antiretroviral therapy for HIV (SLATE): protocol for a randomised evaluation. BMJ Open 2017; 7:e016340. [PMID: 28554939 PMCID: PMC5726128 DOI: 10.1136/bmjopen-2017-016340] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION African countries are rapidly adopting guidelines to offer antiretroviral therapy (ART) to all HIV-infected individuals, regardless of CD4 count. For this policy of 'treat all' to succeed, millions of new patients must be initiated on ART as efficiently as possible. Studies have documented high losses of treatment-eligible patients from care before they receive their first dose of antiretrovirals (ARVs), due in part to a cumbersome, resource-intensive process for treatment initiation, requiring multiple clinic visits over a several-week period. METHODS AND ANALYSIS The Simplified Algorithm for Treatment Eligibility (SLATE) study is an individually randomised evaluation of a simplified clinical algorithm for clinicians to reliably determine a patient's eligibility for immediate ART initiation without waiting for laboratory results or additional clinic visits. SLATE will enrol and randomise (1:1) 960 adult, HIV-positive patients who present for HIV testing or care and are not yet on ART in South Africa and Kenya. Patients randomised to the standard arm will receive routine, standard of care ART initiation from clinic staff. Patients randomised to the intervention arm will be administered a symptom report, medical history, brief physical exam and readiness assessment. Patients who have positive (satisfactory) results for all four components of SLATE will be dispensed ARVs immediately, at the same clinic visit. Patients who have any negative results will be referred for further clinical investigation, counselling, tests or other services prior to being dispensed ARVs. After the initial visit, follow-up will be by passive medical record review. The primary outcomes will be ART initiation ≤28 days and retention in care 8 months after study enrolment. ETHICS AND DISSEMINATION Ethics approval has been provided by the Boston University Institutional Review Board, the University of the Witwatersrand Human Research Ethics Committee (Medical) and the KEMRI Scientific and Ethics Review Unit. Results will be published in peer-reviewed journals and made widely available through presentations and briefing documents. TRIAL REGISTRATION NCT02891135.
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Affiliation(s)
- Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Bruce A Larson
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Alana T Brennan
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute/Walter Reed Project HIV Program, Kericho, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute/Walter Reed Project HIV Program, Kericho, Kenya
| | | | - WD Francois Venter
- Wits Reproductive Health and HIV Institute, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Implementation and Operational Research: Impact of Nurse-Targeted Care on HIV Outcomes Among Immunocompromised Persons: A Before-After Study in Uganda. J Acquir Immune Defic Syndr 2017; 72:e32-6. [PMID: 27003494 DOI: 10.1097/qai.0000000000001002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Improving HIV outcomes among severely immunocompromised HIV-infected persons who have increased morbidity and mortality remains an important issue in sub-Saharan Africa. We sought to evaluate the impact of targeted clinic-based nurse care on antiretroviral therapy (ART) initiation and retention among severely immunocompromised HIV-infected persons. METHODS The study included ART-naive patients with CD4 counts <100 cells per microliter registered in seven urban clinics in Kampala, Uganda. Data were retrospectively collected on patients enrolled from July to December 2011 (routine care cohort). Between July 2012 and September 2013, 1 additional nurse per clinic was hired (nurse counselor cohort) to identify new patients, expedite ART initiation, and trace those who were lost to follow-up. We compared time to ART initiation and 6-month retention in care between cohorts and used a generalized linear model to estimate the relative risk of retention. RESULTS The study included 258 patients in the routine care cohort and 593 in the nurse counselor cohort. The proportion of patients who initiated ART increased from 190 (73.6%) in the routine care cohort to 506 (85.3%) in the nurse counselor cohort (P < 0.001). At 6 months, 62% of the routine care cohort were retained in care versus 76% in the nurse counselor cohort (P = 0.001). A 21% increase in the likelihood of retention in the nurse counselor cohort (relative risk: 1.21, 95% CI: 1.09 to 1.34) compared with the routine care cohort was observed. CONCLUSIONS Implementation of targeted nurse-led care of severely immunocompromised HIV-infected patients in public outpatient health care facilities resulted in decreased time to ART initiation and increased retention.
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High HIV prevalence and incidence among women in Southern Mozambique: Evidence from the MDP microbicide feasibility study. PLoS One 2017; 12:e0173243. [PMID: 28350843 PMCID: PMC5369694 DOI: 10.1371/journal.pone.0173243] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 02/18/2017] [Indexed: 11/23/2022] Open
Abstract
Background The study aimed to assess the feasibility of conducting large scale HIV prevention clinical trials in Mozambique by measuring HIV prevalence and incidence among women of reproductive age. This paper describes the baseline socio-demographic characteristics of the Mozambique Microbicides Development Programme (MDP) feasibility cohort, baseline prevalence of HIV and other STIs, and HIV incidence. Methods The Mozambique MDP feasibility study was conducted from September 2007 to August 2009 in urban Mavalane and rural Manhiça, in Southern Mozambique. Sexually active, HIV negative women aged 18 years and above were recruited to attend the study clinic every 4 weeks for a total of 40 weeks. At baseline, we collected demographic and sexual behaviour data, samples to test for sexually transmitted infections (STI) and conducted HIV rapid testing. STI and HIV testing were repeated at clinical follow-up visits. We describe HIV prevalence of women at screening, the demographic, behavioural and clinical characteristics of women at enrolment, and HIV incidence during follow-up. Results We screened 793 women (369 at Mavalane and 424 at Manhiça) and enrolled 505 eligible women (254 at Mavalane and 251 at Manhiça). Overall HIV prevalence at screening was 17%; 10% at Mavalane and 22% at Manhiça. Women screened at Manhiça were twice as likely as women screened at Mavalane to be HIV positive and HIV positive status was associated with younger age (18–34), lower educational level, not using a reliable method of contraception and being Zionist compared to other Christian religions. At enrolment contraceptive use was low in both clinics at 19% in Mavalane and 21% in Manhiça, as was reported condom use at last sex act at 48% in Mavalane and 25% in Manhiça. At enrolment, 8% of women tested positive for Trichomonas vaginalis, 2% for Neisseria gonorrhoeae, 4% for Chlamydia trachomatis and 46% for bacterial vaginosis. In Manhiça, 8% of women had active syphilis at screening. HIV incidence was 4.3 per 100 person years at Mavalane and 9.2 per 100 person years at Manhiça. Conclusions We demonstrated the ability to recruit a cohort of women at risk of HIV who were willing to participate in clinical research. The high HIV incidence necessitates additional action around HIV prevention for women and offers opportunities to evaluate the impact of available prevention options, such as treatment as prevention and oral PrEP. The high HIV incidence and STI prevalence also offers opportunities to evaluate the added benefit of potential prevention options such as new formulations of oral PrEP, vaginal microbicides (also called topical PrEP), vaccines, and multi-purpose technologies for HIV, STIs and contraception.
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Nachega JB, Adetokunboh O, Uthman OA, Knowlton AW, Altice FL, Schechter M, Galárraga O, Geng E, Peltzer K, Chang LW, Van Cutsem G, Jaffar SS, Ford N, Mellins CA, Remien RH, Mills EJ. Community-Based Interventions to Improve and Sustain Antiretroviral Therapy Adherence, Retention in HIV Care and Clinical Outcomes in Low- and Middle-Income Countries for Achieving the UNAIDS 90-90-90 Targets. Curr HIV/AIDS Rep 2016; 13:241-55. [PMID: 27475643 PMCID: PMC5357578 DOI: 10.1007/s11904-016-0325-9] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Little is known about the effect of community versus health facility-based interventions to improve and sustain antiretroviral therapy (ART) adherence, virologic suppression, and retention in care among HIV-infected individuals in low- and middle-income countries (LMICs). We systematically searched four electronic databases for all available randomized controlled trials (RCTs) and comparative cohort studies in LMICs comparing community versus health facility-based interventions. Relative risks (RRs) for pre-defined adherence, treatment engagement (linkage and retention in care), and relevant clinical outcomes were pooled using random effect models. Eleven cohort studies and eleven RCTs (N = 97,657) were included. Meta-analysis of the included RCTs comparing community- versus health facility-based interventions found comparable outcomes in terms of ART adherence (RR = 1.02, 95 % CI 0.99 to 1.04), virologic suppression (RR = 1.00, 95 % CI 0.98 to 1.03), and all-cause mortality (RR = 0.93, 95 % CI 0.73 to 1.18). The result of pooled analysis from the RCTs (RR = 1.03, 95 % CI 1.01 to 1.06) and cohort studies (RR = 1.09, 95 % CI 1.03 to 1.15) found that participants assigned to community-based interventions had statistically significantly higher rates of treatment engagement. Two studies found community-based ART delivery model either cost-saving or cost-effective. Community- versus facility-based models of ART delivery resulted in at least comparable outcomes for clinically stable HIV-infected patients on treatment in LMICs and are likely to be cost-effective.
