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Delphin M, Mohammed KS, Downs LO, Lumley SF, Waddilove E, Okanda D, Aliyan N, Van Schalkwyk M, Anderson M, Ocama P, Maponga T, Torimiro J, Iwuji C, Ndung'u T, Matthews PC, Taljaard J. Under-representation of the WHO African region in clinical trials of interventions against hepatitis B virus infection. Lancet Gastroenterol Hepatol 2024; 9:383-392. [PMID: 38367632 DOI: 10.1016/s2468-1253(23)00315-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/31/2023] [Accepted: 09/11/2023] [Indexed: 02/19/2024]
Abstract
The WHO African region bears a disproportionate burden of morbidity and mortality related to chronic hepatitis B virus (HBV) infection and accounts for an estimated 70% of new HBV infections worldwide. We investigated the extent to which HBV clinical trials represented populations in this region by searching the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov for interventional clinical trials published in English between database inception and May 29, 2023, using the search term "Hepatitis B". We identified 1804 unique clinical trials, of which 18 (1·0%) recorded involvement of the WHO African region. There is no evidence that the number of HBV clinical trials in this region has improved over time. The diversity of new interventions and industry sponsorship in the WHO African region were low, with trials of HBV comparing poorly with those of other endemic infectious diseases (eg, malaria, HIV, and SARS-CoV-2). HBV research and clinical trial investigations have neglected the WHO African region, leading to profound health inequities. HBV clinical trials are urgently needed to evaluate the efficacy of newly discovered therapeutics and to ensure that interventions can be equitably distributed and deployed as they become available.
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Affiliation(s)
| | - Khadija Said Mohammed
- The Francis Crick Institute, London, UK; Division of Biosciences, Faculty of Life Sciences, University College London, London, UK
| | - Louise O Downs
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; Department of Infectious Diseases and Microbiology, John Radcliffe Hospital, Oxford, UK; Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Sheila F Lumley
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; Department of Infectious Diseases and Microbiology, John Radcliffe Hospital, Oxford, UK
| | | | - Dorcas Okanda
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Marije Van Schalkwyk
- Division of Infectious Diseases, Department of Medicine, Stellenbosch University-Tygerberg Academic Hospital, Cape Town, South Africa
| | - Motswedi Anderson
- The Francis Crick Institute, London, UK; Botswana Harvard AIDS Institute Partnership, Princess Marina Hospital, Gaborone, Botswana; Africa Health Research Institute, Durban, South Africa
| | - Ponsiano Ocama
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Tongai Maponga
- Division of Medical Virology, Stellenbosch University-National Health Laboratory Service Tygerberg Business Unit, Cape Town, South Africa
| | - Judith Torimiro
- Molecular Biology Laboratory, Chantal Biya International Reference Centre for AIDS Research, Yaounde, Cameroon
| | - Collins Iwuji
- Africa Health Research Institute, Durban, South Africa; Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Thumbi Ndung'u
- Division of Infection and Immunity, University College London, London, UK; Africa Health Research Institute, Durban, South Africa
| | - Philippa C Matthews
- The Francis Crick Institute, London, UK; Division of Infection and Immunity, University College London, London, UK; Nuffield Department of Medicine, University of Oxford, Oxford, UK; Department of Infectious Diseases, University College London Hospital, London, London, UK.
| | - Jantjie Taljaard
- Division of Infectious Diseases, Department of Medicine, Stellenbosch University-Tygerberg Academic Hospital, Cape Town, 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] [What about the content of this article? (0)] [Affiliation(s)] [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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3
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Iwuji C, Martin CE, Pillay D, Shamu P, Nzenze S, Murire M, Cox LA, Miners A, Llewellyn C, Mullick S. Implementation preferences for the management of sexually transmitted infections in the South African health system: a discrete choice experiment. Sex Transm Infect 2024; 100:10-16. [PMID: 37918916 PMCID: PMC10850665 DOI: 10.1136/sextrans-2023-055816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 09/19/2023] [Indexed: 11/04/2023] Open
Abstract
OBJECTIVES Despite strengthening HIV prevention with the introduction of pre-exposure prophylaxis (PrEP), STI services have remained relatively unchanged and the standard of care remains syndromic management. We used a discrete choice experiment to investigate service users' preferences for the diagnosis and treatment of STIs in South Africa. METHODS Between 1 March 2021 and 20 April 2021, a cross-sectional online questionnaire hosted on REDCap was administered through access links sent to WhatsApp support groups for HIV PrEP users and attendees of two primary healthcare clinics and two mobile facilities in the Eastern Cape and Gauteng provinces aged between 18 and 49 years. Participants either self-completed the questionnaire or received support from a research assistant. We used a conditional logit model for the initial analysis and latent class model (LCM) to establish class memberships, with results displayed as ORs and probabilities. RESULTS We enrolled 496 individuals; the majority were female (69%) and <30 years (74%). The LCM showed two distinct groups. The first group, comprising 68% of the participants, showed a strong preference for self-sampling compared with no sampling (OR 2.16, 95% CI 1.62 to 2.88). A clinic follow-up appointment for treatment was less preferable to same-day treatment (OR 0.78, 95% CI 0.63 to 0.95). Contact slip from index patient (OR 0.86, 95% CI 0.76 to 0.96) and healthcare professional (HCP)-initiated partner notification (OR 0.63, 95% CI 0.55 to 0.73) were both less preferable than expedited partner treatment (EPT). The second group included 32% of participants with a lower preference for self-sampling compared with no sampling (OR 0.65, 95% CI 0.41 to 1.04). There was no treatment option that was significantly different from the others; however, there was a strong preference for HCP-initiated partner notification to EPT (OR 1.53, 95% CI 1.10 to 2.12). CONCLUSIONS Our results suggest that service users preferred STI testing prior to treatment, with the majority preferring self-taken samples and receiving aetiology-based treatment on the same day.
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Affiliation(s)
- Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
- Africa Health Research Institute, Durban, South Africa
| | - Catherine E Martin
- Department of Implementation Science, Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
| | - Diantha Pillay
- Department of Implementation Science, Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
| | - Patience Shamu
- Department of Implementation Science, Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
| | - Susan Nzenze
- Department of Implementation Science, Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
| | - Mercy Murire
- Department of Implementation Science, Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
| | - Laura Ashleigh Cox
- Department of Implementation Science, Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
| | - Alec Miners
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Carrie Llewellyn
- Primary Care and Public Health, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Saiqa Mullick
- Department of Implementation Science, Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
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4
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Trickey A, Johnson LF, Fung F, Bonifacio R, Iwuji C, Biraro S, Bosomprah S, Chirimuta L, Euvrard J, Fatti G, Fox MP, Von Groote P, Gumulira J, Howard G, Jennings L, Kiragga A, Muula G, Tanser F, Wagener T, Low A, Vickerman P. Associations of inter-annual rainfall decreases with subsequent HIV outcomes for persons with HIV on antiretroviral therapy in Southern Africa: a collaborative analysis of cohort studies. BMC Infect Dis 2023; 23:889. [PMID: 38114912 PMCID: PMC10731689 DOI: 10.1186/s12879-023-08902-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/13/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Periods of droughts can lead to decreased food security, and altered behaviours, potentially affecting outcomes on antiretroviral therapy (ART) among persons with HIV (PWH). We investigated whether decreased rainfall is associated with adverse outcomes among PWH on ART in Southern Africa. METHODS Data were combined from 11 clinical cohorts of PWH in Lesotho, Malawi, Mozambique, South Africa, Zambia, and Zimbabwe, participating in the International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA-SA) collaboration. Adult PWH who had started ART prior to 01/06/2016 and were in follow-up in the year prior to 01/06/2016 were included. Two-year rainfall from June 2014 to May 2016 at the location of each HIV centre was summed and ranked against historical 2-year rainfall amounts (1981-2016) to give an empirical relative percentile rainfall estimate. The IeDEA-SA and rainfall data were combined using each HIV centre's latitude/longitude. In individual-level analyses, multivariable Cox or generalized estimating equation regression models (GEEs) assessed associations between decreased rainfall versus historical levels and four separate outcomes (mortality, CD4 counts < 200 cells/mm3, viral loads > 400 copies/mL, and > 12-month gaps in follow-up) in the two years following the rainfall period. GEEs were used to investigate the association between relative rainfall and monthly numbers of unique visitors per HIV centre. RESULTS Among 270,708 PWH across 386 HIV centres (67% female, median age 39 [IQR: 32-46]), lower rainfall than usual was associated with higher mortality (adjusted Hazard Ratio: 1.18 [95%CI: 1.07-1.32] per 10 percentile rainfall rank decrease) and unsuppressed viral loads (adjusted Odds Ratio: 1.05 [1.01-1.09]). Levels of rainfall were not strongly associated with CD4 counts < 200 cell/mm3 or > 12-month gaps in care. HIV centres in areas with less rainfall than usual had lower numbers of PWH visiting them (adjusted Rate Ratio: 0.80 [0.66-0.98] per 10 percentile rainfall rank decrease). CONCLUSIONS Decreased rainfall could negatively impact on HIV treatment behaviours and outcomes. Further research is needed to explore the reasons for these effects. Interventions to mitigate the health impact of severe weather events are required.
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Affiliation(s)
- Adam Trickey
- Population Health Sciences, University of Bristol, Bristol, UK.
| | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Fai Fung
- Department of Civil Engineering, University of Bristol, Bristol, UK
- UK Meteorological Office, Exeter, UK
| | - Rogerio Bonifacio
- Climate and Earth Observation Unit, Research Assessment and Monitoring Division, World Food Programme HQ, Rome, Italy
| | - Collins Iwuji
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Global Health Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Samuel Biraro
- ICAP at Columbia University, Nakasero, Kampala, Uganda
| | - Samuel Bosomprah
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Biostatistics, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | | | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Geoffrey Fatti
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health and Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Per Von Groote
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Guy Howard
- Department of Civil Engineering and Cabot Institute of the Environment, University of Bristol, Bristol, UK
| | - Lauren Jennings
- Desmond Tutu Health Foundation, Institute of Infectious Diseases and Molecular Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Agnes Kiragga
- Research Division, African Population and Health Research Center, Nairobi, Kenya
| | - Guy Muula
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Frank Tanser
- Centre for Epidemic Response and Innovation, School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Thorsten Wagener
- Institute of Environmental Science and Geography, University of Potsdam, Potsdam, Germany
| | - Andrea Low
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK
- NIHR Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol, Bristol, UK
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5
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Larmarange J, Bachanas P, Skalland T, Balzer LB, Iwuji C, Floyd S, Mills LA, Pillay D, Havlir D, Kamya MR, Ayles H, Wirth K, Dabis F, Hayes R, Petersen M. Population-level viremia predicts HIV incidence at the community level across the Universal Testing and Treatment Trials in eastern and southern Africa. PLOS Glob Public Health 2023; 3:e0002157. [PMID: 37450436 PMCID: PMC10348573 DOI: 10.1371/journal.pgph.0002157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
Universal HIV testing and treatment (UTT) strategies aim to optimize population-level benefits of antiretroviral treatment. Between 2012 and 2018, four large community randomized trials were conducted in eastern and southern Africa. While their results were broadly consistent showing decreased population-level viremia reduces HIV incidence, it remains unclear how much HIV incidence can be reduced by increasing suppression among people living with HIV (PLHIV). We conducted a pooled analysis across the four UTT trials. Leveraging data from 105 communities in five countries, we evaluated the linear relationship between i) population-level viremia (prevalence of non-suppression-defined as plasma HIV RNA >500 or >400 copies/mL-among all adults, irrespective of HIV status) and HIV incidence; and ii) prevalence of non-suppression among PLHIV and HIV incidence, using parametric g-computation. HIV prevalence, measured in 257 929 persons, varied from 2 to 41% across the communities; prevalence of non-suppression among PLHIV, measured in 31 377 persons, from 3 to 70%; population-level viremia, derived from HIV prevalence and non-suppression, from < 1% to 25%; and HIV incidence, measured over 345 844 person-years (PY), from 0.03/100PY to 3.46/100PY. Decreases in population-level viremia were strongly associated with decreased HIV incidence in all trials (between 0.45/100PY and 1.88/100PY decline in HIV incidence per 10 percentage points decline in viremia). Decreases in non-suppression among PLHIV were also associated with decreased HIV incidence in all trials (between 0.06/100PY and 0.17/100PY decline in HIV incidence per 10 percentage points decline in non-suppression). Our results support both the utility of population-level viremia as a predictor of incidence, and thus a tool for targeting prevention interventions, and the ability of UTT approaches to reduce HIV incidence by increasing viral suppression. Implementation of universal HIV testing approaches, coupled with interventions to leverage linkage to treatment, adapted to local contexts, can reduce HIV acquisition at population level.
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Affiliation(s)
- Joseph Larmarange
- Centre Population et Développement, Université Paris Cité, IRD, Inserm, Paris, France
| | - Pamela Bachanas
- Division of Global HIV/AIDS and TB, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Timothy Skalland
- Fred Hutchinson Cancer Center, Seattle, WA, United States of America
| | - Laura B. Balzer
- Division of Biostatistics, School of Public Health, University of California, Berkeley, California, United States of America
| | - Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, United Kingdom
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lisa A. Mills
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Deenan Pillay
- Division of Infection & Immunity, University College London, London, United Kingdom
| | - Diane Havlir
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Moses R. Kamya
- Department of Medicine, Makerere University Kampala, Uganda and the Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Helen Ayles
- Clinical Research Department London School of Hygiene & Tropical Medicine, London, United Kingdom
- Zambart, University of Zambia School of Public Health, Lusaka, Zambia
| | - Kathleen Wirth
- Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - François Dabis
- Université Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, Bordeaux, France
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Maya Petersen
- Division of Biostatistics, School of Public Health, University of California, Berkeley, California, United States of America
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6
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Martyn E, Eisen S, Longley N, Harris P, Surey J, Norman J, Brown M, Sultan B, Maponga TG, Iwuji C, Flanagan S, Ghosh I, Story A, Matthews PC. The forgotten people: Hepatitis B virus (HBV) infection as a priority for the inclusion health agenda. eLife 2023; 12:e81070. [PMID: 36757862 PMCID: PMC9910830 DOI: 10.7554/elife.81070] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 01/19/2023] [Indexed: 02/10/2023] Open
Abstract
Hepatitis B virus (HBV) infection represents a significant global health threat, accounting for 300 million chronic infections and up to 1 million deaths each year. HBV disproportionately affects people who are under-served by health systems due to social exclusion, and can further amplify inequities through its impact on physical and mental health, relationship with stigma and discrimination, and economic costs. The 'inclusion health' agenda focuses on excluded and vulnerable populations, who often experience barriers to accessing healthcare, and are under-represented by research, resources, interventions, advocacy, and policy. In this article, we assimilate evidence to establish HBV on the inclusion health agenda, and consider how this view can inform provision of better approaches to diagnosis, treatment, and prevention. We suggest approaches to redress the unmet need for HBV interventions among excluded populations as an imperative to progress the global goal for the elimination of viral hepatitis as a public health threat.
