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Beres LK, Schwartz S, Simbeza S, McGready J, Eshun-Wilson I, Mwamba C, Sikombe K, Topp SM, Somwe P, Mody A, Mukamba N, Ehrenkranz PD, Padian N, Pry J, Moore CB, Holmes CB, Sikazwe I, Denison JA, Geng E. Patterns and Predictors of Incident Return to HIV Care Among Traced, Disengaged Patients in Zambia: Analysis of a Prospective Cohort. J Acquir Immune Defic Syndr 2021; 86:313-322. [PMID: 33149000 PMCID: PMC7878284 DOI: 10.1097/qai.0000000000002554] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/28/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dynamic movement of patients in and out of HIV care is prevalent, but there is limited information on patterns of patient re-engagement or predictors of return to guide HIV programs to better support patient engagement. METHODS From a probability-based sample of lost to follow-up, adult patients traced by peer educators from 31 Zambian health facilities, we prospectively followed disengaged HIV patients for return clinic visits. We estimated the cumulative incidence of return and the time to return using Kaplan-Meier methods. We used univariate and multivariable Cox proportional hazards regression to conduct a risk factor analysis identifying predictors of incident return across a social ecological framework. RESULTS Of the 556 disengaged patients, 73.0% [95% confidence interval (CI): 61.0 to 83.8] returned to HIV care. The median follow-up time from disengagement was 32.3 months (interquartile range: 23.6-38.9). The rate of return decreased with time postdisengagement. Independent predictors of incident return included a previous gap in care [adjusted Hazard Ratio (aHR): 1.95, 95% CI: 1.23 to 3.09] and confronting a stigmatizer once in the past year (aHR: 2.14, 95% CI: 1.25 to 3.65). Compared with a rural facility, patients were less likely to return if they sought care from an urban facility (aHR: 0.68, 95% CI: 0.48 to 0.96) or hospital (aHR: 0.52, 95% CI: 0.33 to 0.82). CONCLUSIONS Interventions are needed to hasten re-engagement in HIV care. Early and differential interventions by time since disengagement may improve intervention effectiveness. Patients in urban and tertiary care settings may need additional support. Improving patient resilience, outreach after a care gap, and community stigma reduction may facilitate return. Future re-engagement research should include causal evaluation of identified factors.
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Affiliation(s)
- Laura K. Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | - John McGready
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | | | - Stephanie M. Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia;
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | - Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | | | - Nancy Padian
- Division of Epidemiology, University of California Berkeley, Berkeley, CA; and
| | - Jake Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL
| | - Charles B. Holmes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
- Department of Medicine, Georgetown University, Washington, DC
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | - Julie A. Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
| | - Elvin Geng
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
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Brennan A, Maskew M, Larson BA, Tsikhutsu I, Bii M, Vezi L, Fox M, Venter WDF, Ehrenkranz PD, Rosen S. Prevalence of TB symptoms, diagnosis and treatment among people living with HIV (PLHIV) not on ART presenting at outpatient clinics in South Africa and Kenya: baseline results from a clinical trial. BMJ Open 2020; 10:e035794. [PMID: 32895266 PMCID: PMC7476481 DOI: 10.1136/bmjopen-2019-035794] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE We used screening data and routine clinic records for intervention arm patients in the Simplified Algorithm for Treatment Eligibility (SLATE) trials to describe the prevalence of tuberculosis (TB) symptoms, diagnosis and treatment among people living with HIV (PLHIV), not on antiretroviral therapy (ART) and presenting at outpatient clinics in South Africa and Kenya. We compared the performance of the WHO four-symptom TB screening tool with a baseline Xpert test. SETTING Outpatient HIV clinics in South Africa and Kenya. PARTICIPANTS Eligible patients were non-pregnant, PLHIV, >18 years of age, not on ART, willing to provide written informed consent. A total of 594 patients in South Africa and 240 in Kenya were eligible. RESULTS Prevalence of any TB symptom was 38% in Kenya, 35% (SLATE I) and 47% (SLATE II) in South Africa. During SLATE I, 70% of patients in Kenya and 57% in South Africa with ≥1 TB symptom were tested for TB. In SLATE II, 79% of patients with ≥1 TB symptom were tested. Of those, 19% tested positive for TB in Kenya, 15% (SLATE I) and 5% (SLATE II) tested positive in South Africa. Of the 28 patients who tested positive in both trials, 20 initiated TB treatment. The lowest median CD4 counts were among those with active TB (Kenya 124 cells/mm3; South Africa 193 cells/mm3). When comparing the WHO four-symptom screening tool to the Xpert test (SLATE II), we found that increasing the number of symptoms required for a positive screen from one to three or four decreased sensitivity but increased the positive predictive value to >30%. CONCLUSIONS 80% of patients assessed for ART initiation presented with ≥1 TB symptoms. Reconsideration of the 'any symptom' rule may be appropriate, with ART initiation among patients with fewer/milder symptoms commencing while TB test results are pending. TRIAL REGISTRATION NUMBER NCT02891135 and NCT03315013.