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Affiliation(s)
- Jean B Nachega
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
- Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa.
- Johns Hopkins University, Baltimore, MD, USA.
| | - Olatunji Adetokunboh
- Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Olalekan A Uthman
- Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
- Warwick Medical School, The University of Warwick, Coventry, UK
| | | | | | | | - Omar Galárraga
- Brown University School of Public Health, Providence, RI, USA
| | - Elvin Geng
- University of California, San Francisco, CA, USA
| | - Karl Peltzer
- Mahidol University, Salaya, Thailand
- University of Limpopo, Polokwane, South Africa
- Human Sciences Research Council, Pretoria, South Africa
| | | | | | | | - Nathan Ford
- World Health Organization, Geneva, Switzerland
| | - Claude A Mellins
- HIV Center for Clinical and Behavioral Studies, Columbia University, New York, NY, USA
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Rosen S, Fox MP, Larson BA, Sow PS, Ehrenkranz PD, Venter F, Manabe YC, Kaplan J. Accelerating the Uptake and Timing of Antiretroviral Therapy Initiation in Sub-Saharan Africa: An Operations Research Agenda. PLoS Med 2016; 13:e1002106. [PMID: 27505444 PMCID: PMC4978457 DOI: 10.1371/journal.pmed.1002106] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Sydney Rosen and colleagues describe an operations research agenda to accelerating uptake of HIV treatment initiation.
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Affiliation(s)
- Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Bruce A. Larson
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Papa Salif Sow
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
- Department of infectious Diseases, University of Dakar, Dakar, Senegal
| | - Peter D. Ehrenkranz
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Francois Venter
- Wits Reproductive Health and HIV Institute, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yukari C. Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Jonathan Kaplan
- Independent investigator, Atlanta, Georgia, United States of America
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Assessment of linkages from HIV testing to enrolment and retention in HIV care in Central Mozambique. J Int AIDS Soc 2016; 19:20846. [PMID: 27443273 PMCID: PMC4956731 DOI: 10.7448/ias.19.5.20846] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 04/22/2016] [Accepted: 05/02/2016] [Indexed: 12/30/2022] Open
Abstract
Introduction Effectiveness of the rapid expansion of antiretroviral therapy (ART) throughout sub-Saharan Africa is highly dependent on adequate enrolment and retention in HIV care. However, the measurement of both has been challenging in these settings. This study aimed to assess enrolment and retention in HIV care (pre-ART and ART) among HIV-positive adults in Central Mozambique, including identification of barriers and facilitators. Methods We assessed linkages to and retention in HIV care using a mixed quantitative and qualitative approach in six districts of Manica and Sofala provinces. We analyzed routine district and health facility monthly reports and HIV care registries from April 2012 to March 2013 and used single imputation and trimmed means to adjust for missing values. In eight health facilities in the same districts and period, we assessed retention in HIV care among 795 randomly selected adult patient charts (15 years and older). We also conducted 25 focus group discussions and 53 in-depth interviews with HIV-positive adults, healthcare providers and community members to identify facilitators and barriers to enrolment and retention in HIV care. Results Overall, 46% of the monthly HIV testing reports expected at the district level were missing, compared to 6.4% of the pre-ART registry reports. After adjustment for missing values, we estimated that the aggregate numbers of adults registered in pre-ART was 75% of the number of persons tested HIV-positive in the six districts. In the eight health facilities, 40% of the patient charts for adults enrolled in pre-ART and 44% in ART were missing. Of those on ART for whom charts were found, retention in treatment within 90 and 60 days prior to the study team visit was 34 and 25%, respectively. Combining these multiple data sources, the overall estimated retention was 18% in our sample. Individual-level factors were perceived to be key influences to enrolment in HIV care, while health facility and structural-level factors were perceived to be key influences of retention. Conclusions Efforts to increase linkages to and retention in HIV care should address individual, health facility, and structural-level factors in Central Mozambique. However, their outcomes cannot be reliably assessed without improving the quality of routine health information systems.
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Lessons learned and study results from HIVCore, an HIV implementation science initiative. J Int AIDS Soc 2016. [DOI: 10.7448/ias.19.5.21261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Makadzange AT, Bogezi C, Boyd K, Gumbo A, Mukura D, Matubu A, Ndhlovu CE. Evaluation of the FACSPresto, a New Point of Care Device for the Enumeration of CD4% and Absolute CD4+ T Cell Counts in HIV Infection. PLoS One 2016; 11:e0157546. [PMID: 27388763 PMCID: PMC4936750 DOI: 10.1371/journal.pone.0157546] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 06/01/2016] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Enumeration of CD4+ T lymphocytes is important for pre-ART disease staging and screening for opportunistic infections, however access to CD4 testing in resource limited settings is poor. Point of care (POC) technologies can facilitate improved access to CD4 testing. We evaluated the analytical performance of a novel POC device the FACSPresto compared to the FACSCalibur as a reference standard and to the PIMA, a POC device in widespread use in sub-Saharan Africa. METHOD Specimens were obtained from 253 HIV infected adults. Venous blood samples were analyzed on the FACSPresto and the FACSCalibur, in a subset of 41 samples additional analysis was done on the PIMA. RESULTS The absolute CD4 count results obtained on the FACSPresto were comparable to those on the FACSCalibur with low absolute (9.5cells/μl) and relative bias (3.2%). Bias in CD4% values was also low (1.06%) with a relative bias of 4.9%. The sensitivity was lower at a CD4 count threshold of ≤350cells/μl compared with ≤500cells/μl (84.9% vs. 92.8%) resulting in a high upward misclassification rate at low CD4 counts. Specificity at thresholds of ≤350cells/μl and ≤500cells/μl were 96.6% and 96.8% respectively. The PIMA had a high absolute (-68.6cells/μl) and relative bias (-10.5%) when compared with the FACSCalibur. At thresholds of ≤350cells/μl and ≤500cells/μl the sensitivity was 100% and 95.5% respectively; specificity was 85.7% and 84.2% respectively. The coefficients of repeatability were 4.13%, 5.29% and 9.8% respectively. DISCUSSION The analytic performance of the FACSPresto against the reference standard was very good with better agreement and precision than the PIMA. The FACSPresto had comparable sensitivity at a threshold of 500 cells/μl and better specificity than the PIMA. However the FACSPresto showed reduced sensitivity at low CD4 count thresholds. CONCLUSION The FACSPresto can be reliably used as a POC device for enumerating absolute CD4 count and CD4% values.
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Affiliation(s)
- Azure Tariro Makadzange
- Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, United States of America
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
- * E-mail:
| | - Carola Bogezi
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Kathryn Boyd
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Anesu Gumbo
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Dorinda Mukura
- Department of Obstetrics and Gynecology, UZ-UCSF Collaborative Project, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Allen Matubu
- Department of Obstetrics and Gynecology, UZ-UCSF Collaborative Project, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
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Skhosana M, Reddy S, Reddy T, Ntoyanto S, Spooner E, Ramjee G, Ngomane N, Coutsoudis A, Kiepiela P. PIMA™ point-of-care testing for CD4 counts in predicting antiretroviral initiation in HIV-infected individuals in KwaZulu-Natal, Durban, South Africa. South Afr J HIV Med 2016; 17:444. [PMID: 29568605 PMCID: PMC5843260 DOI: 10.4102/sajhivmed.v17i1.444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 03/22/2016] [Indexed: 12/22/2022] Open
Abstract
Introduction Limited information is available on the usefulness of the PIMA™ analyser in predicting antiretroviral treatment eligibility and outcome in a primary healthcare clinic setting in disadvantaged communities in KwaZulu-Natal, South Africa. Materials and methods The study was conducted under the eThekwini Health Unit, Durban, KwaZulu-Natal. Comparison of the enumeration of CD4+ T-cells in 268 patients using the PIMA™ analyser and the predicate National Health Laboratory Services (NHLS) was undertaken during January to July 2013. Bland-Altman analysis to calculate bias and limits of agreement, precision and levels of clinical misclassification at various CD4+ T-cell count thresholds was performed. Results There was high precision of the PIMA™ control bead cartridges with low and normal CD4+ T-cell counts using three different PIMA™ analysers (%CV < 5). Under World Health Organization (WHO) guidelines (≤ 500 cells/mm3), the sensitivity of the PIMA™ analyser was 94%, specificity 78% and positive predictive value (PPV) 95%. There were 24 (9%) misclassifications, of which 13 were false-negative in whom the mean bias was 149 CD4+ T-cells/mm3. Most (87%) patients returned for their CD4 test result but only 67% (110/164) of those eligible (≤ 350 cells/mm3) were initiated on antiretroviral therapy (ART) with a time to treatment of 49 days (interquartile range [IQR], 42–64 days). Conclusion There was adequate agreement between PIMA™ analyser and predicate NHLS CD4+ T-cell count enumeration (≤ 500 cells/mm3) in adult HIV-positive individuals. The high PPV, sensitivity and acceptable specificity of the PIMA™ analyser technology lend it as a reliable tool in predicting eligibility and rapid linkage to care in ART programmes.
