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Lauren E, Shumba K, Fox MP, MacLeod W, Stevens W, Mlisana K, Bor J, Onoya D. The fall-And rise-In hospital-based care for people with HIV in South Africa: 2004-2017. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002127. [PMID: 39236028 PMCID: PMC11376578 DOI: 10.1371/journal.pgph.0002127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/12/2024] [Indexed: 09/07/2024]
Abstract
ART scale-up has reduced HIV mortality in South Africa. However, less is known about trends in hospital-based HIV care, which is costly and may indicate HIV-related morbidity. We assessed trends in hospital-based HIV care using the National Health Laboratory Service (NHLS) National HIV Cohort. Our study included all adults ≥18 years receiving care in South Africa's public sector HIV program from 2004 to 2017 with at least one CD4 count/viral load test in the NHLS database. We compared trends in the number of patients presenting for and receiving HIV care by facility type: hospitals vs. primary care clinics. We then assessed trends and predictors of incident hospitalization, defined as 2 or more hospital-based lab tests taken within 7 days. Finally, we assessed whether trends in incident hospitalizations could be explained by changes in patient demographics, CD4 counts, or facility type at presentation. Data were analyzed on 9,624,951 patients. The percentage of patients presenting and receiving HIV care at hospitals (vs. clinics) declined over time, from approximately 60% in 2004 to 15% in 2017. Risk of hospitalization declined for patients entering care between 2004-2012 and modestly increased for patients entering care after 2012. The risk of hospitalization declined the most in age groups most affected by HIV. Over time, patients presented with higher CD4 counts and were more likely to present at clinics, and these changes explained almost half the decline in hospitalizations. The percentage of HIV care provided in hospitals declined as patients presented in better health and as treatment was increasingly managed at clinics. However, there may still be opportunities to reduce incident hospitalizations in people with HIV.
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Affiliation(s)
- Evelyn Lauren
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Khumbo Shumba
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - William MacLeod
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Wendy Stevens
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu Natal, Durban, South Africa
| | - Koleka Mlisana
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu Natal, Durban, South Africa
- National Health Laboratory Service, Johannesburg, South Africa
| | - Jacob Bor
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Dorina Onoya
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Lippman SA, Grignon JS, Ditshwane B, West RL, Gilmore HJ, Mazibuko S, Mongwe LG, Neilands TB, Gutin SA, O’Connor C, Santana MA, Majam M. Results of the Sukuma Ndoda ("Stand up, Man") HIV Self-Screening and Assisted Linkage to Care Project in Johannesburg: A Quasi-Experimental Pre-Post Evaluation. J Acquir Immune Defic Syndr 2024; 96:367-375. [PMID: 38916430 PMCID: PMC11195924 DOI: 10.1097/qai.0000000000003442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 04/11/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND HIV testing rates among South African men lag behind rates for women and national targets. Community-based HIV self-screening (HIVSS) distribution and follow-up by community health workers (CHWs) is a scalable option to increase testing coverage, diagnosis, and treatment initiation. We provided HIVSS and assisted linkage to care to men not recently tested (within the past 12 months) residing in high-HIV-burden areas of Johannesburg. METHODS CHWs distributed HIVSS in 6 clinic catchment areas. Follow-up to encourage confirmatory testing and antiretroviral therapy initiation was conducted through personal support (PS) or an automated short message service (SMS) follow-up and linkage system in 3 clinic areas each. Using a quasi-experimental pre-post design, we compared differences in the proportion of men testing in the clinic catchment areas during the HIVSS campaign (June-August 2019) to the 3 months prior (March-May 2019) and compared treatment initiations by assisted linkage strategy. RESULTS Among 4793 participants accepting HIVSS, 62% had never tested. Among 3993 participants with follow-up data, 90.6% reported using their HIVSS kit. Testing coverage among men increased by 156%, from under 4% when only clinic-based HIV testing services were available to 9.5% when HIVSS and HIV testing services were available (z = -11.6; P < 0.01). Reported test use was higher for men followed through PS (99% vs. 68% in SMS); however, significantly more men reported reactive self-test results in the SMS group compared with PS (6.4% vs. 2.0%), resulting in more antiretroviral therapy initiations in the SMS group compared with PS (23 vs. 9; P < 0.01). CONCLUSIONS CHW HIVSS distribution significantly increases testing among men. While PS enabled personalized follow-up, reporting differences indicate SMS is more acceptable and better aligned with expectations of privacy associated with HIVSS.
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Affiliation(s)
- Sheri A. Lippman
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Jessica S. Grignon
- International Training and Education Center for Health (I-TECH), Pretoria, South Africa
- Department of Global Health, University of Washington, Seattle, WA
| | - Boitumelo Ditshwane
- International Training and Education Center for Health (I-TECH), Pretoria, South Africa
| | - Rebecca L. West
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Hailey J. Gilmore
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Sipho Mazibuko
- International Training and Education Center for Health (I-TECH), Pretoria, South Africa
| | - Livhuwani G. Mongwe
- International Training and Education Center for Health (I-TECH), Pretoria, South Africa
| | - Torsten B. Neilands
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Sarah A. Gutin
- Department of Medicine, University of California, San Francisco, San Francisco, CA
- School of Nursing, University of California, San Francisco, San Francisco, CA
| | | | - Maideline A. Santana
- Gauteng Department of Health, Johannesburg District, Johannesburg, South Africa; and
| | - Mohammed Majam
- Ezintsha, University of Witwatersrand, Johannesburg, South Africa
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Mody A, Sohn AH, Iwuji C, Tan RKJ, Venter F, Geng EH. HIV epidemiology, prevention, treatment, and implementation strategies for public health. Lancet 2024; 403:471-492. [PMID: 38043552 DOI: 10.1016/s0140-6736(23)01381-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/28/2023] [Accepted: 06/29/2023] [Indexed: 12/05/2023]
Abstract
The global HIV response has made tremendous progress but is entering a new phase with additional challenges. Scientific innovations have led to multiple safe, effective, and durable options for treatment and prevention, and long-acting formulations for 2-monthly and 6-monthly dosing are becoming available with even longer dosing intervals possible on the horizon. The scientific agenda for HIV cure and remission strategies is moving forward but faces uncertain thresholds for success and acceptability. Nonetheless, innovations in prevention and treatment have often failed to reach large segments of the global population (eg, key and marginalised populations), and these major disparities in access and uptake at multiple levels have caused progress to fall short of their potential to affect public health. Moving forward, sharper epidemiologic tools based on longitudinal, person-centred data are needed to more accurately characterise remaining gaps and guide continued progress against the HIV epidemic. We should also increase prioritisation of strategies that address socio-behavioural challenges and can lead to effective and equitable implementation of existing interventions with high levels of quality that better match individual needs. We review HIV epidemiologic trends; advances in HIV prevention, treatment, and care delivery; and discuss emerging challenges for ending the HIV epidemic over the next decade that are relevant for general practitioners and others involved in HIV care.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.
| | - Annette H Sohn
- TREAT Asia, amfAR, The Foundation for AIDS Research, Bangkok, Thailand
| | - Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Rayner K J Tan
- University of North Carolina Project-China, Guangzhou, China; Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
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Perks M, Reddy DL, Venter F. Outcomes and characteristics of patients on protease inhibitors at a tertiary level antiretroviral clinic. South Afr J HIV Med 2023; 24:1536. [PMID: 38222309 PMCID: PMC10784224 DOI: 10.4102/sajhivmed.v24i1.1536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/13/2023] [Indexed: 01/16/2024] Open
Abstract
Background Protease inhibitors (PIs) have been recommended as World Health Organization second-line antiretroviral therapy (ART) for low- to middle-income countries for two decades. As dolutegravir-based regimens have become widely available, the future role of PIs is uncertain. Objectives To describe the characteristics of patients on PI-based ART (in first-line and second-line regimens), double-boosted protease inhibitors (DBPI) and patients who received recycled nucleoside reverse transcriptase inhibitors (NRTI) in second-line regimens at a tertiary level ART clinic. Method We conducted a descriptive retrospective record review of adult patients on PI-based ART who attended Nthabiseng Adult Infectious Diseases Clinic at Chris Hani Baragwanath Academic Hospital in Soweto, South Africa, between January 2021 and April 2022. Results Of the 900 patients sampled, 543 (60.3%) were female, the median age was 45 and 703 (79.1%) had viral loads (VL) below 1000 copies/mL. In contrast, 21 (58.3%) of 36 vertically infected patients had VLs below 1000 copies/mL. Thirty-seven (4.1%) patients were on DBPIs. The commonest reason for DBPI use in 24 (64.9%) patients was drug resistance test (DRT)-guided switch after virological failure. Forty-nine (5.4%) patients were on recycled NRTIs with no DRT, and 24 (2.6%) patients were on NRTIs to which there was documented resistance. Outcomes for these patients were similar to the total sample. Conclusion PIs have long been a cornerstone of second-line ART. This study demonstrates the real-world utility of PIs, as well as their disadvantages. There was no difference in the outcomes of patients who received recycled NRTIs in second-line regimens.
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Affiliation(s)
- Michele Perks
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denasha L. Reddy
- Department of Internal Medicine and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Francois Venter
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Mbokazi N, van Pinxteren M, Murphy K, Mair FS, May CR, Levitt NS. Ubuntu as a mediator in coping with multimorbidity treatment burden in a disadvantaged rural and urban setting in South Africa. Soc Sci Med 2023; 334:116190. [PMID: 37659263 DOI: 10.1016/j.socscimed.2023.116190] [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: 02/02/2023] [Revised: 08/12/2023] [Accepted: 08/22/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND People living with multimorbidity in economically precarious circumstances in low- and middle-income countries (LMICs) experience a high workload trying to meet self-management demands. However, in countries such as South Africa, the availability of social networks and support structures may improve patient capacity, especially when networks are governed by cultural patterns linked to the Pan-African philosophy of Ubuntu, which promotes solidarity through humanness and human dignity. We explore the mediating role Ubuntu plays in people's ability to self-manage HIV/NCD multimorbidity in underprivileged settings in urban and rural South Africa. METHODS We conducted semi-structured interviews with 30 patients living with HIV/NCD multimorbidity between February-April 2022. Patients attended public health clinics in Gugulethu, Cape Town and Bulungula, Eastern Cape. We analysed interviews using framework analysis, using the Cumulative Complexity Model (CuCoM) and Burden of Treatment Theory (BoTT) as frameworks through which to conceptualise the data. RESULTS Despite facing economic hardship, people with multimorbidity in South Africa were able to cope with their workload. They actively used and mobilized family relations and external networks that supported them financially, practically, and emotionally, allowing them to better self-manage their chronic conditions. Embedded in their everyday life, patients, often unconsciously, embraced Ubuntu and its core values, including togetherness, solidarity, and receiving Imbeko (respect) from health workers. This enabled participants to share their treatment workload and increase self-management capacity. CONCLUSION Ubuntu is an important mediator for people living with multimorbidity in South Africa, as it allows them to navigate their treatment workload and increase their social capital and structural resilience, which is key to self-management capacity. Incorporating Ubuntu and linked African support theories into current treatment burden models will enable better understandings of patients' collective support and can inform the development of context-specific social health interventions that fit the needs of people living with chronic conditions in African settings.
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Affiliation(s)
- Nonzuzo Mbokazi
- Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, South Africa
| | - Myrna van Pinxteren
- Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, South Africa.
| | - Katherine Murphy
- Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, South Africa
| | - Frances S Mair
- Institute of Health and Well-Being, University of Glasgow, Scotland, UK
| | - Carl R May
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, NIHR North Thames Applied Research Collaboration, UK
| | - Naomi S Levitt
- Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, South Africa
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Quach LT, Ritchie CS, Tsai AC, Reynolds Z, Paul R, Seeley J, Tong Y, Hoeppner S, Okello S, Nakasujja N, Olivieri-Mui B, Saylor D, Greene M, Asiimwe S, Siedner MJ. The benefits of care: treated HIV infection and health-related quality of life among older-aged people in Uganda. Aging Ment Health 2023; 27:1853-1859. [PMID: 36503332 PMCID: PMC10258228 DOI: 10.1080/13607863.2022.2150143] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/16/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The objective of this study is to explore how HIV care affects health-related quality of life (HRQoL) among older people in Uganda. METHODS We enrolled older-aged (≥49 years) people with HIV receiving HIV care and treatment, along with age- and sex-similar people without HIV. We measured health-related quality of life using the EQ-5D-3L scale. RESULTS People with HIV (n = 298) and people without HIV (n = 302) were similar in median age (58.4 vs. 58.5 years), gender, and number of comorbidities. People with HIV had higher self-reported health status (b = 7.0; 95% confidence interval [CI], 4.2-9.7), higher EQ-5D utility index (b = 0.05; 95% CI, 0.02-0.07), and were more likely to report no problems with self-care (adjusted odds ratio [AOR], 2.0; 95% CI, 1.2-3.3) or pain/discomfort (AOR = 1.8, 95% CI, 1.3-2.8). Relationships between HIV serostatus and health-related quality of life differed by gender, but not age. CONCLUSIONS Older people with HIV receiving care and treatment reported higher health-related quality of life than people without HIV in Uganda. Access to primary care through HIV programs and/or social network mobilization may explain this difference, but further research is needed to elucidate the mechanisms.
