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Jacobs TG, Okemo D, Ssebagereka A, Mwehonge K, Njuguna EM, Burger DM, Colbers A, Suleman F, Mantel-Teeuwisse AK, Ooms GI. Availability and stock-outs of paediatric antiretroviral treatment formulations at health facilities in Kenya and Uganda. HIV Med 2024; 25:805-816. [PMID: 38499513 DOI: 10.1111/hiv.13635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 03/03/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION The large number of deaths among children with HIV is driven by poor antiretroviral treatment (ART) coverage among this cohort. The aim of the study was to assess the availability and stock-outs of paediatric and adult ART formulations in Kenya and Uganda across various regions and types of health facilities. METHODS A survey on availability and stock-outs of paediatric ART at health facilities was adapted from the standardized Health Action International-WHO Medicine Availability Monitoring Tool. All preferred and limited-use formulations, and three phased-out formulations according to the 2021 WHO optimal formulary list were included in the survey, as well as a selection of adult ART formulations suitable for older children, adolescents, and adults. Availability data were collected in June-July 2022 and stock-out data were obtained over the previous year from randomly selected public and private-not-for-profit (PNFP) facilities registered to dispense paediatric ART across six districts per country. All data were analysed descriptively. RESULTS In total, 144 health facilities were included (72 per country); 110 were public and 34 PNFP facilities. Overall availabilities of preferred paediatric ART formulations were 52.2% and 63.5% in Kenya and Uganda, respectively, with dolutegravir (DTG) 10 mg dispersible tablets being available in 70.2% and 77.4% of facilities, respectively, and abacavir/lamivudine dispersible tablets in 89.8% and 98.2% of facilities. Of note, availability of both formulations was low (37.5% and 62.5%, respectively) in Kenyan PNFP facilities. Overall availabilities of paediatric limited-use products were 1.1% in Kenya and 1.9% in Uganda. At least one stock-out of a preferred paediatric ART formulation was reported in 40.0% of Kenyan and 74.7% of Ugandan facilities. Nevirapine solution stock-outs were reported in 43.1% of Ugandan facilities, while alternative formulations for postnatal HIV prophylaxis were not available. CONCLUSIONS Recommended DTG-based first-line ART for children across all ages was reasonably available at health facilities in Kenya and Uganda, with the exception of Kenyan PNFP facilities. Availability of paediatric ART formulations on the limited-use list was extremely low across both countries. Stock-outs were reported regularly, with the high number of reported stock-outs of neonatal ART formulations in Uganda being most concerning.
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Affiliation(s)
- Tom G Jacobs
- Department of Pharmacy, Radboudumc Research Institute for Medical Innovation (RIMI), Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Anthony Ssebagereka
- Coalition for Health Promotion and Social Development (HEPS-Uganda), Kampala, Uganda
| | - Kenneth Mwehonge
- Coalition for Health Promotion and Social Development (HEPS-Uganda), Kampala, Uganda
| | | | - David M Burger
- Department of Pharmacy, Radboudumc Research Institute for Medical Innovation (RIMI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Angela Colbers
- Department of Pharmacy, Radboudumc Research Institute for Medical Innovation (RIMI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fatima Suleman
- School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Aukje K Mantel-Teeuwisse
- Utrecht Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Gaby I Ooms
- Utrecht Centre for Pharmaceutical Policy and Regulation, Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
- Health Action International, Amsterdam, The Netherlands
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Koehler A, Strauss B, Briken P, Fisch M, Soave A, Riechardt S, Nieder TO. Exploring the Relationship between (De-)Centralized Health Care Delivery, Client-Centeredness, and Health Outcomes-Results of a Retrospective, Single-Center Study of Transgender People Undergoing Vaginoplasty. Healthcare (Basel) 2023; 11:1746. [PMID: 37372864 DOI: 10.3390/healthcare11121746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/09/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Introduction: Transgender health care interventions (e.g., gender-affirming surgery) support transgender and gender-diverse people to transition to their gender and are delivered in both centralized (by one interdisciplinary institution) and decentralized settings (by different institutions spread over several locations). In this exploratory study, we investigated the relationship between centralized and decentralized delivery of transgender health care, client-centeredness, and psychosocial outcomes. Methods: A retrospective analysis of 45 clients undergoing vaginoplasty at one medical center was conducted. Mann-Whitney U tests assessed differences regarding five dimensions of client-centeredness and psychosocial outcomes between the health care delivery groups. To address shortcomings regarding the small sample size, we applied a rigorous statistical approach (e.g., Bonferroni correction) to ensure that we only identified predictors that were actually related to the outcomes. Results: All aspects of client-centered care were scored average or high. Decentralized delivery of care was more client-centered in terms of involvement in care/shared decision-making and empowerment. However, participants from decentralized health care delivery settings scored lower on psychosocial health (p = 0.038-0.005). Conclusions: The factor of (de-)centralized health care delivery appears to have a significant impact on the provision of transgender health care and should be investigated by future research.