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Affiliation(s)
- Emily Martyn
- The Francis Crick InstituteLondonUnited Kingdom
- London School of Hygiene & Tropical MedicineLondonUnited Kingdom
- Hospital for Tropical Diseases, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Sarah Eisen
- Hospital for Tropical Diseases, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Nicky Longley
- London School of Hygiene & Tropical MedicineLondonUnited Kingdom
- Hospital for Tropical Diseases, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
- Department of Infectious Diseases, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Philippa Harris
- Find & Treat Service, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Julian Surey
- Find & Treat Service, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
- Institute of Global Health, University College LondonLondonUnited Kingdom
- Universidad Autonoma de Madrid, Ciudad Universitaria de CantoblancoMadridSpain
| | - James Norman
- Find & Treat Service, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Michael Brown
- London School of Hygiene & Tropical MedicineLondonUnited Kingdom
- Department of Infectious Diseases, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
- Find & Treat Service, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
| | - Binta Sultan
- Find & Treat Service, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
- Mortimer Market Centre, Central and North London NHS Foundation TrustLondonUnited Kingdom
| | - Tongai G Maponga
- Stellenbosch University, Faculty of Medicine and Health SciencesTygerbergSouth Africa
| | - Collins Iwuji
- Department of Global Health, Brighton and Sussex Medical School, University of SussexBrightonUnited Kingdom
- Africa Health Research InstituteDurban, KwaZulu-NatalSouth Africa
| | - Stuart Flanagan
- Mortimer Market Centre, Central and North London NHS Foundation TrustLondonUnited Kingdom
| | - Indrajit Ghosh
- Find & Treat Service, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
- Mortimer Market Centre, Central and North London NHS Foundation TrustLondonUnited Kingdom
| | - Alistair Story
- Find & Treat Service, Division of Infection, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
- Collaborative Centre for Inclusion Health, University College LondonLondonUnited Kingdom
| | - Philippa C Matthews
- The Francis Crick InstituteLondonUnited Kingdom
- Department of Infectious Diseases, University College London Hospitals NHS Foundation TrustLondonUnited Kingdom
- Mortimer Market Centre, Central and North London NHS Foundation TrustLondonUnited Kingdom
- Division of Infection and Immunity, University College LondonLondonUnited Kingdom
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7
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Plazy M, Diallo A, Hlabisa T, Okesola N, Iwuji C, Herbst K, Boyer S, Lert F, McGrath N, Pillay D, Dabis F, Larmarange J, Orne-Gliemann J. Implementation and effectiveness of a linkage to HIV care intervention in rural South Africa (ANRS 12249 TasP trial). PLoS One 2023; 18:e0280479. [PMID: 36662803 PMCID: PMC9858381 DOI: 10.1371/journal.pone.0280479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/03/2023] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Timely linkage to care and ART initiation is critical to decrease the risks of HIV-related morbidity, mortality and HIV transmission, but is often challenging. We report on the implementation and effectiveness of a linkage-to-care intervention in rural KwaZulu-Natal, South Africa. METHODS In the ANRS 12249 TasP trial on Universal Testing and Treatment (UTT) implemented between 2012-2016, resident individuals ≥16 years were offered home-based HIV testing every six months. Those ascertained to be HIV-positive were referred to trial clinics. Starting May 2013, a linkage-to-care intervention was implemented in both trial arms, consisting of tracking through phone calls and/or home visits to "re-refer" people who had not linked to care to trial clinics within three months of the first home-based referral. Fidelity in implementing the planned intervention was described using Kaplan-Meier estimation to compute conditional probabilities of being tracked and of being re-referred by the linkage-to-care team. Effect of the intervention on time to linkage-to-care was analysed using a Cox regression model censored for death, migration, and end of data follow-up. RESULTS Among the 2,837 individuals (73.7% female) included in the analysis, 904 (32%) were tracked at least once, and 573 of them (63.4%) were re-referred. Probabilities of being re-referred was 17% within six months of first referral and 31% within twelve months. Compared to individuals not re-referred by the intervention, linkage-to-care was significantly higher among those with at least one re-referral through phone call (adjusted hazard ratio [aHR] = 1.82; 95% confidence interval [95% CI] = 1.47-2.25), and among those with re-referral through both phone call and home visit (aHR = 3.94; 95% CI = 2.07-7.48). CONCLUSIONS Phone calls and home visits following HIV testing were challenging to implement, but appeared effective in improving linkage-to-care amongst those receiving the intervention. Such patient-centred strategies should be part of UTT programs to achieve the UNAIDS 95-95-95 targets.
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Affiliation(s)
- Mélanie Plazy
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Adama Diallo
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Thabile Hlabisa
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | | | - Collins Iwuji
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Kobus Herbst
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
| | - Sylvie Boyer
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, Marseille, France
| | - France Lert
- INSERM, Centre for Research in Epidemiology and Population Health (CESP-U 1018), Villejuif, France
| | - Nuala McGrath
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
- School of Primary Care and Population Sciences and Department of Social Statistics and Demography, University of Southampton, Southampton, United Kingdom
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Deenan Pillay
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - François Dabis
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Joseph Larmarange
- Centre Population et Développement, Institut de Recherche pour le Développement, Inserm, Université de Paris, Paris, France
| | - Joanna Orne-Gliemann
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
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8
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Ross P, Wasan H, Croagh D, Nikfarjam M, Nguyen N, Aghmesheh M, Nagrial A, Bartholomeusz D, Hendlisz A, Ajithkumar T, Iwuji C, Turner D, James D, Harris M. 1308P Comparison of tumour size on outcomes for patients with unresectable locally advanced pancreatic adenocarcinoma (LAPC) receiving P-32 microparticles with standard-of-care chemotherapy (SoC CT). Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.07.1440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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9
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Baisley K, Orne-Gliemann J, Larmarange J, Plazy M, Collier D, Dreyer J, Mngomezulu T, Herbst K, Hanekom W, Dabis F, Siedner MJ, Iwuji C. Early HIV treatment and survival over six years of observation in the ANRS 12249 Treatment as Prevention Trial. HIV Med 2022; 23:922-928. [PMID: 35218300 PMCID: PMC9545558 DOI: 10.1111/hiv.13263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 01/09/2022] [Accepted: 01/18/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Population-based universal test and treat (UTT) trials have shown an impact on population-level virological suppression. We followed the ANRS 12249 TasP trial population for 6 years to determine whether the intervention had longer-term survival benefits. METHODS The TasP trial was a cluster-randomized trial in South Africa from 2012 to 2016. All households were offered 6-monthly home-based HIV testing. Immediate antiretroviral therapy (ART) was offered through trial clinics to all people living with HIV (PLHIV) in intervention clusters and according to national guidelines in control clusters. After the trial, individuals attending the trial clinics were transferred to the public ART programme. Deaths were ascertained through annual demographic surveillance. Random-effects Poisson regression was used to estimate the effect of trial arm on mortality among (i) all PLHIV; (ii) PLHIV aware of their status and not on ART at trial entry; and (iii) PHLIV who started ART during the trial. RESULTS Mortality rates among PLHIV were 9.3/1000 and 10.4/1000 person-years in the control and intervention arms, respectively. There was no evidence that the intervention decreased mortality among all PLHIV [adjusted rate ratio (aRR) = 1.10, 95% confidence interval (CI) = 0.85-1.43, p = 0.46] or among PLHIV who were aware of their status but not on ART. Among individuals who initiated ART, the intervention decreased mortality during the trial (aRR = 0.49, 95% CI = 0.28-0.85, p = 0.01), but not after the trial ended. CONCLUSIONS The 'treat all' strategy reduced mortality among individuals who started ART but not among all PLHIV. To achieve maximum benefit of immediate ART, barriers to ART uptake and retention in care need to be addressed.
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Affiliation(s)
- Kathy Baisley
- Africa Health Research Institute, Durban, South Africa.,Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Joanna Orne-Gliemann
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France
| | - Joseph Larmarange
- Centre Population et Développement (Ceped), Institut de Recherche pour le Développement (IRD), Université de Paris, Inserm, Paris, France
| | - Melanie Plazy
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France
| | - Dami Collier
- Division of Infection and Immunity, University College London, London, UK.,Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Cambridge, UK
| | - Jaco Dreyer
- Africa Health Research Institute, Durban, South Africa
| | | | - Kobus Herbst
- Africa Health Research Institute, Durban, South Africa.,DSI-MRC South African Population Research Infrastructure Network, Durban, South Africa
| | - Willem Hanekom
- Africa Health Research Institute, Durban, South Africa.,Division of Infection and Immunity, University College London, London, UK
| | - Francois Dabis
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France
| | - Mark J Siedner
- Africa Health Research Institute, Durban, South Africa.,Harvard Medical School, Boston, Massachusetts, USA
| | - Collins Iwuji
- Africa Health Research Institute, Durban, South Africa.,Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
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10
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Bousmah MAQ, Iwuji C, Okesola N, Orne-Gliemann J, Pillay D, Dabis F, Larmarange J, Boyer S. Costs and economies of scale in repeated home-based HIV counselling and testing: Evidence from the ANRS 12249 treatment as prevention trial in South Africa. Soc Sci Med 2022; 305:115068. [PMID: 35665689 PMCID: PMC9214548 DOI: 10.1016/j.socscimed.2022.115068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/29/2022] [Accepted: 05/21/2022] [Indexed: 11/27/2022]
Abstract
Universal HIV testing is now recommended in generalised HIV epidemic settings. Although home-based HIV counselling and testing (HB-HCT) has been shown to be effective in achieving high levels of HIV status awareness, little is still known about the cost implications of universal and repeated HB-HCT. We estimated the costs of repeated HB-HCT and the scale economies that can be obtained when increasing the population coverage of the intervention. We used primary data from the ANRS 12249 Treatment as Prevention (TasP) trial in rural South Africa (2012–2016), whose testing component included six-monthly repeated HB-HCT. We relied on the dynamic system generalised method of moments (GMM) approach to produce unbiased short- and long-run estimates of economies of scale, using the number of contacts made by HIV counsellors for HB-HCT as the scale variable. We also estimated the mediating effect of the contact quality – measured as the proportion of HIV tests performed among all contacts eligible for an HIV test – on scale economies. The mean cost (standard deviation) of universal and repeated HB-HCT was $24.2 (13.7) per contact, $1694.3 (1527.8) per new HIV diagnosis, and $269.2 (279.0) per appropriate referral to HIV care. The GMM estimations revealed the presence of economies of scale, with a 1% increase in the number of contacts for HB-HCT leading to a 0.27% decrease in the mean cost. Our results also suggested a significant long-run relationship between mean cost and scale, with a 1% increase in the scale leading to a 0.36% decrease in mean cost in the long run. Overall, we showed that significant cost savings can be made from increasing population coverage. Nevertheless, there is a risk that this gain is made at the expense of quality: the higher the quality of HB-HCT activities, the lower the economies of scale. We estimated the costs of repeated home-based HIV counselling and testing (HB-HCT). The mean cost per new HIV diagnosis, which increased over HB-HCT rounds, was $1694. However, the mean cost per appropriate referral to HIV care was $269. A 1% increase in the scale of HB-HCT reduced the average cost per contact by 0.27%. Expanding the population coverage of HB-HCT offers opportunities for cost savings.
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Affiliation(s)
- Marwân-Al-Qays Bousmah
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France; Université Paris Cité, IRD, Inserm, Ceped, F-75006, Paris, France.
| | - Collins Iwuji
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa; Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | | | - Joanna Orne-Gliemann
- University of Bordeaux, National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, Bordeaux, France
| | - Deenan Pillay
- Research Department of Infection and Population Health, University College London, London, UK; Division of Infection and Immunity, University College London, London, UK
| | - François Dabis
- University of Bordeaux, National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, Bordeaux, France
| | | | - Sylvie Boyer
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
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11
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Kemp SA, Charles OJ, Derache A, Smidt W, Martin DP, Iwuji C, Adamson J, Govender K, de Oliveira T, Dabis F, Pillay D, Goldstein RA, Gupta RK. HIV-1 Evolutionary Dynamics under Nonsuppressive Antiretroviral Therapy. mBio 2022; 13:e0026922. [PMID: 35446121 PMCID: PMC9239331 DOI: 10.1128/mbio.00269-22] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/28/2022] [Indexed: 12/19/2022] Open
Abstract
Prolonged virologic failure on 2nd-line protease inhibitor (PI)-based antiretroviral therapy (ART) without emergence of major protease mutations is well recognized and provides an opportunity to study within-host evolution in long-term viremic individuals. Using next-generation sequencing and in silico haplotype reconstruction, we analyzed whole-genome sequences from longitudinal plasma samples of eight chronically infected HIV-1-positive individuals failing 2nd-line regimens from the French National Agency for AIDS and Viral Hepatitis Research (ANRS) 12249 Treatment as Prevention (TasP) trial. On nonsuppressive ART, there were large fluctuations in synonymous and nonsynonymous variant frequencies despite stable viremia. Reconstructed haplotypes provided evidence for selective sweeps during periods of partial adherence, and viral haplotype competition, during periods of low drug exposure. Drug resistance mutations in reverse transcriptase (RT) were used as markers of viral haplotypes in the reservoir, and their distribution over time indicated recombination. We independently observed linkage disequilibrium decay, indicative of recombination. These data highlight dramatic changes in virus population structure that occur during stable viremia under nonsuppressive ART. IMPORTANCE HIV-1 infections are most commonly initiated with a single founder virus and are characterized by extensive inter- and intraparticipant genetic diversity. However, existing literature on HIV-1 intrahost population dynamics is largely limited to untreated infections, predominantly in subtype B-infected individuals. The manuscript characterizes viral population dynamics in long-term viremic treatment-experienced individuals, which has not been previously characterized. These data are particularly relevant for understanding HIV dynamics but can also be applied to other RNA viruses. With this unique data set we propose that the virus is highly unstable, and we have found compelling evidence of HIV-1 within-host viral diversification, recombination, and haplotype competition during nonsuppressive ART.
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Affiliation(s)
- Steven A. Kemp
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), University of Cambridge, Cambridge, United Kingdom
| | - Oscar J. Charles
- Division of Infection & Immunity, University College London, London, United Kingdom
| | - Anne Derache
- Africa Health Research Institute, Durban, South Africa
| | - Werner Smidt
- Africa Health Research Institute, Durban, South Africa
| | - Darren P. Martin
- Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa
| | - Collins Iwuji
- Africa Health Research Institute, Durban, South Africa
- Research Department of Infection and Population Health, University College London, United Kingdom
| | - John Adamson
- Africa Health Research Institute, Durban, South Africa
| | | | - Tulio de Oliveira
- Africa Health Research Institute, Durban, South Africa
- KRISP - KwaZulu-Natal Research and Innovation Sequencing Platform, UKZN, Durban, South Africa
| | - Francois Dabis
- INSERM U1219-Centre Inserm Bordeaux Population Health, Université de Bordeaux, France
- Université de Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, France
| | - Deenan Pillay
- Division of Infection & Immunity, University College London, London, United Kingdom
| | - Richard A. Goldstein
- Division of Infection & Immunity, University College London, London, United Kingdom
| | - Ravindra K. Gupta
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), University of Cambridge, Cambridge, United Kingdom
- Africa Health Research Institute, Durban, South Africa
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12
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Abstract
Objectives Limited antimicrobial resistance (AMR) surveillance coupled with syndromic management of sexually transmitted infections (STIs) in sub-Saharan Africa (SSA) could be contributing to an increase in AMR in the region. This systematic review aimed to synthesize data on the prevalence of AMR in common STIs in SSA and identify some research gaps that exist. Methods We searched three electronic databases for studies published between 1 January 2000 and 26 May 2020. We screened the titles and abstracts for studies that potentially contained data on AMR in SSA. Then we reviewed the full text of these studies to identify articles that reported data on the prevalence of AMR in Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and Mycoplasma genitalium in SSA. We summarized the data using a narrative synthesis. Results The 40 included studies reported on AMR data from 7961 N. gonorrhoeae isolates from 15 countries in SSA and 350 M. genitalium specimens from South Africa. All four SSA regions reported very high rates of ciprofloxacin, tetracycline and penicillin resistance in N. gonorrhoeae. Resistance to cefixime or ceftriaxone was observed in all regions except West Africa. Azithromycin resistance, recommended as part of dual therapy with an extended-spectrum cephalosporin for gonorrhoea, was reported in all the regions. Both macrolide and fluoroquinolone-associated resistance were reported in M. genitalium in South Africa. Studies investigating AMR in C. trachomatis and T. vaginalis were not identified. Conclusions There is a need to strengthen AMR surveillance in SSA for prompt investigation and notification of drug resistance in STIs.