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Affiliation(s)
- Alana Brennan
- Departments of Epidemiology, Boston University, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University, Boston, Massachusetts, USA
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bruce A Larson
- Department of Global Health, Boston University, Boston, Massachusetts, USA
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute, Nairobi, Kenya
- Henry M. Jackson Foundation Medical Research International, Inc, Nairobi, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute, Nairobi, Kenya
- Henry M. Jackson Foundation Medical Research International, Inc, Nairobi, Kenya
| | - Lungisile Vezi
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew Fox
- Departments of Epidemiology, Boston University, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University, Boston, Massachusetts, USA
| | | | | | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University, Boston, Massachusetts, USA
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Rosen S, Maskew M, Brennan AT, Fox MP, Vezi L, Ehrenkranz PD, Venter WDF. Improved simplified clinical algorithm for identifying patients eligible for immediate initiation of antiretroviral therapy for HIV (SLATE II): protocol for a randomized evaluation. Trials 2018; 19:548. [PMID: 30305142 PMCID: PMC6180640 DOI: 10.1186/s13063-018-2928-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 06/07/2018] [Accepted: 09/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The World Health Organization recommends rapid (≤ 7 days) or same-day initiation of antiretroviral treatment (ART) for HIV-positive patients. South Africa adopted this recommendation in 2017, but multiple clinic visits, long waiting times, and delays for laboratory tests remain common. Streamlined approaches to same-day initiation that allow the majority of patients to start ART immediately, while ensuring that patients who do require additional services receive them, are needed to achieve national and international treatment program goals. METHODS/DESIGN The SLATE II (Simplified Algorithm for Treatment Eligibility) study is an individually randomized evaluation of a clinical algorithm to reliably determine a patient's eligibility for immediate ART initiation without waiting for laboratory results or additional clinic visits. It differs from the earlier SLATE I study in management of patients with symptoms of tuberculosis (under SLATE II these patients may be started on ART immediately) and other criteria for immediate initiation. SLATE II will randomize (1:1) 600 adult, HIV-positive patients who present for HIV testing or care and are not yet on ART in South Africa. Patients randomized to the standard arm will receive standard-of-care ART initiation from clinic staff. Patients randomized to the intervention arm will be administered a symptom report, medical history, brief physical exam, and readiness assessment. Symptomatic patients will also have a tuberculosis (TB) module with lipoarabinomannan antigen of mycobacteria test. Patients who have satisfactory results for all four components will be dispensed antiretrovirals (ARVs) immediately, at the same clinic visit. Patients who have any negative results will be referred for further investigation, care, counseling, tests, or other services prior to being dispensed ARVs. Follow-up will be by passive medical record review. The primary outcomes will be ART initiation in ≤ 7 days and retention in care 8 months after study enrollment. DISCUSSION SLATE II improves upon the SLATE I study by reducing the number of reasons for delaying ART initiation and allowing more patients with TB symptoms to start ART on the day of diagnosis. If successful, SLATE II will provide a simple and streamlined approach that can readily be adopted in other settings without investment in additional technology. TRIAL REGISTRATION ClinicalTrials.gov, NCT03315013 . Registered on 19 October 2017.