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Affiliation(s)
- Andreas Koehler
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- Department for Urology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Bernhard Strauss
- Institute of Psychosocial Medicine, Psychotherapy and Psycho-Oncology, University Hospital Jena, Stoystrasse 3, 07740 Jena, Germany
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- Department for Urology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Margit Fisch
- Department for Urology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- Interdisciplinary Transgender Health Care Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Armin Soave
- Department for Urology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- Interdisciplinary Transgender Health Care Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Silke Riechardt
- Department for Urology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- Interdisciplinary Transgender Health Care Center, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Timo O Nieder
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- Department for Urology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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Abuogi LL, Kulzer JL, Akama E, Odeny TA, Eshun-Wilson I, Petersen M, Shade SB, Montoya LM, Beres LK, Iguna S, Adhiambo HF, Osoro J, Opondo I, Sang N, Kwena Z, Bukusi EA, Geng EH. Adapt for Adolescents: Protocol for a sequential multiple assignment randomized trial to improve retention and viral suppression among adolescents and young adults living with HIV in Kenya. Contemp Clin Trials 2023; 127:107123. [PMID: 36813086 PMCID: PMC10075086 DOI: 10.1016/j.cct.2023.107123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Adolescents and young adults living with HIV (AYAH) aged 14-24 years in Africa experience substantially higher rates of virological failure and HIV-related mortality than adults. We propose to utilize developmentally appropriate interventions with high potential for effectiveness, tailored by AYAH pre-implementation, in a sequential multiple assignment randomized trial (SMART) aimed at improving viral suppression for AYAH in Kenya. METHODS Using a SMART design, we will randomize 880 AYAH in Kisumu, Kenya to either youth-centered education and counseling (standard of care) or electronic peer navigation in which a peer provides support, information, and counseling via phone and automated monthly text messages. Those with a lapse in engagement (defined as either a missed clinic visit by ≥14 days or HIV viral load ≥1000 copies/ml) will be randomized a second time to one of three higher-intensity re-engagement interventions: This study will evaluate which interventions and which dynamic sequence of interventions improve sustained viral suppression and HIV care engagement in AYAH at 24 months post-enrollment and assess the cost-effectiveness of successful strategies. DISCUSSION The study utilizes promising interventions tailored to AYAH while optimizing resources by intensifying services only for those AYAH who need more support. Findings from this innovative study will offer evidence for public health programming to end the HIV epidemic as a public health threat for AYAH in Africa. TRIAL REGISTRATION Clinicaltrials.govNCT04432571, registered June 16, 2020.
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Affiliation(s)
- Lisa L Abuogi
- Department of Pediatrics, University of Colorado, Denver, Aurora, CO, USA.
| | - Jayne Lewis Kulzer
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Eliud Akama
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Thomas A Odeny
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya; School of Medicine, Washington University, St. Louis, MO, USA
| | | | - Maya Petersen
- Division of Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Starley B Shade
- Department of Epidemiology and Biostatistics, Institute for Global Health Sciences, University of California, San Francisco, CA, USA
| | - Lina M Montoya
- Department of Biostatistics, University of North Carolina at Chapel Hill, NC, USA
| | - Laura K Beres
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sarah Iguna
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Harriet F Adhiambo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Joseph Osoro
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Isaya Opondo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Norton Sang
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Zachary Kwena
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elvin H Geng
- School of Medicine, Washington University, St. Louis, MO, USA
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Leshargie CT, Demant D, Burrowes S, Frawley J. The proportion of loss to follow-up from antiretroviral therapy (ART) and its association with age among adolescents living with HIV in sub-Saharan Africa: A systematic review and meta-analysis. PLoS One 2022; 17:e0272906. [PMID: 35951621 PMCID: PMC9371308 DOI: 10.1371/journal.pone.0272906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/29/2022] [Indexed: 11/25/2022] Open
Abstract
Background Human immunodeficiency virus (HIV) remains a global health threat, especially in developing countries. The successful scale-up of antiretroviral therapy (ART) programs to address this threat is hindered by a high proportion of patient loss to follow-up (LTFU). LTFU is associated with poor viral suppression and increased mortality. It is particularly acute among adolescents, who face unique adherence challenges. Although LTFU is a critical obstacle on the continuum of care for adolescents, few regional-level studies report the proportion of LTFU among adolescents receiving ART. Therefore, a systematic review and meta-analysis were conducted to estimate the pooled LTFU in ART programs among adolescents living with HIV in sub-Saharan Africa (SSA). Methods We searched five databases (PubMed, Embase (Elsevier), PsycINFO, CINAHL, and Scopus) for articles published between 2005 and 2020 and reference lists of included articles. The PRISMA guidelines for systematic reviews were followed. A standardised checklist to extract data was used. Descriptive summaries were presented using narrative tables and figures. Heterogeneity within the included studies was examined using the Cochrane Q test statistics and I2 test. Random effect models were used to estimate the pooled prevalence of LTFU among ALHIV. We used Stata version 16 statistical software for our analysis. Results Twenty-nine eligible studies (n = 285,564) were included. An estimated 15.07% (95% CI: 11.07, 19.07) of ALHIV were LTFU. Older adolescents (15–19 years old) were 43% (AOR = 0.57, 95% CI: 0.37, 0.87) more likely to be LTFU than younger (10–14 years old) adolescents. We find an insignificant relationship between gender and LTFU (AOR = 0.95, 95% CI: 0.87, 1.03). A subgroup analysis found that regional differences in the proportion of adolescent LTFU were not statistically significant. The trend analysis indicates an increasing proportion of adolescent LTFU over time. Conclusions and recommendations The proportion of LTFU among HIV-positive adolescents in SSA seems higher than those reported in other regions. Older adolescents in the region are at an increased risk for LTFU than younger adolescents. These findings may help policymakers develop appropriate strategies to retain ALHIV in ART services. Such strategies could include community ART distribution points, appointment spacing, adherence clubs, continuous free access to ART, and community-based adherence support.