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Affiliation(s)
- Mandisa Skhosana
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa.,Medical Research Council of South Africa, HIV Prevention Research Unit, South Africa
| | - Shabashini Reddy
- Medical Research Council of South Africa, HIV Prevention Research Unit, South Africa
| | - Tarylee Reddy
- Medical Research Council of South Africa, Biostatistics Unit, South Africa
| | - Siphelele Ntoyanto
- Medical Research Council of South Africa, HIV Prevention Research Unit, South Africa
| | - Elizabeth Spooner
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa.,Medical Research Council of South Africa, HIV Prevention Research Unit, South Africa
| | - Gita Ramjee
- Medical Research Council of South Africa, HIV Prevention Research Unit, South Africa
| | | | - Anna Coutsoudis
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa
| | - Photini Kiepiela
- Medical Research Council of South Africa, HIV Prevention Research Unit, South Africa
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Llenas-García J, Wikman-Jorgensen P, Hobbins M, Mussa MA, Ehmer J, Keiser O, Mbofana F, Wandeler G. Retention in care of HIV-infected pregnant and lactating women starting ART under Option B+ in rural Mozambique. Trop Med Int Health 2016; 21:1003-1012. [PMID: 27208807 DOI: 10.1111/tmi.12728] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE In 2013, Mozambique adopted Option B+, universal lifelong antiretroviral therapy (ART) for all pregnant and lactating women, as national strategy for prevention of mother-to-child transmission of HIV. We analysed retention in care of pregnant and lactating women starting Option B+ in rural northern Mozambique. METHODS We compared ART outcomes in pregnant ('B+ pregnant'), lactating ('B+ lactating') and non-pregnant non-lactating women of childbearing age starting ART according to clinical and/or immunological criteria ('own health') between July 2013 and June 2014. Lost to follow-up was defined as no contact >180 days after the last visit. Multivariable competing risk models were adjusted for type of facility (type 1 vs. peripheral type 2 health centre), age, WHO stage and time from HIV diagnosis to ART. RESULTS Over 333 person-years of follow-up (243 'B+ pregnant', 65'B+ lactating' and 317 'own health' women), 3.7% of women died and 48.5% were lost to follow-up. 'B+ pregnant' and 'B+ lactating' women were more likely to be lost in the first year (57% vs. 56.9% vs. 31.6%; P < 0.001) and to have no follow-up after the first visit (42.4% vs. 29.2% vs. 16.4%; P < 0.001) than 'own health' women. In adjusted analyses, risk of being lost to follow-up was higher in 'B+ pregnant' (adjusted subhazard ratio [asHR]: 2.77; 95% CI: 2.18-3.50; P < 0.001) and 'B+ lactating' (asHR: 1.94; 95% CI: 1.37-2.74; P < 0.001). Type 2 health centre was the only additional significant risk factor for loss to follow-up. CONCLUSIONS Retention among PLW starting option B+ ART was poor and mainly driven by early losses. The success of Option B+ for prevention of mother-to-child transmission of HIV in rural settings with weak health systems will depend on specific improvements in counselling and retention measures, especially at the beginning of treatment.
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Affiliation(s)
| | | | | | - Manuel Aly Mussa
- Health Provincial Directorate, Operational Research Nucleus of Pemba, Pemba, Mozambique
| | | | - Olivia Keiser
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Gilles Wandeler
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Department of Infectious Diseases, Bern University Hospital, University of Bern, Switzerland
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Megerso A, Garoma S, Eticha T, Workineh T, Daba S, Tarekegn M, Habtamu Z. Predictors of loss to follow-up in antiretroviral treatment for adult patients in the Oromia region, Ethiopia. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2016; 8:83-92. [PMID: 27175095 PMCID: PMC4854271 DOI: 10.2147/hiv.s98137] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Purpose It is known that antiretroviral treatment (ART) reduces mortality from acquired immunodeficiency syndrome related causes. Patient’s lost to follow-up (LTFU) in this treatment poses a paramount problem to the public and health care services. Information on predictors of loss to follow-up is scarce in this study area and similar settings. Therefore, this study aimed at identifying correlates of loss to follow-up in ART among adult patients in the Oromia region of Ethiopia. Methods A case–control study was conducted between February 2015 and April 2015 using medical records. The stratified sampling technique was used to select health facilities. The number of patient records to be included in the study was proportionally allocated to each stratum based on their patient proportion in the regional data. Specific health facilities from which to include the records were randomly selected from a list of the health facilities per stratum. All adult patient records registered as LTFU (416) in the selected health facilities during the 12-month period prior to the data collection date, and 832 patients with good adherence to ART were included. Data were double-entered into Epi Info 7 and analyzed using SPSS 20. Descriptive statistics and binary logistic regression were used to report the results. Qualitative data were thematically analyzed using open code computer software. Results Age 15–24 years (adjusted odds ratio [AOR], 19.82 95% CI: 6.80, 57.73); day laborers (AOR, 5.36; 95% confidence interval [CI]: 3.23, 8.89), rural residents (AOR, 2.35; 95% CI: 1.45, 3.89), World Health Organization clinical stage IV (AOR, 2.29; 95% CI: 1.45, 3.62), baseline CD4 <350 cells/mL (AOR, 2.06; 95% CI: 1.36, 3.13), suboptimal adherence to ART (AOR, 7.42; 95% CI: 1.87, 29.41), were factors which increased the risk of loss to follow-up in ART. Conclusion Multiple risk factors, both socioeconomic and clinical, were associated with loss to follow-up. Attention is required to address these factors during patient preparation for the treatment and follow-up counseling by practitioners. We recommend that other studies identify what happened to the patients registered as LTFU as the current study could not address this issue.
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Affiliation(s)
- Abebe Megerso
- Department of Public Health, Adama Hospital Medical College, Addis Ababa, Ethiopia
| | - Sileshi Garoma
- Department of Public Health, Adama Hospital Medical College, Addis Ababa, Ethiopia
| | - Tolosa Eticha
- Department of Pediatrics and Child Health, Adama Hospital Medical College, Addis Ababa, Ethiopia
| | - Tilaye Workineh
- Department of Public Health, Adama Hospital Medical College, Addis Ababa, Ethiopia
| | - Shallo Daba
- Oromia Regional Health Bureau, HIV/AIDS Prevention and Control Division, Addis Ababa, Ethiopia
| | - Mihretu Tarekegn
- Oromia Regional Health Bureau, HIV/AIDS Prevention and Control Division, Addis Ababa, Ethiopia
| | - Zelalem Habtamu
- Oromia Regional Health Bureau, HIV/AIDS Prevention and Control Division, Addis Ababa, Ethiopia
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Lawan UM, Envuladu EA, Abubakar S. Does Awareness of Status and Risks of Human Immunodeficiency Virus Impact Risky Transmission Behavior Among Infected Adolescents? A Case Study of Clients Attending an Antiretroviral Therapy (ART) Clinic in Kano, Kano State, Nigeria. Indian J Community Med 2016; 41:126-32. [PMID: 27051087 PMCID: PMC4799635 DOI: 10.4103/0970-0218.177533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 09/10/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-positive adolescents by virtue of their position are prone to dangerous behaviors including risk-taking for HIV transmission. OBJECTIVE To determine the awareness of HIV status and risk factors for HIV transmission among HIV-positive adolescents, and how these impact their behavior. MATERIALS AND METHODS A case study approach was used to study a random sample of 400 HIV-positive adolescent children attending an antiretroviral (ART) clinic in Kano, Kano State, Nigeria. Data were analyzed using Statistical Package for the Social Sciences (SPSS) 16.0 computer statistical software. RESULT The mean age of the adolescents was 14.9 ± 3.15 years. The majority were females (54.8%) from a polygamous family (57.5%). About two-thirds or 251 (62.8%) patients knew their HIV status. The age of 14 years and above (z = 11.36, P = 0.0001) and having at least secondary school level of education (z = 2.78, P = 0.005) were significantly associated with awareness of HIV status on binary logistic regression. Up to 311 (77.8%) patients had good awareness of the risks of HIV transmission. Awareness of risk of HIV transmission was associated with awareness of HIV status (X(2) = 166.2, P = 0.0001). There was a significant variation in the behaviors between those who were aware of their HIV status and those who were not. Paradoxically, the percentage differences in risk-taking were remarkably high in all the variables examined, and were all in the direction of the adolescents who had good knowledge of the risk factors for HIV transmission. CONCLUSION AND RECOMMENDATION Health ministries, development partners working in this field, and behavioral change communication experts should develop formidable strategies for addressing this menace. There is also a dire need for further research in this area.
