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K. Banda C, Banda NPK, Gombachika BT, Nyirenda MJ, Hosseinipour MC, Muula AS. Primary health care preparedness to integrate diabetes care in Blantyre, Malawi: A mixed methods study. PLoS One 2024; 19:e0303030. [PMID: 38771783 PMCID: PMC11108178 DOI: 10.1371/journal.pone.0303030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 04/15/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND There is limited access to diabetes care services at primary care facilities in Malawi. Assessing the capacity of facilities to provide diabetes care is an initial step to integrating services at primary care. AIM To assess the preparedness for delivering diabetes services at primary care level within the Blantyre District Health Office (DHO) to support the response to NCD epidemic in Malawi. SETTING Blantyre DHO primary care facilities. MATERIALS AND METHODS A mixed methods approach nested in a national needs assessment for NCD response in Malawi was used. Fourteen primary healthcare facilities from Blantyre DHO were assessed. A tool adapted from the WHO rapid assessment questionnaire was used to identify human resource, equipment, supplies, and medication needed for comprehensive diabetes care. Descriptive statistics were done to analyze the quantitative data. Fisher's exact test was used to assess if there was a statistically significant difference between urban and rural facilities. Seventeen health care workers from the selected facilities participated in key informant interviews. Framework analysis method guided the qualitative data analysis. The quantitative and qualitative data were merged and displayed jointly. RESULTS The quantitative assessment showed that none of the facilities assessed had capacity to provide all the interventions recommended by WHO for diabetes care at primary level. Eight (57%) of the facilities had the capacity to diagnose diabetes, monitor glucose, prevent limb amputations and manage hypoglycemia and hyperglycemia. Four themes emerged from the qualitative data: differences in level of preparedness and implementation of diabetes care; disparities in resources between urban and rural facilities; low utilization of diabetes services; and strategy and policy recommendations for improvement of diabetes care. CONCLUSION Inadequate health financing resulted in significant disparities in the available resources between the rural and urban facilities to offer diabetes care services. There is need to develop national policies and guidelines for diabetes care to strengthen the capacity of primary care facilities to facilitate achievement of universal health coverage.
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Affiliation(s)
- Chimwemwe K. Banda
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Public Health Group, Malawi Liverpool Wellcome Program, Blantyre, Malawi
| | | | | | - Moffat J. Nyirenda
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Uganda MRC/UVRI Research Unit, Entebbe, Uganda
- NCD-BRITE Consortium, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Mina C. Hosseinipour
- NCD-BRITE Consortium, Kamuzu University of Health Sciences, Blantyre, Malawi
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill NC, United States of America
- UNC Project Malawi, Lilongwe, Malawi
| | - Adamson S. Muula
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- NCD-BRITE Consortium, Kamuzu University of Health Sciences, Blantyre, Malawi
- Africa Center of Excellence in Public Health and Herbal Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
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Kerschberger B, Vambe D, Schomaker M, Mabhena E, Daka M, Dlamini T, Ngwenya S, Mamba B, Nxumalo B, Sibanda J, Dube S, Dlamini LM, Mukooza E, Ellman T, Ciglenecki I. Sustained high fatality during TB therapy amid rapid decline in TB mortality at population level: A retrospective cohort and ecological analysis from Shiselweni, Eswatini. Trop Med Int Health 2024; 29:192-205. [PMID: 38100203 DOI: 10.1111/tmi.13961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