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Affiliation(s)
| | - Diantha Pillay
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Patience Shamu
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Mercy Murire
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Susan Nzenze
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Laura Ashleigh Cox
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Saiqa Mullick
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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13
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Orievulu K, Ayeb-Karlsson S, Ngwenya N, Ngema S, McGregor H, Adeagbo O, Siedner MJ, Hanekom W, Kniveton D, Seeley J, Iwuji C. Economic, social and demographic impacts of drought on treatment adherence among people living with HIV in rural South Africa: A qualitative analysis. Clim Risk Manag 2022; 36:100423. [PMID: 36923966 PMCID: PMC7614312 DOI: 10.1016/j.crm.2022.100423] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The 2015 El Niño-triggered drought in Southern Africa caused widespread economic and livelihood disruption in South Africa, imposing multiple physical and health challenges for rural populations including people living with HIV (PLHIV). We examined the economic, social and demographic impacts of drought drawing on 27 in-depth interviews in two cohorts of PLHIV in Hlabisa, uMkhanyakude district, KwaZulu-Natal. Thematic analysis revealed how drought-enforced soil water depletion, dried-up rivers, and dams culminated in a continuum of events such as loss of livestock, reduced agricultural production, and insufficient access to water and food which was understood to indirectly have a negative impact on HIV treatment adherence. This was mediated through disruptions in incomes, livelihoods and food systems, increased risk to general health, forced mobility and exacerbation of contextual vulnerabilities linked to poverty and unemployment. The systems approach, drawn from interview themes, hypothesises the complex pathways of plausible networks of impacts from drought through varying socioeconomic factors, exacerbating longstanding contextual precarity, and ultimately challenging HIV care utilisation. Understanding the multidimensional relationships between climate change, especially drought, and poor HIV care outcomes through the prism of contextual vulnerabilities is vital for shaping policy interventions.
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Affiliation(s)
- Kingsley Orievulu
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
- Centre for Africa-China Studies, University of Johannesburg, Johannesburg, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Sonja Ayeb-Karlsson
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
- United Nations University Institute for Environment and Human Security, Bonn, Germany
- Institute for Risk and Disaster Reduction, University College London, London, United Kingdom
| | | | - Sthembile Ngema
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | - Oluwafemi Adeagbo
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Health Promotion, Education & Behaviour, University of South Carolina, USA
- Department of Sociology, University of Johannesburg, Johannesburg, South Africa
| | - Mark J. Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Harvard Medical School, Boston, MA 02114, USA
| | - Willem Hanekom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | | | - Janet Seeley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Global Health and Development Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Collins Iwuji
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
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14
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Stuart S, Richardson D, Iwuji C, Soni S. How long should clinicians spend sampling the pharynx for gonorrhoea culture specimens? Sex Health 2021; 19:74-75. [PMID: 34969437 DOI: 10.1071/sh21203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 11/05/2021] [Indexed: 11/23/2022]
Abstract
There are few data on the length of time clinicians should take sampling the pharynx to optimise the sensitivity of gonorrhoea culture specimens and we aimed to gain a consensus on sampling time. The estimated mean time clinicians reported that they spent sampling the pharynx for gonorrhoea culture specimens was 4.63 s (s.d.±2.04). There was no significant difference in sampling times between clinicians who had worked in sexual health for over and under 10 years, (4.7 (s.d.±2.02) vs 4.6 (s.d.±2.3); P=0.45). We are now using these findings to design an educational tool with the aim of improving pharyngeal gonorrhoea culture sensitivity.
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Affiliation(s)
- Sarah Stuart
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
| | - Daniel Richardson
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK; and Sexual Health and HIV, University Hospitals Sussex NHS Foundation Trust, BN2 5BE, UK
| | - Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK; and Sexual Health and HIV, University Hospitals Sussex NHS Foundation Trust, BN2 5BE, UK
| | - Suneeta Soni
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK; and Sexual Health and HIV, University Hospitals Sussex NHS Foundation Trust, BN2 5BE, UK
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15
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Ross PJ, Wasan HS, Croagh D, Nikfarjam M, Nguyen N, Aghmesheh M, Nagrial AM, Bartholomeusz D, Hendlisz A, Ajithkumar T, Iwuji C, Wilson NE, Turner DM, James DC, Young E, Harris MT. Results of a single-arm pilot study of 32P microparticles in unresectable locally advanced pancreatic adenocarcinoma with gemcitabine/nab-paclitaxel or FOLFIRINOX chemotherapy. ESMO Open 2021; 7:100356. [PMID: 34953400 PMCID: PMC8717429 DOI: 10.1016/j.esmoop.2021.100356] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 01/02/2023] Open
Abstract
Background Unresectable locally advanced pancreatic cancer (LAPC) is generally managed with chemotherapy or chemoradiotherapy, but prognosis is poor with a median survival of ∼13 months (or up to 19 months in some studies). We assessed a novel brachytherapy device, using phosphorous-32 (32P) microparticles, combined with standard-of-care chemotherapy. Patients and methods In this international, multicentre, single-arm, open-label pilot study, adult patients with histologically or cytologically proven unresectable LAPC received 32P microparticles, via endoscopic ultrasound-guided fine-needle implantation, planned for week 4 of 5-fluorouracil, leucovorin, irinotecan and oxaliplatin (FOLFIRINOX) or gemcitabine/nab-paclitaxel chemotherapy, per investigator’s choice. The primary endpoint was safety and tolerability measured using Common Terminology Criteria for Adverse Events version 4.0. The lead efficacy endpoint was local disease control rate at 16 weeks. Results Fifty patients were enrolled and received chemotherapy [intention-to-treat (ITT) population]. Forty-two patients received 32P microparticle implantation [per protocol (PP) population]. A total of 1102 treatment-emergent adverse events (TEAEs) were reported in the ITT/safety population (956 PP), of which 167 (139 PP) were grade ≥3. In the PP population, 41 TEAEs in 16 (38.1%) patients were possibly or probably related to 32P microparticles or implantation procedure, including 8 grade ≥3 in 3 (7.1%) patients, compared with 609 TEAEs in 42 (100%) patients attributed to chemotherapy, including 67 grade ≥3 in 28 patients (66.7%). The local disease control rate at 16 weeks was 82.0% (95% confidence interval: 68.6% to 90.9%) (ITT) and 90.5% (95% confidence interval: 77.4% to 97.3%) (PP). Tumour volume, carbohydrate antigen 19-9 levels, and metabolic tumour response at week 12 improved significantly. Ten patients (20.0% ITT; 23.8% PP) had surgical resection and median overall survival was 15.2 and 15.5 months for ITT and PP populations, respectively. Conclusions Endoscopic ultrasound-guided 32P microparticle implantation has an acceptable safety profile. This study also suggests clinically relevant benefits of combining 32P microparticles with standard-of-care systemic chemotherapy for patients with unresectable LAPC. PanCO is the first prospective study of intratumoural 32P microparticles for locally advanced pancreatic cancer (LAPC). This single-arm study assessed a novel brachytherapy (32P microparticles) combined with standard-of-care chemotherapy. Treatment-emergent adverse events attributable to 32P microparticle implantation were relatively infrequent. Local disease control rate at 16 weeks (82%) and resection rate (20%) suggest a clinical benefit of 32P microparticles. The results suggest that 32P microparticles may address a significant unmet need in patients with unresectable LAPC.
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Affiliation(s)
- P J Ross
- Guy's & St Thomas' Hospital NHS Foundation Trust, London, UK.
| | - H S Wasan
- Imperial College Healthcare NHS Trust, London, UK
| | - D Croagh
- Monash Health, Clayton, Australia
| | - M Nikfarjam
- Austin Hospital, University of Melbourne, Australia
| | - N Nguyen
- Royal Adelaide Hospital, Adelaide, Australia
| | - M Aghmesheh
- Southern Medical Day Care Centre, Wollongong, Australia
| | - A M Nagrial
- The Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia
| | | | - A Hendlisz
- Institut Jules Bordet, Brussels, Belgium
| | - T Ajithkumar
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - C Iwuji
- Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - N E Wilson
- OncoSil Medical Limited, Sydney, Australia
| | - D M Turner
- OncoSil Medical Limited, Sydney, Australia
| | - D C James
- OncoSil Medical Limited, Sydney, Australia
| | - E Young
- Southern Star Research Pty Ltd, Gordon, Australia
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16
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Iwuji C, Osler M, Mazibuko L, Hounsome N, Ngwenya N, Chimukuche RS, Khoza T, Gareta D, Sunpath H, Boulle A, Herbst K. Optimised electronic patient records to improve clinical monitoring of HIV-positive patients in rural South Africa (MONART trial): study protocol for a cluster-randomised trial. BMC Infect Dis 2021; 21:1266. [PMID: 34930182 PMCID: PMC8686584 DOI: 10.1186/s12879-021-06952-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is poor viral load monitoring (VLM) and inadequate management of virological failure in HIV-positive individuals on antiretroviral therapy in rural KwaZulu-Natal, South Africa. This could be contributing to increasing HIV drug resistance in the setting. This study aims to investigate the clinical and process impediments in VLM within the health system and to evaluate a quality improvement package (QIP) to address the identified gaps. The QIP comprises (i) a designated viral load champion responsible for administrative management and triaging of viral load results (ii) technological enhancement of the routine clinic-based Three Interlinked Electronic Register (TIER.Net) to facilitate daily automatic import of viral load results from the National Health Service Laboratory to TIER.Net (iii) development of a dashboard system to support VLM. METHODS/DESIGN The study will evaluate the effectiveness of the QIP compared to current care for improving VLM and virological suppression using an effectiveness implementation hybrid type 3 design. This will use a cluster-randomised design with the primary healthcare clinics as the unit of randomisation with ten clinics randomised in a 1:1 ratio to either the intervention or control arm. We will enrol 150 HIV-positive individuals who had been on ART for ≥ 12 months from each of the ten clinics (750 in 5 intervention clinics vs. 750 in 5 control clinics) and follow them up for a period of 12 months. The primary outcome is the proportion of all patients who have a viral load (VL) measurement and are virally suppressed (composite outcome) after 12 months of follow up. Secondary outcomes during follow up include proportion of all patients with at least one documented VL in TIER.Net, proportion with VL ≥ 50 copies/mL, proportion with VL ≥ 1000 copies/mL (virological failure) and subsequent switch to second-line ART. DISCUSSION We aim to provide evidence that a staff-centred quality improvement package, designated viral load monitoring champion, and augmentation of TIER.Net with a dashboard system will improve viral load monitoring and lead to improved virological suppression. TRIAL REGISTRATION This trial is registered on ClinicalTrials.gov on 8 Oct 2021. Identifier: NCT05071573; https://clinicaltrials.gov/ct2/show/NCT05071573?term=NCT05071573&draw=2&rank=1.
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Affiliation(s)
- Collins Iwuji
- Department of Global Health Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9PX, UK. .,Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa.
| | - Meg Osler
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Lusanda Mazibuko
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Natalia Hounsome
- Department of Global Health Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9PX, UK
| | - Nothando Ngwenya
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | | | - Thandeka Khoza
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Dickman Gareta
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Henry Sunpath
- Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease 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
| | - Kobus Herbst
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa.,DSI-MRC South African Population Research Infrastructure Network, Durban, South Africa
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17
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Abstract
We describe the case of a 30-year-old care home employee diagnosed with COVID-19 and acute untreated HIV-1. He was unable to return to work for 119 days due to concerns over transmission risk as his SARS-CoV-2 PCR remained detectable. This highlights the uncertainty in interpreting SARS-CoV-2 PCR results post-infection in acute untreated HIV.
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Affiliation(s)
- Rhys D Wenlock
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - Collins Iwuji
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.,Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, UK.,Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Jaime H Vera
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.,Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, UK
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18
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Yapa HM, Kim HY, Petoumenos K, Post FA, Jiamsakul A, De Neve JW, Tanser F, Iwuji C, Baisley K, Shahmanesh M, Pillay D, Siedner MJ, Bärnighausen T, Bor J. CD4+ T-Cell Count at Antiretroviral Therapy Initiation in the "Treat-All" Era in Rural South Africa: An Interrupted Time Series Analysis. Clin Infect Dis 2021; 74:1350-1359. [PMID: 34309633 PMCID: PMC9049265 DOI: 10.1093/cid/ciab650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND South Africa implemented universal test and treat (UTT) in September 2016 in an effort to encourage earlier initiation of antiretroviral therapy (ART). METHODS We therefore conducted an interrupted time series (ITS) analysis to assess the impact of UTT on mean CD4 count at ART initiation among adults aged ≥16 years attending 17 public sector primary care clinics in rural South Africa, between July 2014 and March 2019. RESULTS Among 20 599 individuals (69% women), CD4 counts were available for 74%. Mean CD4 at ART initiation increased from 317.1 cells/μL (95% confidence interval [CI], 308.6 to 325.6) 1 to 8 months prior to UTT to 421.0 cells/μL (95% CI, 413.0 to 429.0) 1 to 12 months after UTT, including an immediate increase of 124.2 cells/μL (95% CI, 102.2 to 146.1). However, mean CD4 count subsequently fell to 389.5 cells/μL (95% CI, 381.8 to 397.1) 13 to 30 months after UTT but remained above pre-UTT levels. Men initiated ART at lower CD4 counts than women (-118.2 cells/μL, 95% CI, -125.5 to -111.0) throughout the study. CONCLUSIONS Although UTT led to an immediate increase in CD4 count at ART initiation in this rural community, the long-term effects were modest. More efforts are needed to increase initiation of ART early in those living with human immunodeficiency virus, particularly men.