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Affiliation(s)
- Umar Muhammad Lawan
- Department of Community Medicine, Bayero University, Aminu Kano Teaching Hospital, Kano, Kano State, Nigeria
| | - Esther Awazzi Envuladu
- Department of Community Health, University of Jos, Jos University Teaching Hospital, Jos, Plateau State, Nigeria
| | - Sanusi Abubakar
- Department of Community Medicine, Bayero University, Aminu Kano Teaching Hospital, Kano, Kano State, Nigeria
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Koenig SP, Bernard D, Dévieux JG, Atwood S, McNairy ML, Severe P, Marcelin A, Julma P, Apollon A, Pape JW. Trends in CD4 Count Testing, Retention in Pre-ART Care, and ART Initiation Rates over the First Decade of Expansion of HIV Services in Haiti. PLoS One 2016; 11:e0146903. [PMID: 26901795 PMCID: PMC4763018 DOI: 10.1371/journal.pone.0146903] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 12/23/2015] [Indexed: 12/26/2022] Open
Abstract
Background High attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is widely reported. Though treatment guidelines have changed to broaden ART eligibility and services have been widely expanded over the past decade, data on the temporal trends in pre-ART outcomes are limited; such data would be useful to guide future policy decisions. Methods We evaluated temporal trends and predictors of retention for each step from HIV testing to ART initiation over the past decade at the GHESKIO clinic in Port-au-Prince Haiti. The 24,925 patients >17 years of age who received a positive HIV test at GHESKIO from March 1, 2003 to February 28, 2013 were included. Patients were followed until they remained in pre-ART care for one year or initiated ART. Results 24,925 patients (61% female, median age 35 years) were included, and 15,008 (60%) had blood drawn for CD4 count within 12 months of HIV testing; the trend increased over time from 36% in Year 1 to 78% in Year 10 (p<0.0001). Excluding transfers, the proportion of patients who were retained in pre-ART care or initiated ART within the first year after HIV testing was 84%, 82%, 64%, and 64%, for CD4 count strata ≤200, 201 to 350, 351 to 500, and >500 cells/mm3, respectively. The trend increased over time for each CD4 strata, and in Year 10, 94%, 95%, 79%, and 74% were retained in pre-ART care or initiated ART for each CD4 strata. Predictors of pre-ART attrition included male gender, low income, and low educational status. Older age and tuberculosis (TB) at HIV testing were associated with retention in care. Conclusions The proportion of patients completing assessments for ART eligibility, remaining in pre-ART care, and initiating ART have increased over the last decade across all CD4 count strata, particularly among patients with CD4 count ≤350 cells/mm3. However, additional retention efforts are needed for patients with higher CD4 counts.
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Affiliation(s)
- Serena P. Koenig
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
- * E-mail:
| | - Daphne Bernard
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jessy G. Dévieux
- AIDS Prevention Program, Florida International University, Miami, FL, United States of America
| | - Sidney Atwood
- Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Margaret L. McNairy
- Center for Global Health, Weill Cornell Medical College, New York, NY, United States of America
| | - Patrice Severe
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Adias Marcelin
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Pierrot Julma
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Alexandra Apollon
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jean W. Pape
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Center for Global Health, Weill Cornell Medical College, New York, NY, United States of America
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Use of a Comprehensive HIV Care Cascade for Evaluating HIV Program Performance: Findings From 4 Sub-Saharan African Countries. J Acquir Immune Defic Syndr 2015; 70:e44-51. [PMID: 26375466 DOI: 10.1097/qai.0000000000000745] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The traditional HIV treatment cascade has been noted to have limitations. A proposed comprehensive HIV care cascade that uses cohort methodology offers additional information as it accounts for all patients. Using data from 4 countries, we compare patient outcomes using both approaches. METHODS Data from 390,603 HIV-infected adults (>15 years) enrolled at 217 facilities in Kenya, Mozambique, Rwanda, and Tanzania from 2005 to 2011 were included. Outcomes of all patients at 3, 6, and 12 months after enrollment were categorized as optimal, suboptimal, or poor. Optimal outcomes included retention in care, antiretroviral therapy (ART) initiation, and documented transfer. Suboptimal outcomes included retention in care without ART initiation among eligible patients or those without eligibility data. Poor outcomes included loss to follow-up and death. RESULTS The comprehensive HIV care cascade demonstrated that at 3, 6 and 12 months, 58%, 51%, and 49% of patients had optimal outcomes; 22%, 12%, and 7% had suboptimal outcomes, and 20%, 37% and 44% had poor outcomes. Of all patients enrolled in care, 56% were retained in care at 12 months after enrollment. In comparison, the traditional HIV treatment cascade found 89% of patients enrolled in HIV care were assessed for ART eligibility, of whom 48% were determined to be ART-eligible with 70% initiating ART, and 78% of those initiated on ART retained at 12 months. CONCLUSIONS The comprehensive HIV care cascade follows outcomes of all patients, including pre-ART patients, who enroll in HIV care over time and uses quality of care parameters for categorizing outcomes. The comprehensive HIV care cascade provides complementary information to that of the traditional HIV treatment cascade and is a valuable tool for monitoring HIV program performance.
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Using BD Vacutainer CD4 Stabilization Tubes for Absolute Cluster of Differentiation Type 4 Cell Count Measurement on BD FacsCount and Partec Cyflow Cytometers: A Method Comparison Study from Zimbabwe. PLoS One 2015; 10:e0136537. [PMID: 26295802 PMCID: PMC4546686 DOI: 10.1371/journal.pone.0136537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 08/04/2015] [Indexed: 11/19/2022] Open
Abstract
Background Blood collected in conventional EDTA tubes requires laboratory analysis within 48 hours to provide valid CD4 cell count results. This restricts access to HIV care for patients from rural areas in resource-constraint settings due to sample transportation problems. Stabilization Tubes with extended storage duration have been developed but not yet evaluated comprehensively. Objective To investigate stability of absolute CD4 cell count measurement of samples in BD Vacutainer CD4 Stabilization Tubes over the course of 30 days. Methods This was a laboratory-based method comparison study conducted at a rural district hospital in Beitbridge, Zimbabwe. Whole peripheral blood from 88 HIV positive adults was drawn into BD Vacutainer CD4 Stabilization Tubes and re-tested 1, 2, 3, 5, 7, 14 and 30 days after collection on BD FacsCount and Partec Cyflow cytometers in parallel. Absolute CD4 cell levels were compared to results from paired samples in EDTA tubes analysed on BD FacsCount at the day of sample collection (references methodology). Bland-Altman analysis based on ratios of the median CD4 counts was used, with acceptable variation ranges for Limits of Agreements of +/-20%. Results Differences in ratios of the medians remained below 10% until day 21 on BD FacsCount and until day 5 on Partec Cyflow. Variations of Limits of Agreement were beyond 20% after day 1 on both cytometers. Specimen quality decreased steadily after day 5, with only 68% and 40% of samples yielding results on BD FacsCount and Partec Cyflow at day 21, respectively. Conclusions We do not recommend the use of BD Vacutainer CD4 Stabilization Tubes for absolute CD4 cell count measurement on BD FacsCount or Partec Cyflow due to large variation of results and decay of specimen quality. Alternative technologies for enhanced CD4 testing in settings with limited laboratory and sample transportation capacity still need to be developed.
