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Anderson K, Iyun V, Eley BS, Rabie H, Ferreira T, Nuttall J, Frigati L, Van Dongen N, Davies MA. Hospitalization among infants who initiate antiretroviral therapy before 3 months of age. AIDS 2023; 37:435-445. [PMID: 36695356 PMCID: PMC9881839 DOI: 10.1097/qad.0000000000003422] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Studies examining hospitalization among infants with HIV in resource-limited settings, in the context of early infant diagnosis and early antiretroviral therapy (ART) initiation, are limited. METHODS We used routinely collected data on infants who initiated ART aged <3 months (Western Cape province, South Africa; 2013-2017) to describe hospitalization from birth until 12 months post-ART initiation. Record reviews were additionally performed at three tertiary-level facilities. We used mixed-effects Poisson regression to examine factors associated with hospitalization. RESULTS Among 840 infants, 579 (69%) were hospitalized; 36% had >1 hospitalization. Median age at ART initiation decreased from 57 days (interquartile range [IQR] 22-74; 2013-2015) to 19 days (IQR 5-54; 2016-2017). Early neonatal hospitalization (age <7 days) occurred in 271 infants (32%) and represented 24% of hospitalizations (272/1131). Overall, 443 infants (53%) were hospitalized at age ≥7 days, including 13% with hospitalizations pre-ART initiation, 15% pre and post-ART initiation and 25% post-ART initiation. Excluding early neonatal hospitalizations, initiating ART at older age vs. age <1 week was associated with higher hospitalization rates: adjusted incidence rate ratios (95% confidence interval) were 1.86 (1.31-2.64); 2.31 (1.62-3.29) and 2.47 (1.76-3.46) if ART initiation age was 1-4 weeks; 5-8 weeks and 9-12 weeks respectively. Among infants whose hospital records were reviewed, reasons for early neonatal hospitalizations mostly related to prematurity or low birthweight (n = 46/60; 77%) whereas hospitalizations at age ≥7 days were mostly due to infections (n = 206/243; 85%). CONCLUSIONS Earlier ART initiation is associated with lower hospitalization rates. High hospitalization rates, despite initiation age <3 months, is concerning.
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Affiliation(s)
- Kim Anderson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, Faculty of Health Sciences
| | - Victoria Iyun
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, Faculty of Health Sciences
| | - Brian S Eley
- Paediatric Infectious Diseases Unit, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town
| | - Helena Rabie
- Department of Paediatrics and Child Health, Tygerberg Hospital, Stellenbosch University, Stellenbosch
| | - Thalia Ferreira
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - James Nuttall
- Paediatric Infectious Diseases Unit, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town
| | - Lisa Frigati
- Department of Paediatrics and Child Health, Tygerberg Hospital, Stellenbosch University, Stellenbosch
| | - Nicola Van Dongen
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, Faculty of Health Sciences
- Directorate of Health Impact Assessment, Western Cape Department of Health, Cape Town, South Africa
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Lain MG, Vaz P, Sanna M, Ismael N, Chicumbe S, Simione TB, Cantarutti A, Porcu G, Rinaldi S, de Armas L, Dinh V, Pallikkuth S, Pahwa R, Palma P, Cotugno N, Pahwa S. Viral Response among Early Treated HIV Perinatally Infected Infants: Description of a Cohort in Southern Mozambique. Healthcare (Basel) 2022; 10:2156. [PMID: 36360495 PMCID: PMC9691232 DOI: 10.3390/healthcare10112156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/21/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022] Open
Abstract
Early initiation of antiretroviral therapy and adherence to achieve viral load suppression (VLS) are crucial for reducing morbidity and mortality of perinatally HIV-infected infants. In this descriptive cohort study of 39 HIV perinatally infected infants, who started treatment at one month of life in Mozambique, we aimed to describe the viral response over 2 years of follow up. VLS ≤ 400 copies/mL, sustained VLS and viral rebound were described using a Kaplan-Meier estimator. Antiretroviral drug transmitted resistance was assessed for a sub-group of non-VLS infants. In total, 61% of infants reached VLS, and 50% had a rebound. Cumulative probability of VLS was 36%, 51%, and 69% at 6, 12 and 24 months of treatment, respectively. The median duration of VLS was 7.4 months (IQR 12.6) and the cumulative probability of rebound at 6 months was 30%. Two infants had resistance biomarkers to drugs included in their treatment regimen. Our findings point to a low rate of VLS and high rate of viral rebound. More frequent viral response monitoring is advisable to identify infants with rebound and offer timely adherence support. It is urgent to tailor the psychosocial support model of care to this specific age group and offer differentiated service delivery to mother-baby pairs.
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Affiliation(s)
- Maria Grazia Lain
- Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo P.O.Box 2822, Mozambique
| | - Paula Vaz
- Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo P.O.Box 2822, Mozambique
| | - Marco Sanna
- Research Unit of Clinical Immunology and Vaccinology, Children’s Hospital Bambino Gesù, IRCCS, 0165 Rome, Italy
| | - Nalia Ismael
- Technological Platforms Department, Instituto Nacional de Saúde, Marracuene, Maputo 1120, Mozambique
| | - Sérgio Chicumbe
- Health System and Policy Program, Instituto Nacional de Saúde, Marracuene, Maputo 1120, Mozambique
| | | | - Anna Cantarutti
- National Centre for Healthcare Research and Pharmaco-Epidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy
| | - Gloria Porcu
- National Centre for Healthcare Research and Pharmaco-Epidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy
| | - Stefano Rinaldi
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Lesley de Armas
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Vinh Dinh
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Suresh Pallikkuth
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Rajendra Pahwa
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Paolo Palma
- Research Unit of Clinical Immunology and Vaccinology, Children’s Hospital Bambino Gesù, IRCCS, 0165 Rome, Italy
- Department of Systems Medicine, University of Rome “Tor Vergata”, 0133 Rome, Italy
| | - Nicola Cotugno
- Research Unit of Clinical Immunology and Vaccinology, Children’s Hospital Bambino Gesù, IRCCS, 0165 Rome, Italy
- Department of Systems Medicine, University of Rome “Tor Vergata”, 0133 Rome, Italy
| | - Savita Pahwa
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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Nsibande DF, Woldesenbet SA, Puren A, Barron P, Maduna VI, Lombard C, Cheyip M, Mogashoa M, Pillay Y, Magasana V, Ramraj T, Kufa T, Kindra G, Goga A, Chirinda W. Investigating the quality of HIV rapid testing practices in public antenatal health care facilities, South Africa. PLoS One 2022; 17:e0268687. [PMID: 36037237 PMCID: PMC9423613 DOI: 10.1371/journal.pone.0268687] [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: 01/06/2022] [Accepted: 05/05/2022] [Indexed: 11/19/2022] Open
Abstract
Monitoring HIV prevalence using antenatal HIV sentinel surveillance is important for efficient epidemic tracking, programme planning and resource allocation. HIV sentinel surveillance usually employs unlinked anonymous HIV testing which raises ethical, epidemiological and public health challenges in the current era of universal test and treat. The World Health Organization (WHO) recommends that countries should consider using routine prevention of mother-to-child transmission of HIV (PMTCT) data for surveillance. We audited antenatal care clinics to assess the quality of HIV rapid testing practices as the first step to assess whether South Africa is ready to utilize PMTCT programme data for antenatal HIV surveillance. In 2017, we conducted a cross-sectional survey in 360 randomly sampled antenatal care clinics using the adapted WHO Stepwise-Process-for-Improving-the-Quality-of-HIV-Rapid-Testing (SPI-RT) checklist. We calculated median percentage scores within a domain (domain-specific median score), and across all domains (overall median percentage scores). The latter was used to classify sites according to five implementation levels; (from 0:<40% to 4: 90% or higher). Of 346 (96.1%) facilities assessed, an overall median percentage score of 62.1% (inter-quartile range (IQR): 50.8-71.9%) was obtained. The lowest domain-specific median percentage scores were obtained under training/certification (35% IQR: 10.0-50.0%) and external quality assurance (12.5% IQR: 0.0-50.0%), respectively. The majority (89%) of sites had an overall median score at level 2 or below; of these, 37% required improvement in specific areas and 6.4% in all areas. Facilities in districts implementing the HIV Rapid Test Quality Improvement Initiative and supported by the President's Emergency Plan for AIDS Relief (PEPFAR) had significantly higher median overall scores (65.6% IQR: 53.9-74.2%) (P-value from rank sum test: <0.001) compared with non-PEPFAR-supported facilities (56.6% IQR:47.7-66.0%). We found sub-optimal implementation of HIV rapid testing practices. We recommend the expansion of the PEPFAR-funded Rapid Test Continuous Quality Improvement (RTCQI) support to all antenatal care testing sites.
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Affiliation(s)
- Duduzile F. Nsibande
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Selamawit A. Woldesenbet
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Adrian Puren
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Peter Barron
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Vincent I. Maduna
- Directorate of Research & Innovation, Tshwane University of Technology, Pretoria, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, University of Stellenbosch, Cape Town, South Africa
| | - Mireille Cheyip
- United States Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Mary Mogashoa
- United States Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
| | - Vuyolwethu Magasana
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Trisha Ramraj
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Tendesayi Kufa
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Gurpreet Kindra
- United States Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Ameena Goga
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa
| | - Witness Chirinda
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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Radebe L, Haeri Mazanderani A, Sherman GG. Evaluating patient data quality in South Africa's National Health Laboratory Service Data Warehouse, 2017-2020: implications for monitoring child health programmes. BMC Public Health 2022; 22:1266. [PMID: 35768861 PMCID: PMC9241268 DOI: 10.1186/s12889-022-13508-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 05/16/2022] [Indexed: 11/20/2022] Open
Abstract
Background South Africa’s National Health Laboratory Service (NHLS), the only clinical laboratory service in the country’s public health sector, is an important resource for monitoring public health programmes. Objectives We describe NHLS data quality, particularly patient demographics among infants, and the effect this has on linking multiple test results to a single patient. Methods Retrospective descriptive analysis of NHLS data from 1st January 2017—1st September 2020 was performed. A validated probabilistic record-linking algorithm linked multiple results to individual patients in lieu of a unique patient identifier. Paediatric HIV PCR data was used to illustrate the effect on monitoring and evaluating a public health programme. Descriptive statistics including medians, proportions and inter quartile ranges are reported, with Chi-square univariate tests for independence used to determine association between variables. Results During the period analysed, 485 300 007 tests, 98 217 642 encounters and 35 771 846 patients met criteria for analysis. Overall, 15.80% (n = 15 515 380) of all encounters had a registered national identity (ID) number, 2.11% (n = 2 069 785) were registered without a given name, 63.15% (n = 62 020 107) were registered to women and 32.89% (n = 32 304 329) of all folder numbers were listed as either the patient’s date of birth or unknown. For infants tested at < 7 days of age (n = 2 565 329), 0.099% (n = 2 534) had an associated ID number and 48.87% (n = 1 253 620) were registered without a given name. Encounters with a given name were linked to a subsequent encounter 40.78% (n = 14 180 409 of 34 775 617) of the time, significantly more often than the 21.85% (n = 217 660 of 996 229) of encounters registered with a baby-derivative name (p-value < 0.001). Conclusion Unavailability and poor capturing of patient demographics, especially among infants and children, affects the ability to accurately monitor routine health programmes. A unique national patient identifier, other than the national ID number, is urgently required and must be available at birth if South Africa is to accurately monitor programmes such as the Prevention of Mother-to-Child Transmission of HIV. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13508-y.
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Affiliation(s)
- Lebohang Radebe
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service, 1 Modderfontein Road, Sandringham, Johannesburg, 2131, South Africa.,Paediatric HIV Diagnostics Division, Wits Health Consortium, Johannesburg, South Africa
| | - Ahmad Haeri Mazanderani
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service, 1 Modderfontein Road, Sandringham, Johannesburg, 2131, South Africa. .,Paediatric HIV Diagnostics Division, Wits Health Consortium, Johannesburg, South Africa. .,Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Gayle G Sherman
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service, 1 Modderfontein Road, Sandringham, Johannesburg, 2131, South Africa.,Paediatric HIV Diagnostics Division, Wits Health Consortium, Johannesburg, South Africa.,Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Stanic T, McCann N, Penazzato M, Flanagan C, Essajee S, Freedberg KA, Doherty M, Putta N, Myer L, Siberry GK, Collins IJ, Vojnov L, Abrams E, Soeteman DI, Ciaranello AL. Cost-effectiveness of Routine Provider-Initiated Testing and Counseling for Children With Undiagnosed HIV in South Africa. Open Forum Infect Dis 2022; 9:ofab603. [PMID: 35028333 PMCID: PMC8753042 DOI: 10.1093/ofid/ofab603] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 12/03/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND We compared the cost-effectiveness of pediatric provider-initiated HIV testing and counseling (PITC) vs no PITC in a range of clinical care settings in South Africa. METHODS We used the Cost-Effectiveness of Preventing AIDS Complications Pediatric model to simulate a cohort of children, aged 2-10 years, presenting for care in 4 settings (outpatient, malnutrition, inpatient, tuberculosis clinic) with varying prevalence of undiagnosed HIV (1.0%, 15.0%, 17.5%, 50.0%, respectively). We compared "PITC" (routine testing offered to all patients; 97% acceptance and 71% linkage to care after HIV diagnosis) with no PITC. Model outcomes included life expectancy, lifetime costs, and incremental cost-effectiveness ratios (ICERs) from the health care system perspective and the proportion of children with HIV (CWH) diagnosed, on antiretroviral therapy (ART), and virally suppressed. We assumed a threshold of $3200/year of life saved (YLS) to determine cost-effectiveness. Sensitivity analyses varied the age distribution of children seeking care and costs for PITC, HIV care, and ART. RESULTS PITC improved the proportion of CWH diagnosed (45.2% to 83.2%), on ART (40.8% to 80.4%), and virally suppressed (32.6% to 63.7%) at 1 year in all settings. PITC increased life expectancy by 0.1-0.7 years for children seeking care (including those with and without HIV). In all settings, the ICER of PITC vs no PITC was very similar, ranging from $710 to $1240/YLS. PITC remained cost-effective unless undiagnosed HIV prevalence was <0.2%. CONCLUSIONS Routine testing improves HIV clinical outcomes and is cost-effective in South Africa if the prevalence of undiagnosed HIV among children exceeds 0.2%. These findings support current recommendations for PITC in outpatient, inpatient, tuberculosis, and malnutrition clinical settings.