OBJECTIVES Despite declining TB notifications in Southern Africa, TB-related deaths remain high. We describe patient- and population-level trends in TB-related deaths in Eswatini over a period of 11 years. METHODS Patient-level (retrospective cohort, from 2009 to 2019) and population-level (ecological analysis, 2009-2017) predictors and rates of TB-related deaths were analysed in HIV-negative and HIV-coinfected first-line TB treatment cases and the population of the Shiselweni region. Patient-level TB treatment data, and population and HIV prevalence estimates were combined to obtain stratified annual mortality rates. Multivariable Poisson regressions models were fitted to identify patient-level and population-level predictors of deaths. RESULTS Of 11,883 TB treatment cases, 1302 (11.0%) patients died during treatment: 210/2798 (7.5%) HIV-negative patients, 984/8443 (11.7%) people living with HIV (PLHIV), and 108/642 (16.8%) patients with unknown HIV-status. The treatment case fatality ratio remained above 10% in most years. At patient-level, fatality risk was higher in PLHIV (aRR 1.74, 1.51-2.02), and for older age and extra-pulmonary TB irrespective of HIV-status. For PLHIV, fatality risk was higher for TB retreatment cases (aRR 1.38, 1.18-1.61) and patients without antiretroviral therapy (aRR 1.70, 1.47-1.97). It decreases with increasing higher CD4 strata and the programmatic availability of TB-LAM testing (aRR 0.65, 0.35-0.90). At population-level, mortality rates decreased 6.4-fold (-147/100,000 population) between 2009 (174/100,000) and 2017 (27/100,000), coinciding with a decline in TB treatment cases (2785 in 2009 to 497 in 2017). Although the absolute decline in mortality rates was most pronounced in PLHIV (-826/100,000 vs. HIV-negative: -23/100,000), the relative population-level mortality risk remained higher in PLHIV (aRR 4.68, 3.25-6.72) compared to the HIV-negative population. CONCLUSIONS TB-related mortality rapidly decreased at population-level and most pronounced in PLHIV. However, case fatality among TB treatment cases remained high. Further strategies to reduce active TB disease and introduce improved TB therapies are warranted.
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Affiliation(s)
- Bernhard Kerschberger
- Médecins sans Frontières, Mbabane, Eswatini
- Médecins sans Frontières/Ärzte ohne Grenzen, Vienna Evaluation Unit, Vienna, Austria
| | - Debrah Vambe
- National TB Control Programme (NTCP), Manzini, Eswatini
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Statistics, Ludwig-Maximilians University Munich, Munich, Germany
| | | | | | | | | | - Bheki Mamba
- National TB Control Programme (NTCP), Manzini, Eswatini
| | | | - Joyce Sibanda
- National TB Control Programme (NTCP), Manzini, Eswatini
| | - Sisi Dube
- National TB Control Programme (NTCP), Manzini, Eswatini
| | | | | | - Tom Ellman
- Médecins sans Frontières, Cape Town, South Africa
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Space-time clustering of recently-diagnosed tuberculosis and impact of ART scale-up: Evidence from an HIV hyper-endemic rural South African population. Sci Rep 2019; 9:10724. [PMID: 31341191 PMCID: PMC6656755 DOI: 10.1038/s41598-019-46455-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/28/2019] [Indexed: 12/26/2022] Open
Abstract
In HIV hyperendemic sub-Saharan African communities, particularly in southern Africa, the likelihood of achieving the Sustainable Development Goal of ending the tuberculosis (TB) epidemic by 2030 is low, due to lack of cost-effective and practical interventions in population settings. We used one of Africa’s largest population-based prospective cohorts from rural KwaZulu-Natal Province, South Africa, to measure the spatial variations in the prevalence of recently-diagnosed TB disease, and to quantify the impact of community coverage of antiretroviral therapy (ART) on recently-diagnosed TB disease. We collected data on TB disease episodes from a population-based sample of 41,812 adult individuals between 2009 and 2015. Spatial clusters (‘hotspots’) of recently-diagnosed TB were identified using a space-time scan statistic. Multilevel logistic regression models were fitted to investigate the relationship between community ART coverage and recently-diagnosed TB. Spatial clusters of recently-diagnosed TB were identified in a region characterized by a high prevalence of HIV and population movement. Every percentage increase in ART coverage was associated with a 2% decrease in the odds of recently-diagnosed TB (aOR = 0.98, 95% CI:0.97–0.99). We identified for the first time the clear occurrence of recently-diagnosed TB hotspots, and quantified potential benefit of increased community ART coverage in lowering tuberculosis, highlighting the need to prioritize the expansion of such effective population interventions targeting high-risk areas.