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Affiliation(s)
- H Manisha Yapa
- The Kirby Institute, University of New South WalesSydney, NSW, Australia,Africa Health Research Institute, KwaZulu-Natal, South Africa,Correspondence: H. Manisha Yapa, Level 6, Wallace Wurth Building, University of New South Wales, High Street, Kensington NSW 2052, Australia ()
| | - Hae-Young Kim
- Africa Health Research Institute, KwaZulu-Natal, South Africa,New York University Grossman School of Medicine, New York, New York, USA
| | - Kathy Petoumenos
- The Kirby Institute, University of New South WalesSydney, NSW, Australia
| | - Frank A Post
- King’s College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Awachana Jiamsakul
- The Kirby Institute, University of New South WalesSydney, NSW, Australia
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Frank Tanser
- Africa Health Research Institute, KwaZulu-Natal, South Africa,College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa,Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, United Kingdom,Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Collins Iwuji
- Africa Health Research Institute, KwaZulu-Natal, South Africa,Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Kathy Baisley
- Africa Health Research Institute, KwaZulu-Natal, South Africa,Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa,Institute for Global Health, University College London, London, United Kingdom
| | - Deenan Pillay
- Africa Health Research Institute, KwaZulu-Natal, South Africa,Division of Infection & Immunity, University College London, London, United Kingdom
| | - Mark J Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa,College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa,Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa,Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany,Institute for Global Health, University College London, London, United Kingdom,Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jacob Bor
- Africa Health Research Institute, KwaZulu-Natal, South Africa,Department of Global Health and Epidemiology, Boston University, Boston, Massachusetts, USA,Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Health Science, University of Witswatersrand, Johannesburg, Gauteng, South Africa
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19
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Ngwenya N, Iwuji C, Petersen N, Myeni N, Nxumalo S, Ngema U, Seeley J. Investigation of post-trial access views among study participants and stakeholders using photovoice and semistructured interviews. J Med Ethics 2021; 48:medethics-2020-107011. [PMID: 34172519 PMCID: PMC9554052 DOI: 10.1136/medethics-2020-107011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 05/14/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE We examine the levels of post-trial responsibility ascribed to different stakeholders, following a community-based clinical trial and how the 'responsibility' is understood. METHODS We employed photovoice, unstructured observations and key informant interviews to gain insights into contexts of access to care following transition to the public health system post trial. We used an inductive narrative analysis to explore experiences and understandings of post-trial access (PTA). RESULTS In their photovoice stories, many participants expressed a sense of abandonment after the trial. This was viewed as a contributing factor to failing to re-engage with care available in the public health system. This led to the experiences of loss as some trial participants defaulted and died. Research investigators, department of health participants and sponsor agreed that PTA was especially important for communities in resource-limited settings. The government has an obligation towards its citizens while researchers have a responsibility to ensure a smooth transition of patients to public clinics. Sponsors have a responsibility to ensure that the trial is conducted in accordance with the protocol and post-trial agreements are in place and adhered to. Research partnerships among stakeholders were affected by power imbalances making it difficult to negotiate and plan for post-trial care responsibilities. CONCLUSIONS The research community still struggles with understanding the scope of PTA responsibilities. Power dynamics between public health actors and research sponsors need to be managed to ensure that government involvement is not tokenistic. The responsibility of trial participants and ethics committees needs to be investigated further.
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Affiliation(s)
- Nothando Ngwenya
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Collins Iwuji
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | | | - Nompilo Myeni
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | - Ursula Ngema
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Janet Seeley
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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20
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Fiorentino M, Nishimwe M, Protopopescu C, Iwuji C, Okesola N, Spire B, Orne-Gliemann J, McGrath N, Pillay D, Dabis F, Larmarange J, Boyer S. Early ART Initiation Improves HIV Status Disclosure and Social Support in People Living with HIV, Linked to Care Within a Universal Test and Treat Program in Rural South Africa (ANRS 12249 TasP Trial). AIDS Behav 2021; 25:1306-1322. [PMID: 33206263 DOI: 10.1007/s10461-020-03101-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 02/01/2023]
Abstract
We investigated the effect of early antiretroviral treatment (ART) initiation on HIV status disclosure and social support in a cluster-randomized, treatment-as-prevention (TasP) trial in rural South Africa. Individuals identified HIV-positive after home-based testing were referred to trial clinics where they were invited to initiate ART immediately irrespective of CD4 count (intervention arm) or following national guidelines (control arm). We used Poisson mixed effects models to assess the independent effects of (a) time since baseline clinical visit, (b) trial arm, and (c) ART initiation on HIV disclosure (n = 182) and social support (n = 152) among participants with a CD4 count > 500 cells/mm3 at baseline. Disclosure and social support significantly improved over follow-up in both arms. Disclosure was higher (incidence rate ratio [95% confidence interval]: 1.24 [1.04; 1.48]), and social support increased faster (1.22 [1.02; 1.46]) in the intervention arm than in the control arm. ART initiation improved both disclosure and social support (1.50 [1.28; 1.75] and 1.34 [1.12; 1.61], respectively), a stronger effect being seen in the intervention arm for social support (1.50 [1.12; 2.01]). Besides clinical benefits, early ART initiation may also improve psychosocial outcomes. This should further encourage countries to implement universal test-and-treat strategies.
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Affiliation(s)
- Marion Fiorentino
- Aix Marseille Univ, UMR912 - INSERM, IRD, SanteRCom, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, Faculté de Médecine, 27 bd Jean Moulin, 13005, Marseille, France.
- ORS PACA, Observatoire Régional de La Santé Provence-Alpes-Côte D'Azur, Marseille, France.
| | - Marie Nishimwe
- Aix Marseille Univ, UMR912 - INSERM, IRD, SanteRCom, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, Faculté de Médecine, 27 bd Jean Moulin, 13005, Marseille, France
- ORS PACA, Observatoire Régional de La Santé Provence-Alpes-Côte D'Azur, Marseille, France
| | - Camelia Protopopescu
- Aix Marseille Univ, UMR912 - INSERM, IRD, SanteRCom, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, Faculté de Médecine, 27 bd Jean Moulin, 13005, Marseille, France
- ORS PACA, Observatoire Régional de La Santé Provence-Alpes-Côte D'Azur, Marseille, France
| | - Collins Iwuji
- Africa Health Research Institute, Durban, South Africa
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, UK
| | | | - Bruno Spire
- Aix Marseille Univ, UMR912 - INSERM, IRD, SanteRCom, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, Faculté de Médecine, 27 bd Jean Moulin, 13005, Marseille, France
- ORS PACA, Observatoire Régional de La Santé Provence-Alpes-Côte D'Azur, Marseille, France
| | | | - Nuala McGrath
- Africa Health Research Institute, Durban, South Africa
- University of Southampton, Southampton, UK
| | - Deenan Pillay
- Africa Health Research Institute, Durban, South Africa
| | - François Dabis
- INSERM, UMR1219 Bordeaux Population Health Research Center, Université de Bordeaux, Bordeaux, France
| | | | - Sylvie Boyer
- Aix Marseille Univ, UMR912 - INSERM, IRD, SanteRCom, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, Faculté de Médecine, 27 bd Jean Moulin, 13005, Marseille, France
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21
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Bertagnolio S, Hermans L, Jordan MR, Avila-Rios S, Iwuji C, Derache A, Delaporte E, Wensing A, Aves T, Borhan ASM, Leenus A, Parkin N, Doherty M, Inzaule S, Mbuagbaw L. Clinical Impact of Pretreatment Human Immunodeficiency Virus Drug Resistance in People Initiating Nonnucleoside Reverse Transcriptase Inhibitor-Containing Antiretroviral Therapy: A Systematic Review and Meta-analysis. J Infect Dis 2020; 224:377-388. [PMID: 33202025 PMCID: PMC8328216 DOI: 10.1093/infdis/jiaa683] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/16/2020] [Indexed: 01/15/2023] Open
Abstract
Background Increased access to antiretroviral therapy (ART) has resulted in rising levels of pretreatment human immunodeficiency virus drug resistance (PDR). This is the first systematic review and meta-analysis to assess the impact of PDR on treatment outcomes among people initiating nonnucleoside reverse transcriptase inhibitor (NNRTI)–based ART, including the combination of efavirenz (EFV), tenofovir (TDF), and lamivudine or emtricitabine (XTC). Methods We systematically reviewed studies and conference proceedings comparing treatment outcomes in populations initiating NNRTI-based ART with and without PDR. We conducted subgroup analyses by regimen: (1) NNRTIs + 2 nucleoside reverse transcriptase inhibitors (NRTIs), (2) EFV + 2 NRTIs, or (3) EFV/TDF/XTC; by population (children vs adults); and by definition of resistance (PDR vs NNRTI PDR). Results Among 6197 studies screened, 32 were analyzed (31 441 patients). We found that individuals with PDR initiating NNRTIs across all the subgroups had increased risk of virological failure compared to those without PDR. Risk of acquisition of new resistance mutations and ART switch was also higher in people with PDR. Conclusions This review shows poorer treatment outcomes in the presence of PDR, supporting the World Health Organization’s recommendation to avoid using NNRTIs in countries where levels of PDR are high.
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Affiliation(s)
- Silvia Bertagnolio
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Lucas Hermans
- Virology, Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.,Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Michael R Jordan
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA.,Division of Geographic Medicine and Infectious Disease, Tufts Medical Center, Boston, Massachusetts, USA.,Tufts Center for Integrated Management of Antimicrobial Resistance, Boston, Massachusetts, USA
| | - Santiago Avila-Rios
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, United Kingdom
| | - Anne Derache
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Eric Delaporte
- TransVIHMI, University of Montpellier, Institut de Recherche pour le Développement, Institut national de la santé et de la recherche médicale, Montpellier, France
| | - Annemarie Wensing
- Virology, Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.,Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Theresa Aves
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - A S M Borhan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alvin Leenus
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Neil Parkin
- Data First Consulting, Sebastopol, California, USA
| | - Meg Doherty
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Seth Inzaule
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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22
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Siedner MJ, Kraemer JD, Meyer MJ, Harling G, Mngomezulu T, Gabela P, Dlamini S, Gareta D, Majozi N, Ngwenya N, Seeley J, Wong E, Iwuji C, Shahmanesh M, Hanekom W, Herbst K. Access to primary healthcare during lockdown measures for COVID-19 in rural South Africa: an interrupted time series analysis. BMJ Open 2020; 10:e043763. [PMID: 33020109 PMCID: PMC7536636 DOI: 10.1136/bmjopen-2020-043763] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/13/2020] [Accepted: 09/18/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES We evaluated whether implementation of lockdown orders in South Africa affected ambulatory clinic visitation in rural Kwa-Zulu Natal (KZN). DESIGN Observational cohort SETTING: Data were analysed from 11 primary healthcare clinics in northern KZN. PARTICIPANTS A total of 46 523 individuals made 89 476 clinic visits during the observation period. EXPOSURE OF INTEREST We conducted an interrupted time series analysis to estimate changes in clinic visitation with a focus on transitions from the prelockdown to the level 5, 4 and 3 lockdown periods. OUTCOME MEASURES Daily clinic visitation at ambulatory clinics. In stratified analyses, we assessed visitation for the following subcategories: child health, perinatal care and family planning, HIV services, non-communicable diseases and by age and sex strata. RESULTS We found no change in total clinic visits/clinic/day at the time of implementation of the level 5 lockdown (change from 90.3 to 84.6 mean visits/clinic/day, 95% CI -16.5 to 3.1), or at the transitions to less stringent level 4 and 3 lockdown levels. We did detect a >50% reduction in child healthcare visits at the start of the level 5 lockdown from 11.9 to 4.7 visits/day (-7.1 visits/clinic/day, 95% CI -8.9 to 5.3), both for children aged <1 year and 1-5 years, with a gradual return to prelockdown within 3 months after the first lockdown measure. In contrast, we found no drop in clinic visitation in adults at the start of the level 5 lockdown, or related to HIV care (from 37.5 to 45.6, 8.0 visits/clinic/day, 95% CI 2.1 to 13.8). CONCLUSIONS In rural KZN, we identified a significant, although temporary, reduction in child healthcare visitation but general resilience of adult ambulatory care provision during the first 4 months of the lockdown. Future work should explore the impacts of the circulating epidemic on primary care provision and long-term impacts of reduced child visitation on outcomes in the region.
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Affiliation(s)
- Mark J Siedner
- Clinical Research Department, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - John D Kraemer
- Department of Health Systems Administration, Georgetown University, Washington, District of Columbia, USA
| | - Mark J Meyer
- Department of Mathematics and Statistics, Georgetown University, Washington, District of Columbia, USA
| | - Guy Harling
- Institute for Global Health, University College London, London, UK
- Department of Social Sciences, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Thobeka Mngomezulu
- Department of Population Research, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Patrick Gabela
- Department of Population Research, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Siphephelo Dlamini
- Department of Nursing, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Dickman Gareta
- Research Data Management, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Nomathamsanqa Majozi
- Public Engagement, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Nothando Ngwenya
- Department of Social Sciences, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Janet Seeley
- Research Unit on AIDS, Medical Research Council and Ugandan Virus Research Institute, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Emily Wong
- Clinical Research Department, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Collins Iwuji
- Department of Sexual Health and HIV Medicine, Brighton and Sussex Medical School, Brighton, Brighton and Hove, UK
| | - Maryam Shahmanesh
- Clinical Research Department, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Willem Hanekom
- Clinical Research Department, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
| | - Kobus Herbst
- Department of Population Research, Africa Health Research Institute, Durban, Kwa-Zulu Natal, South Africa
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23
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Iwuji C, Chimukuche RS, Zuma T, Plazy M, Larmarange J, Orne-Gliemann J, Siedner M, Shahmanesh M, Seeley J. Test but not treat: Community members' experiences with barriers and facilitators to universal antiretroviral therapy uptake in rural KwaZulu-Natal, South Africa. PLoS One 2020; 15:e0239513. [PMID: 32970730 PMCID: PMC7514038 DOI: 10.1371/journal.pone.0239513] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 09/08/2020] [Indexed: 01/20/2023] Open
Abstract
Introduction Antiretroviral therapy (ART) has revolutionised the care of HIV-positive individuals resulting in marked decreases in morbidity and mortality, and markedly reduced transmission to sexual partners. However, these benefits can only be realised if individuals are aware of their HIV-positive status, initiated and retained on suppressive lifelong ART. Framed using the socio-ecological model, the present study explores factors contributing to poor ART uptake among community members despite high acceptance of HIV-testing within a Treatment as Prevention (TasP) trial. In this paper we identify barriers and facilitators to treatment across different levels of the socio-ecological framework covering individual, community and health system components. Methods This research was embedded within a cluster-randomised trial (ClinicalTrials.gov, number NCT01509508) of HIV treatment as Prevention in rural KwaZulu-Natal, South Africa. Data were collected between January 2013 and July 2014 from resident community members. Ten participants contributed to repeat in-depth interviews whilst 42 participants took part in repeat focus group discussions. Data from individual interviews and focus group discussions were triangulated using community walks to give insights into community members’ perception of the barriers and facilitators of ART uptake. We used thematic analysis guided by a socio-ecological framework to analyse participants’ narratives from both individual interviews and focus group discussions. Results Barriers and facilitators operating at the individual, community and health system levels influence ART uptake. Stigma was an over-arching barrier, across all three levels and expressed variably as fear of HIV disclosure, concerns about segregated HIV clinical services and negative community religious perceptions. Other barriers were individual (substance misuse, fear of ART side effects), community (alternative health beliefs). Facilitators cited by participants included individual (expectations of improved health and longer life expectancy following ART, single tablet regimens), community (availability of ART in the community through mobile trial facilities) and health system factors (fast and efficient service provided by friendly staff). Discussion We identified multiple barriers to achieving universal ART uptake. To enhance uptake in HIV care services, and achieve the full benefits of ART requires interventions that tackle persistent HIV stigma, and offer people with HIV respectful, convenient and efficient services. These interventions require evaluation in appropriately designed studies.
