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Di Salvo I, Mnzava D, Nicoletti GJ, Senkoro E, Ndege RC, Huang DJ, Makunja NT, Kassiga GI, Kaufmann AM, Weisser M, Kind AB. Upscaling cervical cancer screening and treatment for women living with HIV at a rural referral hospital in Tanzania: protocol of a before-and-after study exploring HPV testing and novel diagnostics. BMC Health Serv Res 2023; 23:234. [PMID: 36894985 PMCID: PMC9998252 DOI: 10.1186/s12913-023-09113-3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 01/26/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Cervical cancer (CC) is nearly always caused by persistent human papillomavirus (HPV) infection. It is the most common cancer among women living with HIV (WLWH) and is the leading cause of cancer-related death in women in East Africa, with 10,241 new cases reported in Tanzania in 2020. In 2019, the World Health Organization (WHO) presented a global strategy for the elimination of CC as a public health problem, proposing targets to meet by 2030 for HPV vaccine coverage (90% of all 15-year-old girls), CC screening (70% of all women once at 35 and again at 45 years of age) and treatment delivery, to be scaled at national and subnational levels with a context-sensitive approach. This study aims to evaluate the upscaling of screening and treatment services at a rural referral hospital in Tanzania in order to address the second and third WHO targets. METHODS This is an implementation study with a before-and-after design performed at St. Francis Referral Hospital (SFRH) in Ifakara (south-central Tanzania). CC screening and treatment services are integrated within the local HIV Care and Treatment Center (CTC). The standard of care, consisting of visualization of the cervix with acetic acid (VIA) and cryotherapy has been up-scaled with self-sampled HPV testing and also involved the introduction of mobile colposcopy, thermal ablation and loop electrosurgical excision procedure (LEEP). Participants are WLWH aged 18 to 65 years. Outcome measures included the percentage of women screened, HPV prevalence and genotype, and adherence to screening, treatment and follow-up plan. Additionally, we will explore the performance of novel diagnostic tests (QG-MPH®, Prevo-Check® and PT Monitor®), which share the features of being manageable and inexpensive, and thus a potential tool for effective triage in HPV high-prevalence cohorts. DISCUSSION The study will provide relevant information about HPV prevalence and persistence, as well as reproductive and lifestyle indicators in a CC high-risk cohort of WLWH and about upscaling screening and treatment services at the level of a rural referral hospital in Tanzania. Furthermore, it will provide exploratory data on novel assays. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05256862, date of registration 25/02/2022. Retrospectively registered.
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Affiliation(s)
- Ivana Di Salvo
- Colposcopy Unit, Department of Gynaecology and Gynaecologic Oncology, University Hospital of Basel, Spitalstrasse 21, Basel, 4031, Switzerland.,Chronic Disease Clinic, Department for Interventions and Clinical Trials, Ifakara Health Institute, Ifakara, United Republic of Tanzania.,Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Dorcas Mnzava
- Chronic Disease Clinic, Department for Interventions and Clinical Trials, Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | - Giovanni Jacopo Nicoletti
- Chronic Disease Clinic, Department for Interventions and Clinical Trials, Ifakara Health Institute, Ifakara, United Republic of Tanzania.,Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Elizabeth Senkoro
- Chronic Disease Clinic, Department for Interventions and Clinical Trials, Ifakara Health Institute, Ifakara, United Republic of Tanzania.,Saint Francis Referral Hospital, Ifakara, Tanzania
| | - Robert C Ndege
- Chronic Disease Clinic, Department for Interventions and Clinical Trials, Ifakara Health Institute, Ifakara, United Republic of Tanzania.,Saint Francis Referral Hospital, Ifakara, Tanzania
| | - Dorothy J Huang
- Colposcopy Unit, Department of Gynaecology and Gynaecologic Oncology, University Hospital of Basel, Spitalstrasse 21, Basel, 4031, Switzerland
| | - Nathalia Tobias Makunja
- Saint Francis Referral Hospital, Ifakara, Tanzania.,Department of Obstetrics and Gynecology, St. Francis Referral District Hospital, Ifakara, Tanzania
| | - George I Kassiga
- Saint Francis Referral Hospital, Ifakara, Tanzania.,Department of Obstetrics and Gynecology, St. Francis Referral District Hospital, Ifakara, Tanzania
| | - Andreas M Kaufmann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Gynaecology, HPV Laboratory, Berlin, Germany
| | - Maja Weisser
- Chronic Disease Clinic, Department for Interventions and Clinical Trials, Ifakara Health Institute, Ifakara, United Republic of Tanzania.,University of Basel, Basel, Switzerland.,Department of Infectious Diseases & Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland
| | - André B Kind
- Colposcopy Unit, Department of Gynaecology and Gynaecologic Oncology, University Hospital of Basel, Spitalstrasse 21, Basel, 4031, Switzerland. .,University of Basel, Basel, Switzerland.
