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Maluleka LM, Hlongwane N, Mokgatle MM. Knowledge and Perceptions of Healthcare Workers about the Implementation of the Universal Test and Treat Guideline in Under-Resourced, High-HIV Prevalence Rural Settings. Healthcare (Basel) 2023; 11:healthcare11070968. [PMID: 37046895 PMCID: PMC10094157 DOI: 10.3390/healthcare11070968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 03/12/2023] [Accepted: 03/23/2023] [Indexed: 03/31/2023] Open
Abstract
Background: South Africa (SA) began implementing its Universal Test and Treat (UTT) policy in September 2016 and Same Day Initiation (SDI) in 2017, aiming to meet the UNAIDS 90-90-90 targets by 2020. With significant advances in HIV testing, large gaps remain in the linkage and retention in care. As part of a contribution to the successful implementation of UTT, this study aims to examine progress in the implementation of the UTT and to identify gaps and facilitators in the successful implementation of the guidelines from the perspective of healthcare providers from under-resourced, high-HIV prevalence rural settings. Methods: We conducted a census of all 170 professional nurses from 18 primary healthcare (PHC) clinics in Rustenburg, South Africa, between October 2018 and February 2019. The perceptions, knowledge and attitudes of nursing staff associated with UTT implementation were investigated though the dissemination of self-administered questionnaires. Stata 16.0 was used to analyse the data. Frequency and contingency tables were used to present categorical data. The precision of the estimates was measured using a 95% confidence interval (95% CI), and the p-value of statistical significance is p < 0.05. Results: The facilities were found to have adequate governance and supervision, but gaps were identified, including staffing challenges, bottlenecks and under-resourced service delivery platforms. It was found that a high level of knowledge is a predictor of positive perception of the UTT programme and its implementation. Being supported by capacity development and having positive perceptions of UTT were important motivators for UTT implementation. Conclusions: This study was able to identify potential facilitators of the UTT strategy implementation at the selected facilities. Clinical guidelines and policies on UTT contributed to successful implementation, which means that the process of closing the gaps identified should prioritise the delivery, support and prioritisation of capacity development, infrastructure and the provision of clinical guidelines to all healthcare workers. It is recommended that nurses receive training on UTT and its benefits to increase their knowledge and promote its successful implementation in clinics.
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Abstract
OBJECTIVE While life expectancies of people with HIV (PWH) have increased through the successes of antiretroviral treatment, cognitive impairment remains a pressing concern. Prevalence estimates vary worldwide as different definitions for cognitive impairment are used and resource availability differs across geographical settings. We aim to explore this heterogeneity and estimate the global cognitive impairment burden in PWH. DESIGN Systematic literature review and meta-analysis. METHODS We searched PubMed, Embase, SCOPUS, and Web of Science for studies reporting on cognitive impairment prevalence in PWH. Nine factors were investigated for their potential association with the prevalence using a univariate meta-analysis and a meta-regression: assessment method, geographical region, country income, exclusion criteria, study quality, age, sex, publication year, and sample size. RESULTS The literature search identified 8539 records, of which 225 were included. The adjusted prevalence was significantly lower in males than females. Across 44 countries, 12 assessment methods were used; the HIV-associated neurocognitive disorder/Frascati criteria, known for high false-positive rates, was employed in 44.4% of studies. The pooled cognitive impairment prevalence estimate in PWH, including asymptomatic cases, was 39.6% (95% confidence interval: 37.2-42.1%; range: 7-87%). The meta-regression explained 13.3% of between-study variation, with substantial residual heterogeneity ( I2 = 97.7%). CONCLUSION Lack of data from more than 70% of the world's countries, cohorts being unselected for symptoms in most research studies, and limitations of the HIV-associated neurocognitive disorder/Frascati criteria restrict the ability to accurately determine the global burden of cognitive impairment in PWH. More studies in low-resource settings and a standardized approach to assessing cognitive impairment, bridging research and clinical realms, are needed.
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Al-Tawfiq JA, Alhumaid S, Altawfiq KJ, Bearman G. 2022 World AIDS day: Past achievements and future optimism. New Microbes New Infect 2022; 51:101067. [PMID: 36593884 PMCID: PMC9803940 DOI: 10.1016/j.nmni.2022.101067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/10/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022] Open
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Comins CA, Guddera V, Parmley LE, Young K, Mcingana M, Mulumba N, Mishra S, Phetlhu DR, Hausler H, Schwartz S, Baral S. Opportunities and considerations for the design of decentralized delivery of antiretroviral therapy for female sex workers living with HIV in South Africa. BMC Health Serv Res 2022; 22:1166. [PMID: 36114501 PMCID: PMC9482230 DOI: 10.1186/s12913-022-08506-0] [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: 02/14/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
In South Africa, 60% of female sex workers (FSW) are living with HIV, many of whom experience structural and individual barriers to antiretroviral therapy (ART) initiation and adherence. Community-based decentralized treatment provision (DTP) may mitigate these barriers. To characterize optimal implementation strategies, we explored preferences for DTP among FSW living with HIV in Durban, South Africa.
Methods
Thirty-nine semi-structured in-depth interviews were conducted with FSW living with HIV (n = 24), and key informants (n = 15) including HIV program implementers, security personnel, and brothel managers. Participants were recruited using maximum variation and snowball sampling. Interviews were conducted in English or isiZulu between September–November 2017 and analyzed using grounded theory in Atlas.ti 8.
Results
DTP was described as an intervention that could address barriers to ART adherence and retention, minimizing transport costs, time and wage loss from clinic visits, and act as a safety net to address FSW mobility and clinic access challenges. Respondents highlighted contextual considerations for DTP and suggested that DTP should be venue-based, scheduled during less busy times and days, and integrate comprehensive health services including psychological, reproductive, and non-communicable disease services. ART packaging and storage were important for community-based delivery, and participants suggested DTP should be implemented by sex work sensitized staff with discrete uniform and vehicle branding.
Conclusions
Incorporating FSW preferences may support implementation optimization and requires balancing of tensions between preferences and feasibility. These data suggest the potential utility of DTP for FSW as a strategy to address those most marginalized from current ART programs in South Africa.
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Abana CZY, Lamptey H, Bonney EY, Kyei GB. HIV cure strategies: which ones are appropriate for Africa? Cell Mol Life Sci 2022; 79:400. [PMID: 35794316 PMCID: PMC9259540 DOI: 10.1007/s00018-022-04421-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 06/09/2022] [Accepted: 06/10/2022] [Indexed: 11/10/2022]
Abstract
Although combination antiretroviral therapy (ART) has reduced mortality and improved lifespan for people living with HIV, it does not provide a cure. Patients must be on ART for the rest of their lives and contend with side effects, unsustainable costs, and the development of drug resistance. A cure for HIV is, therefore, warranted to avoid the limitations of the current therapy and restore full health. However, this cure is difficult to find due to the persistence of latently infected HIV cellular reservoirs during suppressive ART. Approaches to HIV cure being investigated include boosting the host immune system, genetic approaches to disable co-receptors and the viral genome, purging cells harboring latent HIV with latency-reversing latency agents (LRAs) (shock and kill), intensifying ART as a cure, preventing replication of latent proviruses (block and lock) and boosting T cell turnover to reduce HIV-1 reservoirs (rinse and replace). Since most people living with HIV are in Africa, methods being developed for a cure must be amenable to clinical trials and deployment on the continent. This review discusses the current approaches to HIV cure and comments on their appropriateness for Africa.
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Affiliation(s)
- Christopher Zaab-Yen Abana
- Department of Virology, College of Health Sciences, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Helena Lamptey
- Department of Immunology, College of Health Sciences, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Evelyn Y Bonney
- Department of Virology, College of Health Sciences, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - George B Kyei
- Department of Virology, College of Health Sciences, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana.
- Departments of Medicine and Molecular Microbiology, Washington University in St. Louis, 660 S. Euclid Ave, St. Louis, MO, USA.
- Medical and Scientific Research Center, University of Ghana Medical Centre, Accra, Ghana.
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Zhao Y, Hohlfeld A, Namale P, Meintjes G, Maartens G, Engel ME. Risk of Immune Reconstitution Inflammatory Syndrome With Integrase Inhibitors Versus Other Classes of Antiretrovirals: A Systematic Review and Meta-analysis of Randomized Trials. J Acquir Immune Defic Syndr 2022; 90:232-239. [PMID: 35175970 PMCID: PMC7612870 DOI: 10.1097/qai.0000000000002937] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/02/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Integrase strand transfer inhibitors (InSTIs) decrease HIV plasma viral load faster than other antiretroviral classes. More rapid viral load decline has been associated with higher risk of immune reconstitution inflammatory syndrome (IRIS). There are conflicting reports on the association between InSTI and IRIS. We performed a systematic review and meta-analysis to compare the risk of IRIS among treatment-naive HIV-positive patients starting InSTI versus non-InSTI regimens. METHODS We searched PubMed, Scopus, Web of Science, Africa-Wide, and Cochrane databases from earliest available date to 26 November 2021, for randomized controlled trials (RCTs) having intervention arms with InSTI versus control arms without InSTI in patients initiating first-line antiretroviral therapy. The primary outcome was relative risk (RR) of IRIS, whereas the secondary outcome was RR of paradoxical tuberculosis-associated IRIS (TB-IRIS). Data were combined by random-effects meta-analysis according to the Mantel-Haenszel method. The protocol for this study is registered with PROSPERO, CRD42020213976. RESULTS We included 14 RCTs comprising 8696 participants from 6 continents for the primary outcome of IRIS and a subset of 674 participants (from 3 RCTs) for the secondary outcome of paradoxical TB-IRIS. Risk of IRIS was similar between InSTI and non-InSTI regimens (RR, 0.93; 95% confidence interval: 0.75 to 1.14). There was a trend towards a lower risk of paradoxical TB-IRIS with InSTI versus efavirenz regimens that was not statistically significant (RR, 0.64; 95% confidence interval: 0.34 to 1.19). CONCLUSIONS In this meta-analysis among treatment-naive patients commencing first-line antiretroviral therapy, InSTI regimens were not associated with higher risk of IRIS.
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Affiliation(s)
- Ying Zhao
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ameer Hohlfeld
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Phiona Namale
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mark E Engel
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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Global Health Facility-Based Interventions to Achieve UNAIDS 90-90-90: A Systematic Review and Narrative Analysis. AIDS Behav 2022; 26:1489-1503. [PMID: 34694526 DOI: 10.1007/s10461-021-03503-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
Abstract
To evaluate whether health facility-based HIV interventions align with UNAIDS 90-90-90 targets, we performed a systematic review through the lens of UNAIDS targets. We searched 11 databases, retrieving 5201 citations with 26 eligible studies classified by country income and UNAIDS target. We analyzed whether reporting of study outcome metrics was in line with UNAIDS targets using a standardized extraction form and results were summarized in a narrative synthesis given data heterogeneity. We also assessed the quality of randomized trials with the Cochrane Risk of Bias Tool and observational studies with the Newcastle-Ottawa Scale. Stratification of interventions by country income level revealed themes in successful interventions that provide insight for scale-up in similar resource contexts. Few studies reported outcomes using metrics according to UNAIDS targets. Standardization of reporting according to the UNAIDS framework could facilitate comparability of interventions and inform country-level progress on an international scale.
