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Rautenberg TA, Ng SK, George G, Moosa MYS, McCluskey SM, Gilbert RF, Pillay S, Aturinda I, Ard KL, Muyindike WR, Musinguzi N, Masette G, Pillay M, Moodley P, Brijkumar J, Gandhi RT, Johnson B, Sunpath H, Bwana MB, Marconi VC, Siedner MJ. Determinants of health-related quality of life in people with Human Immunodeficiency Virus, failing first-line treatment in Africa. Health Qual Life Outcomes 2023; 21:94. [PMID: 37605150 PMCID: PMC10441724 DOI: 10.1186/s12955-023-02179-x] [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: 01/18/2023] [Accepted: 08/02/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Antiretroviral treatment improves health related quality of life (HRQoL) of people with human immunodeficiency virus (PWH). However, one third initiating first-line treatment experience virological failure and the determinants of HRQoL in this key population are unknown. Our study aims to identify determinants of among PWH failing antiretroviral treatment in sub-Saharan Africa. METHODS We analysed data from a cohort of PWH having virological failure (> 1,000 copies/mL) on first-line ART in South Africa and Uganda. We measured HRQoL using the EuroQOL EQ-5D-3L and used a two-part regression model to obtain by-country analyses for South Africa and Uganda. The first part identifies risk factors that were associated with the likelihood of participants reporting perfect health (utility = 1) versus non-perfect health (utility < 1). The second part identifies risk factors that were associated with the EQ-5 L-3L utility scores for participants reporting non-perfect health. We performed sensitivity analyses to compare the results between the two-part model using tobit models and ordinary least squares regression. RESULTS In both countries, males were more likely to report perfect health and participants with at least one comorbidity were less likely to report perfect health. In South Africa, participants with side effects and in Uganda those with opportunistic infections were also less likely to report perfect health. In Uganda, participants with 100% ART adherence were more likely to report perfect health. In South Africa, high HIV viral load, experiencing ART side effects, and the presence of opportunistic infections were each associated with lower HRQoL, whereas participants with 100% ART adherence reported higher HRQoL. In Uganda participants with lower CD4 count had lower HRQoL. CONCLUSION Markers of advanced disease (opportunistic infection, high viral load, low CD4), side effects, comorbidities and lack of ART adherence negatively impacted HRQoL for PWH experiencing virological failure. TRIAL REGISTRATION ClinicalTrials.gov: NCT02787499.
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Affiliation(s)
- Tamlyn A Rautenberg
- School of Medicine and Dentistry, Centre for Applied Health Economics, Griffith University, Australia (Sir Samuel Griffith Centre N78 Room 2.34), Nathan campus, QLD, 4111, Australia.
- Menzies Health Institute Queensland, Southport, Australia.
- Metro North Hospital and Health Service Queensland, Herston, Australia.
| | - Shu Kay Ng
- School of Medicine and Dentistry, Centre for Applied Health Economics, Griffith University, Australia (Sir Samuel Griffith Centre N78 Room 2.34), Nathan campus, QLD, 4111, Australia
- Menzies Health Institute Queensland, Southport, Australia
| | - Gavin George
- Health Economics and HIV Research Division, University of KwaZulu-Natal, Durban, South Africa
- Division of Social Medicine and Global Health, Lund University, Lund, Sweden
| | | | - Suzanne M McCluskey
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Rebecca F Gilbert
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Selvan Pillay
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Isaac Aturinda
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Kevin L Ard
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Winnie R Muyindike
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Nicholas Musinguzi
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Godfrey Masette
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Pravi Moodley
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- National Health Laboratory Service, Durban, South Africa
| | - Jaysingh Brijkumar
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Rajesh T Gandhi
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Brent Johnson
- Department of Biostatistics and Computation Biology, University of Rochester, Rochester, NY, USA
| | - Henry Sunpath
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Mwebesa B Bwana
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Vincent C Marconi
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Global Health, Rollins School of Public Health, Atlanta, GA, USA
| | - Mark J Siedner
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
- Africa Health Research Institute, KwaZulu-Natal, Durban, South Africa
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Rautenberg TA, Ng SK, George G, Moosa MYS, McCluskey SM, Gilbert RF, Pillay S, Aturinda I, Ard KL, Muyindike W, Musinguzi N, Masette G, Pillay M, Moodley P, Brijkumar J, Gandhi RT, Johnson B, Sunpath H, Bwana MB, Marconi VC, Siedner MJ. Seemingly Unrelated Regression Analysis of the Cost and Health-Related Quality of Life Outcomes of the REVAMP Randomized Clinical Trial. Value Health Reg Issues 2023; 35:42-47. [PMID: 36863066 PMCID: PMC10256267 DOI: 10.1016/j.vhri.2022.12.006] [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: 09/22/2022] [Revised: 11/29/2022] [Accepted: 12/17/2022] [Indexed: 03/04/2023]
Abstract
OBJECTIVE This study aimed to evaluate the 9-month cost and health-related quality of life (HRQOL) outcomes of resistance versus viral load testing strategies to manage virological failure in low-middle income countries. METHODS We analyzed secondary outcomes from the REVAMP clinical trial: a pragmatic, open label, parallel-arm randomized trial investigating resistance versus viral load testing for individuals failing first-line treatment in South Africa and Uganda. We collected resource data, valued according to local cost data and used the 3-level version of EQ-5D to measure HRQOL at baseline and 9 months. We applied seemingly unrelated regression equations to account for the correlation between cost and HRQOL. We conducted intention-to-treat analyses with multiple imputation using chained equations for missing data and performed sensitivity analyses using complete cases. RESULTS For South Africa, resistance testing and opportunistic infections were associated with statistically significantly higher total costs, and virological suppression was associated with lower total cost. Higher baseline utility, higher cluster of differentiation 4 (CD4) count, and virological suppression were associated with better HRQOL. For Uganda, resistance testing and switching to second-line treatment were associated with higher total cost, and higher CD4 was associated with lower total cost. Higher baseline utility, higher CD4 count, and virological suppression were associated with better HRQOL. Sensitivity analyses of the complete-case analysis confirmed the overall results. CONCLUSION Resistance testing showed no cost or HRQOL advantage in South Africa or Uganda over the 9-month REVAMP clinical trial.