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Ndege RC, Okuma J, Kalinjuma AV, Mkumbo J, Senkoro E, Fue G, Samson L, Mapesi H, Shabani S, Glass TR, Battegay M, Paris DH, Vanobberghen F, Weisser M. Failure to return pillbox is a predictor of being lost to follow-up among people living with HIV on antiretroviral therapy in rural Tanzania. HIV Med 2021; 23:661-672. [PMID: 34964236 PMCID: PMC9306592 DOI: 10.1111/hiv.13223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 09/21/2021] [Revised: 11/22/2021] [Accepted: 12/06/2021] [Indexed: 11/28/2022]
Abstract
Objectives Pill count is used to assess drug adherence in people living with HIV (PLHIV). Carrying a pillbox is associated with fear of concealment and stigma and might indicate poor adherence and predict someone who will be lost to follow‐up (LTFU). We therefore assessed the association between pillbox return and being LTFU in rural Tanzania. Methods This is a nested study of the Kilombero and Ulanga Antiretroviral Cohort (KIULARCO). We included PLHIV aged ≥ 18 years enrolled in KIULARCO between January 2013 and March 2019 with follow‐up through January 2020, who were on antiretroviral treatment (ART) for ≥ 6 months. Baseline was defined as the latest ART initiation or KIULARCO enrolment. We determined the association between time‐dependent failed pillbox return updated at every visit and LTFU using Kaplan–Meier estimation and Cox models. Results Among 2552 PLHIV included in the study, 1735 (68.0%) were female, 959 (40.3%) had a WHO stage III/IV and 1487 (66.4%) had a CD4 cell count < 350 cells/µL. The median age was 38.4 years [interquartile range (IQR): 31.7–46.2]. During a median follow‐up of 33.1 months (IQR: 17.5–52.4), 909 (35.6%) participants were LTFU, 43 (1.7%) died and 194 (7.6%) had transferred to another clinic. The probability of being LTFU was higher among PLHIV with failed pillbox return than among those who returned their pillbox [30.0%, 95% confidence interval (CI): 26.8–33.2% vs. 19.4%, 95% CI: 17.4–21.6%, respectively, at 24 months (hazard ratio = 1.67, 95% CI: 1.46–1.90; p < 0.001)]. Conclusions Failed pillbox return was associated with a higher risk of being LTFU and could be used as a simple tool to identify PLHIV for appropriate interventions to reduce their chance of being LTFU.