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Kim JH, Jiamsakul A, Kiertiburanakul S, Huy BV, Khusuwan S, Kumarasamy N, Ng OT, Ly PS, Lee MP, Chan YJ, Gani YM, Azwa I, Avihingsanon A, Merati TP, Pujari S, Chaiwarith R, Zhang F, Tanuma J, Do CD, Ditangco R, Yunihastuti E, Ross J, Choi JY. Patterns and prognosis of holding regimens for people living with HIV in Asian countries. PLoS One 2022; 17:e0264157. [PMID: 35353840 PMCID: PMC8967045 DOI: 10.1371/journal.pone.0264157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 02/04/2022] [Indexed: 01/11/2023] Open
Abstract
The use of holding regimens for people living with HIV (PLWH) without effective antiretroviral options can have effects on outcomes and future treatment options. We aimed to investigate the use of holding regimens for PLWH in Asian countries. Data from adults enrolled in routine HIV care in IeDEA Asia-Pacific cohorts were included. Individuals were considered to be on holding regimen if they had been on combination antiretroviral therapy for at least 6 months, had two confirmed viral loads (VL) ≥1000 copies/mL, and had remained on the same medications for at least 6 months. Survival time was analyzed using Fine and Gray's competing risk regression. Factors associated with CD4 changes and VL <1000 copies/mL were analyzed using linear regression and logistic regression, respectively. A total of 425 PLWH (72.9% male; 45.2% high-income and 54.8% low-to-middle-income country) met criteria for being on a holding regimen. From high-income countries, 63.0% were on protease inhibitors (PIs); from low-to-middle-income countries, 58.4% were on non-nucleoside reverse transcriptase inhibitors (NNRTIs); overall, 4.5% were on integrase inhibitors. The combination of lamivudine, zidovudine, and efavirenz was the most commonly used single regimen (n = 46, 10.8%), followed by lamivudine, zidovudine, and nevirapine (n = 37, 8.7%). Forty-one PLWH (9.7%) died during follow-up (mortality rate 2.0 per 100 person-years). Age >50 years compared to age 31-40 years (sub-hazard ratio [SHR] 3.29, 95% CI 1.45-7.43, p = 0.004), and VL ≥1000 copies/ml compared to VL <1000 copies/mL (SHR, 2.14, 95% CI 1.08-4.25, p = 0.029) were associated with increased mortality, while higher CD4 counts were protective. In our Asia regional cohort, there was a diversity of holding regimens, and the patterns of PI vs. NNRTI use differed by country income levels. Considering the high mortality rate of PLWH with holding regimen, efforts to extend accessibility to additional antiretroviral options are needed in our region.
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Affiliation(s)
- Jung Ho Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | | | | | - Bui Vu Huy
- National Hospital for Tropical Diseases, Hanoi, Vietnam
| | | | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site (CART CRS), VHS-Infectious Diseases Medical Centre, VHS, Chennai, India
| | - Oon Tek Ng
- Tan Tock Seng Hospital, Singapore, Singapore
| | - Penh Sun Ly
- National Center for HIV/AIDS, Dermatology & STDs, Phnom Penh, Cambodia
| | - Man-Po Lee
- Queen Elizabeth Hospital, Kowloon, Hong Kong SAR
| | - Yu-Jiun Chan
- Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Iskandar Azwa
- University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Anchalee Avihingsanon
- HIV-NAT/ Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Tuberculosis Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Tuti Parwati Merati
- Faculty of Medicine Udayana University & Sanglah Hospital, Denpasar, Bali, Indonesia
| | | | | | - Fujie Zhang
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Junko Tanuma
- National Center for Global Health and Medicine, Tokyo, Japan
| | | | - Rossana Ditangco
- Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Evy Yunihastuti
- Faculty of Medicine Universitas Indonesia—Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Jeremy Ross
- TREAT Asia, amfAR—The Foundation for AIDS Research, Bangkok, Thailand
| | - Jun Yong Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- * E-mail:
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Zhao Y, Keene C, Griesel R, Sayed K, Gcwabe Z, Jackson A, Ngwenya O, Schutz C, Goliath R, Cassidy T, Goemaere E, Hill A, Maartens G, Meintjes G. AntiRetroviral Therapy In Second-line: investigating Tenofovir-lamivudine-dolutegravir (ARTIST): protocol for a randomised controlled trial. Wellcome Open Res 2021; 6:33. [PMID: 36017341 PMCID: PMC9372637 DOI: 10.12688/wellcomeopenres.16597.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Dolutegravir has superior efficacy and tolerability than lopinavir-ritonavir in second-line antiretroviral therapy after failure of a first-line non-nucleoside reverse transcriptase inhibitors-based regimen, when dolutegravir is accompanied by at least one fully active nucleoside reverse transcriptase inhibitor (NRTI). Resistance testing to select NRTIs is not feasible in low- and middle-income countries due to cost and limited laboratory capacity. Evidence suggests that recycling tenofovir plus lamivudine or emtricitabine backbone with dolutegravir could provide an effective second-line option. This study aims to determine the virologic efficacy of tenofovir-lamivudine-dolutegravir (TLD) with and without a lead-in supplementary dose of dolutegravir (to counteract the inducing effect of efavirenz) in patients failing a first-line regimen of tenofovir-emtricitabine-efavirenz (TEE). Methods: We will perform a parallel group, randomised (1:1), double blind, placebo-controlled, Phase II trial, comparing TLD fixed dose combination daily with a lead-in supplementary 50 mg dolutegravir dose versus matching placebo taken 12 hours later for the first 14 days, in patients failing a first-line TEE regimen. The trial will be set in two primary care clinics in Khayelitsha; a large, peri-urban informal settlement in Cape Town, South Africa. We will enrol 130 participants, with follow-up to 48 weeks. The primary endpoint is proportion achieving viral load <50 copies/mL at week 24 using a modified intention-to-treat analysis and the U.S. Food and Drug Administration snapshot algorithm. Secondary endpoints include virologic suppression at weeks 12 and 48, time to suppression, emergence of dolutegravir and new NRTI resistance mutations, safety, and tolerability. Discussion: Impaired viral fitness due to NRTI resistance mutations and dolutegravir's high barrier to resistance provide rationale for switching patients from a failing TEE regimen to TLD; however, clinical evidence regarding virologic efficacy is lacking. This study provides estimates of such a strategy's early virologic efficacy with and without a supplementary dolutegravir dosing. Registration: ClinicalTrials.gov NCT03991013 (19/06/2019).
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Affiliation(s)
- Ying Zhao
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Claire Keene
- Médecins Sans Frontières, Cape Town, South Africa
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rulan Griesel
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kaneez Sayed
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Zimasa Gcwabe
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Amanda Jackson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Olina Ngwenya
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Charlotte Schutz
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Rene Goliath
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Tali Cassidy
- Médecins Sans Frontières, Cape Town, South Africa
- Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Eric Goemaere
- Médecins Sans Frontières, Cape Town, South Africa
- Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Hill
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Onoya D, Mokhele I, Sineke T, Mngoma B, Moolla A, Vujovic M, Bor J, Langa J, Fox MP. Health provider perspectives on the implementation of the same-day-ART initiation policy in the Gauteng province of South Africa. Health Res Policy Syst 2021; 19:2. [PMID: 33407574 PMCID: PMC7789550 DOI: 10.1186/s12961-020-00673-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 12/16/2020] [Indexed: 12/27/2022] Open
Abstract
Background In September 2016, South Africa (SA) began implementing the universal-test-and-treat (UTT) policy in hopes of attaining the UNAIDS 90-90-90 targets by 2020. The SA National Department of Health provided a further directive to initiate antiretroviral therapy (ART) on the day of HIV diagnosis in September 2017. We conducted a qualitative study to determine the progress in implementing UTT and examine health providers' perspectives on the implementation of the same-day initiation (SDI) policy, six months after the policy change. Methods We conducted in-depth interviews with three professional nurses, and four HIV lay counsellors of five primary health clinics in the Gauteng province, between October and December 2017. In September 2018, we also conducted a focus group discussion with ten professional nurses/clinic managers from ten clinic facilities. The interviews and focus groups covered the adoption and implementation of UTT and SDI policies. Interviews were conducted in English, Sotho or Zulu and audio-recorded with participant consent. Audio-recordings were transcribed verbatim, translated to English and analysed thematically using NVivo 11. Results The data indicates inconsistencies across facilities and incongruities between counsellor and nursing provider perspectives regarding the SDI policy implementation. While nurses highlighted the clinical benefits of early ART initiation, they expressed concerns that immediate ART may be overwhelming for some patients, who may be unprepared and likely to disengage from care soon after the initial acceptance of ART. Accordingly, the SDI implementation was slow due to limited patient demand, provider ambivalence to the policy implementations, as well as challenges with infrastructure and human resources. The process for assessing patient readiness was poorly defined by health providers across facilities, inconsistent and counsellor dependent. Providers were also unclear on how to ensure that patients who defer treatment return for ongoing counselling. Conclusions Our results highlight important gaps in the drive to achieve the ART initiation target and demonstrate the need for further engagement with health care providers around the implementation of same-day ART initiation, particularly with regards to infrastructural/capacity needs and the management of patient readiness for lifelong ART on the day of HIV diagnosis. Additionally, there is a need for improved promotion of the SDI provision both in health care settings and in media communications to increase patient demand for early and lifelong ART.
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Affiliation(s)
- Dorina Onoya
- 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.
| | - Idah Mokhele
- 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
| | - Tembeka Sineke
- 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
| | | | - Aneesa Moolla
- 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
| | | | - 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.,Departments of Global Health, Boston University School of Public Health, Boston, MA, United States of America.,Departments of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
| | | | - 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.,Departments of Global Health, Boston University School of Public Health, Boston, MA, United States of America.,Departments of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
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11
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Martin EG, MacDonald RH, Gordon DE, Swain CA, O'Donnell T, Helmeset J, Dwicaksono A, Tesoriero JM. Simulating the End of AIDS in New York: Using Participatory Dynamic Modeling to Improve Implementation of the Ending the Epidemic Initiative. Public Health Rep 2020; 135:158S-171S. [PMID: 32735199 DOI: 10.1177/0033354920935069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES In 2014, the governor of New York announced the Ending the Epidemic (ETE) plan to reduce annual new HIV infections from 3000 to 750, achieve a first-ever decrease in HIV prevalence, and reduce AIDS progression by the end of 2020. The state health department undertook participatory simulation modeling to develop a baseline for comparing epidemic trends and feedback on ETE strategies. METHODS A dynamic compartmental model projected the individual and combined effects of 3 ETE initiatives: enhanced linkage to and retention in HIV treatment, increased preexposure prophylaxis (PrEP) among men who have sex with men, and expanded housing assistance. Data inputs for model calibration and low-, medium-, and high-implementation scenarios (stakeholders' rollout predictions, and lower and upper bounds) came from surveillance and program data through 2014, the literature, and expert judgment. RESULTS Without ETE (baseline scenario), new HIV infections would decline but remain >750, and HIV prevalence would continue to increase by 2020. Concurrently implementing the 3 programs would lower annual new HIV infections by 16.0%, 28.1%, and 45.7% compared with baseline in the low-, medium-, and high-implementation scenarios, respectively. In all concurrent implementation scenarios, although annual new HIV infections would remain >750, there would be fewer new HIV infections than deaths, yielding the first-ever decrease in HIV prevalence. PrEP and enhanced linkage and retention would confer the largest population-level changes. CONCLUSIONS New York State will achieve 1 ETE benchmark under the most realistic (medium) implementation scenario. Findings facilitated framing of ETE goals and underscored the need to prioritize men who have sex with men and maintain ETE's multipronged approach, including other programs not modeled here.
