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Warzywoda S, Dyda A, Fitzgerald L, Mullens A, Debattista J, Durham J, Gu Z, Wenham K, Ariana A, Gilks CF, Bell SFE, Dean JA. A cross-sectional investigation of the factors associated with awareness of PEP and PrEP among Queensland university students. Aust N Z J Public Health 2024; 48:100136. [PMID: 38432178 DOI: 10.1016/j.anzjph.2024.100136] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 01/11/2024] [Accepted: 02/08/2024] [Indexed: 03/05/2024] Open
Abstract
OBJECTIVE University creates unique social environments for many young people that can result in behaviour changes that can impact sexual health-related risks and facilitate transmission of HIV. Little is known about HIV knowledge, risk, and awareness of pre-exposure prophylaxis/post-exposure prophylaxis (PrEP/PEP) among Australian university students. METHODS A 2019 online survey distributed through Queensland universities, using active recruitment/snowball sampling. Descriptive and logistical regression analysis investigated HIV knowledge/risk and PrEP/PEP awareness. RESULTS Of the 4,291 responses, 60.4% were 20-29 years old, 57.0% identified as heterosexual, and 31.8% were born-overseas. Mean HIV knowledge score was 9.8/12. HIV risk scores were higher among men-who-have-sex-with-men (MSM) (mean=5.2/40) compared to all other sexual behaviours (mean=3.1/40). Logistic regression indicated PrEP and PEP awareness was associated with older age (p<0.05), being non-binary/gender-diverse (p<0.05), and MSM (p<0.05). Lower odds of PrEP awareness were associated with international student status (p<0.05). CONCLUSION This study highlights the need for future health promotion targeting younger Australians at risk of HIV to increase uptake of PrEP/PEP, particularly among overseas-born young people and those ineligible for appropriate health care in Australia. IMPLICATIONS FOR PUBLIC HEALTH Addressing these gaps will improve sexual health outcomes for young Australians at risk of HIV and work towards virtual elimination of HIV transmission in Australia.
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Affiliation(s)
- Sarah Warzywoda
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
| | - Amalie Dyda
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Lisa Fitzgerald
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Amy Mullens
- School of Psychology and Wellbeing, Centre for Health Research, Institute for Resilient Regions, University of Southern Queensland, Australia
| | - Joseph Debattista
- Metro North Public Health Unit, Metro North Hospital and Health Service, Australia
| | - Jo Durham
- School of Public Health and Social Work, Queensland University of Technology, Australia
| | - Zhihong Gu
- Ethnic Communities Council of Queensland, Australia
| | - Kathryn Wenham
- School of Health and Behavioural Sciences, University of the Sunshine Coast, Australia
| | - Armin Ariana
- School of Medicine and Dentistry, Griffith University, Australia
| | - Charles F Gilks
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Sara F E Bell
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Judith A Dean
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Endalamaw A, Gilks CF, Assefa Y. Socioeconomic inequality in adults undertaking HIV testing over time in Ethiopia based on data from demographic and health surveys. PLoS One 2024; 19:e0296869. [PMID: 38354195 PMCID: PMC10866500 DOI: 10.1371/journal.pone.0296869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/20/2023] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION HIV testing is the entry point to HIV prevention, care and treatment and needs continuous evaluation to understand whether all social groups have accessed services equally. Addressing disparities in HIV testing between social groups results in effective and efficient response against HIV prevention. Despite these benefits, there was no previous study on inequality and determinants over time in Ethiopia. Thus, the objective of this research was to examine socioeconomic inequality in individuals undertaking HIV testing over time, allowing for the identification of persistent and emerging determinants. METHODS Data sources for the current study were the 2011 and 2016 Ethiopian Demographic Health Surveys. The 2016 population health survey is the one that Ethiopia used to set national AIDS response strategies; there was no other recent survey with HIV/AIDS-related indicators in Ethiopia. The final sample size for the current study was 28,478 for the year 2011 and 25,542 for the year 2016. The concentration curve and Erreygers' concentration index were used to estimate socioeconomic inequality in HIV testing. Subsequently, decomposition analysis was performed to identify persistent and emerging contributors of socioeconomic inequality. Generalized linear regression model with the logit link function was employed to estimate the marginal effect, elasticity, Erreygers' concentration index (ECI), and absolute and percentage contributions of each covariate. RESULTS The concentration curve was below the line of equality over time, revealing the pro-rich inequality in HIV testing. The inequality was observed in both 2011 (ECI = 0.200) and 2016 (ECI = 0.213). A household wealth rank had the highest percentage contribution (49.2%) for inequality in HIV testing in 2011, which increased to 61.1% in 2016. Additional markers include listening to the radio (13.4% in 2011 and 12.1% in 2016), education status (8.1% in 2011 and 6.8% in 2016), and resident (-2.0% in 2011 and 6.3% in 2016). Persistent determinants of individuals undertaking HIV testing were age 20-34 years, geographic region, education status, marital status, religion, income, media exposure (listening to the radio, reading newspaper, watching television), knowledge about HIV/AIDS, and attitudes towards people living with HIV. Age between 35 and 44 years and urban residence emerged as new associated factors in 2016. CONCLUSIONS The higher HIV testing coverage was among individuals with higher socioeconomic status in Ethiopia. Socioeconomic inequality amongst individuals undertaking HIV testing was diverging over time. Household wealth rank, mass media exposure, education status, and resident took the largest share in explaining the disparity in individuals undertaking HIV testing between the lower and higher income groups. Therefore, interventions to equalise HIV testing coverage should take account of these determinants.