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Affiliation(s)
- Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, United Kingdom
- Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
- * E-mail:
| | | | - Thembelihle Zuma
- Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
| | - Melanie Plazy
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Bordeaux, France
| | - Joseph Larmarange
- Institut de Recherche pour le Développement(IRD), Centre Population et Développement (Ceped), Paris, France
| | - Joanna Orne-Gliemann
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Bordeaux, France
| | - Mark Siedner
- Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Maryam Shahmanesh
- Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, United Kingdom
| | - Janet Seeley
- Africa Health Research Institute, Berea, KwaZulu-Natal, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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24
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Villa G, Iwuji C. HIV and chronic hepatitis B virus co-infection in sub-Saharan Africa: a deadly synergy. Public Health Action 2020; 10:85. [PMID: 33134119 PMCID: PMC7577001 DOI: 10.5588/pha.20.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/11/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- G Villa
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Brighton, Brighton, UK
| | - C Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Brighton, Brighton, UK
- Africa Health Research Institute, Mtubatuba, South Africa
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25
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Siedner MJ, Harling G, Derache A, Smit T, Khoza T, Gunda R, Mngomezulu T, Gareta D, Majozi N, Ehlers E, Dreyer J, Nxumalo S, Dayi N, Ording-Jesperson G, Ngwenya N, Wong E, Iwuji C, Shahmanesh M, Seeley J, De Oliveira T, Ndung'u T, Hanekom W, Herbst K. Protocol: Leveraging a demographic and health surveillance system for Covid-19 Surveillance in rural KwaZulu-Natal. Wellcome Open Res 2020; 5:109. [PMID: 32802963 PMCID: PMC7424917 DOI: 10.12688/wellcomeopenres.15949.2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2020] [Indexed: 12/28/2022] Open
Abstract
A coordinated system of disease surveillance will be critical to effectively control the coronavirus disease 2019 (Covid-19) pandemic. Such systems enable rapid detection and mapping of epidemics and inform allocation of scarce prevention and intervention resources. Although many lower- and middle-income settings lack infrastructure for optimal disease surveillance, health and demographic surveillance systems (HDSS) provide a unique opportunity for epidemic monitoring. This protocol describes a surveillance program at the Africa Health Research Institute's Population Intervention Platform site in northern KwaZulu-Natal. The program leverages a longstanding HDSS in a rural, resource-limited setting with very high prevalence of HIV and tuberculosis to perform Covid-19 surveillance. Our primary aims include: describing the epidemiology of the Covid-19 epidemic in rural KwaZulu-Natal; determining the impact of the Covid-19 outbreak and non-pharmaceutical control interventions (NPI) on behaviour and wellbeing; determining the impact of HIV and tuberculosis on Covid-19 susceptibility; and using collected data to support the local public-sector health response. The program involves telephone-based interviews with over 20,000 households every four months, plus a sub-study calling 750 households every two weeks. Each call asks a household representative how the epidemic and NPI are affecting the household and conducts a Covid-19 risk screen for all resident members. Any individuals screening positive are invited to a clinical screen, potential test and referral to necessary care - conducted in-person near their home following careful risk minimization procedures. In this protocol we report the details of our cohort design, questionnaires, data and reporting structures, and standard operating procedures in hopes that our project can inform similar efforts elsewhere.
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Affiliation(s)
- Mark J. Siedner
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Guy Harling
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, UK
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology and Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Anne Derache
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Theresa Smit
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Thandeka Khoza
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Resign Gunda
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | | | - Dickman Gareta
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | | | - Eugene Ehlers
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Jaco Dreyer
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Siyabonga Nxumalo
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Njabulo Dayi
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | | | - Nothando Ngwenya
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Emily Wong
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Collins Iwuji
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Maryam Shahmanesh
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, UK
| | - Janet Seeley
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Global Health and Development Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Tulio De Oliveira
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP)), School of Laboratory Medicine and Medical Sciences, University of KwaZulu Natal, Durban, KwaZulu-Natal, South Africa
- Department of Global Health, University of Washington, Seattle, USA
| | - Thumbi Ndung'u
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu Natal, Durban, KwaZulu-Natal, South Africa
- Max Planck Institute for Infection Biology, Berlin, Germany
| | - Willem Hanekom
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Kobus Herbst
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- SAPRIN, South African Medical Research Council, Cape Town, South Africa
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Siedner MJ, Harling G, Derache A, Smit T, Khoza T, Gunda R, Mngomezulu T, Gareta D, Majozi N, Ehlers E, Dreyer J, Nxumalo S, Dayi N, Ording-Jesperson G, Ngwenya N, Wong E, Iwuji C, Shahmanesh M, Seeley J, De Oliveira T, Ndung'u T, Hanekom W, Herbst K. Protocol: Leveraging a demographic and health surveillance system for Covid-19 Surveillance in rural KwaZulu-Natal. Wellcome Open Res 2020; 5:109. [PMID: 32802963 PMCID: PMC7424917 DOI: 10.12688/wellcomeopenres.15949.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2020] [Indexed: 12/28/2022] Open
Abstract
A coordinated system of disease surveillance will be critical to effectively control the coronavirus disease 2019 (Covid-19) pandemic. Such systems enable rapid detection and mapping of epidemics and inform allocation of scarce prevention and intervention resources. Although many lower- and middle-income settings lack infrastructure for optimal disease surveillance, health and demographic surveillance systems (HDSS) provide a unique opportunity for epidemic monitoring. This protocol describes a surveillance program at the Africa Health Research Institute's Population Intervention Platform site in northern KwaZulu-Natal. The program leverages a longstanding HDSS in a rural, resource-limited setting with very high prevalence of HIV and tuberculosis to perform Covid-19 surveillance. Our primary aims include: describing the epidemiology of the Covid-19 epidemic in rural KwaZulu-Natal; determining the impact of the Covid-19 outbreak and non-pharmaceutical control interventions (NPI) on behaviour and wellbeing; determining the impact of HIV and tuberculosis on Covid-19 susceptibility; and using collected data to support the local public-sector health response. The program involves telephone-based interviews with over 20,000 households every four months, plus a sub-study calling 750 households every two weeks. Each call asks a household representative how the epidemic and NPI are affecting the household and conducts a Covid-19 risk screen for all resident members. Any individuals screening positive are invited to a clinical screen, potential test and referral to necessary care - conducted in-person near their home following careful risk minimization procedures. In this protocol we report the details of our cohort design, questionnaires, data and reporting structures, and standard operating procedures in hopes that our project can inform similar efforts elsewhere.
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Affiliation(s)
- Mark J. Siedner
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Guy Harling
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, UK
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology and Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Anne Derache
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Theresa Smit
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Thandeka Khoza
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Resign Gunda
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | | | - Dickman Gareta
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | | | - Eugene Ehlers
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Jaco Dreyer
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Siyabonga Nxumalo
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Njabulo Dayi
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | | | - Nothando Ngwenya
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Emily Wong
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Collins Iwuji
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Maryam Shahmanesh
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, UK
| | - Janet Seeley
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Global Health and Development Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Tulio De Oliveira
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP)), School of Laboratory Medicine and Medical Sciences, University of KwaZulu Natal, Durban, KwaZulu-Natal, South Africa
- Department of Global Health, University of Washington, Seattle, USA
| | - Thumbi Ndung'u
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
- HIV Pathogenesis Programme, The Doris Duke Medical Research Institute, University of KwaZulu Natal, Durban, KwaZulu-Natal, South Africa
- Max Planck Institute for Infection Biology, Berlin, Germany
| | - Willem Hanekom
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Kobus Herbst
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- SAPRIN, South African Medical Research Council, Cape Town, South Africa
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Siedner MJ, Kraemer JD, Meyer MJ, Harling G, Mngomezulu T, Gabela P, Dlamini S, Gareta D, Majozi N, Ngwenya N, Seeley J, Wong E, Iwuji C, Shahmanesh M, Hanekom W, Herbst K. Access to primary healthcare during lockdown measures for COVID-19 in rural South Africa: a longitudinal cohort study. medRxiv 2020:2020.05.15.20103226. [PMID: 32511504 PMCID: PMC7273272 DOI: 10.1101/2020.05.15.20103226] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objectives Public health interventions designed to interrupt COVID-19 transmission could have deleterious impacts on primary healthcare access. We sought to identify whether implementation of the nationwide lockdown (shelter-in-place) order in South Africa affected ambulatory clinic visitation in rural Kwa-Zulu Natal (KZN). Design Prospective, longitudinal cohort study Setting Data were analyzed from the Africa Health Research Institute Health and Demographic Surveillance System, which includes prospective data capture of clinic visits at eleven primary healthcare clinics in northern KwaZulu-Natal Participants A total of 36,291 individuals made 55,545 clinic visits during the observation period. Exposure of Interest We conducted an interrupted time series analysis with regression discontinuity methods to estimate changes in outpatient clinic visitation from 60 days before through 35 days after the lockdown period. Outcome Measures Daily clinic visitation at ambulatory clinics. In stratified analyses we assessed visitation for the following sub-categories: child health, perinatal care and family planning, HIV services, non-communicable diseases, and by age and sex strata. Results We found no change in total clinic visits/clinic/day from prior to and during the lockdown (-6.9 visits/clinic/day, 95%CI -17.4, 3.7) or trends in clinic visitation over time during the lockdown period (-0.2, 95%CI -3.4, 3.1). We did detect a reduction in child healthcare visits at the lockdown (-7.2 visits/clinic/day, 95%CI -9.2, -5.3), which was seen in both children <1 and children 1-5. In contrast, we found a significant increase in HIV visits immediately after the lockdown (8.4 visits/clinic/day, 95%CI 2.4, 14.4). No other differences in clinic visitation were found for perinatal care and family planning, non-communicable diseases, or among adult men and women. Conclusions In rural KZN, the ambulatory healthcare system was largely resilient during the national-wide lockdown order. A major exception was child healthcare visitation, which declined immediately after the lockdown but began to normalize in the weeks thereafter. Future work should explore efforts to decentralize chronic care for high-risk populations and whether catch-up vaccination programs might be required in the wake of these findings.
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Affiliation(s)
- Mark J. Siedner
- Corresponding Author: Mark J. Siedner, Africa Health Research Institute, KwaZulu-Natal, South Africa,
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Tanser F, Kim HY, Vandormael A, Iwuji C, Bärnighausen T. Opportunities and Challenges in HIV Treatment as Prevention Research: Results from the ANRS 12249 Cluster-Randomized Trial and Associated Population Cohort. Curr HIV/AIDS Rep 2020; 17:97-108. [PMID: 32072468 PMCID: PMC7072051 DOI: 10.1007/s11904-020-00487-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The ANRS 12249 treatment as prevention (TasP) trial investigated the impact of a universal test and treat (UTT) approach on reducing HIV incidence in one of the regions of the world most severely affected by the HIV epidemic-KwaZulu-Natal, South Africa. We summarize key findings from this trial as well as recent findings from controlled studies conducted in the linked population cohort quantifying the long-term effects of expanding ART on directly measured HIV incidence (2004-2017). RECENT FINDINGS The ANRS TasP trial did not-and could not-demonstrate a reduction in HIV incidence, because the offer of UTT in the intervention communities did not increase ART coverage and population viral suppression compared to the standard of care in the control communities. Ten controlled studies from the linked population cohort-including several quasi-experimental study designs-exploit heterogeneity in ART exposure to show a consistent and substantial impact of expanding provision of ART and population viral suppression on reduction in HIV incidence at the couple, household, community, and population levels. In this setting, all of the evidence from large, population-based studies (inclusive of the ANRS TasP trial) is remarkably coherent and consistent-i.e., higher ART coverage and population viral suppression were repeatedly associated with clear, measurable decreases in HIV incidence. Thus, the expanded provision of ART has plausibly contributed in a major way toward the dramatic 43% decline in population-level HIV incidence in this typical rural African population. The outcome of the ANRS TasP trial constitutes a powerful null finding with important insights for overcoming implementation challenges in the population delivery of ART. This finding does not imply lack of ART effectiveness in blocking onward transmission of HIV nor its inability to reduce HIV incidence. Rather, it demonstrates that large increases in ART coverage over current levels will require health systems innovations to attract people living with HIV in early stages of the disease to participate in HIV treatment. Such innovations and new approaches are required for the true potential of UTT to be realized.
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Affiliation(s)
- Frank Tanser
- Lincoln Institute for Health, University of Lincoln, Lincoln, LN6 7TS, UK.
- Africa Health Research Institute, KwaZulu-Natal, South Africa.
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.
| | - Hae-Young Kim
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Population Health, New York University School of Medicine, New York, USA
- KwaZulu-Natal Innovation and Sequencing Platform, Durban, KwaZulu-Natal, South Africa
| | - Alain Vandormael
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- KwaZulu-Natal Innovation and Sequencing Platform, Durban, KwaZulu-Natal, South Africa
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Collins Iwuji
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Havlir D, Lockman S, Ayles H, Larmarange J, Chamie G, Gaolathe T, Iwuji C, Fidler S, Kamya M, Floyd S, Moore J, Hayes R, Petersen M, Dabis F. What do the Universal Test and Treat trials tell us about the path to HIV epidemic control? J Int AIDS Soc 2020; 23:e25455. [PMID: 32091179 PMCID: PMC7038879 DOI: 10.1002/jia2.25455] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/14/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Achieving HIV epidemic control globally will require new strategies to accelerate reductions in HIV incidence and mortality. Universal test and treat (UTT) was evaluated in four randomized population-based trials (BCPP/Ya Tsie, HPTN 071/PopART, SEARCH, ANRS 12249/TasP) conducted in sub-Saharan Africa (SSA) during expanded antiretroviral treatment (ART) eligibility by World Health Organization guidelines and the UNAIDS 90-90-90 campaign. DISCUSSION These three-year studies were conducted in Botswana, Zambia, Uganda, Kenya and South Africa in settings with baseline HIV prevalence from 4% to 30%. Key observations across studies were: (1) Universal testing (implemented via a variety of home and community-based testing approaches) achieved >90% coverage in all studies. (2) When coupled with robust linkage to HIV care, rapid ART start and patient-centred care, UTT achieved among the highest reported population levels of viral suppression in SSA. Significant gains in population-level viral suppression were made in regions with both low and high baseline population viral load; however, viral suppression gains were not uniform across all sub-populations and were lower among youth. (3) UTT resulted in marked reductions in community HIV incidence when universal testing and robust linkage were present. However, HIV elimination targets were not reached. In BCPP and HPTN 071, annualized HIV incidence was approximately 20% to 30% lower in the intervention (which included universal testing) compared to control arms (no universal testing). In SEARCH (where both arms had universal testing), incidence declined 32% over three years. (4) UTT reduced HIV associated mortality by 23% in the intervention versus control communities in SEARCH, a study in which mortality was comprehensively measured. CONCLUSIONS These trials provide strong evidence that UTT inclusive of universal testing increases population-level viral suppression and decreases HIV incidence and mortality faster than the status quo in SSA and should be adapted at a sub-country level as a public health strategy. However, more is needed, including integration of new prevention interventions into UTT, in order to reach UNAIDS HIV elimination targets.