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Affiliation(s)
- Tijana Stanic
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nicole McCann
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Martina Penazzato
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Clare Flanagan
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Meg Doherty
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - Landon Myer
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - George K Siberry
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Intira Jeannie Collins
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Lara Vojnov
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Elaine Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, USA.,Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Djøra I Soeteman
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Andrea L Ciaranello
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Radebe L, Haeri Mazanderani A, Sherman GG. Indeterminate HIV PCR results within South Africa's early infant diagnosis programme, 2010-2019. Clin Microbiol Infect 2021; 28:609.e7-609.e13. [PMID: 34400341 DOI: 10.1016/j.cmi.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 07/14/2021] [Accepted: 08/01/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES We describe the extent of, and variables associated with, indeterminate HIV-PCR results and final HIV status within South Africa's early infant diagnosis (EID) programme between 2010 and 2019. METHODS Retrospective analysis of routine paediatric HIV-PCR laboratory data from South Africa's National Health Laboratory Service Data Warehouse between 2010 and 2019. Final HIV status was determined by linking patient results (including HIV-PCR, HIV viral load, HIV serology and CD4 counts) using a probabilistic matching algorithm. Multivariate logistic regression was performed to determine variables associated with final HIV status among patients with an indeterminate HIV-PCR result. RESULTS Among 4 429 742 specimens registered for HIV-PCR testing from 3 816 166 patients, 113 209 (2.97%) tested positive and 22 899 (0.6%) tested indeterminate. As a proportion of HIV-detected results, 15.7% (23 896/151 832) of total and 31.5% (4900/15 566), 18.8% (11 400/60 794) and 10.1% (7596/75 472) among patients aged <7 days, 7 days-3 months and ≥3 months, respectively, were reported as indeterminate. Overall, 39.7% of patients with an indeterminate result had a linked HIV test to determine HIV status, of which 53.6% were positive with a median time to repeat testing of 30 days (interquartile range 15-69). Among patients who tested indeterminate, variables associated with a significantly higher odds of having a positive HIV status included testing indeterminate at birth (adjusted odds ratio (AOR) 0.63 (0.48-0.83) and 0.52 (0.39-0.69) for testing indeterminate at 7 days-3 months and ≥3 months respectively compared with birth), within a hospital (AOR 2.45 (1.99-3.03)), and in districts with an intra-uterine transmission rate ≥1.1% (AOR 3.14 (1.84-5.35)) (p < 0.001). DISCUSSION Indeterminate HIV-PCR results represent a considerable burden of missed diagnostic opportunities, diagnostic dilemmas and delays in making a definite diagnosis among HIV-infected infants within South Africa's EID programme. Alternative EID verification practices are urgently needed.
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Affiliation(s)
- Lebohang Radebe
- Paediatric HIV Diagnostics Division, Wits Health Consortium, Johannesburg, South Africa
| | - Ahmad Haeri Mazanderani
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; Department of Pathology, Faculty of Health Sciences, University of Limpopo, Polokwane, South Africa.
| | - Gayle G Sherman
- Paediatric HIV Diagnostics Division, Wits Health Consortium, Johannesburg, South Africa; Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa; Department of Paediatrics & Child Health, Faculty of Health Sciences, University of Witwatersrand, South Africa
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Estimating the Cost of Point-of-Care Early Infant Diagnosis in a Program Setting: A Case Study Using Abbott m-PIMA and Cepheid GeneXpert IV in Zimbabwe. J Acquir Immune Defic Syndr 2021; 84 Suppl 1:S63-S69. [PMID: 32520917 DOI: 10.1097/qai.0000000000002371] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Point-of-care early infant diagnosis (POC EID) increases access to HIV test results and shortens time to result-return and antiretroviral therapy initiation, as compared to central laboratory-based EID. However, to scale-up POC EID, governments need more information about programmatic costs. METHODS We evaluated POC EID costs from a health systems perspective. Our primary analysis assessed the Abbott m-PIMA and 2 versions of the Cepheid GeneXpert IV platforms-with a solar battery or gel battery-used in Zimbabwe, with instrument purchase. We also included the following 2 scenarios with zero upfront equipment purchase: (1) m-PIMA using a reagent rental model, with an all-inclusive price when the buyer commits to an average testing volume, and (2) GeneXpert IV, reflecting contexts where GeneXpert is already in place for tuberculosis diagnosis or HIV viral load monitoring. We collected data from project expenditures, observations of health workers, and from government salary scales. We calculated cost per EID test based on number of EID tests performed on each machine per day. RESULTS The cost per successfully completed test was $44.55 for m-PIMA with platform purchase and $25.89 for m-PIMA reagent rental. Costs for GeneXpert IV with platform purchase were $25.70 using a solar battery, $25.29 using a gel battery, and $23.85 under a scenario assuming no equipment costs. In our primary analyses, materials costs comprised 73%-74% total costs, equipment 14%-20%, labor 5%-8%, training 1%, facility upgrades 1%, and monitoring 1%. CONCLUSIONS As countries consider scaling up POC EID, these data are important for budgeting and planning.
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Uganda's "EID Systems Strengthening" model produces significant gains in testing, linkage, and retention of HIV-exposed and infected infants: An impact evaluation. PLoS One 2021; 16:e0246546. [PMID: 33539425 PMCID: PMC7861549 DOI: 10.1371/journal.pone.0246546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 01/20/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction A review of Uganda’s HIV Early Infant Diagnosis (EID) program in 2010 revealed poor retention outcomes for HIV-exposed infants (HEI) after testing. The review informed development of the ‘EID Systems Strengthening’ model: a set of integrated initiatives at health facilities to improve testing, retention, and clinical care of HIV-exposed and infected infants. The program model was piloted at several facilities and later scaled countrywide. This mixed-methods study evaluates the program’s impact and assesses its implementation. Methods We conducted a retrospective cohort study at 12 health facilities in Uganda, comprising all HEI tested by DNA PCR from June 2011 to May 2014 (n = 707). Cohort data were collected manually at the health facilities and analyzed. To assess impact, retention outcomes were statistically compared to the baseline study’s cohort outcomes. We conducted a cross-sectional qualitative assessment of program implementation through 1) structured clinic observation and 2) key informant interviews with health workers, district officials, NGO technical managers, and EID trainers (n = 51). Results The evaluation cohort comprised 707 HEI (67 HIV+). The baseline study cohort contained 1268 HEI (244 HIV+). Among infants testing HIV+, retention in care at an ART clinic increased from 23% (57/244) to 66% (44/67) (p < .0001). Initiation of HIV+ infants on ART increased from 36% (27/75) to 92% (46/50) (p < .0001). HEI receiving 1st PCR results increased from 57% (718/1268) to 73% (518/707) (p < .0001). Among breastfeeding HEI with negative 1st PCR, 55% (192/352) received a confirmatory PCR test, a substantial increase from baseline period. Testing coverage improved significantly: HIV+ pregnant women who brought their infants for testing after birth increased from 18% (67/367) to 52% (175/334) (p < .0001). HEI were tested younger: mean age at DBS test decreased from 6.96 to 4.21 months (p < .0001). Clinical care for HEI was provided more consistently. Implementation fidelity was strong for most program components. The strongest contributory interventions were establishment of ‘EID Care Points’, integration of clinical care, longitudinal patient tracking, and regular health worker mentorship. Gaps included limited follow up of lost infants, inconsistent buy-in/ownership of health facility management, and challenges sustaining health worker motivation. Discussion Uganda’s ‘EID Systems Strengthening’ model has produced significant gains in testing and retention of HEI and HIV+ infants, yet the country still faces major challenges. The 3 core concepts of Uganda’s model are applicable to any country: establish a central service point for HEI, equip it to provide high-quality care and tracking, and develop systems to link HEI to the service point. Uganda’s experience has shown the importance of intensively targeting systemic bottlenecks to HEI retention at facility level, a necessary complement to deploying rapidly scalable technologies and other higher-level initiatives.
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Dunning L, Gandhi AR, Penazzato M, Soeteman DI, Revill P, Frank S, Phillips A, Dugdale C, Abrams E, Weinstein MC, Newell M, Collins IJ, Doherty M, Vojnov L, Fassinou Ekouévi P, Myer L, Mushavi A, Freedberg KA, Ciaranello AL. Optimizing infant HIV diagnosis with additional screening at immunization clinics in three sub-Saharan African settings: a cost-effectiveness analysis. J Int AIDS Soc 2021; 24:e25651. [PMID: 33474817 PMCID: PMC8992471 DOI: 10.1002/jia2.25651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 10/19/2020] [Accepted: 11/17/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Uptake of early infant HIV diagnosis (EID) varies widely across sub-Saharan African settings. We evaluated the potential clinical impact and cost-effectiveness of universal maternal HIV screening at infant immunization visits, with referral to EID and maternal antiretroviral therapy (ART) initiation. METHODS Using the CEPAC-Pediatric model, we compared two strategies for infants born in 2017 in Côte d'Ivoire (CI), South Africa (SA), and Zimbabwe: (1) existing EID programmes offering six-week nucleic acid testing (NAT) for infants with known HIV exposure (EID), and (2) EID plus universal maternal HIV screening at six-week infant immunization visits, leading to referral for infant NAT and maternal ART initiation (screen-and-test). Model inputs included published Ivoirian/South African/Zimbabwean data: maternal HIV prevalence (4.8/30.8/16.1%), current uptake of EID (40/95/65%) and six-week immunization attendance (99/74/94%). Referral rates for infant NAT and maternal ART initiation after screen-and-test were 80%. Costs included NAT ($24/infant), maternal screening ($10/mother-infant pair), ART ($5 to 31/month) and HIV care ($15 to 190/month). Model outcomes included mother-to-child transmission of HIV (MTCT) among HIV-exposed infants, and life expectancy (LE) and mean lifetime per-person costs for children with HIV (CWH) and all children born in 2017. We calculated incremental cost-effectiveness ratios (ICERs) using discounted (3%/year) lifetime costs and LE for all children. We considered two cost-effectiveness thresholds in each country: (1) the per-capita GDP ($1720/6380/2150) per year-of-life saved (YLS), and (2) the CEPAC-generated ICER of offering 2 versus 1 lifetime ART regimens (e.g. offering second-line ART; $520/500/580/YLS). RESULTS With EID, projected six-week MTCT was 9.3% (CI), 4.2% (SA) and 5.2% (Zimbabwe). Screen-and-test decreased total MTCT by 0.2% to 0.5%, improved LE by 2.0 to 3.5 years for CWH and 0.03 to 0.07 years for all children, and increased discounted costs by $17 to 22/child (all children). The ICER of screen-and-test compared to EID was $1340/YLS (CI), $650/YLS (SA) and $670/YLS (Zimbabwe), below the per-capita GDP but above the ICER of 2 versus 1 lifetime ART regimens in all countries. CONCLUSIONS Universal maternal HIV screening at immunization visits with referral to EID and maternal ART initiation may reduce MTCT, improve paediatric LE, and be of comparable value to current HIV-related interventions in high maternal HIV prevalence settings like SA and Zimbabwe.
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Affiliation(s)
- Lorna Dunning
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
| | - Aditya R Gandhi
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
| | - Martina Penazzato
- Global HIV, Hepatitis, and STIs ProgrammeWorld Health OrganizationGenevaSwitzerland
| | - Djøra I Soeteman
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Paul Revill
- Center for Health EconomicsUniversity of YorkYorkUnited Kingdom
| | - Simone Frank
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
| | - Andrew Phillips
- Institute for Global HealthUniversity College LondonLondonUnited Kingdom
| | - Caitlin Dugdale
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Elaine Abrams
- Mailman School of Public HealthICAP at Columbia UniversityNew York CityNYUSA
| | - Milton C Weinstein
- Center for Health Decision ScienceHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Marie‐Louise Newell
- Institute for Development StudiesHuman Development and HealthFaculty of MedicineUniversity of SouthamptonSouthamptonUnited Kingdom
- School of Public HealthFaculty of Health SciencesUniversity of WitwatersrandJohannesburgSouth Africa
| | - Intira J Collins
- Medical Research Council Clinical Trials UnitUniversity College LondonLondonUnited Kingdom
| | - Meg Doherty
- Global HIV, Hepatitis, and STIs ProgrammeWorld Health OrganizationGenevaSwitzerland
| | - Lara Vojnov
- Global HIV, Hepatitis, and STIs ProgrammeWorld Health OrganizationGenevaSwitzerland
| | | | - Landon Myer
- Division of Epidemiology & BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | | | - Kenneth A Freedberg
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Andrea L Ciaranello
- Medical Practice Evaluation CenterMassachusetts General HospitalBostonMAUSA
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
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10
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Pacheco ALO, Sabidó M, Monteiro WM, Andrade SDD. Unsatisfactory long-term virological suppression in human immunodeficiency virus-infected children in the Amazonas State, Brazil. Rev Soc Bras Med Trop 2020; 53:e20200333. [PMID: 33111912 PMCID: PMC7580278 DOI: 10.1590/0037-8682-0333-2020] [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: 06/17/2020] [Accepted: 08/03/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION: Achieving viral suppression (VS) in children is challenging despite the
exponential increase in access to antiretroviral therapy (ART). We evaluated
VS in children >1 year of age and adolescents 5 years after they had
begun ART, in Manaus, Amazonas state, Brazil. METHODS: HIV-infected, ART-naive children >1 year of age between 1999
and 2016 were eligible. Analysis was stratified by age at ART initiation:
1-5 y, >5-10 y, and >10-19 y. CD4+ T-cell count and viral
load were assessed on arrival at the clinic, on ART initiation, and at 6
months, 1 year, 2 years, and 5 years after ART initiation. The primary
outcome was a viral load <50 copies/mL 5 years after ART initiation. RESULTS: Ultimately, 121 patients were included. The mean age at diagnosis was 4.8
years (SD 3.5), mean CD4% was 17.9 (SD 9.8), and mean viral load was 4.6
log10 copies/ml (SD 0.8). Five years after ART initiation, the overall VS
rate was 46.9%. VS by patient age group was as follows: 36.6% for 1-5 y,
53.3% for >5-10 y, and 30% for >10-19 y. Almost all children (90,4%)
showed an increase in CD4%+ T cell count. There were no statistically
significant predictors for detecting children who do not achieve VS with
treatment. VS remained below 65% in all the evaluated periods. CONCLUSIONS: Considerable immunological improvement is seen in children after ART
initiation. Further efforts are needed to maintain adequate long-term VS
levels and improve the survival of this vulnerable population.