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Affiliation(s)
- Robert C Ndege
- Ifakara Health Institute, Ifakara Branch, Ifakara, Tanzania.,St. Francis Referral Hospital, Ifakara, Tanzania
| | - James Okuma
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Aneth V Kalinjuma
- Ifakara Health Institute, Ifakara Branch, Ifakara, Tanzania.,School of Public Health, Faculty of Health Sciences, Department of Epidemiology and Biostatistics, University of the Witwatersrand, Johannesburg, South Africa
| | - Julius Mkumbo
- Ifakara Health Institute, Ifakara Branch, Ifakara, Tanzania
| | - Elizabeth Senkoro
- Ifakara Health Institute, Ifakara Branch, Ifakara, Tanzania.,St. Francis Referral Hospital, Ifakara, Tanzania
| | - Gideon Fue
- St. Francis Referral Hospital, Ifakara, Tanzania
| | - Leila Samson
- Ifakara Health Institute, Ifakara Branch, Ifakara, Tanzania
| | - Herry Mapesi
- Ifakara Health Institute, Ifakara Branch, Ifakara, Tanzania.,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Siraji Shabani
- Ministry of Health, National AIDS Control Program, Dar es Salaam, Tanzania
| | - Tracy R Glass
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Manuel Battegay
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Daniel H Paris
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Fiona Vanobberghen
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Maja Weisser
- Ifakara Health Institute, Ifakara Branch, Ifakara, Tanzania.,Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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Kuemmerle A, Sikalengo G, Vanobberghen F, Ndege RC, Foe G, Schlaeppi C, Burri C, Battegay M, Paris DH, Glass TR, Weisser M, Marzolini C. Recognition and management of clinically significant drug-drug interactions between antiretrovirals and co-medications in a cohort of people living with HIV in rural Tanzania: a prospective questionnaire-based study. J Antimicrob Chemother 2021; 76:2681-2689. [PMID: 34337653 DOI: 10.1093/jac/dkab254] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/25/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The extent to which drug-drug interactions (DDIs) between antiretrovirals (ARVs) and co-medications are recognized and managed has not been thoroughly evaluated in limited-resource settings. OBJECTIVES This prospective questionnaire-based study aimed to determine the prevalence and risk factors for unrecognized/incorrectly managed DDIs in people living with HIV followed-up at the Chronic Diseases Clinic of Ifakara (CDCI) and enrolled in the Kilombero and Ulanga Antiretroviral Cohort (KIULARCO). METHODS We prospectively included ARV-treated adults receiving ≥1 co-medication coming for a follow-up visit at the CDCI between March and July 2017. Using a structured questionnaire, physicians were requested to identify potentially clinically significant DDIs in the prescribed treatment, to provide recommendations for their management and to indicate any hurdles to implement the recommendations. Prescriptions were subsequently screened for DDIs using the Liverpool DDIs database. Identified clinically significant DDIs and their recommended management according to the DDIs database were compared with the information provided in the questionnaires. RESULTS Among 334 participants, the median age was 47 years (IQR = 40-56 years), 69% were female and 82% had ≥1 non-communicable disease (NCD). Overall, 129 participants had ≥1 clinically relevant DDI, which was not recognized and/or incorrectly managed in 56 participants (43%). Of those, 6 (11%) were due to limited monitoring options or medication affordability issues. In the multivariable logistic regression, the presence of ≥1 NCD was associated with an increased risk for unrecognized/incorrect DDI management (OR = 15.8; 95% CI = 1.8-139.6). CONCLUSIONS Recognition/appropriate management of DDIs is suboptimal, highlighting the need for educational programmes, pharmacovigilance activities and increased access to medications and monitoring options. This should become a focus of HIV programmes given the increasing burden of NCDs in sub-Saharan Africa.
