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Mitsui A, Rosen S, Yaxley P, Lapsley J, Tremolada G, Selmic LE. Hypercoagulability based on thromboelastography is common in dogs undergoing adrenalectomy. J Am Vet Med Assoc 2024:1-6. [PMID: 38608654 DOI: 10.2460/javma.23.08.0456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/21/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Thromboelastography (TEG) is a whole blood assay that yields global assessment of hemostasis, as it evaluates clot time, strength, and kinematics of clot formation and lysis. The main objective was to describe preoperative TEG findings in dogs that had an adrenalectomy performed and, secondarily, to describe TEG findings in the dogs with or without hyperadrenocorticism (HAC). ANIMALS 30 dogs that had preoperative TEG and adrenalectomy performed. METHODS Medical records between 2018 and 2022 were reviewed. Signalment, diagnostic data, and perioperative treatment were abstracted. RESULTS 53% (16/30) of the dogs were hypercoagulable, and none were hypocoagulable. Based on histopathology, 6 of 9 dogs with adenocarcinoma were hypercoagulable, 4 of 8 with pheochromocytoma were hypercoagulable, and 6 of 10 with adenoma were hypercoagulable. None of the 3 dogs with other histopathologic diagnoses or combinations of diagnoses (adrenocortical hyperplasia, poorly differentiated sarcoma, and both adrenocortical adenocarcinoma and pheochromocytoma) were hypercoagulable. Of the 14 dogs tested preoperatively for HAC, 4 of 8 HAC dogs were hypercoagulable and 2 of 6 non-HAC dogs were hypercoagulable. CLINICAL RELEVANCE The present report describes for the first time TEG findings for dogs undergoing adrenalectomy and suggests that the majority of dogs with adrenal neoplasia are hypercoagulable based on TEG results.
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Mokhele I, Huber A, Rosen S, Kaiser JL, Lekodeba N, Ntjikelane V, Hendrickson C, Scott N, Pascoe S. Satisfaction with service delivery among HIV treatment clients enrolled in differentiated and conventional models of care in South Africa: a baseline survey. J Int AIDS Soc 2024; 27:e26233. [PMID: 38528370 DOI: 10.1002/jia2.26233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 03/01/2024] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION Differentiated service delivery (DSD) models aim to increase the responsiveness of HIV treatment programmes to the individual needs of antiretroviral therapy (ART) clients to improve treatment outcomes and quality of life. Little is known about how DSD client experiences differ from conventional care. METHODS From May to November 2021, we interviewed adult (≥18) ART clients at 21 primary clinics in four districts of South Africa. Participants were enrolled consecutively at routine visits and stratified into four groups: conventional care-not eligible for DSD (conventional-not-eligible); conventional care eligible for but not enrolled in DSD (conventional-not-enrolled); facility pickup point DSD model; and external pickup point DSD model. Satisfaction was assessed using questions with 5-point Likert-scale responses. Mean scores were categorized as not satisfied (score ≤3) or satisfied (>3). We used logistic regression to assess differences and report crude and adjusted odds ratios (aORs). Qualitative themes were identified through content analysis. RESULTS Eight hundred and sixty-seven participants (70% female, median age 39) were surveyed: 24% facility pick-up points; 27% external pick-up points; 25% conventional-not-eligible; and 24% conventional-not-enrolled. Seventy-four percent of all study participants expressed satisfaction with their HIV care. Those enrolled in DSD models were more likely to be satisfied, with an aOR of 6.24 (95% CI [3.18-12.24]) for external pick-up point versus conventional-not-eligible and an aOR of 3.30 (1.95-5.58) for facility pick-up point versus conventional-not-eligible. Conventional-not-enrolled clients were slightly but not significantly more satisfied than conventional-not-eligible clients (1.29, 0.85-1.96). Those seeking outside healthcare (crude OR 0.57, 0.41-0.81) or reporting more annual clinic visits (0.52, 0.29-0.93) were less likely to be satisfied. Conventional care participants reporting satisfaction with their current model of care perceived providers as helpful, respectful, and friendly and were satisfied with care despite long queues. DSD model participants emphasized ease and convenience, particularly not having to queue. CONCLUSIONS Most adult ART clients in South Africa were satisfied with their care, but those enrolled in DSD models expressed slightly greater satisfaction than those remaining in conventional care. Efforts should focus on enrolling more eligible patients into DSD models, expanding eligibility criteria to cover a wider client base, and further improving the models' desirable characteristics.
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Affiliation(s)
- Idah Mokhele
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy Huber
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jeanette L Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Nkgomeleng Lekodeba
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Vinolia Ntjikelane
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cheryl Hendrickson
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Nancy Scott
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Maskew M, Benade M, Huber A, Pascoe S, Sande L, Malala L, Manganye M, Rosen S. Patterns of engagement in care during clients' first 12 months after HIV treatment initiation in South Africa: A retrospective cohort analysis using routinely collected data. PLOS Glob Public Health 2024; 4:e0002956. [PMID: 38416789 PMCID: PMC10901315 DOI: 10.1371/journal.pgph.0002956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/02/2024] [Indexed: 03/01/2024]
Abstract
Retention on antiretroviral therapy (ART) during the early treatment period is one of the most serious challenges facing HIV programs, but the timing and patterns of early disengagement from care remain poorly understood. We describe patterns of engagement in HIV care during the first year after treatment initiation. We analysed retrospective datasets of routinely collected electronic medical register (EMR) data for ≥18-year-old clients who initiated ART at public sector clinics in South Africa after 01/01/2018 and had ≥14 months of potential follow-up. Using scheduled visit dates, we characterized engagement in care as continuous (no treatment interruption), cyclical (at least one visit >28 days late with a return visit observed) or disengaged (visit not attended and no evidence of return). We report 6- and 12-month patterns of retention in care and viral suppression. Among 35,830 participants (65% female, median age 33), in months 0-6, 59% were continuously in care, 14% had engaged cyclically, 11% had transferred to another facility, 1% had died, and 16% had disengaged from care at the initiating facility. Among disengagers in the first 6 months, 58% did not return after their initiation visit. By 12 months after initiation, the overall proportion disengaged was 23%, 45% were classified as continuously engaged in months 7-12, and only 38% of the cohort had maintained continuous engagement at both the 6- and 12-month endpoints. Participants who were cyclically engaged in months 0-6 were nearly twice as likely to disengage in months 7-12 as were continuous engagers in months 0-6 (relative risk 1.76, 95% CI:1.61-1.91) and were more likely to have an unsuppressed viral load by 12 months on ART (RR = 1.28; 95% CI1.13-1.44). The needs of continuous and cyclical engagers and those disengaging at different timepoints may vary and require different interventions or models of care.
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Affiliation(s)
- Mhairi Maskew
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mariet Benade
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Amy Huber
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Linda Sande
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lufuno Malala
- HIV & AIDS Treatment, Care and Support Directorate, HIV & AIDS and STI Cluster, National Department of Health, Pretoria, South Africa
| | - Musa Manganye
- HIV & AIDS Treatment, Care and Support Directorate, HIV & AIDS and STI Cluster, National Department of Health, Pretoria, South Africa
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
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Rosen S, Blokhina E, Truong V, Bereznicka A, Gnatienko N, Quinn E, Lioznov D, Krupitsky E, Michals A, Lunze K, Samet JH. Comparative costs and potential affordability of a multifaceted intervention to improve treatment outcomes among people with HIV who inject drugs in Russia: economic evaluation of the LINC-II randomized controlled trial. J Int AIDS Soc 2024; 27:e26208. [PMID: 38403887 PMCID: PMC10895073 DOI: 10.1002/jia2.26208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/23/2023] [Indexed: 02/27/2024] Open
Abstract
INTRODUCTION The LINC-II randomized controlled trial in St. Petersburg, Russia for HIV-positive adults who inject drugs found that a multi-component intervention including initiation of antiretroviral therapy (ART) during admission to an addiction hospital, strengths-based case management and naltrexone significantly increased 12-month HIV viral suppression and ART retention. We conducted a comparative cost analysis to determine if the 12-month cost of the intervention is affordable within the current Russian health system. METHODS We used LINC-II trial records and questionnaire responses to calculate the resources utilized by each participant in the study, including inpatient days, medications, laboratory tests, outpatient consultations, case manager interactions and opioid medication treatment. Quantities of resources utilized were multiplied by unit costs for each resource estimated from the service fee or price lists used by the study facilities for each specific service delivered. We report the average cost/study primary (viral suppression at 12 months) or secondary (retention in care at 12 months) outcome/participant in 2021 USD and compare costs between study arms. RESULTS The trial enrolled 225 participants (111 intervention, 114 control) between September 2018 and December 2020. Viral suppression, non-suppression and missing suppression results were 28% and 14%, 49% and 37%, and 31% and 41% for the control and intervention arms, respectively. Retention results were 35% and 51% for the control and intervention arms, respectively. The average cost per study participant was $2714 in the control arm and $4342 in the intervention arm. The average cost per participant virally suppressed at 12 months was $3662 (control) and $6355 (intervention). The average cost per participant retained at 12 months was $4050 (control) and $5448 (intervention). For those retained, the cost difference between the arms was comprised of opioid treatment (35%), case management (31%), outpatient visits (18%) and additional days of ART (12%). CONCLUSIONS The LINC-II intervention increased the cost of care for HIV-positive people who inject drugs in Russia significantly, but some components of the intervention, particularly earlier initiation of ART and case management, may be justifiable due to their success in reaching a challenging subgroup of the population in need. CLINICAL TRIAL NUMBER NCT03290391.
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Affiliation(s)
- Sydney Rosen
- School of Public HealthBoston UniversityBostonMassachusettsUSA
- Health Economics and Epidemiology Research OfficeWits Health ConsortiumFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Elena Blokhina
- Pavlov First State Medical UniversitySt. PetersburgRussian Federation
| | - Ve Truong
- Clinical Addiction Research and Education (CARE) UnitSection of General Internal MedicineDepartment of MedicineBoston Medical CenterBostonMassachusettsUSA
| | - Agata Bereznicka
- Clinical Addiction Research and Education (CARE) UnitSection of General Internal MedicineDepartment of MedicineBoston Medical CenterBostonMassachusettsUSA
| | - Natalia Gnatienko
- Clinical Addiction Research and Education (CARE) UnitSection of General Internal MedicineDepartment of MedicineBoston Medical CenterBostonMassachusettsUSA
| | - Emily Quinn
- Biostatistics and Epidemiology Data Analytics CenterBoston University School of Public HealthBostonMassachusettsUSA
| | - Dmitry Lioznov
- Pavlov First State Medical UniversitySt. PetersburgRussian Federation
- Smorodintsev Research Institute of InfluenzaSt. PetersburgRussian Federation
| | - Evgeny Krupitsky
- Pavlov First State Medical UniversitySt. PetersburgRussian Federation
- V.M. Bekhterev National Medical Research Center for Psychiatry and NeurologySaint PetersburgRussian Federation
| | - Amy Michals
- Biostatistics and Epidemiology Data Analytics CenterBoston University School of Public HealthBostonMassachusettsUSA
| | - Karsten Lunze
- Clinical Addiction Research and Education (CARE) UnitSection of General Internal MedicineDepartment of MedicineBoston Medical CenterBostonMassachusettsUSA
- Section of GeneralInternal MedicineDepartment of MedicineBoston University School of MedicineBostonMassachusettsUSA
| | - Jeffrey H. Samet
- Clinical Addiction Research and Education (CARE) UnitSection of General Internal MedicineDepartment of MedicineBoston Medical CenterBostonMassachusettsUSA
- Section of GeneralInternal MedicineDepartment of MedicineBoston University School of MedicineBostonMassachusettsUSA
- Department of Community Health SciencesBoston University School of Public HealthBostonMassachusettsUSA
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Kileel EM, Zheng A, Bor J, Fox MP, Crowther NJ, George JA, Khoza S, Rosen S, Venter WDF, Raal F, Hibberd P, Brennan AT. Does Engagement in HIV Care Affect Screening, Diagnosis, and Control of Noncommunicable Diseases in Sub-Saharan Africa? A Systematic Review and Meta-analysis. AIDS Behav 2024; 28:591-608. [PMID: 38300475 PMCID: PMC10876721 DOI: 10.1007/s10461-023-04248-0] [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] [Accepted: 12/02/2023] [Indexed: 02/02/2024]
Abstract
Low- and middle-income countries are facing a growing burden of noncommunicable diseases (NCDs). Providing HIV treatment may provide opportunities to increase access to NCD services in under-resourced environments. We conducted a systematic review and meta-analysis to evaluate whether use of antiretroviral therapy (ART) was associated with increased screening, diagnosis, treatment, and control of diabetes, hypertension, chronic kidney disease, or cardiovascular disease among people living with HIV in sub-Saharan Africa (SSA). A comprehensive search of electronic literature databases for studies published between 01 January 2011 and 31 December 2022 yielded 26 studies, describing 13,570 PLWH in SSA, 61% of whom were receiving ART. Random effects models were used to calculate summary odds ratios (ORs) of the risk of diagnosis by ART status and corresponding 95% confidence intervals (95% CIs), where appropriate. ART use was associated with a small but imprecise increase in the odds of diabetes diagnosis (OR 1.07; 95% CI 0.71, 1.60) and an increase in the odds of hypertension diagnosis (OR 2.10, 95% CI 1.42, 3.09). We found minimal data on the association between ART use and screening, treatment, or control of NCDs. Despite a potentially higher NCD risk among PLWH and regional efforts to integrate NCD and HIV care, evidence to support effective care integration models is lacking.
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Affiliation(s)
- Emma M Kileel
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA.
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.
| | - Amy Zheng
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, 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, MA, 02118, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nigel J Crowther
- Department of Chemical Pathology, National Health Laboratory Service, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jaya A George
- Department of Chemical Pathology, National Health Laboratory Service, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Siyabonga Khoza
- Department of Chemical Pathology, National Health Laboratory Service, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Willem D F Venter
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Public Health Medicine, School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Frederick Raal
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Patricia Hibberd
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
| | - Alana T Brennan
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Maskew M, Ntjikelane V, Juntunen A, Scott N, Benade M, Sande L, Hasweeka P, Haimbe P, Lumano-Mulenga P, Shakewelele H, Mukumbwa-Mwenechanya M, Rosen S. Preferences for services in a patient's first six months on antiretroviral therapy for HIV in South Africa and Zambia (PREFER): research protocol for a prospective observational cohort study. Gates Open Res 2024; 7:119. [PMID: 38343769 PMCID: PMC10858017 DOI: 10.12688/gatesopenres.14682.2] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2024] [Indexed: 02/15/2024] Open
Abstract
Background For patients on HIV treatment in sub-Saharan Africa, the highest risk for loss from care remains the first six months after antiretroviral (ART) initiation, when patients are not yet eligible for differentiated service delivery (DSD) models that offer lower-burden, patient-centred care and thus improve treatment outcomes. To reduce early disengagement from care, the PREFER study will use a sequential mixed-methods approach to describe the characteristics, needs, concerns, and preferences of patients in South Africa and Zambia 0-6 months after ART initiation or re-initiation. Protocol PREFER is an observational, prospective cohort study of adults on ART for ≤6 months at 12 public healthcare facilities in Zambia and 18 in South Africa. Its objective is to describe and understand the needs and preferences of initiating and re-initiating ART clients to inform the design of DSD models for the early HIV treatment period, improve early treatment outcomes, and distinguish the barriers encountered by naïve patients from those facing re-initiators. It has four components: 1) survey of clients 0-6 months after ART initiation (identify characteristics and preferences of clients starting ART); 2) follow up through routinely collected medical records for <24 months after enrollment (describe resource utilization and patterns and predictors of engagement in care); 3) focus group discussions and discrete choice experiment (explore reported barriers to and facilitators of retention); and 4) in South Africa only, collection of blood samples (assess the prevalence of ARV metabolites indicating prior ART use). Conclusions PREFER aims to understand why the early treatment period is so challenging and how service delivery can be amended to address the obstacles that lead to early disengagement from care. It will generate information about client characteristics and preferences to help respond to patients' needs and design better strategies for service delivery and improve resource allocation going forward.