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Affiliation(s)
- Tamlyn A Rautenberg
- Centre for Applied Health Economics, Griffith University, Brisbane, QLD, Australia; Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia; Allied Health Services, Metro North Hospital and Health Service, Brisbane, QLD, Australia.
| | - Shu Kay Ng
- Centre for Applied Health Economics, Griffith University, Brisbane, QLD, Australia
| | - Gavin George
- Health Economics and HIV Research Division, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa; Division of Social Medicine and Global Health, Lund University, Lund, Sweden
| | - Mahomed-Yunus S Moosa
- School of Clinical Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Suzanne M McCluskey
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Rebecca F Gilbert
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Selvan Pillay
- School of Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Isaac Aturinda
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Kevin L Ard
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Winnie Muyindike
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Nicholas Musinguzi
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Godfrey Masette
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Melendhran Pillay
- Department of Virology, National Health Laboratory Service, Durban, South Africa
| | - Pravi Moodley
- Department of Virology, National Health Laboratory Service, Durban, South Africa; Department of Virology, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Jaysingh Brijkumar
- Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Rajesh T Gandhi
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Brent Johnson
- Department of Biostatistics and Computation Biology, University of Rochester, Rochester, NY, USA
| | - Henry Sunpath
- Department of Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Mwebesa B Bwana
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Vincent C Marconi
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Department of Global Health, Rollins School of Public Health, Atlanta, GA, USA
| | - Mark J Siedner
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; School of Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa; Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda; Department of Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa; Africa Health Research Institute, KwaZulu-Natal, South Africa
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Pratt MC, Owembabazi M, Muyindike W, Kaida A, Marrazzo JM, Bangsberg DR, Bwana MB, Psaros C, Turan J, Atukunda EC, Matthews LT. 'I still desire to have a child': a qualitative analysis of intersectional HIV- and childlessness-related stigma in rural southwestern Uganda. Cult Health Sex 2023; 25:143-158. [PMID: 35015604 PMCID: PMC9271525 DOI: 10.1080/13691058.2021.2023761] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/24/2021] [Indexed: 06/14/2023]
Abstract
This study explored the intersecting forms of stigma experienced by HIV-serodifferent couples with unmet reproductive goals in rural Uganda. The parent mixed-methods study, which included 131 HIV-exposed women with plans for pregnancy, offered comprehensive HIV prevention counselling and care over a nine-month period. In-depth interviews were conducted with 37 women and seven male partners to explore care experiences and the use of safer conception strategies. This secondary analysis explored how challenges conceiving informed pregnancy plans and HIV prevention behaviours. The following themes were developed (1) partnership conflicts arise from HIV- and infertility-related forms of stigma, contributing to gender-based violence, partnership dissolution and the pursuit of new partners; (2) cultural and gender norms pressure men and women to conceive and maintain partnerships, which is complicated by the stigma directed towards serodifferent couples; (3) frustration with low partner participation in safer conception strategies led to the decreased use of these methods of HIV prevention; (4) health care provider support promotes continued hope of conception and helps overcome stigma. In HIV-affected partnerships, these intersecting forms of stigma may impact HIV prevention. Seeking to fulfil their reproductive needs, partners may increase HIV transmission opportunities as they engage in condomless sex with additional partners and decrease adherence to prevention strategies. Future research programmes should consider the integration of fertility counselling with reproductive and sexual health care.