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Affiliation(s)
- Aklilu Endalamaw
- School of Public Health, The University of Queensland, Brisbane, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Charles F. Gilks
- School of Public Health, The University of Queensland, Brisbane, Australia
| | - Yibeltal Assefa
- School of Public Health, The University of Queensland, Brisbane, Australia
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Endalamaw A, Gilks CF, Ambaw F, Assefa Y. Socioeconomic inequality and contributors in accepting attitudes toward people living with HIV among adults in Ethiopia from 2005 to 2016: a population-based cross-sectional study. BMJ Open 2023; 13:e074694. [PMID: 38040424 PMCID: PMC10693865 DOI: 10.1136/bmjopen-2023-074694] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 11/03/2023] [Indexed: 12/03/2023] Open
Abstract
INTRODUCTION The public's accepting attitude toward people living with HIV is crucial in reducing HIV-related stigma and discrimination, increasing people's access to HIV service. This study examines the inequalities in accepting attitudes toward people living with HIV in Ethiopia from 2005 to 2016. METHODS This cross-sectional study was based on the 2005, 2011 and 2016 Ethiopian Demographic Health Surveys. A total of 17 075, 28 478 and 25 542 adults were included in the 2005, 2011 and 2016 surveys, respectively. Socioeconomic inequality was investigated using the concentration curve and Erreygers' concentration index (ECI), which is scaled from -1 (pro-poor) to +1 (pro-rich). The ECI was decomposed to identify the contributors to socioeconomic inequality using generalised linear regression with the logit link function. RESULTS Accepting attitude toward people living with HIV was 17.9% (95% CI: 16.6%, 19.3%) in 2005, which increased to 33.5% (95% CI: 31.8%, 35.3%) in 2011 and 39.6% (95% CI: 37.6%, 41.9%) in 2016. ECI was 0.342 (p<0.001), 0.436 (p<0.001) and 0.388 (p<0.001), respectively, for 2005, 2011 and 2016. The trend line illustrates socioeconomic inequality seems diverging over time, with an increasing ECI of 0.005 every year (r=0.53; p=0.642; slope=0.005). CONCLUSIONS The current study found that there was pro-rich inequality from 2005 to 2016. People with higher socioeconomic status had a better attitude toward people living with HIV. Comprehensive knowledge about HIV/AIDS, education status, residence, and access to electronic and paper-based media, as well as HIV testing, contribute to a better accepting attitude toward people living with HIV. It is of utmost importance for the country to enhance accepting attitude toward people living with HIV to reduce stigma and discrimination. This requires whole-system response according to the primary healthcare approach toward ending the epidemic of HIV/AIDS in the country.
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Affiliation(s)
- Aklilu Endalamaw
- School of Public Health, the University of Queensland, Brisbane, Queensland, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Amhara, Ethiopia
| | - Charles F Gilks
- School of Public Health, the University of Queensland, Brisbane, Queensland, Australia
| | - Fentie Ambaw
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Amhara, Ethiopia
| | - Yibeltal Assefa
- School of Public Health, the University of Queensland, Brisbane, Queensland, Australia
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Endalamaw A, Gilks CF, Ambaw F, Khatri RB, Assefa Y. Socioeconomic inequality in knowledge about HIV/AIDS over time in Ethiopia: A population-based study. PLOS Glob Public Health 2023; 3:e0002484. [PMID: 37906534 PMCID: PMC10617701 DOI: 10.1371/journal.pgph.0002484] [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: 06/05/2023] [Accepted: 09/23/2023] [Indexed: 11/02/2023]
Abstract
Socioeconomic inequality in comprehensive knowledge about HIV/AIDS can hinder progress towards ending the epidemic threat of this disease. To address the knowledge gap, it is essential to investigate inequality in HIV/AIDS services. This study aimed to investigate socioeconomic inequality, identify contributors, and analyze the trends in inequality in comprehensive knowledge about HIV/AIDS among adults in Ethiopia. A cross-sectional study was conducted using 2005, 2011, and 2016 population-based health survey data. The sample size was 18,818 in 2005, 29,264 in 2011, and 27,261 in 2016. Socioeconomic inequality in comprehensive knowledge about HIV/AIDS was quantified by using a concentration curve and index. Subsequently, the decomposition of the concentration index was conducted using generalised linear regression with a logit link function to quantify covariates' contribution to wealth-based inequality. The Erreygers' concentration index was 0.251, 0.239, and 0.201 in 2005, 2011, and 2016, respectively. Watching television (24.2%), household wealth rank (21.4%), ever having been tested for HIV (15.3%), and education status (14.3%) took the significant share of socioeconomic inequality. The percentage contribution of watching television increased from 4.3% in 2005 to 24.2% in 2016. The household wealth rank contribution increased from 14.6% in 2005 to 21.38% in 2016. Education status contribution decreased from 16.2% to 14.3%. The percentage contribution of listening to the radio decreased from 16.9% in 2005 to -2.4% in 2016. The percentage contribution of residence decreased from 7.8% in 2005 to -0.5% in 2016. This study shows comprehensive knowledge about HIV/AIDS was concentrated among individuals with a higher socioeconomic status. Socioeconomic-related inequality in comprehensive knowledge about HIV/AIDS is woven deeply in Ethiopia, though this disparity has been decreased minimally. A combination of individual and public health approaches entangled in a societal system are crucial remedies for the general population and disadvantaged groups. This requires comprehensive interventions according to the primary health care approach.