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Retention of Adult Patients on Antiretroviral Therapy in Low- and Middle-Income Countries: Systematic Review and Meta-analysis 2008-2013. J Acquir Immune Defic Syndr 2015; 69:98-108. [PMID: 25942461 DOI: 10.1097/qai.0000000000000553] [Citation(s) in RCA: 253] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND We previously published systematic reviews of retention in care after antiretroviral therapy initiation among general adult populations in sub-Saharan Africa. We estimated 36-month retention at 73% for publications from 2007 to 2010. This report extends the review to cover 2008-2013 and expands it to all low- and middle-income countries. METHODS We searched PubMed, Embase, Cochrane Register, and ISI Web of Science from January 1, 2008, to December 31, 2013, and abstracts from AIDS and IAS from 2008-2013. We estimated retention across cohorts using simple averages and interpolated missing times through the last time reported. We estimated all-cause attrition (death, loss to follow-up) for patients receiving first-line antiretroviral therapy in routine settings in low- and middle-income countries. RESULTS We found 123 articles and abstracts reporting retention for 154 patient cohorts and 1,554,773 patients in 42 countries. Overall, 43% of all patients not retained were known to have died. Unweighted averages of reported retention were 78%, 71%, and 69% at 12, 24, and 36 months, after treatment initiation, respectively. We estimated 36-month retention at 65% in Africa, 80% in Asia, and 64% in Latin America and the Caribbean. From lifetable analysis, we estimated retention at 12, 24, 36, 48, and 60 months at 83%, 74%, 68%, 64%, and 60%, respectively. CONCLUSIONS Retention at 36 months on treatment averages 65%-70%. There are several important gaps in the evidence base, which could be filled by further research, especially in terms of geographic coverage and duration of follow-up.
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Wilkinson S, Chiavegatti T, Nauche B, Family Name Deactivated GND, Pant Pai N. Head to head comparisons in performance of CD4 point-of-care assays: a Bayesian meta-analysis (2000–2013). SCIENCEOPEN RESEARCH 2015. [DOI: 10.14293/s2199-1006.1.sor-med.a4qf5y.v2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Timely detection, staging, and treatment initiation are pertinent to controlling HIV infection. CD4+ cell-based point-of-care (POC) devices offer the potential to rapidly stage patients, and decide on initiating treatment, but a comparative evaluation of their performance has not yet been performed. With this in mind, we conducted a systematic review and meta-analyses. For the period January 2000 to April 2014, 19 databases were systematically searched, 6619 citations retrieved, and 25 articles selected. Diagnostic performance was compared across devices (i.e., PIMA, CyFlow, miniPOC, MBioCD4 System) and across specimens (i.e., capillary blood vs. venous blood). A Bayesian approach was used to meta-analyze the data. The primary outcome, the Bland–Altman (BA) mean bias (which represents agreement between cell counts from POC device and flow cytometry), was analyzed with a Bayesian hierarchical normal model. We performed a head-to-head comparison of two POC devices including the PIMA and PointCareNOW CD4. PIMA appears to perform better vs. PointCareNOW with venous samples (BA mean bias: –9.5 cells/μL; 95% CrI: –37.71 to 18.27, vs. 139.3 cells/μL; 95% CrI: –0.85 to 267.4, mean difference = 148.8, 95% CrI: 11.8, 285.8); importantly, PIMA performed well when used with capillary samples (BA mean bias: 2.2 cells/μL; 95% CrI: –19.32 to 23.6). Sufficient data were available to allow pooling of sensitivity and specificity data only at the 350 cells/μL cutoff. For PIMA device sensitivity 91.6 (84.7–95.5) and specificity was 94.8 (90.1–97.3), respectively. There were not sufficient data to allow comparisons between any other devices. PIMA device was comparable to flow cytometry. The estimated differences between the CD4+ cell counts of the device and the reference was small and best estimated in capillary blood specimens. As the evidence stands, the PointCareNOW device will need to improve prior to widespread use and more data on MBio and MiniPOC are needed. Findings inform implementation of PIMA and improvements in other CD4 POC device prior to recommending widespread use.
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Esperance MC, Koenig SP, Guiteau C, Homeus F, Devieux J, Edouard J, Bertrand R, Joseph P, Bellot C, Decome D, Pape JW, Severe P. A successful model for rapid triage of symptomatic patients at an HIV testing site in Haiti. Int Health 2015; 8:96-100. [PMID: 26180112 DOI: 10.1093/inthealth/ihv042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 05/19/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Attrition from HIV testing to antiretroviral therapy (ART) initiation is high. Strengthening linkages in care from testing to treatment may reduce attrition. This study addresses the question: can social workers accurately identify symptomatic patients during HIV testing and fast-track them for rapid provision of services? METHODS This study took place at the Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) in Port-au-Prince, Haiti. We compared symptoms reported by social workers at HIV testing using a checklist to diagnoses made by physicians on an intake exam to determine if social workers could accurately identify symptomatic patients. RESULTS Among the 437 HIV-positive patients included in the study, social workers reported stage-associated symptoms in 100% of patients diagnosed with WHO stage 3 or 4 conditions and in 87% of patients with WHO stage 1 or 2 conditions. The sensitivity, specificity, positive predictive value, and negative predictive value of social worker-reported symptoms for the diagnosis of a WHO stage 3 or 4 condition was 100%, 47%, 31%, and 100%, respectively. CONCLUSIONS Social workers can identify symptomatic patients at HIV testing and refer them for fast-tracked services. This strategy may increase the rate of ART initiation among eligible patients.
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Affiliation(s)
- Morgan C Esperance
- Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Serena P Koenig
- Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Colette Guiteau
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), 33 Harry Truman Boulevard, Port-au-Prince, Haiti
| | - Fabienne Homeus
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), 33 Harry Truman Boulevard, Port-au-Prince, Haiti
| | | | - Jenny Edouard
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), 33 Harry Truman Boulevard, Port-au-Prince, Haiti
| | - Rachel Bertrand
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), 33 Harry Truman Boulevard, Port-au-Prince, Haiti
| | - Patrice Joseph
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), 33 Harry Truman Boulevard, Port-au-Prince, Haiti
| | - Clovy Bellot
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), 33 Harry Truman Boulevard, Port-au-Prince, Haiti
| | - Diessy Decome
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), 33 Harry Truman Boulevard, Port-au-Prince, Haiti
| | - Jean W Pape
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), 33 Harry Truman Boulevard, Port-au-Prince, Haiti Center for Global Health, Weill Cornell Medical College, New York, NY, USA
| | - Patrice Severe
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), 33 Harry Truman Boulevard, Port-au-Prince, Haiti
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Rupérez M, Pou C, Maculuve S, Cedeño S, Luis L, Rodríguez J, Letang E, Moltó J, Macete E, Clotet B, Alonso P, Menéndez C, Naniche D, Paredes R. Determinants of virological failure and antiretroviral drug resistance in Mozambique. J Antimicrob Chemother 2015; 70:2639-47. [PMID: 26084302 DOI: 10.1093/jac/dkv143] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 05/01/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The objective of this study was to inform public health actions to limit first-line ART failure and HIV drug resistance in Mozambique. METHODS This was a cross-sectional study. HIV-1-infected adults on first-line ART for at least 1 year attending routine visits in the Manhiça District Hospital, in a semi-rural area in southern Mozambique with no HIV-1 RNA monitoring available, were evaluated for clinical, socio-demographic, therapeutic, immunological and virological characteristics. Factors associated with HIV-1 RNA ≥1000 copies/mL and HIV drug resistance were determined using multivariate logistic regression. RESULTS The study included 334 adults on first-line ART for a median of 3 years, of which 65% (214/332) had suppressed viraemia, 11% (37/332) had low-level viraemia (HIV-1 RNA 150-999 copies/mL) and 24% (81/332) had overt virological failure (HIV-1 RNA ≥1000 copies/mL). HIV drug resistance was detected in 89% of subjects with virological failure, but in none with low-level viraemia. Younger age [OR = 0.97 per additional year (95% CI = 0.94-1.00), P = 0.039], ART initiation at WHO stage III/IV [OR = 2.10 (95% CI = 1.23-3.57), P = 0.003] and low ART adherence [OR = 2.69 (95% CI = 1.39-5.19), P = 0.003] were associated with virological failure. Longer time on ART [OR = 1.55 per additional year (95% CI = 1.00-2.43), P = 0.052] and illiteracy [OR = 0.24 (95% CI = 0.07-0.89), P = 0.033] were associated with HIV drug resistance. Compared with HIV-1 RNA, clinician's judgement of ART failure, based on clinical and immunological outcomes, only achieved 29% sensitivity and misdiagnosed 1 out of every 4.5 subjects. CONCLUSIONS Public health programmes in Mozambique should focus on early HIV diagnosis, early ART initiation and adherence support. Virological monitoring drastically improves the diagnosis of ART failure, enabling a better use of resources.