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Affiliation(s)
- Madeline C. Pratt
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Jeanne M. Marrazzo
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David R. Bangsberg
- School of Public Health, Oregon Health Sciences University – Portland State University, Portland, OR, USA
| | | | - Christina Psaros
- Department of Psychiatry, Behavioural Medicine Program, Massachusetts General Hospital, Boston, MA, USA
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Lynn T. Matthews
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Siedner MJ, Moosa MYS, McCluskey S, Gilbert RF, Pillay S, Aturinda I, Ard K, Muyindike W, Musinguzi N, Masette G, Pillay M, Moodley P, Brijkumar J, Rautenberg T, George G, Gandhi RT, Johnson BA, Sunpath H, Bwana MB, Marconi VC. Resistance Testing for Management of HIV Virologic Failure in Sub-Saharan Africa : An Unblinded Randomized Controlled Trial. Ann Intern Med 2021; 174:1683-1692. [PMID: 34698502 PMCID: PMC8688215 DOI: 10.7326/m21-2229] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Virologic failure in HIV predicts the development of drug resistance and mortality. Genotypic resistance testing (GRT), which is the standard of care after virologic failure in high-income settings, is rarely implemented in sub-Saharan Africa. OBJECTIVE To estimate the effectiveness of GRT for improving virologic suppression rates among people with HIV in sub-Saharan Africa for whom first-line therapy fails. DESIGN Pragmatic, unblinded, randomized controlled trial. (ClinicalTrials.gov: NCT02787499). SETTING Ambulatory HIV clinics in the public sector in Uganda and South Africa. PATIENTS Adults receiving first-line antiretroviral therapy with a recent HIV RNA viral load of 1000 copies/mL or higher. INTERVENTION Participants were randomly assigned to receive standard of care (SOC), including adherence counseling sessions and repeated viral load testing, or immediate GRT. MEASUREMENTS The primary outcome of interest was achievement of an HIV RNA viral load below 200 copies/mL 9 months after enrollment. RESULTS The trial enrolled 840 persons, divided equally between countries. Approximately half (51%) were women. Most (72%) were receiving a regimen of tenofovir, emtricitabine, and efavirenz at enrollment. The rate of virologic suppression did not differ 9 months after enrollment between the GRT group (63% [263 of 417]) and SOC group (61% [256 of 423]; odds ratio [OR], 1.11 [95% CI, 0.83 to 1.49]; P = 0.46). Among participants with persistent failure (HIV RNA viral load ≥1000 copies/mL) at 9 months, the prevalence of drug resistance was higher in the SOC group (76% [78 of 103] vs. 59% [48 of 82]; OR, 2.30 [CI, 1.22 to 4.35]; P = 0.014). Other secondary outcomes, including 9-month survival and retention in care, were similar between groups. LIMITATION Participants were receiving nonnucleoside reverse transcriptase inhibitor-based therapy at enrollment, limiting the generalizability of the findings. CONCLUSION The addition of GRT to routine care after first-line virologic failure in Uganda and South Africa did not improve rates of resuppression. PRIMARY FUNDING SOURCE The President's Emergency Plan for AIDS Relief and the National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Mark J Siedner
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, Mbarara University of Science and Technology, Mbarara, Uganda, Africa Health Research Institute, KwaZulu-Natal, South Africa, and University of KwaZulu-Natal, Durban, South Africa (M.J.S.)
| | | | - Suzanne McCluskey
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (S.M., K.A., R.T.G.)
| | | | - Selvan Pillay
- University of KwaZulu-Natal, Durban, South Africa (M.S.M., S.P., J.B., G.G., H.S.)
| | - Isaac Aturinda
- Mbarara University of Science and Technology, Mbarara, Uganda (I.A., W.M., N.M., G.M., M.B.B.)
| | - Kevin Ard
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (S.M., K.A., R.T.G.)
| | - Winnie Muyindike
- Mbarara University of Science and Technology, Mbarara, Uganda (I.A., W.M., N.M., G.M., M.B.B.)
| | - Nicholas Musinguzi
- Mbarara University of Science and Technology, Mbarara, Uganda (I.A., W.M., N.M., G.M., M.B.B.)
| | - Godfrey Masette
- Mbarara University of Science and Technology, Mbarara, Uganda (I.A., W.M., N.M., G.M., M.B.B.)
| | - Melendhran Pillay
- National Health Laboratory Service, Durban, South Africa (M.P., P.M.)
| | | | - Jaysingh Brijkumar
- University of KwaZulu-Natal, Durban, South Africa (M.S.M., S.P., J.B., G.G., H.S.)
| | | | - Gavin George
- University of KwaZulu-Natal, Durban, South Africa (M.S.M., S.P., J.B., G.G., H.S.)
| | - Rajesh T Gandhi
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (S.M., K.A., R.T.G.)
| | | | - Henry Sunpath
- University of KwaZulu-Natal, Durban, South Africa (M.S.M., S.P., J.B., G.G., H.S.)
| | - Mwebesa B Bwana
- Mbarara University of Science and Technology, Mbarara, Uganda (I.A., W.M., N.M., G.M., M.B.B.)
| | - Vincent C Marconi
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia (V.C.M.)