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Affiliation(s)
- Mhairi Maskew
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, Johannesburg, Gauteng, South Africa
| | - Vinolia Ntjikelane
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, Johannesburg, Gauteng, South Africa
| | | | - Nancy Scott
- Global Health, Boston University, Boston, MA, 02118, USA
| | - Mariet Benade
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, Johannesburg, Gauteng, South Africa
- Global Health, Boston University, Boston, MA, 02118, USA
- Department of Medical Microbiology, Amsterdam University Medical Center, Amstersdam, The Netherlands
| | - Linda Sande
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, Johannesburg, Gauteng, South Africa
| | | | - Prudence Haimbe
- CHAI-Zambia, Clinton Health Access Initiative, Lusaka, Zambia
| | | | | | | | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, Johannesburg, Gauteng, South Africa
- Global Health, Boston University, Boston, MA, 02118, USA
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Gilbert DC, Nankivell M, Rush H, Clarke NW, Mangar S, Al-Hasso A, Rosen S, Kockelbergh R, Sundaram SK, Dixit S, Laniado M, McPhail N, Shaheen A, Brown S, Gale J, Deighan J, Marshall J, Duong T, Macnair A, Griffiths A, Amos CL, Sydes MR, James ND, Parmar MKB, Langley RE. A Repurposing Programme Evaluating Transdermal Oestradiol Patches for the Treatment of Prostate Cancer Within the PATCH and STAMPEDE Trials: Current Results and Adapting Trial Design. Clin Oncol (R Coll Radiol) 2024; 36:e11-e19. [PMID: 37973477 DOI: 10.1016/j.clon.2023.10.054] [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: 07/03/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
AIMS Androgen deprivation therapy (ADT), usually achieved with luteinising hormone releasing hormone analogues (LHRHa), is central to prostate cancer management. LHRHa reduce both testosterone and oestrogen and are associated with significant long-term toxicity. Previous use of oral oestrogens as ADT was curtailed because of cardiovascular toxicity. Transdermal oestrogen (tE2) patches are a potential alternative ADT, supressing testosterone without the associated oestrogen-depletion toxicities (osteoporosis, hot flushes, metabolic abnormalities) and avoiding cardiovascular toxicity, and we here describe their evaluation in men with prostate cancer. MATERIALS AND METHODS The PATCH (NCT00303784) adaptive trials programme (incorporating recruitment through the STAMPEDE [NCT00268476] platform) is evaluating the safety and efficacy of tE2 patches as ADT for men with prostate cancer. An initial randomised (LHRHa versus tE2) phase II study (n = 251) with cardiovascular toxicity as the primary outcome measure has expanded into a phase III evaluation. Those with locally advanced (M0) or metastatic (M1) prostate cancer are eligible. To reflect changes in both management and prognosis, the PATCH programme is now evaluating these cohorts separately. RESULTS Recruitment is complete, with 1362 and 1128 in the M0 and M1 cohorts, respectively. Rates of androgen suppression with tE2 were equivalent to LHRHa, with improved metabolic parameters, quality of life and bone health indices (mean absolute change in lumbar spine bone mineral density of -3.0% for LHRHa and +7.9% for tE2 with an estimated difference between arms of 9.3% (95% confidence interval 5.3-13.4). Importantly, rates of cardiovascular events were not significantly different between the two arms and the time to first cardiovascular event did not differ between treatment groups (hazard ratio 1.11, 95% confidence interval 0.80-1.53; P = 0.54). Oncological outcomes are awaited. FUTURE Efficacy results for the M0 cohort (primary outcome measure metastases-free survival) are expected in the final quarter of 2023. For M1 patients (primary outcome measure - overall survival), analysis using restricted mean survival time is being explored. Allied translational work on longitudinal samples is underway.
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Affiliation(s)
- D C Gilbert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK; University Hospitals Sussex NHS Foundation Trust, Royal Sussex County Hospital, Brighton, UK.
| | - M Nankivell
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - H Rush
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - N W Clarke
- The Christie and Salford Royal Hospitals, Manchester, UK
| | - S Mangar
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - A Al-Hasso
- Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - S Rosen
- National Heart and Lung Institute, Imperial College, London, UK
| | - R Kockelbergh
- Department of Urology, University Hospitals of Leicester, Leicester, UK
| | - S K Sundaram
- Mid-Yorkshire Teaching NHS Trust, Pinderfields Hospital, Wakefield, UK
| | - S Dixit
- Scunthorpe General Hospital, Scunthorpe, UK
| | | | | | | | - S Brown
- Airedale General Hospital, Keighley, UK
| | - J Gale
- Queen Alexandra Hospital, Portsmouth, UK
| | - J Deighan
- Patient Representative, MRC Clinical Trials Unit at UCL, London, UK
| | - J Marshall
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - T Duong
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - A Macnair
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK; Guys and St Thomas' NHS Foundation Trust, London, UK
| | - A Griffiths
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - C L Amos
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - M R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - N D James
- Institute of Cancer Research, Sutton, UK
| | - M K B Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - R E Langley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
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Brennan AT, Lauren E, Bor J, George JA, Chetty K, Mlisana K, Dai A, Khoza S, Rosen S, Stokes AC, Raal F, Hibberd P, Alexanian SM, Fox MP, Crowther NJ. Gaps in the type 2 diabetes care cascade: a national perspective using South Africa's National Health Laboratory Service (NHLS) database. BMC Health Serv Res 2023; 23:1452. [PMID: 38129852 PMCID: PMC10740239 DOI: 10.1186/s12913-023-10318-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/14/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Research out of South Africa estimates the total unmet need for care for those with type 2 diabetes mellitus (diabetes) at 80%. We evaluated the care cascade using South Africa's National Health Laboratory Service (NHLS) database and assessed if HIV infection impacts progression through its stages. METHODS The cohort includes patients from government facilities with their first glycated hemoglobin A1c (HbA1c) or plasma glucose (fasting (FPG); random (RPG)) measured between January 2012 to March 2015 in the NHLS. Lab-diagnosed diabetes was defined as HbA1c ≥ 6.5%, FPG ≥ 7.0mmol/l, or RPG ≥ 11.1mmol/l. Cascade stages post diagnosis were retention-in-care and glycaemic control (defined as an HbA1c < 7.0% or FPG < 8.0mmol/l or RPG < 10.0mmol/l) over 24-months. We estimated gaps at each stage nationally and by people living with HIV (PLWH) and without (PLWOH). RESULTS Of the 373,889 patients tested for diabetes, 43.2% had an HbA1c or blood glucose measure indicating a diabetes diagnosis. Amongst those with lab-diagnosed diabetes, 30.9% were retained-in-care (based on diabetes labs) and 8.7% reached glycaemic control by 24-months. Prevalence of lab-diagnosed diabetes in PLWH was 28.6% versus 47.3% in PLWOH. Among those with lab-diagnosed diabetes, 34.3% of PLWH were retained-in-care versus 30.3% PLWOH. Among people retained-in-care, 33.8% of PLWH reached glycaemic control over 24-months versus 28.6% of PLWOH. CONCLUSIONS In our analysis of South Africa's NHLS database, we observed that 70% of patients diagnosed with diabetes did not maintain in consistent diabetes care, with fewer than 10% reaching glycemic control within 24 months. We noted a disparity in diabetes prevalence between PLWH and PLWOH, potentially linked to different screening methods. These differences underscore the intricacies in care but also emphasize how HIV care practices could guide better management of chronic diseases like diabetes. Our results underscore the imperative for specialized strategies to bolster diabetes care in South Africa.
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Affiliation(s)
- Alana T Brennan
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.
| | - Evelyn Lauren
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Jaya A George
- Wits Diagnostic Innovation Hub, University of the Witwatersrand, Johannesburg, South Africa
| | - Kamy Chetty
- National Health Laboratory Service, Johannesburg, South Africa
| | - Koleka Mlisana
- Academic Affairs, Research & Quality Assurance, National Health Laboratory Service, Johannesburg, South Africa
| | - Andrew Dai
- Department of Mathematics and Statistics, Boston University, Boston, USA
| | - Siyabonga Khoza
- National Health Laboratory Service, Johannesburg, South Africa
- Department of Chemical Pathology, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew C Stokes
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Frederick Raal
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Patricia Hibberd
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | | | - Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Nigel J Crowther
- National Health Laboratory Service, Johannesburg, South Africa
- Department of Chemical Pathology, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
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9
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Benade M, Maskew M, Juntunen A, Flynn DB, Rosen S. Prior exposure to antiretroviral therapy among adult patients presenting for HIV treatment initiation or reinitiation in sub-Saharan Africa: a systematic review. BMJ Open 2023; 13:e071283. [PMID: 37984944 PMCID: PMC10660894 DOI: 10.1136/bmjopen-2022-071283] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 09/13/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVES As countries have scaled up access to antiretroviral therapy (ART) for HIV, attrition rates of up to 30% annually have created a large pool of individuals who initiate treatment with prior ART experience. Little is known about the proportion of non-naïve reinitiators within the population presenting for treatment initiation. DESIGN Systematic review of published articles and abstracts reporting proportions of non-naïve adult patients initiating ART in sub-Saharan Africa. DATA SOURCES PubMed, Embase Elsevier, Web of Science Core Collection, International AIDS Society conferences, Conference on Retroviruses and Opportunistic Infections conferences. ELIGIBILITY CRITERIA Clinical trials and observational studies; reporting on adults in sub-Saharan Africa who initiated lifelong ART; published in English between 1 January 2018 and 11 July 2023 and with data collected after January 2016. Initiator self-report, laboratory discernment of antiretroviral metabolites, and viral suppression at initiation or in the medical record were accepted as evidence of prior exposure. DATA EXTRACTION AND SYNTHESIS We captured study and sample characteristics, proportions with previous ART exposure and the indicator of previous exposure reported. We report results of each eligible study, estimate the risk of bias and identify gaps in the literature. RESULTS Of 2740 articles, 11 articles describing 12 cohorts contained sufficient information for the review. Proportions of initiators with evidence of prior ART use ranged from 5% (self-report only) to 53% (presence of ART metabolites in hair or blood sample). The vast majority of screened studies did not report naïve/non-naïve status. Metrics used to determine and report non-naïve proportions were inconsistent and difficult to interpret. CONCLUSIONS The proportion of patients initiating HIV treatment who are truly ART naïve is not well documented. It is likely that 20%-50% of ART patients who present for ART are reinitiators. Standard reporting metrics and diligence in reporting are needed, as is research to understand the reluctance of patients to report prior ART exposure. PROSPERO REGISTRATION NUMBER CRD42022324136.
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Affiliation(s)
- Mariet Benade
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, Gauteng, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, Gauteng, South Africa
| | - Allison Juntunen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - David B Flynn
- Alumni Medical Library, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, Gauteng, South Africa
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10
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Labhardt ND, Brown JA, Sass N, Ford N, Rosen S. Treatment Outcomes After Offering Same-Day Initiation of Human Immunodeficiency Virus Treatment-How to Interpret Discrepancies Between Different Studies. Clin Infect Dis 2023; 77:1176-1184. [PMID: 37229594 PMCID: PMC10573746 DOI: 10.1093/cid/ciad317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/18/2023] [Accepted: 05/23/2023] [Indexed: 05/27/2023] Open
Abstract
The World Health Organization recommends same-day initiation of antiretroviral therapy (ART) for all persons diagnosed with HIV and ready to start treatment. Evidence, mainly from randomized trials, indicates offering same-day ART increases engagement in care and viral suppression during the first year. In contrast, most observational studies using routine data find same-day ART to be associated with lower engagement in care. We argue that this discrepancy is mainly driven by different time points of enrollment, leading to different denominators. While randomized trials enroll individuals when tested positive, most observational studies start at the time point when ART is initiated. Thus, most observational studies omit those who are lost between diagnosis and treatment, thereby introducing a selection bias in the group with delayed ART. This viewpoint article summarizes the available evidence and argues that the benefits of same-day ART outweigh a potential higher risk of attrition from care after ART initiation.
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Affiliation(s)
- Niklaus Daniel Labhardt
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Jennifer Anne Brown
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Nikita Sass
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Nathan Ford
- Department of HIV, Hepatitis, and Sexually Transmitted Infections, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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11
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Maskew M, Rosen S. Estimating the impact of differentiated models for HIV care. Lancet HIV 2023; 10:e628-e630. [PMID: 37802565 DOI: 10.1016/s2352-3018(23)00225-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Mhairi Maskew
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2192, South Africa.
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2192, South Africa; Boston University School of Public Health, Boston, MA, USA
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12
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Samet JH, Blokhina E, Cheng DM, Rosen S, Lioznov D, Lunze K, Truong V, Gnatienko N, Quinn E, Bushara N, Raj A, Krupitsky E. Rapid access to antiretroviral therapy, receipt of naltrexone, and strengths-based case management versus standard of care for HIV viral load suppression in people with HIV who inject drugs in Russia (LINC-II): an open-label, randomised controlled trial. Lancet HIV 2023; 10:e578-e587. [PMID: 37659841 PMCID: PMC10653654 DOI: 10.1016/s2352-3018(23)00143-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Antiretroviral therapy (ART) coverage in Russia is low for people with HIV who inject drugs. HIV and addiction treatment in Russia are not well integrated. We aimed to evaluate an intervention to link people with HIV in addiction treatment to HIV care to achieve HIV viral load suppression. METHODS LINC-II was a two-arm, open-label, randomised controlled trial at the City Addiction Hospital, Saint Petersburg, Russia. Eligible participants were aged 18 years or older, had a positive HIV status, were not currently on ART, were admitted to a narcology hospital, and had a current diagnosis of opioid use disorder. Participants were randomly assigned (1:1) to a multicomponent intervention (ie, rapid access to ART, naltrexone for opioid use disorder, and strengths-based case management) or standard of care. Blocked randomisation was stratified by history of ART use. The primary outcome was undetectable HIV viral load at 12 months, defined as less than 40 copies per mL. The trial was conducted and analysed according to the intention-to-treat principle. This trial is registered with ClinicalTrials.gov, NCT03290391. FINDINGS Between Sept 19, 2018, and Dec 25, 2020, 953 individuals were screened for eligibility, 225 of whom were randomly assigned to the intervention (n=111) or standard of care (n=114). 136 (60%) participants were male and 89 (40%) were female. Participants in the intervention group had higher odds of HIV viral load suppression at 12 months compared with participants in the standard-of-care group (52 [47%] vs 26 [23%]; adjusted odds ratio 3·0 [95% CI 1·4-6·4]; p=0·0039). 21 adverse events (18 in the intervention group and three in the standard-of-care group)and 14 deaths (four in the intervention group and ten in the standard-of-care group) were reported in the study. INTERPRETATION Given the effectiveness of the LINC-II intervention, scaling up this model could be one strategy to advance the UNAIDS goal of ending the HIV epidemic. FUNDING National Institute on Drug Abuse and Providence/Boston Center for AIDS Research.