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Affiliation(s)
- Lien T Quach
- Medical Practice Evaluation Center, Massachusetts General Hospital, MA, USA
- Centre for Aging and Serious Illness, Massachusetts General Hospital, MA, USA
- Department of Gerontology, University of Massachusetts Boston, MA, USA
| | - Christine S Ritchie
- Centre for Aging and Serious Illness, Massachusetts General Hospital, MA, USA
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, MA, USA
| | - Alexander C Tsai
- Department of Medicine, Harvard Medical School, Harvard University, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, MA, USA
- Faculty of Medicine, Mbarara University of Science and Technology in Mbarara, Uganda
| | - Zahra Reynolds
- Medical Practice Evaluation Center, Massachusetts General Hospital, MA, USA
| | - Robert Paul
- Missouri Institute of Mental Health University of Missouri - St Louis, MO, USA
| | - Janet Seeley
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Yao Tong
- Medical Practice Evaluation Center, Massachusetts General Hospital, MA, USA
| | - Susanne Hoeppner
- Medical Practice Evaluation Center, Massachusetts General Hospital, MA, USA
- Department of Medicine, Harvard Medical School, Harvard University, MA, USA
| | - Samson Okello
- Faculty of Medicine, Mbarara University of Science and Technology in Mbarara, Uganda
- Department of Epidemiology, University of North Carolina, NC, USA
| | - Noeline Nakasujja
- Department of Psychiatry, the College of Health Sciences, Makerere University, Uganda
| | | | - Deanna Saylor
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Meredith Greene
- Department of Medicine, University of California, San Francisco, USA
| | - Stephen Asiimwe
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
- Kabwohe Clinical Research Center (KCRC), Kabwohe, Uganda
- Center for Global Health, Massachusetts General Hospital, MA, USA
| | - Mark J Siedner
- Medical Practice Evaluation Center, Massachusetts General Hospital, MA, USA
- Department of Medicine, Harvard Medical School, Harvard University, MA, USA
- Faculty of Medicine, Mbarara University of Science and Technology in Mbarara, Uganda
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van Pinxteren M, Mbokazi N, Murphy K, Mair FS, May C, Levitt N. The impact of persistent precarity on patients' capacity to manage their treatment burden: A comparative qualitative study between urban and rural patients with multimorbidity in South Africa. Front Med (Lausanne) 2023; 10:1061190. [PMID: 37064034 PMCID: PMC10098191 DOI: 10.3389/fmed.2023.1061190] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 03/07/2023] [Indexed: 04/18/2023] Open
Abstract
Background People living with multimorbidity in low-and middle-income countries (LMICs) experience a high workload trying to meet the demands of self-management. In an unequal society like South Africa, many people face continuous economic uncertainty, which can impact on their capacity to manage their illnesses and lead to poor health outcomes. Using precariousness - the real and perceived impact of uncertainty - as a lens, this paper aims to identify, characterise, and understand the workload and capacity associated with self-management amongst people with multimorbidity living in precarious circumstances in urban and rural South Africa. Methods We conducted qualitative semi-structured interviews with 30 patients with HIV and co-morbidities between February and April 2021. Patients were attending public clinics in Cape Town (Western Cape) and Bulungula (Eastern Cape). Interviews were transcribed and data analysed using qualitative framework analysis. Burden of Treatment Theory (BoTT) and the Cumulative Complexity Model (CuCoM) were used as theoretical lenses through which to conceptualise the data. Results People with multimorbidity in rural and urban South Africa experienced multi-faceted precariousness, including financial and housing insecurity, dangerous living circumstances and exposure to violence. Women felt unsafe in their communities and sometimes their homes, whilst men struggled with substance use and a lack of social support. Older patients relied on small income grants often shared with others, whilst younger patients struggled to find stable employment and combine self-management with family responsibilities. Precariousness impacted access to health services and information and peoples' ability to buy healthy foods and out-of-pocket medication, thus increasing their treatment burden and reducing their capacity. Conclusion This study highlights that precariousness reduces the capacity and increases treatment burden for patients with multimorbidity in low-income settings in South Africa. Precariousness is both accumulative and cyclic, as financial insecurity impacts every aspect of peoples' daily lives. Findings emphasise that current models examining treatment burden need to be adapted to accommodate patients' experiences in low-income settings and address cumulative precariousness. Understanding treatment burden and capacity for patients in LMICs is a crucial first step to redesign health systems which aim to improve self-management and offer comprehensive person-centred care.
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Affiliation(s)
- Myrna van Pinxteren
- Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Nonzuzo Mbokazi
- Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Katherine Murphy
- Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Frances S. Mair
- School of Health and Well-Being, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Carl May
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- NIHR North Thames Applied Research Collaboration, London, United Kingdom
| | - Naomi Levitt
- Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Singsumran K, Sungkanuparph S. Long-term virological and immunological outcomes between HIV-positive individuals with and without pretreatment HIV drug resistance. Int J STD AIDS 2023; 34:322-327. [PMID: 36626357 DOI: 10.1177/09564624221149775] [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: 01/11/2023]
Abstract
BACKGROUND Pretreatment HIV drug resistance (PHDR) has emerged after scaling-up access to antiretroviral therapy (ART). This study aimed to compare long-term virological and immunological outcomes between HIV-positive individuals with and without PHDR. METHODS An observational cohort study was conducted in HIV-positive individuals who had a genotypic resistance test performed prior to ART initiation. RESULTS Of 335 participants, 39 were in the PHDR group and 296 were in the control group. ART regimen in PHDR group was adjusted at 6-10 weeks after ART initiation when results of baseline genotypic resistance test were available. Proportions of participants with undetectable viral load were significantly lower in PHDR group at 6 and 12 months (46.2% vs 79.4% (p < .001) and 74.4% vs 90.5% (p = .003), respectively). These virological responses became similar between two groups (p > .05) from 18 through 60 months. Mean change of CD4 counts of PHDR group was significantly lower only at 6 months (+59 vs + 81 cells/mm3 (p = .012); these immunological responses were similar between two groups from 12 through 60 months. CONCLUSION Early virological response was lower in HIV-positive participants with PHDR compared to participants without PHDR. Subsequent adjustment of ART according to pretreatment genotypic resistance has contributed to the long-term virological and immunological success that is similar to participants without PHDR.
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Affiliation(s)
- Kanokwan Singsumran
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Somnuek Sungkanuparph
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, 26685Mahidol University, Samut Prakan, Thailand
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van Pinxteren M, Mbokazi N, Murphy K, Mair FS, May C, Levitt NS. Using qualitative study designs to understand treatment burden and capacity for self-care among patients with HIV/NCD multimorbidity in South Africa: A methods paper. JOURNAL OF MULTIMORBIDITY AND COMORBIDITY 2023; 13:26335565231168041. [PMID: 37057034 PMCID: PMC10088413 DOI: 10.1177/26335565231168041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
Background Low- and middle-income countries (LMICs), including South Africa, are currently experiencing multiple epidemics: HIV and the rising burden of non-communicable diseases (NCDs), leading to different patterns of multimorbidity (the occurrence of two or more chronic conditions) than experienced in high income settings. These adversely affect health outcomes, increase patients' perceived burden of treatment, and impact the workload of self-management. This paper outlines the methods used in a qualitative study exploring burden of treatment among people living with HIV/NCD multimorbidity in South Africa. Methods We undertook a comparative qualitative study to examine the interaction between individuals' treatment burden (self-management workload) and their capacity to take on this workload, using the dual lenses of Burden of Treatment Theory (BoTT) and Cumulative Complexity Model (CuCoM) to aid conceptualisation of the data. We interviewed 30 people with multimorbidity and 16 carers in rural Eastern Cape and urban Cape Town between February-April 2021. Data was analysed through framework analysis. Findings This paper discusses the methodological procedures considered when conducting qualitative research among people with multimorbidity in low-income settings in South Africa. We highlight the decisions made when developing the research design, recruiting participants, and selecting field-sites. We also explore data analysis processes and reflect on the positionality of the research project and researchers. Conclusion This paper illustrates the decision-making processes conducting this qualitative research and may be helpful in informing future research aiming to qualitatively investigate treatment burden among patients in LMICs.
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Affiliation(s)
- Myrna van Pinxteren
- Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, South Africa
| | - Nonzuzo Mbokazi
- Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, South Africa
| | - Katherine Murphy
- Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, South Africa
| | - Frances S Mair
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK; NIHR North Thames Applied Research Collaboration, London, UK
| | - Carl May
- School of Health and Well-Being, College of Medical, Veterinary and Life Sciences, University of Glasgow, Scotland, UK
| | - Naomi S Levitt
- Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, South Africa
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Leslie HH, Mooney AC, Gilmore HJ, Agnew E, Grignon JS, deKadt J, Shade SB, Ratlhagana MJ, Sumitani J, Barnhart S, Steward WT, Lippman SA. Prevalence, motivation, and outcomes of clinic transfer in a clinical cohort of people living with HIV in North West Province, South Africa. BMC Health Serv Res 2022; 22:1584. [PMID: 36572869 PMCID: PMC9791728 DOI: 10.1186/s12913-022-08962-8] [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: 09/07/2022] [Accepted: 12/13/2022] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Continuity of care is an attribute of high-quality health systems and a necessary component of chronic disease management. Assessment of health information systems for HIV care in South Africa has identified substantial rates of clinic transfer, much of it undocumented. Understanding the reasons for changing sources of care and the implications for patient outcomes is important in informing policy responses. METHODS In this secondary analysis of the 2014 - 2016 I-Care trial, we examined self-reported changes in source of HIV care among a cohort of individuals living with HIV and in care in North West Province, South Africa. Individuals were enrolled in the study within 1 year of diagnosis; participants completed surveys at 6 and 12 months including items on sources of care. Clinical data were extracted from records at participants' original clinic for 12 months following enrollment. We assessed frequency and reason for changing clinics and compared the demographics and care outcomes of those changing and not changing source of care. RESULTS Six hundred seventy-five (89.8%) of 752 study participants completed follow-up surveys with information on sources of HIV care; 101 (15%) reported receiving care at a different facility by month 12 of follow-up. The primary reason for changing was mobility (N=78, 77%). Those who changed clinics were more likely to be young adults, non-citizens, and pregnant at time of diagnosis. Self-reported clinic attendance and ART adherence did not differ based on changing clinics. Those on ART not changing clinics reported 0.66 visits more on average than were documented in clinic records. CONCLUSION At least 1 in 6 participants in HIV care changed clinics within 2 years of diagnosis, mainly driven by mobility; while most appeared lost to follow-up based on records from the original clinic, self-reported visits and adherence were equivalent to those not changing clinics. Routine clinic visits could incorporate questions about care at other locations as well as potential relocation, particularly for younger, pregnant, and non-citizen patients, to support existing efforts to make HIV care records portable and facilitate continuity of care across clinics. TRIAL REGISTRATION The original trial was registered with ClinicalTrials.gov , NCT02417233, on 12 December 2014.
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Affiliation(s)
- Hannah H. Leslie
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Alyssa C. Mooney
- Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA USA
| | - Hailey J. Gilmore
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Emily Agnew
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Jessica S. Grignon
- Department of Global Health, University of Washington, Seattle, WA USA
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Julia deKadt
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Starley B. Shade
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Mary Jane Ratlhagana
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Jeri Sumitani
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, WA USA
| | - Wayne T. Steward
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Sheri A. Lippman
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
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11
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Lowane MP, Lebese RT. Why adult patients on antiretroviral therapy miss clinical appointments in rural villages of Limpopo Province, South Africa: An exploratory study. Health SA 2022; 27:1989. [DOI: 10.4102/hsag.v27i0.1989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/15/2022] [Indexed: 11/07/2022] Open
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12
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The health impact of free access to antiretroviral therapy in South Africa. Soc Sci Med 2022; 299:114832. [PMID: 35290814 DOI: 10.1016/j.socscimed.2022.114832] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 01/16/2023]
Abstract
Since 2004 the South African government has rolled out free antiretroviral therapy (ART) at public health care facilities nationwide. No prior studies have estimated the impact of the ART rollout on health and survival using a longitudinal household survey with national coverage. We match household member deaths and self-assessed health from a large national longitudinal survey to community-level ART availability in clinics to estimate the reduction in mortality and morbidity attributable to ART availability between 2006 and 2016, using a difference-in-difference model. Our analysis focuses on black Africans aged 25-49 because this demographic group represents more than two-thirds of all South African HIV cases. We find that the rollout of free ART has reduced annual mortality by 27% and decreased the likelihood of reporting poor health by 36% for black Africans aged 25-49. These estimates amount to annual reductions in this demographic category of 31% in annual mortality and 47% in individuals reporting poor health. Our findings confirm that making ART treatment freely available nationwide has had a dramatic impact in terms of both prolonged survival and improved health, with most of these gains concentrated in the high HIV prevalence group of black Africans aged 25-49.
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13
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Nardell MF, Adeoti O, Peters C, Kakuhikire B, Govathson-Mandimika C, Long L, Pascoe S, Tsai AC, Katz IT. Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis. J Int AIDS Soc 2022; 25:e25889. [PMID: 35324089 PMCID: PMC8944222 DOI: 10.1002/jia2.25889] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 02/01/2022] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Men are missing along the HIV care continuum. However, the estimated proportions of men in sub-Saharan Africa meeting the UNAIDS 95-95-95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95-95-95 goals across studies in sub-Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement. METHODS We systematically searched PubMed and Embase for peer-reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95-95-95 goal in sub-Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion-Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta-synthesis. RESULTS AND DISCUSSION We screened 14,896 studies and included 129 studies in the meta-analysis, compiling data over the data collection period. Forty-seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41-0.58; range, 0.09-0.97]) or not being on treatment (0.58 [95% CI, 0.51-0.65; range, 0.07-0.97]), while over three-quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77-0.81; range, 0.39-0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta-synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty. CONCLUSIONS Psychosocial and systems-level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.
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Affiliation(s)
- Maria F Nardell
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Oluwatomi Adeoti
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Carson Peters
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Bernard Kakuhikire
- Faculty of Business and Management Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Caroline Govathson-Mandimika
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Alexander C Tsai
- Harvard Medical School, Boston, Massachusetts, USA
- Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Global Health Institute, Cambridge, Massachusetts, USA
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14
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Chimoyi L, Chikovore J, Musenge E, Mabuto T, Chetty-Makkan CM, Munyai R, Nchachi T, Charalambous S, Setswe G. Understanding factors influencing utilization of HIV prevention and treatment services among patients and providers in a heterogeneous setting: A qualitative study from South Africa. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000132. [PMID: 36962320 PMCID: PMC10021737 DOI: 10.1371/journal.pgph.0000132] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 11/29/2021] [Indexed: 12/16/2022]
Abstract
Despite advances made in HIV prevention and treatment interventions in South Africa, barriers to their utilization continue to exist. Understanding perspectives from patients and providers of healthcare can shed light on the necessary strategies to enhance uptake of HIV services. A cross-sectional qualitative study was conducted in July 2020 in Ekurhuleni District. Based on HIV prevalence estimates from a national survey, male condom use coverage and antiretroviral treatment (ART) initiation rates from routinely collected clinical data for 2012, we selected facilities from geographical areas with varying HIV prevalence and uptake of HIV services. In-depth interviews were conducted with adult (≥18 years) patients and healthcare workers in selected primary healthcare facilities. Thematic analysis was performed following a framework built around the social cognitive theory to describe behavioural, personal, and social/environmental factors influencing utilization of HIV services. Behavioural factors facilitating uptake of HIV services included awareness of the protective value of condoms, and the benefits of ART in suppressing viral load and preventing mother-to-child HIV transmission which was evident across geographical areas. Barriers in high prevalence areas included suboptimal condom use, fears of a positive HIV result, and anticipated HIV-related stigma while seeking healthcare services. Across the geographical areas, personal factors included ability to correctly use available services enhanced by knowledge acquired during counselling sessions and community-based health promotion activities. Further, social support from family reinforced engagement in care. Compared to low uptake areas, clinics in high uptake areas used care-facilitators, outreach teams and decanting programs to address the environmental barriers including staff shortages and long queues. Barriers at multiple levels prevent optimal utilization of HIV services, calling for strategies that target and address the different levels and tailored to needs of specific settings. Overall, improved delivery of HIV prevention or treatment interventions can be achieved through strengthening training of healthcare providers in facilities and communities and addressing negative sequelae from utilising services in low uptake areas.