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Katz IT, Musinguzi N, Bell K, Cross A, Bwana MB, Amanyire G, Asiimwe S, Orrell C, Bangsberg DR, Haberer JE. Brief Report: The Impact of Disease Stage on Early Gaps in ART in the "Treatment for All" Era-A Multisite Cohort Study. J Acquir Immune Defic Syndr 2021; 86:562-567. [PMID: 33351529 PMCID: PMC7938906 DOI: 10.1097/qai.0000000000002605] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/09/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Adoption of "Treat All" policies has increased antiretroviral therapy (ART) initiation in sub-Saharan Africa; however, unexplained early losses continue to occur. More information is needed to understand why treatment discontinuation continues at this vulnerable stage in care. METHODS The Monitoring Early Treatment Adherence Study involved a prospective observational cohort of individuals initiating ART at early-stage versus late-stage disease in South Africa and Uganda. Surveys and HIV-1 RNA levels were performed at baseline, 6, and 12 months, with adherence monitored electronically. This analysis included nonpregnant participants in the first 6 months of follow-up; demographic and clinical factors were compared across groups with χ2, univariable, and multivariable models. RESULTS Of 669 eligible participants, 91 (14%) showed early gaps of ≥30 days in ART use (22% in South Africa and 6% in Uganda) with the median time to gap of 77 days (interquartile range: 43-101) and 87 days (74, 105), respectively. Although 71 (78%) ultimately resumed care, having an early gap was still significantly associated with detectable viremia at 6 months (P ≤ 0.01). Multivariable modeling, restricted to South Africa, found secondary education and higher physical health score protected against early gaps [adjusted odds ratio (aOR) 0.4, 95% confidence interval (CI): 0.2 to 0.8 and (aOR 0.93, 95% CI: 0.9 to 1.0), respectively]. Participants reporting clinics as "too far" had double the odds of early gaps (aOR 2.2: 95% CI: 1.2 to 4.1). DISCUSSION Early gaps in ART persist, resulting in higher odds of detectable viremia, particularly in South Africa. Interventions targeting health management and access to care are critical to reducing early gaps.
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Affiliation(s)
- Ingrid T. Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Harvard Global Health Institute, Cambridge, MA
| | | | - Kathleen Bell
- Massachusetts General Hospital Center for Global Health, Boston, MA
| | - Anna Cross
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | | | - Gideon Amanyire
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Stephen Asiimwe
- Mbarara University of Science and Technology, Mbarara, Uganda
- Kabwohe Clinical Research Center, Kabwohe, Uganda; and
| | - Catherine Orrell
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - David R. Bangsberg
- Oregon Health and Science University-Portland State University School of Public Health, Portland, OR
| | - Jessica E. Haberer
- Harvard Medical School, Boston, MA
- Massachusetts General Hospital Center for Global Health, Boston, MA
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6
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Umviligihozo G, Cobarrubias KD, Chandrarathna S, Jin SW, Reddy N, Byakwaga H, Muzoora C, Bwana MB, Lee GQ, Hunt PW, Martin JN, Brumme CJ, Bangsberg DR, Karita E, Allen S, Hunter E, Ndung'u T, Brumme ZL, Brockman MA. Differential Vpu-Mediated CD4 and Tetherin Downregulation Functions among Major HIV-1 Group M Subtypes. J Virol 2020; 94:e00293-20. [PMID: 32376625 PMCID: PMC7343213 DOI: 10.1128/jvi.00293-20] [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] [Received: 02/23/2020] [Accepted: 04/30/2020] [Indexed: 12/12/2022] Open
Abstract
Downregulation of BST-2/tetherin and CD4 by HIV-1 viral protein U (Vpu) promotes viral egress and allows infected cells to evade host immunity. Little is known however about the natural variability in these Vpu functions among the genetically diverse viral subtypes that contribute to the HIV-1 pandemic. We collected Vpu isolates from 332 treatment-naive individuals living with chronic HIV-1 infection in Uganda, Rwanda, South Africa, and Canada. Together, these Vpu isolates represent four major HIV-1 group M subtypes (A [n = 63], B [n = 84], C [n = 94], and D [n = 59]) plus intersubtype recombinants and uncommon strains (n = 32). The ability of each Vpu clone to downregulate endogenous CD4 and tetherin was quantified using flow cytometry following transfection into an immortalized T-cell line and compared to that of a reference Vpu clone derived from HIV-1 subtype B NL4.3. Overall, the median CD4 downregulation function of natural Vpu isolates was similar to that of NL4.3 (1.01 [interquartile range {IQR}, 0.86 to 1.18]), while the median tetherin downregulation function was moderately lower than that of NL4.3 (0.90 [0.79 to 0.97]). Both Vpu functions varied significantly among HIV-1 subtypes (Kruskal-Wallis P < 0.0001). Specifically, subtype C clones exhibited the lowest CD4 and tetherin downregulation activities, while subtype D and B clones were most functional for both activities. We also identified Vpu polymorphisms associated with CD4 or tetherin downregulation function and validated six of these using site-directed mutagenesis. Our results highlight the marked extent to which Vpu function varies among global HIV-1 strains, raising the possibility that natural variation in this accessory protein may contribute to viral pathogenesis and/or spread.IMPORTANCE The HIV-1 accessory protein Vpu enhances viral spread by downregulating CD4 and BST-2/tetherin on the surface of infected cells. Natural variability in these Vpu functions may contribute to HIV-1 pathogenesis, but this has not been investigated among the diverse viral subtypes that contribute to the HIV-1 pandemic. In this study, we found that Vpu function differs significantly among HIV-1 subtypes A, B, C, and D. On average, subtype C clones displayed the lowest ability to downregulate both CD4 and tetherin, while subtype B and D clones were more functional. We also identified Vpu polymorphisms that associate with functional differences among HIV-1 isolates and subtypes. Our study suggests that genetic diversity in Vpu may play an important role in the differential pathogenesis and/or spread of HIV-1.