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Affiliation(s)
- Aklilu Endalamaw
- School of Public Health, The University of Queensland, Brisbane, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Charles F. Gilks
- School of Public Health, The University of Queensland, Brisbane, Australia
| | - Fentie Ambaw
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Resham B. Khatri
- School of Public Health, The University of Queensland, Brisbane, Australia
- Health Social Science and Development Research Institute, Kathmandu, Nepal
| | - Yibeltal Assefa
- School of Public Health, The University of Queensland, Brisbane, Australia
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Zhu Y, Almeida FJ, Baillie JK, Bowen AC, Britton PN, Brizuela ME, Buonsenso D, Burgner D, Chew KY, Chokephaibulkit K, Cohen C, Cormier SA, Crawford N, Curtis N, Farias CGA, Gilks CF, von Gottberg A, Hamer D, Jarovsky D, Jassat W, Jesus AR, Kemp LS, Khumcha B, McCallum G, Miller JE, Morello R, Munro APS, Openshaw PJM, Padmanabhan S, Phongsamart W, Reubenson G, Ritz N, Rodrigues F, Rungmaitree S, Russell F, Sáfadi MAP, Saner C, Semple MG, Prado da Silva DGB, de Sousa LMM, Diogo Moço Souza M, Spann K, Walaza S, Wolter N, Xia Y, Yeoh DK, Zar HJ, Zimmermann P, Short KR. International Pediatric COVID-19 Severity Over the Course of the Pandemic. JAMA Pediatr 2023; 177:1073-1084. [PMID: 37603343 PMCID: PMC10442787 DOI: 10.1001/jamapediatrics.2023.3117] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/21/2023] [Indexed: 08/22/2023]
Abstract
Importance Multiple SARS-CoV-2 variants have emerged over the COVID-19 pandemic. The implications for COVID-19 severity in children worldwide are unclear. Objective To determine whether the dominant circulating SARS-CoV-2 variants of concern (VOCs) were associated with differences in COVID-19 severity among hospitalized children. Design, Setting, and Participants Clinical data from hospitalized children and adolescents (younger than 18 years) who were SARS-CoV-2 positive were obtained from 9 countries (Australia, Brazil, Italy, Portugal, South Africa, Switzerland, Thailand, UK, and the US) during 3 different time frames. Time frames 1 (T1), 2 (T2), and 3 (T3) were defined to represent periods of dominance by the ancestral virus, pre-Omicron VOCs, and Omicron, respectively. Age groups for analysis were younger than 6 months, 6 months to younger than 5 years, and 5 to younger than 18 years. Children with an incidental positive test result for SARS-CoV-2 were excluded. Exposures SARS-CoV-2 hospitalization during the stipulated time frame. Main Outcomes and Measures The severity of disease was assessed by admission to intensive care unit (ICU), the need for ventilatory support, or oxygen therapy. Results Among 31 785 hospitalized children and adolescents, the median age was 4 (IQR 1-12) years and 16 639 were male (52.3%). In children younger than 5 years, across successive SARS-CoV-2 waves, there was a reduction in ICU admission (T3 vs T1: risk ratio [RR], 0.56; 95% CI, 0.42-0.75 [younger than 6 months]; RR, 0.61, 95% CI; 0.47-0.79 [6 months to younger than 5 years]), but not ventilatory support or oxygen therapy. In contrast, ICU admission (T3 vs T1: RR, 0.39, 95% CI, 0.32-0.48), ventilatory support (T3 vs T1: RR, 0.37; 95% CI, 0.27-0.51), and oxygen therapy (T3 vs T1: RR, 0.47; 95% CI, 0.32-0.70) decreased across SARS-CoV-2 waves in children 5 years to younger than 18 years old. The results were consistent when data were restricted to unvaccinated children. Conclusions and Relevance This study provides valuable insights into the impact of SARS-CoV-2 VOCs on the severity of COVID-19 in hospitalized children across different age groups and countries, suggesting that while ICU admissions decreased across the pandemic in all age groups, ventilatory and oxygen support generally did not decrease over time in children aged younger than 5 years. These findings highlight the importance of considering different pediatric age groups when assessing disease severity in COVID-19.