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Affiliation(s)
- Lucy Chimoyi
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Jeremiah Chikovore
- Human and Social Capabilities Research Division, Human Sciences Research Council, Durban, South Africa
| | - Eustasius Musenge
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Tonderai Mabuto
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
| | - Candice M Chetty-Makkan
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Reuben Munyai
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
| | - Tshegang Nchachi
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
| | - Salome Charalambous
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Geoffrey Setswe
- Implementation Research Division, The Aurum Institute, Johannesburg, South Africa
- Department of Health Studies, University of South Africa, Pretoria, South Africa
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15
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Bassett IV, Xu A, Giddy J, Bogart LM, Boulle A, Millham L, Losina E, Parker RA. Changing contextual factors from baseline to 9-months post-HIV diagnosis predict 5-year mortality in Durban, South Africa. AIDS Care 2021; 33:1543-1550. [PMID: 33138630 PMCID: PMC8088454 DOI: 10.1080/09540121.2020.1837338] [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: 03/04/2020] [Accepted: 10/06/2020] [Indexed: 10/23/2022]
Abstract
Changes in an individual's contextual factors following HIV diagnosis may influence long-term outcomes. We evaluated how changes to contextual factors between HIV diagnosis and 9-month follow-up predict 5-year mortality among HIV-infected individuals in Durban, South Africa enrolled in the Sizanani Trial (NCT01188941). We used random survival forests to identify 9-month variables and changes from baseline predictive of time to mortality. We incorporated these into a Cox proportional hazards model including age, sex, and starting ART by 9 months a priori, 9-month social support and competing needs, and changes in mental health between baseline and 9 months. Among 1,154 participants with South African ID numbers, 900 (78%) had baseline and 9-month data available of whom 109 (12%) died after 9-month follow-up. Those who reported less social support at 9 months had a 16% higher risk of mortality. Participants who went without basic needs or healthcare at 9 months had a 2.6 times higher hazard of death compared to participants who did not. Low social support and competing needs at 9-month follow-up substantially increase long-term mortality risk. Reassessing contextual factors during follow-up and targeting interventions to increase social support and affordability of care may reduce long-term mortality for HIV-infected individuals in South Africa.
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Affiliation(s)
- Ingrid V. Bassett
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard University Center for AIDS Research, Harvard University, Boston, MA, USA
| | - Ai Xu
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Andrew Boulle
- Centre for Infectious Diseases, Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town
| | - Lucia Millham
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Elena Losina
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Robert A. Parker
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard University Center for AIDS Research, Harvard University, Boston, MA, USA
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
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16
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Bruns C. Using Human-Centered Design to Develop a Program to Engage South African Men Living With HIV in Care and Treatment. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:S234-S243. [PMID: 34845047 PMCID: PMC8628503 DOI: 10.9745/ghsp-d-21-00239] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/26/2021] [Indexed: 01/05/2023]
Abstract
Human-centered design (HCD) is a useful methodology for understanding the lived realities, needs, and preferences of men living with HIV and engaging them in the design and pilot of a peer-support program to support their engagement in care. Background: Although HIV care is widely available in South Africa, men are less likely than women to know their HIV status, begin treatment upon diagnosis, and adhere to treatment. Men are also more likely to die from causes related to HIV compared to women. To overcome this inequity, tailored approaches designed with men’s specific needs are required. Methods: As part of the Testing and Treatment for Men project, a 3-year multicomponent, mixed-methods study that aimed to better understand young South African men’s needs concerning HIV testing and treatment, we used human-centered design (HCD) methods to identify, develop, and pilot test a male-friendly peer-support intervention. We engaged key stakeholders in the development of several prototype interventions to improve men’s engagement across the HIV cascade, one of which was selected for further development. Results: Use of HCD methods, informed by the results of our team’s prior qualitative and quantitative research, led to the development of Coach Mpilo, a peer-support intervention to engage and retain men living with HIV in South Africa in care and treatment. By designing with empathy for the lived experiences of these men, our intervention achieved the authenticity and credibility required to build trusting relationships in the affected communities. Preliminary results of Coach Mpilo have demonstrated a high level of acceptability by men living with HIV as well as key government and other implementing partners. Conclusion: HCD as a critical ingredient became an integral and essential component in developing and field-testing the Coach Mpilo pilot. The key elements of our HCD approach that resulted in the successful generation of the Coach Mpilo pilot intervention and its implementation were understanding and addressing the specific issues identified by men living with HIV and leveraging newly created empathy with men as an approach to solving the issues collaboratively and innovatively.
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Affiliation(s)
- Cal Bruns
- Matchboxology, Cape Town, South Africa.
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17
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Myers B, Lombard C, Joska JA, Abdullah F, Naledi T, Lund C, Petersen Williams P, Stein DJ, Sorsdahl KR. Associations Between Patterns of Alcohol Use and Viral Load Suppression Amongst Women Living with HIV in South Africa. AIDS Behav 2021; 25:3758-3769. [PMID: 33876383 PMCID: PMC8560660 DOI: 10.1007/s10461-021-03263-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 12/13/2022]
Abstract
This study aimed to identify alcohol use patterns associated with viral non-suppression among women living with HIV (WLWH) and the extent to which adherence mediated these relationships. Baseline data on covariates, alcohol consumption, ART adherence, and viral load were collected from 608 WLWH on ART living in the Western Cape, South Africa. We defined three consumption patterns: no/light drinking (drinking ≤ 1/week and ≤ 4 drinks/occasion), occasional heavy episodic drinking (HED) (drinking > 1 and ≤ 2/week and ≥ 5 drinks/occasion) and frequent HED (drinking ≥ 3 times/week and ≥ 5 drinks/occasion). In multivariable analyses, occasional HED (OR 3.07, 95% CI 1.78–5.30) and frequent HED (OR 7.11, 95% CI 4.24–11.92) were associated with suboptimal adherence. Frequent HED was associated with viral non-suppression (OR 2.08, 95% CI 1.30–3.28). Suboptimal adherence partially mediated the relationship between frequent HED and viral non-suppression. Findings suggest a direct relationship between frequency of HED and viral suppression. Given the mediating effects of adherence on this relationship, alcohol interventions should be tailored to frequency of HED while also addressing adherence.
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Affiliation(s)
- B Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Tygerberg, PO Box 19070, Cape Town, 7505, South Africa.
- Department of Psychiatry & Mental Health, University of Cape Town, Cape Town, South Africa.
| | - C Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - J A Joska
- Department of Psychiatry & Mental Health, University of Cape Town, Cape Town, South Africa
| | - F Abdullah
- Office of AIDS and TB Research, South African Medical Research Council, Pretoria, South Africa
| | - T Naledi
- Dean's Office, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - C Lund
- Department of Psychiatry & Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
| | - P Petersen Williams
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Tygerberg, PO Box 19070, Cape Town, 7505, South Africa
- Department of Psychiatry & Mental Health, University of Cape Town, Cape Town, South Africa
| | - D J Stein
- Department of Psychiatry & Mental Health, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council's Unit on Risk & Resilience in Mental Disorders, Cape Town, South Africa
| | - K R Sorsdahl
- Department of Psychiatry & Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
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18
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Smith PJ, Joseph Davey DL, Schmucker L, Bruns C, Bekker LG, Medina-Marino A, Thirumurthy H, Buttenheim AM. Participatory Prototyping of a Tailored Undetectable Equals Untransmittable Message to Increase HIV Testing Among Men in Western Cape, South Africa. AIDS Patient Care STDS 2021; 35:428-434. [PMID: 34739334 DOI: 10.1089/apc.2021.0101] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Daily antiretroviral therapy (ART) suppresses viral replication, rendering HIV undetectable through viral load (VL) testing. People living with HIV (PLWH) who have an undetectable VL cannot transmit HIV to sexual partners or through giving birth, a message commonly referred to as U = U (undetectable equals untransmittable). To increase knowledge and understanding of U = U among men, who have poorer HIV testing and treatment outcomes than women, we engaged men from high HIV burden communities in Cape Town in two interactive human-centered design cocreation workshops to develop local U = U messaging for men. Two trained workshop facilitators, explained the U = U message to 39 adult men (in two separate workshops), and asked them how to effectively communicate U = U to other men in the local language (isiXhosa). Participant-designed messages sought to inform men about U = U to help assuage fears of testing HIV positive (by removing the stigma of living with HIV and being a vector of disease), and to explain that ART enables PLWH to live normal healthy lives, making HIV "untransmittable" to sex partners. Participants' messages emphasized that when virally suppressed, "I cannot spread HIV to the other person" and "(the pill) keeps on killing the virus so I can live a normal life for the rest of my life." Men cocreated simple local U = U messages to address fears of testing HIV positive and emphasizing ART's positive effects. Cocreated tailored messaging may reduce stigma associated with living with HIV and improve the uptake of HIV testing and treatment among South African men. This study was registered at clinicaltrials.gov under NCT04364165.
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Affiliation(s)
- Philip J Smith
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
| | - Dvora L Joseph Davey
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Laura Schmucker
- Medical Ethics and Health Policy, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Health Incentives and Behavioral Economics, Medical Ethics and Health Policy, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cal Bruns
- Matchboxology, Kalk Bay, Cape Town, South Africa
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
| | - Andrew Medina-Marino
- Division of Men's Health, Desmond Tutu HIV Centre, University of Cape Town, South Africa
- Department of Psychiatry, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Harsha Thirumurthy
- Medical Ethics and Health Policy, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Health Incentives and Behavioral Economics, Medical Ethics and Health Policy, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alison M Buttenheim
- Medical Ethics and Health Policy, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Health Incentives and Behavioral Economics, Medical Ethics and Health Policy, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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19
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Nyein PP, Aung E, Aung NM, Kyi MM, Boyd M, Lin KS, Hanson J. The impact of gender and the social determinants of health on the clinical course of people living with HIV in Myanmar: an observational study. AIDS Res Ther 2021; 18:50. [PMID: 34372879 PMCID: PMC8350926 DOI: 10.1186/s12981-021-00364-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 07/01/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is a growing recognition of the impact of gender and the social determinants of health on the clinical course of people living with HIV (PLHIV). However, the relative contribution of these factors to clinical outcomes of PLHIV is incompletely defined in many countries. This study was performed to gain a greater understanding of the non-clinical determinants of prognosis of PLHIV in Myanmar. METHODS Selected demographic, behavioural and socioeconomic characteristics of outpatients at two specialist HIV hospitals and one general hospital in Yangon, Myanmar were correlated with their subsequent clinical course; a poor outcome was defined as death, hospitalisation, loss to follow-up or a detectable viral load at 6 months of follow-up. RESULTS 221 consecutive individuals with advanced HIV commencing anti-retroviral therapy (ART) were enrolled in the study; their median CD4 T-cell count was 92 (44-158) cells/mm3, 138 (62.4%) were male. Socioeconomic disadvantage was common: the median (interquartile range (IQR) monthly per-capita income in the cohort was US$48 (31-77); 153 (69.9%) had not completed high school. However, in a multivariate analysis that considered demographic, behavioural, clinical factors and social determinants of health, male gender was the only predictor of a poor outcome: odds ratio (95% confidence interval): 2.33 (1.26-4.32, p = 0.007). All eight of the deaths and hospitalisations in the cohort occurred in males (p = 0.03). CONCLUSIONS Men starting ART in Myanmar have a poorer prognosis than women. Expanded implementation of gender-specific management strategies is likely to be necessary to improve outcomes.
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Affiliation(s)
- Phyo Pyae Nyein
- Mingaladon Specialist Hospital, Mingaladon Township, Yangon, Myanmar
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar
| | - Eithandee Aung
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia
| | - Ne Myo Aung
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar
- Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Mar Mar Kyi
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar
- Insein General Hospital, Insein Township, Yangon, Myanmar
| | - Mark Boyd
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Kyaw Swar Lin
- Mingaladon Specialist Hospital, Mingaladon Township, Yangon, Myanmar
| | - Josh Hanson
- University of Medicine 2, North Okkalapa Township, Yangon, Myanmar.
- The Kirby Institute, University of New South Wales Sydney, Sydney, Australia.
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Osman M, van Schalkwyk C, Naidoo P, Seddon JA, Dunbar R, Dlamini SS, Welte A, Hesseling AC, Claassens MM. Mortality during tuberculosis treatment in South Africa using an 8-year analysis of the national tuberculosis treatment register. Sci Rep 2021; 11:15894. [PMID: 34354135 PMCID: PMC8342475 DOI: 10.1038/s41598-021-95331-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 07/20/2021] [Indexed: 11/18/2022] Open
Abstract
In 2011, the South African HIV treatment eligibility criteria were expanded to allow all tuberculosis (TB) patients lifelong ART. The impact of this change on TB mortality in South Africa is not known. We evaluated mortality in all adults (≥ 15 years old) treated for drug-susceptible TB in South Africa between 2009 and 2016. Using a Cox regression model, we quantified risk factors for mortality during TB treatment and present standardised mortality ratios (SMR) stratified by year, age, sex, and HIV status. During the study period, 8.6% (219,618/2,551,058) of adults on TB treatment died. Older age, male sex, previous TB treatment and HIV infection (with or without the use of ART) were associated with increased hazard of mortality. There was a 19% reduction in hazard of mortality amongst all TB patients between 2009 and 2016 (adjusted hazard ratio: 0.81 95%CI 0.80-0.83). The highest SMR was in 15-24-year-old women, more than double that of men (42.3 in 2016). Between 2009 and 2016, the SMR for HIV-positive TB patients increased, from 9.0 to 19.6 in women, and 7.0 to 10.6 in men. In South Africa, case fatality during TB treatment is decreasing and further interventions to address specific risk factors for TB mortality are required. Young women (15-24-year-olds) with TB experience a disproportionate burden of mortality and interventions targeting this age-group are needed.
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Affiliation(s)
- Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa.
| | - Cari van Schalkwyk
- DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa
| | - Sicelo S Dlamini
- Research Information Monitoring, Evaluation & Surveillance (RIMES), National TB Control & Management Cluster, National Department of Health, Pretoria, South Africa
| | - Alex Welte
- DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa
| | - Mareli M Claassens
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Parow, Cape Town, 7505, South Africa.
- Department of Biochemistry and Microbiology, School of Medicine, University of Namibia, Bach Street, Windhoek, Namibia.