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Affiliation(s)
- Gisele Umviligihozo
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Kyle D Cobarrubias
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Sandali Chandrarathna
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Steven W Jin
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Nicole Reddy
- University of KwaZulu-Natal, Durban, South Africa
- Africa Health Research Institute, Durban, South Africa
| | - Helen Byakwaga
- Mbarara University of Science and Technology, Mbarara, Uganda
- University of California, San Francisco, California, USA
| | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mwebesa B Bwana
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Guinevere Q Lee
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Peter W Hunt
- University of California, San Francisco, California, USA
| | - Jeff N Martin
- University of California, San Francisco, California, USA
| | - Chanson J Brumme
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- University of British Columbia, Vancouver, British Columbia, Canada
| | - David R Bangsberg
- Oregon Health and Science University-Portland State University School of Public Health, Portland, Oregon, USA
| | - Etienne Karita
- Rwanda Zambia HIV Research Group-Projet San Francisco, Kigali, Rwanda
| | - Susan Allen
- Rwanda Zambia HIV Research Group-Projet San Francisco, Kigali, Rwanda
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia, USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Eric Hunter
- Rwanda Zambia HIV Research Group-Projet San Francisco, Kigali, Rwanda
- Emory Vaccine Center at Yerkes National Primate Research Center, Emory University, Atlanta, Georgia, USA
| | - Thumbi Ndung'u
- University of KwaZulu-Natal, Durban, South Africa
- Africa Health Research Institute, Durban, South Africa
- Max Planck Institute for Infection Biology, Berlin, Germany
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Zabrina L Brumme
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Mark A Brockman
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
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7
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Benitez AE, Musinguzi N, Bangsberg DR, Bwana MB, Muzoora C, Hunt PW, Martin JN, Haberer JE, Petersen ML. Super learner analysis of real-time electronically monitored adherence to antiretroviral therapy under constrained optimization and comparison to non-differentiated care approaches for persons living with HIV in rural Uganda. J Int AIDS Soc 2020; 23:e25467. [PMID: 32202067 PMCID: PMC7086301 DOI: 10.1002/jia2.25467] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 04/18/2019] [Accepted: 01/27/2020] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Real-time electronic adherence monitoring (EAM) systems could inform on-going risk assessment for HIV viraemia and be used to personalize viral load testing schedules. We evaluated the potential of real-time EAM (transferred via cellular signal) and standard EAM (downloaded via USB cable) in rural Uganda to inform individually differentiated viral load testing strategies by applying machine learning approaches. METHODS We evaluated an observational cohort of persons living with HIV and treated with antiretroviral therapy (ART) who were monitored longitudinally with standard EAM from 2005 to 2011 and real-time EAM from 2011 to 2015. Super learner, an ensemble machine learning method, was used to develop a tool for targeting viral load testing to detect viraemia (>1000 copies/ml) based on clinical (CD4 count, ART regimen), viral load and demographic data, together with EAM-based adherence. Using sample-splitting (cross-validation), we evaluated area under the receiver operating characteristic curve (cvAUC), potential for EAM data to selectively defer viral load tests while minimizing delays in viraemia detection, and performance compared to WHO-recommended testing schedules. RESULTS In total, 443 persons (1801 person-years) and 485 persons (930 person-years) contributed to standard and real-time EAM analyses respectively. In the 2011 to 2015 dataset, addition of real-time EAM (cvAUC: 0.88; 95% CI: 0.83, 0.93) significantly improved prediction compared to clinical/demographic data alone (cvAUC: 0.78; 95% CI: 0.72, 0.86; p = 0.03). In the 2005 to 2011 dataset, addition of standard EAM (cvAUC: 0.77; 95% CI: 0.72, 0.81) did not significantly improve prediction compared to clinical/demographic data alone (cvAUC: 0.70; 95% CI: 0.64, 0.76; p = 0.08). A hypothetical testing strategy using real-time EAM to guide deferral of viral load tests would have reduced the number of tests by 32% while detecting 87% of viraemia cases without delay. By comparison, the WHO-recommended testing schedule would have reduced the number of tests by 69%, but resulted in delayed detection of viraemia a mean of 74 days for 84% of individuals with viraemia. Similar rules derived from standard EAM also resulted in potential testing frequency reductions. CONCLUSIONS Our machine learning approach demonstrates potential for combining EAM data with other clinical measures to develop a selective testing rule that reduces number of viral load tests ordered, while still identifying those at highest risk for viraemia.