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Affiliation(s)
- Yanshan Zhu
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Flávia Jacqueline Almeida
- Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
- Hospital Infantil Sabará, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - J Kenneth Baillie
- Baillie Gifford Pandemic Science Hub, Centre for Inflammation Research, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
- Roslin Institute, University of Edinburgh, Easter Bush, Edinburgh, United Kingdom
- MRC Human Genetics Unit, Institute of Genetics and Cancer, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Asha C Bowen
- Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Philip N Britton
- Department of Infectious Diseases and Microbiology, the Children's Hospital, Westmead, New South Wales, Australia
- Sydney Medical School and Sydney Infectious Diseases, University of Sydney, Sydney, New South Wales, Australia
| | | | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - David Burgner
- Infection and Immunity, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Pediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Department of General Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Keng Yih Chew
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Kulkanya Chokephaibulkit
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Cheryl Cohen
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephania A Cormier
- Department of Biological Sciences, Louisiana State University, Baton Rouge, Louisiana
- Pennington Biomedical Research Center, Baton Rouge, Louisiana
| | - Nigel Crawford
- Infection and Immunity, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of General Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Nigel Curtis
- Infection and Immunity, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Pediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Infectious Diseases, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Camila G A Farias
- Hospital Infantil Sabará, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Charles F Gilks
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Anne von Gottberg
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Diana Hamer
- Our Lady of the Lake Children's Hospital, Baton Rouge, Louisiana
| | - Daniel Jarovsky
- Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
- Hospital Infantil Sabará, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Waasila Jassat
- Division of the National Health Laboratory Services, National Institute of Communicable Diseases, Johannesburg, South Africa
| | - Ana Rita Jesus
- Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Lisa S Kemp
- Our Lady of the Lake Children's Hospital, Baton Rouge, Louisiana
| | - Benjawan Khumcha
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Georgina McCallum
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Jessica E Miller
- Infection and Immunity, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Pediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Rosa Morello
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Alasdair P S Munro
- NIHR Southampton Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Peter J M Openshaw
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust: London, London, United Kingdom
| | - Srivatsan Padmanabhan
- Elson S. Floyd College of Medicine, Washington State University, Tacoma, Washington
- St Joseph Medical Center, Tacoma, Washington
| | - Wanatpreeya Phongsamart
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Gary Reubenson
- Empilweni Service & Research Unit, Rahima Moosa Mother & Child Hospital, Department of Paediatrics & Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicole Ritz
- Department of Pediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Mycobacterial and Migrant Health Research Group, University of Basel Children's Hospital Basel and Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Pediatrics and Pediatric Infectious Diseases, Children's Hospital Lucerne and Faculty of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Fernanda Rodrigues
- Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Supattra Rungmaitree
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Fiona Russell
- Infection and Immunity, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Pediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Marco A P Sáfadi
- Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
- Hospital Infantil Sabará, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Christoph Saner
- Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, University Hospital Inselspital, University of Bern, Bern, Switzerland
- Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Malcolm G Semple
- NIHR Health Protection Research Unit, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
- Respiratory Medicine, Alder Hey Children's Hospital, Institute in The Park, University of Liverpool, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | | | | | | | - Kirsten Spann
- Centre for Immunology and Infection Control, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sibongile Walaza
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicole Wolter
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yao Xia
- Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Daniel K Yeoh
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, SA- MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Petra Zimmermann
- Department of Community Health, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
| | - Kirsty R Short
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, Queensland, Australia
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Phillips AN, Bansi-Matharu L, Shahmanesh M, Hargreaves JR, Smith J, Revill P, Sibanda E, Ehrenkranz P, Sikwese K, Rodger A, Lundgren JD, Gilks CF, Godfrey C, Cowan F, Cambiano V. Potential cost-effectiveness of community availability of tenofovir, lamivudine, and dolutegravir for HIV prevention and treatment in east, central, southern, and west Africa: a modelling analysis. Lancet Glob Health 2023; 11:e1648-e1657. [PMID: 37734807 DOI: 10.1016/s2214-109x(23)00383-2] [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: 02/17/2023] [Revised: 07/23/2023] [Accepted: 08/04/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Post-exposure prophylaxis (PEP) offers protection from HIV after condomless sex, but is not widely available in a timely manner in east, central, southern, and west Africa. To inform the potential pilot implementation of such an approach, we modelled the effect and cost-effectiveness of making PEP consisting of tenofovir, lamivudine, and dolutegravir (TLD) freely and locally available in communities without prescription, with the aim of enabling PEP use within 24 h of condomless sex. Free community availability of TLD (referred to as community TLD) might also result in some use of TLD as pre-exposure prophylaxis (PrEP) and as antiretroviral therapy for people living with HIV. METHODS Using an existing individual-based model (HIV Synthesis), we explicitly modelled the potential positive and negative effects of community TLD. Through the sampling of parameter values we created 1000 setting-scenarios, reflecting the uncertainty in assumptions and a range of settings similar to those seen in east, central, southern, and west Africa (with a median HIV prevalence of 14·8% in women and 8·1% in men). For each setting scenario, we considered the effects of community TLD. TLD PEP was assumed to have at least 90% efficacy in preventing HIV infection after condomless sex with a person living with HIV. FINDINGS The modelled effects of community TLD availability based on an assumed high uptake of TLD resulted in a mean reduction in incidence of 31% (90% range over setting scenarios, 6% increase to 57% decrease) over 20 years, with an HIV incidence reduction over 50 years in 91% of the 1000 setting scenarios, deaths averted in 55% of scenarios, reduction in costs in 92% of scenarios, and disability-adjusted life-years averted in 64% of scenarios with community TLD. Community TLD was cost-effective in 90% of setting scenarios and cost-saving (with disability-adjusted life-years averted) in 58% of scenarios. When only examining setting scenarios in which there was lower uptake of community TLD, community TLD is cost-effective in 92% of setting scenarios. INTERPRETATION The introduction of community TLD, enabling greater PEP access, is a promising approach to consider further in pilot implementation projects. FUNDING Bill & Melinda Gates Foundation to the HIV Modelling Consortium.