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Affiliation(s)
- María Rupérez
- Manhiça Health Research Center (CISM), Manhiça, Maputo, Mozambique Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain
| | - Christian Pou
- IrsiCaixa AIDS Research Institute, Badalona, Catalonia, Spain
| | - Sonia Maculuve
- Manhiça Health Research Center (CISM), Manhiça, Maputo, Mozambique
| | - Samandhy Cedeño
- IrsiCaixa AIDS Research Institute, Badalona, Catalonia, Spain
| | - Leopoldina Luis
- Manhiça Health Research Center (CISM), Manhiça, Maputo, Mozambique
| | | | - Emilio Letang
- Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland
| | - José Moltó
- Lluita Contra la Sida Foundation, HIV Unit, Hosp Univ Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Eusébio Macete
- Manhiça Health Research Center (CISM), Manhiça, Maputo, Mozambique
| | - Bonaventura Clotet
- IrsiCaixa AIDS Research Institute, Badalona, Catalonia, Spain Lluita Contra la Sida Foundation, HIV Unit, Hosp Univ Germans Trias i Pujol, Badalona, Catalonia, Spain Universitat de Vic-Universitat Central de Catalunya, Vic, Catalonia, Spain
| | - Pedro Alonso
- Manhiça Health Research Center (CISM), Manhiça, Maputo, Mozambique Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain
| | - Clara Menéndez
- Manhiça Health Research Center (CISM), Manhiça, Maputo, Mozambique Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain
| | - Denise Naniche
- Manhiça Health Research Center (CISM), Manhiça, Maputo, Mozambique Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain
| | - Roger Paredes
- IrsiCaixa AIDS Research Institute, Badalona, Catalonia, Spain Lluita Contra la Sida Foundation, HIV Unit, Hosp Univ Germans Trias i Pujol, Badalona, Catalonia, Spain Universitat de Vic-Universitat Central de Catalunya, Vic, Catalonia, Spain
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A prospective observational study of bacteraemia in adults admitted to an urban Mozambican hospital. S Afr Med J 2015; 105:370-4. [PMID: 26242671 DOI: 10.7196/samj.8780] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Bacteraemia is a common cause of fever among patients presenting to hospitals in sub-Saharan Africa. The worldwide rise of antibiotic resistance makes empirical therapy increasingly difficult, especially in resource-limited settings. OBJECTIVES To describe the incidence of bacteraemia in febrile adults presenting to Maputo Central Hospital (MCH), an urban referral hospital in the capital of Mozambique, and characterise the causative organisms and antibiotic susceptibilities. We aimed to describe the antibiotic prescribing habits of local doctors, to identify areas for quality improvement. METHODS Inclusion criteria were: (i) ≥18 years of age; (ii) axillary temperature ≥38°C or ≤35°C; (iii) admission to MCH medical wards in the past 24 hours; and (iv) no receipt of antibiotics as an inpatient. Blood cultures were drawn from enrolled patients and incubated using the BacT/Alert automated system (bioMérieux, France). Antibiotic susceptibilities were tested using the Kirby-Bauer disc diffusion method. RESULTS Of the 841 patients enrolled, 63 (7.5%) had a bloodstream infection. The most common isolates were Staphylococcus aureus, Escherichia coli, and non-typhoidal Salmonella. Antibiotic resistance was common, with 20/59 (33.9%) of all bacterial isolates showing resistance to ceftriaxone, the broadest-spectrum antibiotic commonly available at MCH. Receipt of insufficiently broad empirical antibiotics was associated with poor in-hospital outcomes (odds ratio 8.05; 95% confidence interval 1.62 - 39.91; p=0.04). CONCLUSION This study highlights several opportunities for quality improvement, including educating doctors to have a higher index of suspicion for bacteraemia, improving local antibiotic guidelines, improving communication between laboratory and doctors, and increasing the supply of some key antibiotics.
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Abstract
Within Mozambique's current HIV care system, there are numerous opportunities for a person to become lost to follow-up (LTFU) prior to initiating antiretroviral therapy (pre-ART). We explored pre-ART LTFU in Zambézia province utilizing quantitative and qualitative methods. Patients were deemed LTFU if they were more than 60 days late for either a scheduled appointment or a CD4+ cell count blood draw, according to national guidelines. Among 13,968 adult patients registered for care, 211 (1.8 %) died, one transferred, 2,196 (15.7 %) initiated ART, and 9,195 (65.8 %) were LTFU during the first year. Being male, younger, less educated, and/or having no home electricity were associated with LTFU. Qualitative interviews revealed that poor clinical care, logistics and competing priorities contribute to attrition. In addition, many expressed fears of stigma and/or rejection by family or community members because they were HIV-infected. At 66 %, pre-ART LTFU in Zambézia, Mozambique is a significant problem. This study highlights characteristics of lost patients and discusses barriers requiring consideration to improve retention.
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Blevins M, José E, Bilhete FR, Vaz LM, Shepherd BE, Audet CM, Vermund SH, Moon TD. Two-year death and loss to follow-up outcomes by source of referral to HIV care for HIV-infected patients initiating antiretroviral therapy in rural Mozambique. AIDS Res Hum Retroviruses 2015; 31:198-207. [PMID: 25381732 DOI: 10.1089/aid.2014.0007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We studied patient outcomes by type of referral site following 2 years of combination antiretroviral therapy (cART) during scale-up from June 2006 to July 2011 in Mozambique's rural Zambézia Province. Loss to follow-up (LTFU) was defined as no contact within 60 days after scheduled medication pickup. Endpoints included LTFU, mortality, and combined mortality/LTFU; we used Kaplan-Meier and cumulative incidence estimates. The referral site was the source of HIV testing. We modeled 2-year outcomes using Cox regression stratified by district, adjusting for sociodemographics and health status. Of 7,615 HIV-infected patients ≥15 years starting cART, 61% were female and the median age was 30 years. Two-year LTFU was 38.1% (95% CI: 36.9-39.3%) and mortality was 14.2% (95% CI 13.2-15.2%). Patients arrived from voluntary counseling and testing (VCT) sites (51%), general outpatient clinics (21%), antenatal care (8%), inpatient care (3%), HIV/tuberculosis/laboratory facilities (<4%), or other sources of referral (14%). Compared with VCT, patients referred from inpatient, tuberculosis, or antenatal care had higher hazards of LTFU. Adjusted hazard ratios (AHR; 95% CI) for 2-year mortality by referral site (VCT as referent) were inpatient 1.87 (1.36-2.58), outpatient 1.44 (1.11-1.85), and antenatal care 0.69 (0.43-1.11) and for mortality/LTFU were inpatient 1.60 (1.34-1.91), outpatient 1.17 (1.02-1.33), tuberculosis care 1.38 (1.08-1.75), and antenatal care 1.24 (1.06-1.44). That source of referral was associated with mortality/LTFU after adjusting for patient characteristics at cART initiation suggests that (1) additional unmeasured factors are influential, and (2) retention programs may benefit from targeting patient populations based on source of referral with focused counseling and/or social support.