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Kanyerere H, Girma B, Mpunga J, Tayler-Smith K, Harries AD, Jahn A, Chimbwandira FM. Scale-up of ART in Malawi has reduced case notification rates in HIV-positive and HIV-negative tuberculosis. Public Health Action 2016; 6:247-251. [PMID: 28123962 DOI: 10.5588/pha.16.0053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 09/02/2016] [Indexed: 02/01/2023] Open
Abstract
Setting: For 30 years, Malawi has experienced a dual epidemic of human immunodeficiency virus (HIV) infection and tuberculosis (TB) that has recently begun to be attenuated by the scale-up of antiretroviral therapy (ART). Objective: To report on the correlation between ART scale-up and annual national TB case notification rates (CNR) in Malawi, stratified by HIV-positive and HIV-negative status, from 2005 to 2015. Design: A retrospective descriptive ecological study using aggregate data from national reports. Results: From 2005 to 2015, ART was scaled up in Malawi from 28 470 to 618 488 total patients, with population coverage increasing from 2.4% to 52.2%. During this time, annual TB notifications declined by 35%, from 26 344 to 17 104, and the TB CNR per 100 000 population declined by 49%, from 206 to 105. HIV testing uptake increased from 51% to 92%. In known HIV-positive TB patients, the CNR decreased from a high of 1247/100 000 to 710/100 000, a 43% decrease. In known HIV-negative TB patients, the CNR also decreased, from a high of 66/100 000 to 49/100 000, a 26% decrease. Conclusion: TB case notifications have continued to decline in association with ART scale-up, with the decline seen more in HIV-positive than HIV-negative TB. These findings have programmatic implications for national TB control efforts.
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Affiliation(s)
- H Kanyerere
- Community Health Science Unit, National Tuberculosis Control Programme, Lilongwe, Malawi
| | - B Girma
- Community Health Science Unit, National Tuberculosis Control Programme, Lilongwe, Malawi ; International Training and Education Center for Health (I-TECH) Malawi, Department of Global Health, University of Washington, Seattle, Washington, USA
| | - J Mpunga
- Community Health Science Unit, National Tuberculosis Control Programme, Lilongwe, Malawi
| | - K Tayler-Smith
- Medical Department, Médecins Sans Frontières, Operational Centre Brussels, Luxembourg City, Luxembourg
| | - A D Harries
- International Union Against Tuberculosis and Lung Disease, Paris, France ; London School of Hygiene & Tropical Medicine, London, UK
| | - A Jahn
- International Training and Education Center for Health (I-TECH) Malawi, Department of Global Health, University of Washington, Seattle, Washington, USA ; Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - F M Chimbwandira
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
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Takarinda KC, Harries AD, Sandy C, Mutasa-Apollo T, Zishiri C. Declining tuberculosis case notification rates with the scale-up of antiretroviral therapy in Zimbabwe. Public Health Action 2016; 6:164-168. [PMID: 27695678 DOI: 10.5588/pha.16.0029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 06/24/2016] [Indexed: 01/17/2023] Open
Abstract
Setting: Zimbabwe has a human immunodeficiency virus (HIV) driven tuberculosis (TB) epidemic, with antiretroviral therapy (ART) scaled up in the public sector since 2004. Objective: To determine whether national ART scale-up was associated with annual national TB case notification rates (CNR), stratified by disease type and category, between 2000 and 2013. Design: This was a retrospective study using aggregate data from global reports. Results: The number of people living with HIV and retained on ART from 2004 to 2013 increased from 8400 to 665 299, with ART coverage increasing from <0.5% to 48%. TB CNRs, all types and categories, increased from 2000 to 2003, and declined thereafter from 2004 to 2013. The decreases in annual TB notifications between the highest rates (before 2004) and lowest rates (2013) were all forms of TB (56%), new TB (60%), previously treated TB (53%), new smear-positive pulmonary TB (PTB) (40%), new smear-negative/smear-unknown PTB (58%) and extra-pulmonary TB (58%). Conclusion: Significant declines in TB CNRs were observed during ART scale-up, especially for smear-negative PTB and extra-pulmonary TB. These encouraging national trends support the continued scale-up of ART for people living with HIV as a way of tackling the twin epidemics of HIV/acquired immune-deficiency syndrome and TB in Zimbabwe.