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Affiliation(s)
- Andrea Kuemmerle
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | | | - Fiona Vanobberghen
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | | | - Gideon Foe
- Saint Francis Referral Hospital, Ifakara, Tanzania
| | | | - Christian Burri
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Manuel Battegay
- University of Basel, Basel, Switzerland.,Department of Infectious Diseases & Hospital Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Daniel H Paris
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Tracy R Glass
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Maja Weisser
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Ifakara Health Institute, Ifakara, Tanzania.,Department of Infectious Diseases & Hospital Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Catia Marzolini
- University of Basel, Basel, Switzerland.,Department of Infectious Diseases & Hospital Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland.,Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Schlaeppi C, Vanobberghen F, Sikalengo G, Glass TR, Ndege RC, Foe G, Kuemmerle A, Paris DH, Battegay M, Marzolini C, Weisser M. Prevalence and management of drug-drug interactions with antiretroviral treatment in 2069 people living with HIV in rural Tanzania: a prospective cohort study. HIV Med 2020; 21:53-63. [PMID: 31532898 PMCID: PMC6916175 DOI: 10.1111/hiv.12801] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Widespread access to antiretroviral therapy (ART) has substantially increased life expectancy in sub-Saharan African countries. As a result, the rates of comorbidities and use of co-medications among people living with HIV are increasing, necessitating a sound understanding of drug-drug interactions (DDIs). We aimed to assess the prevalence and management of DDIs with ART in a rural Tanzanian setting. METHODS We included consenting HIV-positive adults initiating ART in the Kilombero and Ulanga Antiretroviral Cohort (KIULARCO) between January 2013 and December 2016. DDIs were classified using www.hiv-druginteractions.org as red (contra-indicated), amber (potential clinical relevance requiring dosage adjustment/monitoring), yellow (weak clinical significance unlikely to require further management) or green (no interaction). We assessed management of amber DDIs by evaluating monitoring of laboratory or clinical parameters, or changes in drug dosages. RESULTS Of 2069 participants, 1945 (94%) were prescribed at least one co-medication during a median follow-up of 1.8 years. Of these, 645 (33%) had at least one potentially clinically relevant DDI, with the highest grade being red in nine (< 1%) and amber in 636 (33%) participants. Of the 23 283 prescriptions, 19 (< 1%) and 1745 (7%) were classified as red and amber DDIs, respectively. Overall, 351 (2%) prescriptions were red DDIs or not appropriately managed amber DDIs. CONCLUSIONS Co-medication use was common in this rural sub-Saharan cohort. A third of participants had DDIs requiring further management. Of the 9% of participants with not appropriately managed DDIs, most were with cardiovascular and analgesic drugs. This highlights the importance of physicians' awareness of DDIs for their recognition and management.
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Affiliation(s)
- C Schlaeppi
- Swiss Tropical and Public Health InstituteBaselSwitzerland
- University of BaselBaselSwitzerland
| | - F Vanobberghen
- Swiss Tropical and Public Health InstituteBaselSwitzerland
- University of BaselBaselSwitzerland
| | - G Sikalengo
- Ifakara Health InstituteIfakaraTanzania
- St Francis Referral HospitalIfakaraTanzania
| | - TR Glass
- Swiss Tropical and Public Health InstituteBaselSwitzerland
- University of BaselBaselSwitzerland
| | - RC Ndege
- Ifakara Health InstituteIfakaraTanzania
- St Francis Referral HospitalIfakaraTanzania
| | - G Foe
- St Francis Referral HospitalIfakaraTanzania
| | - A Kuemmerle
- Swiss Tropical and Public Health InstituteBaselSwitzerland
- University of BaselBaselSwitzerland
| | - DH Paris
- Swiss Tropical and Public Health InstituteBaselSwitzerland
- University of BaselBaselSwitzerland
| | - M Battegay
- University of BaselBaselSwitzerland
- Division of Infectious Diseases & Hospital EpidemiologyUniversity Hospital BaselBaselSwitzerland
| | - C Marzolini
- University of BaselBaselSwitzerland
- Division of Infectious Diseases & Hospital EpidemiologyUniversity Hospital BaselBaselSwitzerland
- Department of Molecular and Clinical PharmacologyInstitute of Translational MedicineUniversity of LiverpoolLiverpoolUK
| | - M Weisser
- Swiss Tropical and Public Health InstituteBaselSwitzerland
- University of BaselBaselSwitzerland
- Ifakara Health InstituteIfakaraTanzania
- Division of Infectious Diseases & Hospital EpidemiologyUniversity Hospital BaselBaselSwitzerland
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