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Affiliation(s)
- Diane Havlir
- Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Shahin Lockman
- Brigham and Women's HospitalBostonMAUSA
- Harvard School T.H. Chan School of Public HealthBostonMAUSA
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
| | - Helen Ayles
- Clinical Research DepartmentLondon School of Hygiene & Tropical MedicineLondonUnited Kingdom
- ZambartLusakaZambia
| | - Joseph Larmarange
- Centre Population et DéveloppementInstitut de Recherche pour le DéveloppementUniversité Paris DescartesInsermParisFrance
- Africa Health Research InstituteSomkheleSouth Africa
| | - Gabriel Chamie
- Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Tendani Gaolathe
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
- University of BotswanaGaboroneBotswana
| | - Collins Iwuji
- Department of Global Health & InfectionBrighton and Sussex Medical SchoolBrightonUnited Kingdom
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Research Department of Infection and Population HealthUniversity College LondonLondonUnited Kingdom
| | - Sarah Fidler
- Imperial CollegeNational Institute for Health Research Biomedical Research CenterLondonUnited Kingdom
- Department of Infectious DiseaseImperial College LondonLondonUnited Kingdom
| | - Moses Kamya
- Department of MedicineMakerere UniversityKampalaUganda
- Infectious Diseases Research Collaboration (IDRC)KampalaUganda
| | - Sian Floyd
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Janet Moore
- Division of Global HIV/AIDS and TBCenters for Disease Control and PreventionAtlantaGAUSA
| | - Richard Hayes
- Department of Infectious Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Maya Petersen
- School of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
| | - Francois Dabis
- ISPED & Inserm Bordeaux Population Health UMR 1219Univ BordeauxBordeauxFrance
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Larmarange J, Diallo MH, McGrath N, Iwuji C, Plazy M, Thiébaut R, Tanser F, Bärnighausen T, Orne‐Gliemann J, Pillay D, Dabis F. Temporal trends of population viral suppression in the context of Universal Test and Treat: the ANRS 12249 TasP trial in rural South Africa. J Int AIDS Soc 2019; 22:e25402. [PMID: 31637821 PMCID: PMC6803817 DOI: 10.1002/jia2.25402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 09/03/2019] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION The universal test-and-treat (UTT) strategy aims to maximize population viral suppression (PVS), that is, the proportion of all people living with HIV (PLHIV) on antiretroviral treatment (ART) and virally suppressed, with the goal of reducing HIV transmission at the population level. This article explores the extent to which temporal changes in PVS explain the observed lack of association between universal treatment and cumulative HIV incidence seen in the ANRS 12249 TasP trial conducted in rural South Africa. METHODS The TasP cluster-randomized trial (2012 to 2016) implemented six-monthly repeat home-based HIV counselling and testing (RHBCT) and referral of PLHIV to local HIV clinics in 2 × 11 clusters opened sequentially. ART was initiated according to national guidelines in control clusters and regardless of CD4 count in intervention clusters. We measured residency status, HIV status, and HIV care status for each participant on a daily basis. PVS was computed per cluster among all resident PLHIV (≥16, including those not in care) at cluster opening and daily thereafter. We used a mixed linear model to explore time patterns in PVS, adjusting for sociodemographic changes at the cluster level. RESULTS 8563 PLHIV were followed. During the course of the trial, PVS increased significantly in both arms (23.5% to 46.2% in intervention, +22.8, p < 0.001; 26.0% to 44.6% in control, +18.6, p < 0.001). That increase was similar in both arms (p = 0.514). In the final adjusted model, PVS increase was most associated with increased RHBCT and the implementation of local trial clinics (measured by time since cluster opening). Contextual changes (measured by calendar time) also contributed slightly. The effect of universal ART (trial arm) was positive but limited. CONCLUSIONS PVS was improved significantly but similarly in both trial arms, explaining partly the null effect observed in terms of cumulative HIV incidence between arms. The PVS gains due to changes in ART-initiation guidelines alone are relatively small compared to gains obtained by strategies to maximize testing and linkage to care. The achievement of the 90-90-90 targets will not be met if the operational and implementational challenges limiting access to care and treatment, often context-specific, are not properly addressed. Clinical trial number: NCT01509508 (clinicalTrials.gov)/DOH-27-0512-3974 (South African National Clinical Trials Register).
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Affiliation(s)
- Joseph Larmarange
- Centre Population et DéveloppementInstitut de Recherche pour le DéveloppementUniversité Paris DescartesInsermParisFrance
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
| | - Mamadou H Diallo
- Centre Population et DéveloppementInstitut de Recherche pour le DéveloppementUniversité Paris DescartesInsermParisFrance
| | - Nuala McGrath
- Africa Health Research InstituteSchool of Nursing and Public HealthUniversity of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
- Faculty of Medicine and Faculty of Social SciencesUniversity of SouthamptonSouthamptonUnited Kingdom
- Research Department of Infection and Population HealthUniversity College LondonLondonUnited Kingdom
| | - Collins Iwuji
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Research Department of Infection and Population HealthUniversity College LondonLondonUnited Kingdom
- Department of Global Health & InfectionBrighton and Sussex Medical SchoolBrightonUnited Kingdom
| | - Mélanie Plazy
- School of Public Health (ISPED)InsermBordeaux Population Health Research CenterUMR 1219Bordeaux UniversityBordeauxFrance
| | - Rodolphe Thiébaut
- School of Public Health (ISPED)InsermBordeaux Population Health Research CenterUMR 1219Bordeaux UniversityBordeauxFrance
| | - Frank Tanser
- Africa Health Research InstituteSchool of Nursing and Public HealthUniversity of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
| | - Till Bärnighausen
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Department of Global Health & PopulationHarvard School of Public HealthHarvard UniversityBostonUSA
- Faculty of MedicineInstitute of Public HealthHeidelberg UniversityHeidelbergGermany
| | - Joanna Orne‐Gliemann
- School of Public Health (ISPED)InsermBordeaux Population Health Research CenterUMR 1219Bordeaux UniversityBordeauxFrance
| | - Deenan Pillay
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Division of Infection and ImmunityUniversity College LondonLondonUnited Kingdom
| | - François Dabis
- School of Public Health (ISPED)InsermBordeaux Population Health Research CenterUMR 1219Bordeaux UniversityBordeauxFrance
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31
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Eguzo K, Jacob A, Okwuosa C, Mbogu F, Owuenyi N, Okoye I, Eguzo C, Ekong E, Okparah M, Sariel P, Oluoha C, Nwankwo G, Nwanyanwu J, Emenike F, Agharanya P, Njoku I, Nworu C, Iwuji C, Nnamani A, Ekanem S, Ezeilo L, Emeonye P. Exploratory Use of Cloud Computing and Social Media for Prostate Cancer Advocacy in Nigeria. J Glob Oncol 2018. [DOI: 10.1200/jgo.18.19900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background and context: Prostate cancer is the commonest cancer affecting Nigerian men, with worse outcome compared with men from the developed world. There is limited public awareness about prostate cancer in Nigeria. Oga Blue 4 Prostate Awareness (OB4PA) was created by a consortium of Nigerian nonprofits for prostate cancer advocacy (PCA). Aims: -Design PCA using videos, printed brochure and social media -Implement PCA in five Nigerian states -Evaluate the reach and impact of PCA campaign Program/Policy process: Community-based participatory process, involving the medical community, prostate cancer survivor, and the public was used. Multimedia teaching was used to enhance learning and retention; social media was used to engage groups and individuals. Content development involved iterative consultation among project leaders, medical experts and target audience, often on social media. High-quality teaching videos were recorded in English and Nigerian Pidgin languages. Videos ensured consistency and ease of broadcast. Videos were accessed by OB4PA partners through cloud computing (OneDrive). Facebook was used to promote the campaign, engage local audience, and for Facebook Live presentation. Local health professionals projected the video in appropriate language to audiences in religious and community groups. Brochure detailing clinical features and local service providers was distributed. Audience evaluation was obtained following each interaction. Outcomes: In 6 weeks, 20 presentations were made to 1800 persons. The Facebook Live presentation had 1500 views, reached 9302 people and was shared 107 times. A total of 25 Facebook posts were made, resulting in 628 like, 1908 video views, 160 shares, and reached 14,222 people. Almost all participants had positive feedback on the free and detailed advocacy. Most questions focused on the causes and prevention of prostate cancer, especially on the use of nutritional supplements. What was learned: Cloud computing enabled us to have one presenter; this eliminated the need to find a presenter for each organization. Audience appreciated simplified videos used in explaining the disease process and need for personalized early detection. Facebook live presentation attracted the most reactions on social media, with most comments showing that people liked the intervention. Audience feedback showed that adding advocacy cellphone video by a survivor helped demystify prostate cancer. Having the main presentation video in different file formats and sizes enhanced sharing on social media, as most Nigerians access the Internet on cell phones. Reliable access to projectors was challenging, especially in remote areas. Overall, use of cloud computing and social media were crucial in the success of the PCA project. Lessons from OB4PA informed the design of the current We Can, I Can Conquer Cervical Cancer Awareness project in Nigeria.
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Affiliation(s)
- K. Eguzo
- University of Saskatchewan - College of Medicine, Saskatoon, Canada
- Marjorie Bash Foundation, Aba, Nigeria
| | - A. Jacob
- Marjorie Bash Foundation, Uyo, Nigeria
| | | | - F. Mbogu
- Health Development Initiative, Aba, Nigeria
| | - N. Owuenyi
- Health Development Initiative, Aba, Nigeria
| | - I. Okoye
- Breast Without Spot, Enugu, Nigeria
| | - C. Eguzo
- Marjorie Bash Foundation, Aba, Nigeria
| | - E. Ekong
- Stand Up To Cancer Foundation, Abuja, Nigeria
| | - M. Okparah
- MAN Project Foundation, Port Harcourt, Nigeria
| | - P. Sariel
- Marjorie Bash Foundation, Jos, Nigeria
| | - C. Oluoha
- Initiative for Public Health Advancement and Research, Umuahia, Nigeria
| | - G. Nwankwo
- Marjorie Bash Foundation, Port Harcourt, Nigeria
| | - J. Nwanyanwu
- Marjorie Bash Foundation, Port Harcourt, Nigeria
| | | | | | - I. Njoku
- Marjorie Bash Foundation, Aba, Nigeria
| | - C. Nworu
- Marjorie Bash Foundation, Aba, Nigeria
| | - C. Iwuji
- University Hospitals of Leicester, Leicester, United Kingdom
| | | | - S. Ekanem
- Stand Up To Cancer Foundation, Lagos, Nigeria
| | | | - P. Emeonye
- Abia State University, Nursing Science, Uturu, Nigeria
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Larmarange J, Diallo MH, McGrath N, Iwuji C, Plazy M, Thiébaut R, Tanser F, Bärnighausen T, Pillay D, Dabis F, Orne‐Gliemann J. The impact of population dynamics on the population HIV care cascade: results from the ANRS 12249 Treatment as Prevention trial in rural KwaZulu-Natal (South Africa). J Int AIDS Soc 2018; 21 Suppl 4:e25128. [PMID: 30027600 PMCID: PMC6053480 DOI: 10.1002/jia2.25128] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 05/17/2018] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION The universal test and treat strategy (UTT) was developed to maximize the proportion of all HIV-positive individuals on antiretroviral treatment (ART) and virally suppressed, assuming that it will lead to a reduction in HIV incidence at the population level. The evolution over time of the cross-sectional HIV care cascade is determined by individual longitudinal trajectories through the HIV care continuum and underlying population dynamics. The purpose of this paper is to quantify the contribution of each component of population change (in- and out-migration, HIV seroconversion, ageing into the cohort and definitive exit such as death) on the HIV care cascade in the context of the ANRS 12249 Treatment as Prevention (TasP) cluster-randomized trial, investigating UTT in rural KwaZulu-Natal, South Africa, between 2012 and 2016. METHODS HIV test results and information on clinic visits, ART prescriptions, viral load and CD4 count, migration and deaths were used to calculate residency status, HIV status and HIV care status for each individual on a daily basis. Position within the HIV care continuum was considered as a score ranging from 0 (undiagnosed) to 4 (virally suppressed). We compared the cascade score of each individual joining or leaving the population of resident adults living with HIV with the average score of their cluster at the time of entry or exit. Then, we computed the contribution of each entry or exit on the average cascade score and their annualized total contribution, by component of change. RESULTS While the average cascade score increased over time in all clusters, that increase was constrained by population dynamics. Permanent exits and ageing into the people living with HIV cohort had a marginal effect. Both in-migrants and out-migrants were less likely to be retained at each step of the HIV care continuum. However, their overall impact on the cross-sectional cascade was limited as the effect of in- and out-migration balanced each other. The contribution of HIV seroconversions was negative in all clusters. CONCLUSIONS In a context of high HIV incidence, the continuous flow of newly infected individuals slows down the efforts to increase ART coverage and population viral suppression, ultimately attenuating any population-level impact on HIV incidence. CLINICAL TRIAL NUMBER NCT01509508 (clinicalTrials.gov)/DOH-27-0512-3974 (South African National Clinical Trials Register).
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Affiliation(s)
- Joseph Larmarange
- Centre Population et DéveloppementInstitut de Recherche pour le DéveloppementUniversité Paris DescartesInsermParisFrance
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
| | - Mamadou Hassimiou Diallo
- Centre Population et DéveloppementInstitut de Recherche pour le DéveloppementUniversité Paris DescartesInsermParisFrance
| | - Nuala McGrath
- School of Nursing and Public HealthAfrica Health Research InstituteUniversity of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
- Faculty of Medicine and Faculty of Social, Human and Mathematical SciencesUniversity of SouthamptonSouthamptonUK
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
| | - Collins Iwuji
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
- Department of Global Health & InfectionBrighton and Sussex Medical SchoolFalmerBrightonUK
| | - Mélanie Plazy
- ISPEDInsermBordeaux Population Health Research CenterUniversité de BordeauxBordeauxFrance
| | - Rodolphe Thiébaut
- ISPEDInsermBordeaux Population Health Research CenterUniversité de BordeauxBordeauxFrance
| | - Frank Tanser
- School of Nursing and Public HealthAfrica Health Research InstituteUniversity of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
| | - Till Bärnighausen
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Department of Global Health & PopulationHarvard School of Public HealthHarvard UniversityBostonMAUSA
- Institute of Public HealthFaculty of MedicineHeidelberg UniversityHeidelbergGermany
| | - Deenan Pillay
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Division of Infection and ImmunityUniversity College LondonLondonUK
| | - François Dabis
- ISPEDInsermBordeaux Population Health Research CenterUniversité de BordeauxBordeauxFrance
| | - Joanna Orne‐Gliemann
- ISPEDInsermBordeaux Population Health Research CenterUniversité de BordeauxBordeauxFrance
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Iwuji C, McGrath N, Calmy A, Dabis F, Pillay D, Newell M, Baisley K, Porter K. Universal test and treat is not associated with sub-optimal antiretroviral therapy adherence in rural South Africa: the ANRS 12249 TasP trial. J Int AIDS Soc 2018; 21:e25112. [PMID: 29890048 PMCID: PMC5995313 DOI: 10.1002/jia2.25112] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 04/26/2018] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION HIV treatment guidelines now recommend antiretroviral therapy (ART) initiation regardless of CD4 count to maximize benefit both for the individual and society. It is unknown whether the initiation of ART at higher CD4 counts would affect adherence levels. We investigated whether initiating ART at higher CD4 counts was associated with sub-optimal adherence (<95%) during the first 12 months of ART. METHODS A prospective cohort study nested within a two-arm cluster-randomized trial of universal test and treat was implemented from March 2012 to June 2016 to measure the impact of ART on HIV incidence in rural KwaZulu-Natal. ART was initiated regardless of CD4 count in the intervention arm and according to national guidelines in the control arm. ART adherence was measured monthly using a visual analogue scale (VAS) and pill counts (PC). HIV viral load was measured at ART initiation, three and six months, and six-monthly thereafter. We pooled data from participants in both arms and used random-effects logistic regression models to examine the association between CD4 count at ART initiation and sub-optimal adherence, and assessed if adherence levels were associated with virological suppression. RESULTS Among 900 individuals who initiated ART ≥12 months before study end, median (IQR) CD4 at ART initiation was 350 cells/mm3 (234, 503); median age was 34.6 years (IQR 27.4 to 46.4) and 71.7% were female. Adherence was sub-optimal in 14.7% of visits as measured by VAS and 20.7% by PC. In both the crude analyses and after adjusting for potential confounders, adherence was not significantly associated with CD4 count at ART initiation (adjusted OR for linear trend in sub-optimal adherence with every 100 cells/mm3 increase in CD4 count: 1.00, 95% CI 0.95 to 1.05, for VAS, and 1.03, 95% CI 0.99 to 1.07, for PC). Virological suppression at 12 months was 97%. Optimal adherence by both measures was significantly associated with virological suppression (p < 0.001 for VAS; p = 0.006 for PC). CONCLUSIONS We found no evidence that higher CD4 counts at ART initiation were associated with sub-optimal ART adherence in the first 12 months. Our findings should alleviate concerns about adherence in individuals initiating ART at higher CD4 counts, however long-term outcomes are needed. ClinicalTrials.gov NCT01509508.