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Affiliation(s)
- Alejandra E Benitez
- Division of BiostatisticsSchool of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
| | - Nicholas Musinguzi
- Global Health CollaborativeMbarara University of Science and TechnologyMbararaUganda
| | - David R Bangsberg
- Oregon Health & Science University‐Portland State University School of Public HealthPortlandORUSA
| | - Mwebesa B Bwana
- Department of Internal MedicineMbarara University of Science & TechnologyMbararaUganda
| | - Conrad Muzoora
- Department of Internal MedicineMbarara University of Science & TechnologyMbararaUganda
| | - Peter W Hunt
- Division of Experimental MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Jeffrey N Martin
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCAUSA
| | - Jessica E Haberer
- Massachusetts General Hospital Center for Global HealthBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Maya L Petersen
- Division of BiostatisticsSchool of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
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McCluskey SM, Lee GQ, Kamelian K, Kembabazi A, Musinguzi N, Bwana MB, Muzoora C, Haberer JE, Hunt PW, Martin JN, Boum Y, Bangsberg DR, Harrigan PR, Siedner MJ. Increasing Prevalence of HIV Pretreatment Drug Resistance in Women But Not Men in Rural Uganda During 2005-2013. AIDS Patient Care STDS 2018; 32:257-264. [PMID: 29985647 DOI: 10.1089/apc.2018.0020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 11/13/2022] Open
Abstract
The prevalence of HIV pretreatment drug resistance (PDR) is increasing in sub-Saharan Africa. We sought to describe correlates of PDR and evaluate effects of PDR on clinical outcomes in rural Uganda. We analyzed data from the Uganda AIDS Rural Treatment Outcomes study, a cohort of antiretroviral therapy (ART)-naive adults with HIV (2005-2015). We performed resistance testing on pre-ART specimens. We defined PDR as any World Health Organization (WHO) 2009 surveillance drug resistance mutation and classified PDR level using the Stanford algorithm. We fit unadjusted and sex-stratified log binomial regression and Cox proportional hazard models to identify correlates of PDR and the impact of PDR on viral suppression, loss to follow-up (LTFU), and death. We analyzed data from 738 participants (median age 33 years, 69% female). Overall, prevalence of PDR was 3.5% (n = 26), owing mostly to resistance to non-nucleoside reverse transcriptase inhibitors. PDR increased over time in women (1.8% in those enrolling in clinic in 2001-2006, vs. 7.0% in 2007-2013; p = 0.006), but not in men (1.15% vs. 0.72%, p = 0.737). Lower pre-ART log10 HIV RNA was also associated with higher prevalence of PDR. We identified longer time to viral suppression among those with PDR compared with without PDR (0.5 and 0.3 years, respectively, p = 0.023), but there was no significant relationship with mortality or LTFU (p = 0.139). We observed increasing rates of PDR in women in southwestern Uganda. Implications of this trend, particularly to prevention of mother-to-child transmission programs in the region, require attention due to delayed viral suppression among those with PDR.
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Affiliation(s)
- Suzanne M. McCluskey
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Guinevere Q. Lee
- Harvard Medical School, Boston, Massachusetts
- The Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts
- BC Center for Excellence in HIV/AIDS, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Kimia Kamelian
- BC Center for Excellence in HIV/AIDS, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Annet Kembabazi
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jessica E. Haberer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Peter W. Hunt
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Jeffrey N. Martin
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Yap Boum
- Epicenter Mbarara Research Center, Mbarara, Uganda
| | - David R. Bangsberg
- Oregon Health Sciences University–Portland State University School of Public Health, Portland, Oregon
| | | | - Mark J. Siedner
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Mbarara University of Science and Technology, Mbarara, Uganda
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Siedner MJ, Bwana MB, Moosa MYS, Paul M, Pillay S, McCluskey S, Aturinda I, Ard K, Muyindike W, Moodley P, Brijkumar J, Rautenberg T, George G, Johnson B, Gandhi RT, Sunpath H, Marconi VC. The REVAMP trial to evaluate HIV resistance testing in sub-Saharan Africa: a case study in clinical trial design in resource limited settings to optimize effectiveness and cost effectiveness estimates. HIV Clin Trials 2017; 18:149-155. [PMID: 28720039 DOI: 10.1080/15284336.2017.1349028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND In sub-Saharan Africa, rates of sustained HIV virologic suppression remain below international goals. HIV resistance testing, while common in resource-rich settings, has not gained traction due to concerns about cost and sustainability. OBJECTIVE We designed a randomized clinical trial to determine the feasibility, effectiveness, and cost-effectiveness of routine HIV resistance testing in sub-Saharan Africa. APPROACH We describe challenges common to intervention studies in resource-limited settings, and strategies used to address them, including: (1) optimizing generalizability and cost-effectiveness estimates to promote transition from study results to policy; (2) minimizing bias due to patient attrition; and (3) addressing ethical issues related to enrollment of pregnant women. METHODS The study randomizes people in Uganda and South Africa with virologic failure on first-line therapy to standard of care virologic monitoring or immediate resistance testing. To strengthen external validity, study procedures are conducted within publicly supported laboratory and clinical facilities using local staff. To optimize cost estimates, we collect primary data on quality of life and medical resource utilization. To minimize losses from observation, we collect locally relevant contact information, including Whatsapp account details, for field-based tracking of missing participants. Finally, pregnant women are followed with an adapted protocol which includes an increased visit frequency to minimize risk to them and their fetuses. CONCLUSIONS REVAMP is a pragammatic randomized clinical trial designed to test the effectiveness and cost-effectiveness of HIV resistance testing versus standard of care in sub-Saharan Africa. We anticipate the results will directly inform HIV policy in sub-Saharan Africa to optimize care for HIV-infected patients.