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Affiliation(s)
- Erika G Martin
- 1084 Department of Public Administration and Policy, University at Albany, Albany, NY, USA.,Center for Collaborative HIV Research in Practice and Policy, Albany, NY, USA
| | - Roderick H MacDonald
- 3745 School of Integrated Science, James Madison University, Harrisonburg, VA, USA
| | - Daniel E Gordon
- 1094 AIDS Institute, New York State Department of Health, Albany, NY, USA
| | - Carol-Ann Swain
- 1094 AIDS Institute, New York State Department of Health, Albany, NY, USA
| | - Travis O'Donnell
- 1094 AIDS Institute, New York State Department of Health, Albany, NY, USA
| | - John Helmeset
- 1094 AIDS Institute, New York State Department of Health, Albany, NY, USA
| | - Adenantera Dwicaksono
- 1084 Department of Public Administration and Policy, University at Albany, Albany, NY, USA.,School of Architecture, Planning, and Policy Development, Institut Teknologi Bandung, Indonesia
| | - James M Tesoriero
- Center for Collaborative HIV Research in Practice and Policy, Albany, NY, USA.,1094 AIDS Institute, New York State Department of Health, Albany, NY, USA
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12
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Train KJ, April K. Compassion capability in resource-limited organizations in South Africa. AFRICA JOURNAL OF MANAGEMENT 2020. [DOI: 10.1080/23322373.2020.1717284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Katherine J. Train
- Graduate School of Business, University of Cape Town, Cape Town, South Africa
| | - Kurt April
- Graduate School of Business, University of Cape Town, Cape Town, South Africa
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13
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All-cause mortality after antiretroviral therapy initiation in HIV-positive women from Europe, Sub-Saharan Africa and the Americas. AIDS 2020; 34:277-289. [PMID: 31876592 PMCID: PMC6948801 DOI: 10.1097/qad.0000000000002399] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Supplemental Digital Content is available in the text Background: Women account for over half of persons living with HIV/AIDS globally. We examined geographic variation in all-cause mortality after antiretroviral therapy (ART) for women living with HIV (WLWH) worldwide. Methods: We pooled data from WLWH at least 18 years initiating ART 2000–2014 within COHERE (Europe) and IeDEA regions (East Africa, West Africa, South Africa, North America, Latin America/Caribbean). Mortality rates were calculated at 0–3, 3–6, 6–12, 12–24 and 24–48 months after ART, and mortality rate ratios were compared with European rates with piecewise exponential parametric survival models based on Poisson regression. Findings: One hundred ninety thousand, one hundred and seventy-five WLWH (16% Europe, 47% East Africa, 13% West Africa, 19% South Africa, 1% South America, 3% North America and 2% Central America/Caribbean) were included. The highest death rates occurred 0–3 months after ART [1.51 (95% CI 1.25–1.82) per 100 person-years in Europe, 12.45 (11.30–13.73), 14.03 (13.12–15.02) and 9.44 (8.80–10.11) in East, West and South Africa, and 1.53 (0.97–2.43), 7.83 (5.44–11.27) and 17.02 (14.62–19.81) in North, South America and Central America/Caribbean, respectively] and declined thereafter. Mortality in Europe was the lowest, with regional differences greatest in the first 3 months and smaller at longer ART durations [adjusted rate ratios 24–48 months after ART: 3.63 (95% CI 3.04–4.33), 5.61 (4.84–6.51) and 3.47 (2.97–4.06) for East, West and South Africa; 2.86 (2.26–3.62), 2.42 (1.65–3.55) and 2.50 (1.92–3.26) for North, South America and Central America/Caribbean, respectively]. Conclusion: Global variations in short-term and long-term mortality among WLWH initiating ART may inform context-specific interventions.
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14
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Moretti S, Cafaro A, Tripiciano A, Picconi O, Buttò S, Ensoli F, Sgadari C, Monini P, Ensoli B. HIV therapeutic vaccines aimed at intensifying combination antiretroviral therapy. Expert Rev Vaccines 2020; 19:71-84. [PMID: 31957513 DOI: 10.1080/14760584.2020.1712199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Although successful at suppressing HIV replication, combination antiretroviral therapy (cART) only partially restores immune functions and fails to reduce the latent HIV reservoir, thus requiring novel interventions for its intensification.Areas covered: Here are reviewed therapeutic vaccine candidates that are being developed to this goal. Among them, the Tat vaccine has been shown to promote immune restoration, including CD4+ T-cell recovery in low immunological responders, and to reduce the virus reservoirs well beyond what achieved with long-term suppressive cART.Expert opinion: The authors propose the Tat vaccine as a promising vaccine candidate for cART intensification toward HIV reservoirs depletion, functional cure, and eradication strategies, suggesting that targeting a key protein in the virus life cycle is pivotal to success.
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Affiliation(s)
- Sonia Moretti
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, Rome, Italy
| | - Aurelio Cafaro
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, Rome, Italy
| | | | - Orietta Picconi
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, Rome, Italy
| | - Stefano Buttò
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, Rome, Italy
| | - Fabrizio Ensoli
- Pathology and Microbiology, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Cecilia Sgadari
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, Rome, Italy
| | - Paolo Monini
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, Rome, Italy
| | - Barbara Ensoli
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, Rome, Italy
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15
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Bekelynck A, Larmarange J. Pepfar 3.0's HIV testing policy in Côte d'Ivoire (2014 to 2018): fragmentation, acceleration and disconnection. J Int AIDS Soc 2019; 22:e25424. [PMID: 31854504 PMCID: PMC6921083 DOI: 10.1002/jia2.25424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 11/14/2019] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION HIV Testing and Counselling (HTC) remains a key challenge in achieving control of the HIV epidemic by 2030. In the early 2010s, the President's Emergency Plan for AIDS Relief (Pepfar) adopted targeted HTC strategies for populations and geographical areas most affected by HIV. We examine how Pepfar defined targeted HTC in Côte d'Ivoire, a country with a mixed HIV epidemic, after a decade of expanding HTC services. METHODS We explored the evolution of HTC strategies through the Country Operational Plans (COP) of Pepfar during its phase 3.0, from COP 14 to COP 17 (October 2014 to September 2018) in Côte d'Ivoire. We conducted an analysis of the grey literature over the period 2014 to 2018 (Budget & Target Report, Strategic Direction Summary, Sustainability Index and Dashboard Summary, https://data.pepfar.gov). We also conducted a qualitative study in Côte d'Ivoire (2015 to 2018) using in-depth interviews with stakeholders in the AIDS public response: CDC/Pepfar (3), Ministry of Health (3), intermediary NGOs (7); and public meeting observations (14). RESULTS Since the COP 14, Pepfar's HIV testing strategies have been characterized by significant variations in terms of numerical, geographical and population targets. While the aim of COP 14 and COP 15 seemed to be the improvement of testing efficacy in general and testing yield in particular, COP 16 and COP 17 prioritized accelerating progress towards the "first 90" (i.e. reducing the proportion of people living with HIV who are unaware of their HIV). A shift was observed in the definition of testing targets, with less focus on the inclusion of programmatic data and feedback from field actors, and greater emphasis on the use of models to estimate and disaggregate the targets by geographical units and sub-populations (even if the availability of data by this disaggregation was limited or uncertain); increasingly leading to gaps between targets and results. CONCLUSIONS These trials and tribulations question the real and long-term effectiveness of annually-revised, fragmented strategies, which widen an increasing disparity between the realities of the actors on the ground and the objectives set in Washington.
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Affiliation(s)
- Anne Bekelynck
- PAC‐CI/ANRS Research Site ProgramTreichville University HospitalAbidjanIvory Coast
- Centre Population et Développement (Ceped)Université Paris Descartes, IRD, InsermParisFrance
| | - Joseph Larmarange
- Centre Population et Développement (Ceped)Université Paris Descartes, IRD, InsermParisFrance
- Institut de Recherche et Développement (IRD)ParisFrance
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16
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Mendez‐Lopez A, McKee M, Stuckler D, Granich R, Gupta S, Noori T, Semenza JC. Population uptake and effectiveness of test-and-treat antiretroviral therapy guidelines for preventing the global spread of HIV: an ecological cross-national analysis. HIV Med 2019; 20:501-512. [PMID: 31140715 PMCID: PMC6772052 DOI: 10.1111/hiv.12750] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Although the benefits of adopting test-and-treat antiretroviral therapy (ART) guidelines that recommend initiation of ART regardless of CD4 cell counts have been demonstrated at the individual level, there is uncertainty about how this translates to the population level. Here, we explored whether adopting ART guidelines recommending earlier treatment initiation improves population ART access and viral suppression and reduces overall disease transmission. METHODS Data on ART initiation guidelines and treatment coverage, viral suppression, and HIV incidence from 37 European and Central Asian countries were collected from the European Centre for Disease Prevention and Control and the Global HIV Policy Watch and HIV 90-90-90 Watch databases. We used multivariate linear regression models to quantify the association of ART initiation guidelines with population ART access, viral suppression, and HIV incidence, adjusting for potential confounding factors. RESULTS Test-and-treat policies were associated with 15.2 percentage points (pp) [95% confidence interval (CI) 0.8-29.6 pp; P = 0.039] greater treatment coverage (proportion of HIV-positive people on ART) compared with countries with ART initiation at CD4 cell counts ≤ 350 cells/μL. The presence of test-and-treat policies was associated with 15.8 pp (95% CI 2.4-29.1 pp; P = 0.023) higher viral suppression rates (people on ART virally suppressed) compared with countries with treatment initiation at CD4 counts ≤ 350 cells/μL. ART initiation at CD4 counts ≤ 500 cells/μL did not significantly improve ART coverage compared to initiation at CD4 counts ≤ 350 cells/μL but achieved similar degrees of viral suppression as test-and-treat. CONCLUSIONS Test-and-treat was found to be associated with substantial improvements in population-level access to ART and viral suppression, further strengthening evidence that rapid initiation of treatment will help curb the spread of HIV.
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Affiliation(s)
| | - M McKee
- Department of Public Health & PolicyLondon School of Hygiene & Tropical MedicineLondonUK
| | - D Stuckler
- Department of Public Health & PolicyLondon School of Hygiene & Tropical MedicineLondonUK
- Dondena Research CentreUniversity of BocconiMilanItaly
| | - R Granich
- Independent Public Health ConsultantSan FranciscoCAUSA
| | - S Gupta
- Independent Public Health ConsultantDelhiIndia
| | - T Noori
- European Centre for Disease Prevention and ControlStockholmSweden
| | - JC Semenza
- European Centre for Disease Prevention and ControlStockholmSweden
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17
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Casale M, Carlqvist A, Cluver L. Recent Interventions to Improve Retention in HIV Care and Adherence to Antiretroviral Treatment Among Adolescents and Youth: A Systematic Review. AIDS Patient Care STDS 2019; 33:237-252. [PMID: 31166783 PMCID: PMC6588099 DOI: 10.1089/apc.2018.0320] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Adolescents represent a growing proportion of people living with HIV worldwide and the highest risk population group for treatment attrition and AIDS-related mortality. There is an urgent need to design, implement, and test interventions that keep young people in HIV treatment and care. However, previous systematic reviews show scarce and inconclusive evidence of effective interventions for this age group. Recent years have seen an increase in focus on adolescent health and a rapidly changing programmatic environment. This systematic review article provides an evidence update by synthesizing empirical evaluations of interventions designed to improve antiretroviral therapy adherence and retention among adolescents (10-19) and youth (15-24) living with HIV, published between January 2016 and June 2018. A search of 11 health and humanities databases generated 2425 citations and 10 relevant studies, the large majority conducted in sub-Saharan Africa. These include six clinic-level interventions, one individual-level m-Health trial, and three community- or household-level interventions. Implications of their findings for future programming and research with young adults are discussed, in relation to previous reviews and the broader empirical evidence in this area. Findings highlight the need to further develop and test multi-faceted interventions that go beyond health facilities, to address broader social barriers to adherence and retention. In particular, further intervention studies with adolescents (10-19) should be a priority, if we are to retain these young people in treatment and care and aspire to achieve the United Nation's Sustainable Development Goals and 90-90-90 targets.