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Affiliation(s)
- Cheru Tesema Leshargie
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, Australia
- * E-mail:
| | - Daniel Demant
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, Australia
- School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Sahai Burrowes
- Public Health Program, College of Education and Health Sciences, Touro University California, Vallejo, CA, United States of America
| | - Jane Frawley
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, Australia
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Growth improvement following antiretroviral therapy initiation in children with perinatally-acquired HIV diagnosed in older childhood in Zimbabwe: a prospective cohort study. BMC Pediatr 2022; 22:446. [PMID: 35879693 PMCID: PMC9317209 DOI: 10.1186/s12887-022-03466-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 07/01/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Children who initiate antiretroviral therapy (ART) before age 5 years can recover height and weight compared to uninfected peers, but growth outcomes are unknown for children initiating ART at older ages. We investigated factors associated with growth failure at ART initiation and modelled growth by age on ART. METHODS We conducted secondary analysis of cohort of children aged 6-15 years late-diagnosed with HIV in Harare, Zimbabwe, with entry at ART initiation in 2013-2015. Factors associated with height-for-age (HAZ), weight-for-age (WAZ) and BMI-for-age (BAZ) z-scores <- 2 (stunting, underweight and wasting respectively) at ART initiation were assessed using multivariable logistic regression. These outcomes were compared at ART initiation and 12 month follow-up using paired t-tests. HAZ and BAZ were modelled using restricted cubic splines. RESULTS Participants (N = 302; 51.6% female; median age 11 years) were followed for a median of 16.6 months (IQR 11.0-19.8). At ART initiation 34.8% were stunted, 34.5% underweight and 15.1% wasted. Stunting was associated with age ≥ 12 years, CD4 count < 200 cells/μl, tuberculosis (TB) history and history of hospitalisation. Underweight was associated with older age, male sex and TB history, and wasting was associated with older age, TB history and hospitalisation. One year post-initiation, t-tests showed increased WAZ (p = 0.007) and BAZ (p = 0.004), but no evidence of changed HAZ (p = 0.85). Modelling showed that HAZ and BAZ decreased in early adolescence for boys on ART, but not girls. CONCLUSION Stunting and underweight were prevalent at ART initiation among late-diagnosed children, and HAZ did not improve after 1 year. Adolescent boys with perinatally acquired HIV and late diagnosis are particularly at risk of growth failure in puberty.
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Koehler A, Strauss B, Briken P, Szuecs D, Nieder TO. Centralized and Decentralized Delivery of Transgender Health Care Services: A Systematic Review and a Global Expert Survey in 39 Countries. Front Endocrinol (Lausanne) 2021; 12:717914. [PMID: 34630327 PMCID: PMC8497761 DOI: 10.3389/fendo.2021.717914] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/20/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction Transgender health care is delivered in both centralized (by one interdisciplinary institution) and decentralized settings (by different medical institutions spread over several locations). However, the health care delivery setting has not gained attention in research so far. Based on a systematic review and a global expert survey, we aim to investigate its role in transgender health care quality. Methods We performed two studies. In 2019, we systematically reviewed the literature published in databases (Cochrane, MEDLINE, EMBASE, Web of Science) from January 2000 to April 2019. Secondly, we conducted a cross-sectional global expert survey. To complete the evidence on the question of (de-)centralized delivery of transgender health care, we performed a grey literature search for additional information than the systematic review and the expert survey revealed. These analyses were conducted in 2020. Results Eleven articles met the inclusion criteria of the systematic review. 125 participants from 39 countries took part in the expert survey. With insights from the grey literature search, we found transgender health care in Europe was primarily delivered centralized. In most other countries, both centralized and decentralized delivery structures were present. Comprehensive care with medical standards and individual access to care were central topics associated with the different health care delivery settings. Discussion The setting in which transgender health care is delivered differs between countries and health systems and could influence different aspects of transgender health care quality. Consequently, it should gain significant attention in clinical practice and future health care research.