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Tiendrebeogo T, Messou E, Arikawa S, Ekouevi DK, Tanon A, Kwaghe V, Balestre E, Zannou MD, Poda A, Dabis F, Jaquet A, Minga A, Becquet R. Ten-year attrition and antiretroviral therapy response among HIV-positive adults: a sex-based cohort analysis from eight West African countries. J Int AIDS Soc 2021; 24:e25723. [PMID: 34021714 PMCID: PMC8140184 DOI: 10.1002/jia2.25723] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 03/29/2021] [Accepted: 04/09/2021] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Sex differences have already been reported in sub-Saharan Africa for attrition and immunological response after antiretroviral therapy (ART) initiation, but follow-up was usually limited to the first two to three years after ART initiation. We evaluated sex differences on the same outcomes in the 10 years following ART initiation in West African adults. METHODS We used cohort data of patients included in the IeDEA West Africa collaboration, who initiated ART between 2002 and 2014. We modelled no-follow-up and 10-year attrition risks, and immunological response by sex using logistic regression analysis, survival analysis with random effect and linear mixed models respectively. RESULTS A total of 71,283 patients (65.8% women) contributed to 310,007 person-years of follow-up in 16 clinics in eight West African countries. The cumulative attrition incidence at 10-year after ART initiation reached 75% and 68% for men and women respectively. Being male was associated with an increased risk of no follow-up after starting ART (5.1% vs. 4.0%, adjusted Odds Ratio: 1.25 [95% CI: 1.15 to 1.35]) and of 10-year attrition throughout the 10-year period following ART initiation: adjusted Hazard Ratios were 1.22 [95% CI: 1.17 to 1.27], 1.08 [95% CI: 1.04 to 1.12] and 1.04 [95% CI: 1.01 to 1.08] during year 1, years 2 to 4 and 5 to 10 respectively. A better immunological response was achieved by women than men: monthly CD4 gain was 30.2 and 28.3 cells/mL in the first four months and 2.6 and 1.9 cells/μL thereafter. Ultimately, women reached the average threshold of 500 CD4 cells/μL in their sixth year of follow-up, whereas men failed to reach it even at the end of the 10-year follow-up period. The proportion of patients reaching the threshold was much higher in women than in men after 10 years since ART initiation (65% vs. 44%). CONCLUSIONS In West Africa, attrition is unacceptably high in both sexes. Men are more vulnerable than women on both attrition and immunological response to ART in the 10 years following ART initiation. Innovative tracing strategies that are sex-adapted are needed for patients in care to monitor attrition, detect early high-risk groups so that they can stay in care with a durably controlled infection.
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Affiliation(s)
- Thierry Tiendrebeogo
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Eugène Messou
- Centre de Prise en charge de Recherche et de Formation (Aconda-CePReF), Abidjan, Côte d'Ivoire
| | - Shino Arikawa
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Didier K Ekouevi
- Département des Sciences Fondamentales et Santé Publique, Université de Lomé, Lomé, Togo
| | - Aristophane Tanon
- Service de Maladies Infectieuses et Tropicales (SMIT), Treichville Teaching Hospital, Abidjan, Côte d'Ivoire
| | - Vivian Kwaghe
- University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Eric Balestre
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Marcel Djimon Zannou
- Centre de Traitement Ambulatoire (CTA), Centre National Hospitalier Universitaire (CNHU), Cotonou, Benin
| | - Armel Poda
- Institut Supérieur des Sciences de la santé, Université Polytechnique de Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso
| | - François Dabis
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Antoine Jaquet
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Albert Minga
- Centre Médical de Suivi des Donneurs de Sang (CMSDS), Centre National de Transfusion Sanguine (CNTS), Abidjan, Côte d'Ivoire
| | - Renaud Becquet
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
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22
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Mbokazi N, Madzima R, Leon N, Lurie MN, Cornell M, Schmidt BM, Colvin CJ. Health Worker Experiences of and Perspectives on Engaging Men in HIV Care: A Qualitative Study in Cape Town, South Africa. J Int Assoc Provid AIDS Care 2021; 19:2325958220935691. [PMID: 32597712 PMCID: PMC7325454 DOI: 10.1177/2325958220935691] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Men generally fare worse than women across the HIV cascade. While we know much about how men perceive the health services, we know little about how health workers (HWs) themselves have experienced engaging with men and what strategies they have used to improve this engagement. We interviewed 12 HWs in public health care services in Cape Town to better understand their experiences and perspectives. Health workers felt there were significant gaps in men’s engagement with HIV care and identified masculine gender norms, the persistent impact of HIV stigma, and the competing priorities of employment as key barriers. They also highlighted a number of health service-related challenges, including a poor perception of the patient–provider relationship, frustration at low service quality, and unrealistic expectations of the health services. Health workers also described several strategies for more effectively engaging men and for making the health services both more male friendly and more people friendly.
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Affiliation(s)
- Nonzuzo Mbokazi
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Rutendo Madzima
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Natalie Leon
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa.,Department of Epidemiology, Brown University, Providence, RI, USA
| | - Mark N Lurie
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Department of Epidemiology, Brown University, Providence, RI, USA
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology & Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Bey-Marrie Schmidt
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
| | - Christopher J Colvin
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Department of Epidemiology, Brown University, Providence, RI, USA.,Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
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Nyondo-Mipando AL, Kapesa LS, Salimu S, Kazuma T, Mwapasa V. "Dispense antiretrovirals daily!" restructuring the delivery of HIV services to optimize antiretroviral initiation among men in Malawi. PLoS One 2021; 16:e0247409. [PMID: 33617561 PMCID: PMC7899340 DOI: 10.1371/journal.pone.0247409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 02/07/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Gender disparities exist in the scale-up and uptake of HIV services with men being disproportionately under-represented in the services. In Eastern and Southern Africa, of the people living with HIV infection, more adult women than men were on treatment highlighting the disparities in HIV services. Delayed initiation of antiretroviral treatment creates a missed opportunity to prevent transmission of HIV while increasing HIV and AIDS-associated morbidity and mortality. The main objective of this study was to assess the strategies that men prefer for Antiretroviral Therapy (ART) initiation in Blantyre, Malawi. METHODS This was a qualitative study conducted in 7 Health facilities in Blantyre from January to July 2017. We selected participants following purposive sampling. We conducted 20 in-depth interviews (IDIs) with men of different HIV statuses, 17 interviews with health care workers (HCWs), and 14 focus group discussions (FGDs) among men of varying HIV statuses. We digitally recorded all the data, transcribed verbatim, managed using NVivo, and analysed it thematically. RESULTS Restructuring the delivery of antiretroviral (ARVs) treatment and conduct of ART clinics is key to optimizing early initiation of treatment among heterosexual men in Blantyre. The areas requiring restructuring included: Clinic days by offering ARVs daily; Clinic hours to accommodate schedules of men; Clinic layout and flow that preserves privacy and establishment of male-specific clinics; ARV dispensing procedures where clients receive more pills to last them longer than 3 months. Additionally there is need to improve the packaging of ARVs, invent ARVs with less dosing frequency, and dispense ARVs from the main pharmacy. It was further suggested that the test-and-treat strategy be implemented with fidelity and revising the content in counseling sessions with an emphasis on the benefits of ARVs. CONCLUSION The success in ART initiation among men will require a restructuring of the current ART services to make them accessible and available for men to initiate treatment. The inclusion of people-centered approaches will ensure that individual preferences are incorporated into the initiation of ARVs. The type, frequency, distribution, and packaging of ARVs should be aligned with other medicines readily available within a health facility to minimize stigma.
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Affiliation(s)
- Alinane Linda Nyondo-Mipando
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Leticia Suwedi Kapesa
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Sangwani Salimu
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Thokozani Kazuma
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Victor Mwapasa
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
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Lopez-Varela E, Augusto O, Fuente-Soro L, Sacoor C, Nhacolo A, Casavant I, Karajeanes E, Vaz P, Naniche D. Quantifying the gender gap in the HIV care cascade in southern Mozambique: We are missing the men. PLoS One 2021; 16:e0245461. [PMID: 33577559 PMCID: PMC7880488 DOI: 10.1371/journal.pone.0245461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 01/04/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND HIV-infected men have higher rates of delayed diagnosis, reduced antiretroviral treatment (ART) retention and mortality than women. We aimed to assess, by gender, the first two UNAIDS 90 targets in rural southern Mozambique. METHODS This analysis was embedded in a larger prospective cohort enrolling individuals with new HIV diagnosis between May 2014-June 2015 from clinic and home-based testing (HBT). We assessed gender differences between steps of the HIV-cascade. Adjusted HIV-community prevalence was estimated using multiple imputation (MI). RESULTS Among 11,773 adults randomized in HBT (7084 female and 4689 male), the response rate before HIV testing was 48.7% among eligible men and 62.0% among women (p<0.001). MI did not significantly modify all-age HIV-prevalence for men but did decrease prevalence estimates in women from 36.4%to 33.0%. Estimated proportion of HIV-infected individuals aware of their status was 75.9% for men and 88.9% for women. In individuals <25 years, we observed up to 22.2% disparity in awareness of serostatus between genders. Among individuals eligible for ART, similar proportions of men and women initiated treatment (81.2% and 85.9%, respectively). Fourfold more men than womenwere in WHO stage III/IV AIDS at first clinical visit. Once on ART, men had a twofold higher 18-month loss to follow-up rate than women. CONCLUSION The contribution of missing HIV-serostatus data differentially impacted indicators of HIV prevalence and of achievement of UNAIDS targets by age and gender and men were missing long before the second 90. Increased efforts to characterize missing men and their needs will and their needs will allow us to urgently address the barriers to men accessing care and ensure men are not left behind in the UNAIDS 90-90-90 targets achievement.
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Affiliation(s)
- Elisa Lopez-Varela
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Instituto de Salud Global de Barcelona, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Orvalho Augusto
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Facultade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Laura Fuente-Soro
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Instituto de Salud Global de Barcelona, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Charfudin Sacoor
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Ariel Nhacolo
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | | | | | - Paula Vaz
- Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo, Mozambique
| | - Denise Naniche
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Instituto de Salud Global de Barcelona, Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
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Palanuphap K, Sungkanuparph S. Switching protease inhibitors to rilpivirine in HIV-positive individuals with complete viral suppression and without prior HIV drug resistance in a resource-limited setting: a randomized controlled trial. J Int AIDS Soc 2020; 23:e25462. [PMID: 32277868 PMCID: PMC7150595 DOI: 10.1002/jia2.25462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 12/20/2019] [Accepted: 01/20/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Prior to the availability of rilpivirine (RPV), patients who could not tolerate efavirenz and nevirapine (NVP) were treated with protease inhibitor (PI)‐based antiretroviral therapy (ART). Dyslipidaemia and other metabolic complications are commonly associated with PI use. This study aimed to compare the efficacy and adverse events between switching from PI‐based to RPV‐based regimen, versus continuing PI‐based regimens in HIV‐positive individuals with complete viral suppression. Methods A randomized controlled trial was conducted in HIV‐positive individuals receiving PI‐based regimens with undetectable HIV RNA and without prior HIV drug resistance. Patients were enrolled between July and December 2017 in a university medical centre in Bangkok, Thailand. They were randomized to switch from PIs to RPV (switch group) or continue ritonavir‐boosted PI (control group). Primary endpoint was the proportion of patients with undetectable HIV RNA at 48 weeks. Changes in CD4 cell counts, lipid profiles and adverse events were also analysed. Results and discussion A total of 84 patients were enrolled, 42 in each group. Mean age was 47.7 years and 53.6% were males. At 48 weeks, 95.2% of patients in the switch group and 92.9% of control group had maintained undetectable HIV RNA (difference rate 2.4%; 95% CI, −9.6 to 14.7). Means of CD4 cell counts were 611 and 641 cells/mm3 in switch and control groups respectively (p = 0.632). Mean changes in lipid profiles (switch vs. control groups) were: total cholesterol, −12.5 versus + 12.2 (p = 0.024); LDL, −3.4 versus + 6.2 (p = 0.040); HDL, +1.6 versus + 1.9 (p = 0.887); and triglycerides, −82.6 versus − 24.4 mg/dL (p = 0.031). The mean changes of glucose and eGFR were similar (p > 0.05) between the two groups. The mean change of ALT was significantly greater in switch group (18.2 vs. 4.0 U/L, p = 0.017). One patient in switch group had anorexia and elevated ALT at 14 weeks and completely recovered after RPV discontinuation. Conclusions Switching PIs to RPV, in patients with complete viral suppression and without prior HIV drug resistance, sustains viral suppression and yields better lipid profiles. This finding supports its use as switching therapy in patients receiving PI‐based regimens due to intolerance to efavirenz and NVP and previous alternatives limited to PI in resource‐limited settings.
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Affiliation(s)
- Kulissara Palanuphap
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Somnuek Sungkanuparph
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
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Ssempijja V, Namulema E, Ankunda R, Quinn TC, Cobelens F, Hoog AV, Reynolds SJ. Temporal trends of early mortality and its risk factors in HIV-infected adults initiating antiretroviral therapy in Uganda. EClinicalMedicine 2020; 28:100600. [PMID: 33294814 PMCID: PMC7700951 DOI: 10.1016/j.eclinm.2020.100600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 09/25/2020] [Accepted: 09/30/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND A decline in mortality rates during the first 12 months of antiretroviral therapy (ART) has been mainly linked to increased ART initiation at higher CD4 counts and at less advanced World Health Organization (WHO) clinical stages of HIV infection; however, the role of improved patient care has not been well studied. We estimated improvements in early mortality due to improved patient care. METHODS We conducted a retrospective cohort study of HIV-infected individuals ages 18 and older who initiated ART at the Mengo HIV Counseling and Home Care Clinic between 2006 and 2016. We conducted a mediation analysis using generalized structural equation models with inverse odds ratio weighting to estimate the natural direct and indirect effects of ART initiation time on early mortality. FINDINGS Among 6,847 patients, most were female (69%), with a median age of 32 (interquartile range [IQR] = 28-38), versus a median age of 38 (IQR = 32-45) for males. The median CD4 count at ART initiation increased from 142 cells/ul (95% confidence interval [CI] = 135-150) in 2006-2010 to 302 cells/ul (95% CI = 283-323) in 2015-2016 (p < 0·001). The number of patients at WHO clinical stages I/II increased from 52% in 2006-2010 to 78% in 2015-2016 (p < 0·001). Annual early mortality decreased from 8·8 deaths/100 person years (PYS) in 2006 to 2.5 deaths/100 pys in 2016 (p < 0·001). Mediation by CD4 counts and WHO clinical stages accounted for 54% of the total effect of ART initiation timing on early mortality. In comparison, 46% remained as the direct effect, reflecting the contribution of improved patient care. INTERPRETATION Improved patient care practices should be promoted as a strategy for reducing early mortality after ART initiation, above and beyond the effects from ART initiation at higher CD4 counts and less advanced WHO clinical stage alone. FUNDING This research was supported by the President's Emergency Plan for AIDS Relief (PEPFAR), the National Institute of Allergy and Infectious Diseases Division of Intramural Research, and the National Cancer Institute.