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Affiliation(s)
- Marisa Casale
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Anna Carlqvist
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
| | - Lucie Cluver
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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18
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Fan J, Liang H, Ji X, Wang S, Xue J, Li D, Peng H, Qin C, Yee C, Shao Y. CTL-mediated immunotherapy can suppress SHIV rebound in ART-free macaques. Nat Commun 2019; 10:2257. [PMID: 31113957 PMCID: PMC6529452 DOI: 10.1038/s41467-019-09725-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 03/26/2019] [Indexed: 01/05/2023] Open
Abstract
A major barrier to human immunodeficiency virus (HIV) cure is the existence of viral reservoirs that lead to viral rebound following discontinuation of antiretroviral therapy (ART). We postulate that enhancing cytotoxic T lymphocytes (CTL) targeting conserved envelope (Env) regions can eliminate HIV infected cells in latency. Here, we evaluate the use of adoptively transferred HIV vaccine-induced subtype C Env-specific CTLs in a macaque subtype B simian-human immunodeficiency virus (SHIV) model to determine whether plasma viremia can be controlled after ART interruption. We demonstrate that adoptive cellular therapy (ACT) using autologous Env-specific T cells augmented by therapeutic vaccination can suppress ART-free viral rebound in the SHIV model. Furthermore, phenotypic and functional characterization of adoptively transferred cells in ACT-responsive and nonresponsive animals support a critical role for cross-reactive central memory T cells in viremia control. Our study offers an approach to potentiate immunological suppression of HIV in the absence of antiviral drugs. Viral rebound following discontinuation of antiretroviral therapy (ART) is a major obstacle for HIV cure. Here, the authors show that adoptive cellular therapy using autologous Env-specific T cells augmented by therapeutic vaccination can control viral rebound after ART interruption in a SHIV macaque model.
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Affiliation(s)
- Jin Fan
- Department of Microbiology & Infectious Disease Center, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China.,State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China
| | - Hua Liang
- State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China
| | - Xiaolin Ji
- State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China
| | - Shuo Wang
- State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China
| | - Jing Xue
- Key Laboratory of Human Disease Comparative Medicine, Chinese Ministry of Health, Beijing Key Laboratory for Animal Models of Emerging and Remerging Infectious Diseases, Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences and Comparative Medicine Center, Peking Union Medical College, Beijing, China
| | - Dan Li
- State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China
| | - Hong Peng
- State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China
| | - Chuan Qin
- Key Laboratory of Human Disease Comparative Medicine, Chinese Ministry of Health, Beijing Key Laboratory for Animal Models of Emerging and Remerging Infectious Diseases, Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences and Comparative Medicine Center, Peking Union Medical College, Beijing, China
| | - Cassian Yee
- Department of Melanoma Medical Oncology, Department of Immunology, UT MD Anderson Cancer Center, Houston, USA.
| | - Yiming Shao
- Department of Microbiology & Infectious Disease Center, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China. .,State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China.
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19
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Saravolatz S, Szpunar S, Johnson L. The association of psychiatric medication use with adherence in patients with HIV. AIDS Care 2019; 31:988-993. [PMID: 31046415 DOI: 10.1080/09540121.2019.1612011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Over two million new cases of HIV infection will occur annually, worldwide. Triple drug anti-retroviral therapy (ART) decreases the viral load in patients with HIV, helping to stop progression of HIV infection to AIDs. Our study assessed how pharmacologic treatment for mental health issues affects medication adherence and viral load in patients with HIV. We conducted a retrospective chart review of 163 patients with HIV who had at least 2 visits at the HIV-clinic at Ascension St. John Hospital. Data were collected on demographics, medications, CD4 counts and viral loads. Data were analyzed using Student's t-test, the χ2 test, the Mann-Whitney U test and logistic regression. "Poor Compliance" was defined as at least 2 consecutive visits with a CD4 count <200 µL and/or with viral load ≥100 IU/ml. Patients taking antidepressants were less likely to have poor compliance than those not on anti-depressants (6.3% vs. 22.3%, p = 0.04). A similar association was found for patients taking any psychiatric drug (7.0% vs. 23.5%, p = 0.02). On multivariable analysis, the odds of poor compliance were 6.3 times higher in patients who stopped HIV therapy for greater than one week between visits (p = 0.004) and 3.6 times lower in patients taking any psychiatric medication (p = 0.05).
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Affiliation(s)
- Stephanie Saravolatz
- a Department of Internal Medicine , Ascension St. John Hospital , Grosse Pointe Woods , MI , USA
| | - Susan Szpunar
- b Department of Medical Education , Ascension St. John Hospital , Grosse Pointe Woods , MI , USA
| | - Leonard Johnson
- a Department of Internal Medicine , Ascension St. John Hospital , Grosse Pointe Woods , MI , USA
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20
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Nansseu JR, Bigna JJ, Kaze AD, Noubiap JJ. Incidence and Risk Factors for Prediabetes and Diabetes Mellitus Among HIV-infected Adults on Antiretroviral Therapy: A Systematic Review and Meta-analysis. Epidemiology 2019; 29:431-441. [PMID: 29394189 DOI: 10.1097/ede.0000000000000815] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To summarize evidence on the rates and drivers of progression from normoglycemia to prediabetes and/or diabetes mellitus (hereafter "diabetes") in antiretroviral treatment (ART)-exposed HIV-infected people. METHODS We searched EMBASE, PubMed, Web of Science, and Global Index Medicus to identify articles published from 1 January 2000 to 30 April 2017. A random-effects model produced a summary estimate of the incidence across studies and heterogeneity was assessed using Cochrane's Q statistic. RESULTS We included 44 studies, whose methodologic quality was high with only 10 (30%) medium-quality studies and none of low quality. There was substantial heterogeneity between studies in estimates of the incidence of diabetes and prediabetes. The pooled incidence rate of overt diabetes and prediabetes were 13.7 per 1,000 person-years of follow-up (95% CI = 13, 20; I = 98.1%) among 396,496 person-years and 125 per 1,000 person-years (95% CI = 0, 123; I = 99.4) among 1,532 person-years, respectively. The major risk factors for diabetes and prediabetes were aging, family history of diabetes, Black or Hispanic origin, overweight/obesity, central obesity, lipodystrophy/lipoatrophy, dyslipidemia, metabolic syndrome, increased baseline fasting glycemia, and certain ART regimens. CONCLUSIONS These data highlight the important and fast-increasing burden of diabetes and prediabetes among the ART-exposed HIV-infected population. More research is needed to better capture the interplay between prediabetes/diabetes and ART in HIV-infected patients, considering the increasing number of ART-exposed patients subsequent to the World Health Organization's recommendation of initiating ART at HIV infection diagnosis regardless of CD4 count and age.
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21
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Chihana ML, Huerga H, Van Cutsem G, Ellman T, Wanjala S, Masiku C, Szumilin E, Etard JF, Davies MA, Maman D. Impact of "test and treat" recommendations on eligibility for antiretroviral treatment: Cross sectional population survey data from three high HIV prevalence countries. PLoS One 2018; 13:e0207656. [PMID: 30475865 PMCID: PMC6261019 DOI: 10.1371/journal.pone.0207656] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 11/05/2018] [Indexed: 12/02/2022] Open
Abstract
Background Latest WHO guidelines recommend starting HIV-positive individuals on antiretroviral therapy treatment (ART) regardless of CD4 count. We assessed additional impact of adopting new WHO guidelines. Methods We used data of individuals aged 15–59 years from three HIV population surveys conducted in 2012 (Kenya) and 2013 (Malawi and South Africa). Individuals were interviewed at home followed by rapid HIV and CD4 testing if tested HIV-positive. HIV-positive individuals were classified as “eligible for ART” if (i) had ever been initiated on ART or (ii) were not yet on ART but met the criteria for starting ART based on country’s guidelines at the time of the survey (Kenya–CD4< = 350 cells/μl and WHO Stage 3 or 4 disease, Malawi as for Kenya plus lifelong ART for all pregnant and breastfeeding women, South Africa as for Kenya plus ART for pregnant and breastfeeding women until cessation of breastfeeding). Findings Of 18,991 individuals who tested, 4,113 (21.7%) were HIV-positive. Using country’s ART eligibility guidelines at the time of the survey, the proportion of HIV-infected individuals eligible for ART was 60.0% (95% CI: 57.2–62.7) (Kenya), 73.4% (70.8–75.8) (South Africa) and 80.1% (77.3–82.6) (Malawi). Applying WHO 2013 guidelines (eligibility at CD4< = 500 and Option B+ for pregnant and breastfeeding women), the proportions eligible were 82.0% (79.8–84.1) (Kenya), 83.7% (81.5–85.6) (South Africa) and 87.6% (85.0–89.8) (Malawi). Adopting “test and treat” would mean a further 18.0% HIV-positive individuals (Kenya), 16.3% (South Africa) and 12.4% (Malawi) would become eligible. In all countries, about 20% of adolescents (aged 15–19 years), became eligible for ART moving from WHO 2013 to “test and treat” while no differences by sex were observed. Conclusion Countries that have already implemented 2013 WHO recommendations, the burden of implementing “test and treat” would be small. Youth friendly programmes to help adolescents access and adhere to treatment will be needed.
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Affiliation(s)
- Menard Laurent Chihana
- Centre for Infectious Diseases and Epidemiology, University of Cape Town, Cape Town, South Africa
- Epicentre, Cape Town, South Africa
- * E-mail:
| | | | - Gilles Van Cutsem
- Centre for Infectious Diseases and Epidemiology, University of Cape Town, Cape Town, South Africa
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Tom Ellman
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | | | | | | | - Jean Francois Etard
- Epicentre, Paris, France
- IRD UMI 233, INSERM U1175, Montpellier University, TransVIHMI, Montpellier, France
| | - Mary-Ann Davies
- Centre for Infectious Diseases and Epidemiology, University of Cape Town, Cape Town, South Africa
| | - David Maman
- Centre for Infectious Diseases and Epidemiology, University of Cape Town, Cape Town, South Africa
- Epicentre, Cape Town, South Africa
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22
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Jacobson K, Ogbuagu O. Integrase inhibitor-based regimens result in more rapid virologic suppression rates among treatment-naïve human immunodeficiency virus-infected patients compared to non-nucleoside and protease inhibitor-based regimens in a real-world clinical setting: A retrospective cohort study. Medicine (Baltimore) 2018; 97:e13016. [PMID: 30412140 PMCID: PMC6221636 DOI: 10.1097/md.0000000000013016] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The integrase strand transfer inhibitor (INSTI) class of antiretroviral therapy (ART) may result in faster time to virologic suppression compared with regimens that contain protease inhibitors (PIs) or non-nucleoside reverse transcriptase inhibitors (NNRTIs). However, differences in time to achieve virologic suppression are not well-defined in routine clinical settings with contemporary antiretroviral agents.Study was a retrospective single-center study of treatment-naïve human immunodeficiency virus (HIV) patients initiating ART between 2013 and 2016. Among patients on different ART regimen types, we compared rates of and median time to virologic suppression [viral load (VL) <50 copies/mL].A total of 155 patients-45 (29%) female and 110 (71%) male-met study inclusion criteria. Median age was 42 years (interquartile range 31-52), and median baseline CD4 count was 288 cells/μL and VL was 60,000 copies/mL. Seventy-one (46%) initiated an INSTI-based regimen, 58 (37%) were on NNRTI-based regimens, and 26 (17%) on PI-based regimens. In total, 112 (72%) patients achieved virologic suppression at 12 months. Patients on INSTI-based regimens were more likely to achieve virologic suppression by 3, 6, and 12 months (P < .01), and had lower median time to suppression (60 vs 137 days on NNRTI-based regimens and 147 days on PI-based regimens, P < .01).Patients on INSTI-based ART regimens in a real-world setting experienced higher rates of virologic suppression and shorter time from ART initiation to virologic suppression. For HIV patients on INSTI-based ART regimens, virologic failure should be suspected in those with VLs >50 copies/mL before the current recommendation of 48 weeks.