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Affiliation(s)
- S Rosen
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Ave Room 390, Boston, MA 02118 USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - A T Brennan
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Ave Room 390, Boston, MA 02118 USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA USA
| | - M P Fox
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Ave Room 390, Boston, MA 02118 USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA USA
| | - L Vezi
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - W D F Venter
- Wits Reproductive Health and HIV Institute, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Ehrenkranz PD, Calleja JMG, El‐Sadr W, Fakoya AO, Ford N, Grimsrud A, Harris KL, Jed SL, Low‐Beer D, Patel SV, Rabkin M, Reidy WJ, Reinisch A, Siberry GK, Tally LA, Zulu I, Zaidi I. A pragmatic approach to monitor and evaluate implementation and impact of differentiated ART delivery for global and national stakeholders. J Int AIDS Soc 2018; 21:e25080. [PMID: 29537628 PMCID: PMC5851343 DOI: 10.1002/jia2.25080] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 09/29/2017] [Accepted: 01/29/2018] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION The World Health Organization's (WHO) recommendation of "Treat All" has accelerated the call for differentiated antiretroviral therapy (ART) delivery, a method of care that efficiently uses limited resources to increase access to HIV treatment. WHO has further recommended that stable individuals on ART receive refills every 3 to 6 months and attend clinical visits every 3 to 6 months. However, there is not yet consensus on how to ensure that the quality of services is maintained as countries strive to meet these standards. This commentary responds to this gap by defining a pragmatic approach to the monitoring and evaluation (M&E) of the scale up of differentiated ART delivery for global and national stakeholders. DISCUSSION Programme managers need to demonstrate that the scale up of differentiated ART delivery is achieving the desired effectiveness and efficiency outcomes to justify continued support by national and global stakeholders. To achieve this goal, the two existing global WHO HIV treatment indicators of ART retention and viral suppression should be augmented with two broad aggregate measures. The addition of indicators measuring the frequency of (1) clinical and (2) refill visits by PLHIV per year will allow evaluation of the pace of scale up while monitoring its overall effect on the quality and efficiency of services. The combination of these four routinely collected aggregate indicators will also facilitate the comparison of outcomes among facilities, regions or countries implementing different models of ART delivery. Enhanced monitoring or additional assessments will be required to answer other critical questions on the process of implementation, acceptability, effectiveness and efficiency. CONCLUSIONS These proposed outcomes are useful markers for the effectiveness and efficiency of the health system's attempts to deliver quality treatment to those who need it-and still reserve as much of the available resource pool as possible for other key elements of the HIV response.
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Affiliation(s)
| | | | - Wafaa El‐Sadr
- ICAP at Columbia UniversityColumbia University Mailman School of Public HealthNew YorkNYUSA
| | - Ade O Fakoya
- Technical Advice and Partnerships DepartmentThe Global Fund to Fight AIDS, Tuberculosis and MalariaGenevaSwitzerland
| | - Nathan Ford
- Department of HIV and HepatitisWHOGenevaSwitzerland
| | - Anna Grimsrud
- HIV Programmes & AdvocacyInternational AIDS SocietyCape TownSouth Africa
| | - Kate L Harris
- Global DevelopmentBill & Melinda Gates FoundationSeattleWAUSA
| | - Suzanne L Jed
- Office of the U.S. Global AIDS Coordinator and Health DiplomacyU.S. Department of StateWashingtonDCUSA
- Global Division, HIV/AIDS BureauU.S. Health Resources and Services AdministrationRockvilleMDUSA
| | | | - Sadhna V Patel
- Division of Global HIV and TBCenter for Global HealthCenters for Disease Control and PreventionAtlantaGAUSA
| | - Miriam Rabkin
- ICAP at Columbia UniversityColumbia University Mailman School of Public HealthNew YorkNYUSA
| | - William John Reidy
- ICAP at Columbia UniversityColumbia University Mailman School of Public HealthNew YorkNYUSA
| | - Annette Reinisch
- Technical Advice and Partnerships DepartmentThe Global Fund to Fight AIDS, Tuberculosis and MalariaGenevaSwitzerland
| | - George K Siberry
- Office of the U.S. Global AIDS Coordinator and Health DiplomacyU.S. Department of StateWashingtonDCUSA
| | - Leigh A Tally
- Division of Global HIV and TBCenter for Global HealthCenters for Disease Control and PreventionAtlantaGAUSA
| | - Isaac Zulu
- Division of Global HIV and TBCenter for Global HealthCenters for Disease Control and PreventionAtlantaGAUSA
| | - Irum Zaidi
- Office of the U.S. Global AIDS Coordinator and Health DiplomacyU.S. Department of StateWashingtonDCUSA