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Affiliation(s)
- Victor Ssempijja
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
- Department of Global Health, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Edith Namulema
- HIV Counseling and Home Care Clinic, Mengo Hospital, Kampala, Uganda
| | - Racheal Ankunda
- HIV Counseling and Home Care Clinic, Mengo Hospital, Kampala, Uganda
| | - Thomas C. Quinn
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, USA
| | - Frank Cobelens
- Department of Global Health, Amsterdam University Medical Centers, Amsterdam, Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | - Anja van't Hoog
- Department of Global Health, Amsterdam University Medical Centers, Amsterdam, Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | - Steven J. Reynolds
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, USA
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Chauke P, Huma M, Madiba S. Lost to follow up rate in the first year of ART in adults initiated in a universal test and treat programme: a retrospective cohort study in Ekurhuleni District, South Africa. Pan Afr Med J 2020; 37:198. [PMID: 33505567 PMCID: PMC7813655 DOI: 10.11604/pamj.2020.37.198.25294] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 09/26/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction South Africa adopted and implemented the Universal Test and Treat (UTT) strategy for HIV since 2016. However, the care outcomes for patients initiated antiretroviral therapy (ART) through the UTT strategy have not been established. We determined the rate of lost to follow up (LTFU) and associated factors in patients who were initiated on ART through the UTT and the pre-ART strategy at 12 months post ART initiation. Methods this retrospective study analyzed the records of a cohort of patients at 12 months post the initiation of ART. We extracted data from the TIER.Net electronic database of selected facilities in a sub-district in Gauteng Province, South Africa. Factors associated with LFTU at 12 months of ART were assessed and logistic regression performed to identify predictors of LFTU. Results records of 367 patients were evaluated, and 54% were initiated ART through the UTT strategy. The mean age was 36.3 years, mean CD4 cell count at ART initiation was 341 cells/mm3, and 25% were initiated at CD4 cell count above 500 cells/mm3. LTFU at 12 months was 28%, 50% were LFTU within six months, and 28% within three months of ART. LFTU in the UTT cohort was higher than in the pre-ART cohort, patients initiated through UTT were twice more likely to be LTFU (AOR = 1.84, CI: 1.13-3.00) than pre-ART patients. Conclusion the rate of LTFU at 12 months of ART was 28%, which indicate that the retention in care rate (60%) falls far short of the triple 90 targets required for viral suppression.
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Affiliation(s)
- Patricia Chauke
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Mmampedi Huma
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Sphiwe Madiba
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
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Madut DB, Park LP, Yao J, Reddy EA, Njau B, Ostermann J, Whetten K, Thielman NM. Predictors of mortality in treatment experienced HIV-infected patients in northern Tanzania. PLoS One 2020; 15:e0240293. [PMID: 33031434 PMCID: PMC7544106 DOI: 10.1371/journal.pone.0240293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 09/24/2020] [Indexed: 11/25/2022] Open
Abstract
Background While factors that drive early mortality among people living with HIV (PLWH) initiating antiretroviral therapy (ART) in sub-Saharan Africa (SSA) have been described, less is known about the predictors of long-term mortality for those with ART experience. Methods PLWH and on ART attending two HIV treatment clinics in Moshi, Tanzania were enrolled from 2008 through 2009 and followed for 3.5 years. Demographic, psychosocial, and clinical information were collected at enrollment. Plasma HIV RNA measurements were collected annually. Cause of death was adjudicated by two independent reviewers based on verbal autopsy information and medical records. Bivariable and multivariable analyses were conducted using Cox proportional hazard models to identify predictors of mortality. Results The analysis included 403 participants. The median (IQR) age in years was 42 (36–48) and 277 (68.7%) participants were female. The proportion of participants virologically suppressed during the 4 collection time points was 88.5%, 94.7%, 91.5%, and 94.5%. During follow-up, 24 participants died; the overall mortality rate was 1.8 deaths per 100 person-years. Of the deaths, 14 (58.3%) were suspected to be HIV/AIDS related. Predictors of mortality (adjusted hazard ratio, 95% confidence interval) were male sex (2.63, 1.01–6.83), secondary or higher education (7.70, 3.02–19.60), receiving care at the regional referral hospital in comparison to the larger zonal referral hospital (6.33, 1.93–20.76), and moderate to severe depression symptoms (6.35, 1.69–23.87). Conclusions As ART coverage continues to expand in SSA, HIV programs should recognize the need for interventions to promote HIV care engagement for men and the integration of mental health screening and treatment with HIV care. Facility-level barriers may contribute to challenges faced by PLWH as they progress through the HIV care continuum, and further understanding of these barriers is needed. The association of higher educational attainment with mortality merits further investigation.
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Affiliation(s)
- Deng B. Madut
- Department of Medicine, Duke University, Durham, NC, United States of America
- * E-mail:
| | - Lawrence P. Park
- Department of Medicine, Duke University, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
| | - Jia Yao
- Center for Health Policy and Inequalities Research, Durham, NC, United States of America
- Duke Sanford School of Public Policy, Duke University, Durham, NC, United States of America
| | - Elizabeth A. Reddy
- Division of Infectious Disease, SUNY Upstate Medical University, Syracuse, NY, United States of America
| | - Bernard Njau
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Jan Ostermann
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
| | - Kathryn Whetten
- Duke Global Health Institute, Durham, NC, United States of America
- Center for Health Policy and Inequalities Research, Durham, NC, United States of America
- Duke Sanford School of Public Policy, Duke University, Durham, NC, United States of America
| | - Nathan M. Thielman
- Department of Medicine, Duke University, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
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Richterman A, Leandre F, Jerome JG, Tsai AC, Ivers LC. Mortality Over Long-term Follow-up for People With HIV Receiving Longitudinal Care and Antiretroviral Therapy in Rural Haiti. Open Forum Infect Dis 2020; 7:ofaa328. [PMID: 32851109 PMCID: PMC7442269 DOI: 10.1093/ofid/ofaa328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/05/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Deaths from HIV have fallen dramatically with the increasing availability of fully suppressive antiretroviral therapy (ART), and yet HIV remains the ninth leading cause of death in low-income countries. As more people with HIV enter care and receive ART, the focus will need to shift from expanding ART to including long-term program effectiveness and outcomes for people with HIV already engaged in care. METHODS We evaluated risk factors for mortality among people with HIV on ART receiving longitudinal care in rural Haiti. We assessed baseline characteristics using a household survey and abstracted clinical characteristics from the electronic record. We used multivariable Cox regression models to identify risk factors for mortality. RESULTS There were 464 people included in this study with a median follow-up (interquartile range [IQR]) of 69 (44-77) months, during which time 37 (8%) were lost to follow-up and 118 (25%) died (median time to death [IQR], 29 [12-53] months). After adjustment, poverty (adjusted hazard ratio [AHR], 1.12 per 10-percentage point increased probability; 95% CI, 1.01-1.24) and single marital status (AHR, 1.59; 95% CI, 1.08-2.36) were associated with increased mortality. Age (AHR, 0.78 per 10-year increase; 95% CI, 0.64-0.94), role function quality of life (AHR, 0.75 per quintile increase; 95% CI, 0.62-0.90), and CD4 count (AHR, 0.66 per 100 cells/μL; 95% CI, 0.58-0.75) were associated with decreased mortality. CONCLUSIONS Poverty, marital status, and quality of life were associated with mortality. Social protection should be evaluated as a strategy to reduce mortality for people with HIV in concert with increasing access to ART.
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Affiliation(s)
- Aaron Richterman
- Division of Infectious Diseases, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fernet Leandre
- Zanmi Lasante/Partners In Health, Cange, Haiti
- Division of Global Health Equity, Brigham and Women Hospital, Boston, Massachusetts, USA
| | | | - Alexander C Tsai
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Louise C Ivers
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Bengtson AM, Colvin C, Kirwa K, Cornell M, Lurie MN. Estimating retention in HIV care accounting for clinic transfers using electronic medical records: evidence from a large antiretroviral treatment programme in the Western Cape, South Africa. Trop Med Int Health 2020; 25:936-943. [PMID: 32406961 PMCID: PMC8841816 DOI: 10.1111/tmi.13412] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Estimates of retention in antiretroviral treatment (ART) programmes may be biased if patients who transfer to healthcare clinics are misclassified as lost to follow-up (LTFU) at their original clinic. In a large cohort, we estimated retention in care accounting for patient transfers using medical records. METHODS Using linked electronic medical records, we followed adults living with HIV (PLWH) in Cape Town, South Africa from ART initiation (2012-2016) through database closure at 36 months or 30 June 2016, whichever came first. Retention was defined as alive and with a healthcare visit in the 180 days between database closure and administrative censoring on 31 December 2016. Participants who died or did not have a healthcare visit in > 180 days were censored at their last healthcare visit. We estimated the cumulative incidence of retention using Kaplan-Meier methods considering (i) only records from a participant's ART initiation clinic (not accounting for transfers) and (ii) all records (accounting for transfers), over time and by gender. We estimated risk differences and bootstrapped 95% confidence intervals to quantify misclassification in retention estimates due to patient transfers. RESULTS We included 3406 PLWH initiating ART. Retention through 36 months on ART rose from 45.4% (95% CI 43.6%, 47.2%) to 54.3% (95% CI 52.4%, 56.1%) after accounting for patient transfers. Overall, 8.9% (95% CI 8.1%, 9.7%) of participants were misclassified as LTFU due to patient transfers. CONCLUSIONS Patient transfers can appreciably bias estimates of retention in HIV care. Electronic medical records can help quantify patient transfers and improve retention estimates.
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Affiliation(s)
| | - Christopher Colvin
- Department of Epidemiology, Brown University, Providence, RI, USA
- Division of Social and Behavioural Sciences, University of Cape Town, Cape Town, South Africa
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Kipruto Kirwa
- Department of Environmental Health Engineering, Tufts University, Medford, MA, USA
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Mark N Lurie
- Department of Epidemiology, Brown University, Providence, RI, USA
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31
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Digban TO, Iweriebor BC, Obi LC, Nwodo U, Okoh AI. Molecular Genetics and the Incidence of Transmitted Drug Resistance Among Pre-Treatment HIV-1 Infected Patients in the Eastern Cape, South Africa. Curr HIV Res 2020; 17:335-342. [PMID: 31584370 DOI: 10.2174/1570162x17666191004093433] [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: 05/25/2019] [Revised: 09/17/2019] [Accepted: 09/20/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Transmitted drug resistance (TDR) remains a significant threat to Human immunodeficiency virus (HIV) infected patients that are not exposed to antiretroviral treatment. Although, combined antiretroviral therapy (cART) has reduced deaths among infected individuals, emergence of drug resistance is gradually on rise. OBJECTIVE To determine the drug resistance mutations and subtypes of HIV-1 among pre-treatment patients in the Eastern Cape of South Africa. METHODS Viral RNA was extracted from blood samples of 70 pre-treatment HIV-1 patients while partial pol gene fragment amplification was achieved with specific primers by RT-PCR followed by nested PCR and positive amplicons were sequenced utilizing ABI Prism 316 genetic sequencer. Drug resistance mutations (DRMs) analysis was performed by submitting the generated sequences to Stanford HIV drug resistance database. RESULTS Viral DNA was successful for 66 (94.3%) samples of which 52 edited sequences were obtained from the protease and 44 reverse transcriptase sequences were also fully edited. Four major protease inhibitor (PI) related mutations (I54V, V82A/L, L76V and L90M) were observed in seven patients while several other minor and accessory PIs were also identified. A total of 11(25.0%) patients had NRTIs related mutations while NNRTIs were observed among 14(31.8%) patients. K103N/S, V106M and M184V were the most common mutations identified among the viral sequences. Phylogenetic analysis of the partial pol gene indicated all sequences clustered with subtype C. CONCLUSION This study indicates that HIV-1 subtype C still predominates and responsible for driving the epidemic in the Eastern Cape of South Africa with slow rise in the occurrence of transmitted drug resistance.
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Affiliation(s)
- Tennison Onoriode Digban
- Applied Environmental and Microbiology Research Group, University of Fort Hare, Private Mail Bag X1314, Alice 5700, Eastern Cape, South Africa.,Department of Microbiology and Biochemistry, University of Fort Hare, Private mail bag X1314, Alice 5700, Eastern Cape, South Africa
| | - Benson Chucks Iweriebor
- Applied Environmental and Microbiology Research Group, University of Fort Hare, Private Mail Bag X1314, Alice 5700, Eastern Cape, South Africa
| | - Larry Chikwelu Obi
- Department of Microbiology and Biochemistry, University of Fort Hare, Private mail bag X1314, Alice 5700, Eastern Cape, South Africa
| | - Uchechuwku Nwodo
- Applied Environmental and Microbiology Research Group, University of Fort Hare, Private Mail Bag X1314, Alice 5700, Eastern Cape, South Africa.,Department of Microbiology and Biochemistry, University of Fort Hare, Private mail bag X1314, Alice 5700, Eastern Cape, South Africa
| | - Anthony Ifeanyi Okoh
- Applied Environmental and Microbiology Research Group, University of Fort Hare, Private Mail Bag X1314, Alice 5700, Eastern Cape, South Africa.,Department of Microbiology and Biochemistry, University of Fort Hare, Private mail bag X1314, Alice 5700, Eastern Cape, South Africa
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Kerkhoff AD, Sikombe K, Eshun-Wilson I, Sikazwe I, Glidden DV, Pry JM, Somwe P, Beres LK, Simbeza S, Mwamba C, Bukankala C, Hantuba C, Moore CB, Holmes CB, Padian N, Geng EH. Mortality estimates by age and sex among persons living with HIV after ART initiation in Zambia using electronic medical records supplemented with tracing a sample of lost patients: A cohort study. PLoS Med 2020; 17:e1003107. [PMID: 32401797 PMCID: PMC7219718 DOI: 10.1371/journal.pmed.1003107] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 04/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Men in sub-Saharan Africa have lower engagement and retention in HIV services compared to women, which may result in differential survival. However, the true magnitude of difference in HIV-related mortality between men and women receiving antiretroviral therapy (ART) is incompletely characterized. METHODS AND FINDINGS We evaluated HIV-positive adults ≥18 years old newly initiating ART in 4 Zambian provinces (Eastern, Lusaka, Southern, and Western). In addition to mortality data obtained from routine electronic medical records, we intensively traced a random sample of patients lost to follow-up (LTFU) and incorporated tracing outcomes through inverse probability weights. Sex-specific mortality rates and rate differences were determined using Poisson regression. Parametric g-computation was used to estimate adjusted mortality rates by sex and age. The study included 49,129 adults newly initiated on ART between August 2013 and July 2015; overall, the median age among patients was 35 years, the median baseline CD4 count was 262 cells/μl, and 37.2% were men. Men comprised a smaller proportion of individuals starting ART (37.2% versus 62.8%), tended to be older (median age 37 versus 33 years), and tended to have lower CD4 counts (median 220 versus 289 cells/μl) at the time of ART initiation compared to women. The overall rate of mortality among men was 10.3 (95% CI 8.2-12.4) deaths/100 person-years (PYs), compared to 5.5 (95% CI 4.3-6.8) deaths/100 PYs among women (difference +4.7 [95% CI 2.3-7.2] deaths/100 PYs; p < 0.001). Compared to women in the same age groups, men's mortality rates were particularly elevated among those <30 years old (+6.7 deaths/100 PYs difference), those attending rural health centers (+9.4 deaths/100 PYs difference), those who had an initial CD4 count < 100 cells/μl (+9.2 deaths/100 PYs difference), and those who were unmarried (+8.0 deaths/100 PYs difference). After adjustment for potential confounders and mediators including CD4 count, a substantially higher mortality rate was predicted among men <30 years old compared to women of the same age, while women ≥50 years old had a mortality rate similar to that of age-matched men, but considerably higher than that predicted among young women (<30 years old). No clinically significant differences were evident with respect to rates of facility transfer or care disengagement between men and women. The main study limitations were the inability to successfully ascertain outcomes in all patients selected for tracing and missing clinical and laboratory data due to the use of medical records. CONCLUSIONS In this study, we found that among HIV-positive adults newly initiating ART, mortality among men exceeded mortality among women; disparities were most pronounced among young patients. Older women, however, also experienced high mortality. Specific interventions for men and older women at highest mortality risk are needed to improve HIV treatment outcomes.