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Affiliation(s)
- Mark J Siedner
- a Department of Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Mwebesa B Bwana
- b Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda
| | | | - Michelle Paul
- a Department of Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Selvan Pillay
- c Division of Medicine , University of KwaZulu-Natal , Durban , South Africa
| | - Suzanne McCluskey
- a Department of Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Isaac Aturinda
- b Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda
| | - Kevin Ard
- a Department of Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Winnie Muyindike
- b Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda
| | | | - Jaysingh Brijkumar
- c Division of Medicine , University of KwaZulu-Natal , Durban , South Africa
| | - Tamlyn Rautenberg
- c Division of Medicine , University of KwaZulu-Natal , Durban , South Africa
| | - Gavin George
- c Division of Medicine , University of KwaZulu-Natal , Durban , South Africa
| | - Brent Johnson
- e Department of Biostatistics and Computational Biology , University of Rochester , Rochester , NY , USA
| | - Rajesh T Gandhi
- a Department of Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Henry Sunpath
- c Division of Medicine , University of KwaZulu-Natal , Durban , South Africa
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Siedner MJ, Santorino D, Lankowski AJ, Kanyesigye M, Bwana MB, Haberer JE, Bangsberg DR. A combination SMS and transportation reimbursement intervention to improve HIV care following abnormal CD4 test results in rural Uganda: a prospective observational cohort study. BMC Med 2015; 13:160. [PMID: 26149722 PMCID: PMC4494725 DOI: 10.1186/s12916-015-0397-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/12/2015] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Up to 50 % of HIV-infected persons in sub-Saharan Africa are lost from care between HIV diagnosis and antiretroviral therapy (ART) initiation. Structural barriers, including cost of transportation to clinic and poor communication systems, are major contributors. METHODS We conducted a prospective, pragmatic, before-and-after clinical trial to evaluate a combination mobile health and transportation reimbursement intervention to improve care at a publicly operated HIV clinic in Uganda. Patients undergoing CD4 count testing were enrolled, and clinicians selected a result threshold that would prompt early return for ART initiation or further care. Participants enrolled in the pre-intervention period (January - August 2012) served as a control group. Participants in the intervention period (September 2012 - November 2013) were randomized to receive daily short message service (SMS) messages for up to seven days in one of three formats: 1) messages reporting an abnormal result directly, 2) personal identification number-protected messages reporting an abnormal result, or 3) messages reading "ABCDEFG" to confidentially convey an abnormal result. Participants returning within seven days of their first message received transportation reimbursements (about $6USD). Our primary outcomes of interest were time to return to clinic and time to ART initiation. RESULTS There were 45 participants in the pre-intervention period and 138 participants in the intervention period (46, 49, and 43 in the direct, PIN, and coded groups, respectively) with low CD4 count results. Median time to clinic return was 33 days (IQR 11-49) in the pre-intervention period and 6 days (IQR 3-16) in the intervention period (P < 0.001); and median time to ART initiation was 47 days (IQR 11-75) versus 12 days (IQR 5-19), (P < 0.001). In multivariable models, participants in the intervention period had earlier return to clinic (AHR 2.32, 95 %CI 1.53 to 3.51) and earlier time to ART initiation (AHR 2.27, 95 %CI 1.38 to 3.72). All three randomized message formats improved time to return to clinic and time to ART initiation (P < 0.01 for all comparisons versus the pre-intervention period). CONCLUSIONS A combination of an SMS laboratory result communication system and transportation reimbursements significantly decreased time to clinic return and time to ART initiation after abnormal CD4 test results. TRIAL REGISTRATIONS Clinicaltrials.gov NCT01579214 , approved 13 April 2012.
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Affiliation(s)
- Mark J Siedner
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA, 02114, USA.
| | - Data Santorino
- Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Alexander J Lankowski
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA.
| | | | - Mwebesa B Bwana
- Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Jessica E Haberer
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, and Harvard School of Public Health, Boston, MA, 02114, USA.
| | - David R Bangsberg
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA, 02114, USA.
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Geng EH, Hunt PW, Diero LO, Kimaiyo S, Somi GR, Okong P, Bangsberg DR, Bwana MB, Cohen CR, Otieno JA, Wabwire D, Elul B, Nash D, Easterbrook PJ, Braitstein P, Musick BS, Martin JN, Yiannoutsos CT, Wools-Kaloustian K. Trends in the clinical characteristics of HIV-infected patients initiating antiretroviral therapy in Kenya, Uganda and Tanzania between 2002 and 2009. J Int AIDS Soc 2011; 14:46. [PMID: 21955541 PMCID: PMC3204275 DOI: 10.1186/1758-2652-14-46] [Citation(s) in RCA: 43] [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: 02/19/2011] [Accepted: 09/28/2011] [Indexed: 11/10/2022] Open
Abstract
Background East Africa has experienced a rapid expansion in access to antiretroviral therapy (ART) for HIV-infected patients. Regionally representative socio-demographic, laboratory and clinical characteristics of patients accessing ART over time and across sites have not been well described. Methods We conducted a cross-sectional analysis of characteristics of HIV-infected adults initiating ART between 2002 and 2009 in Kenya, Uganda and Tanzania and in the International Epidemiologic Databases to Evaluate AIDS Consortium. Characteristics associated with advanced disease (defined as either a CD4 cell count level of less than 50 cells/mm3 or a WHO Stage 4 condition) at the time of ART initiation and use of stavudine (D4T) or nevirapine (NVP) were identified using a log-link Poisson model with robust standard errors. Results Among 48, 658 patients (69% from Kenya, 22% from Uganda and 9% from Tanzania) accessing ART at 30 clinic sites, the median age at the time of ART initiation was 37 years (IQR: 31-43) and 65% were women. Pre-therapy CD4 counts rose from 87 cells/mm3 (IQR: 26-161) in 2002-03 to 154 cells/mm3 (IQR: 71-233) in 2008-09 (p < 0.001). Accessing ART at advanced disease peaked at 35% in 2005-06 and fell to 27% in 2008-09. D4T use in the initial regimen fell from a peak of 88% in 2004-05 to 59% in 2008-09, and a greater extent of decline was observed in Uganda than in Kenya and Tanzania. Self-pay for ART peaked at 18% in 2003, but fell to less than 1% by 2005. In multivariable analyses, accessing ART at advanced immunosuppression was associated with male sex, women without a history of treatment for prevention of mother to child transmission (both as compared with women with such a history) and younger age after adjusting for year of ART initiation and country of residence. Receipt of D4T in the initial regimen was associated with female sex, earlier year of ART initiation, higher WHO stage, and lower CD4 levels at ART initiation and the absence of co-prevalent tuberculosis. Conclusions Public health ART services in east Africa have improved over time, but the fraction of patients accessing ART with advanced immunosuppression is still high, men consistently access ART with more advanced disease, and D4T continues to be common in most settings. Strategies to facilitate access to ART, overcome barriers among men and reduce D4T use are needed.