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Affiliation(s)
- Andreas Koehler
- University Medical Center Hamburg-Eppendorf, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - Bernhard Strauss
- University Hospital Jena, Institute of Psychosocial Medicine, Psychotherapy, and Psycho-Oncology, Jena, Germany
| | - Peer Briken
- University Medical Center Hamburg-Eppendorf, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - Daria Szuecs
- University Medical Center Hamburg-Eppendorf, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - Timo O Nieder
- University Medical Center Hamburg-Eppendorf, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
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Badejo O, Noestlinger C, Jolayemi T, Adeola J, Okonkwo P, Van Belle S, Wouters E, Laga M. Multilevel modelling and multiple group analysis of disparities in continuity of care and viral suppression among adolescents and youths living with HIV in Nigeria. BMJ Glob Health 2021; 5:bmjgh-2020-003269. [PMID: 33154102 PMCID: PMC7646327 DOI: 10.1136/bmjgh-2020-003269] [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: 07/01/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Substantial disparities in care outcomes exist between different subgroups of adolescents and youths living with HIV (AYLHIV). Understanding variation in individual and health facility characteristics could be key to identifying targets for interventions to reduce these disparities. We modelled variation in AYLHIV retention in care and viral suppression, and quantified the extent to which individual and facility characteristics account for observed variations. METHODS We included 1170 young adolescents (10-14 years), 3206 older adolescents (15-19 years) and 9151 young adults (20-24 years) who were initiated on antiretroviral therapy (ART) between January 2015 and December 2017 across 124 healthcare facilities in Nigeria. For each age group, we used multilevel modelling to partition observed variation of main outcomes (retention in care and viral suppression at 12 months after ART initiation) by individual (level one) and health facility (level two) characteristics. We used multiple group analysis to compare the effects of individual and facility characteristics across age groups. RESULTS Facility characteristics explained most of the observed variance in retention in care in all the age groups, with smaller contributions from individual-level characteristics (14%-22.22% vs 0%-3.84%). For viral suppression, facility characteristics accounted for a higher proportion of variance in young adolescents (15.79%), but not in older adolescents (0%) and young adults (3.45%). Males were more likely to not be retained in care (adjusted OR (aOR)=1.28; p<0.001 young adults) and less likely to achieve viral suppression (aOR=0.69; p<0.05 older adolescent). Increasing facility-level viral load testing reduced the likelihood of non-retention in care, while baseline regimen TDF/3TC/EFV or NVP increased the likelihood of viral suppression. CONCLUSIONS Differences in characteristics of healthcare facilities accounted for observed disparities in retention in care and, to a lesser extent, disparities in viral suppression. An optimal combination of individual and health services approaches is, therefore, necessary to reduce disparities in the health and well-being of AYLHIV.
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Affiliation(s)
- Okikiolu Badejo
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium .,APIN Public Health Initiative, Abuja, Nigeria.,Department of Sociology, University of Antwerp, Antwerpen, Belgium
| | | | | | | | | | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Edwin Wouters
- Department of Sociology, University of Antwerp, Antwerpen, Belgium
| | - Marie Laga
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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High rate of loss to follow-up and virological non-suppression in HIV-infected children on antiretroviral therapy highlights the need to improve quality of care in South Africa. Epidemiol Infect 2021; 149:e88. [PMID: 33745490 PMCID: PMC8080219 DOI: 10.1017/s0950268821000637] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Provision of high-quality care and ensuring retention of children on antiretroviral therapy (ART) are essential to reduce human immunodeficiency virus (HIV)-associated morbidity and mortality. Virological non-suppression (≥1000 viral copies/ml) is an indication of suboptimal HIV care and support. This retrospective cohort study included ART-naïve children who initiated first-line ART between July 2015 and August 2017 in Johannesburg and rural Mopani district. Of 2739 children started on ART, 29.5% (807/2739) were lost to care at the point of analysis in August 2018. Among retained children, overall virological non-suppression was 30.2% (469/1554). Virological non-suppression was associated with higher loss to care 30.3% (229/755) compared with suppressed children (9.7%, 136/1399, P < 0.001). Receiving treatment in Mopani was associated with virological non-suppression in children under 5 years (adjusted odds ratio (aOR) 1.7 (95% confidence interval (CI) 1.1-2.4), 5-9 years (aOR 1.8 (1.1-3.0)) and 10-14 years (aOR 1.9 (1.2-2.8)). Virological non-suppression was associated with lower CD4 count in children 5-9 years (aOR 2.1 (1.1-4.1)) and 10-14 years (aOR 2.1 (1.2-3.8)). Additional factors included a shorter time on ART (<5 years aOR 1.8-3.7 (1.3-8.2)), and male gender (5-9 years, aOR1.5 (1.01-2.3)), and receiving cotrimoxazole prophylaxis (10-14 years aOR 2.0 (1.2-3.6)). In conclusion, virological non-suppression is a factor of subsequent programme loss in both regions, and factors affecting the quality of care need to be addressed to achieve the third UNAIDS 90 in paediatric HIV.