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Affiliation(s)
- Andrew D. Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, United States of America
| | | | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Department of Medicine, Washington University, St. Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - David V. Glidden
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, United States of America
| | - Jake M. Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, Department of Medicine, Washington University, St. Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Laura K. Beres
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Chama Bukankala
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Cardinal Hantuba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Charles B. Holmes
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
- Georgetown University, Washington, District of Columbia, United States of America
| | - Nancy Padian
- University of California, Berkeley, Berkeley, California, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, Department of Medicine, Washington University, St. Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
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Kehoe K, Boulle A, Tsondai PR, Euvrard J, Davies MA, Cornell M. Long-term virologic responses to antiretroviral therapy among HIV-positive patients entering adherence clubs in Khayelitsha, Cape Town, South Africa: a longitudinal analysis. J Int AIDS Soc 2020; 23:e25476. [PMID: 32406983 PMCID: PMC7224308 DOI: 10.1002/jia2.25476] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION In South Africa, an estimated 4.6 million people were accessing antiretroviral therapy (ART) in 2018. As universal Test and Treat is implemented, these numbers will continue to increase. Given the need for lifelong care for millions of individuals, differentiated service delivery models for ART services such as adherence clubs (ACs) for stable patients are required. In this study, we describe long-term virologic outcomes of patients who have ever entered ACs in Khayelitsha, Cape Town. METHODS We included adult patients enrolled in ACs in Khayelitsha between January 2011 and December 2016 with a recorded viral load (VL) before enrolment. Risk factors for an elevated VL (VL >1000 copies/mL) and confirmed virologic failure (two consecutive VLs >1000 copies/mL one year apart) were estimated using Cox proportional hazards models. VL completeness over time was assessed. RESULTS Overall, 8058 patients were included in the analysis, contributing 16,047 person-years of follow-up from AC entry (median follow-up time 1.7 years, interquartile range [IQR]:0.9 to 2.9). At AC entry, 74% were female, 46% were aged between 35 and 44 years, and the median duration on ART was 4.8 years (IQR: 3.0 to 7.2). Among patients virologically suppressed at AC entry (n = 8058), 7136 (89%) had a subsequent VL test, of which 441 (6%) experienced an elevated VL (median time from AC entry 363 days, IQR: 170 to 728). Older age (adjusted hazard ratio [aHR] 0.64, 95% confidence interval [CI] 0.46 to 0.88), more recent year of AC entry (aHR 0.76, 95% CI 0.68 to 0.84) and higher CD4 count (aHR 0.67, 95% CI 0.54 to 0.84) were protective against experiencing an elevated VL. Among patients with an elevated VL, 52% (150/291) with a repeat VL test subsequently experienced confirmed virologic failure in a median time of 112 days (IQR: 56 to 168). Frequency of VL testing was constant over time (82 to 85%), with over 90% of patients remaining virologically suppressed. CONCLUSIONS This study demonstrates low prevalence of elevated VLs and confirmed virologic failure among patients who entered ACs. Although ACs were expanded rapidly, most patients were well monitored and remained stable, supporting the continued rollout of this model.
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Affiliation(s)
- Kathleen Kehoe
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Khayelitsha ART Programme and Médecins Sans FrontièresCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Priscilla R Tsondai
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Khayelitsha ART Programme and Médecins Sans FrontièresCape TownSouth Africa
| | - Mary Ann Davies
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
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Chihana ML, Huerga H, Van Cutsem G, Ellman T, Goemaere E, Wanjala S, Masiku C, Szumilin E, Etard JF, Maman D, Davies MA. Distribution of advanced HIV disease from three high HIV prevalence settings in Sub-Saharan Africa: a secondary analysis data from three population-based cross-sectional surveys in Eshowe (South Africa), Ndhiwa (Kenya) and Chiradzulu (Malawi). Glob Health Action 2020; 12:1679472. [PMID: 31679482 PMCID: PMC6844432 DOI: 10.1080/16549716.2019.1679472] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Despite substantial progress in antiretroviral therapy (ART) scale up, some people living with HIV (PLHIV) continue to present with advanced HIV disease, contributing to ongoing HIV-related morbidity and mortality.Objective: We aimed to quantify population-level estimates of advanced HIV from three high HIV prevalence settings in Sub-Saharan Africa.Methods: Three cross-sectional surveys were conducted in (Ndhiwa (Kenya): September-November 2012), (Chiradzulu (Malawi): February-May 2013) and (Eshowe (South Africa): July-October 2013). Eligible individuals 15-59 years old who consented were interviewed at home followed by rapid HIV test and CD4 count test if tested HIV-positive. Advanced HIV was defined as CD4 < 200 cells/µl. We used logistic regression to identify patient characteristics associated with advanced HIV.Results: Among 18,991 (39.2% male) individuals, 4113 (21.7%) tested HIV-positive; 385/3957 (9.7% (95% Confidence Interval [CI]: 8.8-10.7)) had advanced HIV, ranging from 7.8% (95%CI 6.4-9.5) Chiradzulu (Malawi) to 11.8% (95%CI 9.8-14.2) Ndhiwa (Kenya). The proportion of PLHIV with advanced disease was higher among men 15.3% (95% CI 13.2-17.5) than women 7.5% (95%CI 6.6-8.6) p < 0.001. Overall, 62.7% of all individuals with advanced HIV were aware of their HIV status and 40.3% were currently on ART. Overall, 65.6% of individuals not on ART had not previously been diagnosed with HIV, while only 29.6% of those on ART had been on ART for ≥6 months. Individuals with advanced HIV disease were more likely to be men (adjusted Odds Ratio [aOR]; 2.1 (95%CI 1.7-2.6), and more likely not to be on ART (aOR; 1.7 (95%CI 1.3-2.1).Conclusion: In our study, about 1 in 10 PLHIV had advanced HIV with nearly 40% of them unaware of their HIV status. However, a substantial proportion of patients with advanced HIV were established on ART. Our findings suggest the need for a dual focus on alternative testing strategies to identify PLHIV earlier as well as improving ART retention.
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Affiliation(s)
- Menard L Chihana
- Epicentre, Cape Town, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Gilles Van Cutsem
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,MSF Southern Africa Medical Unit (SAMU), Cape Town, South Africa
| | - Tom Ellman
- MSF Southern Africa Medical Unit (SAMU), Cape Town, South Africa
| | - Eric Goemaere
- MSF Southern Africa Medical Unit (SAMU), Cape Town, South Africa
| | | | | | | | - Jean-Francois Etard
- International Research Unit (UMI), IRD UMI 233, INSERM U1175, Montpellier University, TransVIHMI, Montpellier, France
| | - David Maman
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,MSF Nairobi, Nairobi, Kenya
| | - Mary-Ann Davies
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Global variations in mortality in adults after initiating antiretroviral treatment: an updated analysis of the International epidemiology Databases to Evaluate AIDS cohort collaboration. AIDS 2019; 33 Suppl 3:S283-S294. [PMID: 31800405 PMCID: PMC6919233 DOI: 10.1097/qad.0000000000002358] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND UNAIDS models use data from the International epidemiology Databases to Evaluate AIDS (IeDEA) collaboration in setting assumptions about mortality rates after antiretroviral treatment (ART) initiation. This study aims to update these assumptions with new data, to quantify the extent of regional variation in ART mortality and to assess trends in ART mortality. METHODS Adult ART patients from Africa, Asia and the Americas were included if they had a known date of ART initiation during 2001-2017 and a baseline CD4 cell count. In cohorts that relied only on passive follow-up (no patient tracing or linkage to vital registration systems), mortality outcomes were imputed in patients lost to follow-up based on a meta-analysis of tracing study data. Poisson regression models were fitted to the mortality data. RESULTS 464 048 ART patients were included. In multivariable analysis, mortality rates were lowest in Asia and highest in Africa, with no significant differences between African regions. Adjusted mortality rates varied significantly between programmes within regions. Mortality rates in the first 12 months after ART initiation were significantly higher during 2001-2006 than during 2010-2014, although the difference was more substantial in Asia and the Americas [adjusted incidence rate ratio (aIRR) 1.43, 95% CI: 1.22-1.66] than in Africa (aIRR 1.07, 95% CI: 1.04-1.11). CONCLUSION There is substantial variation in ART mortality between and within regions, even after controlling for differences in mortality by age, sex, baseline CD4 category and calendar period. ART mortality rates have declined substantially over time, although declines have been slower in Africa.
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Quinn C, Kadengye DT, Johnson CC, Baggaley R, Dalal S. Who are the missing men? Characterising men who never tested for HIV from population-based surveys in six sub-Saharan African countries. J Int AIDS Soc 2019; 22:e25398. [PMID: 31631576 PMCID: PMC6801221 DOI: 10.1002/jia2.25398] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 09/06/2019] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION We sought to characterize men who had never tested for HIV, understand factors associated with not testing, and measure survey HIV test uptake among never testers. We analysed nationally representative Demographic and Health Surveys of six African countries from 2013 to 2016: Ethiopia, Malawi, Zimbabwe, Rwanda, Lesotho and Zambia. METHODS Eligible men were household residents or overnight visitors aged 15 to 59 years. We analysed questionnaire responses on HIV testing, known behavioural risk factors, and corresponding HIV laboratory results. We used survey-weighted logistic regression to identify factors associated with never testing for HIV. RESULTS Approximately double the proportion of men had never tested for HIV compared to women (Malawi: 30% vs. 17%, p < 0.0001; Zimbabwe: 35% vs. 19%, p < 0.0001; Lesotho: 34% vs. 15%, p < 0.0001; Zambia: 36% vs. 20%, p < 0.0001); although, less of a differential existed in Ethiopia (54% vs. 56%, p = 0.12) and Rwanda (19% vs. 14%, p < 0.0001). When offered a test during the survey, 85% to 99% of sexually active men who reported never previously testing, accepted testing. HIV positivity ranged from <0.05% to 14% for never tested men. After adjusting for age, factors associated with never having tested for HIV were never being married (aOR range: 1.46 to 10.39), not having children (aOR: 1.36 to 3.59) and lower education (less than primary education aOR: 2.77 to 5.59). CONCLUSIONS Although higher proportions of men than women had never tested for HIV, 85% to 99% of men did accept a test when offered. Finding opportunities to offer HIV testing to single men without children, older men who have never tested, and those disadvantaged with less schooling and employment, alongside other facility and community-based services, will be important in identifying those living with undiagnosed HIV and improving men's health.