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Affiliation(s)
- Ana Luisa Opromolla Pacheco
- Universidade do Estado do Amazonas, Departamento de Medicina, Manaus, AM, Brasil.,Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Programa de Pós-Graduação em Medicina Tropical, Manaus AM, Brasil
| | - Meritxell Sabidó
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Programa de Pós-Graduação em Medicina Tropical, Manaus AM, Brasil.,Universitat de Girona, Department of Medical Sciences, Catalunya, Spain
| | - Wuelton Marcelo Monteiro
- Universidade do Estado do Amazonas, Departamento de Medicina, Manaus, AM, Brasil.,Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Programa de Pós-Graduação em Medicina Tropical, Manaus AM, Brasil
| | - Solange Dourado de Andrade
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Programa de Pós-Graduação em Medicina Tropical, Manaus AM, Brasil
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11
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Point of Care Diagnostics in Resource-Limited Settings: A Review of the Present and Future of PoC in Its Most Needed Environment. BIOSENSORS-BASEL 2020; 10:bios10100133. [PMID: 32987809 PMCID: PMC7598644 DOI: 10.3390/bios10100133] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/11/2020] [Accepted: 09/23/2020] [Indexed: 12/11/2022]
Abstract
Point of care (PoC) diagnostics are at the focus of government initiatives, NGOs and fundamental research alike. In high-income countries, the hope is to streamline the diagnostic procedure, minimize costs and make healthcare processes more efficient and faster, which, in some cases, can be more a matter of convenience than necessity. However, in resource-limited settings such as low-income countries, PoC-diagnostics might be the only viable route, when the next laboratory is hours away. Therefore, it is especially important to focus research into novel diagnostics for these countries in order to alleviate suffering due to infectious disease. In this review, the current research describing the use of PoC diagnostics in resource-limited settings and the potential bottlenecks along the value chain that prevent their widespread application is summarized. To this end, we will look at literature that investigates different parts of the value chain, such as fundamental research and market economics, as well as actual use at healthcare providers. We aim to create an integrated picture of potential PoC barriers, from the first start of research at universities to patient treatment in the field. Results from the literature will be discussed with the aim to bring all important steps and aspects together in order to illustrate how effectively PoC is being used in low-income countries. In addition, we discuss what is needed to improve the situation further, in order to use this technology to its fullest advantage and avoid “leaks in the pipeline”, when a promising device fails to take the next step of the valorization pathway and is abandoned.
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12
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Steep Declines in Pediatric AIDS Mortality in South Africa, Despite Poor Progress Toward Pediatric Diagnosis and Treatment Targets. Pediatr Infect Dis J 2020; 39:843-848. [PMID: 32433224 PMCID: PMC7958302 DOI: 10.1097/inf.0000000000002680] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Few attempts have been made to monitor progress toward HIV diagnosis and antiretroviral treatment (ART) coverage targets in children, and the impact that ART and prevention of mother-to-child transmission (PMTCT) programs have had on pediatric HIV incidence and mortality. METHODS A multiparameter evidence synthesis approach was adopted to integrate South African pediatric HIV data sources. A previously developed model of HIV in South Africa was calibrated to household survey HIV prevalence data, routine antibody testing data, data on numbers and ages of children on ART, vital registration data and data on HIV diagnosis at death. The impact of ART and PMTCT was estimated by comparing validated model outputs against model predictions of the trends that would have been expected in the absence of ART and PMTCT. RESULTS By mid-2018, the model estimated that 75.2% (95% CI: 73.9%-76.8%) of HIV-positive children were diagnosed, substantially lower than the corresponding estimates in HIV-positive adults (91.0%). ART coverage in children in 2018 (51.2%, 95% CI: 49.4%-52.7%) was also lower than that in adults (62.0%). In 2017-2018, the numbers of new cases of mother-to-child transmission and pediatric AIDS deaths were reduced by 84% and 94%, respectively, relative to what would have been expected in the absence of interventions, but reductions in mortality were driven largely by PMTCT. CONCLUSIONS Although levels of AIDS mortality in children have declined dramatically in South Africa, this has mostly been due to successful PMTCT programs, and progress toward the 90-90-90 targets appears relatively poor when compared with that in adults.
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13
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Jacob N, Rice B, Kalk E, Heekes A, Morgan J, Hargreaves J, Boulle A. Utility of digitising point of care HIV test results to accurately measure, and improve performance towards, the UNAIDS 90-90-90 targets. PLoS One 2020; 15:e0235471. [PMID: 32603374 PMCID: PMC7326208 DOI: 10.1371/journal.pone.0235471] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 06/09/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION High rates of pre-treatment loss to care among persons diagnosed with HIV persist. Linkage to care can be improved through active digitally-based surveillance. Currently, record-keeping for HIV diagnoses in South Africa is paper-based. Aggregated testing data are reported routinely, and only discordant findings result in a specimen being tested at a laboratory and digitised. The Western Cape Province in South Africa has a Provincial Health Data Centre (PHDC) where person-level routine electronic data are consolidated in a single database, leveraging the existence of a unique patient identifier. To facilitate improved HIV surveillance, a pre-carbonated point-of-care test (PoCT) form was piloted, where one copy was routed to a central point and digitised for PHDC inclusion. METHODS We evaluated the utility of the intervention using cross-sectional and retrospective cohort analyses, as well as comparisons with aggregate data. Data were linked to the Patient Master Index of the PHDC using unique identifiers. Prior evidences of HIV within the PHDC were used to differentiate newly diagnosed patients and those retesting, as well as linkage to care and treatment. RESULTS From May 2017 to June 2018, 11337 digitised point-of-care HIV testing records were linked to the PHDC. Overall, 96% of records in the aggregate dataset were digitised, with 97% linked to the PHDC. Of those tested, 79% were female (median age 27 years). Linkage demonstrated that 51.3% (95% CI 48.4-54.1%) of patients testing HIV-positive were retesting. Of those newly diagnosed, 81% (95% CI 77.9-84.3%) were linked to HIV care and 25% (95% CI 21.6-28.7%) were initiated on antiretroviral therapy immediately. CONCLUSION Digitisation of PoCT results provides individuated HIV testing data to assist in linkage to care and in differentiating newly diagnosed patients from positive patients retesting. Actionable and accurate data can improve the measurement of performance towards the UNAIDS 90-90-90 targets.
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Affiliation(s)
- Nisha Jacob
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Brian Rice
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Emma Kalk
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Alexa Heekes
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Western Cape Government: Health, Cape Town, South Africa
| | - Jennie Morgan
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Western Cape Government: Health, Cape Town, South Africa
| | - James Hargreaves
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Andrew Boulle
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Western Cape Government: Health, Cape Town, South Africa
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14
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Bassett IV, Huang M, Cloete C, Candy S, Giddy J, Frank SC, Freedberg KA, Losina E, Walensky RP, Parker RA. Using national laboratory data to assess cumulative frequency of linkage after transfer to community-based HIV clinics in South Africa. J Int AIDS Soc 2020; 22:e25326. [PMID: 31243898 PMCID: PMC6595194 DOI: 10.1002/jia2.25326] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 05/22/2019] [Indexed: 12/29/2022] Open
Abstract
Introduction Changes to the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) funding have led to closures of non‐governmental HIV clinics with patient transfers to government‐funded clinics. We sought to determine the success of transfers in South Africa using a national data source. Methods All adults (≥18 years) on antiretroviral therapy (ART) who visited a single PEPFAR‐funded hospital‐based HIV clinic in Durban, South Africa from March to June 2012 were transferred to community‐based clinics. Previously, we matched patient records from the hospital‐based HIV clinic with National Health Laboratory Services (NHLS) Corporate Data Warehouse (CDW) data to estimate the proportion of patients with a CD4 count or viral load (VL) in the CDW during the year before transfer. As a proxy for retention in care, in this study we evaluated whether patients had a CD4 count or VL at another facility within approximately three years of transfer. Patients referred to a private doctor at transfer were excluded from the analysis. We assessed predictors (age, sex, CD4 count, VL status, ART duration and location of future care) of not having post‐transfer laboratory data using Cox proportional hazards models. Results Of the 3893 patients referred to a government facility at transfer, 41% were male and median age was 39 years (IQR 34 to 46). There was a post‐transfer CD4 count or VL from another facility for 23% of these individuals within six months, 44% within one year, 57% within two years and 61% within approximately three years. Male sex (aHR 1.20, 95% CI 1.10 to 1.31) and shorter duration on ART (<3 months, aHR 3.80, 95% CI 2.77 to 5.21; three months to one year, aHR 1.32, 95% CI 1.15 to 1.51, each compared with >1 year) were associated with not having a post‐transfer record. Conclusions Using data from the NHLS CDW, 61% of patients had evidence of a post‐transfer laboratory record at another facility within approximately three years after closure of a large South African HIV clinic. Males and those with shorter time on ART prior to transfer were at highest risk for lacking follow‐up laboratory data. As patients transfer care, national data sources can be used to evaluate long‐term patient care trajectories.
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Affiliation(s)
- Ingrid V Bassett
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Mingshu Huang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Sue Candy
- Department of Academic Affairs, Research and Quality Assurance, Corporate Data Warehouse, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Simone C Frank
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kenneth A Freedberg
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Departments of Epidemiology and Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Elena Losina
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Departments of Biostatistics and Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Division of Rheumatology, Department of Medicine, and Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Rochelle P Walensky
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Robert A Parker
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
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15
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Vieira L, Mahumane AM, Napua M, Chale F, Manuel JL, Cowan JG, Sherr K, Chapman RR, Pfeiffer JT. HIV-exposed infant follow-up in Mozambique: formative research findings for the design of a cluster randomized controlled trial to improve testing and ART initiation. BMC Health Serv Res 2020; 20:226. [PMID: 32183779 PMCID: PMC7079378 DOI: 10.1186/s12913-020-5051-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 02/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early infant diagnosis (EID) of HIV-exposed and initiation of HIV-positive infants on anti-retroviral therapy (ART) requires a well-coordinated cascade of care. Loss-to-follow-up (LTFU) can occur at multiple steps and effective EID is impeded by human resource constraints, difficulty with patient tracking, and long waiting periods. The objective of this research was to conduct formative research to guide the development of an intervention to improve the pediatric HIV care cascade in central Mozambique. The study was conducted in Manica and Sofala Provinces where the adult HIV burden is higher than the national average. The research focused on 3 large clinics in each province, along the highly populated Beira corridor. METHODS The research was conducted in 2014 over 3 months at six facilities and consisted of 1) patient flow mapping and collection of health systems data from postpartum, child-at-risk, and ART service registries, 2) measurement of clinic waiting times, and 3) patient and health worker focus groups. RESULTS HIV testing and ART initiation coverage for mothers tends to be high, but EID and pediatric ART initiation are hampered by lack of patient tracking, long waiting times, and inadequate counseling to navigate the care cascade. About 76% of HIV-positive infants were LTFU and did not initiate ART. CONCLUSIONS Effective interventions to reduce LTFU in EID and improve pediatric ART initiation should focus on patient tracking, active follow-up of defaulting patients, reduction in EID turn-around times for PCR results, and initiation of ART by nurses in child-at-risk services. TRIAL REGISTRATION Retrospectively registered, ISRCTN67747315, July 24, 2019.
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Affiliation(s)
- Lúcia Vieira
- Ministry of Health, Centro de Investigação Operacional da Beira, Institute Nacional de Saúde, 1323 Correia de Brito Street, Ponta-gêa Health Center Building, Beira, Sofala, Mozambique.
| | - Arlete Miloque Mahumane
- Ministry of Health, Centro de Investigação Operacional da Beira, Institute Nacional de Saúde, 1323 Correia de Brito Street, Ponta-gêa Health Center Building, Beira, Sofala, Mozambique
| | - Manuel Napua
- Ministry of Health, Centro de Investigação Operacional da Beira, Institute Nacional de Saúde, 1323 Correia de Brito Street, Ponta-gêa Health Center Building, Beira, Sofala, Mozambique
| | - Falume Chale
- Ministry of Health, Centro de Investigação Operacional da Beira, Institute Nacional de Saúde, 1323 Correia de Brito Street, Ponta-gêa Health Center Building, Beira, Sofala, Mozambique
| | - João Luís Manuel
- Ministry of Health, Centro de Investigação Operacional da Beira, Institute Nacional de Saúde, 1323 Correia de Brito Street, Ponta-gêa Health Center Building, Beira, Sofala, Mozambique
| | - Jessica Greenberg Cowan
- School of Nursing, University of Washington, Seattle, USA
- Department of Family Medicine, University of Washington, Seattle, USA
| | - Kenneth Sherr
- School of Nursing, University of Washington, Seattle, USA
- Health Alliance International, Beira, Mozambique
| | - Rachel R Chapman
- Department of Anthropology, University of Washington, Seattle, USA
| | - James T Pfeiffer
- School of Nursing, University of Washington, Seattle, USA
- Health Alliance International, Beira, Mozambique
- Department of Anthropology, University of Washington, Seattle, USA
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16
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Chappell E, Lyall H, Riordan A, Thorne C, Foster C, Butler K, Prime K, Bamford A, Peters H, Judd A, Collins IJ. The cascade of care for children and adolescents with HIV in the UK and Ireland, 2010 to 2016. J Int AIDS Soc 2019; 22:e25379. [PMID: 31498566 PMCID: PMC6733246 DOI: 10.1002/jia2.25379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 07/31/2019] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION The UNAIDS 90-90-90 targets for the cascade of care are widely used to monitor the success of HIV care programmes but there are few studies in children. We assessed the cascade for children and adolescents living with HIV in the national Collaborative HIV Paediatric Study (CHIPS) in the UK and Ireland. METHODS Utilizing longitudinal data from CHIPS we compared the cascade of care for 2010, 2013 and 2016. Among children diagnosed with HIV and not known to be lost to follow-up at the start of each calendar year, we summarized the proportion in active paediatric care during that year (defined as having ≥1 clinic visit, CD4 or viral load measurement, or change to antiretroviral therapy (ART) regimen), and of these, the proportion on ART at last visit in that year. Among those on ART, the proportion with viral suppression (<200 copies/mL) and good immune status (WHO immunological stage none-/mild-for-age) at last visit in the year were summarized. Among those in care in 2016, outcomes were compared by current age, place of birth (born abroad vs. UK/Ireland) and sex. RESULTS Of children in paediatric HIV care at the start of 2010, 2013 and 2016 (n = 1249, 1157, 905 respectively), the proportion in active care during that calendar year was high throughout at 97 to 99%. Of those in active care, the proportion on ART increased from 79% to 85% and 92% respectively (p < 0.001). Among those on ART, the proportion with viral suppression and good immune status was stable at 83% to 86% and 85% to 88%, respectively, across the years. Among children in care in 2016, those aged ≥15 years were less likely to be virally suppressed (79% vs. 91%, p < 0.001) or to have good immune status (78% vs. 94%, p < 0.001) compared to younger children; there were no differences by place of birth or sex. CONCLUSIONS Children and adolescents in the UK and Ireland national cohort had high retention in care. The proportion on ART increased significantly over time although there was no change in viral suppression or good immune status. Poorer outcomes among adolescents highlight the need for targeted support for this population.