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Affiliation(s)
- Meridith Blevins
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eurico José
- Friends in Global Health, Quelimane and Maputo, Mozambique
| | | | - Lara M.E. Vaz
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee
- Friends in Global Health, Quelimane and Maputo, Mozambique
- Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Bryan E. Shepherd
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Carolyn M. Audet
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Sten H. Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee
- Friends in Global Health, Quelimane and Maputo, Mozambique
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Troy D. Moon
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee
- Friends in Global Health, Quelimane and Maputo, Mozambique
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
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Fajardo E, Metcalf C, Mbofana E, van Vyve C, Munyaradzi D, Simons S, Kuhudzayi M, Bygrave H. Opportunities to improve storage and transportation of blood specimens for CD4 testing in a rural district in Zimbabwe using BD vacutainer CD4 stabilization tubes: a stability and diagnostic accuracy study. BMC Infect Dis 2014; 14:553. [PMID: 25330812 PMCID: PMC4209078 DOI: 10.1186/s12879-014-0553-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 10/10/2014] [Indexed: 11/18/2022] Open
Abstract
Background CD4+ T-cell testing of blood specimens collected in standard EDTA Vacutainer tubes and transported at ambient temperature, must be completed within 48 hours with the BD FACSCount™ flow cytometer, restricting specimen collection in remote clinics with no on-site testing and limited specimen transport services. We conducted a study in Buhera District, Zimbabwe, to assess the stability and accuracy of CD4+ T-cell results of samples collected in Stabilization Tubes (ST) and stored at ambient temperature for varying time periods. Methods Paired EDTA and ST samples were collected from 51 HIV-positive patients aged 18 years and older. CD4+ T-cell testing was done on arrival in the laboratory (Day 0). ST samples were retested on Days 3, 5, and 7. Nineteen ST samples were stored for an additional week and retested on Day 14. Results There was a strong correlation between absolute CD4+ T-cell counts measured in the EDTA Day 0 reference sample and Day 7 ST sample (Spearman's rho: 0.9778; mean difference: -4.9 cells/μL and limits of agreement (LOA): 98.5 and 88.7 cells/μL); and the reference sample and Day 14 ST sample (Spearman's rho: 0.9632; mean difference 5.1 cells/μL and LOA: -99.6 and 109.8 cells/μL. Using a 350 cells/μL threshold, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were all 100% on Day 7, and 83.3%, 100%, 100% and 92.9% on Day 14. Using a 500 cells/μL threshold, the sensitivity, specificity, PPV and NVP were 100%, 88.5%, 88.5% and 100% on Day 7 and 88.9%, 80.0%, 80.0% and 88.9% on Day 14. Conclusions CD4 ST can be used and stored up to 7 days as a reliable alternative to standard EDTA tubes in settings where CD4+ T-cell testing within 48 hours is not feasible. Despite the small sample size, results suggest that ST may be stored up to 14 days at room temperature for CD4 testing, without compromising accuracy. However, further studies with larger sample sizes are needed to confirm this preliminary finding. Electronic supplementary material The online version of this article (doi:10.1186/s12879-014-0553-9) contains supplementary material, which is available to authorized users.
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Gimbel S, Voss J, Mercer MA, Zierler B, Gloyd S, Coutinho MDJ, Floriano F, Cuembelo MDF, Einberg J, Sherr K. The prevention of mother-to-child transmission of HIV cascade analysis tool: supporting health managers to improve facility-level service delivery. BMC Res Notes 2014; 7:743. [PMID: 25335783 PMCID: PMC4216351 DOI: 10.1186/1756-0500-7-743] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 10/10/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND The objective of the prevention of Mother-to-Child Transmission (pMTCT) cascade analysis tool is to provide frontline health managers at the facility level with the means to rapidly, independently and quantitatively track patient flows through the pMTCT cascade, and readily identify priority areas for clinic-level improvement interventions. Over a period of six months, five experienced maternal-child health managers and researchers iteratively adapted and tested this systems analysis tool for pMTCT services. They prioritized components of the pMTCT cascade for inclusion, disseminated multiple versions to 27 health managers and piloted it in five facilities. Process mapping techniques were used to chart PMTCT cascade steps in these five facilities, to document antenatal care attendance, HIV testing and counseling, provision of prophylactic anti-retrovirals, safe delivery, safe infant feeding, infant follow-up including HIV testing, and family planning, in order to obtain site-specific knowledge of service delivery. RESULTS Seven pMTCT cascade steps were included in the Excel-based final tool. Prevalence calculations were incorporated as sub-headings under relevant steps. Cells not requiring data inputs were locked, wording was simplified and stepwise drop-offs and maximization functions were included at key steps along the cascade. While the drop off function allows health workers to rapidly assess how many patients were lost at each step, the maximization function details the additional people served if only one step improves to 100% capacity while others stay constant. CONCLUSIONS Our experience suggests that adaptation of a cascade analysis tool for facility-level pMTCT services is feasible and appropriate as a starting point for discussions of where to implement improvement strategies. The resulting tool facilitates the engagement of frontline health workers and managers who fill out, interpret, apply the tool, and then follow up with quality improvement activities. Research on adoption, interpretation, and sustainability of this pMTCT cascade analysis tool by frontline health managers is needed. TRIAL REGISTRATION ClinicalTrials.gov NCT02023658, December 9, 2013.
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Affiliation(s)
- Sarah Gimbel
- />Department of Family Child Nursing, University of Washington, Box 357262, Seattle, USA
- />Department of Global Health, University of Washington, Seattle, USA
- />Health Alliance International, Seattle, WA USA
| | - Joachim Voss
- />Department of Global Health, University of Washington, Seattle, USA
- />Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, USA
| | - Mary Anne Mercer
- />Department of Global Health, University of Washington, Seattle, USA
| | - Brenda Zierler
- />Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, USA
| | - Stephen Gloyd
- />Department of Global Health, University of Washington, Seattle, USA
- />Health Alliance International, Seattle, WA USA
| | | | | | | | | | - Kenneth Sherr
- />Department of Global Health, University of Washington, Seattle, USA
- />Health Alliance International, Seattle, WA USA
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Elul B, Lahuerta M, Abacassamo F, Lamb MR, Ahoua L, McNairy ML, Tomo M, Horowitz D, Sutton R, Mussa A, Gurr D, Jani I. A combination strategy for enhancing linkage to and retention in HIV care among adults newly diagnosed with HIV in Mozambique: study protocol for a site-randomized implementation science study. BMC Infect Dis 2014; 14:549. [PMID: 25311998 PMCID: PMC4210581 DOI: 10.1186/s12879-014-0549-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 10/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the extraordinary scale up of HIV prevention, care and treatment services in sub-Saharan Africa (SSA) over the past decade, the overall effectiveness of HIV programs has been significantly hindered by high levels of attrition across the HIV care continuum. Data from "real-life" settings are needed on the effectiveness of an easy to deliver package of services that can improve overall performance of the HIV care continuum. METHODS/DESIGN We are conducting an implementation science study using a two-arm cluster site-randomized design to determine the effectiveness of a combination intervention strategy (CIS) using feasible, evidence-based, and practical interventions-including (1) point-of-care (POC) CD4 count testing, (2) accelerated antiretroviral therapy initiation for eligible individuals, and (3) SMS reminders for linkage to and retention in care-as compared to the standard of care (SOC) in Mozambique in improving linkage and retention among adults following HIV diagnosis. A pre-post intervention two-sample design is nested within the CIS arm to assess the incremental effectiveness of the CIS plus financial incentives (CIS + FI) compared to the CIS without FI on study outcomes. Randomization is done at the level of the study site, defined as a primary health facility. Five sites are included from the City of Maputo and five from Inhambane Province. Target enrollment is a total of 2,250 adults: 750 in the SOC arm, 750 in the CIS cohort of the intervention arm and 750 in the CIS + FI cohort of the intervention arm (average of 150 participants per site). Participants are followed for 12 months from time of HIV testing to ascertain a combined endpoint of linkage to care within 1 month after testing and retention in care 12 months from HIV test. Cost-effectiveness analyses of CIS compared to SOC and CIS + FI compared to CIS will also be conducted. DISCUSSION Study findings will provide evidence on the effectiveness of a CIS and the incremental effectiveness of a CIS + FI in a "real-life" service delivery system in a SSA country severely impacted by HIV. TRIAL REGISTRATION Clinicaltrials.gov, NCT01930084.
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Affiliation(s)
- Batya Elul
- ICAP, Columbia University, New York, NY, USA.
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Dokubo EK, Shiraishi RW, Young PW, Neal JJ, Aberle-Grasse J, Honwana N, Mbofana F. Awareness of HIV status, prevention knowledge and condom use among people living with HIV in Mozambique. PLoS One 2014; 9:e106760. [PMID: 25222010 PMCID: PMC4164358 DOI: 10.1371/journal.pone.0106760] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 08/09/2014] [Indexed: 12/23/2022] Open
Abstract
Objective To determine factors associated with HIV status unawareness and assess HIV prevention knowledge and condom use among people living with HIV/AIDS (PLHIV) in Mozambique. Design Cross-sectional household-based nationally representative AIDS Indicator Survey. Methods Analyses focused on HIV-infected adults and were weighted for the complex sampling design. We identified PLHIV who had never been tested for HIV or received their test results prior to this survey. Logistic regression was used to assess factors associated with HIV status unawareness. Results Of persons with positive HIV test results (N = 1182), 61% (95% confidence interval [CI] 57–65%) were unaware of their serostatus. Men had twice the odds of being unaware of their serostatus compared with women [adjusted odds ratio (aOR) 2.05, CI 1.40–2.98]. PLHIV in the poorest wealth quintile were most likely to be unaware of their serostatus (aOR 3.15, CI 1.09–9.12) compared to those in the middle wealth quintile. Most PLHIV (83%, CI 79–87%) reported not using a condom during their last sexual intercourse, and PLHIV who reported not using a condom during their last sexual intercourse were more likely to be unaware of their serostatus (aOR 2.32, CI 1.57–3.43) than those who used a condom. Conclusions Knowledge of HIV-positive status is associated with more frequent condom use in Mozambique. However, most HIV-infected persons are unaware of their serostatus, with men and persons in the poorest wealth quintile being more likely to be unaware. These findings support calls for expanded HIV testing, especially among groups less likely to be aware of their HIV status and key populations at higher risk for infection.