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Affiliation(s)
- Collins Iwuji
- Department of Global Health and InfectionBrighton and Sussex Medical SchoolBrightonUK
- Africa Health Research InstituteDurbanSouth Africa
- Institute for Global HealthUniversity College LondonLondonUK
| | - Nuala McGrath
- Africa Health Research InstituteSchool of Nursing & Public HealthUniversity of KwaZulu‐ NatalKwaZulu‐NatalSouth Africa
- Faculty of Medicine and Faculty of Human, Social and Mathematical SciencesUniversity of SouthamptonSouthamptonUK
- Research Department of Epidemiology & Public HealthUniversity College LondonLondonUK
| | - Alexandra Calmy
- Service des Maladies InfectieusesHIV UnitHôpitaux Universitaires de GenèveGenevaSwitzerland
| | - Francois Dabis
- Centre INSERM U1219Bordeaux Population HealthUniversité de BordeauxBordeauxFrance
| | - Deenan Pillay
- Department of Global Health and InfectionBrighton and Sussex Medical SchoolBrightonUK
- Division of Infection and ImmunityUniversity College LondonLondonUK
| | - Marie‐Louise Newell
- Human Development and Health and Global Health Research InstituteFaculty of MedicineUniversity of SouthamptonSouthamptonUK
| | - Kathy Baisley
- Department of Global Health and InfectionBrighton and Sussex Medical SchoolBrightonUK
- Department of Infectious Disease EpidemiologyFaculty of Epidemiology & Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Kholoud Porter
- Institute for Global HealthUniversity College LondonLondonUK
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Corrie P, Qian W, Gopinathan A, Williams M, Brais R, Valle J, Basu B, Falk S, Iwuji C, Wasan H, Palmer D, Scott-Brown M, Wadsley J, Arif S, Bax L, Bundi P, Skells R, Neesse A, Tuveson D, Jodrell D. Strong tumour cytidine deaminase (CDA) staining predicts for improved survival associated with sequential nab-Paclitaxel (nabP) and gemcitabine (GEM) chemotherapy as first line treatment of patients (pts) with metastatic pancreatic adenocarcinoma (mPDAC). Ann Oncol 2017. [DOI: 10.1093/annonc/mdx369.121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Boyer S, Iwuji C, Gosset A, Protopopescu C, Okesola N, Plazy M, Spire B, Orne-Gliemann J, McGrath N, Pillay D, Dabis F, Larmarange J. Factors associated with antiretroviral treatment initiation amongst HIV-positive individuals linked to care within a universal test and treat programme: early findings of the ANRS 12249 TasP trial in rural South Africa. AIDS Care 2017; 28 Suppl 3:39-51. [PMID: 27421051 PMCID: PMC5096681 DOI: 10.1080/09540121.2016.1164808] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Prompt uptake of antiretroviral treatment (ART) is essential to ensure the success of universal test and treat (UTT) strategies to prevent HIV transmission in high-prevalence settings. We describe ART initiation rates and associated factors within an ongoing UTT cluster-randomized trial in rural South Africa. HIV-positive individuals were offered immediate ART in the intervention arm vs. national guidelines recommended initiation (CD4≤350 cells/mm(3)) in the control arm. We used data collected up to July 2015 among the ART-eligible individuals linked to TasP clinics before January 2015. ART initiation rates at one (M1), three (M3) and six months (M6) from baseline visit were described by cluster and CD4 count strata (cells/mm(3)) and other eligibility criteria: ≤100; 100-200; 200-350; CD4>350 with WHO stage 3/4 or pregnancy; CD4>350 without WHO stage 3/4 or pregnancy. A Cox model accounting for covariate effect changes over time was used to assess factors associated with ART initiation. The 514 participants had a median [interquartile range] follow-up duration of 1.08 [0.69; 2.07] months until ART initiation or last visit. ART initiation rates at M1 varied substantially (36.9% in the group CD4>350 without WHO stage 3/4 or pregnancy, and 55.2-71.8% in the three groups with CD4≤350) but less at M6 (from 85.3% in the first group to 96.1-98.3% in the three other groups). Factors associated with lower ART initiation at M1 were a higher CD4 count and attending clinics with both high patient load and higher cluster HIV prevalence. After M1, having a regular partner was the only factor associated with higher likelihood of ART initiation. These findings suggest good ART uptake within a UTT setting, even among individuals with high CD4 count. However, inadequate staffing and healthcare professional practices could result in prioritizing ART initiation in patients with the lowest CD4 counts.
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Affiliation(s)
- Sylvie Boyer
- a INSERM, UMR_S 912, « Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale » (SESSTIM) , Marseille , France.,b Aix Marseille Université, UMR_S 912, IRD , Marseille , France
| | - Collins Iwuji
- c Africa Centre for Population Health , University of KwaZulu-Natal , Somkhele , South Africa.,d Research Department of Infection and Population Health , University College London , London , UK
| | - Andréa Gosset
- a INSERM, UMR_S 912, « Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale » (SESSTIM) , Marseille , France.,b Aix Marseille Université, UMR_S 912, IRD , Marseille , France.,e ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur , Marseille , France
| | - Camelia Protopopescu
- a INSERM, UMR_S 912, « Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale » (SESSTIM) , Marseille , France.,b Aix Marseille Université, UMR_S 912, IRD , Marseille , France.,e ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur , Marseille , France
| | - Nonhlanhla Okesola
- c Africa Centre for Population Health , University of KwaZulu-Natal , Somkhele , South Africa
| | - Mélanie Plazy
- f ISPED, Centre Inserm U1219 Bordeaux Population Health, University of Bordeaux , Bordeaux , France.,g INSERM, ISPED, Centre Inserm U1219 Bordeaux Population Health , Bordeaux , France
| | - Bruno Spire
- a INSERM, UMR_S 912, « Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale » (SESSTIM) , Marseille , France.,b Aix Marseille Université, UMR_S 912, IRD , Marseille , France.,e ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur , Marseille , France
| | - Joanna Orne-Gliemann
- f ISPED, Centre Inserm U1219 Bordeaux Population Health, University of Bordeaux , Bordeaux , France.,g INSERM, ISPED, Centre Inserm U1219 Bordeaux Population Health , Bordeaux , France
| | - Nuala McGrath
- c Africa Centre for Population Health , University of KwaZulu-Natal , Somkhele , South Africa.,d Research Department of Infection and Population Health , University College London , London , UK.,h Faculty of Medicine and Faculty of Human, Social and Mathematical Sciences , University of Southampton , Southampton , UK
| | - Deenan Pillay
- c Africa Centre for Population Health , University of KwaZulu-Natal , Somkhele , South Africa.,i Faculty of Medical Sciences , University College London , London , UK
| | - François Dabis
- f ISPED, Centre Inserm U1219 Bordeaux Population Health, University of Bordeaux , Bordeaux , France.,g INSERM, ISPED, Centre Inserm U1219 Bordeaux Population Health , Bordeaux , France
| | - Joseph Larmarange
- c Africa Centre for Population Health , University of KwaZulu-Natal , Somkhele , South Africa.,j CEPED (Centre Population & Développement-UMR 196-Paris Descartes/IRD) , IRD (Institut de Recherche pour le Développement) , Paris , France
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Orne-Gliemann J, Zuma T, Chikovore J, Gillespie N, Grant M, Iwuji C, Larmarange J, McGrath N, Lert F, Imrie J. Community perceptions of repeat HIV-testing: experiences of the ANRS 12249 Treatment as Prevention trial in rural South Africa. AIDS Care 2017; 28 Suppl 3:14-23. [PMID: 27421048 DOI: 10.1080/09540121.2016.1164805] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In the context of the ANRS 12249 Treatment as Prevention (TasP) trial, we investigated perceptions of regular and repeat HIV-testing in rural KwaZulu-Natal (South Africa), an area of very high HIV prevalence and incidence. We conducted two qualitative studies, before (2010) and during the early implementation stages of the trial (2013-2014), to appreciate the evolution in community perceptions of repeat HIV-testing over this period of rapid changes in HIV-testing and treatment approaches. Repeated focus group discussions were organized with young adults, older adults and mixed groups. Repeat and regular HIV-testing was overall well perceived before, and well received during, trial implementation. Yet community members were not able to articulate reasons why people might want to test regularly or repeatedly, apart from individual sexual risk-taking. Repeat home-based HIV-testing was considered as feasible and convenient, and described as more acceptable than clinic-based HIV-testing, mostly because of privacy and confidentiality. However, socially regulated discourses around appropriate sexual behaviour and perceptions of stigma and prejudice regarding HIV and sexual risk-taking were consistently reported. This study suggests several avenues to improve HIV-testing acceptability, including implementing diverse and personalised approaches to HIV-testing and care, and providing opportunities for antiretroviral therapy initiation and care at home.
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Affiliation(s)
- Joanna Orne-Gliemann
- a INSERM U1219 - Centre Inserm Bordeaux Population Health , Université de Bordeaux , Bordeaux , France.,b Centre INSERM U1219-Bordeaux Population Health, Université de Bordeaux, ISPED , Bordeaux , France
| | - Thembelihle Zuma
- c Africa Centre for Population Health , University of KwaZulu-Natal , Durban , South Africa
| | - Jeremiah Chikovore
- d HIV/AIDS, STIs and TB Department , Human Sciences Research Council , Pretoria , South Africa
| | - Natasha Gillespie
- e Human and Social Development Department , Human Sciences Research Council , Pretoria , South Africa
| | - Merridy Grant
- f Centre for Rural Health , University of KwaZulu-Natal , Durban , South Africa
| | - Collins Iwuji
- c Africa Centre for Population Health , University of KwaZulu-Natal , Durban , South Africa
| | - Joseph Larmarange
- c Africa Centre for Population Health , University of KwaZulu-Natal , Durban , South Africa.,g Centre Population & Développement (Ceped UMR 196 UPD IRD) , Institut de Recherche pour le Développement , Marseille , France
| | - Nuala McGrath
- c Africa Centre for Population Health , University of KwaZulu-Natal , Durban , South Africa.,h Faculty of Medicine and Faculty of Human, Social and Mathematical Sciences , University of Southampton , Southampton , UK.,i Research Department of Infection and Population Health , University College London , London , UK
| | - France Lert
- j INSERM U1018, CESP, Epidemiology of Occupational and Social Determinants of Health , Villejuif , France
| | - John Imrie
- c Africa Centre for Population Health , University of KwaZulu-Natal , Durban , South Africa.,k Centre for Sexual Health and HIV Research, Research Department of Infection and Population, Faculty of Population Health Sciences , University College London , London , UK.,l Wits RHI, University of the Witwatersrand , Johannesburg , South Africa
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Affiliation(s)
- Collins Iwuji
- Research Department of Infection and Population Health, University College London, London, UK.,Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Marie-Louise Newell
- Human Development and Health and Global Health Research Institute, Faculty of Medicine, University of Southampton, Southampton, UK
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Abstract
In a Perspective, Collins Iwuji and Marie-Louise Newell discuss early findings from Richard Hayes and colleagues' PopART study on HIV testing and treatment.
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Affiliation(s)
- Collins Iwuji
- Research Department of Infection and Population Health, University College London, London, United Kingdom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- * E-mail:
| | - Marie-Louise Newell
- Human Development and Health and Global Health Research Institute, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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Collier D, Iwuji C, Derache A, de Oliveira T, Okesola N, Calmy A, Dabis F, Pillay D, Gupta RK. Virological Outcomes of Second-line Protease Inhibitor-Based Treatment for Human Immunodeficiency Virus Type 1 in a High-Prevalence Rural South African Setting: A Competing-Risks Prospective Cohort Analysis. Clin Infect Dis 2017; 64:1006-1016. [PMID: 28329393 PMCID: PMC5439490 DOI: 10.1093/cid/cix015] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/12/2017] [Indexed: 11/20/2022] Open
Abstract
Background Second-line antiretroviral therapy (ART) based on ritonavir-boosted protease inhibitors (bPIs) represents the only available option after first-line failure for the majority of individuals living with human immunodeficiency virus (HIV) worldwide. Maximizing their effectiveness is imperative. Methods This cohort study was nested within the French National Agency for AIDS and Viral Hepatitis Research (ANRS) 12249 Treatment as Prevention (TasP) cluster-randomized trial in rural KwaZulu-Natal, South Africa. We prospectively investigated risk factors for virological failure (VF) of bPI-based ART in the combined study arms. VF was defined by a plasma viral load >1000 copies/mL ≥6 months after initiating bPI-based ART. Cumulative incidence of VF was estimated and competing risk regression was used to derive the subdistribution hazard ratio (SHR) of the associations between VF and patient clinical and demographic factors, taking into account death and loss to follow-up. Results One hundred one participants contributed 178.7 person-years of follow-up. Sixty-five percent were female; the median age was 37.4 years. Second-line ART regimens were based on ritonavir-boosted lopinavir, combined with zidovudine or tenofovir plus lamivudine or emtricitabine. The incidence of VF on second-line ART was 12.9 per 100 person-years (n = 23), and prevalence of VF at censoring was 17.8%. Thirteen of these 23 (56.5%) virologic failures resuppressed after a median of 8.0 months (interquartile range, 2.8-16.8 months) in this setting where viral load monitoring was available. Tuberculosis treatment was associated with VF (SHR, 11.50 [95% confidence interval, 3.92-33.74]; P < .001). Conclusions Second-line VF was frequent in this setting. Resuppression occurred in more than half of failures, highlighting the value of viral load monitoring of second-line ART. Tuberculosis was associated with VF; therefore, novel approaches to optimize the effectiveness of PI-based ART in high-tuberculosis-burden settings are needed. Clinical Trials Registration NCT01509508.