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Affiliation(s)
- Caitlin Quinn
- Department of HIV/AIDSWorld Health OrganizationGenevaSwitzerland
| | | | - Cheryl C Johnson
- Department of HIV/AIDSWorld Health OrganizationGenevaSwitzerland
| | - Rachel Baggaley
- Department of HIV/AIDSWorld Health OrganizationGenevaSwitzerland
| | - Shona Dalal
- Department of HIV/AIDSWorld Health OrganizationGenevaSwitzerland
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Bassett IV, Xu A, Giddy J, Bogart LM, Boulle A, Millham L, Losina E, Parker RA. Assessing rates and contextual predictors of 5-year mortality among HIV-infected and HIV-uninfected individuals following HIV testing in Durban, South Africa. BMC Infect Dis 2019; 19:751. [PMID: 31455229 PMCID: PMC6712739 DOI: 10.1186/s12879-019-4373-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/12/2019] [Indexed: 01/06/2023] Open
Abstract
Background Little is known about contextual factors that predict long-term mortality following HIV testing in resource-limited settings. We evaluated the impact of contextual factors on 5-year mortality among HIV-infected and HIV-uninfected individuals in Durban, South Africa. Methods We used data from the Sizanani trial (NCT01188941) in which adults (≥18y) were enrolled prior to HIV testing at 4 outpatient sites. We ascertained vital status via the South African National Population Register. We used random survival forests to identify the most influential predictors of time to death and incorporated these into a Cox model that included age, gender, HIV status, CD4 count, healthcare usage, health facility type, mental health, and self-identified barriers to care (i.e., service delivery, financial, logistical, structural and perceived health). Results Among 4816 participants, 39% were HIV-infected. Median age was 31y and 49% were female. 380 of 2508 with survival information (15%) died during median follow-up of 5.8y. For both HIV-infected and HIV-uninfected participants, each additional barrier domain increased the HR of dying by 11% (HR 1.11, 95% CI 1.05–1.18). Every 10-point increase in mental health score decreased the HR by 7% (HR 0.93, 95% CI 0.89–0.97). The hazard ratio (HR) for death of HIV-infected versus HIV-uninfected varied by age: HR of 6.59 (95% CI: 4.79–9.06) at age 20 dropping to a HR of 1.13 (95% CI: 0.86–1.48) at age 60. Conclusions Independent of serostatus, more self-identified barrier domains and poorer mental health increased mortality risk. Additionally, the impact of HIV on mortality was most pronounced in younger persons. These factors may be used to identify high-risk individuals requiring intensive follow up, regardless of serostatus. Trial registration Clinical Trials.gov Identifier NCT01188941. Registered 26 August 2010. Electronic supplementary material The online version of this article (10.1186/s12879-019-4373-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ingrid V Bassett
- Division of Infectious Diseases, Massachusetts General Hospital, 100 Cambridge Street, 16th Floor, Boston, MA, 02114, USA. .,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Harvard University Center for AIDS Research, Harvard University, Boston, MA, USA.
| | - Ai Xu
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Andrew Boulle
- Centre for Infectious Diseases, Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Lucia Millham
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Elena Losina
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Robert A Parker
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard University Center for AIDS Research, Harvard University, Boston, MA, USA.,Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
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38
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Osingada CP, Siu G, Amollo M, Muwanguzi P, Sewankambo N, Kiwanuka N. Acceptability of HIV testing for men attending televised football venues in Uganda. BMC Public Health 2019; 19:1136. [PMID: 31426776 PMCID: PMC6700992 DOI: 10.1186/s12889-019-7478-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 08/12/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Worldwide, HIV remains a major public health challenge, especially in Sub-Saharan Africa. Literature indicates that men's involvement in HIV testing, care, and treatment services is lower compared to women, therefore novel approaches are required to engage men in the cascade of HIV care. This study aimed to explore men's perception on the provision of HIV testing services in venues where English Premier League football games are televised. METHODS An exploratory qualitative study was conducted between February and May 2018. Six focus group discussions were conducted with 50 conveniently selected men aged 18 years and older using a pre-tested discussion guide. All focus group discussions were audio recorded, transcribed verbatim, and analyzed thematically. RESULTS Overall, HIV testing at venues telecasting English Premier League football games was acceptable to men. There was a very strong preference for health workers providing testing and counseling services be external or unknown in the local community. Possible motivators for testing services provided in these settings include subsidizing or eliminating entrance fee to venues telecasting games, integrating testing and counseling with health promotion or screening for other diseases, use of local football games as mobilization tools and use of expert clients as role models. CONCLUSIONS This study suggests that HIV testing services at venues where EPL football games are televised is generally acceptable to men. In implementing such services, consideration should be given to preferences for external or unknown health workers and the motivating factors contributing to the use of these services. Given that HIV testing is currently not conducted in these settings, further research should be conducted to evaluate the feasibility of this approach as a means of enhancing HIV testing among Ugandan men.
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Affiliation(s)
- Charles Peter Osingada
- Department of Nursing, Makerere University College of Health Sciences, School of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Godfrey Siu
- Makerere University Child Health and Development Centre, P.O Box 7072, Kampala, Uganda
| | - Mathew Amollo
- Department of Community and Environmental Health, Makerere University College of Health Sciences, School of Public Health, P.O Box 7072, Kampala, Uganda
| | - Patience Muwanguzi
- Department of Nursing, Makerere University College of Health Sciences, School of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Nelson Sewankambo
- Department of Internal Medicine, School of Medicine, Makerere College of Health Sciences, P.O Box 7072, Kampala, Uganda
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, P.O Box 7072, Kampala, Uganda
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Lilian RR, Rees K, Mabitsi M, McIntyre JA, Struthers HE, Peters RPH. Baseline CD4 and mortality trends in the South African human immunodeficiency virus programme: Analysis of routine data. South Afr J HIV Med 2019; 20:963. [PMID: 31392037 PMCID: PMC6676982 DOI: 10.4102/sajhivmed.v20i1.963] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 04/11/2019] [Indexed: 01/08/2023] Open
Abstract
Background Despite widespread availability of antiretroviral therapy (ART) in South Africa, there remains a considerable burden of human immunodeficiency virus (HIV)-related morbidity and mortality. Objectives To describe ART initiation and outcome trends over time, with a focus on clients presenting with advanced HIV-infection, so as to identify interventions to reduce morbidity and mortality. Methods Routine TIER.Net data from HIV-infected adults who had a documented baseline CD4 count and were newly initiating ART in Johannesburg or Mopani districts from 2004 to 2017 were analysed. Trends in baseline CD4 count and 5-year mortality were investigated and the population initiating ART with CD4 < 200 cells/mm3 was described. Results The Johannesburg and Mopani data sets comprised 203 131 and 101 814 records, respectively. Although median CD4 count increased over time, the proportion of initiations at CD4 < 200 cells/mm3 in 2017 remained high (Johannesburg 39%, Mopani 35%). Mortality was significantly increased among clients with CD4 < 200 compared to those with higher baseline counts (p < 0.001). Even though mortality among clients with low CD4 declined over time, likely because of improved drug regimens, in 2016-2017 mortality was still significantly increased among these clients (p < 0.001). Delivery of cotrimoxazole prophylaxis to clients with low CD4 declined over time to < 30% in 2017 and was associated with clinical stage. Presentation with CD4 < 200 cells/mm3 was associated with older age, male gender and hospitalisation. Conclusion A concerningly large proportion of South Africans still initiate ART at low CD4 counts. This is associated with increased mortality and requires targeted interventions to improve delivery of prophylactic regimens and early engagement in care.
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Affiliation(s)
| | - Kate Rees
- Anova Health Institute, Johannesburg, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - James A McIntyre
- Anova Health Institute, Johannesburg, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen E Struthers
- Anova Health Institute, Johannesburg, South Africa.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Remco P H Peters
- Anova Health Institute, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Department of Medical Microbiology, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, Maastricht, the Netherlands
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Fox MP, Pascoe S, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Adherence clubs and decentralized medication delivery to support patient retention and sustained viral suppression in care: Results from a cluster-randomized evaluation of differentiated ART delivery models in South Africa. PLoS Med 2019; 16:e1002874. [PMID: 31335865 PMCID: PMC6650049 DOI: 10.1371/journal.pmed.1002874] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/28/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Differentiated antiretroviral therapy (ART) delivery models, in which patients are provided with care relevant to their current status (e.g., newly initiating, stable on treatment, or unstable on treatment) has become an essential part of patient-centered health systems. In 2015, the South African government implemented Chronic Disease Adherence Guidelines (AGLs), which involved five interventions: Fast Track Initiation Counseling for newly initiating patients, Enhanced Adherence Counseling for patients with an unsuppressed viral load, Early Tracing of patients who miss visits, and Adherence Clubs (ACs) and Decentralized Medication Delivery (DMD) for stable patients. We evaluated two of these interventions in 24 South African facilities: ACs, in which patients meet in groups outside usual clinic procedures and receive medication; and DMD, in which patients pick up their medication outside usual pharmacy queues. METHODS AND FINDINGS We compared those participating in ACs or receiving DMD at intervention sites to those eligible for ACs or DMD at control sites. Outcomes were retention and sustained viral suppression (<400 copies/mL) 12 months after AC or DMD enrollment (or comparable time for controls). 12 facilities were randomly allocated to intervention and 12 to control arms in four provinces (Gauteng, North West, Limpopo, and KwaZulu Natal). We calculated adjusted risk differences (aRDs) with cluster adjustment using generalized estimating equations (GEEs) using difference in differences (DiD) with patients eligible for ACs/DMD prior to implementation (Jan 1, 2015) for comparison. For DMD, randomization was not preserved, and the analysis was treated as observational. For ACs, 275 intervention and 294 control patients were enrolled; 72% of patients were female, 61% were aged 30-49 years, and median CD4 count at ART initiation was 268 cells/μL. AC patients had higher 1-year retention (89.5% versus 81.6%, aRD: 8.3%; 95% CI: 1.1% to 15.6%) and comparable sustained 1-year viral suppression (<400 copies/mL any time ≤ 18 months) (80.0% versus 79.6%, aRD: 3.8%; 95% CI: -6.9% to 14.4%). Retention associations were apparently stronger for men than women (men RD: 13.1%, 95% CI: 0.3% to 23.5%; women RD: 6.0%, 95% CI: -0.9% to 12.9%). For DMD, 232 intervention and 346 control patients were enrolled; 71% of patients were female, 65% were aged 30-49 years, and median CD4 count at ART initiation was 270 cells/μL. DMD patients had apparently lower retention (81.5% versus 87.2%, aRD: -5.9%; 95% CI: -12.5% to 0.8%) and comparable viral suppression versus standard of care (77.2% versus 74.3%, aRD: -1.0%; 95% CI: -12.2% to 10.1%), though in both cases, our findings were imprecise. We also noted apparently increased viral suppression among men (RD: 11.1%; 95% CI: -3.4% to 25.5%). The main study limitations were missing data and lack of randomization in the DMD analysis. CONCLUSIONS In this study, we found comparable DMD outcomes versus standard of care at facilities, a benefit for retention of patients in care with ACs, and apparent benefits in terms of retention (for AC patients) and sustained viral suppression (for DMD patients) among men. This suggests the importance of alternative service delivery models for men and of community-based strategies to decongest primary healthcare facilities. Because these strategies also reduce patient inconvenience and decongest clinics, comparable outcomes are a potential success. The cost of all five AGL interventions and possible effects on reducing clinic congestion should be investigated. CLINICAL TRIAL REGISTRATION NCT02536768.
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Affiliation(s)
- Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy N. Huber
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - David Wilson
- The World Bank Group, Washington DC, United States of America
| | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
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Lippman SA, El Ayadi AM, Grignon JS, Puren A, Liegler T, Venter WDF, Ratlhagana MJ, Morris JL, Naidoo E, Agnew E, Barnhart S, Shade SB. Improvements in the South African HIV care cascade: findings on 90-90-90 targets from successive population-representative surveys in North West Province. J Int AIDS Soc 2019; 22:e25295. [PMID: 31190460 PMCID: PMC6562149 DOI: 10.1002/jia2.25295] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 04/30/2019] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION To achieve epidemic control of HIV by 2030, countries aim to meet 90-90-90 targets to increase knowledge of HIV-positive status, initiation of antiretroviral therapy (ART) and viral suppression by 2020. We assessed the progress towards these targets from 2014 to 2016 in South Africa as expanded treatment policies were introduced using population-representative surveys. METHODS Data were collected in January to March 2014 and August to November 2016 in Dr. Ruth Segomotsi Mompati District, North West Province. Each multi-stage cluster sample included 46 enumeration areas (EA), a target of 36 dwelling units (DU) per EA, and a single resident aged 18 to 49 per DU. Data collection included behavioural surveys, rapid HIV antibody testing and dried blood spot collection. We used weighted general linear regression to evaluate differences in the HIV care continuum over time. RESULTS Overall, 1044 and 971 participants enrolled in 2014 and 2016 respectively with approximately 77% undergoing HIV testing. Despite increases in reported testing, known status among people living with HIV (PLHIV) remained similar at 68.7% (95% Confidence Interval (CI) = 60.9-75.6) in 2014 and 72.8% (95% CI = 63.6-80.4) in 2016. Men were consistently less likely than women to know their status. Among those with known status, PLHIV on ART increased significantly from 80.9% (95% CI = 71.9-87.4) to 91.5% (95% CI = 84.4-95.5). Viral suppression (<5000 copies/mL using DBS) among those on ART increased significantly from 55.0% (95% CI = 39.6-70.4) in 2014 to 81.4% (95% CI = 72.0-90.8) in 2016. Among all PLHIV an estimated 72.0% (95% CI = 63.8-80.1) of women and 45.8% (95% CI = 27.0-64.7) of men achieved viral suppression by 2016. CONCLUSIONS Over a period during which fixed-dose combination was introduced, ART eligibility expanded, and efforts to streamline treatment were implemented, major improvements in the second and third 90-90-90 targets were achieved. Achieving the first 90 target will require targeted and improved testing models for men.
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Affiliation(s)
- Sheri A Lippman
- Center for AIDS Prevention StudiesDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Alison M El Ayadi
- Bixby Center for Global Reproductive HealthDepartment of Obstetrics, Gynecology and Reproductive SciencesUniversity of CaliforniaSan FranciscoCAUSA
| | - Jessica S Grignon
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- International Training and Education Center for Health (I‐TECH) South AfricaPretoriaRepublic of South Africa
| | - Adrian Puren
- Centre for HIV and STIsNational Institute for Communicable Diseases/NHLSDivision of VirologySchool of PathologyUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Teri Liegler
- HIV/AIDS DivisionDepartment of MedicineHIV, Infectious Diseases and Global Health DivisionUniversity of CaliforniaSan FranciscoCAUSA
| | - W D Francois Venter
- Wits Reproductive Health and HIV Institute (WRHI)Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Mary J Ratlhagana
- International Training and Education Center for Health (I‐TECH) South AfricaPretoriaRepublic of South Africa
| | - Jessica L Morris
- Center for AIDS Prevention StudiesDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Evasen Naidoo
- International Training and Education Center for Health (I‐TECH) South AfricaPretoriaRepublic of South Africa
| | - Emily Agnew
- Center for AIDS Prevention StudiesDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Scott Barnhart
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Starley B Shade
- Center for AIDS Prevention StudiesDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
- Institute for Global Health ScienceDepartment of Epidemiology and BiostatisticsUniversity of CaliforniaSan FranciscoCAUSA
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Strategies for engaging men in HIV services. Lancet HIV 2019; 6:e191-e200. [PMID: 30777726 DOI: 10.1016/s2352-3018(19)30032-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 12/20/2018] [Accepted: 12/20/2018] [Indexed: 12/14/2022]
Abstract
The importance of men in the global HIV response is increasingly recognised. In most settings, men are less engaged in HIV services and have worse health outcomes than women. The multiple gender, social, economic, political, and institutional factors behind these patterns are well documented. More recently, researchers have been reporting evidence on strategies aimed at improving the engagement of men in HIV services. Several promising approaches exist, including community-based outreach programmes, gender-transformative interventions to shift gender norms and practices, and the development of more responsive, male-friendly health services. Challenges remain, however, in terms of cost and sustainability, intersecting inequalities like race and class, and the difficulty of changing community-level gender norms. Future research should focus on developing theory-informed interventions and evaluations, on improving the understanding of specific subpopulations of men, and on broadening the evidence base beyond the few countries that produce most research in this field.