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Affiliation(s)
| | - Hermione Lyall
- St Mary's HospitalImperial College NHS Healthcare TrustLondonUK
| | | | - Claire Thorne
- UCL Great Ormond Street Institute of Child HealthLondonUK
| | - Caroline Foster
- St Mary's HospitalImperial College NHS Healthcare TrustLondonUK
| | - Karina Butler
- Paediatric DepartmentOur Lady's Children's HospitalCrumlinIreland
| | - Katia Prime
- St George's University Hospitals NHS TrustLondonUK
| | - Alasdair Bamford
- MRC Clinical Trials Unit at UCLLondonUK
- UCL Great Ormond Street Institute of Child HealthLondonUK
- Great Ormond Street Hospital for ChildrenNHS Foundation TrustLondonUK
| | - Helen Peters
- UCL Great Ormond Street Institute of Child HealthLondonUK
| | - Ali Judd
- MRC Clinical Trials Unit at UCLLondonUK
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17
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Mutanga JN, Mutembo S, Ezeamama AE, Fubisha RC, Sialondwe D, Simuchembu B, Mutukwa M, Chinyonga J, Thuma PE, Whalen CC. Tracking Progress Toward Elimination of Mother to Child Transmission of HIV in Zambia: Findings from the Early Infant Diagnosis of HIV Program (2009-2017). J Trop Pediatr 2019; 66:56-65. [PMID: 31089687 PMCID: PMC7156365 DOI: 10.1093/tropej/fmz030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND We carried out analyses of early infant testing results at Livingstone Central Hospital in Zambia to assess time of testing, linkages to care and availability of test results for clinical decision making. METHODS We abstracted data from registers of HIV-exposed infants who had dried blood spots cards (DBS) collected for DNA-PCR from January 2009 to December 2017. Only those tested from 2014 to 2017 had additional data which were used to estimate risk factors for mother-to-child HIV transmission using logistic regression models. RESULTS DBS were collected from 2630 children. The proportion of HIV-positive tests decreased from 21% in 2009 to 2% in 2016 and 2017. Median turnaround time for results was 9 weeks (IQR: 5, 15) for HIV-negative, 7 weeks (IQR: 5, 13) for HIV-positive children. Only 2% of infants whose mothers took antiretroviral therapy (ART) were HIV positive, while 18% of infants whose mothers took short course antiretroviral drugs (ARVs) were infected. Infants of mothers who did not take ARVs had 9 times the odds of an HIV positive test (OR = 8.9, 95% CI: 3.6, 22.6). Infants of mothers who received short course ARVs were 40% less likely to get an HIV test within the first 2 months of life (OR = 0.6, 95% CI: 0.4, 0.9) compared to infants of mothers who received ART. Only 52% had a third test at median age 52 weeks (IQR: 50, 54). CONCLUSIONS Long turnaround time for test results and low retention in care after the initial HIV test were critical challenges to clinical decision making.
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Affiliation(s)
- Jane N Mutanga
- Department of Pediatrics and Child Health, Livingstone Central Hospital, Livingstone, Zambia,Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens GA, 30602, USA,Global Health Institute, College of Public Health University of Georgia, Athens GA, 30602, USA,Correspondence: Jane N. Mutanga, Livingstone Central Hospital, Akapelwa Street, Livingstone, 10101, Zambia. E-mail <>
| | - Simon Mutembo
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens GA, 30602, USA,Global Health Institute, College of Public Health University of Georgia, Athens GA, 30602, USA,Southern Province Medical Office, Ministry of Health, Choma, 10101, Zambia
| | - Amara E Ezeamama
- Research Division, Department of Psychiatry, Michigan State University, East Lansing, MI, 48824, USA
| | - Robert C Fubisha
- Department of Pediatrics and Child Health, Livingstone Central Hospital, Livingstone, Zambia
| | - Derrick Sialondwe
- Department of Pediatrics and Child Health, Livingstone Central Hospital, Livingstone, Zambia
| | - Brenda Simuchembu
- Department of Pediatrics and Child Health, Livingstone Central Hospital, Livingstone, Zambia
| | - Macwani Mutukwa
- Department of Pediatrics and Child Health, Livingstone Central Hospital, Livingstone, Zambia
| | - Jelita Chinyonga
- Southern Province Medical Office, Ministry of Health, Choma, 10101, Zambia
| | | | - Christopher C Whalen
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens GA, 30602, USA,Global Health Institute, College of Public Health University of Georgia, Athens GA, 30602, USA
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Minn AC, Kyaw NTT, Aung TK, Mon OM, Htun T, Oo MM, Moe J, Mon AA, Satyanarayana S, Oo HN. Attrition among HIV positive children enrolled under integrated HIV care programme in Myanmar: 12 years cohort analysis. Glob Health Action 2019; 11:1510593. [PMID: 30191749 PMCID: PMC6136349 DOI: 10.1080/16549716.2018.1510593] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: In Myanmar, HIV seropositive children are being enrolled in an integrated HIV care (IHC) Program for HIV treatment and care since 2005. Objectives: To assess the: (a) attrition (death or loss-to-follow-up) rates among children (aged ≥ 18 months to < 15 years) enrolled into the programme before and after initiation of anti-retroviral therapy (ART) (pre-ART and ART periods); (b) demographic and clinical factors associated with attrition during these two periods. Methods: Children enrolled in IHC Programme and their status (death, lost to follow-up, regular follow-up or transferred out) was assessed as on 30 June 2017. Attrition rates (per 100 person-years) at pre – ART and ART periods were calculated and the association between demographic and clinical characteristics with attrition was assessed using Cox proportional hazards model. Results: Among 2,736 children enrolled, pre-ART attrition rate was 19 per 100 person-years of follow-up (95% CI: 17–21) and ART attrition rate was 4 per 100 person-years of follow-up (95% CI: 3–4) with higher levels during the initial few months of enrolment. The 36-month retention rates during pre-ART period was 75% (95% CI: 72–78) and during ART period was 87% (95% CI: 86–88). The children ‘at enrolment’ with relatively lower levels of haemoglobin, immune deficiency, underweight for age, higher WHO clinical stages, presence of hepatitis B infection had higher hazards of attrition in both periods. Conclusion: The attrition rates are high particularly among children with relatively poorer clinical, nutritional profiles at enrolment. The study suggests the urgent need for improving adherence counselling especially during the initial few months of enrolment and early ART initiation.
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Affiliation(s)
- Aung Chan Minn
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Nang Thu Thu Kyaw
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Thet Ko Aung
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Ohn Mar Mon
- b Ministry of Health and Sports (MOHS) , 550 bedded Children Hospital , Mandalay , Myanmar
| | - Thurain Htun
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Myo Minn Oo
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - July Moe
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Aye Aye Mon
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Srinath Satyanarayana
- c Center for Operational Research , International Union Against Tuberculosis and Lung Diseases , Paris , France
| | - Htun Nyunt Oo
- d National AIDS Program, Department of Public Health , Ministry of Health and Sports , Nay Pyi Taw , Myanmar
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Opollo VS, Nikuze A, Ben-Farhat J, Anyango E, Humwa F, Oyaro B, Wanjala S, Omwoyo W, Majiwa M, Akelo V, Zeh C, Maman D. Field evaluation of near point of care Cepheid GeneXpert HIV-1 Qual for early infant diagnosis. PLoS One 2018; 13:e0209778. [PMID: 30589900 PMCID: PMC6307732 DOI: 10.1371/journal.pone.0209778] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 12/11/2018] [Indexed: 11/18/2022] Open
Abstract
Background Access to point-of-care HIV testing shortens turn-around times, time to diagnosis and reduces loss to follow-up hence minimizing barriers to early linkage to care and treatment among HIV infected infants. Currently samples for early infant HIV diagnosis are sent to centralized testing facilities which are few and located only at specific regions in Kenya. However, there are Point of Care (POC) early infant diagnosis [EID] technologies elsewhere such as SAMBA and ALERE-Q that are yet to be evaluated in Kenya despite the urgent need for data to inform policy formulation regarding EID. The Cepheid GeneXpert HIV-1 Qual (GeneXpert) technology for POC EID offers a great opportunity to minimize HIV associated morbidity, mortality and loss to follow-up through decentralization of early infant HIV testing to the clinics. This technology also allows for same-day results thus facilitating prompt linkage to care. Methods We evaluated the GeneXpert HIV Qual EID POC in Homabay County against the standard of care platform, Roche CAP/CTM HIV-1 qualitative PCR, using dried blood spots (DBS). Between February—July 2016, DBS samples were collected from HIV exposed children <18 months of age enrolled in a cross-sectional study. Samples were collected by qualified nurse counselors, and were tested by trained technicians using field based GeneXpert and conventional laboratory based Roche CAP/CTM HIV-1 qualitative PCR. Sensitivity and specificity were determined. Results Overall, 3,814 mother/infant pairs were included in the study, out of which 921 infants were HIV exposed as per the mothers’ HIV status and based on the infant’s HIV rapid test. A total of 969 PCR tests were performed, out of which 30 (3.3%) infants were concordantly positive using both platforms. GeneXpert HIV-1 Qual yielded a sensitivity of 94.1% and specificity of 99.8% with an overall error rate of 0.7%. Conclusion Our findings show that GeneXpert HIV-1 Qual performs well compared to CAP/CTM using DBS samples, suggesting that this technology may be adopted in decentralized laboratories as a near POC device. It may contribute to prompt diagnosis of HIV exposed infants hence enabling early linkage to care, thus advancing further gains in EID.
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Affiliation(s)
- Valarie Sarah Opollo
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
- * E-mail:
| | | | | | - Emily Anyango
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | - Felix Humwa
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | - Boaz Oyaro
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | | | | | - Maxwel Majiwa
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | - Victor Akelo
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | - Clement Zeh
- U.S. Centers for Disease Control and Prevention, Clinical Research Center, Kisumu, Kenya
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Bassett IV, Huang M, Cloete C, Candy S, Giddy J, Frank SC, Parker RA. Assessing the completeness and accuracy of South African National Laboratory CD4 and viral load data: a cross-sectional study. BMJ Open 2018; 8:e021506. [PMID: 30139898 PMCID: PMC6112393 DOI: 10.1136/bmjopen-2018-021506] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To assess the accuracy of the South African National Health Laboratory Services (NHLS) corporate data warehouse (CDW) using a novel data cross-matching method. METHODS Adults (≥18 years) on antiretroviral therapy (ART) who visited a hospital-based HIV clinic in Durban from March to June 2012 were included. We matched patient identifiers, CD4 and viral load (VL) records from the HIV clinic's electronic record with the NHLS CDW according to a set of matching criteria for patient identifiers, test values and test dates. We calculated the matching rates for patient identifiers, CD4 and VL records, and an overall matching rate. RESULTS NHLS returned records for 3498 (89.6%) of the 3906 individuals requested. Using our computer algorithm, we confidently matched 3278 patients (83.9% of the total request). Considering less than confident matches as well, and then manually reviewing questionable matches using only patient identifiers, only nine (0.3% of records returned by NHLS) of the suggested matches were judged incorrect. CONCLUSIONS We developed a data cross-matching method to evaluate national laboratory data and were able to match almost 9 of 10 patients with data we expected to find in the NHLS CDW. We found few questionable matches, suggesting that manual review of records returned was not essential. As the number of patients initiating ART in South Africa grows, maintaining a comprehensive and accurate national data repository is of critical importance, since it may serve as a valuable tool to evaluate the effectiveness of the country's HIV care system. This study helps validate the use of NHLS CDW data in future research on South Africa's HIV care system and may inform analyses in similar settings with national laboratory systems.
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Affiliation(s)
- Ingrid Valerie Bassett
- Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Mingshu Huang
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts, USA
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Sue Candy
- Corporate Data Warehouse, Department of Information Technology, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Simone Claire Frank
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert A Parker
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
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21
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Peter T, Zeh C, Katz Z, Elbireer A, Alemayehu B, Vojnov L, Costa A, Doi N, Jani I. Scaling up HIV viral load - lessons from the large-scale implementation of HIV early infant diagnosis and CD4 testing. J Int AIDS Soc 2018; 20 Suppl 7. [PMID: 29130601 PMCID: PMC5978645 DOI: 10.1002/jia2.25008] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 08/21/2017] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION The scale-up of effective HIV viral load (VL) testing is an urgent public health priority. Implementation of testing is supported by the availability of accurate, nucleic acid based laboratory and point-of-care (POC) VL technologies and strong WHO guidance recommending routine testing to identify treatment failure. However, test implementation faces challenges related to the developing health systems in many low-resource countries. The purpose of this commentary is to review the challenges and solutions from the large-scale implementation of other diagnostic tests, namely nucleic-acid based early infant HIV diagnosis (EID) and CD4 testing, and identify key lessons to inform the scale-up of VL. DISCUSSION Experience with EID and CD4 testing provides many key lessons to inform VL implementation and may enable more effective and rapid scale-up. The primary lessons from earlier implementation efforts are to strengthen linkage to clinical care after testing, and to improve the efficiency of testing. Opportunities to improve linkage include data systems to support the follow-up of patients through the cascade of care and test delivery, rapid sample referral networks, and POC tests. Opportunities to increase testing efficiency include improvements to procurement and supply chain practices, well connected tiered laboratory networks with rational deployment of test capacity across different levels of health services, routine resource mapping and mobilization to ensure adequate resources for testing programs, and improved operational and quality management of testing services. If applied to VL testing programs, these approaches could help improve the impact of VL on ART failure management and patient outcomes, reduce overall costs and help ensure the sustainable access to reduced pricing for test commodities, as well as improve supportive health systems such as efficient, and more rigorous quality assurance. These lessons draw from traditional laboratory practices as well as fields such as logistics, operations management and business. CONCLUSIONS The lessons and innovations from large-scale EID and CD4 programs described here can be adapted to inform more effective scale-up approaches for VL. They demonstrate that an integrated approach to health system strengthening focusing on key levers for test access such as data systems, supply efficiencies and network management. They also highlight the challenges with implementation and the need for more innovative approaches and effective partnerships to achieve equitable and cost-effective test access.
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Affiliation(s)
- Trevor Peter
- Clinton Health Access Initiative, Gaborone, Botswana
| | - Clement Zeh
- United States Centers for Disease Control, Addis Ababa, Ethiopia
| | - Zachary Katz
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Ali Elbireer
- African Society for Laboratory Medicine, Addid Ababa, Ethiopia
| | | | - Lara Vojnov
- World Health Organization, Geneva, Switzerland
| | | | - Naoko Doi
- Clinton Health Access Initiative, Gaborone, Botswana
| | - Ilesh Jani
- Institut Nacional Da Saude, Maputo, Mozambique
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22
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Dunning L, Kroon M, Hsiao NY, Myer L. Field evaluation of HIV point-of-care testing for early infant diagnosis in Cape Town, South Africa. PLoS One 2017; 12:e0189226. [PMID: 29261707 PMCID: PMC5738050 DOI: 10.1371/journal.pone.0189226] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 11/21/2017] [Indexed: 12/21/2022] Open
Abstract
Background Early infant HIV diagnosis (EID) coverage and uptake remains challenging. Point-of-care (POC) testing may improve access and turn-around-times, but, while several POC technologies are in development there are few data on their implementation in the field. Methods We conducted an implementation study of the Alere q Detect POC system for EID at two public sector health facilities in Cape Town. HIV-exposed neonates undergoing routine EID testing at a large maternity hospital and a primary care clinic received both laboratory-based HIV PCR testing per local protocols and a POC test. We analysed the performance of POC versus laboratory testing, and conducted semi-structured interviews with providers to assess acceptability and implementation issues. Results Overall 478 specimens were taken: 311 tests were performed at the obstetric hospital (median child age, 1 days) and 167 six-week tests in primary care (median child age, 42 days). 9.0% of all tests resulted in an error with no differences by site; most errors resolved with retesting. POC was more sensitive (100%; lower 95% CI, 39.8%) and specific (100%, lower 95% CI, 98%) among older children tested in primary care compared with birth testing in hospital (90.0%, 95% CI, 55.5–99.8% and 100.0%, lower 95% CI, 98.4%, respectively). Negative predictive value was high (>99%) at both sites. In interviews, providers felt the device was simple to use and facilitated decision-making in the management of infants. However, many wanted clarity on the cause of errors on the POC device to help guide repeat testing. Conclusions POC EID testing performs well in field implementation in health care facilities and appears highly acceptable to health care providers.