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Affiliation(s)
| | | | - Maryam Shahmanesh
- Institute for Global Health, University College London, London, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | - Jennifer Smith
- Institute for Global Health, University College London, London, UK
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Euphemia Sibanda
- CeSHHAR Zimbabwe, Harare, Zimbabwe; Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Alison Rodger
- Institute for Global Health, University College London, London, UK
| | - Jens D Lundgren
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Catherine Godfrey
- Office of the Global AIDS Coordinator, Department of State, Washington, DC, USA
| | - Frances Cowan
- CeSHHAR Zimbabwe, Harare, Zimbabwe; Liverpool School of Tropical Medicine, Liverpool, UK
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Engstrom T, Waller M, Mullens AB, Debattista J, Durham J, Gu Z, Wenham K, Daken K, Ariana A, Gilks CF, Bell SFE, Williams OD, Dingle K, Dean JA. STI and HIV testing: examining factors that influence uptake among domestic Australian-born, domestic overseas-born and international tertiary students studying in Australia. BMC Public Health 2023; 23:505. [PMID: 36922801 PMCID: PMC10018943 DOI: 10.1186/s12889-023-15418-z] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 03/10/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVES Sexual health knowledge among international students in Australia is lower than domestic students, however, little is known about what factors affect the uptake of STI testing, nor if there are differences for overseas-born domestic students. METHODS We included sexually active respondents from a survey of university students in Australia (N = 3,075). Multivariate regression and mediation analyses investigated associations of STI and HIV testing with STI and HIV knowledge respectively, sexual risk behaviour and demographics, including comparisons among: domestic Australian-born, domestic overseas-born, and international students. RESULTS STI and HIV knowledge was positively associated with STI and HIV testing respectively (STI OR = 1.13, 95% CI: 1.09, 1.16; HIV OR = 1.37, 95% CI: 1.27, 1.48). STI knowledge was significantly lower for international than domestic Australian-born students (10.8 vs. 12.2 out of 16), as was STI testing (32% vs. 38%); the difference in knowledge accounted for half the difference in STI testing rates between these two groups. International students from Southern Asia, and Eastern Asia reported the lowest STI testing rates. HIV testing was highest amongst international students from Africa and North America. Higher sexual risk behaviour, younger age, and identifying as gay or bisexual were positively associated with higher STI and HIV testing rates. CONCLUSIONS Our study supports greater investment and commitment by universities for the provision of sexual health education that can promote access to testing to improve the health of their students.
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Affiliation(s)
- Teyl Engstrom
- School of Public Health, Faculty of Medicine, The University of Queensland, Public Health Building, Herston, QLD, 4006, Australia.
| | - Michael Waller
- School of Public Health, Faculty of Medicine, The University of Queensland, Public Health Building, Herston, QLD, 4006, Australia
| | - Amy B Mullens
- School of Psychology and Wellbeing, Centre for Health Research, Institute for Resilient Regions, University of Southern Queensland, Ipswich, Australia
| | - Joseph Debattista
- Metro North Public Health Unit, Metro North Hospital and Health Service, Herston, Australia
| | - Jo Durham
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Zhihong Gu
- Ethnic Communities Council of Queensland, West End, Australia
| | - Kathryn Wenham
- School of Health and Behavioural Sciences, University of the Sunshine Coast, Sippy Downs, Australia
| | - Kirstie Daken
- School of Psychology and Wellbeing, Centre for Health Research, Institute for Resilient Regions, University of Southern Queensland, Ipswich, Australia
| | - Armin Ariana
- School of Medicine and Dentistry, Griffith University, Nathan, Australia
| | - Charles F Gilks
- School of Public Health, Faculty of Medicine, The University of Queensland, Public Health Building, Herston, QLD, 4006, Australia
| | - Sara F E Bell
- School of Public Health, Faculty of Medicine, The University of Queensland, Public Health Building, Herston, QLD, 4006, Australia
| | - Owain D Williams
- School of Public Health, Faculty of Medicine, The University of Queensland, Public Health Building, Herston, QLD, 4006, Australia
| | - Kaeleen Dingle
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Judith A Dean
- School of Public Health, Faculty of Medicine, The University of Queensland, Public Health Building, Herston, QLD, 4006, Australia
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8