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Githinji L, Zar HJ. Respiratory Complications in Children and Adolescents with Human Immunodeficiency Virus. Pediatr Clin North Am 2021; 68:131-145. [PMID: 33228928 DOI: 10.1016/j.pcl.2020.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Respiratory complications comprise a large proportion of the burden of mortality and morbidity in children with human immunodeficiency virus (HIV). HIV-associated lower respiratory tract infection (LRTI) has declined in incidence with early diagnosis and use of antiretroviral therapy (ART) but is widespread in areas with limited access to ART. HIV-exposed uninfected infants have a higher risk of LRTI early in life than unexposed infants. Pulmonary tuberculosis (PTB) presenting as acute or chronic disease is common in highly TB endemic areas. Chronic lung disease is common; preceding LRTI, PTB or late initiation of ART are risk factors.
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Affiliation(s)
- Leah Githinji
- Department of Paediatrics and Child Health, South Africa MRC Unit on Child & Adolescent Health, University of Cape Town, Red Cross War Memorial Children's Hospital, ICH Building, Klipfontein Road, Rondebosch 7700, South Africa
| | - Heather J Zar
- Department of Paediatrics and Child Health, South Africa MRC Unit on Child & Adolescent Health, University of Cape Town, Red Cross War Memorial Children's Hospital, ICH Building, Klipfontein Road, Rondebosch 7700, South Africa.
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Matsena Zingoni Z, Chirwa T, Todd J, Musenge E. Competing risk of mortality on loss to follow-up outcome among patients with HIV on ART: a retrospective cohort study from the Zimbabwe national ART programme. BMJ Open 2020; 10:e036136. [PMID: 33028546 PMCID: PMC7539573 DOI: 10.1136/bmjopen-2019-036136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 08/24/2020] [Accepted: 09/01/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine the loss to follow-up (LTFU) rates at different healthcare levels after antiretroviral therapy (ART) services decentralisation among ART patients who initiated ART between 2004 and 2017 using the competing risk model in addition to the Kaplan-Meier and Cox regressions analysis. DESIGN A retrospective cohort study. SETTING The study was done in Zimbabwe using a nationwide routinely collected HIV patient-level data from various health levels of care facilities compiled through the electronic patient management system (ePMS). PARTICIPANTS We analysed 390 771 participants aged 15 years and above from 538 health facilities. OUTCOMES The primary endpoint was LTFU defined as a failure of a patient to report for drug refill for at least 90 days from last appointment date or if the patient missed the next scheduled visit date and never showed up again. Mortality was considered a secondary outcome if a patient was reported to have died. RESULTS The total exposure time contributed was 1 544 468 person-years. LTFU rate was 5.75 (95% CI 5.71 to 5.78) per 100 person-years. Adjustment for the competing event independently increased LTFU rate ratio in provincial and referral (adjusted sub-HRs (AsHR) 1.22; 95% CI 1.18 to 1.26) and district and mission (AsHR 1.47; 95% CI 1.45 to 1.50) hospitals (reference: primary healthcare); in urban sites (AsHR 1.61; 95% CI 1.59 to 1.63) (reference: rural); and among adolescence and young adults (15-24 years) group (AsHR 1.19; 95% CI 1.16 to 1.21) (reference: 35-44 years). We also detected overwhelming association between LTFU and tuberculosis-infected patients (AsHR 1.53; 95% CI 1.45 to 1.62) (reference: no tuberculosis). CONCLUSIONS We have observed considerable findings that 'leakages' (LTFU) within the ART treatment cascade persist even after the decentralisation of health services. Risk factors for LTFU reflect those found in sub-Saharan African studies. Interventions that retain patients in care by minimising any 'leakages' along the treatment cascade are essential in attaining the 90-90-90 UNAIDS fast-track targets.
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Affiliation(s)
- Zvifadzo Matsena Zingoni
- Division of Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Institute of Health Research, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Tobias Chirwa
- Division of Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jim Todd
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Eustasius Musenge
- Division of Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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11
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Broström S, Andersson A, Hallström IK, Jerene D. Transitioning from child to adult-oriented HIV clinical care for adolescents living with HIV in Ethiopia: results from a retrospective cohort study. Pan Afr Med J 2020; 37:13. [PMID: 33062116 PMCID: PMC7532856 DOI: 10.11604/pamj.2020.37.13.21407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 07/13/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Ethiopia has one of the largest number of adolescents living with HIV (ALHIV). As these adolescents reach adulthood they need to transfer from pediatric to adult-oriented clinics. Clear implementation guidelines for transition are lacking and factors associated with successful transition are inadequately investigated. Our objective was to describe the rate and age of transition from child- to adult-oriented care and the factors associated with transition success among ALHIV in selected health facilities in Ethiopia. METHODS a retrospective cohort study of adolescents was conducted in eight health facilities in two regions of Ethiopia: Addis Ababa and the Southern Nations, Nationalities and Peoples´ Region (SNNPR). The study was embedded within a broader study originally aimed at studying clinical outcomes of adolescents. The proportion of adolescents who transitioned was calculated and the association between baseline characteristics and transition was assessed by bivariate and multivariate analysis. RESULTS of 1072 adolescents, 8.7% transitioned to adult care. The most frequent age of transition was 15 (range: 10-22). Multivariate analysis generated two significant findings: adolescents from Addis Ababa were more to likely transitioned than adolescents from SNNPR (aOR: 2.18; 95% CI=1.17-4.06; p<0.01), as well as disclosed adolescents compared to those not disclosed of their HIV-status (aOR: 4.19; 95% CI=1.57-11.98; p<0.01). CONCLUSION transition occurred in less than 10% of participants, in a wide range of age, indicating a lack of implementation policies regarding the transition process. Thereto, we found that adolescents from Addis Ababa and those disclosed of their disease, were more likely to transition. Further studies are needed to better understand factors associated with transition success.