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Affiliation(s)
- Lorna Dunning
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Max Kroon
- Department of Neonatal Medicine, University of Cape Town, Cape Town, South Africa
| | - Nei-yuan Hsiao
- Division of Medical Virology, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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El-Sadr WM, Rabkin M, Nkengasong J, Birx DL. Realizing the potential of routine viral load testing in sub-Saharan Africa. J Int AIDS Soc 2017; 20 Suppl 7. [PMID: 29130621 PMCID: PMC5978658 DOI: 10.1002/jia2.25010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 12/11/2022] Open
Affiliation(s)
| | | | - John Nkengasong
- Africa Centres for Disease Control and Prevention, Addis Ababa, Ethiopia
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24
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Dunning L, Francke JA, Mallampati D, MacLean RL, Penazzato M, Hou T, Myer L, Abrams EJ, Walensky RP, Leroy V, Freedberg KA, Ciaranello A. The value of confirmatory testing in early infant HIV diagnosis programmes in South Africa: A cost-effectiveness analysis. PLoS Med 2017; 14:e1002446. [PMID: 29161262 PMCID: PMC5697827 DOI: 10.1371/journal.pmed.1002446] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 10/18/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The specificity of nucleic acid amplification tests (NAATs) used for early infant diagnosis (EID) of HIV infection is <100%, leading some HIV-uninfected infants to be incorrectly identified as HIV-infected. The World Health Organization recommends that infants undergo a second NAAT to confirm any positive test result, but implementation is limited. Our objective was to determine the impact and cost-effectiveness of confirmatory HIV testing for EID programmes in South Africa. METHOD AND FINDINGS Using the Cost-effectiveness of Preventing AIDS Complications (CEPAC)-Pediatric model, we simulated EID testing at age 6 weeks for HIV-exposed infants without and with confirmatory testing. We assumed a NAAT cost of US$25, NAAT specificity of 99.6%, NAAT sensitivity of 100% for infants infected in pregnancy or at least 4 weeks prior to testing, and a mother-to-child transmission (MTCT) rate at 12 months of 4.9%; we simulated guideline-concordant rates of testing uptake, result return, and antiretroviral therapy (ART) initiation (100%). After diagnosis, infants were linked to and retained in care for 10 years (false-positive) or lifelong (true-positive). All parameters were varied widely in sensitivity analyses. Outcomes included number of infants with false-positive diagnoses linked to ART per 1,000 ART initiations, life expectancy (LE, in years) and per-person lifetime HIV-related healthcare costs. Both without and with confirmatory testing, LE was 26.2 years for HIV-infected infants and 61.4 years for all HIV-exposed infants; clinical outcomes for truly infected infants did not differ by strategy. Without confirmatory testing, 128/1,000 ART initiations were false-positive diagnoses; with confirmatory testing, 1/1,000 ART initiations were false-positive diagnoses. Because confirmatory testing averted costly HIV care and ART in truly HIV-uninfected infants, it was cost-saving: total cost US$1,790/infant tested, compared to US$1,830/infant tested without confirmatory testing. Confirmatory testing remained cost-saving unless NAAT cost exceeded US$400 or the HIV-uninfected status of infants incorrectly identified as infected was ascertained and ART stopped within 3 months of starting. Limitations include uncertainty in the data used in the model, which we examined with sensitivity and uncertainty analyses. We also excluded clinical harms to HIV-uninfected infants incorrectly treated with ART after false-positive diagnosis (e.g., medication toxicities); including these outcomes would further increase the value of confirmatory testing. CONCLUSIONS Without confirmatory testing, in settings with MTCT rates similar to that of South Africa, more than 10% of infants who initiate ART may reflect false-positive diagnoses. Confirmatory testing prevents inappropriate HIV diagnosis, is cost-saving, and should be adopted in all EID programmes.
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Affiliation(s)
- Lorna Dunning
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jordan A. Francke
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Divya Mallampati
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, United States of America
| | - Rachel L. MacLean
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Martina Penazzato
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Taige Hou
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- College of Physicians & Surgeons, Columbia University, New York, New York, United States of America
| | - Rochelle P. Walensky
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America
| | | | - Kenneth A. Freedberg
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Andrea Ciaranello
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Madaline TF, Hochman SE, Seydel KB, Liomba A, Saidi A, Matebule G, Mowrey WB, O'Hare B, Milner DA, Kim K. Rapid Diagnostic Testing of Hospitalized Malawian Children Reveals Opportunities for Improved HIV Diagnosis and Treatment. Am J Trop Med Hyg 2017; 97:1929-1935. [PMID: 29141709 DOI: 10.4269/ajtmh.17-0067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Recent World Health Organization (WHO) guidelines recommend antiretroviral therapy (ART) for all HIV-infected people; previously CD4+ T lymphocyte quantification (CD4 count) or clinical staging determined eligibility for children ≥ 5 years old in low- and middle-income countries. We examined positive predictive value (PPV) of a rapid diagnostic test (RDT) algorithm and ART eligibility for hospitalized children with newly diagnosed HIV infection. We enrolled 363 hospitalized Malawian children age 2 months to 16 years with two serial positive HIV RDT from 2013 to 2015. Children aged ≤ 18 months whose nucleic acid testing was negative or unavailable were later excluded from the analysis (N = 16). If RNA PCR was undetectable, human immunodeficiency virus (HIV) enzyme immunoassay (EIA) and western blot (WB) were performed. Those with negative or discordant EIA and WB were considered HIV negative and excluded from further analysis (N = 6). ART eligibility was assessed using age, CD4 count, and clinical HIV stage. Among 150 patients with HIV RNA PCR results, 15 had undetectable HIV RNA. Of those, EIA and WB were positive in nine patients and negative or discordant in six patients. PPV of serial RDT was 90% versus RNA PCR alone and 96% versus combined RNA PCR, EIA, and WB. Of all patients aged ≥ 5 years, 8.9% were ineligible for ART under previous WHO guidelines. Improved HIV testing algorithms are needed for accurate diagnosis of HIV infection in children as prevalence of pediatric HIV declines. Universal treatment will significantly increase the numbers of older children who qualify for ART.
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Affiliation(s)
- Theresa F Madaline
- Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Sarah E Hochman
- Department of Medicine, New York University Langone Medical Center and New York University School of Medicine, New York, New York
| | - Karl B Seydel
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, Michigan State University College of Osteopathic Medicine, East Lansing, Michigan
| | - Alice Liomba
- Department of Paediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi.,Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Alex Saidi
- Department of Paediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi.,Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Grace Matebule
- Department of Paediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Wenzhu B Mowrey
- Department of Epidemiology & Population Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Bernadette O'Hare
- Global Health Implementation, University of St. Andrews School of Medicine, North Haugh, United Kingdom.,Department of Paediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Danny A Milner
- American Society for Clinical Pathology, Chicago, Illinois
| | - Kami Kim
- Departments of Pathology and Microbiology and Immunology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.,Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
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Scale-up of Early Infant HIV Diagnosis and Improving Access to Pediatric HIV Care in Global Plan Countries: Past and Future Perspectives. J Acquir Immune Defic Syndr 2017; 75 Suppl 1:S51-S58. [PMID: 28398997 DOI: 10.1097/qai.0000000000001319] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Investment to scale-up early infant diagnosis (EID) of HIV has increased substantially in the last decade. This investment includes physical infrastructure, equipment, human resources, and specimen transportation systems as well as specialized mechanisms to deliver laboratory results to clinics. The Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive, as well as related international initiatives to prevent mother-to-child transmission of HIV and treat children living with HIV have been important drivers of this scale-up by mobilizing resources, creating advocacy, developing normative recommendations, and providing direct technical support to countries through the global community of international stakeholders. As a result, the number of early infant diagnosis tests performed annually has increased 10-fold between 2005 and 2015, and many thousands of infants are now receiving life-saving antiretroviral therapy because of this improved access. Despite these efforts and many success stories, timely infant diagnosis remains a challenge in many Global Plan countries. The most recent data (from the end of 2015) suggest a large variation in access. Some countries report that almost 90% of HIV-exposed infants are being tested; others report that the level of access has stagnated at 30%. Still, just over half of all exposed infants in Global Plan countries receive a test in the first 2 months of life. We discuss the key factors that are responsible for this scale-up of diagnostic capacity, highlight some of the challenges that have hampered progress, and describe priorities for the future that can help maintain momentum to achieve true universal access to HIV testing for children.
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Optimizing Infant HIV Diagnosis in Resource-Limited Settings: Modeling the Impact of HIV DNA PCR Testing at Birth. J Acquir Immune Defic Syndr 2017; 73:454-462. [PMID: 27792684 DOI: 10.1097/qai.0000000000001126] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Early antiretroviral therapy (ART) initiation in HIV-infected infants significantly improves survival but is often delayed in resource-limited settings. Adding HIV testing of infants at birth to the current recommendation of testing at age 4-6 weeks may improve testing rates and decrease time to ART initiation. We modeled the benefit of adding HIV testing at birth to the current 6-week testing algorithm. METHODS Microsoft Excel was used to create a decision-tree model of the care continuum for the estimated 1,400,000 HIV-infected women and their infants in sub-Saharan Africa in 2012. The model assumed average published rates for facility births (42.9%), prevention of mother-to-child HIV transmission utilization (63%), mother-to-child-transmission rates based on prevention of mother-to-child HIV transmission regimen (5%-40%), return of test results (41%), enrollment in HIV care (52%), and ART initiation (54%). We conducted sensitivity analyses to model the impact of key variables and applied the model to specific country examples. RESULTS Adding HIV testing at birth would increase the number of infants on ART by 204% by age 18 months. The greatest increase is seen in early ART initiations (543% by age 3 months). The increase would lead to a corresponding increase in survival at 12 months of age, with 5108 fewer infant deaths (44,550, versus 49,658). CONCLUSION Adding HIV testing at birth has the potential to improve the number and timing of ART initiation of HIV-infected infants, leading to a decrease in infant mortality. Using this model, countries should investigate a combination of HIV testing at birth and during the early infant period.
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Meggi B, Bollinger T, Mabunda N, Vubil A, Tobaiwa O, Quevedo JI, Loquiha O, Vojnov L, Peter TF, Jani IV. Point-Of-Care p24 Infant Testing for HIV May Increase Patient Identification despite Low Sensitivity. PLoS One 2017; 12:e0169497. [PMID: 28060886 PMCID: PMC5218410 DOI: 10.1371/journal.pone.0169497] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 12/16/2016] [Indexed: 11/18/2022] Open
Abstract
The long delay in returning test results during early infant diagnosis of HIV (EID) often causes loss-to-follow-up prior to antiretroviral treatment (ART) initiation in resource-limited settings. A point-of-care (POC) test may help overcome these challenges. We evaluated the performance of the LYNX p24 Antigen POC test in Mozambique. 879 HIV-exposed infants under 18 months of age were enrolled consecutively at three primary healthcare clinics (PHC). Lancet heel-drawn blood was tested on-site by nurses using a prototype POC test for HIV Gag p24 antigen detection. Results of POC testing were compared to laboratory-based nucleic acid testing on dried blood spots. A comparison of the effect of sensitivity and timely test results return on successful diagnosis by POC and laboratory-based platforms was also calculated. The sensitivity and specificity of the LYNX p24 Ag test were 71.9%; (95% confidence interval [CI]: 58.5-83.0%) and 99.6% (95% CI: 98.9-99.9%), respectively. The predictive value of positive and negative tests were 93.2% (95% CI: 81.3-98.6%) and 97.9% (95% CI: 96.8-98.8%), respectively. Overall agreement was high (Cohen Kappa = 0.80; 95% CI: 0.71-0.89). Despite its lower sensitivity, the POC test had the potential to provide test results to up to 81% more patients compared to the laboratory-based test. This prototype POC p24 assay was feasible for use in PHCs but demonstrated low sensitivity for HIV detection. POC EID technologies that perform below standard recommendations may still be valuable diagnostic tools in settings with inefficient EID networks.
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Affiliation(s)
- Bindiya Meggi
- Instituto Nacional de Saúde, Maputo, Mozambique
- * E-mail:
| | | | | | | | - Ocean Tobaiwa
- Clinton Health Access Initiative, Maputo, Mozambique
| | | | - Osvaldo Loquiha
- Department of Mathematics and Informatics, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Lara Vojnov
- Clinton Health Access Initiative, Maputo, Mozambique
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Francke JA, Penazzato M, Hou T, Abrams EJ, MacLean RL, Myer L, Walensky RP, Leroy V, Weinstein MC, Parker RA, Freedberg KA, Ciaranello A. Clinical Impact and Cost-effectiveness of Diagnosing HIV Infection During Early Infancy in South Africa: Test Timing and Frequency. J Infect Dis 2016; 214:1319-1328. [PMID: 27540110 PMCID: PMC5079370 DOI: 10.1093/infdis/jiw379] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 07/14/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Diagnosis of human immunodeficiency virus (HIV) infection during early infancy (commonly known as "early infant HIV diagnosis" [EID]) followed by prompt initiation of antiretroviral therapy dramatically reduces mortality. EID testing is recommended at 6 weeks of age, but many infant infections are missed. DESIGN/METHODS We simulated 4 EID testing strategies for HIV-exposed infants in South Africa: no EID (diagnosis only after illness; hereafter, "no EID"), testing once (at birth alone or at 6 weeks of age alone; hereafter, "birth alone" and "6 weeks alone," respectively), and testing twice (at birth and 6 weeks of age; hereafter "birth and 6 weeks"). We calculated incremental cost-effectiveness ratios (ICERs), using discounted costs and life expectancies for all HIV-exposed (infected and uninfected) infants. RESULTS In the base case (guideline-concordant care), the no EID strategy produced a life expectancy of 21.1 years (in the HIV-infected group) and 61.1 years (in the HIV-exposed group); lifetime cost averaged $1430/HIV-exposed infant. The birth and 6 weeks strategy maximized life expectancy (26.5 years in the HIV-infected group and 61.4 years in the HIV-exposed group), costing $1840/infant tested. The ICER of the 6 weeks alone strategy versus the no EID strategy was $1250/year of life saved (19% of South Africa's per capita gross domestic product); the ICER for the birth and 6 weeks strategy versus the 6 weeks alone strategy was $2900/year of life saved (45% of South Africa's per capita gross domestic product). Increasing the proportion of caregivers who receive test results and the linkage of HIV-positive infants to antiretroviral therapy with the 6 weeks alone strategy improved survival more than adding a second test. CONCLUSIONS EID at birth and 6 weeks improves outcomes and is cost-effective, compared with EID at 6 weeks alone. If scale-up costs are comparable, programs should add birth testing after strengthening 6-week testing programs.