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Affiliation(s)
- Jeffrey H Samet
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA.
| | - Elena Blokhina
- First Pavlov State Medical University of St Petersburg, Saint Petersburg, Russia
| | - Debbie M Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Dmitry Lioznov
- First Pavlov State Medical University of St Petersburg, Saint Petersburg, Russia
| | - Karsten Lunze
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Ve Truong
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Natalia Gnatienko
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Emily Quinn
- The Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Natalia Bushara
- First Pavlov State Medical University of St Petersburg, Saint Petersburg, Russia
| | - Anita Raj
- Center on Gender Equity and Health, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Evgeny Krupitsky
- Bekhterev National Medical Research Center for Psychiatry and Neurology, Saint Petersburg, Russia
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13
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Pascoe S, Huber A, Mokhele I, Lekodeba N, Ntjikelane V, Sande L, Tchereni T, Haimbe P, Rosen S. The SENTINEL study of differentiated service delivery models for HIV treatment in Malawi, South Africa, and Zambia: research protocol for a prospective cohort study. BMC Health Serv Res 2023; 23:891. [PMID: 37612720 PMCID: PMC10463463 DOI: 10.1186/s12913-023-09813-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/13/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Many countries in sub-Saharan Africa are rapidly scaling up "differentiated service delivery" (DSD) models for HIV treatment to improve the quality of care, increase access, reduce costs, and support the continued expansion and sustainability of antiretroviral therapy (ART) programs. Although there is some published evidence about the health outcomes of patients in DSD models, little is known about their impacts on healthcare providers' job satisfaction, patients' quality of life, costs to providers or patients, or how DSD models affect resource allocation at the facility level. METHODS SENTINEL is a multi-year observational study that will collect detailed data about DSD models for ART delivery and related services from 12 healthcare facilities in Malawi, 24 in South Africa, and 12 in Zambia. The first round of SENTINEL included a patient survey, provider survey, provider time-and-motion observations, and facility resource use inventory. A survey of clients testing for HIV and a supplement to the facility resource use component to describe service delivery integration will be added for the second round. The patient survey will ask up to 10 patients enrolled in each DSD model at each study site about their experiences in HIV care and in DSD models, costs incurred seeking treatment, and preferences for HIV service delivery. The provider survey will ask up to 10 providers per site about the impact of DSD models on their positions and clinics. The time-and-motion component will directly observe the time use of a sample of providers implementing DSD models. Finally, the resource utilization component will collect facility-level data about DSD model availability and enrollment and the human and other resources needed to implement them. SENTINEL is planned to include four or more approximately annual rounds of data collection between 2021 and 2026. DISCUSSION As national DSD programs for HIV treatment mature, it is important to understand how individual healthcare facilities are interpreting and implementing national guidelines and how healthcare workers and clients are adapting to new models of service delivery. SENTINEL will help policy makers and program managers understand the benefits and costs of differentiated service delivery and improve resource allocation going forward.
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Affiliation(s)
- Sophie Pascoe
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Amy Huber
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Idah Mokhele
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Nkgomeleng Lekodeba
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Vinolia Ntjikelane
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Linda Sande
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Timothy Tchereni
- Clinton Health Access Initiative-Malawi, Private Bag 68, Lilongwe, Malawi
| | - Prudence Haimbe
- Clinton Health Access Initiative-Zambia, P.O. Box 51071, Ridgeway, Lusaka, Zambia
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa.
- Department of Global Health, School of Public Health, Boston University, 801 Massachusetts Ave, 3rd Fl, Boston, MA, 02118, USA.
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14
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Kileel EM, Zheng A, Bor J, Fox MP, Crowther NJ, George JA, Khoza S, Rosen S, Venter WD, Raal F, Hibberd P, Brennan AT. Does engagement in HIV care affect screening, diagnosis, and control of noncommunicable diseases in sub-Saharan Africa? A systematic review and meta-analysis. medRxiv 2023:2023.01.30.23285196. [PMID: 36778439 PMCID: PMC9915817 DOI: 10.1101/2023.01.30.23285196] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective Low- and middle-income countries are facing a growing burden of noncommunicable diseases (NCDs). Providing HIV treatment may also provide opportunities to increase access to NCD services in under-resourced environments. We sought to investigate whether reported use of antiretroviral therapy (ART) was associated with increased screening, diagnosis, treatment, and/or control of diabetes, hypertension, chronic kidney disease, or cardiovascular disease among people living with HIV (PLWH) in sub-Saharan Africa (SSA). Design Systematic review and meta-analysis. Methods We searched 10 electronic literature databases for studies published between 01 January 2011 and 31 December 2022 using a comprehensive search strategy. We sought studies reporting on screening, diagnosis, treatment, and/or control of NCDs of interest by ART use among non-pregnant adults with HIV ≥16 years of age in SSA. Random effects models were used to calculate summary odds ratios (ORs) of the risk of diagnosis by ART status and corresponding 95% confidence intervals (95% CIs), where appropriate. Results Twenty-six studies, describing 13,570 PLWH in SSA, 61% of whom were receiving ART, were included. ART use was associated with a small but imprecise increase in the odds of diabetes diagnosis (OR: 1.07; 95% CI: 0.71, 1.60) and an increase in the odds of hypertension diagnosis (OR: 2.10, 95% CI: 1.42, 3.09). We found minimal data on the association between ART use and screening, treatment, or control of NCDs. Conclusion Despite a potentially higher NCD risk among PLWH and regional efforts to integrate NCD and HIV care, evidence to support effective care integration models is lacking.
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Affiliation(s)
- Emma M Kileel
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Amy Zheng
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, 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, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, 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
| | - Nigel J Crowther
- Department of Chemical Pathology, National Health Laboratory Service and University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Jaya A George
- Department of Chemical Pathology, National Health Laboratory Service and University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Siyabonga Khoza
- Department of Chemical Pathology, National Health Laboratory Service and University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Willem Df Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Frederick Raal
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Patricia Hibberd
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Alana T Brennan
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, 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
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15
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Huber A, Hirasen K, Brennan AT, Phiri B, Tcherini T, Mulenga L, Haimbe P, Shakwelele H, Nyirenda R, Wilson Matola B, Gunda A, Rosen S. Uptake of same-day initiation of HIV treatment in Malawi, South Africa, and Zambia as reported in routinely collected data: the SPRINT retrospective cohort study. Gates Open Res 2023; 7:42. [PMID: 37153118 PMCID: PMC10160348 DOI: 10.12688/gatesopenres.14424.2] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 05/11/2023] Open
Abstract
Background: Since 2017 global guidelines have recommended "same-day initiation" (SDI) of antiretroviral treatment (ART) for patients considered ready for treatment on the day of HIV diagnosis. Many countries have incorporated a SDI option into national guidelines, but SDI uptake is not well documented. We estimated average time to ART initiation at 12 public healthcare facilities in Malawi, five in South Africa, and 12 in Zambia. Methods: We identified patients eligible to start ART between January 2018 and June 2019 from facility testing registers and reviewed their medical records from HIV diagnosis to the earlier date of treatment initiation or 6 months. We estimated the proportion of patients initiating ART on the same day or within 7, 14, 30, or 180 days of baseline. Results: We enrolled 825 patients in Malawi, 534 in South Africa, and 1,984 in Zambia. Overall, 88% of patients in Malawi, 57% in South Africa, and 91% in Zambia received SDI. In Malawi, most who did not receive SDI had not initiated ART ≤6 months. In South Africa, an additional 13% initiated ≤1 week, but 21% had no record of initiation ≤6 months. Among those who did initiate within 6 months in Zambia, most started ≤1 week. There were no major differences by sex. WHO Stage III/IV and tuberculosis symptoms were associated with delays in ART initiation; clinic size and having a CD4 count done were associated with an increased likelihood of SDI. Conclusions: As of 2020, SDI of ART was widespread, if not nearly universal, in Malawi and Zambia but considerably less common in South Africa. Limitations of the study include pre-COVID-19 data that do not reflect pandemic adaptations and potentially missing data for Zambia. South Africa may be able to increase overall ART coverage by reducing numbers of patients who do not initiate ≤6 months.
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Affiliation(s)
- Amy Huber
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
| | - Kamban Hirasen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
| | - Alana T. Brennan
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
- Department Epidemiology, Boston University School of Public Health, Boston, MA, 02118, USA
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
| | - Bevis Phiri
- Clinton Health Access Institute-Zambia, Lusaka, Zambia
| | | | | | | | | | | | | | - Andrews Gunda
- Clinton Health Access Institute-Malawi, Lilongwe, Malawi
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
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Brennan AT, Nattey C, Kileel EM, Rosen S, Maskew M, Stokes AC, Fox MP, Venter WD. Change in body weight and risk of hypertension after switching from efavirenz to dolutegravir in adults living with HIV: evidence from routine care in Johannesburg, South Africa. EClinicalMedicine 2023; 57:101836. [PMID: 36816348 PMCID: PMC9932660 DOI: 10.1016/j.eclinm.2023.101836] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/09/2023] [Accepted: 01/09/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The integrase strand transfer inhibitor (INSTI) dolutegravir is recommended in World Health Organization guidelines, but is associated with weight gain. We evaluated weight change in patients switching from efavirenz to dolutegravir in first-line antiretroviral therapy (ART) in Johannesburg, South Africa. METHODS We conducted a prospective cohort study of adults (≥16 years) of black African ancestry with HIV who initiated ART between January 2010-December 2020. Patients were propensity score-matched 1:1 (unexposed i.e. remaining on efavirenz: exposed i.e. switched from efavirenz to dolutegravir) on sex, age, months on ART, first ART regimen, haemoglobin, body mass index (BMI), blood pressure, viral load and CD4 count. We used linear regression to assess the effect of switching from efavirenz to dolutegravir on weight change and hypertension 12 months after exposure. FINDINGS We matched 794 patients switching to dolutegravir to 794 remaining on efavirenz. Exposed patients had a higher mean change in weight (1.78 kg; 95% confidence interval (CI):1.04,2.52 kg) from start of follow-up to 12 months vs. unexposed. We also found a 14.2 percentage point increase (95% CI: 10.6,17.7) in the risk of hypertension in those exposed to dolutegravir vs those that remained on efavirenz. INTERPRETATION In a real-world population, patients gained more weight and were at higher risk of hypertension after switching from efavirenz to dolutegravir than those remaining on efavirenz. Longer follow-up is needed, however, to determine if INSTI-associated weight gain is associated with changes in non-communicable disease risk over the long-term, or whether weight gain is sustained, as seen in clinical trials. FUNDING This study has been made possible by the generous support of the American People and the President's Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID), under the terms of cooperative agreement cooperative Agreement 72067419CA00004. In addition to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) 1K01MH105320-01A1.
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Affiliation(s)
- Alana T. Brennan
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
- Corresponding author. Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center, 3rd Floor, Boston, MA 02119, USA.
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Emma M. Kileel
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew C. Stokes
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Matthew P. Fox
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Willem D.F. Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Huber A, Hirasen K, Brennan AT, Phiri B, Tcherini T, Mulenga L, Haimbe P, Shakwelele H, Nyirenda R, Wilson Matola B, Gunda A, Rosen S. Uptake of same-day initiation of HIV treatment among adult men and women in Malawi, South Africa, and Zambia: the SPRINT retrospective cohort study. Gates Open Res 2023; 7:42. [PMID: 37153118 PMCID: PMC10160348 DOI: 10.12688/gatesopenres.14424.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 02/24/2023] Open
Abstract
Background: Since 2017 global guidelines have recommended "same-day initiation" (SDI) of antiretroviral treatment (ART) for patients considered ready for treatment on the day of HIV diagnosis. Many countries have incorporated a SDI option into national guidelines, but SDI uptake is not well documented. We estimated average time to ART initiation at 12 public healthcare facilities in Malawi, five in South Africa, and 12 in Zambia. Methods: We sequentially enrolled patients eligible to start ART between January 2018 and June 2019 and reviewed their medical records from the point of HIV diagnosis or first HIV-related interaction with the clinic to the earlier date of treatment initiation or 6 months. We estimated the proportion of patients initiating ART on the same day or within 7, 14, 30, or 180 days of baseline. Results: We enrolled 826 patients in Malawi, 534 in South Africa, and 1,984 in Zambia. Overall, 88% of patients in Malawi, 57% in South Africa, and 91% in Zambia were offered and accepted SDI. In Malawi, most who did not receive SDI had not initiated ART ≤6 months. In South Africa, an additional 13% initiated ≤1 week, but 21% had no record of initiation ≤6 months. Among those who did initiate within 6 months in Zambia, most started ≤1 week. There were no major differences by sex. WHO Stage III/IV and tuberculosis symptoms were associated with delays in ART initiation. Conclusions: As of 2020, SDI of ART was widespread, if not nearly universal, in Malawi and Zambia but considerably less common in South Africa. Limitations of the study include pre-COVID-19 data that do not reflect pandemic adaptations and potentially missing data for Zambia. South Africa may be able to increase overall ART coverage by reducing numbers of patients who do not initiate ≤6 months. Registration: Clinicaltrials.gov ( NCT04468399; NCT04170374; NCT04470011).
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Affiliation(s)
- Amy Huber
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
| | - Kamban Hirasen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
| | - Alana T. Brennan
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
- Department Epidemiology, Boston University School of Public Health, Boston, MA, 02118, USA
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
| | - Bevis Phiri
- Clinton Health Access Institute-Zambia, Lusaka, Zambia
| | | | | | | | | | | | | | - Andrews Gunda
- Clinton Health Access Institute-Malawi, Lilongwe, Malawi
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, 2193, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
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Benade M, Nichols BE, Fatti G, Kuchukhidze S, Takarinda K, Mabhena-Ngorima N, Grimwood A, Rosen S. Economic evaluation of a cluster randomized, non-inferiority trial of differentiated service delivery models of HIV treatment in Zimbabwe. PLOS Glob Public Health 2023; 3:e0000493. [PMID: 36962960 PMCID: PMC10021451 DOI: 10.1371/journal.pgph.0000493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/30/2023] [Indexed: 03/15/2023]
Abstract
About 85% of Zimbabwe's >1.4 million people living with HIV are on antiretroviral treatment (ART). Further expansion of its treatment program will require more efficient use of existing resources. Two promising strategies for reducing resource utilization per patient are multi-month medication dispensing and community-based service delivery. We evaluated the costs to providers and patients of community-based, multi-month ART delivery models in Zimbabwe. We used resource and outcome data from a cluster-randomized non-inferiority trial of three differentiated service delivery (DSD) models targeted to patients stable on ART: 3-month facility-based care (3MF), community ART refill groups (CAGs) with 3-month dispensing (3MC), and CAGs with 6-month dispensing (6MC). Using local unit costs, we estimated the annual cost in 2020 USD of providing HIV treatment per patient from the provider and patient perspectives. In the trial, retention at 12 months was 93.0% in the 3MF, 94.8% in the 3MC, and 95.5% in the 6MC arms. The total average annual cost of HIV treatment per patient was $187 (standard deviation $39), $178 ($30), and $167 ($39) in each of the three arms, respectively. The annual cost/patient was dominated by ART medications (79% in 3MF, 87% in 3MC; 92% in 6MC), followed by facility visits (12%, 5%, 5%, respectively) and viral load (8%, 8%, 2%, respectively). When costs were stratified by district, DSD models cost slightly less, with 6MC the least expensive in all districts. Savings were driven by differences in the number of facility visits made/year, as expected, and low uptake of annual viral load tests in the 6-month arm. The total annual cost to patients to obtain HIV care was $10.03 ($2) in the 3MF arm, $5.12 ($0.41) in the 3MC arm, and $4.40 ($0.39) in the 6MF arm. For stable ART patients in Zimbabwe, 3- and 6-month community-based multi-month dispensing models cost less for both providers and patients than 3-month facility-based care and had non-inferior outcomes.