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Martin F, Gilks CF, Gibb R, Jenkins A, Protani M, Francis F, Redmond AM, Neilsen G, Mudge D, Wolley M, Binotto E, Norton R, Nimmo GR, Heney C. Human T-cell leukaemia virus type 1 and Adult T-cell leukaemia/lymphoma in Queensland, Australia: a retrospective cross-sectional study. Sex Transm Infect 2023; 99:50-52. [PMID: 35523573 PMCID: PMC9887394 DOI: 10.1136/sextrans-2021-055241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 04/01/2022] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES Human T-cell leukaemia virus type 1 (HTLV-1), an STI, is reported to be highly prevalent in Indigenous communities in Central Australia. HTLV-1 is an incurable, chronic infection which can cause Adult T-cell leukaemia/lymphoma (ATL). ATL is associated with high morbidity and mortality, with limited treatment options. We studied the prevalence of HTLV-1 and ATL in the state of Queensland, Australia. METHODS Serum samples stored at healthcare services in Brisbane, Townsville and Cairns and at haemodialysis units in Brisbane (2018-2019) were screened for HTLV-1/2 antibodies using the Abbott ARCHITECT chemiluminescent microparticle immunoassay (CMIA) for antibodies against gp46-I, gp46-II and GD21 (Abbott CMIA, ARCHITECT). Reactive samples were confirmed through Western blot. Pooled Australian National Cancer Registry surveillance data reporting on cases coded for ATL (2004-2015) were analysed. RESULTS Two out of 2000 hospital and health services samples were confirmed HTLV-1-positive (0.1%, 95% CI 0.02% to 0.4%), both in older women, one Indigenous and one non-Indigenous. All 540 haemodialysis samples tested negative for HTLV. All samples were HTLV-2-negative. Ten out of 42 (24.8%) reported cases of ATL in Australia were from Queensland (crude incidence rate 0.025/100 000; 95% CI 0.011 to 0.045); most cases were seen in adult men of non-Indigenous origin. Nineteen deaths due to ATL were recorded in Australia. CONCLUSION We confirm that HTLV-1 and ATL were detected in Queensland in Indigenous and non-Indigenous people. These results highlight the need for HTLV-1 prevalence studies in populations at risk of STIs to allow the implementation of focused public health sexual and mother-to-child transmission prevention strategies.
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Affiliation(s)
- Fabiola Martin
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Charles F Gilks
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Robert Gibb
- Department of Microbiology, Pathology Queensland, Queensland Health, Brisbane, Queensland, Australia
| | - Alana Jenkins
- Department of Microbiology, Pathology Queensland, Queensland Health, Brisbane, Queensland, Australia
| | - Melinda Protani
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Fleur Francis
- Pathology Queensland, Townsville University Hospital, Queensland Health, Townsville, Queensland, Australia
| | - Andrew M Redmond
- Department of Infectious Diseases Unit, Metro North Hospital and Health Service, Queensland Health, Brisbane, Queensland, Australia
| | - Graham Neilsen
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - David Mudge
- Department of Nephrology, Princess Alexandra Hospital, Metro South Hospital and Health Service, Queensland Health, The University of Queensland Faculty of Medicine, Brisbane, Queensland, Australia
| | - Martin Wolley
- Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Queensland, Australia
| | - Enzo Binotto
- Pathology Queensland, Cairns Hospital, Queensland Health, Cairns, Queensland, Australia
| | - Robert Norton
- Pathology Queensland, Townsville University Hospital, Queensland Health, Townsville, Queensland, Australia
| | - Graeme R Nimmo
- Department of Microbiology, Pathology Queensland, Queensland Health, Brisbane, Queensland, Australia
| | - Claire Heney
- Department of Microbiology, Pathology Queensland, Queensland Health, Brisbane, Queensland, Australia
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9
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Endalamaw A, Gilks CF, Ambaw F, Habtewold TD, Assefa Y. Universal Health Coverage for Antiretroviral Treatment: A Review. Infect Dis Rep 2022; 15:1-15. [PMID: 36648855 PMCID: PMC9844463 DOI: 10.3390/idr15010001] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Universal health coverage is essential for the progress to end threats of the acquired immunodeficiency syndrome epidemic. The current review assesses the publication rate, strategies and barriers for antiretroviral therapy (ART) coverage, equity, quality of care, and financial protection. We searched Web of Science, PubMed, and Google Scholar. Of the available articles, 43.13% were on ART coverage, 40.28% were on financial protection, 10.43% were on quality of care, and 6.16% were on equity. A lack of ART, fear of unwanted disclosure, lack of transportation, unaffordable health care costs, long waiting time to receive care, and poverty were barriers to ART coverage. Catastrophic health care costs were higher among individuals who were living in rural settings, walked greater distances to reach health care institutions, had a lower socioeconomic status, and were immunocompromised. There were challenges to the provision of quality of care, including health care providers' inadequate salary, high workload and inadequate health workforce, inappropriate infrastructure, lack of training opportunities, unclear division of responsibility, and the presence of strict auditing. In conclusion, ART coverage was below the global average, and key populations were disproportionally less covered with ART in most countries. Huge catastrophic health expenditures were observed. UHC contexts of ART will be improved by reaching people with poor socioeconomic status, delivering appropriate services, establishing a proper health workforce and service stewardship.