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Affiliation(s)
- Jordan A Francke
- Division of General Internal Medicine
- Medical Practice Evaluation Center
| | - Martina Penazzato
- Medical Research Council Clinical Trials Unit London, United Kingdom
- World Health Organization, Geneva, Switzerland
| | - Taige Hou
- Division of General Internal Medicine
- Medical Practice Evaluation Center
| | - Elaine J Abrams
- International Center for AIDS Care and Treatment Program, Mailman School of Public Health
- College of Physicians and Surgeons, Columbia University, New York
| | - Rachel L MacLean
- Division of General Internal Medicine
- Medical Practice Evaluation Center
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Rochelle P Walensky
- Division of General Internal Medicine
- Medical Practice Evaluation Center
- Division of Infectious Diseases, Department of Medicine
- Division of Infectious Diseases, Brigham and Women's Hospital
- Center for AIDS Research, Harvard University
| | | | - Milton C Weinstein
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health
- Harvard Medical School, Boston, Massachusetts
| | - Robert A Parker
- Division of General Internal Medicine
- Medical Practice Evaluation Center
- Biostatistics Center, Massachusetts General Hospital
- Center for AIDS Research, Harvard University
- Harvard Medical School, Boston, Massachusetts
| | - Kenneth A Freedberg
- Division of General Internal Medicine
- Medical Practice Evaluation Center
- Division of Infectious Diseases, Department of Medicine
- Center for AIDS Research, Harvard University
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health
| | - Andrea Ciaranello
- Medical Practice Evaluation Center
- Division of Infectious Diseases, Department of Medicine
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Ritchie AV, Goel N, Sembongi H, Lehga J, Farleigh LE, Edemaga D, Wisniewski CA, Lee HH. Performance evaluation of the point-of-care SAMBA I and II HIV-1 Qual whole blood tests. J Virol Methods 2016; 237:143-149. [PMID: 27568275 DOI: 10.1016/j.jviromet.2016.08.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/22/2016] [Accepted: 08/24/2016] [Indexed: 11/15/2022]
Abstract
The SAMBA HIV-1 Qual Whole Blood Test is a nucleic acid-based amplification assay for the qualitative detection of HIV-1 in whole blood of adults or infants. The test can be run on either the semi-automated SAMBA I system for clinical use or the fully automated, including readout, SAMBA II system for point-of-care use in resource-limited settings. We have assessed the performance characteristics of the SAMBA HIV-1 Qual Whole Blood Test on SAMBA I and SAMBA II. The limit of detection obtained for the two tests were 518IU/ml and 399copies/ml on SAMBA I and 457IU/ml and 433copies/ml on SAMBA II. Test specificity on both systems was 100% with a panel of 503 HIV-1 negative samples. Evaluation of test reproducibility showed 100% concordance with expected gold standard results as well as 100% agreement between operators, days, and runs as well as within runs on both SAMBA I and SAMBA II. Our results thus show that the SAMBA HIV-1 Qual Whole Blood Test performs equivalently on SAMBA I and SAMBA II, and also suggest that the test is suitable for implementation in medium-throughput clinical facilities (SAMBA I) or low-throughput point-of-care (POC) settings (SAMBA II) in resource-poor regions.
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Affiliation(s)
- Allyson V Ritchie
- Diagnostics Development Unit, Department of Haematology, University of Cambridge, Science Village, Chesterford Research Park, Great Chesterford, CB10 1XL, UK
| | - Neha Goel
- Diagnostics Development Unit, Department of Haematology, University of Cambridge, Science Village, Chesterford Research Park, Great Chesterford, CB10 1XL, UK
| | - Hiroshi Sembongi
- Diagnostics for the Real World EU Ltd., Science Village, Chesterford Research Park, Great Chesterford, CB10 1XL, UK
| | - Jesse Lehga
- Diagnostics for the Real World Ltd., 840 Del Rey Avenue, Sunnyvale, CA 94085, USA
| | - Laura E Farleigh
- Diagnostics for the Real World EU Ltd., Science Village, Chesterford Research Park, Great Chesterford, CB10 1XL, UK
| | - Daniel Edemaga
- Diagnostics for the Real World Ltd., 840 Del Rey Avenue, Sunnyvale, CA 94085, USA
| | - Craig A Wisniewski
- Diagnostics Development Unit, Department of Haematology, University of Cambridge, Science Village, Chesterford Research Park, Great Chesterford, CB10 1XL, UK; Diagnostics for the Real World Ltd., 840 Del Rey Avenue, Sunnyvale, CA 94085, USA
| | - Helen H Lee
- Diagnostics Development Unit, Department of Haematology, University of Cambridge, Science Village, Chesterford Research Park, Great Chesterford, CB10 1XL, UK; Diagnostics for the Real World Ltd., 840 Del Rey Avenue, Sunnyvale, CA 94085, USA.
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Abstract
PURPOSE OF REVIEW To provide an update on the HIV treatment cascade in children and adolescents. We reviewed the literature on the steps in the cascade, for the period 2014-2015. RECENT FINDINGS There remains high attrition of children with regards to early testing and linking those patients who are positive to early treatment. Barriers to screening and testing in children and adolescents are multifactorial. Linkage to pre-antiretroviral therapy care and retention in care are the main steps at which attrition occurs. There are a number of new formulations available for use in adolescents and children which offer more options for antiretroviral therapy treatment. Adherence levels appear to be reasonable in Africa and Asia; however, achieving viral load suppression remains a challenge. SUMMARY We have a long way to go to achieve decreased attrition at each step of the cascade and retain patients in care. Recent improvements in each step of the cascade are bringing us closer to achieving treatment success.
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Sirirungsi W, Khamduang W, Collins IJ, Pusamang A, Leechanachai P, Chaivooth S, Ngo-Giang-Huong N, Samleerat T. Early infant HIV diagnosis and entry to HIV care cascade in Thailand: an observational study. Lancet HIV 2016; 3:e259-65. [PMID: 27240788 PMCID: PMC6047735 DOI: 10.1016/s2352-3018(16)00045-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 02/15/2016] [Accepted: 03/10/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Early infant diagnosis of HIV is crucial for timely initiation of antiretroviral therapy (ART) in infected children who are at high risk of mortality. Early infant diagnosis with dried blood spot testing was provided by the National AIDS Programme in Thailand from 2007. We report ART initiation and vital status in children with HIV after 7 years of rollout in Thailand. METHODS Dried blood spot samples were collected from HIV-exposed children in hospitals in Thailand and mailed to the Faculty of Associated Medical Sciences, Chiang Mai University, where HIV DNA was assessed with real-time PCR to establish HIV infection. We linked data from children with an HIV infection to the National AIDS Programme database to ascertain ART and vital status. FINDINGS Between April 5, 2007, and Oct 1, 2014, 16 046 dried blood spot samples were sent from 8859 children in 364 hospitals in Thailand. Median age at first dried blood spot test was 2·1 (IQR 1·8-2·5) months. Of 7174 (81%) children with two or more samples, 223 (3%) were HIV positive (including five unconfirmed). Of 1685 (19%) children with one sample, 70 (4%) were unconfirmed positive. Of 293 (3%) children who were HIV positive, 220 (75%) registered for HIV care and 170 (58%) initiated ART. Median age at ART initiation decreased from 14·2 months (IQR 10·2-25·6) in 2007 to 6·1 months (4·2-9·2) in 2013, and the number of children initiating ART aged younger than 1 year increased from five (33%) of 15 children initiating ART in 2007 to ten (83%) of 12 initiating ART in 2013. 15 (9%) of 170 children who initiated ART died and 16 (32%) of 50 who had no ART record died. INTERPRETATION Early infant diagnosis with dried blood spot testing had high uptake in primary care settings. Further improvement of linkage to HIV care is needed to ensure timely treatment of all children with an HIV infection. FUNDING None.
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Affiliation(s)
- Wasna Sirirungsi
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand.
| | - Woottichai Khamduang
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; Institut de Recherche pour le Développement, Unité Mixte Internationale 174-Program for HIV Prevention and Treatment, Chiang Mai, Thailand
| | - Intira Jeannie Collins
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Artit Pusamang
- HIV/AIDS and Tuberculosis Program, National Health Security Office, Bangkok, Thailand
| | - Pranee Leechanachai
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Suchada Chaivooth
- HIV/AIDS and Tuberculosis Program, National Health Security Office, Bangkok, Thailand
| | - Nicole Ngo-Giang-Huong
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; Institut de Recherche pour le Développement, Unité Mixte Internationale 174-Program for HIV Prevention and Treatment, Chiang Mai, Thailand; Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Tanawan Samleerat
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
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Incidence of AIDS-defining and Other Cancers in HIV-positive Children in South Africa: Record Linkage Study. Pediatr Infect Dis J 2016; 35:e164-70. [PMID: 26906162 PMCID: PMC4865449 DOI: 10.1097/inf.0000000000001117] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little is known on the risk of cancer in HIV-positive children in sub-Saharan Africa. We examined incidence and risk factors of AIDS-defining and other cancers in pediatric antiretroviral therapy (ART) programs in South Africa. METHODS We linked the records of 5 ART programs in Johannesburg and Cape Town to those of pediatric oncology units, based on name and surname, date of birth, folder and civil identification numbers. We calculated incidence rates and obtained hazard ratios (HR) with 95% confidence intervals (CI) from Cox regression models including ART, sex, age and degree of immunodeficiency. Missing CD4 counts and CD4% were multiply imputed. Immunodeficiency was defined according to World Health Organization 2005 criteria. RESULTS Data of 11,707 HIV-positive children were included in the analysis. During 29,348 person-years of follow-up 24 cancers were diagnosed, for an incidence rate of 82 per 100,000 person-years (95% CI: 55-122). The most frequent cancers were Kaposi sarcoma (34 per 100,000 person-years) and non-Hodgkin Lymphoma (31 per 100,000 person-years). The incidence of non AIDS-defining malignancies was 17 per 100,000. The risk of developing cancer was lower on ART (HR: 0.29; 95% CI: 0.09-0.86), and increased with age at enrollment (>10 vs. <3 years: HR: 7.3; 95% CI: 2.2-24.6) and immunodeficiency at enrollment (advanced/severe versus no/mild: HR: 3.5; 95% CI: 1.1-12.0). The HR for the effect of ART from complete case analysis was similar but ceased to be statistically significant (P = 0.078). CONCLUSIONS Early HIV diagnosis and linkage to care, with start of ART before advanced immunodeficiency develops, may substantially reduce the burden of cancer in HIV-positive children in South Africa and elsewhere.
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Hsiao NY, Dunning L, Kroon M, Myer L. Laboratory Evaluation of the Alere q Point-of-Care System for Early Infant HIV Diagnosis. PLoS One 2016; 11:e0152672. [PMID: 27032094 PMCID: PMC4816318 DOI: 10.1371/journal.pone.0152672] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 03/17/2016] [Indexed: 11/21/2022] Open
Abstract
Introduction Early infant diagnosis (EID) and prompt linkage to care are critical to minimise the high morbidity and mortality associated with infant HIV infection. Attrition in the “EID cascade” is common; however, point-of-care (POC) EID assays with same-day result could facilitate prompt linkage of HIV-infected infant to treatment. Despite a number of POC EID assays in development, few have been independently evaluated and data on new technologies are urgently needed to inform policy. Methods We compared Alere q 1/2 Detect POC system laboratory test characteristics with the local standard of care (SOC), Roche CAP/CTM HIV-1 qualitative PCR in an independent laboratory-based evaluation in Cape Town, South Africa. Routinely EID samples collected between November 2013 and September 2014 were each tested by both SOC and POC systems. Repeat testing was done to troubleshoot any discrepancy between POC and SOC results. Results Overall, 1098 children with a median age of 47 days (IQR, 42–117) were included. Birth PCR (age <7 days) comprised of 8% (n = 92) tests while 56% (n = 620) of children tested as part of routine EID (ages 6–14 weeks). In the overall direct comparison, Alere q Detect achieved sensitivity of 95.5% (95% CI, 91.7–97.9%) and a specificity of 99.8% (95% CI, 99.1–100%). Following repeat testing of discordant samples and exclusion of any inconclusive results, the POC assay sensitivity and specificity were 96.9% (95% CI 93.4–98.9%) and 100% (lower 95% CI 98%) respectively. Among birth PCR tests the POC assay had slightly lower sensitivity (93.3% vs 96.5% in routine EID) and higher assay error rate (10% vs 5% in samples of older children, p = 0.04). Conclusion Our results indicate this POC assay performs well for EID in the laboratory. The high specificity and thus high positive predictive value would suggest a positive POC result may be adequate for immediate infant ART initiation. While POC testing for EID may have particular utility for birth testing at delivery facilities, the lower sensitivity and error rate requires further attention, as does field implementation of POC EID technologies in other clinical care settings.
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Affiliation(s)
- Nei-yuan Hsiao
- Division of Medical Virology, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Lorna Dunning
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Max Kroon
- Department of Neonatal Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Njuguna IN, Wagner AD, Cranmer LM, Otieno VO, Onyango JA, Chebet DJ, Okinyi HM, Benki-Nugent S, Maleche-Obimbo E, Slyker JA, John-Stewart GC, Wamalwa DC. Hospitalized Children Reveal Health Systems Gaps in the Mother-Child HIV Care Cascade in Kenya. AIDS Patient Care STDS 2016; 30:119-24. [PMID: 27308805 DOI: 10.1089/apc.2015.0239] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
To identify missed opportunities in HIV prevention, diagnosis, and linkage to care, we enrolled 183 hospitalized, HIV-infected, ART-naïve Kenyan children 0-12 years from four hospitals in Nairobi and Kisumu, and reviewed prevention of mother-to-child transmission of HIV (PMTCT), hospitalization, and HIV testing history. Median age was 1.8 years (IQR = 0.8, 4.5). Most mothers received HIV testing during pregnancy (77%). Among mothers tested, 60% and 40% reported HIV-negative and positive results, respectively; 33% of HIV-diagnosed mothers did not receive PMTCT antiretrovirals. First missed opportunities for pediatric diagnosis and linkage were due to failure to test mothers (23.1%), maternal HIV acquisition following initial negative test (45.7%), no early infant diagnosis (EID) or provider-initiated testing (PITC) (12.7%), late breastfeeding transmission (8.7%), failure to collect child HIV test results (1.2%), and no linkage to care following HIV diagnosis (8.7%). Among previously hospitalized children, 38% never received an HIV test. Strengthening initial and repeat maternal HIV testing and PITC are key interventions to prevent, detect, and treat pediatric HIV infections.