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Affiliation(s)
- E. Kainne Dokubo
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
- * E-mail:
| | - Ray W. Shiraishi
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | - Peter W. Young
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), Maputo, Mozambique
| | - Joyce J. Neal
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | - John Aberle-Grasse
- Division of Global HIV/AIDS, U.S. Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | - Nely Honwana
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), Maputo, Mozambique
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The clinical and economic impact of point-of-care CD4 testing in mozambique and other resource-limited settings: a cost-effectiveness analysis. PLoS Med 2014; 11:e1001725. [PMID: 25225800 PMCID: PMC4165752 DOI: 10.1371/journal.pmed.1001725] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/30/2014] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Point-of-care CD4 tests at HIV diagnosis could improve linkage to care in resource-limited settings. Our objective is to evaluate the clinical and economic impact of point-of-care CD4 tests compared to laboratory-based tests in Mozambique. METHODS AND FINDINGS We use a validated model of HIV testing, linkage, and treatment (CEPAC-International) to examine two strategies of immunological staging in Mozambique: (1) laboratory-based CD4 testing (LAB-CD4) and (2) point-of-care CD4 testing (POC-CD4). Model outcomes include 5-y survival, life expectancy, lifetime costs, and incremental cost-effectiveness ratios (ICERs). Input parameters include linkage to care (LAB-CD4, 34%; POC-CD4, 61%), probability of correctly detecting antiretroviral therapy (ART) eligibility (sensitivity: LAB-CD4, 100%; POC-CD4, 90%) or ART ineligibility (specificity: LAB-CD4, 100%; POC-CD4, 85%), and test cost (LAB-CD4, US$10; POC-CD4, US$24). In sensitivity analyses, we vary POC-CD4-specific parameters, as well as cohort and setting parameters to reflect a range of scenarios in sub-Saharan Africa. We consider ICERs less than three times the per capita gross domestic product in Mozambique (US$570) to be cost-effective, and ICERs less than one times the per capita gross domestic product in Mozambique to be very cost-effective. Projected 5-y survival in HIV-infected persons with LAB-CD4 is 60.9% (95% CI, 60.9%-61.0%), increasing to 65.0% (95% CI, 64.9%-65.1%) with POC-CD4. Discounted life expectancy and per person lifetime costs with LAB-CD4 are 9.6 y (95% CI, 9.6-9.6 y) and US$2,440 (95% CI, US$2,440-US$2,450) and increase with POC-CD4 to 10.3 y (95% CI, 10.3-10.3 y) and US$2,800 (95% CI, US$2,790-US$2,800); the ICER of POC-CD4 compared to LAB-CD4 is US$500/year of life saved (YLS) (95% CI, US$480-US$520/YLS). POC-CD4 improves clinical outcomes and remains near the very cost-effective threshold in sensitivity analyses, even if point-of-care CD4 tests have lower sensitivity/specificity and higher cost than published values. In other resource-limited settings with fewer opportunities to access care, POC-CD4 has a greater impact on clinical outcomes and remains cost-effective compared to LAB-CD4. Limitations of the analysis include the uncertainty around input parameters, which is examined in sensitivity analyses. The potential added benefits due to decreased transmission are excluded; their inclusion would likely further increase the value of POC-CD4 compared to LAB-CD4. CONCLUSIONS POC-CD4 at the time of HIV diagnosis could improve survival and be cost-effective compared to LAB-CD4 in Mozambique, if it improves linkage to care. POC-CD4 could have the greatest impact on mortality in settings where resources for HIV testing and linkage are most limited. Please see later in the article for the Editors' Summary.
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Nuwagaba-Biribonwoha H, Jakubowski A, Mugisha V, Basinga P, Asiimwe A, Nash D, Elul B. Low risk of attrition among adults on antiretroviral therapy in the Rwandan national program: a retrospective cohort analysis of 6, 12, and 18 month outcomes. BMC Public Health 2014; 14:889. [PMID: 25168699 PMCID: PMC4161887 DOI: 10.1186/1471-2458-14-889] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 07/29/2014] [Indexed: 12/01/2022] Open
Abstract
Background We report levels and determinants of attrition in Rwanda, one of the few African countries with universal ART access. Methods We analyzed data abstracted from health facility records of a nationally representative sample of adults [≥18 years] who initiated ART 6, 12, and 18 months prior to data collection; and collected facility characteristics with a health facility assessment questionnaire. Weighted proportions and rates of attrition [loss to follow-up or death] were calculated, and patient- and health facility-level factors associated with attrition examined using Cox proportional hazard models. Results 1678 adults initiated ART 6, 12 and 18 months prior to data collection, with 1508 person-years [PY] on ART. Attrition was 6.8% [95% confidence interval [CI] 6.0-7.8]: 2.9% [2.4-3.5] recorded deaths and 3.9% [3.4-4.5] lost to follow-up. Population attrition rate was 7.5/100PY [6.1-9.3]. Adjusted hazard ratio [aHR] for attrition was 4.2 [3.0-5.7] among adults enrolled from in-patient wards [vs 2.2 [1.6-3.0] from PMTCT, ref: VCT]. Compared to adults who initiated ART 18 months earlier, aHR for adults who initiated ART 12 and 6 months earlier was 1.8 [1.3-2.5] and 1.3 [0.9-1.9] respectively. Male aHR was 1.4 [1.0-1.8]. AHR of adults enrolled at urban health facilities was 1.4 [1.1-1.8, ref: rural health facilities]. AHR for adults with CD4+ ≥200 cells/μL vs <200 cells/μL was 0.8 [0.6-1.0]; and adults attending facilities with performance-based financing since 2004–2006 [vs. 2007–2008] had aHR 0.8 [0.6-0.9]. Conclusions Attrition was low in the Rwandan national program. The above patient and facility correlates of attrition can be the focus of interventions to sustain high retention.
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Delay of antiretroviral therapy initiation is common in East African HIV-infected individuals in serodiscordant partnerships. J Acquir Immune Defic Syndr 2014; 66:436-42. [PMID: 24798765 DOI: 10.1097/qai.0000000000000192] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE WHO guidance recommends antiretroviral therapy (ART) initiation for all persons with a known HIV-uninfected partner, as a strategy to prevent HIV transmission. Uptake of ART among HIV-infected partners in serodiscordant partnerships is not known, which we evaluated in African HIV serodiscordant couples. DESIGN Prospective cohort study. METHODS Among HIV-infected persons from Kenya and Uganda who had a known heterosexual HIV-uninfected partner, we assessed ART initiation in those who became ART eligible under national guidelines during follow-up. Participants received quarterly clinical and semi-annual CD4 monitoring, and active referral for ART upon becoming eligible. RESULTS Of 1958 HIV-infected ART-eligible partners, 58% were women, and the median age was 34 years. At the first visit when determined to be ART eligible, the median CD4 count was 273 cells per microliter (interquartile range, 221-330), 77% had WHO stage 1 or 2 HIV disease, and 96% were receiving trimethoprim-sulfamethoxazole prophylaxis. The cumulative probabilities of initiating ART at 6, 12, and 24 months after eligibility were 49.9%, 70.0%, and 87.6%, respectively. Younger age [<25 years; adjusted hazard ratio (AHR), 1.39; P = 0.001], higher CD4 count (AHR, 1.95; P < 0.001 for >350 compared with <200 cells/µL), higher education (AHR, 1.25; P < 0.001), and lack of income (AHR, 1.15; P = 0.02) were independent predictors for delay in ART initiation. CONCLUSIONS In the context of close CD4 monitoring, ART counseling, and active linkage to HIV care, a substantial proportion of HIV-infected persons with a known HIV-uninfected partner delayed ART initiation. Strategies to motivate ART initiation are needed, particularly for younger persons with higher CD4 counts.
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