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Affiliation(s)
- Mariet Benade
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, United States of America
| | - Brooke E Nichols
- Department of Global Health, School of Public Health, Boston University, 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 Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Geoffrey Fatti
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Salome Kuchukhidze
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, United States of America
| | | | | | | | - Sydney Rosen
- Department of Global Health, School of Public Health, Boston University, 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
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Jo Y, Jamieson L, Phiri B, Grimsrud A, Mwansa M, Shakwelele H, Haimbe P, Mukumbwa-Mwenechanya M, Mulenga PL, Nichols BE, Rosen S. Attrition from HIV treatment after enrollment in a differentiated service delivery model: A cohort analysis of routine care in Zambia. PLoS One 2023; 18:e0280748. [PMID: 36917568 PMCID: PMC10013882 DOI: 10.1371/journal.pone.0280748] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 01/07/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Many sub-Saharan Africa countries are scaling up differentiated service delivery (DSD) models for HIV treatment to increase access and remove barriers to care. We assessed factors associated with attrition after DSD model enrollment in Zambia, focusing on patient-level characteristics. METHODS We conducted a retrospective record review using electronic medical records (EMR) of adults (≥15 years) initiated on antiretroviral (ART) between 01 January 2018 and 30 November 2021. Attrition was defined as lost to follow-up (LTFU) or died by November 30, 2021. We categorized DSD models into eight groups: fast-track, adherence groups, community pick-up points, home ART delivery, extended facility hours, facility multi-month dispensing (MMD, 4-6-month ART dispensing), frequent refill care (facility 1-2 month dispensing), and conventional care (facility 3 month dispensing, reference group). We used Fine and Gray competing risk regression to assess patient-level factors associated with attrition, stratified by sex and rural/urban setting. RESULTS Of 547,281 eligible patients, 68% (n = 372,409) enrolled in DSD models, most commonly facility MMD (n = 306,430, 82%), frequent refill care (n = 47,142, 13%), and fast track (n = 14,433, 4%), with <2% enrolled in the other DSD groups. Retention was higher in nearly all DSD models for all dispensing intervals, compared to the reference group, except fast track for the ≤2 month dispensing group. Retention benefits were greatest for patients in the extended clinic hours group and least for fast track dispensing. CONCLUSION Although retention in HIV treatment differed by DSD type, dispensing interval, and patient characteristics, nearly all DSD models out-performed conventional care. Understanding the factors that influence the retention of patients in DSD models could provide an important step towards improving DSD implementation.
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Affiliation(s)
- Youngji Jo
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA, United States of America
| | - Lise Jamieson
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Bevis Phiri
- Clinton Health Access Initiative, Lusaka, Zambia
| | - Anna Grimsrud
- HIV Programmes and Advocacy, International AIDS Society, Cape Town, South Africa
| | | | | | | | | | | | - Brooke E. Nichols
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, Netherlands
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
| | - Sydney Rosen
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- * E-mail:
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Nazir M, Murphy T, Poku N, Wheen P, Nowbar A, Andres M, Ramalingham S, Rosen S, Nicol E, Lyon A. Clinical Utility And Prognostic Value Of Coronary Computed Tomography Angiography In Cancer Patients. J Cardiovasc Comput Tomogr 2023. [DOI: 10.1016/j.jcct.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
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Jamieson L, Rosen S, Phiri B, Grimsrud A, Mwansa M, Shakwelele H, Haimbe P, Mukumbwa-Mwenechanya M, Lumano-Mulenga P, Chiboma I, Nichols BE. How soon should patients be eligible for differentiated service delivery models for antiretroviral treatment? Evidence from a retrospective cohort study in Zambia. BMJ Open 2022; 12:e064070. [PMID: 36549722 PMCID: PMC9772670 DOI: 10.1136/bmjopen-2022-064070] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Patient attrition is high the first 6 months after antiretroviral therapy (ART) initiation. Patients with <6 months of ART are systematically excluded from most differentiated service delivery (DSD) models, which are intended to support retention. Despite DSD eligibility criteria requiring ≥6 months on ART, some patients enrol earlier. We compared loss to follow-up (LTFU) between patients enrolling in DSD models early with those enrolled according to guidelines, assessing whether the ART experience eligibility criterion is necessary. DESIGN Retrospective cohort study using routinely collected electronic medical record data. SETTING PARTICIPANTS: Adults (≥15 years) who initiated ART between 1 January 2019 and 31 December 2020. OUTCOMES LTFU (>30 days late for scheduled visit) at 18 months for 'early enrollers' (DSD enrolment after <6 months on ART) and 'established enrollers' (DSD enrolment after ≥6 months on ART). We used a log-binomial model to compare LTFU risk, adjusting for age, sex, location, ART refill interval and DSD model. RESULTS For 6340 early enrollers and 25 857 established enrollers, there were no differences in sex (61% female), age (median 37 years) or location (65% urban). ART refill intervals were longer for established versus early enrollers (72% vs 55% were given 4-6 months refills). LTFU at 18 months was 3% (192 of 6340) for early enrollers and 5% (24 646 of 25 857) for established enrollers. Early enrollers were 41% less likely to be LTFU than established patients (adjusted risk ratio 0.59, 95% CI 0.50 to 0.68). CONCLUSIONS Patients enrolled in DSD after <6 months of ART were more likely to be retained than patients established on ART prior to DSD enrolment. A limitation is that early enrollers may have been selected for DSD due to providers' and patients' expectations about future retention. Offering DSD models to ART patients soon after ART initiation may help address high attrition during the early treatment period. TRIAL REGISTERATION NUMBER NCT04158882.
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Affiliation(s)
- Lise Jamieson
- Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Bevis Phiri
- Clinton Health Access Initiative, Lusaka, Zambia
| | | | | | | | | | | | | | | | - Brooke E Nichols
- Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
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Antoniak S, Chasela CS, Freiman MJ, Stopolianska Y, Barnard T, Gandhi MM, Liulchuk M, Tsenilova Z, Viktor T, Dible J, Wose Kinge C, Akpan F, Minior T, Sigwebela N, Mohamed S, Barralon M, Marange F, Cavenaugh C, Horst CV, Antonyak S, Xulu T, Chew KW, Sanne I, Rosen S. Treatment outcomes and costs of a simplified antiretroviral treatment strategy for hepatitis C among Hepatitis C Virus and Human Immuno deficiency Virus co-infected patients in Ukraine. JGH Open 2022; 6:894-903. [PMID: 36514496 PMCID: PMC9730727 DOI: 10.1002/jgh3.12839] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 10/12/2022] [Accepted: 10/21/2022] [Indexed: 11/18/2022]
Abstract
Background and Aim To demonstrate the use of a standard dose of ledipasvir (LDV) and sofosbuvir (SOF), with or without ribavirin, to treat hepatitis C and hepatitis C/HIV co-infection in Ukraine. Methods Eligible HCV viraemic adults from two clinics in Kyiv were treated with LDV/SOF with or without weight-based ribavirin for 12 weeks. Clinical assessments were performed at screening and at week 24, and as needed; treatment was dispensed every 4 weeks. The primary outcome was sustained virologic response (SVR) 12 weeks after treatment, with analysis by intention to treat. Cost per patient was estimated in USD (2018) over the 24-week period. Results Of 868 patients included in the study and initiated on therapy, 482 (55.5%) were co-infected with HIV. The common genotypes were 1 (74.1%) and 3 (22%). Overall, SVR was achieved in 831 of the 868 patients (95.7%). SVR in patients with hepatitis C alone and hepatitis C/HIV co-infection was 98.4% and 93.6%, respectively. Adverse events were infrequent and usually mild. Using generic medication, cost per patient was estimated at US$680. Conclusion A standard dose of LDV and SOF, with ribavirin as per protocol, resulted in good outcomes for patients with both hepatitis C alone and co-infected with hepatitis C/HIV. Program costs in Ukraine were modest using generic medication.
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Affiliation(s)
| | - Charles S Chasela
- Right to CarePretoriaSouth Africa
- Department of Epidemiology and Biostatistics, Faculty of Health Sciences, School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | | | - Tetiana Barnard
- United States Agency for International DevelopmentWashingtonDistrict of ColumbiaUSA
| | - Malini M Gandhi
- David Geffen School of Medicine at University of California Los AngelesLos AngelesCaliforniaUSA
| | - Maria Liulchuk
- Public Health Centre of Ministry of Healthcare of UkraineKyivUkraine
| | | | | | - Jeri Dible
- United States Agency for International DevelopmentWashingtonDistrict of ColumbiaUSA
| | | | | | - Thomas Minior
- United States Agency for International DevelopmentWashingtonDistrict of ColumbiaUSA
| | | | - Sofiane Mohamed
- Advanced Biological Laboratories (ABL)Luxembourg CityLuxembourg
| | | | | | - Clint Cavenaugh
- United States Agency for International DevelopmentWashingtonDistrict of ColumbiaUSA
| | | | - Svitlana Antonyak
- Gromashevsky Research Institute of Epidemiology and Infectious DiseasesMedical Academy of Sciences of UkraineKyivUkraine
| | | | - Kara W Chew
- David Geffen School of Medicine at University of California Los AngelesLos AngelesCaliforniaUSA
| | - Ian Sanne
- Right to CarePretoriaSouth Africa
- Wits HIV Research Unit, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sydney Rosen
- Boston UniversityBostonMassachusettsUSA
- Health Economics and Epidemiology Research OfficeWits Health Consortium, Faculty of Health Sciences, University of the WitwatersrandJohannesburgSouth Africa
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Rosen S, Lumbrezer‐Johnson S, Hostnik E, Salyer S, Selmic LE. Recurrent liver abscessation in a dog with an incompletely resected hepatocellular adenoma. Vet Record Case Reports 2022. [DOI: 10.1002/vrc2.536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Sydney Rosen
- Department of Veterinary Clinical Sciences College of Veterinary Medicine The Ohio State University Columbus Ohio USA
| | - Sarah Lumbrezer‐Johnson
- Department of Veterinary Clinical Sciences College of Veterinary Medicine The Ohio State University Columbus Ohio USA
| | - Eric Hostnik
- Department of Veterinary Clinical Sciences College of Veterinary Medicine The Ohio State University Columbus Ohio USA
| | - Sarah Salyer
- Department of Veterinary Clinical Sciences College of Veterinary Medicine The Ohio State University Columbus Ohio USA
| | - Laura E. Selmic
- Department of Veterinary Clinical Sciences College of Veterinary Medicine The Ohio State University Columbus Ohio USA
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Guthrie T, Muheki C, Rosen S, Kanoowe S, Lagony S, Greener R, Miot J, Balidawa H, Kiggundu J, Calnan J, Dejene S, Xulu T, Sigwebela N, Long LC. Similar costs and outcomes for differentiated service delivery models for HIV treatment in Uganda. BMC Health Serv Res 2022; 22:1315. [PMID: 36329450 PMCID: PMC9635081 DOI: 10.1186/s12913-022-08629-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 09/15/2022] [Indexed: 11/06/2022] Open
Abstract
This cost-outcome study estimated, from the perspective of the service provider, the total annual cost per client on antiretroviral therapy (ART) and total annual cost per client virally suppressed (defined as < 1000 copies/ml at the time of the study) in Uganda in five ART differentiated service delivery models (DSDMs). These included both facility- and community-based models and the standard of care (SOC), known as the facility-based individual management (FBIM) model. The Ministry of Health (MOH) adopted guidelines for DSDMs in 2017 and sought to measure their costs and outcomes, in order to effectively plan for their resourcing, implementation, and scale-up. In Uganda, the standard of care (FBIM) is considered as a DSDM option for clients requiring specialized treatment and support, or for those who select not to join an alternative DSDM. Note that clients on second-line regimes and considered as “established on treatment” can join a suitable DSDM. Using retrospective client record review of a cohort of clients over a two-year period, with bottom-up collection of clients’ resource utilization data, top-down collection of above-delivery level and delivery-level providers’ fixed operational costs, and local unit costs. Forty-seven DSDMs located at facilities or community-based points in the four regions of Uganda were included in the study, with 653 adults on ART (> 18 years old) enrolled in a DSDM. The study found that retention in care was 98% for the sample as a whole [96–100%], and viral suppression, 91% [86-93%]. The mean cost to the provider (MOH or NGO implementers) was $152 per annum per client treated, ranging from $141 to $166. Differences among the models’ costs were largely due to clients’ ARV regimens and the proportions of clients on second line regimens. Service delivery costs, excluding ARVs, other medicines and laboratory tests, were modest, ranging from $9.66–16.43 per client per year. We conclude that differentiated ART service delivery in Uganda achieved excellent treatment outcomes at a cost similar to the standard of care. While large budgetary savings might not be immediately realized, the reallocation of “saved” staff time could improve health system efficiency and with their equivalent or better outcomes and large benefits to clients, client-centred differentiated models would nevertheless add great societal value.
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Benade M, Long L, Meyer-Rath G, Miot J, Evans D, Tucker JM, Moultrie H, Rosen S. Reduction in initiations of drug-sensitive tuberculosis treatment in South Africa during the COVID-19 pandemic: Analysis of retrospective, facility-level data. PLOS Glob Public Health 2022; 2:e0000559. [PMID: 36962535 PMCID: PMC10021649 DOI: 10.1371/journal.pgph.0000559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 09/13/2022] [Indexed: 05/29/2023]
Abstract
In response to the global pandemic of COVID-19, South Africa implemented a strict lockdown in March 2020 before its first COVID-19 wave started, gradually lifted restrictions between May and September 2020, and then re-imposed restrictions in December 2020 in response to its second wave. There is concern that COVID-19-related morbidity and mortality, the deprioritization of TB activities, fear of transmission, and societal restrictions led to a reduction in tuberculosis (TB) treatment initiations. We analysed monthly public sector, facility-level data from South Africa's District Health Information System (DHIS) from January 2019 to April 2021 to quantify changes in TB treatment initiation numbers stratified by province, setting, and facility type and compared the timing of these changes to COVID-19 case numbers and government lockdown levels. At the 1189 facilities that reported observations for all 28 months of our study period, TB treatment initiations in 2020 were 20.4% lower than in 2019 and 21.9% lower in the first four months of 2021 than in 2019. At the 3669 facilities that reported observations in ≤28 months, numbers of TB treatment initiations declined sharply in all provinces in May-August 2020, compared to the same months in 2019. After recovering somewhat in the last four months of 2020, numbers plummeted again in early 2021. Percentage reductions were somewhat larger in urban and peri-urban areas than in rural areas. Most provinces experienced a clear inverse relationship between COVID-19 cases and TB treatment initiations but little relationship between TB treatment initiations and lockdown level. The COVID-19 pandemic and responses to it resulted in substantial declines in the number of individuals starting treatment for TB in South Africa and risked progress toward achieving TB management goals. Exceptional effort will be needed to sustain gains in combating TB.