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Affiliation(s)
- Dami Collier
- Department of Infection and Immunity, University College London, United Kingdom
| | - Collins Iwuji
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Research Department of Infection and Population Health, University College London, United Kingdom
| | - Anne Derache
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Sorbonne Universités, University Pierre and Marie Curie Université Paris 06, Inserm, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Tulio de Oliveira
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- University of KwaZulu-Natal, Durban, South Africa
| | | | - Alexandra Calmy
- Geneva University Hospital, HIV Unit, Department of Internal Medicine, Switzerland
| | - Francois Dabis
- INSERM U1219-Centre Inserm Bordeaux Population Health, Université de Bordeaux, France
- Université de Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, France
| | - Deenan Pillay
- Department of Infection and Immunity, University College London, United Kingdom
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Ravindra K Gupta
- Department of Infection and Immunity, University College London, United Kingdom
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
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King J, Palmer DH, Johnson P, Ross P, Hubner RA, Sumpter K, Darby S, Braconi C, Iwuji C, Swinson D, Collins P, Patel K, Nobes J, Muazzam I, Blesing C, Kirkwood A, Nash S, Meyer T. Sorafenib for the Treatment of Advanced Hepatocellular Cancer - a UK Audit. Clin Oncol (R Coll Radiol) 2017; 29:256-262. [PMID: 27964898 DOI: 10.1016/j.clon.2016.11.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 10/28/2016] [Accepted: 11/01/2016] [Indexed: 01/08/2023]
Abstract
AIMS Sorafenib is the current standard treatment for advanced hepatocellular carcinoma. We carried out a national audit of UK patients treated with sorafenib as standard-of-care and those treated with systemic therapy in first-line trials. MATERIALS AND METHODS Sorafenib-treated and trial-treated patients were identified via the Cancer Drugs Fund and local databases. Data were collected retrospectively from medical records according to a standard case report form. The primary outcome measure was overall survival, estimated by the Kaplan-Meier method. RESULTS Data were obtained for 448 sorafenib-treated patients from 15 hospitals. The median age was 68 years (range 17-89) and 75% had performance status ≤ 1. At baseline, 77% were Child-Pugh A and 16.1% Child-Pugh B; 38% were albumin-bilirubin grade 1 (ALBI-1) and 48% ALBI-2; 23% were Barcelona Clinic Liver Classification B (BCLC-B) and 72% BCLC-C. The median time on sorafenib was 3.6 months, with a mean daily dose of 590 mg. The median overall survival for 448 evaluable sorafenib-treated patients was 8.5 months. There were significant differences in overall survival comparing Child-Pugh A versus Child-Pugh B (9.5 versus 4.6 months), ALBI-1 versus ALBI-2 (12.9 versus 5.9 months) and BCLC-B versus BCLC-C (13.0 versus 8.3 months). For trial-treated patients (n=109), the median overall survival was 8.1 months and this was not significantly different from the sorafenib-treated patients. CONCLUSION For Child-Pugh A patients with good performance status, survival outcomes were similar to those reported in global randomised controlled trials. Patients with ALBI grade > 1, Child-Pugh B or poor performance status seem to derive limited benefit from sorafenib treatment.
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Affiliation(s)
- J King
- Department of Oncology, Royal Free London NHS Foundation Trust, London, UK
| | - D H Palmer
- University of Birmingham, Birmingham, UK; University of Liverpool, Liverpool, UK; Clatterbridge Cancer Centre, Wirral, UK
| | - P Johnson
- University of Birmingham, Birmingham, UK; University of Liverpool, Liverpool, UK; Clatterbridge Cancer Centre, Wirral, UK
| | - P Ross
- King's College Hospital, London, UK
| | - R A Hubner
- The Christie NHS Foundation Trust, Manchester, UK
| | - K Sumpter
- The Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - S Darby
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - C Braconi
- University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - C Iwuji
- Leicester Royal Infirmary, Leicester, UK
| | - D Swinson
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - P Collins
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - K Patel
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - J Nobes
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - I Muazzam
- Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - C Blesing
- Great Western Hospital NHS Trust, Swindon, UK
| | - A Kirkwood
- Cancer Research UK & UCL Cancer Trials Centre, London, UK
| | - S Nash
- Cancer Research UK & UCL Cancer Trials Centre, London, UK
| | - T Meyer
- Department of Oncology, Royal Free London NHS Foundation Trust, London, UK; UCL Cancer Institute, London, UK.
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Newell ML, Iwuji C. HIV treatment as prevention: applicable in sub-Saharan Africa? Lancet Infect Dis 2016; 16:754-755. [PMID: 27174505 DOI: 10.1016/s1473-3099(16)30057-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 04/15/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Marie-Louise Newell
- Academic Unit of Health and Development and Global Health Research Institute, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK.
| | - Collins Iwuji
- Africa Centre for Population Health, University of KwaZulu-Natal, South Africa; Research Department of Infection and Population Health, University College London, UK
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Moshabela M, Zuma T, Orne-Gliemann J, Iwuji C, Larmarange J, McGrath N. "It is better to die": experiences of traditional health practitioners within the HIV treatment as prevention trial communities in rural South Africa (ANRS 12249 TasP trial). AIDS Care 2016; 28 Suppl 3:24-32. [PMID: 27421049 PMCID: PMC5096678 DOI: 10.1080/09540121.2016.1181296] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The ANRS 12249 Treatment-as-Prevention (TasP) cluster-randomized trial in rural South Africa uses a "test and treat" approach. Home-based testing services and antiretroviral treatment initiation satellite clinics were implemented in every cluster as part of the trial. A social science research agenda was nested within TasP with the aim of understanding the social, economic and contextual factors that affect individuals, households, communities and health systems with respect to TasP. Considering the rural nature of the trial setting, we sought to understand community perceptions and experiences of the TasP Trial interventions as seen through the eyes of traditional health practitioners (THPs). A qualitative study design was adopted using four repeat focus group discussions conducted with nine THPs, combined with community walks and photo-voice techniques, over a period of 18 months. A descriptive, interpretive and explanatory approach to analysis was adopted. Findings indicate that THPs engaged with the home-based testing services and HIV clinics established for TasP. Specifically, home-based testing services were perceived as relatively successful in increasing access to HIV testing. A major gap observed by THPs was linkage to HIV clinics. Most of their clients, and some of the THPs themselves, found it difficult to use HIV clinics due to fear of labelling, stigma and discrimination, and the ensuing personal implications of unsolicited disclosure. On the one hand, a growing number of patients diagnosed with HIV have found sanctuary with THPs as alternatives to clinics. On the other hand, THPs in turn have been struggling to channel patients suspected of HIV into clinics through referrals. Therefore, acceptability of the TasP test and treat approach by THPs is a major boost to the intervention, but further success can be achieved through strengthened ties with communities to combat stigma and effectively link patients into HIV care, including partnerships with THPs themselves.
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Affiliation(s)
- Mosa Moshabela
- a Africa Centre for Population Health , University of KwaZulu-Natal , Mtubatuba , South Africa
- b School of Nursing and Public Health , University of KwaZulu-Natal , Durban , South Africa
| | - Thembelihle Zuma
- a Africa Centre for Population Health , University of KwaZulu-Natal , Mtubatuba , South Africa
| | - Joanna Orne-Gliemann
- c INSERM U1219 - Centre Inserm Bordeaux Population Health , Université de Bordeaux , Bordeaux , France
- d Université de Bordeaux, ISPED , Centre INSERM U1219-Bordeaux Population Health , Bordeaux , France
| | - Collins Iwuji
- a Africa Centre for Population Health , University of KwaZulu-Natal , Mtubatuba , South Africa
- e Research Department of Infection and Population Health , University College London , London , UK
| | - Joseph Larmarange
- a Africa Centre for Population Health , University of KwaZulu-Natal , Mtubatuba , South Africa
- f Centre Population & Développement (Ceped UMR 196 UPD IRD) , Institut de Recherche pour le Développement , Paris , France
| | - Nuala McGrath
- a Africa Centre for Population Health , University of KwaZulu-Natal , Mtubatuba , South Africa
- e Research Department of Infection and Population Health , University College London , London , UK
- f Centre Population & Développement (Ceped UMR 196 UPD IRD) , Institut de Recherche pour le Développement , Paris , France
- g Faculty of Medicine and Faculty of Social, Human and Mathematical Sciences , University of Southampton , Southampton , UK
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Orne-Gliemann J, Larmarange J, Boyer S, Iwuji C, McGrath N, Bärnighausen T, Zuma T, Dray-Spira R, Spire B, Rochat T, Lert F, Imrie J. Addressing social issues in a universal HIV test and treat intervention trial (ANRS 12249 TasP) in South Africa: methods for appraisal. BMC Public Health 2015; 15:209. [PMID: 25880823 PMCID: PMC4351958 DOI: 10.1186/s12889-015-1344-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 01/02/2015] [Indexed: 12/21/2022] Open
Abstract
Background The Universal HIV Test and Treat (UTT) strategy represents a challenge for science, but is also a challenge for individuals and societies. Are repeated offers of provider-initiated HIV testing and immediate antiretroviral therapy (ART) socially-acceptable and can these become normalized over time? Can UTT be implemented without potentially adding to individual and community stigma, or threatening individual rights? What are the social, cultural and economic implications of UTT for households and communities? And can UTT be implemented within capacity constraints and other threats to the overall provision of HIV services? The answers to these research questions will be critical for routine implementation of UTT strategies. Methods/design A social science research programme is nested within the ANRS 12249 Treatment-as-Prevention (TasP) cluster-randomised trial in rural South Africa. The programme aims to inform understanding of the (i) social, economic and environmental factors affecting uptake of services at each step of the continuum of HIV prevention, treatment and care and (ii) the causal impacts of the TasP intervention package on social and economic factors at the individual, household, community and health system level. We describe a multidisciplinary, multi-level, mixed-method research protocol that includes individual, household, community and clinic surveys, and combines quantitative and qualitative methods. Discussion The UTT strategy is changing the overall approach to HIV prevention, treatment and care, and substantial social consequences may be anticipated, such as changes in social representations of HIV transmission, prevention, HIV testing and ART use, as well as changes in individual perceptions and behaviours in terms of uptake and frequency of HIV testing and ART initiation at high CD4. Triangulation of social science studies within the ANRS 12249 TasP trial will provide comprehensive insights into the acceptability and feasibility of the TasP intervention package at individual, community, patient and health system level, to complement the trial’s clinical and epidemiological outcomes. It will also increase understanding of the causal impacts of UTT on social and economic outcomes, which will be critical for the long-term sustainability and routine UTT implementation. Trial registration Clinicaltrials.gov: NCT01509508; South African Trial Register: DOH-27-0512-3974. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1344-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joanna Orne-Gliemann
- INSERM/University of Bordeaux, ISPED, Centre Inserm U897- Épidemiologie-Biostatistique, Bordeaux, France.
| | - Joseph Larmarange
- Centre Population et Développement (CEPED UMR 196 Université Paris Descartes Ined IRD), Paris, France. .,Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa.
| | - Sylvie Boyer
- INSERM-IRD-Aix-Marseille University, Faculty of Medicine, Aix-Marseille School of Economics (AMSE), SESSTIM-UMR 912, 13006, Marseille, France.
| | - Collins Iwuji
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa.
| | - Nuala McGrath
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa. .,Academic Unit of Primary Care and Population Sciences, and Department of Social statistics and Demography, University of Southampton, Southampton, UK.
| | - Till Bärnighausen
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa. .,Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, USA.
| | - Thembelile Zuma
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa.
| | - Rosemary Dray-Spira
- INSERM, UMR_S1136, Pierre Louis Institute of Epidemiology and Public Health, Research Team in social epidemiology, F-75013, Paris, France. .,Sorbonne Universités, UPMC Univ Paris 06, UMR_S1136, Pierre Louis Institute of Epidemiology and Public Health, Team Research in social epidemiology, F-75013, Paris, France.
| | - Bruno Spire
- INSERM-IRD-Aix-Marseille University, Faculty of Medicine, Aix-Marseille School of Economics (AMSE), SESSTIM-UMR 912, 13006, Marseille, France.
| | - Tamsen Rochat
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa.
| | - France Lert
- Centre de recherche en Épidémiologie et Santé des Populations (CESP, Inserm Unité 1018), Villejuif, France.
| | - John Imrie
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa. .,Centre for Sexual Health and HIV Research, Research Department of Infection and Population Health, Faculty of Population Health Sciences, University College London, London, UK.
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Larmarange J, Balestre É, Orne-Gliemann J, Iwuji C, Okesola N, Newell ML, Dabis F, Lert F. HIV Ascertainment through Repeat Home-based Testing in the Context of a Treatment as Prevention Trial (ANRS 12249 TasP) in Rural South Africa. AIDS Res Hum Retroviruses 2014. [DOI: 10.1089/aid.2014.5650.abstract] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Joseph Larmarange
- IRD, CEPED (UMR 196 Paris Descartes Ined IRD), Paris, France
- University of KwaZulu Natal, Africa Centre for Health and Population Studies, Mtubatuba, South Africa
| | - Éric Balestre
- Inserm, ISPED (Unité 897 Inserm Université Bordeaux Segalen), Bordeaux, France
| | | | - Collins Iwuji
- University of KwaZulu Natal, Africa Centre for Health and Population Studies, Mtubatuba, South Africa
| | - Nonhlanhla Okesola
- University of KwaZulu Natal, Africa Centre for Health and Population Studies, Mtubatuba, South Africa
| | - Marie-Louise Newell
- University of Southampton, Faculty of Medicine, Faculty of Social and Human Sciences, Southampton, United Kingdom
| | - François Dabis
- Inserm, ISPED (Unité 897 Inserm Université Bordeaux Segalen), Bordeaux, France
| | - France Lert
- Inserm, CESP (Unité 1018), Villejuif, France
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Manasa J, Lessells R, Rossouw T, Naidu K, Van Vuuren C, Goedhals D, van Zyl G, Bester A, Skingsley A, Stott K, Danaviah S, Chetty T, Singh L, Moodley P, Iwuji C, McGrath N, Seebregts CJ, de Oliveira T. Southern African Treatment Resistance Network (SATuRN) RegaDB HIV drug resistance and clinical management database: supporting patient management, surveillance and research in southern Africa. Database (Oxford) 2014; 2014:bat082. [PMID: 24504151 PMCID: PMC5630899 DOI: 10.1093/database/bat082] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Substantial amounts of data have been generated from patient management and academic exercises designed to better understand the human immunodeficiency virus (HIV) epidemic and design interventions to control it. A number of specialized databases have been designed to manage huge data sets from HIV cohort, vaccine, host genomic and drug resistance studies. Besides databases from cohort studies, most of the online databases contain limited curated data and are thus sequence repositories. HIV drug resistance has been shown to have a great potential to derail the progress made thus far through antiretroviral therapy. Thus, a lot of resources have been invested in generating drug resistance data for patient management and surveillance purposes. Unfortunately, most of the data currently available relate to subtype B even though >60% of the epidemic is caused by HIV-1 subtype C. A consortium of clinicians, scientists, public health experts and policy markers working in southern Africa came together and formed a network, the Southern African Treatment and Resistance Network (SATuRN), with the aim of increasing curated HIV-1 subtype C and tuberculosis drug resistance data. This article describes the HIV-1 data curation process using the SATuRN Rega database. The data curation is a manual and time-consuming process done by clinical, laboratory and data curation specialists. Access to the highly curated data sets is through applications that are reviewed by the SATuRN executive committee. Examples of research outputs from the analysis of the curated data include trends in the level of transmitted drug resistance in South Africa, analysis of the levels of acquired resistance among patients failing therapy and factors associated with the absence of genotypic evidence of drug resistance among patients failing therapy. All these studies have been important for informing first- and second-line therapy. This database is a free password-protected open source database available on www.bioafrica.net. Database URL:http://www.bioafrica.net/regadb/
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Affiliation(s)
- Justen Manasa
- Africa Centre for Health and Population Studies, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Mtubatuba, South Africa, Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK, Immunology department, University of Pretoria, Pretoria, South Africa, Infectious Diseases, Internal Medicine, University of the Free State School of Medicine, Bloemfontein, South Africa and Division of Medical Virology, Stellenbosch University, Stellenbosch, South Africa, National Health Laboratory Service Tygerberg, Cape Town, South Africa, Department of Virology, National Health Laboratory Service, University of KwaZulu-Natal, Durban, South Africa, The Brighton Doctoral College, Brighton and Sussex Medical School, UK, Academic Unit of primary Care and Population Science, Division of Social Statistics and Geography, University of Southampton, Southampton, UK, Jembi Health Systems, Cape Town, South Africa, School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Westville, South Africa and Research Department of Infection, University College of London (UCL), London, UK
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Iwuji C, Rosich-Medina A, Swaminathan N, Baguley D, Kirwin C, Austin K, Kurukulaaratchy RJ. The potential for patient-led COPD admission avoidance schemes. Eur Respir J 2008; 32:1128-9. [DOI: 10.1183/09031936.00078608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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