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Affiliation(s)
- Elvin H Geng
- Department of Medicine, San Francisco General Hospital, University of California at San Francisco, 995 Potrero Avenue, San Francisco, CA, USA.
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12
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Geng EH, Bwana MB, Kabakyenga J, Muyindike W, Emenyonu NI, Musinguzi N, Mugyenyi P, Martin JN, Bangsberg DR. Diminishing availability of publicly funded slots for antiretroviral initiation among HIV-infected ART-eligible patients in Uganda. PLoS One 2010; 5:e14098. [PMID: 21124842 PMCID: PMC2991339 DOI: 10.1371/journal.pone.0014098] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [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: 07/11/2010] [Accepted: 11/02/2010] [Indexed: 11/21/2022] Open
Abstract
Background The impact of flat-line funding in the global scale up of antiretroviral therapy (ART) for HIV-infected patients in Africa has not yet been well described. Methods We evaluated ART-eligible patients and patients starting ART at a prototypical scale up ART clinic in Mbarara, Uganda between April 1, 2009 and May 14, 2010 where four stakeholders sponsor treatment – two PEPFAR implementing organizations, the Ugandan Ministry of Health – Global Fund (MOH-GF) and a private foundation named the Family Treatment Fund (FTF). We assessed temporal trends in the number of eligible patients, the number starting ART and tabulated the distribution of the stakeholders supporting ART initiation by month and quartile of time during this interval. We used survival analyses to assess changes in the rate of ART initiation over calendar time. Findings A total of 1309 patients who were eligible for ART made visits over the 14 month period of the study and of these 819 started ART. The median number of ART eligible patients each month was 88 (IQR: 74 to 115). By quartile of calendar time, PEPFAR and MOH sponsored 290, 192, 180, and 49 ART initiations whereas the FTF started 1, 2, 1 and 104 patients respectively. By May of 2010 (the last calendar month of observation) FTF sponsored 88% of all ART initiations. Becoming eligible for ART in the 3rd (HR = 0.58, 95% 0.45–0.74) and 4th quartiles (HR = 0.49, 95% CI: 0.36–0.65) was associated with delay in ART initiation compared to the first quartile in multivariable analyses. Interpretation During a period of flat line funding from multinational donors for ART programs, reductions in the number of ART initiations by public programs (i.e., PEPFAR and MOH-GF) and delays in ART initiation became apparent at the a large prototypical scale-up ART clinic in Uganda.
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Affiliation(s)
- Elvin H. Geng
- Division of HIV/AIDS, Department of Medicine, San Francisco General Hospital, San Francisco, California, United States of America
- The East Africa International Databases to Evaluate AIDS Consortium
| | - Mwebesa B. Bwana
- Mbarara University of Science and Technology, Mbarara, Uganda
- The East Africa International Databases to Evaluate AIDS Consortium
| | | | - Winnie Muyindike
- Mbarara University of Science and Technology, Mbarara, Uganda
- The East Africa International Databases to Evaluate AIDS Consortium
| | - Nneka I. Emenyonu
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Massachusetts General Hospital Center for Global Health, Harvard Medical School, Boston, Massachusetts, United States of America
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Nicholas Musinguzi
- Mbarara University of Science and Technology, Mbarara, Uganda
- The East Africa International Databases to Evaluate AIDS Consortium
| | - Peter Mugyenyi
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jeffrey N. Martin
- Division of HIV/AIDS, Department of Medicine, San Francisco General Hospital, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
- The East Africa International Databases to Evaluate AIDS Consortium
| | - David R. Bangsberg
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Massachusetts General Hospital Center for Global Health, Harvard Medical School, Boston, Massachusetts, United States of America
- Mbarara University of Science and Technology, Mbarara, Uganda
- The East Africa International Databases to Evaluate AIDS Consortium
- * E-mail:
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