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Affiliation(s)
- Sander Broström
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Axel Andersson
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | | | - Degu Jerene
- KNCV Tuberculosis Foundation, The Hague, Netherlands
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12
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Moazen B, Deckert A, Saeedi Moghaddam S, Owusu PN, Mehdipour P, Shokoohi M, Noori A, Lotfizadeh M, Bosworth R, Neuhann F, Farzadfar F, Stöver H, Dolan K. National and sub-national HIV/AIDS-related mortality in Iran, 1990-2015: a population-based modeling study. Int J STD AIDS 2019; 30:1362-1372. [PMID: 31739749 DOI: 10.1177/0956462419869520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Surveillance of HIV/AIDS mortality is crucial to evaluate a country’s response to the disease. With a modified estimation approach, this study aimed to provide more accurate estimates on deaths due to HIV/AIDS in Iran from 1990 to 2015 at national and sub-national levels. Using a comprehensive data set, death registration incompleteness and misclassification were addressed by demographical and statistical methods. Trends of mortality due to HIV/AIDS at national and sub-national levels were estimated by applying a set of models. A total of 474 men (95% uncertainty interval [UI]: 175–1332) and 256 women (95% UI: 36–1871) died due to HIV/AIDS in 2015 in Iran. Peaked in 1995, HIV/AIDS-related mortality has steadily declined among both genders. Mortality rates were remarkably higher among men than women during the period studied. At the sub-national level, the highest and the lowest annual percent change were found at 10.97 and −1.36% for women, and 4.04 and −3.47% for men, respectively. The findings of our study (731 deaths) were remarkably lower than the Joint United Nations Programme on HIV and AIDS (4000) but higher than Global Burden of Disease (339) estimates in 2015. The overall decrease in mortality due to HIV/AIDS may be attributed to the increasing burden of noncommunicable diseases; however, the role of the national and international organizations to fight HIV/AIDS should not be overlooked. To decrease HIV/AIDS mortality and to achieve international goals, evidence-based action is required. To fast-track targets, the priority must be to prevent infection, promote early diagnosis, provide access to treatment, and to ensure treatment adherence among patients.
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Affiliation(s)
- Babak Moazen
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany.,Department of Health and Social Work, Institute of Addiction Research (ISFF), Frankfurt University of Applied Sciences, Frankfurt/Main, Germany
| | - Andreas Deckert
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Sahar Saeedi Moghaddam
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Priscilla N Owusu
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Parinaz Mehdipour
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Mostafa Shokoohi
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.,Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Canada
| | - Atefeh Noori
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Masoud Lotfizadeh
- Social Determinants of Health Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran.,Department of Community Health, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Rebecca Bosworth
- Program of International Research and Training, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Florian Neuhann
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Heino Stöver
- Department of Health and Social Work, Institute of Addiction Research (ISFF), Frankfurt University of Applied Sciences, Frankfurt/Main, Germany
| | - Kate Dolan
- Program of International Research and Training, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
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13
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Enane LA, Vreeman RC, Foster C. Retention and adherence: global challenges for the long-term care of adolescents and young adults living with HIV. Curr Opin HIV AIDS 2019; 13:212-219. [PMID: 29570471 DOI: 10.1097/coh.0000000000000459] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Adolescents living with HIV are the only age group with increasing HIV mortality at a time of global scale-up of access to antiretroviral therapy (ART). As a 'treat all' strategy is implemented worldwide, it is critically important to optimize retention and adherence for this vulnerable group. RECENT FINDINGS Adolescents and young adults living with HIV have poorer outcomes when compared with adults at each stage of the HIV care cascade, irrespective of income setting. Rates of viral suppression are lowest for adolescents living with HIV, and adherence to ART remains an enormous challenge. High-quality studies of interventions to improve linkage to, and retention in, care on suppressive ART are starkly lacking for adolescents and young adults living with HIV across the globe. However, examples of good practice are beginning to emerge but require large-scale implementation studies with outcome data disaggregated by age, route of infection, and income setting, and include young pregnant women and key populations groups. SUMMARY There is an urgent need for evidence-based interventions addressing gaps in the adolescent HIV care cascade, including supporting retention in care and adherence to ART.