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Affiliation(s)
| | - Onyema Ogbuagu
- Yale AIDS Program, Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT
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Zakumumpa H, Dube N, Damian RS, Rutebemberwa E. Understanding the dynamic interactions driving the sustainability of ART scale-up implementation in Uganda. Glob Health Res Policy 2018; 3:23. [PMID: 30123838 PMCID: PMC6091155 DOI: 10.1186/s41256-018-0079-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 07/16/2018] [Indexed: 01/01/2023] Open
Abstract
Background Despite increasing recognition that health-systems constraints are the fundamental barrier to attaining anti-retroviral therapy (ART) scale-up targets in Sub-Saharan Africa, current discourses are dominated by a focus on financial sustainability. Utilizing the health system dynamics framework, this study aimed to explore the interactions in health system components and their influence on the sustainability of ART scale-up implementation in Uganda. Methods This study entailed qualitative organizational case-studies within a two-phased mixed-methods sequential explanatory research design. In Phase One, a survey of 195 health facilities across Uganda which commenced ART services between 2004 and 2009 was conducted. In Phase Two, six health facilities were purposively selected for in-depth examination involving i) In-depth interviews (n = 44) ii) and semi-structured interviews (n = 35). Qualitative data was analyzed by coding and thematic analysis. Descriptive statistics were managed in STATA (v 13). Results Five dynamic interactions in ART program sustainability drivers were identified; i) Failure to update basic ART program records contributed to chronic ART medicines stock-outs ii) Health workforce shortages and escalating patient volumes prompted adaptations in ART service delivery models iii) Broader governance issues manifested in poor road networks undermined ART medicines supply chains iv) Sustained financing for ART programs was influenced by external donors v) The values associated with the ownership-type of a health facility affected ART service delivery and coverage. Conclusion The sustainability of ART programs at the facility-level in Uganda is a function of a complex interaction in elements of the health system and must be understood beyond sustaining international funding for ART scale-up.
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Affiliation(s)
- Henry Zakumumpa
- 1School of Public Health, Makerere University, Kampala, Uganda
| | - Nkosiyazi Dube
- 2School of Health and Community Development, University of the Witwatersrand, Johannesburg, South Africa
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High CD4 counts associated with better economic outcomes for HIV-positive adults and their HIV-negative household members in the SEARCH Trial. PLoS One 2018; 13:e0198912. [PMID: 29944678 PMCID: PMC6019679 DOI: 10.1371/journal.pone.0198912] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 05/29/2018] [Indexed: 12/30/2022] Open
Abstract
Background Country decisions to scale-up “test and treat” approaches for HIV depend on consideration of both the health and economic consequences of such investments. Evidence about economic impacts of expanded antiretroviral therapy (ART) provision is particularly relevant for decisions regarding foreign assistance levels for HIV/AIDS programs. We used baseline data from the Sustainable East Africa Research in Community Health (SEARCH) cluster randomized controlled trial in Kenya and Uganda to examine the association between HIV status, CD4+ T-cell counts, viral suppression, and multiple indicators of economic well-being. Methods and findings Socio-economic surveys were conducted in households with HIV-positive and HIV-negative adults sampled after a census of 32 communities participating in the SEARCH trial (NCT01864603). Data were obtained for 11,500 individuals from 5,884 households in study communities. Participants were stratified based on their own HIV status as well as CD4 counts and viral suppression status if they were HIV-positive. HIV-negative participants residing in households with no HIV-positive adults were considered separately from HIV-negative participants residing in households with ≥1 HIV-positive adult. Generalized estimating equation models were used to examine the relationship between HIV status, CD4 counts, ART, viral suppression, and outcomes of employment, self-reported illness, lost time from usual activities due to illness, healthcare utilization, health expenditures, and hospitalizations. In all models, HIV-negative participants in households with no HIV-positive persons were the reference group. There was no significant difference in the probability of being employed between HIV-positive participants with CD4>500 and the reference group of HIV-negative participants residing in households with no HIV-positive adults (marginal effect, ME, 1.49 percentage points; 95% confidence interval, CI, -1.09, 4.08). However, HIV-positive participants with CD4 351–500 were less likely to be employed than the reference group (ME -4.50, 95% CI -7.99, -1.01), as were HIV-positive participants with CD4 ≤350 (ME -7.41, 95% CI -10.96, -3.85). Similarly, there was no significant difference in employment likelihood between HIV-negative participants who resided in households with a CD4>500 HIV-positive person and the reference group (ME -1.78, 95% CI -5.16, 1.59). HIV-negative participants residing with an HIV-positive person with CD4 351–500, however, were less likely to be employed than the reference group (ME -7.03, 95% CI -11.49, -2.57), as were people residing with a household member with CD4 ≤350 (ME -6.28, 95% CI -10.76, -1.80). HIV-positive participants in all CD4 categories were more likely to have lost time from usual activities due to illness and have incurred healthcare expenditures. Those with CD4>500 had better economic outcomes than those with CD4 351–500, even among those not virally suppressed (p = 0.004) and not on ART (p = 0.01). Conclusions Data from a large population-representative sample of households in east Africa showed a strong association between the health of HIV-positive persons and economic outcomes. The findings suggest there may be economic benefits associated with maintaining high CD4 counts, both for HIV-positive persons and their HIV-negative household members. The association of high CD4 counts with improved outcomes is consistent with the hypothesis that early ART initiation can avert declines in employment and other economic outcomes. Prospective longitudinal evaluation is needed to assess the causal impact of early ART initiation on economic functioning of households.
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Abstract
BACKGROUND Tuberculosis (TB) is the major cause of mortality in HIV-infected children globally. Current guidelines about the management of antiretroviral therapy in children with TB are based on a limited number of nonrandomized studies involving small numbers of participants. The aim of the study was to systematically retrieve and critically appraise available evidence on the efficacy and safety of different antiretroviral regimens in children with HIV infection who are receiving treatment for active TB. METHODS We conducted a systematic review of the literature according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Records were retrieved through March 2016 from Medline, Embase and manual screening of key conference proceedings. Four specific research questions assessing available treatment options were defined. RESULTS Although 4 independent searches were conducted (1 for each Population, Intervention, Comparator, Outcomes question), results were elaborated and interpreted together because of significant overlap among the retrieved records. Six observational studies were selected for qualitative synthesis while meta-analysis could not be performed. CONCLUSION Evidence for optimal treatment options for HIV/TB coinfected children is limited. As the global community strives to reach the fast-track HIV treatment targets and eliminate childhood TB deaths, it must ensure that coinfected children are included in key treatment studies and expand this neglected but crucial area of research.
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Kim MH, Mazenga AC, Simon K, Yu X, Ahmed S, Nyasulu P, Kazembe PN, Ngoma S, Abrams EJ. Burnout and self-reported suboptimal patient care amongst health care workers providing HIV care in Malawi. PLoS One 2018; 13:e0192983. [PMID: 29466443 PMCID: PMC5821338 DOI: 10.1371/journal.pone.0192983] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 02/01/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The well-documented shortages of health care workers (HCWs) in sub-Saharan Africa are further intensified by the increased human resource needs of expanding HIV treatment programs. Burnout is a syndrome of emotional exhaustion (EE), depersonalization (DP), and a sense of low personal accomplishment (PA). HCWs' burnout can negatively impact the delivery of health services. Our main objective was to examine the prevalence of burnout amongst HCWs in Malawi and explore its relationship to self-reported suboptimal patient care. METHODS A cross-sectional study among HCWs providing HIV care in 89 facilities, across eight districts in Malawi was conducted. Burnout was measured using the Maslach Burnout Inventory defined as scores in the mid-high range on the EE or DP subscales. Nine questions adapted for this study assessed self-reported suboptimal patient care. Surveys were administered anonymously and included socio-demographic and work-related questions. Validated questionnaires assessed depression and at-risk alcohol use. Chi-square test or two-sample t-test was used to explore associations between variables and self-reported suboptimal patient care. Bivariate analyses identified candidate variables (p < 0.2). Final regression models included variables with significant main effects. RESULTS Of 520 HCWs, 62% met criteria for burnout. In the three dimensions of burnout, 55% reported moderate-high EE, 31% moderate-high DP, and 46% low-moderate PA. The majority (89%) reported engaging in suboptimal patient care/attitudes including making mistakes in treatment not due to lack of knowledge/experience (52%), shouting at patients (45%), and not performing diagnostic tests due to a desire to finish quickly (35%). In multivariate analysis, only burnout remained associated with self-reported suboptimal patient care (OR 3.22, [CI 2.11 to 4.90]; p<0.0001). CONCLUSION Burnout was common among HCWs providing HIV care and was associated with self-reported suboptimal patient care practices/attitudes. Research is needed to understand factors that contribute to and protect against burnout and that inform the development of strategies to reduce burnout.
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Affiliation(s)
- Maria H. Kim
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Baylor International Pediatric AIDS Initiative at Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States of America
| | - Alick C. Mazenga
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
| | - Katie Simon
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Baylor International Pediatric AIDS Initiative at Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States of America
| | - Xiaoying Yu
- Design and Analysis Core, Baylor-UT Houston Center for AIDS Research, Houston, TX, United States of America
| | - Saeed Ahmed
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Baylor International Pediatric AIDS Initiative at Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States of America
| | - Phoebe Nyasulu
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
| | - Peter N. Kazembe
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
- Baylor International Pediatric AIDS Initiative at Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States of America
| | - Stanley Ngoma
- Malawi Ministry of Health, HIV Unit, Lilongwe, Malawi
| | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
- College of Physicians & Surgeons, Columbia University, New York, NY, United States of America
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Omosun YO, Blackstock AJ, Williamson J, van Eijk AM, Ayisi J, Otieno J, Lal RB, ter Kuile FO, Slutsker L, Shi YP. Association of maternal KIR gene content polymorphisms with reduction in perinatal transmission of HIV-1. PLoS One 2018; 13:e0191733. [PMID: 29360870 PMCID: PMC5779696 DOI: 10.1371/journal.pone.0191733] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 01/10/2018] [Indexed: 12/29/2022] Open
Abstract
The role of killer cell immunoglobulin-like receptors (KIRs) in the transmission of HIV-1 has not been extensively studied. Here, we investigated the association of KIR gene content polymorphisms with perinatal HIV-1 transmission. The KIR gene family comprising 16 genes was genotyped in 313 HIV-1 positive Kenyan mothers paired with their infants. Gene content polymorphisms were presented as presence of individual KIR genes, haplotypes, genotypes and KIR gene concordance. The genetic data were analyzed for associations with perinatal transmission of HIV. There was no association of infant KIR genes with perinatal HIV-1 transmission. After adjustment for gravidity, viral load, and CD4 cell count, there was evidence of an association between reduction in perinatal HIV-1 transmission and the maternal individual KIR genes KIR2DL2 (adjusted OR = 0.50; 95% CI: 0.24–1.02, P = 0.06), KIR2DL5 (adjusted OR = 0.47; 95% CI: 0.23–0.95, P = 0.04) and KIR2DS5 (adjusted OR = 0.39; 95% CI: 0.18–0.80, P = 0.01). Furthermore, these maternal KIR genes were only significantly associated with reduction in perinatal HIV transmission in women with CD4 cell count ≥ 350 cells/ μl and viral load <10000 copies/ml. Concordance analysis showed that when both mother and child had KIR2DS2, there was less likelihood of perinatal HIV-1 transmission (adjusted OR = 0.44; 95% CI: 0.20–0.96, P = 0.039). In conclusion, the maternal KIR genes KIR2DL2, KIR2DL5, KIR2DS5, and KIR2DS2 were associated with reduction of HIV-1 transmission from mother to child. Furthermore, maternal immune status is an important factor in the association of KIR with perinatal HIV transmission.