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Affiliation(s)
- Mariet Benade
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Lawrence Long
- 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 Witwatersrand, Johannesburg, South Africa
| | - Gesine Meyer-Rath
- 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 Witwatersrand, Johannesburg, South Africa
| | - Jacqui Miot
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | | | - Harry Moultrie
- Division of the National Health Laboratory Services, National Institute of Communicable Diseases, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Rosen S, Duerr FM, Elam LH. Prospective evaluation of complications associated with orthosis and prosthesis use in canine patients. Front Vet Sci 2022; 9:892662. [PMID: 35967994 PMCID: PMC9372342 DOI: 10.3389/fvets.2022.892662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionThe use of orthoses and prostheses is expanding in veterinary medicine. However, research evaluating the efficacy and complications of these devices in veterinary patients is limited. The primary objective of this study was to prospectively determine the complications and outcomes associated with custom orthosis and prosthesis use in the canine patient.Materials and MethodsThis was a prospective, clinical trial that followed patients for 12 months following device fitting. Owner-perceived complications, clinical metrology instruments, and objective gait analysis were used as outcome measures at various time points. The patients were grouped into the following four major categories: Patients with a carpal orthosis, patients with a stifle orthosis, patients with a tarsal orthosis, and patients with a prosthetic device.ResultsForty-three patients were included in the study. Thirty-nine out of 43 patients (91%) experienced at least one complication, with 7/7 (100%) prosthesis patients experiencing at least one complication. At least one skin complication was reported for the following patient groups during the first 3 months of use: 8/14 (58%) stifle orthoses, 9/10 (90%) carpal orthoses, 6/10 (60%) tarsal orthoses, and 4/7 (58%) prostheses. Patient non-acceptance of the device was identified in 2/15 (14%) stifle orthoses, 1/10 (10%) tarsal orthoses, and 4/7 (55%) prostheses. One out of 15 (7%) stifle orthoses, 4/10 (40%) carpal orthoses, 4/10 (40%) tarsal orthoses, and 1/7 (15%) prostheses experienced mechanical device problems necessitating repair. The majority of patients with carpal and stifle orthoses showed improvement on objective gait analysis in percent body weight distribution of the affected limb between baseline and the most recent follow-up without the device donned: 83% (n = 6) of patients with carpal orthoses, 100% (n = 11) of patients with stifle orthoses. None of the patients with tarsal orthoses showed a similar improvement (0%; n = 4).Discussion and conclusionThree major complications associated with canine orthosis and prosthesis use were identified in this study as follows: Skin complications (abrasions, loss of hair, and sores), mechanical device problems, and patient non-acceptance of the device. Owners should be notified of these potential complications prior to pursuing orthoses or prostheses as a potential treatment option. Although clinical improvement was noted in the majority of patients with stifle and carpal pathology, given the lack of a control group, it is unknown how much of this improvement can be attributed to the orthoses.
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Benade M, Rosen S, Antoniak S, Chasela C, Stopolianska Y, Barnard T, Gandhi MM, Ivanchuk I, Tretiakov V, Dible J, Minior T, Chew KW, van der Horst C, Tsenilova Z, Sanne I. Impact of direct-acting antiviral treatment of hepatitis C on the quality of life of adults in Ukraine. BMC Infect Dis 2022; 22:650. [PMID: 35896987 PMCID: PMC9330669 DOI: 10.1186/s12879-022-07615-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 07/04/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Direct-acting antivirals (DAAs) are highly effective in achieving sustained virologic response among those with chronic hepatitis C virus (HCV) infection. Quality of life (QOL) benefits for an HCV-infected population with high numbers of people who inject drugs and people living with HIV (PLHIV) in Eastern Europe have not been explored. We estimated such benefits for Ukraine. METHODS Using data from a demonstration study of 12-week DAA conducted in Kyiv, we compared self-reported QOL as captured with the MOS-SF20 at study entry and 12 weeks after treatment completion (week 24). We calculated domain scores for health perception, physical, role and social functioning, mental health and pain to at entry and week 24, stratified by HIV status. RESULTS Among the 857 patients included in the final analysis, health perception was the domain that showed the largest change, with an improvement of 85.7% between entry and week 24. The improvement was larger among those who were HIV negative (104.4%) than among those living with HIV (69.9%). Other domains that showed significant and meaningful improvements were physical functioning, which improved from 80.5 (95% CI 78.9-82.1) at study entry to 89.4 (88.1-90.7) at 24 weeks, role functioning (64.5 [62.3-66.8] to 86.5 [84.9-88.2]), social functioning (74.2 [72.1-76.2] to 84.8 [83.2-86.5]) and bodily pain (70.1 [68.2-72.0] to 89.8 [88.5-91.1]). Across all domains, QOL improvements among PLHIV were more modest than among HIV-negative participants. CONCLUSION QOL improved substantially across all domains between study entry and week 24. Changes over the study period were smaller among PLHIV.
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Affiliation(s)
- M Benade
- Boston University School of Public Health, Boston, MA, USA.
| | - S Rosen
- Boston University School of Public Health, Boston, MA, 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
| | | | - C Chasela
- Right to Care, Centurion, Pretoria, South Africa
- Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - T Barnard
- United States Agency for International Development, Washington, DC, USA
| | - M M Gandhi
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - I Ivanchuk
- Public Health Centre of Ministry of Healthcare of Ukraine, Kyiv, Ukraine
| | | | - J Dible
- United States Agency for International Development, Washington, DC, USA
| | - T Minior
- United States Agency for International Development, Washington, DC, USA
| | - K W Chew
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | | | - I Sanne
- 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
- Right to Care, Centurion, Pretoria, South Africa
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Benade M, Long L, Rosen S, Meyer-Rath G, Tucker JM, Miot J. Reduction in initiations of HIV treatment in South Africa during the COVID pandemic. BMC Health Serv Res 2022; 22:428. [PMID: 35361209 PMCID: PMC8970413 DOI: 10.1186/s12913-022-07714-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 02/28/2022] [Indexed: 11/23/2022] Open
Abstract
Background In response to the global pandemic of COVID-19, countries around the world began imposing stay-at-home orders, restrictions on transport, and closures of businesses in early 2020. South Africa implemented a strict lockdown in March 2020 before its first COVID-19 wave started, gradually lifted restrictions between May and September 2020, and then re-imposed restrictions in December 2020 in response to its second wave. There is concern that COVID-19-related morbidity and mortality, fear of transmission, and government responses may have led to a reduction in antiretroviral treatment (ART) initiations for HIV-infected individuals in countries like South Africa. Methods We analyzed national, public sector, facility-level data from South Africa’s District Health Information System (DHIS) from January 2019 to March 2021 to quantify changes in ART initiation rates stratified by province, setting, facility size and type and compared the timing of these changes to COVID-19 case numbers and government lockdown levels. We excluded facilities with missing data, mobile clinics, and correctional facilities. We estimated the total number of ART initiations per study month for each stratum and compared monthly totals, by year. Results At the 2471 facilities in the final data set (59% of all ART sites in the DHIS), 28% fewer initiations occurred in 2020 than in 2019. Numbers of ART initiations declined sharply in all provinces in April-June 2020, compared to the same months in 2019, and remained low for the rest of 2020, with some recovery between COVID-19 waves in October 2020 and possible improvement beginning in March 2021. Percentage reductions were largest in district hospitals, larger facilities, and urban areas. After the initial decline in April-June 2020, most provinces experienced a clear inverse relationship between COVID-19 cases and ART initiations but little relationship between ART initiations and lockdown level. Conclusions The COVID-19 pandemic and responses to it resulted in substantial declines in the number of HIV-infected individuals starting treatment in South Africa, with no recovery of numbers during 2020. These delays may lead to worse treatment outcomes for those with HIV and potentially higher HIV transmission. Exceptional effort will be needed to sustain gains in combatting HIV.
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Affiliation(s)
- Mariet Benade
- Department of Global Health, Boston University School of Public Health, Boston, USA.
| | - Lawrence Long
- Department of Global Health, Boston University School of Public Health, Boston, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Gesine Meyer-Rath
- Department of Global Health, Boston University School of Public Health, Boston, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | | | - Jacqui Miot
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Rosen S, Nichols B, Guthrie T, Benade M, Kuchukhidze S, Long L. Do differentiated service delivery models for HIV treatment in sub-Saharan Africa save money? Synthesis of evidence from field studies conducted in sub-Saharan Africa in 2017-2019. Gates Open Res 2022; 5:177. [PMID: 35310814 PMCID: PMC8907143 DOI: 10.12688/gatesopenres.13458.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction: “Differentiated service delivery” (DSD) for antiretroviral therapy (ART) for HIV is rapidly being scaled up throughout sub-Saharan Africa, but only recently have data become available on the costs of DSD models to healthcare providers and to patients. We synthesized recent studies of DSD model costs in five African countries. Methods: The studies included cluster randomized trials in Lesotho, Malawi, Zambia, and Zimbabwe and observational studies in Uganda and Zambia. For 3-5 models per country, studies collected patient-level data on clinical outcomes and provider costs for 12 months. We compared costs of differentiated models to those of conventional care, identified drivers of cost differences, and summarized patient costs of seeking care. Results: The studies described 22 models, including conventional care. Of these, 13 were facility-based and 9 community-based models; 15 were individual and 7 group models. Average provider cost/patient/year ranged from $100 for conventional care in Zambia to $187 for conventional care with 3-month dispensing in Zimbabwe. Most DSD models had comparable costs to conventional care, with a difference in mean annual cost per patient ranging from 11.4% less to 9.2% more, though some models in Zambia cost substantially more. Compared to all other models, models incorporating 6-month dispensing were consistently slightly less expensive to the provider per patient treated. Savings to patients were substantial for most models, with patients’ costs roughly halved. Conclusion: In five field studies of the costs of DSD models for HIV treatment, most models within each country had relatively similar costs to one another and to conventional care. 6-month dispensing models were slightly less expensive, and most models provided substantial savings to patients. Limitations of our analysis included differences in costs included in each study. Research is needed to understand the effect of DSD models on the costs of ART programmes as a whole.
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Affiliation(s)
- Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
- Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, 2193, South Africa
| | - Brooke Nichols
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
- Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, 2193, South Africa
| | - Teresa Guthrie
- Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, 2193, South Africa
| | - Mariet Benade
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
| | - Salome Kuchukhidze
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
| | - Lawrence Long
- Department of Global Health, Boston University School of Public Health, Boston, MA, 02118, USA
- Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, 2193, South Africa
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Rosen S, Nichols B, Guthrie T, Benade M, Kuchukhidze S, Long L. Do differentiated service delivery models for HIV treatment in sub-Saharan Africa save money? Synthesis of evidence from field studies conducted in sub-Saharan Africa in 2017-2019. Gates Open Res 2021; 5:177. [DOI: 10.12688/gatesopenres.13458.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction: “Differentiated service delivery” (DSD) for antiretroviral therapy (ART) for HIV is rapidly being scaled up throughout sub-Saharan Africa, but only recently have data become available on the costs of DSD models to providers and patients. We synthesized recent studies of DSD model costs in five African countries. Methods: The studies included cluster randomized trials in Lesotho, Malawi, Zambia, and Zimbabwe and observational studies in Uganda and Zambia. For 3-5 models per country, studies collected patient-level data on clinical outcomes and provider costs for 12 months, and some studies surveyed patients about costs they incurred. We compared costs of differentiated models to those of conventional care and identified drivers of cost differences. We also report patient costs of seeking care. Results: The studies described 22 models, including facility-based conventional care. Of these, 13 were facility-based and 9 community-based models; 15 were individual and 7 group models. Average provider cost/patient/year ranged from $100 in Zambia to $187 in Zimbabwe, in both cases for facility-based conventional care. Conventional care was less expensive than any other model in the Zambia observational study, more expensive than any other model in Lesotho, Malawi, and Zimbabwe, and in the middle of the range in the Zambia trial and the observational study in Uganda. Models incorporating 6-month dispensing were consistently less expensive to the provider per patient treated. Savings to patients were substantial for most models, with patients’ costs roughly halved. Conclusion: In five field studies of the costs of DSD models for HIV treatment, most models within each country had relatively similar costs, except for 6-month dispensing models, which were slightly less expensive. Most models provided substantial savings to patients. Research is needed to understand the effect of DSD models on the costs of ART programmes as a whole.
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Bor J, Fischer C, Modi M, Richman B, Kinker C, King R, Calabrese SK, Mokhele I, Sineke T, Zuma T, Rosen S, Bärnighausen T, Mayer KH, Onoya D. Changing Knowledge and Attitudes Towards HIV Treatment-as-Prevention and "Undetectable = Untransmittable": A Systematic Review. AIDS Behav 2021; 25:4209-4224. [PMID: 34036459 PMCID: PMC8147591 DOI: 10.1007/s10461-021-03296-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [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: 04/30/2021] [Indexed: 12/12/2022]
Abstract
People on HIV treatment with undetectable virus cannot transmit HIV sexually (Undetectable = Untransmittable, U = U). However, the science of treatment-as-prevention (TasP) may not be widely understood by people with and without HIV who could benefit from this information. We systematically reviewed the global literature on knowledge and attitudes related to TasP and interventions providing TasP or U = U information. We included studies of providers, patients, and communities from all regions of the world, published 2008–2020. We screened 885 papers and abstracts and identified 72 for inclusion. Studies in high-income settings reported high awareness of TasP but gaps in knowledge about the likelihood of transmission with undetectable HIV. Greater knowledge was associated with more positive attitudes towards TasP. Extant literature shows low awareness of TasP in Africa where 2 in 3 people with HIV live. The emerging evidence on interventions delivering information on TasP suggests beneficial impacts on knowledge, stigma, HIV testing, and viral suppression. Review was pre-registered at PROSPERO: CRD42020153725
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Affiliation(s)
- Jacob Bor
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02119, USA.