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Zhu J, Yang W, Feng Y, Lo C, Chen H, Zhu Q, Shen Z, Lan G, Chen Y, Tang Z, Xing H, Shao Y, Ruan Y, Li L. Treatment effects of the differential first-line antiretroviral regimens among HIV/HBV coinfected patients in southwest China: an observational study. Sci Rep 2019; 9:1006. [PMID: 30700732 PMCID: PMC6353888 DOI: 10.1038/s41598-018-37148-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 11/26/2018] [Indexed: 12/30/2022] Open
Abstract
HIV with HBV co-infection can result in greater HIV-related immunosuppression, morbidity and mortality. Currently, there are few studies to evaluate direct treatment effects on mortality and attrition rates between first-line antiretroviral therapy (ART) based-on tenofovir (TDF) and/or lamivudine (3TC) in a real-world setting. We used Cox proportional hazard models to evaluate direct treatment effects of the first-line ART containing stavudine (d4T), azidothymidine (AZT) and TDF on death and attrition among HIV patients with HBV coinfection. A total of 3912 patients met study eligibility criteria. The overall mortality rate and attrition rate was 2.85 (95% CI: 2.55-3.16) and 8.87 (95% CI: 8.32-9.41) per 100 person-years, respectively. The ART containing TDF had a significantly lower risk of death [adjusted hazard ratio (AHR) = 0.58, 95% CI: 0.44-0.77] when compared to the ART containing d4T, but the risk of death was not significantly different when compared to the ART containing AZT (AHR = 0.91, 95% CI: 0.69-1.20). Patients with HIV/HBV coinfection receiving the ART containing TDF had significantly lower risk rates of attrition compared to those receiving the ART containing d4T (AHR = 0.72, 95% CI: 0.60-0.86) or AZT (AHR = 0.67, 95% CI: 0.58-0.77). Compared with the ART containing d4T, the ART containing AZT was significant and not significant associated with a lower risk of death and attrition, respectively. The ART containing TDF had significant effects on both of death and attrition among HIV patients with HBV coinfection.
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Affiliation(s)
- Jinhui Zhu
- School of Public Health, Peking University, Beijing, China
| | - Wenmin Yang
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Yuan Feng
- School of Public Health, Yale University, New Haven, USA
| | - Cody Lo
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Huanhuan Chen
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Qiuying Zhu
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Zhiyong Shen
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Guanghua Lan
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Yi Chen
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Zhenzhu Tang
- Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Hui Xing
- Guangxi Center for Disease Control and Prevention, Nanning, China
- State Key Laboratory of Infectious Disease Prevention and Control (SKLID), Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Chinese Center for Disease Control and Prevention (China CDC), Beijing, China
| | - Yiming Shao
- Guangxi Center for Disease Control and Prevention, Nanning, China
- State Key Laboratory of Infectious Disease Prevention and Control (SKLID), Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Chinese Center for Disease Control and Prevention (China CDC), Beijing, China
| | - Yuhua Ruan
- Guangxi Center for Disease Control and Prevention, Nanning, China
- State Key Laboratory of Infectious Disease Prevention and Control (SKLID), Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Chinese Center for Disease Control and Prevention (China CDC), Beijing, China
| | - Liming Li
- School of Public Health, Peking University, Beijing, China.
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Fox MP, Pascoe SJS, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Effectiveness of interventions for unstable patients on antiretroviral therapy in South Africa: results of a cluster-randomised evaluation. Trop Med Int Health 2018; 23:1314-1325. [PMID: 30281882 DOI: 10.1111/tmi.13152] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND As loss from HIV care is an ongoing challenge globally, interventions are needed for patients who don't achieve or maintain ART stability. The 2015 South African National Adherence Guidelines (AGL) for Chronic Diseases include two interventions targeted at unstable patients: early tracing of patients who miss visits (TRIC) and enhanced adherence counselling (EAC). METHODS As part of a cluster-randomised evaluation at 12 intervention and 12 control clinics in four provinces, intervention sites implemented the AGL interventions, while control sites retained standard care. We report on outcomes of EAC for patients with an elevated viral load (>400 copies/ml) and for TRIC patients who missed a visit by >5 days. We estimated risk differences (RD) of 3 and 12-month viral resuppression (<400 copies/ml) and 12-month retention with cluster adjustment using generalised estimating equations and controlled for imbalances using difference-in-differences compared to all eligible in 2015, prior to intervention roll-out. RESULTS For EAC, we had 358 intervention and 505 control site patients (61% female, median ART initiation CD4 count 154 cells/μl). We found no difference between arms in 3-month resuppression (RD: -1.7%; 95%CI: -4.3% to 0.9%), but <20% of patients had a repeat viral load within 3 months (19.8% intervention, 13.5% control). Including the entire clinic population eligible for EAC with a repeat viral load at all evaluation sites (n = 934), intervention sites showed a small increase in 3-month resuppression (28% vs. 25%, RD 3.0%; 95%CI: -2.7% to 8.8%). Adjusting for baseline differences increased the RD to 8.1% (95% CI: -0.1% to 17.2%). However, we found no differences in 12-month suppression (RD: 1.5%; 95% CI: -14.1% to 17.1% but suppression was low overall at 40%) or retention (RD: 2.8%; 95% CI: -7.5% to 13.2%). For TRIC, we enrolled 155 at intervention sites and 248 at control sites (44% >40 years, 67% female, median CD4 count 212 cells/μl). We found no difference between groups in return to care by 12 months (RD: -6.8%; 95% CI: -17.7% to 4.8%). During the study period, control sites continued to use tracing within standard care, however, potentially masking intervention effects. CONCLUSIONS Enhanced adherence counselling showed no benefit over 12 months. Implementation of the tracing intervention under the new guidelines was similar to the standard of care. Interventions that aim to return unstable patients to care should incorporate active monitoring to determine if the interventions are effective.
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Affiliation(s)
- Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Sophie J S Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy N Huber
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
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Hendrickson CJ, Pascoe SJS, Huber AN, Moolla A, Maskew M, Long LC, Fox MP. "My future is bright…I won't die with the cause of AIDS": ten-year patient ART outcomes and experiences in South Africa. J Int AIDS Soc 2018; 21:e25184. [PMID: 30318848 PMCID: PMC6186968 DOI: 10.1002/jia2.25184] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 08/13/2018] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION South Africa is moving into a new era of HIV treatment with "treat all" policies where people may be on treatment for most of their lives. We need to understand treatment outcomes and facilitators of long-term antiretroviral treatment (ART) adherence and retention-in-care in the South African context. In one of the first studies to investigate long-term treatment outcomes in South Africa, we aimed to describe ten-year patient outcomes at a large public-sector HIV clinic in Johannesburg and explore patient experiences of the treatment programme over this time in order to ascertain factors that may aid or hinder long-term adherence and retention. METHODS We conducted a cohort analysis (n = 6644) and in-depth interviews (n = 24) among HIV-positive adults initiating first-line ART between April 2004 and March 2007. Using clinical records, we ascertained twelve-month and ten-year all-cause mortality and loss to follow-up (LTF). Cox proportional hazards regression was used to identify baseline predictors of attrition (mortality and LTF (>3 months late for the last scheduled visit)) at twelve months and ten years. Twenty-four patients were purposively selected and interviewed to explore treatment programme experiences over ten years on ART. RESULTS Excluding transfers, 79.5% (95% confidence intervals (CI): 78.5 to 80.5) of the cohort were alive, in care at twelve months dropping to 35.1% (95% CI: 33.7 to 36.4) at ten years. Over 44% of deaths occurred within 12 months. Ten-year all-cause mortality increased, while LTF decreased slightly, with age. Year and age at ART initiation, sex, nationality, baseline CD4 count, anaemia, body mass index and initiating regimen were predictors of ten-year attrition. Among patients interviewed, the pretreatment clinic environment, feelings of gratitude and good fortune, support networks, and self-efficacy were facilitators of care; side effects, travel and worsening clinical conditions were barriers. Participants were generally optimistic about their futures and were committed to continued care. CONCLUSIONS This study demonstrates the complexities of long-term chronic HIV treatment with declining all-cause mortality and increasing LTF over ten years. Barriers to long-term retention still present a significant challenge. As more people become eligible for ART in South Africa under "treatment for all," new healthcare delivery challenges will arise; interventions are needed to ensure long-term programme successes continue.
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Affiliation(s)
- Cheryl J Hendrickson
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sophie J S Pascoe
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Amy N Huber
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Aneesa Moolla
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Mhairi Maskew
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Lawrence C Long
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Matthew P Fox
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
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Mak D, Sengayi M, Chen WC, Babb de Villiers C, Singh E, Kramvis A. Liver cancer mortality trends in South Africa: 1999-2015. BMC Cancer 2018; 18:798. [PMID: 30086727 PMCID: PMC6081797 DOI: 10.1186/s12885-018-4695-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 07/26/2018] [Indexed: 12/11/2022] Open
Abstract
Background In South Africa (SA), liver cancer (LC) is a public health problem and information is limited. Methods Joinpoint regression analysis was computed for the most recent LC mortality data from Statistics South Africa (StatsSA), by age group, sex and population group. The mortality-to-incidence ratios (MIRs) were calculated as the age-adjusted mortality rate divided by the age-adjusted incidence rate. Results From 1999 to 2015, the overall LC mortality significantly decreased in men (− 4.9%) and women (− 2.7%). Overall a significant decrease was noted in black African men aged 20–29 and 40–49 years, and white women older than 60 years but mortality rates increased among 50–59 and 60–69 year old black African men (from 2010/2009–2015) and women (from 2004/2009–2015). The mortality rates increased with age, and were higher among blacks Africans compared to whites in all age groups - with a peak black African-to-white mortality rate ratio of six in men and three in women at ages 30–39 years. The average MIR for black African men and women was 4 and 3.3 respectively, and 2.2 and 1.8 in their white counterparts. Moreover, decreasing LC mortality rates among younger and the increase in rates in older black Africans suggest that the nadir of the disease may be near or may have passed. Conclusions Findings of population-age subgroup variations in LC mortality and the number of underdiagnosed cases can inform surveillance efforts, while more extensive investigations of the aetiological risk factors are needed. Impact: There was a large race, sex and age differences in trends of LC mortality in SA. These findings should inform more extensive evaluation of the aetiology and risk factors of LC in the country in order to guide control efforts.
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Affiliation(s)
- Daniel Mak
- Hepatitis Virus Diversity Research Unit (HVDRU), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Mazvita Sengayi
- National Cancer Registry, National Health Laboratory Service, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Wenlong C Chen
- National Cancer Registry, National Health Laboratory Service, Johannesburg, South Africa.,Sydney Brenner Institute for Molecular Bioscience, University of the Witwatersrand, Johannesburg, South Africa
| | - Chantal Babb de Villiers
- Division of Human Genetics, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Elvira Singh
- National Cancer Registry, National Health Laboratory Service, Johannesburg, South Africa. .,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Anna Kramvis
- Hepatitis Virus Diversity Research Unit (HVDRU), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
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Holmes CB, Sikazwe I, Sikombe K, Eshun-Wilson I, Czaicki N, Beres LK, Mukamba N, Simbeza S, Bolton Moore C, Hantuba C, Mwaba P, Phiri C, Padian N, Glidden DV, Geng E. Estimated mortality on HIV treatment among active patients and patients lost to follow-up in 4 provinces of Zambia: Findings from a multistage sampling-based survey. PLoS Med 2018; 15:e1002489. [PMID: 29329301 PMCID: PMC5766235 DOI: 10.1371/journal.pmed.1002489] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/11/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Survival represents the single most important indicator of successful HIV treatment. Routine monitoring fails to capture most deaths. As a result, both regional assessments of the impact of HIV services and identification of hotspots for improvement efforts are limited. We sought to assess true mortality on treatment, characterize the extent under-reporting of mortality in routine health information systems in Zambia, and identify drivers of mortality across sites and over time using a multistage, regionally representative sampling approach. METHODS AND FINDINGS We enumerated all HIV infected adults on antiretroviral therapy (ART) who visited any one of 64 facilities across 4 provinces in Zambia during the 24-month period from 1 August 2013 to 31 July 2015. We identified a probability sample of patients who were lost to follow-up through selecting facilities probability proportional to size and then a simple random sample of lost patients. Outcomes among patients lost to follow-up were incorporated into survival analysis and multivariate regression through probability weights. Of 165,464 individuals (64% female, median age 39 years (IQR 33-46), median CD4 201 cells/mm3 (IQR 111-312), the 2-year cumulative incidence of mortality increased from 1.9% (95% CI 1.7%-2.0%) to a corrected rate of 7.0% (95% CI 5.7%-8.4%) (all ART users) and from 2.1% (95% CI 1.8%-2.4%) to 8.3% (95% CI 6.1%-10.7%) (new ART users). Revised provincial mortality rates ranged from 3-9 times higher than naïve rates for new ART users and were lowest in Lusaka Province (4.6 per 100 person-years) and highest in Western Province (8.7 per 100 person-years) after correction. Corrected mortality rates varied markedly by clinic, with an IQR of 3.5 to 7.5 deaths per 100 person-years and a high of 13.4 deaths per 100 person-years among new ART users, even after adjustment for clinical (e.g., pretherapy CD4) and contextual (e.g., province and clinic size) factors. Mortality rates (all ART users) were highest year 1 after treatment at 4.6/100 person-years (95% CI 3.9-5.5), 2.9/100 person-years (95% CI 2.1-3.9) in year 2, and approximately 1.6% per year through 8 years on treatment. In multivariate analysis, patient-level factors including male sex and pretherapy CD4 levels and WHO stage were associated with higher mortality among new ART users, while male sex and HIV disclosure were associated with mortality among all ART users. In both cases, being late (>14 days late for appointment) or lost (>90 days late for an appointment) was associated with deaths. We were unable to ascertain the vital status of about one-quarter of those lost and selected for tracing and did not adjudicate causes of death. CONCLUSIONS HIV treatment in Zambia is not optimally effective. The high and sustained mortality rates and marked under-reporting of mortality at the provincial-level and unexplained heterogeneity between regions and sites suggest opportunities for the use of corrected mortality rates for quality improvement. A regionally representative sampling-based approach can bring gaps and opportunities for programs into clear epidemiological focus for local and global decision makers.
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Affiliation(s)
- Charles B Holmes
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,Johns Hopkins University, Baltimore, Maryland, United States of America.,Georgetown University, Washington, DC, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | | | - Nancy Czaicki
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,University of California, Berkeley, Berkeley, California, United States of America
| | - Laura K Beres
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Cardinal Hantuba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Peter Mwaba
- Lusaka Apex Medical University, Lusaka, Zambia
| | - Caroline Phiri
- Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia
| | - Nancy Padian
- University of California, Berkeley, Berkeley, California, United States of America
| | - David V Glidden
- University of California, San Francisco, San Francisco, California, United States of America
| | - Elvin Geng
- University of California, San Francisco, San Francisco, California, United States of America
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