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Affiliation(s)
- K C Takarinda
- AIDS and TB Department, Ministry of Health and Child Care, Harare, Zimbabwe ; International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - A D Harries
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France ; London School of Hygiene & Tropical Medicine, London, UK
| | - C Sandy
- AIDS and TB Department, Ministry of Health and Child Care, Harare, Zimbabwe
| | - T Mutasa-Apollo
- AIDS and TB Department, Ministry of Health and Child Care, Harare, Zimbabwe
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Harries AD, Kumar AMV, Kyaw NTT, Hoa NB, Takarinda KC, Zachariah R. The role of antiretroviral therapy in reducing TB incidence and mortality in high HIV-TB burden countries. ASIAN PACIFIC JOURNAL OF TROPICAL DISEASE 2016. [DOI: 10.1016/s2222-1808(15)61023-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kanyerere H, Harries AD, Tayler-Smith K, Jahn A, Zachariah R, Chimbwandira FM, Mpunga J. The rise and fall of tuberculosis in Malawi: associations with HIV infection and antiretroviral therapy. Trop Med Int Health 2015; 21:101-107. [PMID: 26509352 PMCID: PMC4738452 DOI: 10.1111/tmi.12630] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Since 1985, Malawi has experienced a dual epidemic of HIV and tuberculosis (TB) which has been moderated recently by the advent of antiretroviral therapy (ART). The aim of this study was to describe the association over several decades between HIV/AIDS, the scale-up of ART and TB case notifications. METHODS Aggregate data were extracted from annual reports of the National TB Control Programme, the Ministry of Health HIV Department and the National Statistics Office. ART coverage was calculated using the total HIV population as denominator (derived from UNAIDS Spectrum software). RESULTS In 1970, there were no HIV-infected persons but numbers had increased to a maximum of 1.18 million by 2014. HIV prevalence reached a maximum of 10.8% in 2000, thereafter decreasing to 7.5% by 2014. Numbers alive on ART increased from 2586 in 2003 to 536 527 (coverage 45.3%) by 2014. In 1985, there were 5286 TB cases which reached a maximum of 28 234 in 2003 and then decreased to 17 723 by 2014 (37% decline from 2003). There were increases in all types of new TB between 1998-2003 which then declined by 30% for extrapulmonary TB, by 37% for new smear-positive PTB and by 50% for smear-negative PTB. Previously treated TB cases reached a maximum of 3443 in 2003 and then declined by 42% by 2014. CONCLUSION The rise and fall of TB in Malawi between 1985 and 2014 was strongly associated with HIV infection and ART scale-up; this has implications for ending the TB epidemic in high HIV-TB burden countries.
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Affiliation(s)
- Henry Kanyerere
- Community Health Science Unit, National Tuberculosis Control Programme, Lilongwe, Malawi
| | - Anthony D Harries
- International Union Against Tuberculosis and Lung Disease, Paris, France.,London School of Hygiene and Tropical Medicine, London, UK
| | - Katie Tayler-Smith
- Médecins sans Frontières, Medical Department, Operational Centre Brussels, MSF-Luxembourg, Luxembourg
| | - Andreas Jahn
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi.,ITECH, Malawi and University of Washington, Seattle, WA, USA
| | - Rony Zachariah
- Médecins sans Frontières, Medical Department, Operational Centre Brussels, MSF-Luxembourg, Luxembourg
| | | | - James Mpunga
- Community Health Science Unit, National Tuberculosis Control Programme, Lilongwe, Malawi
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Benefits of combined preventive therapy with co-trimoxazole and isoniazid in adults living with HIV: time to consider a fixed-dose, single tablet coformulation. THE LANCET. INFECTIOUS DISEASES 2015; 15:1492-6. [PMID: 26515525 DOI: 10.1016/s1473-3099(15)00242-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/30/2015] [Accepted: 07/23/2015] [Indexed: 12/31/2022]
Abstract
Antiretroviral therapy (ART) is the main intervention needed to reduce morbidity and mortality and to prevent tuberculosis in adults living with HIV. However, in most resource-limited countries, especially in sub-Saharan Africa, ART is started too late to have an effect with substantial early morbidity and mortality, and in high tuberculosis burden settings ART does not reduce the tuberculosis risk to that reported in individuals not infected with HIV. Co-trimoxazole preventive therapy started before or with ART, irrespective of CD4 cell count, reduces morbidity and mortality with benefits that continue indefinitely. Isoniazid preventive therapy as an adjunct to ART prevents tuberculosis in high-exposure settings, with long-term treatment likely to be needed to sustain this benefit. Unfortunately, both preventive therapies are underused in low-income and high-burden settings. ART development has benefited from patient-centred simplification with several effective regimens now available as a one per day pill. We argue that co-trimoxazole and isoniazid should also be combined into a single fixed-dose pill, along with pyridoxine (vitamin B6), that would be taken once per day to help with individual uptake and national scale-up of therapies.