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Affiliation(s)
- Irene N. Njuguna
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, Washington
| | - Lisa M. Cranmer
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Vincent O. Otieno
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Judith A. Onyango
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Daisy J. Chebet
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Helen M. Okinyi
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | | | - Jennifer A. Slyker
- Department of Global Health, University of Washington, Seattle, Washington
| | - Grace C. John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology and Pediatrics, University of Washington, Seattle, Washington
| | - Dalton C. Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Bhardwaj S, Carter B, Aarons GA, Chi BH. Implementation Research for the Prevention of Mother-to-Child HIV Transmission in Sub-Saharan Africa: Existing Evidence, Current Gaps, and New Opportunities. Curr HIV/AIDS Rep 2016; 12:246-55. [PMID: 25877252 DOI: 10.1007/s11904-015-0260-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tremendous gains have been made in the prevention of mother-to-child HIV transmission (PMTCT) in sub-Saharan Africa. Ambitious goals for the "virtual elimination" of pediatric HIV appear increasingly feasible, driven by new scientific advances, forward-thinking health policy, and substantial donor investment. To fulfill this promise, however, rapid and effective implementation of evidence-based practices must be brought to scale across a diversity of settings. The discipline of implementation research can facilitate this translation from policy into practice; however, to date, its core principles and frameworks have been inconsistently applied in the field. We reviewed the recent developments in implementation research across each of the four "prongs" of a comprehensive PMTCT approach. While significant progress continues to be made, a greater emphasis on context, fidelity, and scalability-in the design and dissemination of study results-would greatly enhance current efforts and provide the necessary foundation for future evidence-based programs.
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Mother-to-child Transmission of HIV From 1999 to 2011 in the Amazonas, Brazil: Risk Factors and Remaining Gaps in Prevention Strategies. Pediatr Infect Dis J 2016; 35:189-95. [PMID: 26484428 DOI: 10.1097/inf.0000000000000966] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The purpose of the study was to estimate rates of mother-to-child transmission (MTCT) of HIV in the Amazonas, Brazil, and to identify the associated factors. METHODS This was a retrospective cohort study of 1210 children born to HIV-infected women between 1999 and 2011 and enrolled before age of 18 months in a reference HIV/AIDS pediatrics service in Manaus. We used multivariable logistic regression to assess the effect of maternal, obstetric and prophylactic interventions on MTCT of HIV. RESULTS Ten children were excluded because of undocumented maternal HIV status. Among 1200 children, 163 (13.6%) were lost to follow-up. We included in the analysis 1037 children with known HIV status. Of those, 68 children were HIV infected, resulting in a MTCT rate of 6.6% [95% confidence interval (CI): 5.3-8.3]. Among mothers, 76.1% had received antiretroviral therapy during pregnancy, 59.3% elective caesarean, and 9.7% were breastfed. Factors associated with lower odds of MTCT of HIV were antiretroviral therapy during pregnancy [odds ratio (OR): 0.26; 95% CI: 0.12-0.58], elective caesarean (OR: 0.48; 95% CI: 0.23-0.98) and with MTCT: being breastfed (OR: 4.56; 95% CI: 2.19-9.50). Transmission decreased from 7.5% in 2007-2008 to 3.2% in 2011, while breastfeeding decreased from 30.8% in 1999-2000 to 3.9% in 2011-2012. CONCLUSIONS The HIV rate of MTCT is still high in the Amazonas and challenges for its prevention prevail including lost to follow-up and gaps in critical strategies such as antiretroviral use during pregnancy. More efforts are needed to increase the number of women and babies who successfully complete the prevention of MTCT cascade and work toward elimination of MTCT of HIV.
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Point-of-care HIV early infant diagnosis: is test sensitivity everything? J Int AIDS Soc 2015; 18:20235. [PMID: 26344017 PMCID: PMC4561293 DOI: 10.7448/ias.18.1.20235] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 06/17/2015] [Indexed: 11/08/2022] Open
Abstract
Despite improvements in PMTCT services in low- and middle-income countries, there are still almost 200,000 new paediatric HIV infections annually in sub-Saharan Africa. This has led to early infant HIV diagnosis (EID) programmes becoming a public health priority, but until recently, EID has required specialist laboratory equipment and trained personnel which is only feasible in urban, centralized facilities. It is thought that the successful implementation of a point-of-care (POC) test for EID has the potential to increase access to virological tests and address some of the barriers regarding retention of infants in care. However, POC evaluation has not integrated focus on performance characteristics with the health systems issues surrounding the adoption of and optimum use of these new technologies. We propose that moderate improvements in linkage to care can more than offset suboptimal sensitivity of a POC EID test which could be critical in adjusting the focus for EID programme management away from test performance and towards their ability to facilitate successful linkage to antiretroviral therapy (ART) services. These findings also highlight the urgent need to explore the implementation and operational aspects of emerging POC tests in order to fully realize the potential benefits of new technologies in practice.
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Porter M, Davies MA, Mapani MK, Rabie H, Phiri S, Nuttall J, Fairlie L, Technau KG, Stinson K, Wood R, Wellington M, Haas AD, Giddy J, Tanser F, Eley B. Outcomes of Infants Starting Antiretroviral Therapy in Southern Africa, 2004-2012. J Acquir Immune Defic Syndr 2015; 69:593-601. [PMID: 26167620 PMCID: PMC4509628 DOI: 10.1097/qai.0000000000000683] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND There are limited published data on the outcomes of infants starting antiretroviral therapy (ART) in routine care in Southern Africa. This study aimed to examine the baseline characteristics and outcomes of infants initiating ART. METHODS We analyzed prospectively collected cohort data from routine ART initiation in infants from 11 cohorts contributing to the International Epidemiologic Database to Evaluate AIDS in Southern Africa. We included ART-naive HIV-infected infants aged <12 months initiating ≥3 antiretroviral drugs between 2004 and 2012. Kaplan-Meier estimates were calculated for mortality, loss to follow-up (LTFU), transfer out, and virological suppression. We used Cox proportional hazard models stratified by cohort to determine baseline characteristics associated with outcomes mortality and virological suppression. RESULTS The median (interquartile range) age at ART initiation of 4945 infants was 5.9 months (3.7-8.7) with follow-up of 11.2 months (2.8-20.0). At ART initiation, 77% had WHO clinical stage 3 or 4 disease and 87% were severely immunosuppressed. Three-year mortality probability was 16% and LTFU 29%. Severe immunosuppression, WHO stage 3 or 4, anemia, being severely underweight, and initiation of treatment before 2010 were associated with higher mortality. At 12 months after ART initiation, 17% of infants were severely immunosuppressed and the probability of attaining virological suppression was 56%. CONCLUSIONS Most infants initiating ART in Southern Africa had severe disease with high probability of LTFU and mortality on ART. Although the majority of infants remaining in care showed immune recovery and virological suppression, these responses were suboptimal.
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Affiliation(s)
- Mireille Porter
- School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Mary-Ann Davies
- School of Public Health and Family Medicine, University of Cape Town, South Africa
| | | | - Helena Rabie
- Tygerberg Academic Hospital and Stellenbosch University, Tygerberg, W Cape
| | - Sam Phiri
- Lighthouse Trust Clinic, Lilongwe, Malawi
| | - James Nuttall
- Red Cross War Memorial Children's Hospital, Cape Town, and School of Child and Adolescent Health, University of Cape Town, South Africa
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Karl-Günter Technau
- Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - Kathryn Stinson
- Médecins Sans Frontierès, Khayelitsha and School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Robin Wood
- Gugulethu Community Health Centre and Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, South Africa
| | | | - Andreas D. Haas
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland
| | | | - Frank Tanser
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
| | - Brian Eley
- Red Cross War Memorial Children's Hospital, Cape Town, and School of Child and Adolescent Health, University of Cape Town, South Africa
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Improving early infant HIV diagnosis in Kenya: study protocol of a cluster-randomized efficacy trial of the HITSystem. Implement Sci 2015; 10:96. [PMID: 26155932 PMCID: PMC4496871 DOI: 10.1186/s13012-015-0284-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 06/23/2015] [Indexed: 11/23/2022] Open
Abstract
Background Early infant diagnosis among human immunodeficiency virus (HIV)-exposed infants is a critical component of prevention of mother-to-child transmission programs. Barriers to early infant diagnosis include poor uptake, low retention at designated re-testing intervals, delayed test results, passive systems of communication, and poor linkage to treatment. This study will evaluate the HIV Infant Tracking System (HITSystem), an eHealth intervention that streamlines communication and accountability between the key early infant diagnosis stakeholders: HIV+ mothers and their HIV-exposed infants, healthcare providers, and central laboratory personnel. It is hypothesized that the HITSystem will significantly improve early infant diagnosis retention at 9 and 18 months postnatal and the timely provision of services. Methods/design Using a phased cluster-randomized controlled trial design, we will evaluate the impact of the HITSystem on eight primary benchmarks in the 18-month long cascade of care for early infant diagnosis. Study sites are six government hospitals in Kenya matched on geographic region, resource level, and patient volume. Early infant diagnosis outcomes of mother-infant dyads (n = 120 per site) at intervention hospitals (n = 3) where the HITSystem is deployed at baseline will be compared to the matched control sites providing standard care. After allowing for sufficient time for enrollment and 18-month follow-up of dyads, the HITSystem will be deployed at the control sites in the end of Year 3. Primary outcomes are retention among mother-infant dyads, initiation of antiretroviral therapy among HIV-infected infants, and the proportion of services delivered within the optimal time window indicated by national and study guidelines. Satisfaction interviews with participants and providers will inform intervention improvements. Cost-effectiveness analyses will be conducted to inform the sustainability of the HITSystem. Hypothesized outcomes include significantly higher retention throughout the 18-month early infant diagnosis process, significantly more services provided on-time at intervention sites, and a potential savings to the healthcare system. Discussion This study will evaluate the public health impact of the HITSystem to improve critical early infant diagnosis outcomes in low-resource settings. Cost-effectiveness analyses will inform the feasibility of scale-up in other settings. Trial registration ClinicalTrials.gov: NCT02072603
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Davies MA. Research gaps in neonatal HIV-related care. South Afr J HIV Med 2015; 16:375. [PMID: 29568592 PMCID: PMC5843028 DOI: 10.4102/sajhivmed.v16i1.375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 03/16/2015] [Indexed: 12/19/2022] Open
Abstract
The South African prevention of mother to child transmission programme has made excellent progress in reducing vertical HIV transmission, and paediatric antiretroviral therapy programmes have demonstrated good outcomes with increasing treatment initiation in younger children and infants. However, both in South Africa and across sub-Saharan African, lack of boosted peri-partum prophylaxis for high-risk vertical transmission, loss to follow-up, and failure to initiate HIV-infected infants on antiretroviral therapy (ART) before disease progression are key remaining gaps in neonatal HIV-related care. In this issue of the Southern African Journal of HIV Medicine, experts provide valuable recommendations for addressing these gaps. The present article highlights a number of areas where evidence is lacking to inform guidelines and programme development for optimal neonatal HIV-related care.
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Affiliation(s)
- Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
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Audu R, Onwuamah C, Salu O, Okwuraiwe A, Ou CY, Bolu O, Bond KB, Diallo K, Lu L, Jelpe T, Okoye M, Ngige E, Vertefeuille J. Development and implementation challenges of a quality assured HIV infant diagnosis program in Nigeria using dried blood spots and DNA polymerase chain reaction. AIDS Res Hum Retroviruses 2015; 31:433-8. [PMID: 25381805 PMCID: PMC4696874 DOI: 10.1089/aid.2014.0159] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Nigeria has one of the highest HIV burdens as well as mother-to-infant transmission rates in the world. A pilot program using polymerase chain reaction (PCR)-based testing of dried blood spot (DBS) specimens was implemented to enable early identification of HIV-infected infants and timely referral and linkage to care. From February 2007 to October 2008, whole blood was collected by finger prick to prepare DBS from infants <18 months presenting in six public mother-and-child health facilities in Lagos, Nigeria. The DBS were tested using the Roche Amplicor HIV-1 DNA Test, v1.5. To monitor laboratory testing quality, all of the PCR-positive and 10% of the PCR-negative DBS were retested by the same method at another reference laboratory. Three hundred and sixty-five randomly selected infants were screened using HIV rapid tests (RT) according to the national algorithm and RT-negative and PCR-positive specimens were also tested using Genscreen enzyme-linked immunosorbent assay (EIA) (Bio-Rad, France). The turnaround time (TAT) from sample collection, testing, and dispatching of results from each health facility was monitored. A total of 1,273 infants with a median age of 12.6 weeks (1 day to 71.6 weeks) participated in the program and 280 (22.0%) were PCR positive. HIV transmission levels varied greatly in the different health facilities ranging from 7.1% to 38.4%. Infants aged 48 to 72 weeks had the highest level of PCR positivity (41.1%). All PCR-positive specimens were confirmed by retesting. The mean turnaround time from DBS collection to returning of the laboratory result to the health facilities was 25 days. Three infants were found to be HIV antibody negative by rapid tests but were positive by both PCR and the fourth generation EIA. The DBS-based PCR program accurately identified all of the HIV-infected infants. However, many programmatic challenges related to the laboratory and TAT were identified.
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Affiliation(s)
- Rosemary Audu
- Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria
| | - Chika Onwuamah
- Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria
| | - Olumuyiwa Salu
- Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria
| | - Azuka Okwuraiwe
- Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria
| | - Chin-Yih Ou
- CDC, Global AIDS Program in Beijing, Beijing, China
| | - Omotayo Bolu
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Kyle B. Bond
- CDC, Global AIDS Program in Abuja, Abuja, Nigeria
| | - Karidia Diallo
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Lydia Lu
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | | | - McPaul Okoye
- United States Agency for International Development (USAID), Abuja, Nigeria
| | - Evelyn Ngige
- HIV and AIDS Division, Federal Ministry of Health, Abuja, Nigeria
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Abstract
Millennium Development Goal (MDG) 6 has two HIV/AIDS commitments: to have halted and begun to reverse the spread of HIV/AIDS by 2015 and to ensure access to treatment among all those in need by 2010. Given the almost universal lack of access to HIV testing, prevention and treatment for children in high prevalence countries in 2000, the achievements of the past 15 years have been extraordinary, fuelled by massive donor investment, strong political commitment and ambitious global targets; however, MDG 6 is some way from being attained. Prevention of mother-to-child transmission (PMTCT) services have expanded enormously, with new infections among children falling by 58% between 2002 and 2013. There has been a shift towards initiation of lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women, although low HIV testing rates in pregnancy, suboptimal PMTCT coverage and poor retention in care remain barriers to achieving HIV elimination among children. Early infant diagnosis has expanded substantially but, in 2013, only 44% of all HIV-exposed infants were tested before 2 months of age. Diagnosis of HIV, therefore, frequently occurs late, leading to delays in ART initiation. By the end of 2013, approximately 760 000 children were receiving ART, leading to 40% decline in AIDS-related mortality. However, only 24% of HIV-infected children were receiving ART, compared with 36% of adults, leading to a 'treatment gap'. In this review, we summarise progress and remaining challenges in reaching MDG 6 and discuss future strategies to achieve the ambitious goals of paediatric HIV elimination and universal access to treatment.