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Affiliation(s)
- Yusuf O. Omosun
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Atlanta Research and Education Foundation, Atlanta, Georgia, United States of America
| | - Anna J. Blackstock
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - John Williamson
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Anne Maria van Eijk
- Center for Global Health Research, Kenyan Medical Research Institute, Kisumu, Kenya
- Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - John Ayisi
- Center for Global Health Research, Kenyan Medical Research Institute, Kisumu, Kenya
| | - Juliana Otieno
- New Nyanza Provincial General Hospital, Ministry of Health, Kisumu, Kenya
| | - Renu B. Lal
- Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Feiko O. ter Kuile
- Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Laurence Slutsker
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Ya Ping Shi
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
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Kumar S, Samaras K. The Impact of Weight Gain During HIV Treatment on Risk of Pre-diabetes, Diabetes Mellitus, Cardiovascular Disease, and Mortality. Front Endocrinol (Lausanne) 2018; 9:705. [PMID: 30542325 PMCID: PMC6277792 DOI: 10.3389/fendo.2018.00705] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 11/08/2018] [Indexed: 12/14/2022] Open
Abstract
Since the introduction of combined antiretroviral therapy (cART) and more effective treatments for AIDS, there has been a dramatic shift from the weight loss and wasting that characterised HIV/AIDS (and still does in countries where cART is not readily available or is initiated late) to healthy weight, or even overweight and obesity at rates mirroring those seen in the general population. These trends are attributable to several factors, including the "return to health" weight gain with reversal of the catabolic effects of HIV-infection following cART-initiation, strategies for earlier cART-initiation in the course of HIV-infection which have prevented many people living with HIV-infection from developing wasting, in addition to exposure to the modern obesogenic environment. Older cART regimens were associated with increased risk of body fat partitioning disorders (lipodystrophy) and cardiometabolic complications including atherothrombotic cardiovascular disease (CVD) and diabetes mellitus. Whilst cART now avoids those medications implicated in causing lipodystrophy, long-term cardiometabolic data on more modern cART regimens are lacking. Longitudinal studies show increased rates of incident CVD and diabetes mellitus with weight gain in treated HIV-infection. Abdominal fat gain, weight gain, and rising body mass index (BMI) in the short-term during HIV treatment was found to increase incident diabetes risk. Rising BMI was associated with increased risk of incident CVD, however the relationship varied depending on pre-cART BMI category. In contrast, a protective association with mortality is evident, predominantly in the underweight and in resource-poor settings, where weight gain reflects access to cART and virological suppression. The question of how to best evaluate, manage (and perhaps constrain) weight gain during HIV treatment is of clinical relevance, especially in the current climate of increasingly widespread cART use, rising overweight, and obesity prevalence and growing metabolic and cardiovascular disease burden in people living with HIV-infection. Large prospective studies to further characterise the relationship between weight gain during HIV treatment and risk of diabetes, CVD and mortality are required.
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Affiliation(s)
- Shejil Kumar
- St George Clinical School, University of New South Wales, Sydney, NSW, Australia
- *Correspondence: Shejil Kumar
| | - Katherine Samaras
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
- Diabetes and Metabolism Program, Garvan Institute of Medical Research, Sydney, NSW, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
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Kumi Smith M, Jewell BL, Hallett TB, Cohen MS. Treatment of HIV for the Prevention of Transmission in Discordant Couples and at the Population Level. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1075:125-162. [PMID: 30030792 DOI: 10.1007/978-981-13-0484-2_6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The scientific breakthrough proving that antiretroviral therapy (ART) can halt heterosexual HIV transmission came in the form of a landmark clinical trial conducted among serodiscordant couples. Study findings immediately informed global recommendations for the use of treatment as prevention in serodiscordant couples. The extent to which these findings are generalizable to other key populations or to groups exposed to HIV through nonsexual transmission routes (i.e., anal intercourse or unsafe injection of drugs) has since driven a large body of research. This review explores the history of HIV research in serodiscordant couples, the implications for management of couples, subsequent research on treatment as prevention in other key populations, and challenges in community implementation of these strategies.
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Affiliation(s)
- M Kumi Smith
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
| | | | | | - Myron S Cohen
- University of North Carolina Chapel Hill, Chapel Hill, NC, USA
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Abstract
Fungi must meet four criteria to infect humans: growth at human body temperatures, circumvention or penetration of surface barriers, lysis and absorption of tissue, and resistance to immune defenses, including elevated body temperatures. Morphogenesis between small round, detachable cells and long, connected cells is the mechanism by which fungi solve problems of locomotion around or through host barriers. Secretion of lytic enzymes, and uptake systems for the released nutrients, are necessary if a fungus is to nutritionally utilize human tissue. Last, the potent human immune system evolved in the interaction with potential fungal pathogens, so few fungi meet all four conditions for a healthy human host. Paradoxically, the advances of modern medicine have made millions of people newly susceptible to fungal infections by disrupting immune defenses. This article explores how different members of four fungal phyla use different strategies to fulfill the four criteria to infect humans: the Entomophthorales, the Mucorales, the Ascomycota, and the Basidiomycota. Unique traits confer human pathogenic potential on various important members of these phyla: pathogenic Onygenales comprising thermal dimorphs such as Histoplasma and Coccidioides; the Cryptococcus spp. that infect immunocompromised as well as healthy humans; and important pathogens of immunocompromised patients-Candida, Pneumocystis, and Aspergillus spp. Also discussed are agents of neglected tropical diseases important in global health such as mycetoma and paracoccidiomycosis and common pathogens rarely implicated in serious illness such as dermatophytes. Commensalism is considered, as well as parasitism, in shaping genomes and physiological systems of hosts and fungi during evolution.
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Can differentiated care models solve the crisis in HIV treatment financing? Analysis of prospects for 38 countries in sub-Saharan Africa. J Int AIDS Soc 2017; 20:21648. [PMID: 28770597 PMCID: PMC5577732 DOI: 10.7448/ias.20.5.21648] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction: Rapid scale-up of antiretroviral therapy (ART) in the context of financial and health system constraints has resulted in calls to maximize efficiency in ART service delivery. Adopting differentiated care models (DCMs) for ART could potentially be more cost-efficient and improve outcomes. However, no study comprehensively projects the cost savings across countries. We model the potential reduction in facility-level costs and number of health workers needed when implementing two types of DCMs while attempting to reach 90-90-90 targets in 38 sub-Saharan African countries from 2016 to 2020. Methods: We estimated the costs of three service delivery models: (1) undifferentiated care, (2) differentiated care by patient age and stability, and (3) differentiated care by patient age, stability, key vs. general population status, and urban vs. rural location. Frequency of facility visits, type and frequency of laboratory testing, and coverage of community ART support vary by patient subgroup. For each model, we estimated the total costs of antiretroviral drugs, laboratory commodities, and facility-level personnel and overhead. Certain groups under four-criteria differentiation require more intensive inputs. Community-based ART costs were included in the DCMs. We take into account underlying uncertainty in the projected numbers on ART and unit costs. Results: Total five-year facility-based ART costs for undifferentiated care are estimated to be US$23.33 billion (95% confidence interval [CI]: $23.3–$23.5 billion). An estimated 17.5% (95% CI: 17.4%–17.7%) and 16.8% (95% CI: 16.7%–17.0%) could be saved from 2016 to 2020 from implementing the age and stability DCM and four-criteria DCM, respectively, with annual cost savings increasing over time. DCMs decrease the full-time equivalent (FTE) health workforce requirements for ART. An estimated 46.4% (95% CI: 46.1%–46.7%) fewer FTE health workers are needed in 2020 for the age and stability DCM compared with undifferentiated care. Conclusions: Adopting DCMs can result in significant efficiency gains in terms of reduced costs and health workforce needs, even with the costs of scaling up community-based ART support under DCMs. Efficiency gains remained flat with increased differentiation. More evidence is needed on how to translate analyzed efficiency gains into implemented cost reductions at the facility level.
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Plazy M, Perriat D, Gumede D, Boyer S, Pillay D, Dabis F, Seeley J, Orne-Gliemann J. Implementing universal HIV treatment in a high HIV prevalence and rural South African setting - Field experiences and recommendations of health care providers. PLoS One 2017; 12:e0186883. [PMID: 29155832 PMCID: PMC5695789 DOI: 10.1371/journal.pone.0186883] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 10/09/2017] [Indexed: 12/18/2022] Open
Abstract
Background We aimed to describe the field experiences and recommendations of clinic-based health care providers (HCP) regarding the implementation of universal antiretroviral therapy (ART) in rural KwaZulu-Natal, South Africa. Methods In Hlabisa sub-district, the local HIV programme of the Department of Health (DoH) is decentralized in 18 clinics, where ART was offered at a CD4 count ≤500 cells/μL from January 2015 to September 2016. Within the ANRS 12249 TasP trial, implemented in part of the sub-district, universal ART (no eligibility criteria) was offered in 11 mobile clinics between March 2012 and June 2016. A cross-sectional qualitative survey was conducted in April–July 2016 among clinic-based nurses and counsellors providing HIV care in the DoH and TasP trial clinics. In total, 13 individual interviews and two focus groups discussions (including 6 and 7 participants) were conducted, audio-recorded, transcribed, and thematically analyzed. Results All HCPs reported an overall good experience of delivering ART early in the course of HIV infection, with most patients willing to initiate ART before being symptomatic. Yet, HCPs underlined that not feeling sick could challenge early ART initiation and adherence, and thus highlighted the need to take time for counselling as an important component to achieve universal ART. HCPs also foresaw logistical challenges of universal ART, and were especially concerned about increasing workload and ART shortage. HCPs finally recommended the need to strengthen the existing model of care to facilitate access to ART, e.g., community-based and integrated HIV services. Conclusions The provision of universal ART is feasible and acceptable according to HCPs in this rural South-African area. However their experiences suggest that universal ART, and more generally the 90-90-90 UNAIDS targets, will be difficult to achieve without the implementation of new models of health service delivery.
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Affiliation(s)
- Melanie Plazy
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- * E-mail:
| | - Delphine Perriat
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
| | - Dumile Gumede
- Africa Health Research Institute, Somkhele, South Africa
| | - Sylvie Boyer
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, South Africa
- University College London, Division of Infection and Immunity, London, United Kingdom
| | - François Dabis
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
| | - Janet Seeley
- Africa Health Research Institute, Somkhele, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joanna Orne-Gliemann
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
- Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
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Maheu-Giroux M, Vesga JF, Diabaté S, Alary M, Baral S, Diouf D, Abo K, Boily MC. Population-level impact of an accelerated HIV response plan to reach the UNAIDS 90-90-90 target in Côte d'Ivoire: Insights from mathematical modeling. PLoS Med 2017; 14:e1002321. [PMID: 28617810 PMCID: PMC5472267 DOI: 10.1371/journal.pmed.1002321] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 05/09/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND National responses will need to be markedly accelerated to achieve the ambitious target of the Joint United Nations Programme on HIV/AIDS (UNAIDS). This target aims for 90% of HIV-positive individuals to be aware of their status, for 90% of those aware to receive antiretroviral therapy (ART), and for 90% of those on treatment to have a suppressed viral load by 2020, with each individual target reaching 95% by 2030. We aimed to estimate the impact of various treatment-as-prevention scenarios in Côte d'Ivoire, one of the countries with the highest HIV incidence in West Africa, with unmet HIV prevention and treatment needs, and where key populations are important to the broader HIV epidemic. METHODS AND FINDINGS An age-stratified dynamic model was developed and calibrated to epidemiological and programmatic data using a Bayesian framework. The model represents sexual and vertical HIV transmission in the general population, female sex workers (FSW), and men who have sex with men (MSM). We estimated the impact of scaling up interventions to reach the UNAIDS targets, as well as the impact of 8 other scenarios, on HIV transmission in adults and children, compared to our baseline scenario that maintains 2015 rates of testing, ART initiation, ART discontinuation, treatment failure, and levels of condom use. In 2015, we estimated that 52% (95% credible intervals: 46%-58%) of HIV-positive individuals were aware of their status, 72% (57%-82%) of those aware were on ART, and 77% (74%-79%) of those on ART were virologically suppressed. Reaching the UNAIDS targets on time would avert 50% (42%-60%) of new HIV infections over 2015-2030 compared to 30% (25%-36%) if the 90-90-90 target is reached in 2025. Attaining the UNAIDS targets in FSW, their clients, and MSM (but not in the rest of the population) would avert a similar fraction of new infections (30%; 21%-39%). A 25-percentage-point drop in condom use from the 2015 levels among FSW and MSM would reduce the impact of reaching the UNAIDS targets, with 38% (26%-51%) of infections averted. The study's main limitation is that homogenous spatial coverage of interventions was assumed, and future lines of inquiry should examine how geographical prioritization could affect HIV transmission. CONCLUSIONS Maximizing the impact of the UNAIDS targets will require rapid scale-up of interventions, particularly testing, ART initiation, and limiting ART discontinuation. Reaching clients of FSW, as well as key populations, can efficiently reduce transmission. Sustaining the high condom-use levels among key populations should remain an important prevention pillar.