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Temporal trends in TB notification rates during ART scale-up in Cape Town: an ecological analysis. J Int AIDS Soc 2015; 18:20240. [PMID: 26411694 PMCID: PMC4584214 DOI: 10.7448/ias.18.1.20240] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 08/17/2015] [Accepted: 08/25/2015] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Although antiretroviral therapy (ART) reduces individual tuberculosis (TB) risk by two-thirds, the population-level impact remains uncertain. Cape Town reports high TB notification rates associated with endemic HIV. We examined population trends in TB notification rates during a 10-year period of expanding ART. METHODS Annual Cape Town TB notifications were used as numerators and mid-year Cape Town populations as denominators. HIV-stratified population was calculated using overall HIV prevalence estimates from the Actuarial Society of South Africa AIDS and Demographic model. ART provision numbers from Western Cape government reports were used to calculate overall ART coverage. We calculated rates per 100,000 population over time, overall and stratified by HIV status. Rates per 100,000 total population were also calculated by ART use at treatment initiation. Absolute numbers of notifications were compared by age and sub-district. Changes over time were described related to ART provision in the city as a whole (ART coverage) and by sub-district (numbers on ART). RESULTS From 2003 to 2013, Cape Town's population grew from 3.1 to 3.7 million inhabitants, and estimated HIV prevalence increased from 3.6 to 5.2%. ART coverage increased from 0 to 63% in 2013. TB notification rates declined by 16% (95% confidence interval (CI), 14-17%) from a 2008 peak (851/100,000) to a 2013 nadir (713/100,000). Decreases were higher among the HIV-positive (21% (95% CI, 19-23%)) than the HIV-negative (9% (95% CI, 7-11%)) population. The number of HIV-positive TB notifications decreased mainly among 0- to 4- and 20- to 34-year-olds. Total population rates on ART at TB treatment initiation increased over time but levelled off in 2013. Overall median CD4 counts increased from 146 cells/µl (interquartile range (IQR), 66, 264) to 178 cells/µl (IQR 75, 330; p<0.001). Sub-district antenatal HIV seroprevalence differed (10-33%) as did numbers on ART (9-29 thousand). Across sub-districts, infant HIV-positive TB decreased consistently whereas adult decreases varied. CONCLUSIONS HIV-positive TB notification rates declined during a period of rapid scale-up of ART. Nevertheless, both HIV-positive and HIV-negative TB notification rates remained very high. Decreases among HIV positives were likely blunted by TB remaining a major entry to the ART programme and occurring after delayed ART initiation.
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Lawn SD. Enhancing the impact of antiretroviral scale-up on the HIV-associated tuberculosis epidemic in Malawi. Public Health Action 2015; 4:204. [PMID: 26393084 DOI: 10.5588/pha.14.0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Stephen D Lawn
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. ; The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Lawn SD, Wilkinson RJ. ART and prevention of HIV-associated tuberculosis. Lancet HIV 2015; 2:e221-e222. [PMID: 26423189 DOI: 10.1016/s2352-3018(15)00081-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 04/30/2015] [Indexed: 06/05/2023]
Affiliation(s)
- Stephen D Lawn
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK; The Desmond Tutu HIV Centre, and Clinical Infectious Diseases Research Initiative; Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, Republic of South Africa.
| | - Robert J Wilkinson
- The Desmond Tutu HIV Centre, and Clinical Infectious Diseases Research Initiative; Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, Republic of South Africa; The Francis Crick Institute Mill Hill Laboratory, London, UK; Department of Medicine, Imperial College, London, UK
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