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Rosen S, Fox MP, Larson BA, Brennan AT, Maskew M, Tsikhutsu I, Bii M, Ehrenkranz PD, Venter WDF. Simplified clinical algorithm for identifying patients eligible for immediate initiation of antiretroviral therapy for HIV (SLATE): protocol for a randomised evaluation. BMJ Open 2017; 7:e016340. [PMID: 28554939 PMCID: PMC5726128 DOI: 10.1136/bmjopen-2017-016340] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION African countries are rapidly adopting guidelines to offer antiretroviral therapy (ART) to all HIV-infected individuals, regardless of CD4 count. For this policy of 'treat all' to succeed, millions of new patients must be initiated on ART as efficiently as possible. Studies have documented high losses of treatment-eligible patients from care before they receive their first dose of antiretrovirals (ARVs), due in part to a cumbersome, resource-intensive process for treatment initiation, requiring multiple clinic visits over a several-week period. METHODS AND ANALYSIS The Simplified Algorithm for Treatment Eligibility (SLATE) study is an individually randomised evaluation of a simplified clinical algorithm for clinicians to reliably determine a patient's eligibility for immediate ART initiation without waiting for laboratory results or additional clinic visits. SLATE will enrol and randomise (1:1) 960 adult, HIV-positive patients who present for HIV testing or care and are not yet on ART in South Africa and Kenya. Patients randomised to the standard arm will receive routine, standard of care ART initiation from clinic staff. Patients randomised to the intervention arm will be administered a symptom report, medical history, brief physical exam and readiness assessment. Patients who have positive (satisfactory) results for all four components of SLATE will be dispensed ARVs immediately, at the same clinic visit. Patients who have any negative results will be referred for further clinical investigation, counselling, tests or other services prior to being dispensed ARVs. After the initial visit, follow-up will be by passive medical record review. The primary outcomes will be ART initiation ≤28 days and retention in care 8 months after study enrolment. ETHICS AND DISSEMINATION Ethics approval has been provided by the Boston University Institutional Review Board, the University of the Witwatersrand Human Research Ethics Committee (Medical) and the KEMRI Scientific and Ethics Review Unit. Results will be published in peer-reviewed journals and made widely available through presentations and briefing documents. TRIAL REGISTRATION NCT02891135.
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Affiliation(s)
- Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Bruce A Larson
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Alana T Brennan
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute/Walter Reed Project HIV Program, Kericho, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute/Walter Reed Project HIV Program, Kericho, Kenya
| | | | - WD Francois Venter
- Wits Reproductive Health and HIV Institute, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Rosen S, Fox MP, Larson BA, Sow PS, Ehrenkranz PD, Venter F, Manabe YC, Kaplan J. Accelerating the Uptake and Timing of Antiretroviral Therapy Initiation in Sub-Saharan Africa: An Operations Research Agenda. PLoS Med 2016; 13:e1002106. [PMID: 27505444 PMCID: PMC4978457 DOI: 10.1371/journal.pmed.1002106] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Sydney Rosen and colleagues describe an operations research agenda to accelerating uptake of HIV treatment initiation.
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Affiliation(s)
- Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Bruce A. Larson
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Papa Salif Sow
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
- Department of infectious Diseases, University of Dakar, Dakar, Senegal
| | - Peter D. Ehrenkranz
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Francois Venter
- Wits Reproductive Health and HIV Institute, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yukari C. Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Jonathan Kaplan
- Independent investigator, Atlanta, Georgia, United States of America
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Bock NN, Emerson RC, Reed JB, Nkambule R, Donnell DJ, Bicego GT, Okello V, Philip NM, Ehrenkranz PD, Duong YT, Moore JS, Justman JE. Changing Antiretroviral Eligibility Criteria: Impact on the Number and Proportion of Adults Requiring Treatment in Swaziland. J Acquir Immune Defic Syndr 2016; 71:338-44. [PMID: 26361174 PMCID: PMC4752404 DOI: 10.1097/qai.0000000000000846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 05/11/2015] [Accepted: 08/21/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Early initiation of antiretroviral treatment (ART) at CD4 cell count ≥ 500 cells per microliter reduces morbidity and mortality in HIV-infected adults. We determined the proportion of HIV-infected people with high viral load (VL) for whom transmission prevention would be an additional benefit of early treatment. DESIGN A randomly selected subset of a nationally representative sample of HIV-infected adults in Swaziland in 2012. METHODS Eight to 12 months after a national survey to determine adult HIV prevalence, 1067 of 5802 individuals identified as HIV-infected were asked to participate in a follow-up cross-sectional assessment. CD4 cell enumeration, VL measurements, and ART status were obtained to estimate the proportion of currently untreated adults and of the entire HIV-infected population with high VL (≥ 1000 copies/mL) whose treatment under a test-and-treat or VL threshold eligibility strategy would reduce HIV transmission. RESULTS Of the 927 (87% of 1067) participants enrolled, 466 (50%) reported no ART use. Among them, 424 (91%) had VL ≥ 1000 copies per milliliter; of these, 148 (35%) were eligible for ART at the then existing CD4 count threshold of <350 cells per microliter; an additional 107 (25%) were eligible with expanded CD4 criterion of <500 cells per microliter; and 169 (40%) remained ART ineligible. Thus, 36% of the 466 currently untreated and 18% of the total 927 had high VL yet remained ART ineligible under a CD4 criterion of <500 cells per microliter. CONCLUSIONS A test-and-treat or VL threshold for treatment eligibility is necessary to maximize the HIV transmission prevention benefits of ART.