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, GP, South Africa.
| | - Charlie Fischer
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02119, USA
| | - Mirva Modi
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02119, USA
| | | | | | - Rachel King
- UCSF Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | | | - Idah Mokhele
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, GP, South Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, GP, South Africa
| | - Thembelihle Zuma
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- University of KwaZulu-Natal, Durban, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02119, USA
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, GP, South Africa
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Kenneth H Mayer
- Fenway Health Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, GP, South Africa
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Nichols BE, Rosen S. Economic evaluations of differentiated service delivery should include savings and ancillary benefits, not only health system costs: authors' reply. AIDS 2021; 35:2235-2236. [PMID: 34602596 DOI: 10.1097/qad.0000000000003034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Brooke E Nichols
- Department of Global Health, Boston University School of Public Health, Boston, MA, 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
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Maskew M, Brennan AT, Venter WDF, Fox MP, Vezi L, Rosen S. Retention in care and viral suppression after same-day ART initiation: One-year outcomes of the SLATE I and II individually randomized clinical trials in South Africa. J Int AIDS Soc 2021; 24:e25825. [PMID: 34612601 PMCID: PMC8694178 DOI: 10.1002/jia2.25825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 09/10/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction Same‐day initiation (SDI) of antiretroviral therapy (ART) for HIV consistently increases ART uptake, but concerns remain about higher attrition from care after initiation. We analysed 12‐month retention in the SLATE SDI trials. Methods SLATE I (Simplified Algorithms for Treatment Eligibility I, enrolment 06 March–28 July 2017) and SLATE II (enrolment 14 March–18 September 2018) were individually randomized trials at public outpatient clinics in Johannesburg that enrolled patients not yet on ART and administered the SLATE I or II algorithm. This included a symptom self‐report, medical history, brief physical examination and readiness questionnaire to assess the eligibility for SDI. The studies compared the offer of SDI using the SLATE algorithms to standard of care initiation procedures. ART uptake and early retention were previously reported. Using routine clinic records, we conducted a pooled analysis of retention in care and HIV viral suppression 14 months after study enrolment, a time point equivalent to 12 months potential on ART, with an additional month allowed on either end to initiate ART and to return for the 12‐month visit. Results and discussion We enrolled 1193 study participants (standard arms, n = 599, 50%; intervention arms, n = 594, 50%) and analysed by originally assigned groups. By 14 months after enrolment, 50% of intervention arm patients and 46% of standard arm patients remained in care at the initiating site (crude risk difference 4% (95% confidence interval −1%‐10%); crude relative risk 1.10 (0.97–1.23), with similar viral suppression between arms. Observed attrition from care at site by 14 months was high in both study arms, but we found no evidence that the offer of SDI led to greater overall attrition or lower rates of viral suppression 1 year after starting ART and may have generated small improvements. SDI may have shifted some attrition from before to after dispensing of the first dose of medication. Conclusions An offer of SDI of ART, following a carefully designed protocol to identify patients who are eligible and ready to start treatment, is not inherently associated with an overall increase in patient attrition from care and leads to similar rates of viral suppression. Trial registration Clinicaltrials.gov NCT02891135, registered 01 September 2016. First participant enrolled 06 March 2017 in South Africa. Clinicaltrials.gov NCT03315013, registered 19 October 2017. First participant enrolled 14 March 2018.
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Affiliation(s)
- 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
| | - Alana T Brennan
- 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 School of Public Health, Boston, Massachusetts, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Willem D F Venter
- Ezintsha, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- 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 School of Public Health, Boston, Massachusetts, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - 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
| | - 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 School of Public Health, Boston, Massachusetts, USA
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Jo Y, Rosen S, Sy KTL, Phiri B, Huber AN, Mwansa M, Shakwelele H, Haimbe P, Mwenechanya MM, Lumano‐Mulenga P, Nichols BE. Changes in HIV treatment differentiated care uptake during the COVID-19 pandemic in Zambia: interrupted time series analysis. J Int AIDS Soc 2021; 24 Suppl 6:e25808. [PMID: 34713620 PMCID: PMC8554218 DOI: 10.1002/jia2.25808] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 08/03/2021] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Differentiated service delivery (DSD) models aim to improve the access of human immunodeficiency virus treatment on clients and reduce requirements for facility visits by extending dispensing intervals. With the advent of the COVID-19 pandemic, minimising client contact with healthcare facilities and other clients, while maintaining treatment continuity and avoiding loss to care, has become more urgent, resulting in efforts to increase DSD uptake. We assessed the extent to which DSD coverage and antiretroviral treatment (ART) dispensing intervals have changed during the COVID-19 pandemic in Zambia. METHODS We used client data from Zambia's electronic medical record system (SmartCare) for 737 health facilities, representing about three-fourths of all ART clients nationally. We compared the numbers and proportional distributions of clients enrolled in DSD models in the 6 months before and 6 months after the first case of COVID-19 was diagnosed in Zambia in March 2020. Segmented linear regression was used to determine whether the outbreak of COVID-19 in Zambia further accelerated the increase in DSD scale-up. RESULTS AND DISCUSSION Between September 2019 and August 2020, 181,317 clients aged 15 or older (81,520 and 99,797 from 1 September 2019 to 1 March 2020 and from 1 March to 31 August 2020, respectively) enrolled in DSD models in Zambia. Overall participation in all DSD models increased over the study period, but uptake varied by model. The rate of acceleration increased in the second period for home ART delivery (152%), ≤ 2-month fast-track (143%) and 3-month MMD (139%). There was a significant reduction in the enrolment rates for 4- to 6-month fast-track (-28%) and "other" models (-19%). CONCLUSIONS Participation in DSD models for stable ART clients in Zambia increased after the advent of COVID-19, but dispensing intervals diminished. Eliminating obstacles to longer dispensing intervals, including those related to supply chain management, should be prioritized to achieve the expected benefits of DSD models and minimize COVID-19 risk.
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Affiliation(s)
- Youngji Jo
- Section of Infectious DiseasesDepartment of MedicineBoston Medical CenterBostonMassachusettsUSA
| | - Sydney Rosen
- Department of Global HealthBoston University School of Public HealthBostonMassachusettsUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Karla Therese L. Sy
- Department of Global HealthBoston University School of Public HealthBostonMassachusettsUSA
- Department of EpidemiologyBoston University School of Public HealthBostonMassachusettsUSA
| | - Bevis Phiri
- Clinton Health Access InitiativeLusakaZambia
| | - Amy N. Huber
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | | | | | | | | | - Brooke E. Nichols
- Department of Global HealthBoston University School of Public HealthBostonMassachusettsUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Medical MicrobiologyAmsterdam University Medical CentreAmsterdamThe Netherlands
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Long LC, Rosen S, Nichols B, Larson BA, Ndlovu N, Meyer‐Rath G. Getting resources to those who need them: the evidence we need to budget for underserved populations in sub-Saharan Africa. J Int AIDS Soc 2021; 24 Suppl 3:e25707. [PMID: 34189873 PMCID: PMC8242975 DOI: 10.1002/jia2.25707] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 03/17/2021] [Accepted: 03/23/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION In recent years, many countries have adopted evidence-based budgeting (EBB) to encourage the best use of limited and decreasing HIV resources. The lack of data and evidence for hard to reach, marginalized and vulnerable populations could cause EBB to further disadvantage those who are already underserved and who carry a disproportionate HIV burden (USDB). We outline the critical data required to use EBB to support USDB people in the context of the generalized epidemics of sub-Saharan Africa (SSA). DISCUSSION To be considered in an EBB cycle, an intervention needs at a minimum to have an estimate of a) the average cost, typically per recipient of the intervention; b) the effectiveness of the intervention and c) the size of the intervention target population. The methods commonly used for general populations are not sufficient for generating valid estimates for USDB populations. USDB populations may require additional resources to learn about, access, and/or successfully participate in an intervention, increasing the cost per recipient. USDB populations may experience different health outcomes and/or other benefits than in general populations, influencing the effectiveness of the interventions. Finally, USDB population size estimation is critical for accurate programming but is difficult to obtain with almost no national estimates for countries in SSA. We explain these limitations and make recommendations for addressing them. CONCLUSIONS EBB is a strong tool to achieve efficient allocation of resources, but in SSA the evidence necessary for USDB populations may be lacking. Rather than excluding USDB populations from the budgeting process, more should be invested in understanding the needs of these populations.
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Affiliation(s)
- Lawrence C Long
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of WitwatersrandJohannesburgSouth Africa
- Health Economics and Epidemiology Research OfficeWits Health ConsortiumJohannesburgSouth Africa
| | - Sydney Rosen
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of WitwatersrandJohannesburgSouth Africa
- Health Economics and Epidemiology Research OfficeWits Health ConsortiumJohannesburgSouth Africa
| | - Brooke Nichols
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of WitwatersrandJohannesburgSouth Africa
- Health Economics and Epidemiology Research OfficeWits Health ConsortiumJohannesburgSouth Africa
| | - Bruce A Larson
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of WitwatersrandJohannesburgSouth Africa
- Health Economics and Epidemiology Research OfficeWits Health ConsortiumJohannesburgSouth Africa
| | - Nhlanhla Ndlovu
- Centre for Economic Governance and Accountability in Africa (CEGAA)PietermaritzburgSouth Africa
| | - Gesine Meyer‐Rath
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of WitwatersrandJohannesburgSouth Africa
- Health Economics and Epidemiology Research OfficeWits Health ConsortiumJohannesburgSouth Africa
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Huber A, Pascoe S, Nichols B, Long L, Kuchukhidze S, Phiri B, Tchereni T, Rosen S. Differentiated Service Delivery Models for HIV Treatment in Malawi, South Africa, and Zambia: A Landscape Analysis. Glob Health Sci Pract 2021; 9:296-307. [PMID: 34234023 PMCID: PMC8324204 DOI: 10.9745/ghsp-d-20-00532] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 03/02/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Many countries in Africa are scaling up differentiated service delivery (DSD) models for HIV treatment, but most existing data systems do not describe the models in use. We surveyed organizations that were supporting DSD models in 2019 in Malawi, South Africa, and Zambia to describe the diversity of DSD models being implemented at that time. METHODS We interviewed DSD model implementing organizations for descriptive information about each of the organization's models of care. We described the key characteristics of each model, including population of patients served, location of service delivery, frequency of interactions with patients, duration of dispensing, and cadre(s) of provider involved. To facilitate analysis, we refer to 1 organization supporting 1 model of care as an "organization-model." RESULTS The 34 respondents (8 in Malawi, 16 in South Africa, 10 in Zambia) interviewed described a total of 110 organization-models, which included 19 facility-based individual models, 21 out-of-facility-based individual models, 14 health care worker-led groups, and 3 client-led groups; jointly, these encompassed 12 specific service delivery strategies, such as multimonth dispensing, adherence clubs, home delivery, and changes to facility hours. Over two-thirds (n=78) of the organization-models were limited to clinically stable patients. Almost all organization-models (n=96) continued to provide clinical care at established health care facilities; medication pickup took place at facilities, external pickup points, and adherence clubs. Required numbers of provider interactions per year varied widely, from 2 to 12. Dispensing intervals were typically 3 or 6 months in Malawi and Zambia and 2 months in South Africa. Individual models relied more on clinical staff, while group models made greater use of lay personnel. CONCLUSIONS As of 2019, there was a large variety of differentiated service models being offered for HIV treatment in Malawi, South Africa, and Zambia, serving diverse patient populations.
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Affiliation(s)
- Amy Huber
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, South Africa
| | - Brooke Nichols
- Health Economics and Epidemiology Research Office, Wits Health Consortium, 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 School of Public Health, Boston, MA, USA
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, Wits Health Consortium, 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 School of Public Health, Boston, MA, USA
| | - Salome Kuchukhidze
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Bevis Phiri
- Clinton Health Access Initiative, Lusaka, Zambia
| | | | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Wits Health Consortium, 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 School of Public Health, Boston, MA, USA
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Hoffman RM, Moyo C, Balakasi KT, Siwale Z, Hubbard J, Bardon A, Fox MP, Kakwesa G, Kalua T, Nyasa-Haambokoma M, Dovel K, Campbell PM, Tseng CH, Pisa PT, Cele R, Gupta S, Benade M, Long L, Xulu T, Sanne I, Rosen S. Multimonth dispensing of up to 6 months of antiretroviral therapy in Malawi and Zambia (INTERVAL): a cluster-randomised, non-blinded, non-inferiority trial. Lancet Glob Health 2021; 9:e628-e638. [PMID: 33865471 DOI: 10.1016/s2214-109x(21)00039-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Facility-based, multimonth dispensing of antiretroviral therapy (ART) for HIV could reduce burdens on patients and providers and improve retention in care. We assessed whether 6-monthly ART dispensing was non-inferior to standard of care and 3-monthly ART dispensing. METHODS We did a pragmatic, cluster-randomised, unblinded, non-inferiority trial (INTERVAL) at 30 health facilities in Malawi and Zambia. Eligible participants were aged 18 years or older, HIV-positive, and were clinically stable on ART. Before randomisation, health facilities (clusters) were matched on the basis of country, ART cohort size, facility type (ie, hospital vs health centre), and region or province. Matched clusters were randomly allocated (1:1:1) to standard of care, 3-monthly ART dispensing, or 6-monthly ART dispensing using a simple random allocation sequence. The primary outcome was retention in care at 12 months, defined as the proportion of patients with less than 60 consecutive days without ART during study follow-up, analysed by intention to treat. A 2·5% margin was used to assess non-inferiority. This study is registered with ClinicalTrials.gov, NCT03101592. FINDINGS Between May 15, 2017, and April 30, 2018, 9118 participants were randomly assigned, of whom 8719 participants (n=3012, standard of care group; n=2726, 3-monthly ART dispensing group; n=2981, 6-monthly ART dispensing group) had primary outcome data available at 12 months and were included in the primary analysis. The median age of participants was 42·7 years (IQR 36·1-49·9) and 5774 (66·2%) of 8719 were women. The primary outcome was met by 2478 (82·3%) of 3012 participants in the standard of care group, 2356 (86·4%) of 2726 participants in the 3-monthly ART dispensing group, and 2729 (91·5%) of 2981 participants in the 6-monthly ART dispensing group. After adjusting for clustering, for retention in care at 12 months, the 6-monthly ART dispensing group was non-inferior to the standard of care group (percentage-point increase 9·1 [95% CI 0·9-17·2]) and to the 3-monthly ART dispensing group (5·0% [1·0-9·1]). INTERPRETATION Clinical visits with ART dispensing every 6 months was non-inferior to standard of care and 3-monthly ART dispensing. 6-monthly ART dispensing is a promising strategy for the expansion of ART provision and achievement of HIV treatment targets in resource-constrained settings. FUNDING US Agency for International Development.
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Affiliation(s)
- Risa M Hoffman
- Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA.
| | | | | | | | - Julie Hubbard
- Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Ashley Bardon
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - Matthew P Fox
- Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA; Department of Global Health, School of Public Health, Boston University, Boston, MA, USA; Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Thokozani Kalua
- Department of HIV and AIDS, Malawi Ministry of Health, Lilongwe, Malawi
| | | | - Kathryn Dovel
- Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Paula M Campbell
- Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Chi-Hong Tseng
- Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Pedro T Pisa
- Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa; Right to Care South Africa, Centurion, South Africa
| | - Refiloe Cele
- Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
| | - Sundeep Gupta
- Department of Medicine, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Mariet Benade
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Lawrence Long
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA; Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
| | - Thembi Xulu
- Right to Care South Africa, Centurion, South Africa
| | - Ian Sanne
- Right to Care South Africa, Centurion, South Africa
| | - Sydney Rosen
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA; Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
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Evans D, van Rensburg C, Govathson C, Ivanova O, Rieß F, Siroka A, Sillah AK, Ntinginya NE, Jani I, Sathar F, Rosen S, Sanne I, Rachow A, Lönnroth K. Adaptation of WHO's generic tuberculosis patient cost instrument for a longitudinal study in Africa. Glob Health Action 2021; 14:1865625. [PMID: 33491593 PMCID: PMC7850383 DOI: 10.1080/16549716.2020.1865625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
The WHO developed a generic 'TB patient cost survey' tool and a standardized approach to assess the direct and indirect costs of TB incurred by patients and their households, estimate the proportion of patients experiencing catastrophic costs, and measure the impact of interventions to reduce patient costs. While the generic tool is a facility-based cross-sectional survey, this standardized approach needs to be adapted for longitudinal studies. A longitudinal approach may overcome some of the limitations of a cross-sectional design and estimate the economic burden of TB more precisely. We describe the process of creating a longitudinal instrument and its application to the TB Sequel study, an ongoing multi-country, multi-center observational cohort study. We adapted the cross-sectional WHO generic TB patient cost survey instrument for the longitudinal study design of TB Sequel and the local context in each study country (South Africa, Mozambique, Tanzania, and The Gambia). The generic instrument was adapted for use at enrollment (start of TB treatment; Day 0) and at 2, 6, 12 and 24 months after enrollment, time points intended to capture costs incurred for diagnosis, during treatment, at the end of treatment, and during long-term follow-up once treatment has been completed. These time points make the adapted version suitable for use in patients with either drug-sensitive or drug-resistant TB. Using the adapted tool provides the opportunity to repeat measures and make comparisons over time, describe changes that extend beyond treatment completion, and link cost survey data to treatment outcomes and post-TB sequelae. Trial registration: ClinicalTrials.gov: NCT032516 August 1196, 2017. Abbreviations: DOTS: Directly observed treatment, short-course; DR-TB: Drug-resistant tuberculosis; MDR-TB: Multi-drug resistant tuberculosis; NTP: National Tuberculosis Programme; TB: Tuberculosis; USD: United States Dollar; WHO: World Health Organization.