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Affiliation(s)
- Aklilu Endalamaw
- School of Public Health, The University of Queensland, Brisbane, QLD 4072, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar P.O. Box 79, Ethiopia
- Correspondence: ; Tel.: +61-424-690-121
| | - Charles F Gilks
- School of Public Health, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Fentie Ambaw
- School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar P.O. Box 79, Ethiopia
| | - Tesfa Dejenie Habtewold
- Branch of Epidemiology, Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
| | - Yibeltal Assefa
- School of Public Health, The University of Queensland, Brisbane, QLD 4072, Australia
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10
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Endalamaw A, Gilks CF, Ambaw F, Chatfield MD, Assefa Y. Satisfaction of tuberculosis patients to healthcare services at the global level: A systematic review. Health Soc Care Community 2022; 30:e3435-e3446. [PMID: 35920598 PMCID: PMC10087702 DOI: 10.1111/hsc.13953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/16/2022] [Accepted: 07/16/2022] [Indexed: 06/15/2023]
Abstract
Patient satisfaction is a critical component of quality of care assessment in the pursuit of universal health coverage to end the tuberculosis epidemic and other diseases. This study aimed to review the level of satisfaction of tuberculosis patients and related factors. Articles were accessed from Web of Science, EMBASE, PubMed and Google Scholar. Twenty-six papers fulfilled the eligibility criteria from 13 countries. The percentage of satisfied tuberculosis patients ranged from 53.5% to 97.0% in the five African countries, 67.8 to 97.2% in India, South-East Asia, 82.0% in Pakistan, East-Mediterranean and 92.9% in Armenia, the European region. Accessibility, healthcare cost, treatment duration and taking supervised-directly observed treatment were healthcare service-related determinants. Technical competency, interpersonal relationships, confidentiality, time spent with healthcare providers, time spent waiting for care and counselling and health education were health worker-related determinants. Patient-related variables that determine satisfaction were gender, age, ethnicity, place of residence, marital status, educational status, income and health status. Developing and/or approaching an internationally-agreed tool to measure tuberculosis patient satisfaction in healthcare settings will improve the availability of high-quality and comparable data to verify actual variation across and within a country. A multidimensional approach considering clients, health workers and healthcare settings is required to holistically address satisfaction issues of tuberculosis patients to gradually realise universal health coverage.
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Affiliation(s)
- Aklilu Endalamaw
- School of Public HealthThe University of QueenslandBrisbaneAustralia
- College of Medicine and Health SciencesBahir Dar UniversityBahir DarEthiopia
| | - Charles F. Gilks
- School of Public HealthThe University of QueenslandBrisbaneAustralia
| | - Fentie Ambaw
- School of Public Health, College of Medicine and Health SciencesBahir Dar UniversityBahir DarEthiopia
| | - Mark D. Chatfield
- School of Public HealthThe University of QueenslandBrisbaneAustralia
| | - Yibeltal Assefa
- School of Public HealthThe University of QueenslandBrisbaneAustralia
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11
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Endalamaw A, Gilks CF, Ambaw F, Assefa Y. Universality of universal health coverage: A scoping review. PLoS One 2022; 17:e0269507. [PMID: 35994455 PMCID: PMC9394787 DOI: 10.1371/journal.pone.0269507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
Background The progress of Universal health coverage (UHC) is measured using tracer indicators of key interventions, which have been implemented in healthcare system. UHC is about population, comprehensive health services and financial coverage for equitable quality services and health outcome. There is dearth of evidence about the extent of the universality of UHC in terms of types of health services, its integrated definition (dimensions) and tracer indicators utilized in the measurement of UHC. Therefore, we mapped the existing literature to assess universality of UHC and summarize the challenges towards UHC. Methods The checklist Preferred Reporting Items for Systematic reviews and Meta-analysis extension for Scoping Reviews was used. A systematic search was carried out in the Web of Science and PubMed databases. Hand searches were also conducted to find articles from Google Scholar, the World Bank Library, the World Health Organization Library, the United Nations Digital Library Collections, and Google. Article search date was between 20 October 2021 and 12 November 2021 and the most recent update was done on 03 March 2022. Articles on UHC coverage, financial risk protection, quality of care, and inequity were included. The Population, Concept, and Context framework was used to determine the eligibility of research questions. A stepwise approach was used to identify and select relevant studies, conduct data charting, collation and summarization, as well as report results. Simple descriptive statistics and narrative synthesis were used to present the findings. Results Forty-seven papers were included in the final review. One-fourth of the articles (25.5%) were from the African region and 29.8% were from lower-middle-income countries. More than half of the articles (54.1%) followed a quantitative research approach. Of included articles, coverage was assessed by 53.2% of articles; financial risk protection by 27.7%, inequity by 25.5% and quality by 6.4% of the articles as the main research objectives or mentioned in result section. Most (42.5%) of articles investigated health promotion and 2.1% palliation and rehabilitation services. Policy and healthcare level and cross-cutting barriers of UHC were identified. Financing, leadership/governance, inequity, weak regulation and supervision mechanism, and poverty were most repeated policy level barriers. Poor quality health services and inadequate health workforce were the common barriers from health sector challenges. Lack of common understanding on UHC was frequently mentioned as a cross-cutting barrier. Conclusions The review showed that majority of the articles were from the African region. Methodologically, quantitative research design was more frequently used to investigate UHC. Palliation and rehabilitation health care services need attention in the monitoring and evaluation of UHC progress. It is also noteworthy to focus on quality and inequity of health services. The study implies that urgent action on the identified policy, health system and cross-cutting barriers is required to achieve UHC.