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Affiliation(s)
- Mathieu Maheu-Giroux
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Québec, Canada
- * E-mail:
| | - Juan F. Vesga
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Hospital, London, United Kingdom
| | - Souleymane Diabaté
- Centre de recherche du CHU de Québec - Université Laval, Québec, Canada
- Département d’infectiologie et santé publique, Université Alassane Ouattara, Bouaké, Côte d’Ivoire
| | - Michel Alary
- Centre de recherche du CHU de Québec - Université Laval, Québec, Canada
- Département de médecine sociale et préventive, Université Laval, Québec, Canada
- Institut national de santé publique du Québec, Québec, Canada
| | - Stefan Baral
- Key Populations Program, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Kouamé Abo
- Programme National de Lutte contre le SIDA, Ministère de la Santé et de l’Hygiène Publique, Abidjan, Côte d’Ivoire
| | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Imperial College London, St Mary’s Hospital, London, United Kingdom
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Desai MA, Okal DO, Rose CE, Ndivo R, Oyaro B, Otieno FO, Williams T, Chen RT, Zeh C, Samandari T. Effect of point-of-care CD4 cell count results on linkage to care and antiretroviral initiation during a home-based HIV testing campaign: a non-blinded, cluster-randomised trial. Lancet HIV 2017; 4:e393-e401. [PMID: 28579225 DOI: 10.1016/s2352-3018(17)30091-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 04/14/2017] [Accepted: 04/20/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND HIV disease staging with referral laboratory-based CD4 cell count testing is a key barrier to the initiation of antiretroviral treatment (ART). Point-of-care CD4 cell counts can improve linkage to HIV care among people living with HIV, but its effect has not been assessed with a randomised controlled trial in the context of home-based HIV counselling and testing (HBCT). METHODS We did a two-arm, cluster-randomised, controlled efficacy trial in two districts of western Kenya with ongoing HBCT. Housing compounds were randomly assigned (1:1) to point-of-care CD4 cell counts (366 compounds with 417 participants) or standard-of-care (318 compounds with 353 participants) CD4 cell counts done at one of three referral laboratories serving the study catchment area. In each compound, we enrolled people with HIV not engaged in care in the previous 6 months. All participants received post-test counselling and referral for HIV care. Point-of-care test participants received additional counselling on the result, including ART eligibility if CD4 was less than 350 cells per μL, the cutoff in Kenyan guidelines. Participants were interviewed 6 months after enrolment to ascertain whether they sought HIV care, verified through chart reviews at 23 local clinics. The prevalence of loss to follow-up at 6 months (LTFU) was listed as the main outcome in the study protocol. We analysed linkage to care at 6 months (defined as 1-LTFU) as the primary outcome. All analyses were by intention to treat. This trial is registered at ClinicalTrials.gov, number NCT02515149. FINDINGS We enrolled 770 participants between July 1, 2013, and Feb 28, 2014. 692 (90%) had verified linkage to care status and 78 (10%) were lost to follow-up. Of 371 participants in the point-of-care group, 215 (58%) had linked to care within 6 months versus 108 (34%) of 321 in the standard-of-care group (Cox proportional multivariable hazard ratio [HR] 2·14, 95% CI 1·67-2·74; log rank p<0·0001). INTERPRETATION Point-of-care CD4 cell counts in a resource-limited HBCT setting doubled linkage to care and thereby improved ART initiation. Given the substantial economic and logistic hindrances to providing ART for all people with HIV in resource-limited settings in the near term, point of care CD4 cell counts might have a role in prioritising care and improving linkage to care. FUNDING US Centers for Disease Control and Prevention.
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Affiliation(s)
- Mitesh A Desai
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | | | - Charles E Rose
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Boaz Oyaro
- Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Tiffany Williams
- ICF International, Assigned to Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Robert T Chen
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Clement Zeh
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Taraz Samandari
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
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McRobie E, Wringe A, Nakiyingi-Miiro J, Kiweewa F, Lutalo T, Nakigozi G, Todd J, Eaton JW, Zaba B, Church K. HIV policy implementation in two health and demographic surveillance sites in Uganda: findings from a national policy review, health facility surveys and key informant interviews. Implement Sci 2017; 12:47. [PMID: 28381264 PMCID: PMC5382427 DOI: 10.1186/s13012-017-0574-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 03/16/2017] [Indexed: 01/02/2023] Open
Abstract
Background Successful HIV testing, care and treatment policy implementation is essential for realising the reductions in morbidity and mortality those policies are designed to target. While adoption of new HIV policies is rapid, less is known about the facility-level implementation of new policies and the factors influencing this. Methods We assessed implementation of national policies about HIV testing, treatment and retention at health facilities serving two health and demographic surveillance sites (HDSS) (10 in Kyamulibwa, 14 in Rakai). Ugandan Ministry of Health HIV policy documents were reviewed in 2013, and pre-determined indicators were extracted relating to the content and nature of guidance on HIV service provision. Facility-level policy implementation was assessed via a structured questionnaire administered to in-charge staff from each health facility. Implementation of policies was classified as wide (≥75% facilities), partial (26–74% facilities) or minimal (≤25% facilities). Semi-structured interviews were conducted with key informants (policy-makers, implementers, researchers) to identify factors influencing implementation; data were analysed using the Framework Method of thematic analysis. Results Most policies were widely implemented in both HDSS (free testing, free antiretroviral treatment (ART), WHO first-line regimen as standard, Option B+). Both had notable implementation gaps for policies relating to retention on treatment (availability of nutritional supplements, support groups or isoniazid preventive therapy). Rakai implemented more policies relating to provision of antiretroviral treatment than Kyamulibwa and performed better on quality of care indicators, such as frequency of stock-outs. Factors facilitating implementation were donor investment and support, strong scientific evidence, low policy complexity, phased implementation and effective planning. Limited human resources, infrastructure and health management information systems were perceived as major barriers to effective implementation. Conclusions Most HIV policies were widely implemented in the two settings; however, gaps in implementation coverage prevail and the value of ensuring complete coverage of existing policies should be considered against the adoption of new policies in regard to resource needs and health benefits.
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Affiliation(s)
- Ellen McRobie
- Imperial College London, Norfolk Place, London, W2 1PG, UK.
| | - Alison Wringe
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | | | | | - Tom Lutalo
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | - Jim Todd
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | | | - Basia Zaba
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Kathryn Church
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
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Haberer JE, Sabin L, Amico KR, Orrell C, Galárraga O, Tsai AC, Vreeman RC, Wilson I, Sam‐Agudu NA, Blaschke TF, Vrijens B, Mellins CA, Remien RH, Weiser SD, Lowenthal E, Stirratt MJ, Sow PS, Thomas B, Ford N, Mills E, Lester R, Nachega JB, Bwana BM, Ssewamala F, Mbuagbaw L, Munderi P, Geng E, Bangsberg DR. Improving antiretroviral therapy adherence in resource-limited settings at scale: a discussion of interventions and recommendations. J Int AIDS Soc 2017; 20:21371. [PMID: 28630651 PMCID: PMC5467606 DOI: 10.7448/ias.20.1.21371] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 02/24/2017] [Indexed: 01/01/2023] Open
Abstract
Introduction: Successful population-level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale-up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource-limited settings. Methods: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource-limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta-analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low- and middle-income countries. Interventions are categorized broadly as education and counselling; information and communication technology-enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described. Results and discussion: The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource-limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi-media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement. Conclusions: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS.
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Affiliation(s)
- Jessica E. Haberer
- Massachusetts General Hospital Global Health, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lora Sabin
- Department of Global Health, Center for Global Health and Department, Boston University School of Public Health, Boston, MA, USA
| | - K. Rivet Amico
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Omar Galárraga
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Alexander C. Tsai
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Rachel C. Vreeman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ira Wilson
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Nadia A. Sam‐Agudu
- Clinical Department, Institute of Human Virology Nigeria, Abuja, Nigeria
- Institute of Human Virology and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Terrence F. Blaschke
- Department of Medicine and Clinical Pharmacology, Stanford University School of Medicine, Stanford, CA, USA
| | - Bernard Vrijens
- Department of Biostatistics, University of Liège, Liège, Wallonia, Belgium
- WestRock Healthcare, Sion, Switzerland
| | - Claude A. Mellins
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Robert H. Remien
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Sheri D. Weiser
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Elizabeth Lowenthal
- Departments of Pediatrics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael J. Stirratt
- Division of AIDS Research, National Institute of Mental Health, Bethesda, MD, USA
| | - Papa Salif Sow
- Bill and Melinda Gates Foundation, Seattle, WA, USA
- Department of Infectious diseases, University of Dakar, Dakar, Sénégal
| | | | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Edward Mills
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard Lester
- Division of Infectious Diseases, Department of Medicine, University of British Columbia
| | - Jean B. Nachega
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Bosco Mwebesa Bwana
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Fred Ssewamala
- Columbia University School of Social Work & School of International and Public Affairs, New York, NY, USA
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Paula Munderi
- HIV Care Research Program, Medical Research Council, Uganda Virus Research Institute, Entebbe, Uganda
| | - Elvin Geng
- Division of HIV, Infectious Disease and Global Medicine, San Francisco General Hospital, Department of Medicine, University of California, San Francisco, CA, USA
| | - David R. Bangsberg
- Oregon Health & Sciences University‐Portland State University School of Public Health, Portland, OR, USA
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Zakumumpa H, Bennett S, Ssengooba F. Alternative financing mechanisms for ART programs in health facilities in Uganda: a mixed-methods approach. BMC Health Serv Res 2017; 17:65. [PMID: 28114932 PMCID: PMC5259831 DOI: 10.1186/s12913-017-2009-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 01/12/2017] [Indexed: 01/24/2023] Open
Abstract
Background Sub-Saharan Africa is heavily dependent on global health initiatives (GHIs) for funding antiretroviral therapy (ART) scale-up. There are indications that global investments for ART scale-up are flattening. It is unclear what new funding channels can bridge the funding gap for ART service delivery. Many previous studies have focused on domestic government spending and international funding especially from GHIs. The objective of this study was to identify the funding strategies adopted by health facilities in Uganda to sustain ART programs between 2004 and 2014 and to explore variations in financing mechanisms by ownership of health facility. Methods A mixed-methods approach was employed. A survey of health facilities (N = 195) across Uganda which commenced ART delivery between 2004 and 2009 was conducted. Six health facilities were purposively selected for in-depth examination. Semi-structured interviews (N = 18) were conducted with ART Clinic managers (three from each of the six health facilities). Statistical analyses were performed in STATA (Version 12.0) and qualitative data were analyzed by coding and thematic analysis. Results Multiple funding sources for ART programs were common with 140 (72%) of the health facilities indicating at least two concurrent grants supporting ART service delivery between 2009 and 2014. Private philanthropic aid emerged as an important source of supplemental funding for ART service delivery. ART financing strategies were differentiated by ownership of health facility. Private not-for-profit providers were more externally-focused (multiple grants, philanthropic aid). For-profit providers were more client-oriented (fee-for-service, insurance schemes). Public facilities sought additional funding streams not dissimilar to other health facility ownership-types. Conclusion Over the 10-year study period, health facilities in Uganda diversified funding sources for ART service delivery. The identified alternative funding mechanisms could reduce dependence on GHI funding and increase local ownership of HIV programs. Further research evaluating the potential contribution of the identified alternative financing mechanisms in bridging the global HIV funding gap is recommended.