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Affiliation(s)
- Denise Evans
- 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
| | - Craig van Rensburg
- 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
| | - Caroline Govathson
- 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
| | - Olena Ivanova
- Division of Infectious Diseases & Tropical Medicine, Klinikum of the University of Munich , Munich, Germany
| | - Friedrich Rieß
- Division of Infectious Diseases & Tropical Medicine, Klinikum of the University of Munich , Munich, Germany
| | - Andrew Siroka
- Health Financing Department, World Health Organization , Geneva, Switzerland
| | - Abdou K Sillah
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine , Fajara, The Gambia
| | | | - Ilesh Jani
- Instituto Nacional de Sauúde (INS) , Maputo, Mozambique
| | | | - 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 School of Public Health , Boston, MA, USA
| | - Ian Sanne
- 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.,Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - Andrea Rachow
- Division of Infectious Diseases & Tropical Medicine, Klinikum of the University of Munich , Munich, Germany
| | - Knut Lönnroth
- Department of Global Public Health, Karolinska Institute , Stockholm, Sweden
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Moyal L, Arkin C, Gorovitz-Haris B, Querfeld C, Rosen S, Knaneh J, Amitay-Laish I, Prag-Naveh H, Jacob-Hirsch J, Hodak E. Mycosis fungoides-derived exosomes promote cell motility and are enriched with microRNA-155 and microRNA-1246, and their plasma-cell-free expression may serve as a potential biomarker for disease burden. Br J Dermatol 2021; 185:999-1012. [PMID: 34053079 DOI: 10.1111/bjd.20519] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Literature regarding exosomes as mediators in intercellular communication to promote progression in mycosis fungoides (MF) is lacking. OBJECTIVES To characterize MF-derived exosomes and their involvement in the disease. METHODS Exosomes were isolated by ultracentrifugation from cutaneous T-cell lymphoma (CTCL) cell lines, and from plasma of patients with MF and controls (healthy individuals). Exosomes were confirmed by electron microscopy, NanoSight and CD81 staining. Cell-line exosomes were profiled for microRNA array. Exosomal microRNA (exomiRNA) expression and uptake, and plasma-cell-free microRNA (cfmiRNA) were analysed by reverse-transcriptase quantitative polymerase chain reaction. Exosome uptake was monitored by fluorescent labelling and CD81 immunostaining. Migration was analysed by transwell migration assay. RESULTS MyLa- and MJ-derived exosomes had a distinctive microRNA signature with abundant microRNA (miR)-155 and miR-1246. Both microRNAs were delivered into target cells, but only exomiR-155 was tested, demonstrating a migratory effect on target cells. Plasma levels of cfmiR-1246 were significantly highest in combined plaque/tumour MF, followed by patch MF, and were lowest in controls (plaque/tumour > patch > healthy), while cfmiR-155 was upregulated only in plaque/tumour MF vs. controls. Specifically, exomiR-1246 (and not exomiR-155) was higher in plasma of plaque/tumour MF than in healthy controls. Plasma exosomes from MF but not from controls increased cell migration. CONCLUSIONS Our findings show that MF-derived exosomes promote cell motility and are enriched with miR-155, a well-known microRNA in MF, and miR-1246, not previously reported in MF. Based on their plasma expression we suggest that they may serve as potential biomarkers for tumour burden.
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Affiliation(s)
- L Moyal
- Laboratory for Molecular Dermatology, Felsenstein Medical Research Center, Petach Tikva, 4941492, Israel.,Division of Dermatology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, 4941492, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - C Arkin
- Laboratory for Molecular Dermatology, Felsenstein Medical Research Center, Petach Tikva, 4941492, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - B Gorovitz-Haris
- Laboratory for Molecular Dermatology, Felsenstein Medical Research Center, Petach Tikva, 4941492, Israel.,Division of Dermatology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, 4941492, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - C Querfeld
- Department of Pathology & Division of Dermatology, City of Hope, and Beckman Research Institute, Duarte, CA, USA
| | - S Rosen
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope Comprehensive Cancer Center, Duarte, CA, USA.,Beckman Research Institute, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - J Knaneh
- Laboratory for Molecular Dermatology, Felsenstein Medical Research Center, Petach Tikva, 4941492, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - I Amitay-Laish
- Division of Dermatology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, 4941492, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - H Prag-Naveh
- Division of Dermatology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, 4941492, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - J Jacob-Hirsch
- Cancer Research Center, Sheba Medical Center, Tel Hashomer, Israel
| | - E Hodak
- Laboratory for Molecular Dermatology, Felsenstein Medical Research Center, Petach Tikva, 4941492, Israel.,Division of Dermatology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, 4941492, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
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Martinez X, Zain J, Abdulla F, Rosen S, Querfeld C. 355 Significant disparities in prognosis and survival in Black cutaneous lymphoma patients emphasize the need for more focused study and care. J Invest Dermatol 2021. [DOI: 10.1016/j.jid.2021.02.377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ehrenkranz P, Rosen S, Boulle A, Eaton JW, Ford N, Fox MP, Grimsrud A, Rice BD, Sikazwe I, Holmes CB. The revolving door of HIV care: Revising the service delivery cascade to achieve the UNAIDS 95-95-95 goals. PLoS Med 2021; 18:e1003651. [PMID: 34029346 PMCID: PMC8186775 DOI: 10.1371/journal.pmed.1003651] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 06/08/2021] [Indexed: 01/01/2023] Open
Abstract
Peter Ehrenkranz and co-authors present a cyclical cascade of care for people with HIV infection, aiming to facilitate assessment of outcomes.
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Affiliation(s)
- Peter Ehrenkranz
- Global Health, Bill & Melinda Gates Foundation, Seattle, WA, United States of America
- * E-mail:
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, 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
| | - Andrew Boulle
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Jeffrey W. Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Nathan Ford
- HIV & Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, 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, MA, United States of America
| | - Anna Grimsrud
- HIV Programmes & Advocacy Department, International AIDS Society, Cape Town, South Africa
| | - Brian D. Rice
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Charles B. Holmes
- Center for Innovation in Global Health, Georgetown University, Washington, DC, United States of America
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Masuku SD, Berhanu R, Van Rensburg C, Ndjeka N, Rosen S, Long L, Evans D, Nichols BE. Managing multidrug-resistant tuberculosis in South Africa: a budget impact analysis. Int J Tuberc Lung Dis 2021; 24:376-382. [PMID: 32317060 DOI: 10.5588/ijtld.19.0409] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: In South Africa prior to 2016, the standard treatment regimen for multidrug- and rifampicin-resistant tuberculosis (MDR/RR-TB) was 24 months long and required daily injectable aminoglycoside (IA) treatment during the first 6 months. Recent evidence supports the replacement of IA with well-tolerated oral bedaquiline (BDQ) and a shortened 9-12 month regimen.DESIGN: Using a Markov model, we analyzed the 5-year budgetary impact and cost per successful treatment outcome of four regimens: 1) IA long-course, 2) oral long-course, 3) IA short-course, and 4) oral short-course. We used the South African MDR/RR-TB case register (2013-2015) to assess treatment outcomes for the then-standard IA long-course. Data on the improvement in outcomes for BDQ-based regimens were based on the literature. Costs were estimated from the provider perspective using costs incurred to provide decentralized treatment for MDR-TB at a Johannesburg hospital.RESULTS: Based on our analysis, by 2023, the cost/successful outcome for the four regimens was respectively 1) US$7374, 2) US$7860, 3) US$5149, and 4) US$4922. The annual total cost of each regimen was US$37 million, US$43 million, US$26 million, and US$28 million.CONCLUSION: Despite the high cost of BDQ, a BDQ-based shortened regimen for the treatment of MDR/RR-TB will result in improved treatment outcomes and cost savings for South Africa.
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Affiliation(s)
- S D Masuku
- 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
| | - R Berhanu
- 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, MA, USA
| | - C Van Rensburg
- 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
| | - N Ndjeka
- National Department of Health, Pretoria, South Africa
| | - S 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, MA, USA
| | - L Long
- 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, MA, USA
| | - D Evans
- 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
| | - B E Nichols
- 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, MA, USA
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Nichols BE, Cele R, Lekodeba N, Tukei B, Ngorima-Mabhena N, Tiam A, Maotoe T, Sejana MV, Faturiyele IO, Chasela C, Rosen S, Fatti G. Economic evaluation of differentiated service delivery models for HIV treatment in Lesotho: costs to providers and patients. J Int AIDS Soc 2021; 24:e25692. [PMID: 33838012 PMCID: PMC8035675 DOI: 10.1002/jia2.25692] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 06/26/2020] [Revised: 01/25/2021] [Accepted: 02/23/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Lesotho, the country with the second-highest HIV/AIDS prevalence (23.6%) in the world, has made considerable progress towards achieving the "95-95-95" UNAIDS targets, but recent success in improving treatment access to all known HIV positive individuals has severely strained existing healthcare infrastructure, financial and human resources. Lesotho also faces the challenge of a largely rural population who incur a significant time and financial burden to visit healthcare facilities. Using data from a cluster-randomized non-inferiority trial conducted between August 2017 and July 2019, we evaluated costs to providers and costs to patients of community-based differentiated models of multi-month delivery of antiretroviral therapy (ART) in Lesotho. METHODS The trial of multi-month dispensing compared 12-month retention in care among three arms: conventional care, which required quarterly facility visits and ART dispensation (3MF); three-month community adherence groups (CAGs) (3MC) and six-month community ART distribution (6MCD). We first estimated the average total annual cost of providing HIV care and treatment followed by the total cost per patient retained 12 months after entry for each arm, using resource utilization data from the trial and local unit costs. We then estimated the average annual cost to patients in each arm with self-reported questionnaire data. RESULTS The average total annual cost of providing HIV care and treatment per patient was the highest in the 3MF arm ($122.28, standard deviation [SD] $23.91), followed by 3MC ($114.20, SD $23.03) and the 6MCD arm ($112.58, SD $21.44). Per patient retained in care, the average provider cost was $125.99 (SD $24.64) in the 3MF arm and 6% to 8% less for the other two arms ($118.38, SD $23.87 and $118.83, SD $22.63 for the 3MC and 6MCD respectively). There was a large reduction in patient costs for both differentiated service delivery arms: from $44.42 (SD $12.06) annually in the 3MF arm to $16.34 (SD $5.11) annually in the 3MC (63% reduction) and $18.77 (SD $8.31) annually in 6MCD arm (58% reduction). CONCLUSIONS Community-based, multi-month models of ART in Lesotho are likely to produce small cost savings to treatment providers and large savings to patients in Lesotho. Patient cost savings may support long-term adherence and retention in care.
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Affiliation(s)
- Brooke E Nichols
- Department of Global Health, School of Public Health, Boston University, Boston, MA, 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
| | - Refiloe Cele
- 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
| | - Nkgomeleng Lekodeba
- 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
| | - Betty Tukei
- Right to Care, Centurion, South Africa.,EQUIP Lesotho, Maseru, Lesotho
| | | | | | | | | | - Iyiola O Faturiyele
- Department of Epidemiology & Biostatistics, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Charles Chasela
- Right to Care, Centurion, South Africa.,USAID, Washington DC, USA
| | - Sydney Rosen
- Department of Global Health, School of Public Health, Boston University, Boston, MA, 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
| | - Geoffrey Fatti
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Nichols BE, Cele R, Jamieson L, Long LC, Siwale Z, Banda P, Moyo C, Rosen S. Community-based delivery of HIV treatment in Zambia: costs and outcomes. AIDS 2021; 35:299-306. [PMID: 33170578 PMCID: PMC7810408 DOI: 10.1097/qad.0000000000002737] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/21/2020] [Accepted: 09/02/2020] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The aim is to determine the total annual cost per patient treated and total cost per patient retained on antiretroviral therapy in Zambia in conventional care in facilities and across community-based differentiated service delivery (DSD) models. DESIGN Economic evaluation was conducted using retrospective electronic record review.Twenty healthcare facilities (13 with DSD models and 7 as comparison sites) in six of Zambia's 10 provinces were considered. METHODS All individuals on antiretroviral therapy (ART) >18 years old at the study sites were enrolled in a DSD model or conventional care by site type, respectively, with at least 12 months of follow-up data. Accessing care through DSD models [community adherence groups (CAGs), urban adherence groups (UAGs), home ART delivery and care, and mobile ART services] or facility-based conventional care with 3-monthly visits. Total annual cost per patient treated and the annual cost per patient retained in care 12 months after model enrolment. Retention in care was defined as attending a clinic visit at 12 months ± 3 months. RESULTS The DSD models assessed cost more per patient/year than conventional care. Costs ranged from an annual $116 to $199 for the DSD models, compared with $100 for conventional care. CAGs and UAGs increased retention by 2 and 14%, respectively. All DSD models cost more per patient retained at 12 months than conventional care. The CAG had the lowest cost/patient retained for DSD models ($140-157). CONCLUSIONS Although they achieve equal or improved retention in care, out-of-facility models of ART were more expensive than conventional care.
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Affiliation(s)
- Brooke E. Nichols
- Department of Global Health, School of Public Health, 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
| | - Refiloe Cele
- 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
| | - Lise Jamieson
- 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
| | - Lawrence C. Long
- Department of Global Health, School of Public Health, 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
| | | | | | | | - Sydney Rosen
- Department of Global Health, School of Public Health, 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
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Min Thaung Y, Chasela CS, Chew KW, Minior T, Lwin AA, Sein YY, Drame N, Marange F, van der Horst C, Thwin HT, Freiman MJ, Gandhi MM, Bijl M, Wose Kinge C, Rosen S, Thura S, Mohamed S, Xulu T, Naing AY, Barralon M, Cavenaugh C, Kyi KP, Sanne I. Treatment outcomes and costs of a simplified antiviral treatment strategy for hepatitis C among monoinfected and HIV and/or hepatitis B virus-co-infected patients in Myanmar. J Viral Hepat 2021; 28:147-158. [PMID: 32935438 PMCID: PMC7746582 DOI: 10.1111/jvh.13405] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/01/2020] [Indexed: 12/13/2022]
Abstract
Access to hepatitis C virus (HCV) testing and treatment is limited in Myanmar. We assessed an integrated HIV and viral hepatitis testing and HCV treatment strategy. Sofosbuvir/velpatasvir (SOF/VEL) ± weight-based ribavirin for 12 weeks was provided at three treatment sites in Myanmar and sustained virologic response (SVR) assessed at 12 weeks after treatment. Participants co-infected with HBV were treated concurrently with tenofovir. Cost estimates in 2018 USD were made at Yangon and Mandalay using standard micro-costing methods. 803 participants initiated SOF/VEL; 4.8% were lost to follow-up. SVR was achieved in 680/803 (84.6%) by intention-to-treat analysis. SVR amongst people who inject drugs (PWID) was 79.7% (381/497), but 92.5% among PWID on opioid substitution therapy (OST) (74/80), and 97.4% among non-PWID (298/306). Utilizing data from 492 participants, of whom 93% achieved SVR, the estimated average cost of treatment per patient initiated was $1030 (of which 54% were medication costs), with a production cost per successful outcome (SVR) of $1109 and real-world estimate of $1250. High SVR rates were achieved for non-PWID and PWID on OST. However, the estimated average cost of the intervention (under the assumption of no genotype testing and reduced real-world effectiveness) of $1250/patient is unaffordable for a national elimination strategy. Reductions in the cost of antivirals and linkage to social and behavioural health services including substance use disorder treatment to increase retention and adherence to treatment are critical to HCV elimination in this population.