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Affiliation(s)
- Leslie A Enane
- Department of Pediatrics, The Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Academic Model Providing Access to Healthcare (AMPATH)
| | - Rachel C Vreeman
- Department of Pediatrics, The Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Academic Model Providing Access to Healthcare (AMPATH).,Department of Child Health and Pediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Caroline Foster
- Departments of GUM/HIV and Pediatrics, Imperial College Healthcare NHS Trust, London, United Kingdom
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14
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The global epidemiology of adolescents living with HIV: time for more granular data to improve adolescent health outcomes. Curr Opin HIV AIDS 2019; 13:170-178. [PMID: 29432227 DOI: 10.1097/coh.0000000000000449] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to summarize recent evidence on the global epidemiology of adolescents (age 10-19 years) living with HIV (ALHIV), the burden of HIV on the health of adolescents and HIV-associated mortality. RECENT FINDINGS In 2016, there were an estimated 2.1 million (uncertainty bound 1.4-2.7 million) ALHIV; 770 000 younger (age 10-14 years) and 1.03 million older (age 15-19 years) ALHIV, 84% living in sub-Saharan Africa. The population of ALHIV is increasing, as more peri/postnatally infected ALHIV survive into older ages; an estimated 35% of older female ALHIV were peri/postnatally infected, compared with 57% of older male ALHIV. Although the numbers of younger ALHIV deaths are declining, deaths among older ALHIV have remained static since peaking in 2012. In 2015, HIV-associated mortality was the eighth leading cause of adolescent death globally and the fourth leading cause in African low and middle-income countries. SUMMARY Needed investments into characterizing and improving adolescent HIV-related health outcomes include strengthening systems for nationally and globally disaggregated data by age, sex and mode of infection; collecting more granular data within routine programmes to identify structural, social and mental health challenges to accessing testing and care; and prioritizing viral load monitoring and adolescent-focused differentiated models of care.
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15
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Ahmed I, Lemma S. Mortality among pediatric patients on HIV treatment in sub-Saharan African countries: a systematic review and meta-analysis. BMC Public Health 2019; 19:149. [PMID: 30717720 PMCID: PMC6360742 DOI: 10.1186/s12889-019-6482-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/25/2019] [Indexed: 12/29/2022] Open
Abstract
Background Despite substantial improvements in accessibility of Anti-Retroviral Treatment (ART), death of children on ART remains a prevailing challenge in sub-Saharan African (SSA) countries. However, the pooled magnitude of mortality at different ART follow-up periods remains unknown for the region. We estimated the pooled proportion of all-cause mortality for pediatric patients receiving first-line ART at 3, 6, 12, and 24 months follow-up period in SSA. Methods We searched for relevant articles published between January 2014 and June 2018 on PubMed, Hinari and Google scholar databases. We searched for additional articles from reference lists and 2014–2018 abstracts archived by the Conference on Retroviruses and Opportunistic Infections (CROI) and the International AIDS Society Conference on HIV Science (IAS). Results We reviewed 29 articles reporting mortality among pediatric ART patients at different follow-up periods in countries from 2001 to 2016. Among the 51,619 pediatric ART patients in these cohorts, studies reported 4061 (7.9%) all-cause cumulative death. The cumulative pooled proportion of mortality at 3, 6, 12 and 24 months of ART were 3% (95% CI: 3.0–4.0), 5% (95% CI: 4.0–6.0), 6% (95% CI: 5.0–7.0) and 7% (95% CI: 6.0–8.0), respectively. Conclusions In SSA, significant proportion of mortality among children occurs in the first 3–6 months of ART initiation. Western Africa has a little higher estimate of mortality among pediatric ART patients at 6 and 12 months of follow-up. Strategies to prevent early mortality including thorough screening and management of opportunistic infections before ART initiation are needed. Electronic supplementary material The online version of this article (10.1186/s12889-019-6482-1) contains supplementary material, which is available to authorized users.
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16
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Enane LA, Davies MA, Leroy V, Edmonds A, Apondi E, Adedimeji A, Vreeman RC. Traversing the cascade: urgent research priorities for implementing the 'treat all' strategy for children and adolescents living with HIV in sub-Saharan Africa. J Virus Erad 2018; 4:40-46. [PMID: 30515313 PMCID: PMC6248846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Children and adolescents living with HIV (CALHIV) in sub-Saharan Africa experience significant morbidity and alarmingly high mortality rates due to critical gaps in the HIV care cascade, including late diagnosis and initiation of treatment, as well as poor retention in care and adherence to treatment. Interventions to strengthen the adult HIV care cascade may not be as effective in improving the cascade for CALHIV, for whom specific strategies are needed. Particular attention needs to be paid to the contexts of sub-Saharan Africa, where more than 85% of the world's CALHIV live. Implementing the 'treat all' strategy in sub-Saharan Africa requires dedicated efforts to address the unique diagnosis and care needs of CALHIV, in order to improve paediatric and adolescent outcomes, prevent viral resistance and reduce the number of new HIV infections. We consider the UNAIDS 90-90-90 targets from the perspective of infants, children and adolescents, and discuss the key challenges, knowledge gaps and urgent research priorities for CALHIV in implementation of the 'treat all' strategy in sub-Saharan Africa.