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Affiliation(s)
- Naomi N. Bock
- Centers for Disease Control and Prevention, Center for Global Health, Division of HIV/AIDS, Atlanta, GA
| | - Ruth C. Emerson
- Statistical Center for HIV/AIDS Research and Prevention and the Vaccine and Infectious Disease Institute, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jason B. Reed
- Centers for Disease Control and Prevention, Center for Global Health, Division of HIV/AIDS, Atlanta, GA
| | | | - Deborah J. Donnell
- Statistical Center for HIV/AIDS Research and Prevention and the Vaccine and Infectious Disease Institute, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - George T. Bicego
- Centers for Disease Control and Prevention, Center for Global Health, Division of HIV/AIDS, Atlanta, GA
| | | | - Neena M. Philip
- ICAP-Columbia, Mailman School of Public Health, Columbia University, New York, NY; and
| | | | - Yen T. Duong
- Centers for Disease Control and Prevention, Center for Global Health, Division of HIV/AIDS, Atlanta, GA
| | - Janet S. Moore
- Centers for Disease Control and Prevention, Center for Global Health, Division of HIV/AIDS, Atlanta, GA
| | - Jessica E. Justman
- ICAP-Columbia, Mailman School of Public Health, Columbia University, New York, NY; and
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Ehrenkranz PD, Ahn CJ, Metlay JP, Camargo CA, Holmes WC, Rothman R. Availability of rapid human immunodeficiency virus testing in academic emergency departments. Acad Emerg Med 2008; 15:144-50. [PMID: 18275444 DOI: 10.1111/j.1553-2712.2008.00028.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The Centers for Disease Control and Prevention (CDC) recommends routine human immunodeficiency virus (HIV) screening of emergency department (ED) patients aged 13 to 64 years. The study objectives were to determine the accessibility of rapid HIV testing in academic EDs, to identify factors that influence an ED's adoption of testing, and to describe current HIV testing practices. METHODS Online surveys were sent to EDs affiliated with emergency medicine (EM) residency programs (n = 128), excluding federal hospitals and facilities in U.S. territories. Eighty percent (n = 102) responded. Most e-mail recipients (n = 121) were Emergency Medicine Network (EMNet) investigators; remaining contacts were obtained from residency-related Web sites. RESULTS Most academic EDs (n = 58; 57%; 95% confidence interval (CI) = 47% to 66%) offer rapid HIV testing. Among this group, 26 (45%) allow providers to order tests without restrictions. Of the other 32 EDs, 100% have policies allowing for rapid HIV testing following occupational exposures, but less than 10% have guidelines for testing in other clinical situations. Forty-seven percent expect to routinely offer HIV testing in the next 2 to 3 years. Only 59% of the EDs that offered rapid tests in any situation could link an HIV-positive patient to subspecialty care. The facility characteristic most important to availability of rapid HIV testing was the presence of on-site HIV counselors. CONCLUSIONS Most academic EDs now offer rapid HIV testing (57%), but few use it in situations other than occupational exposure. Less than half of academic EDs expect to implement CDC guidelines regarding routine screening within the next few years. The authors identified facility characteristics (e.g., counseling, ability to refer) that may influence adoption of rapid HIV testing.
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Affiliation(s)
- Peter D Ehrenkranz
- Robert Wood Johnson Clinical Scholars Program, University of Pennsylvania, Philadelphia, PA, USA
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