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Affiliation(s)
| | - Charles S. Chasela
- Right to Care/EQUIP HealthPretoriaSouth Africa,Department of Epidemiology and BiostatisticsSchool of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Kara W. Chew
- David Geffen School of Medicine at UCLALos AngelesCAUSA
| | - Thomas Minior
- U.S. Agency for International DevelopmentWashingtonDCUSA
| | - Aye A. Lwin
- Advanced Biological Laboratories (ABL) SARue des jardiniersLuxembourg
| | | | - Ndeye Drame
- School of Public HealthBoston UniversityBostonMAUSA
| | | | | | | | | | | | - Murdo Bijl
- Asian Harm Reduction NetworkKachinMyanmar
| | - Constance Wose Kinge
- Division of Epidemiology and SurveillanceNational Institute for Occupational HealthJohannesburgSouth Africa,Hepatitis Virus Diversity Research UnitDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sydney Rosen
- School of Public HealthBoston UniversityBostonMAUSA,Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Si Thura
- Community Partners InternationalYangonMyanmar
| | - Sofiane Mohamed
- Advanced Biological Laboratories (ABL) SARue des jardiniersLuxembourg
| | | | | | - Matthiue Barralon
- Advanced Biological Laboratories (ABL) SARue des jardiniersLuxembourg
| | | | | | - Ian Sanne
- Right to Care/EQUIP HealthPretoriaSouth Africa,School of Public HealthBoston UniversityBostonMAUSA,Department of MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburg,Immunology Research Division, Department of Medical ResearchMinistry of Health and SportsYangonMyanmar
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Long L, Kuchukhidze S, Pascoe S, Nichols BE, Fox MP, Cele R, Govathson C, Huber AN, Flynn D, Rosen S. Retention in care and viral suppression in differentiated service delivery models for HIV treatment delivery in sub-Saharan Africa: a rapid systematic review. J Int AIDS Soc 2020; 23:e25640. [PMID: 33247517 PMCID: PMC7696000 DOI: 10.1002/jia2.25640] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 09/16/2020] [Accepted: 10/22/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Differentiated service delivery (DSD) models for antiretroviral treatment (ART) for HIV are being scaled up in the expectation that they will better meet the needs of patients, improve the quality and efficiency of treatment delivery and reduce costs while maintaining at least equivalent clinical outcomes. We reviewed the recent literature on DSD models to describe what is known about clinical outcomes. METHODS We conducted a rapid systematic review of peer-reviewed publications in PubMed, Embase and the Web of Science and major international conference abstracts that reported outcomes of DSD models for the provision of ART in sub-Saharan Africa from January 1, 2016 to September 12, 2019. Sources reporting standard clinical HIV treatment metrics, primarily retention in care and viral load suppression, were reviewed and categorized by DSD model and source quality assessed. RESULTS AND DISCUSSION Twenty-nine papers and abstracts describing 37 DSD models and reporting 52 discrete outcomes met search inclusion criteria. Of the 37 models, 7 (19%) were facility-based individual models, 12 (32%) out-of-facility-based individual models, 5 (14%) client-led groups and 13 (35%) healthcare worker-led groups. Retention was reported for 29 (78%) of the models and viral suppression for 22 (59%). Where a comparison with conventional care was provided, retention in most DSD models was within 5% of that for conventional care; where no comparison was provided, retention generally exceeded 80% (range 47% to 100%). For viral suppression, all those with a comparison to conventional care reported a small increase in suppression in the DSD model; reported suppression exceeded 90% (range 77% to 98%) in 11/21 models. Analysis was limited by the extensive heterogeneity of study designs, outcomes, models and populations. Most sources did not provide comparisons with conventional care, and metrics for assessing outcomes varied widely and were in many cases poorly defined. CONCLUSIONS Existing evidence on the clinical outcomes of DSD models for HIV treatment in sub-Saharan Africa is limited in both quantity and quality but suggests that retention in care and viral suppression are roughly equivalent to those in conventional models of care.
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Affiliation(s)
- Lawrence Long
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Salome Kuchukhidze
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Brooke E Nichols
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Matthew P Fox
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Refiloe Cele
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Caroline Govathson
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Amy N Huber
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - David Flynn
- Alumni Medical LibraryBoston UniversityBostonMAUSA
| | - Sydney Rosen
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
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Vallota-Eastman A, Arrington EC, Meeken S, Roux S, Dasari K, Rosen S, Miller JF, Valentine DL, Paul BG. Role of diversity-generating retroelements for regulatory pathway tuning in cyanobacteria. BMC Genomics 2020; 21:664. [PMID: 32977771 PMCID: PMC7517822 DOI: 10.1186/s12864-020-07052-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 06/15/2020] [Accepted: 09/03/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Cyanobacteria maintain extensive repertoires of regulatory genes that are vital for adaptation to environmental stress. Some cyanobacterial genomes have been noted to encode diversity-generating retroelements (DGRs), which promote protein hypervariation through localized retrohoming and codon rewriting in target genes. Past research has shown DGRs to mainly diversify proteins involved in cell-cell attachment or viral-host attachment within viral, bacterial, and archaeal lineages. However, these elements may be critical in driving variation for proteins involved in other core cellular processes. RESULTS Members of 31 cyanobacterial genera encode at least one DGR, and together, their retroelements form a monophyletic clade of closely-related reverse transcriptases. This class of retroelements diversifies target proteins with unique domain architectures: modular ligand-binding domains often paired with a second domain that is linked to signal response or regulation. Comparative analysis indicates recent intragenomic duplication of DGR targets as paralogs, but also apparent intergenomic exchange of DGR components. The prevalence of DGRs and the paralogs of their targets is disproportionately high among colonial and filamentous strains of cyanobacteria. CONCLUSION We find that colonial and filamentous cyanobacteria have recruited DGRs to optimize a ligand-binding module for apparent function in signal response or regulation. These represent a unique class of hypervariable proteins, which might offer cyanobacteria a form of plasticity to adapt to environmental stress. This analysis supports the hypothesis that DGR-driven mutation modulates signaling and regulatory networks in cyanobacteria, suggestive of a new framework for the utility of localized genetic hypervariation.
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Affiliation(s)
- Alec Vallota-Eastman
- Interdepartmental Graduate Program for Marine Science, University of California Santa Barbara, Santa Barbara, CA, 93106, USA
| | - Eleanor C Arrington
- Interdepartmental Graduate Program for Marine Science, University of California Santa Barbara, Santa Barbara, CA, 93106, USA
| | - Siobhan Meeken
- Josephine Bay Paul Center, Marine Biological Laboratory, 7 MBL St, Woods Hole, MA, 02543, USA
| | - Simon Roux
- DOE Joint Genome Institute, Berkeley, CA, 94720, USA
| | - Krishna Dasari
- Research Mentorship Program (RMP), University of California, Santa Barbara, CA, 93106, USA
| | - Sydney Rosen
- Research Mentorship Program (RMP), University of California, Santa Barbara, CA, 93106, USA
| | - Jeff F Miller
- Microbiology, Immunology and Molecular Genetics, University of California, Los Angeles, CA, 90095, USA
- California NanoSystems Institute, University of California, Los Angeles, CA, 90095, USA
| | - David L Valentine
- Marine Science Institute, University of California Santa Barbara, Santa Barbara, CA, 93106, USA
- Department of Earth Science, University of California Santa Barbara, Santa Barbara, CA, 93106, USA
| | - Blair G Paul
- Josephine Bay Paul Center, Marine Biological Laboratory, 7 MBL St, Woods Hole, MA, 02543, USA.
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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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Nichols BE, Offorjebe OA, Cele R, Shaba F, Balakasi K, Chivwara M, Hoffman RM, Long LC, Rosen S, Dovel K. Economic evaluation of facility-based HIV self-testing among adult outpatients in Malawi. J Int AIDS Soc 2020; 23:e25612. [PMID: 32909387 PMCID: PMC7507468 DOI: 10.1002/jia2.25612] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/24/2020] [Accepted: 08/02/2020] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION HIV self-testing (HIVST) in outpatient departments (OPD) is a promising strategy for HIV testing in Malawi, given high OPD patient volumes and substantial wait times. To evaluate the relative cost and expected impact of facility-based HIVST (FB-HIVST) at OPDs in Malawi for increasing HIV status awareness, we conducted an economic evaluation of an HIVST cluster-randomized controlled trial. METHODS A cluster-randomized trial was conducted at 15 sites in Malawi from September 2017 to February 2018 with three arms: 1) Standard provider-initiated-testing-and-counselling (PITC); 2) Optimized PITC (additional provider training and job-aids) and 3) FB-HIVST (HIVST demonstration, distribution and kit use in OPD, private kit interpretation and optional HIV counselling). The total production cost per newly identified positive and per person newly initiated on ART were calculated by study arm. These were calculated as the total cost of testing everyone divided by the number of newly identified positives; and the total cost of testing everyone divided by the number of those initiated on ART. Cost-outcomes were calculated under three cost scenarios: (1) full study costs, (2) routine implementation costs and (3) routine implementation + reduced cost for HIVST kits. RESULTS The average cost per person newly diagnosed in the full study cost scenario was $101, $156 and $189, and cost per person initiated on ART was $121, $156 and $279 for Standard PITC, Optimized PITC and FB-HIVST respectively. In the routine implementation cost scenario, the average cost per person newly diagnosed was reduced to $83, and $93, and cost per person initiated on ART to $83, and $137 for Optimized PITC and FB-HIVST respectively. In the negotiated HIVST cost scenario, the average cost per person newly diagnosed was reduced to $55 and cost per person newly initiated on ART reduced to $81 in the FB-HIVST arm. CONCLUSIONS While the cost per new ART initiation through FB-HIVST was higher than Standard PITC, FB-HIVST could become cost-saving compared to PITC if the cost of kits is reduced or if treatment linkage rate were increased in the FB-HIVST arm. For high volume OPDs, HIVST may increase facility capacity and increase the number of newly diagnosed positives.
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Affiliation(s)
- Brooke E Nichols
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - O Agatha Offorjebe
- David Geffen School of MedicineUniversity of California Los AngelesLos AngelesCAUSA
- Charles R. Drew University of Medicine and ScienceLos AngelesCAUSA
| | - Refiloe Cele
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | | | | | - Risa M Hoffman
- Partners in HopeLilongweMalawi
- Division of Infectious DiseasesDepartment of MedicineUniversity of California Los AngelesLos AngelesCAUSA
| | - Lawrence C Long
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sydney Rosen
- Department of Global HealthSchool of Public HealthBoston UniversityBostonMAUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Kathryn Dovel
- Partners in HopeLilongweMalawi
- Division of Infectious DiseasesDepartment of MedicineUniversity of California Los AngelesLos AngelesCAUSA
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Maskew M, Brennan AT, Fox MP, Vezi L, Venter WDF, Ehrenkranz P, Rosen S. A clinical algorithm for same-day HIV treatment initiation in settings with high TB symptom prevalence in South Africa: The SLATE II individually randomized clinical trial. PLoS Med 2020; 17:e1003226. [PMID: 32853271 PMCID: PMC7451542 DOI: 10.1371/journal.pmed.1003226] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/22/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Many countries encourage same-day initiation of antiretroviral therapy (ART), but evidence on eligibility for same-day initiation, how best to implement it, and its impact on outcomes remains scarce. Building on the Simplified Algorithm for Treatment Eligibility (SLATE) I trial, in which nearly half of participants were ineligible for same-day initiation mainly because of TB symptoms, the study evaluated the revised SLATE II algorithm, which allowed same-day initiation for patients with mild TB symptoms and other less serious reasons for delay. METHODS AND FINDINGS SLATE II was a nonblinded, 1:1 individually randomized pragmatic trial at three primary healthcare clinics in Johannesburg, South Africa. It randomized adult patients presenting for an HIV test or any HIV care but not yet on ART. Intervention arm patients were assessed with a symptom screen, medical history, brief physical examination, and readiness questionnaire to distinguish between patients eligible for immediate ART dispensing and those requiring further care before initiation. Standard arm patients received usual care. Follow-up was by review of routine clinic records. Primary outcomes were (1) ART initiation in ≤7 days and (2) ART initiation in ≤28 days and retention in care at 8 months (composite outcome). From 14 March to 18 September 2018, 593 adult HIV+, nonpregnant patients were enrolled (median interquartile range [IQR] age 35 [29-43]; 63% (n = 373) female; median CD4 count 293 [133-487]). Half of study patients (n = 295) presented with TB symptoms, whereas only 13 (4%) standard arm and 7 (2%) intervention arm patients tested positive for TB disease. Among 140 intervention arm patients with TB symptoms, 72% were eligible for same-day initiation. Initiation was higher in the intervention (n = 296) versus standard arm (n = 297) by 7 days (91% versus 68%; risk difference [RD] 23% [95% confidence interval (CI) 17%-29%]) and 28 days (94% versus 82%; RD 12% [7%-17%]) after enrollment. In total, 87% of intervention and 38% of standard arm patients initiated on the same day. By 8 months after study enrollment, 74% (220/296) of intervention and 59% (175/297) of standard arm patients had both initiated ART in ≤28 days and been retained in care (RD 15% [7%-23%]). Among the 41% of participants with viral load results available, suppression was 90% in the standard arm and 92% in the intervention arm among patients initiated in ≤28 days. No ART-associated adverse events were reported after initiation; two intervention and four standard arm patients were reported to have died during passive follow-up. Limitations of the study included limited geographic generalizability, exclusion of patients too sick to consent, fluctuations in procedures in the standard arm over the course of the study, high fidelity to the trial protocol by study staff, and the possibility of overestimating loss to follow-up due to data constraints. CONCLUSIONS More than 85% of patients presenting for HIV testing or care, including those newly diagnosed, were eligible and ready for same-day initiation under the SLATE II algorithm. The algorithm increased initiation within 7 days without appearing to compromise retention and viral suppression at 8 months, offering a practical and acceptable approach that can be widely and immediately utilized by existing providers. TRIAL REGISTRATION Clinicaltrials.gov NCT03315013, registered 19 October 2017. First participant enrolled 14 March 2018.
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Affiliation(s)
- 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
- * E-mail:
| | - Alana T. Brennan
- 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 School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Matthew P. Fox
- 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 School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - 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
| | - Willem D. F. Venter
- Ezintsha, 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
| | - Peter Ehrenkranz
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - 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 School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
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