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Affiliation(s)
- Leslie A Enane
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine,
Indianapolis, IN,
USA,Corresponding author:
Leslie Enane, 1044 W Walnut Street, Room 402A,
Indianapolis,
Indiana,
46202,
USA
| | - Mary-Ann Davies
- Center for Infectious Disease Epidemiology and Research, University of Cape Town,
South Africa
| | - Valériane Leroy
- Inserm (French Institute of Health and Medical Research), UMR 1027, Université Toulouse 3,
France
| | - Andrew Edmonds
- Department of Epidemiology, University of North Carolina at Chapel Hill,
NC,
USA
| | - Edith Apondi
- Moi Teaching and Referral Hospital,
Eldoret,
Kenya
| | - Adebola Adedimeji
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine,
Bronx, NY,
USA
| | - Rachel C Vreeman
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine,
Indianapolis, IN,
USA
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17
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Enane LA, Davies MA, Leroy V, Edmonds A, Apondi E, Adedimeji A, Vreeman RC. Traversing the cascade: urgent research priorities for implementing the ‘treat all’ strategy for children and adolescents living with HIV in sub-Saharan Africa. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30344-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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18
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CD4+ cell count recovery following initiation of HIV antiretroviral therapy in older childhood and adolescence. AIDS 2018; 32:1977-1982. [PMID: 29927784 PMCID: PMC6125740 DOI: 10.1097/qad.0000000000001905] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text Objective: To investigate CD4+ cell count recovery following ART initiation in perinatally HIV-infected children diagnosed in later childhood. Design: Observational prospective cohort study of newly diagnosed children aged 6–15 in Harare, Zimbabwe. Methods: Participants were enrolled into a cohort at seven primary healthcare clinics between January 2013 and January 2015. ART was initiated according to national guidelines and CD4+ cell counts were performed 6-monthly over 18 months. The relationship between CD4+ cell count and time on ART was investigated using regression analysis with fixed (population) and random (individual) effects, and age at ART initiation as a covariate. Results: Of the 307 participants who initiated ART, the median age at initiation was 11.7 years (interquartile range 9.6–13.8). The addition of an individual intercept and slope as random effects significantly improved the model fit compared with a fixed effects-only model. CD4+ response (using a square-root transformation) was best modelled using a two-knot linear spline, with significant effects of time on ART and age at ART initiation. Younger children had a higher CD4+ cell count at ART initiation (−17.9 cells/μl per year of age), an accelerated increase during the first 3 months on ART (−38.9 cells/μl per year of age at day 84), and a sustained higher CD4+ cell count. Conclusion: Earlier ART initiation in older children is associated with accelerated CD4+ cell count recovery and lasting immune reconstitution. Our findings support WHO guidance recommending ART initiation in all children, irrespective of disease stage and CD4+ cell count.
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Chandiwana N, Sawry S, Chersich M, Kachingwe E, Makhathini B, Fairlie L. High loss to follow-up of children on antiretroviral treatment in a primary care HIV clinic in Johannesburg, South Africa. Medicine (Baltimore) 2018; 97:e10901. [PMID: 30024494 PMCID: PMC6086461 DOI: 10.1097/md.0000000000010901] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Outcomes of HIV-infected children have improved dramatically over the past decade, but are undermined by patient loss to follow-up (LTFU). We assessed patterns of LTFU among HIV-infected children receiving antiretroviral treatment (ART) at a large inner-city HIV clinic in Johannesburg, South Africa between 2005 and 2014.Demographic and clinical data were extracted from clinic records of children under 12 years. Differences between characteristics of children retained in care and LTFU were assessed using Wilcoxon rank sum tests or Pearson χ tests. Cox proportional hazard models then identified characteristics associated with LTFU.Of 135 children, the median age at ART initiation was 21.5 months (IQR: 6.3-47.7) with a median follow-up time of 3.3 years (IQR: 1.4-5.0). The incidence rate of LTFU was 10.8 per 100 person-years (95% CI: 8.2-14.4); cumulatively 36% of children were LTFU. Almost a third (n = 39) of children missed a clinic visit, but then returned to care; 77% of these were eventually LTFU. In total, 18% of children had elevated viral loads after 6 or more months of ART. Older age at ART initiation (18-59 months: aHR 1.6, 95% CI: 3.9-14.2) and ever missing a clinic visit (aHR 7.4 95% CI: 3.9-14.2) were independent predictors of LTFU.High rates of LTFU were observed in this primary care clinic. Risks for LTFU included older age (>18 months old) and missed clinic visits. Identifying children who miss scheduled visits and developing strategies directed at retaining them in care is critical to improving long-term pediatric HIV outcomes.
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Affiliation(s)
- Nomathemba Chandiwana
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | - Shobna Sawry
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | - Matthew Chersich
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | - Elizabeth Kachingwe
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | | | - Lee Fairlie
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
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