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Affiliation(s)
- Henry Zakumumpa
- Makerere University, School of Public Health, Kampala, Uganda.
| | - Sara Bennett
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, USA
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Prevention literacy: community-based advocacy for access and ownership of the HIV prevention toolkit. J Int AIDS Soc 2016; 19:21092. [PMID: 27702430 PMCID: PMC5045969 DOI: 10.7448/ias.19.1.21092] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 08/27/2016] [Accepted: 09/01/2016] [Indexed: 01/11/2023] Open
Abstract
Introduction Critical technological advances have yielded a toolkit of HIV prevention strategies. This literature review sought to provide contextual and historical reflection needed to bridge the conceptual gap between clinical efficacy and community effectiveness (i.e. knowledge and usage) of existing HIV prevention options, especially in resource-poor settings. Methods Between January 2015 and October 2015, we reviewed scholarly and grey literatures to define treatment literacy and health literacy and assess the current need for literacy related to HIV prevention. The review included searches in electronic databases including MEDLINE, PsycINFO, PubMed, and Google Scholar. Permutations of the following search terms were used: “treatment literacy,” “treatment education,” “health literacy,” and “prevention literacy.” Through an iterative process of analyses and searches, titles and/or abstracts and reference lists of retrieved articles were reviewed for additional articles, and historical content analyses of grey literature and websites were additionally conducted. Results and discussion Treatment literacy was a well-established concept developed in the global South, which was later partially adopted by international agencies such as the World Health Organization. Treatment literacy emerged as more effective antiretroviral therapies became available. Developed from popular pedagogy and grassroots efforts during an intense struggle for treatment access, treatment literacy addressed the need to extend access to underserved communities and low-income settings that might otherwise be excluded from access. In contrast, prevention literacy is absent in the recent surge of new biomedical prevention strategies; prevention literacy was scarcely referenced and undertheorized in the available literature. Prevention efforts today include multimodal techniques, which jointly comprise a toolkit of biomedical, behavioural, and structural/environmental approaches. However, linkages to community advocacy and mobilization efforts are limited and unsustainable. Success of prevention efforts depends on equity of access, community-based ownership, and multilevel support structures to enable usage and sustainability. Conclusions For existing HIV prevention efforts to be effective in “real-world” settings, with limited resources, reflection on historical lessons and contextual realities (i.e. policies, financial constraints, and biomedical patents) indicated the need to extend principles developed for treatment access and treatment literacy, to support prevention literacy and prevention access as an integral part of the global response to HIV.
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Swadling L, Halliday J, Kelly C, Brown A, Capone S, Ansari MA, Bonsall D, Richardson R, Hartnell F, Collier J, Ammendola V, Del Sorbo M, Von Delft A, Traboni C, Hill AVS, Colloca S, Nicosia A, Cortese R, Klenerman P, Folgori A, Barnes E. Highly-Immunogenic Virally-Vectored T-cell Vaccines Cannot Overcome Subversion of the T-cell Response by HCV during Chronic Infection. Vaccines (Basel) 2016; 4:E27. [PMID: 27490575 PMCID: PMC5041021 DOI: 10.3390/vaccines4030027] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/19/2016] [Accepted: 07/19/2016] [Indexed: 02/06/2023] Open
Abstract
An effective therapeutic vaccine for the treatment of chronic hepatitis C virus (HCV) infection, as an adjunct to newly developed directly-acting antivirals (DAA), or for the prevention of reinfection, would significantly reduce the global burden of disease associated with chronic HCV infection. A recombinant chimpanzee adenoviral (ChAd3) vector and a modified vaccinia Ankara (MVA), encoding the non-structural proteins of HCV (NSmut), used in a heterologous prime/boost regimen induced multi-specific, high-magnitude, durable HCV-specific CD4+ and CD8+ T-cell responses in healthy volunteers, and was more immunogenic than a heterologous Ad regimen. We now assess the immunogenicity of this vaccine regimen in HCV infected patients (including patients with a low viral load suppressed with interferon/ribavirin therapy), determine T-cell cross-reactivity to endogenous virus, and compare immunogenicity with that observed previously in both healthy volunteers and in HCV infected patients vaccinated with the heterologous Ad regimen. Vaccination of HCV infected patients with ChAd3-NSmut/MVA-NSmut was well tolerated. Vaccine-induced HCV-specific T-cell responses were detected in 8/12 patients; however, CD4+ T-cell responses were rarely detected, and the overall magnitude of HCV-specific T-cell responses was markedly reduced when compared to vaccinated healthy volunteers. Furthermore, HCV-specific cells had a distinct partially-functional phenotype (lower expression of activation markers, granzyme B, and TNFα production, weaker in vitro proliferation, and higher Tim3 expression, with comparable Tbet and Eomes expression) compared to healthy volunteers. Robust anti-vector T-cells and antibodies were induced, showing that there is no global defect in immunity. The level of viremia at the time of vaccination did not correlate with the magnitude of the vaccine-induced T-cell response. Full-length, next-generation sequencing of the circulating virus demonstrated that T-cells were only induced by vaccination when there was a sequence mismatch between the autologous virus and the vaccine immunogen. However, these T-cells were not cross-reactive with the endogenous viral variant epitopes. Conversely, when there was complete homology between the immunogen and circulating virus at a given epitope T-cells were not induced. T-cell induction following vaccination had no significant impact on HCV viral load. In vitro T-cell culture experiments identified the presence of T-cells at baseline that could be expanded by vaccination; thus, HCV-specific T-cells may have been expanded from pre-existing low-level memory T-cell populations that had been exposed to HCV antigens during natural infection, explaining the partial T-cell dysfunction. In conclusion, vaccination with ChAd3-NSmut and MVA-NSmut prime/boost, a potent vaccine regimen previously optimized in healthy volunteers was unable to reconstitute HCV-specific T-cell immunity in HCV infected patients. This highlights the major challenge of overcoming T-cell exhaustion in the context of persistent antigen exposure.
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Affiliation(s)
- Leo Swadling
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK.
| | - John Halliday
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK.
- Oxford NIHR BRC, and Translational Gastroenterology Unit, Oxford OX3 9DU, UK.
- Royal Melbourne Hospital, Parkville, Victoria 3050, Australia.
| | - Christabel Kelly
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK.
- Oxford NIHR BRC, and Translational Gastroenterology Unit, Oxford OX3 9DU, UK.
| | - Anthony Brown
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK.
| | - Stefania Capone
- Reithera Srl (former Okairos Srl), Viale Città d'Europa, 679, Rome 00144, Italy.
| | - M Azim Ansari
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK.
| | - David Bonsall
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK.
| | - Rachel Richardson
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK.
| | - Felicity Hartnell
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK.
| | - Jane Collier
- Oxford NIHR BRC, and Translational Gastroenterology Unit, Oxford OX3 9DU, UK.
| | - Virginia Ammendola
- Reithera Srl (former Okairos Srl), Viale Città d'Europa, 679, Rome 00144, Italy.
| | | | - Annette Von Delft
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK.
| | - Cinzia Traboni
- Reithera Srl (former Okairos Srl), Viale Città d'Europa, 679, Rome 00144, Italy.
| | - Adrian V S Hill
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK.
- The Jenner Institute, University of Oxford, Oxford, OX3 7DQ, UK.
| | - Stefano Colloca
- Reithera Srl (former Okairos Srl), Viale Città d'Europa, 679, Rome 00144, Italy.
| | - Alfredo Nicosia
- Reithera Srl (former Okairos Srl), Viale Città d'Europa, 679, Rome 00144, Italy.
- CEINGE, via Gaetano Salvatore 486, Naples 80145, Italy.
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Via S. Pansini 5, Naples 80131, Italy.
| | | | - Paul Klenerman
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK.
- Oxford NIHR BRC, and Translational Gastroenterology Unit, Oxford OX3 9DU, UK.
- The Jenner Institute, University of Oxford, Oxford, OX3 7DQ, UK.
| | - Antonella Folgori
- Reithera Srl (former Okairos Srl), Viale Città d'Europa, 679, Rome 00144, Italy.
| | - Eleanor Barnes
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK.
- Oxford NIHR BRC, and Translational Gastroenterology Unit, Oxford OX3 9DU, UK.
- The Jenner Institute, University of Oxford, Oxford, OX3 7DQ, UK.
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Di Giorgio L, Moses MW, Fullman N, Wollum A, Conner RO, Achan J, Achoki T, Bannon KA, Burstein R, Dansereau E, DeCenso B, Delwiche K, Duber HC, Gakidou E, Gasasira A, Haakenstad A, Hanlon M, Ikilezi G, Kisia C, Levine AJ, Maboshe M, Masiye F, Masters SH, Mphuka C, Njuguna P, Odeny TA, Okiro EA, Roberts DA, Murray CJL, Flaxman AD. The potential to expand antiretroviral therapy by improving health facility efficiency: evidence from Kenya, Uganda, and Zambia. BMC Med 2016; 14:108. [PMID: 27439621 PMCID: PMC4952151 DOI: 10.1186/s12916-016-0653-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/06/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Since 2000, international funding for HIV has supported scaling up antiretroviral therapy (ART) in sub-Saharan Africa. However, such funding has stagnated for years, threatening the sustainability and reach of ART programs amid efforts to achieve universal treatment. Improving health system efficiencies, particularly at the facility level, is an increasingly critical avenue for extending limited resources for ART; nevertheless, the potential impact of increased facility efficiency on ART capacity remains largely unknown. Through the present study, we sought to quantify facility-level technical efficiency across countries, assess potential determinants of efficiency, and predict the potential for additional ART expansion. METHODS Using nationally-representative facility datasets from Kenya, Uganda and Zambia, and measures adjusting for structural quality, we estimated facility-level technical efficiency using an ensemble approach that combined restricted versions of Data Envelopment Analysis and Stochastic Distance Function. We then conducted a series of bivariate and multivariate regression analyses to evaluate possible determinants of higher or lower technical efficiency. Finally, we predicted the potential for ART expansion across efficiency improvement scenarios, estimating how many additional ART visits could be accommodated if facilities with low efficiency thresholds reached those levels of efficiency. RESULTS In each country, national averages of efficiency fell below 50 % and facility-level efficiency markedly varied. Among facilities providing ART, average efficiency scores spanned from 50 % (95 % uncertainty interval (UI), 48-62 %) in Uganda to 59 % (95 % UI, 53-67 %) in Zambia. Of the facility determinants analyzed, few were consistently associated with higher or lower technical efficiency scores, suggesting that other factors may be more strongly related to facility-level efficiency. Based on observed facility resources and an efficiency improvement scenario where all facilities providing ART reached 80 % efficiency, we predicted a 33 % potential increase in ART visits in Kenya, 62 % in Uganda, and 33 % in Zambia. Given observed resources in facilities offering ART, we estimated that 459,000 new ART patients could be seen if facilities in these countries reached 80 % efficiency, equating to a 40 % increase in new patients. CONCLUSIONS Health facilities in Kenya, Uganda, and Zambia could notably expand ART services if the efficiency with which they operate increased. Improving how facility resources are used, and not simply increasing their quantity, has the potential to substantially elevate the impact of global health investments and reduce treatment gaps for people living with HIV.
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Affiliation(s)
- Laura Di Giorgio
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Mark W. Moses
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Nancy Fullman
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Alexandra Wollum
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Ruben O. Conner
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Jane Achan
- />Infectious Diseases Research Collaboration, Mulago Hospital Complex, Kampala, Uganda
| | - Tom Achoki
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Kelsey A. Bannon
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Roy Burstein
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Emily Dansereau
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Brendan DeCenso
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Kristen Delwiche
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Herbert C. Duber
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Emmanuela Gakidou
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | | | - Annie Haakenstad
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Michael Hanlon
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Gloria Ikilezi
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
- />Infectious Diseases Research Collaboration, Mulago Hospital Complex, Kampala, Uganda
| | | | - Aubrey J. Levine
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Mashekwa Maboshe
- />School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia
| | - Felix Masiye
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
- />School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia
| | - Samuel H. Masters
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Chrispin Mphuka
- />School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia
| | | | - Thomas A. Odeny
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | | | - D. Allen Roberts
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Christopher J. L. Murray
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
| | - Abraham D. Flaxman
- />Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA 98121 USA
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