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Affiliation(s)
- Andrew J Prendergast
- Centre for Paediatrics, Blizard Institute, Queen Mary University of London, London, UK Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Accurate Early Infant HIV Diagnosis in Primary Health Clinics Using a Point-of-Care Nucleic Acid Test. J Acquir Immune Defic Syndr 2014; 67:e1-4. [DOI: 10.1097/qai.0000000000000250] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chan AK, Ford D, Namata H, Muzambi M, Nkhata MJ, Abongomera G, Mambule I, South A, Revill P, Grundy C, Mabugu T, Chiwaula L, Cataldo F, Hakim J, Seeley J, Kityo C, Reid A, Katabira E, Sodhi S, Gilks CF, Gibb DM. The Lablite project: a cross-sectional mapping survey of decentralized HIV service provision in Malawi, Uganda and Zimbabwe. BMC Health Serv Res 2014; 14:352. [PMID: 25138583 PMCID: PMC4148932 DOI: 10.1186/1472-6963-14-352] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 07/29/2014] [Indexed: 12/05/2022] Open
Abstract
Background In sub-Saharan Africa antiretroviral therapy (ART) is being decentralized from tertiary/secondary care facilities to primary care. The Lablite project supports effective decentralization in 3 countries. It began with a cross-sectional survey to describe HIV and ART services. Methods 81 purposively sampled health facilities in Malawi, Uganda and Zimbabwe were surveyed. Results The lowest level primary health centres comprised 16/20, 21/39 and 16/22 facilities included in Malawi, Uganda and Zimbabwe respectively. In Malawi and Uganda most primary health facilities had at least 1 medical assistant/clinical officer, with average 2.5 and 4 nurses/midwives for median catchment populations of 29,275 and 9,000 respectively. Primary health facilities in Zimbabwe were run by nurses/midwives, with average 6 for a median catchment population of 8,616. All primary health facilities provided HIV testing and counselling, 50/53 (94%) cotrimoxazole preventive therapy (CPT), 52/53 (98%) prevention of mother-to-child transmission of HIV (PMTCT) and 30/53 (57%) ART management (1/30 post ART-initiation follow-up only). All secondary and tertiary-level facilities provided HIV and ART services. In total, 58/81 had ART provision. Stock-outs during the 3 months prior to survey occurred across facility levels for HIV test-kits in 55%, 26% and 9% facilities in Malawi, Uganda and Zimbabwe respectively; for CPT in 58%, 32% and 9% and for PMTCT drugs in 26%, 10% and 0% of facilities (excluding facilities where patients were referred out for either drug). Across all countries, in facilities with ART stored on-site, adult ART stock-outs were reported in 3/44 (7%) facilities compared with 10/43 (23%) facility stock-outs of paediatric ART. Laboratory services at primary health facilities were limited: CD4 was used for ART initiation in 4/9, 5/6 and 13/14 in Malawi, Uganda and Zimbabwe respectively, but frequently only in selected patients. Routine viral load monitoring was not used; 6/58 (10%) facilities with ART provision accessed centralised viral loads for selected patients. Conclusions Although coverage of HIV testing, PMTCT and cotrimoxazole prophylaxis was high in all countries, decentralization of ART services was variable and incomplete. Challenges of staffing and stock management were evident. Laboratory testing for toxicity and treatment effectiveness monitoring was not available in most primary level facilities. Electronic supplementary material The online version of this article (doi:10.1186/1472-6963-14-352) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Deborah Ford
- MRC Clinical Trials Unit at University College London, London, U,K.
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Smith SJ, Nimmo C, Fredlund V, Moodley P. Early infant diagnosis of HIV and fast initiation of anti-retroviral therapy in a rural African setting: how well are we doing? Paediatr Int Child Health 2014; 34:203-7. [PMID: 24655116 DOI: 10.1179/2046905514y.0000000119] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND In South Africa, current estimates indicate that 1% of infants will be HIV PCR-positive by 2 months of age. WHO recommends early infant diagnosis (EID) and immediate initiation of antiretroviral therapy (ART) in infants who are diagnosed with HIV infection within the first year of life. AIMS To investigate rates of EID and subsequent ART initiation in infants attending the Primary Health Care (PHC) clinics which fed Mseleni Hospital during 2012. OBJECTIVES To measure the number of infants (<1 year of age) testing HIV PCR-positive who are currently collecting ART and those lost to follow-up. METHODS HIV PCR test results from Mseleni Hospital in 2012 were cross-referenced with the national database (TIER.net) for ART initiation and follow-up from the National Health Laboratory Service (NHLS) database. RESULTS 455 of 843 (54%) HIV-exposed infants (<2 months) were tested by HIV PCR, 11 of whom (2·4%) tested positive, reflecting the national prevalence. Of 897 HIV PCR tests undertaken in infants <1 year, 51 (5·7%) were positive, and 36 were included for analysis. Only 13 (36·1%) of these infants are currently collecting ART; seven (19·4%) commenced ART but were lost to follow-up, and 16 (44·5%) never started ART. CONCLUSION 16 (44·5%) HIV PCR-positive infants in Mseleni Hospital and its feeder PHCs were not commenced on ART. This may reflect a similar problem in other rural hospitals in South Africa. Specific interventions are required to rapidly up-scale early initiation of ART in this vulnerable group of infants.
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Penazzato M, Revill P, Prendergast AJ, Collins IJ, Walker S, Elyanu PJ, Sculpher M, Gibb DM. Early infant diagnosis of HIV infection in low-income and middle-income countries: does one size fit all? THE LANCET. INFECTIOUS DISEASES 2014; 14:650-5. [PMID: 24456814 DOI: 10.1016/s1473-3099(13)70262-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Despite expansion of services for prevention of mother-to-child transmission of HIV (PMTCT), about 700 infants acquire HIV every day. Early initiation of antiretroviral therapy for HIV-infected infants reduces mortality but requires diagnosis by virological testing, which is complex, expensive, and inaccessible in many settings. Little cost-effectiveness evidence exists about different strategies to deliver early infant diagnosis services. Cost-effectiveness will vary depending on entry points for testing, underlying prevalences of HIV, PMTCT coverage, treatment availability, programme attrition, and other factors. Appropriate policy responses are therefore context-specific. In most cases, early infant diagnosis should be concentrated at entry points where underlying infant HIV prevalence is highest (eg, malnutrition wards). This strategy contrasts with the tendency at present to test mainly within PMTCT programmes. If testing is undertaken in PMTCT programmes with high coverage, addition of a virological test at birth might have advantages, including greater predictive value, earlier diagnosis, and better infant follow-up. National programme managers should recognise the opportunity costs of the limited resources available, acknowledge the changing scenario of PMTCT scale-up, ensure implementation of provider-initiated testing and counselling, and tailor early infant diagnosis programmes to maximise health gains for children.
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Affiliation(s)
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Andrew J Prendergast
- MRC Clinical Trials Unit, London, UK; Centre for Paediatrics, Blizard Institute, Queen Mary University of London, London, UK; Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe
| | | | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | - Peter J Elyanu
- STD/AIDS Control Program, Ministry of Health, Kampala, Uganda
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
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Dicko F, Desmonde S, Koumakpai S, Dior-Mbodj H, Kouéta F, Baeta N, Koné N, Akakpo J, Signate Sy H, Ye D, Renner L, Lewden C, Leroy V. Reasons for hospitalization in HIV-infected children in West Africa. J Int AIDS Soc 2014; 17:18818. [PMID: 24763078 PMCID: PMC3999943 DOI: 10.7448/ias.17.1.18818] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 02/17/2014] [Accepted: 03/12/2014] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Current knowledge on morbidity and mortality in HIV-infected children comes from data collected in specific research programmes, which may offer a different standard of care compared to routine care. We described hospitalization data within a large observational cohort of HIV-infected children in West Africa (IeDEA West Africa collaboration). METHODS We performed a six-month prospective multicentre survey from April to October 2010 in five HIV-specialized paediatric hospital wards in Ouagadougou, Accra, Cotonou, Dakar and Bamako. Baseline and follow-up data during hospitalization were recorded using a standardized clinical form, and extracted from hospitalization files and local databases. Event validation committees reviewed diagnoses within each centre. HIV-related events were defined according to the WHO definitions. RESULTS From April to October 2010, 155 HIV-infected children were hospitalized; median age was 3 years [1-8]. Among them, 90 (58%) were confirmed for HIV infection during their stay; 138 (89%) were already receiving cotrimoxazole prophylaxis and 64 children (40%) had initiated antiretroviral therapy (ART). The median length of stay was 13 days (IQR: 7-23); 25 children (16%) died during hospitalization and four (3%) were transferred out. The leading causes of hospitalization were WHO stage 3 opportunistic infections (37%), non-AIDS-defining events (28%), cachexia and other WHO stage 4 events (25%). CONCLUSIONS Overall, most causes of hospitalizations were HIV related but one hospitalization in three was caused by a non-AIDS-defining event, mostly in children on ART. HIV-related fatality is also high despite the scaling-up of access to ART in resource-limited settings.
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Affiliation(s)
- Fatoumata Dicko
- Service Pédiatrie Centre Hospitalier, Universitaire Gabriel Toure, Bamako, Mali
| | - Sophie Desmonde
- Inserm, Centre Inserm U897 - Epidémiologie - Biostatistiques, University of Bordeaux, Bordeaux, France; University of Bordeaux, ISPED, Centre Inserm U897 - Epidémiologie - Biostatistiques, Bordeaux, France;
| | - Sikiratou Koumakpai
- Service Pédiatrie, Centre National Hospitalier Universitaire, Cotonou, Bénin
| | | | - Fla Kouéta
- Service Pédiatrie, Hopital Général de Gaulle, Ouagadougou, Burkina Faso
| | | | - Niaboula Koné
- Service Pédiatrie Centre Hospitalier, Universitaire Gabriel Toure, Bamako, Mali
| | - Jocelyn Akakpo
- Service Pédiatrie, Centre National Hospitalier Universitaire, Cotonou, Bénin
| | | | - Diarra Ye
- Service Pédiatrie, Hopital Général de Gaulle, Ouagadougou, Burkina Faso
| | | | - Charlotte Lewden
- Inserm, Centre Inserm U897 - Epidémiologie - Biostatistiques, University of Bordeaux, Bordeaux, France; University of Bordeaux, ISPED, Centre Inserm U897 - Epidémiologie - Biostatistiques, Bordeaux, France
| | - Valériane Leroy
- Inserm, Centre Inserm U897 - Epidémiologie - Biostatistiques, University of Bordeaux, Bordeaux, France; University of Bordeaux, ISPED, Centre Inserm U897 - Epidémiologie - Biostatistiques, Bordeaux, France
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Cost-effectiveness of early infant HIV diagnosis of HIV-exposed infants and immediate antiretroviral therapy in HIV-infected children under 24 months in Thailand. PLoS One 2014; 9:e91004. [PMID: 24632750 PMCID: PMC3954590 DOI: 10.1371/journal.pone.0091004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 01/30/2014] [Indexed: 11/19/2022] Open
Abstract
Background HIV-infected infants have high risk of death in the first two years of life if untreated. WHO guidelines recommend early infant HIV diagnosis (EID) of all HIV-exposed infants and immediate antiretroviral therapy (ART) in HIV-infected children under 24-months. We assessed the cost-effectiveness of this strategy in HIV-exposed non-breastfed children in Thailand. Methods A decision analytic model of HIV diagnosis and disease progression compared: EID using DNA PCR with immediate ART (Early-Early); or EID with deferred ART based on immune/clinical criteria (Early-Late); vs. clinical/serology based diagnosis and deferred ART (Reference). The model was populated with survival and cost data from a Thai observational cohort and the literature. Incremental cost-effectiveness ratio per life-year gained (LYG) was compared against the Reference strategy. Costs and outcomes were discounted at 3%. Results Mean discounted life expectancy of HIV-infected children increased from 13.3 years in the Reference strategy to 14.3 in the Early-Late and 17.8 years in Early-Early strategies. The mean discounted lifetime cost was $17,335, $22,583 and $29,108, respectively. The cost-effectiveness ratio of Early-Late and Early-Early strategies was $5,149 and $2,615 per LYG, respectively as compared to the Reference strategy. The Early-Early strategy was most cost-effective at approximately half the domestic product per capita per LYG ($4,420 in Thailand 2011). The results were robust in deterministic and probabilistic sensitivity analyses including varying perinatal transmission rates. Conclusion In Thailand, EID and immediate ART would lead to major survival benefits and is cost- effective. These findings strongly support the adoption of WHO recommendations as routine care.
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Pediatric treatment 2.0: ensuring a holistic response to caring for HIV-exposed and infected children. AIDS 2013; 27 Suppl 2:S215-24. [PMID: 24361631 DOI: 10.1097/qad.0000000000000091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Treatment 2.0 is an initiative launched by UNAIDS and WHO in 2011 to catalyze the next phase of treatment scale-up for HIV. The initiative defines strategic activities in 5 key areas, drugs, diagnostics, commodity costs, service delivery and community engagement in an effort to simplify treatment, expand access and maximize program efficiency. For adults, many of these activities have already been turned into treatment policies. The recent WHO recommendation to use a universal first line regimen regardless of gender, pregnancy and TB status is a treatment simplification very much in line with Treatment 2.0. But despite that fact that Treatment 2.0 encompasses all people living with HIV, we have not seen the same evolution in policy development for children. In this paper we discuss how Treatment 2.0 principles can be adapted for the pediatric population. There are several intrinsic challenges. The need for distinct treatment regimens in children of different ages makes it hard to define a one size fits all approach. In addition, the fact that many providers are reluctant to treat children without the advice of specialists can hamper decentralization of service delivery. But at the same time, there are opportunities that can be availed now and in the future to scale up pediatric treatment along the lines of Treatment 2.0. We examine each of the five pillars of Treatment 2.0 from a pediatric perspective and present eight specific action points that would result in simplification of pediatric treatment and scale up of HIV services for children.
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