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Affiliation(s)
- Aklilu Endalamaw
- School of Public Health, The University of Queensland, Brisbane, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
- * E-mail:
| | - Charles F. Gilks
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Fentie Ambaw
- School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Yibeltal Assefa
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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12
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Assefa Y, Woldeyohannes S, Cullerton K, Gilks CF, Reid S, Van Damme W. Attributes of national governance for an effective response to public health emergencies: Lessons from the response to the COVID-19 pandemic. J Glob Health 2022; 12:05021. [PMID: 35787525 PMCID: PMC9258903 DOI: 10.7189/jogh.12.05021] [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] [Indexed: 11/16/2022] Open
Abstract
Background The Coronavirus Disease 2019 (COVID-19) pandemic takes variable shapes and forms in different regions and countries. This variability is explained by several factors, including the governance of the epidemic. We aimed to identify the key attributes of governance in response to the COVID-19 pandemic and gain lessons for an effective response to public health emergencies. Methods We employed a mixed-methods design. We mapped the attributes of governance from well-established governance frameworks. A negative binomial regression was conducted to identify the effect of the established governance measures on the epidemiology of the COVID-19 pandemic. We used publicly available data on COVID-19 cases and deaths in countries around the world. Document review was conducted to identify the key approaches and attributes of governance during the pre-vaccine era of the response to the COVID-19 pandemic. We conducted a thematic analysis to identify key attributes for effective governance. Results The established governance measures, including generation of intelligence, strategic direction, regulation, partnership, accountability, transparency, rule of law, control of corruption, responsiveness, effectiveness, efficiency, equity, ethics, and inclusiveness, are necessary but not sufficient to effectively respond to and contain the COVID-19 pandemic. Additional attributes of national governance were identified: 1) agile, adaptive, and transformative governance; 2) collective (collaborative, inclusive, cooperative, accountable, and transparent) governance; 3) multi-level governance; 4) smart and ethical governance: sensible, pragmatic, evidence-based, political, learner, and ethical. Conclusions The current governance frameworks and their attributes are not adequate to contain the COVID-19 pandemic. We argue that countries need agile, adaptable, and transformational, collaborative, multi-level, smart and ethical governance to effectively respond to emerging and re-emerging public health threats. In addition, an effective response to public health emergencies depends not only on national governance but also on global governance. Hence, global health governance should be urgently renewed through a paradigm shift towards universal health coverage and health security to all populations and in all countries. This requires enhanced and consistent global health diplomacy based on knowledge, solidarity, and negotiation.
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Affiliation(s)
- Yibeltal Assefa
- School of Public Health, the University of Queensland, Brisbane, Australia
| | | | | | - Charles F Gilks
- School of Public Health, the University of Queensland, Brisbane, Australia
| | - Simon Reid
- School of Public Health, the University of Queensland, Brisbane, Australia
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13
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Assefa Y, Gilks CF, Reid S, van de Pas R, Gete DG, Van Damme W. Analysis of the COVID-19 pandemic: lessons towards a more effective response to public health emergencies. Global Health 2022; 18:10. [PMID: 35120537 PMCID: PMC8815718 DOI: 10.1186/s12992-022-00805-9] [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: 08/04/2021] [Accepted: 01/14/2022] [Indexed: 01/08/2023] Open
Abstract
Background The pandemic of Coronavirus Disease 2019 (COVID-19) is a timely reminder of the nature and impact of Public Health Emergencies of International Concern. As of 12 January 2022, there were over 314 million cases and over 5.5 million deaths notified since the start of the pandemic. The COVID-19 pandemic takes variable shapes and forms, in terms of cases and deaths, in different regions and countries of the world. The objective of this study is to analyse the variable expression of COVID-19 pandemic so that lessons can be learned towards an effective public health emergency response. Methods We conducted a mixed-methods study to understand the heterogeneity of cases and deaths due to the COVID-19 pandemic. Correlation analysis and scatter plot were employed for the quantitative data. We used Spearman’s correlation analysis to determine relationship strength between cases and deaths and socio-economic and health systems. We organized qualitative information from the literature and conducted a thematic analysis to recognize patterns of cases and deaths and explain the findings from the quantitative data. Results We have found that regions and countries with high human development index have higher cases and deaths per million population due to COVID-19. This is due to international connectedness and mobility of their population related to trade and tourism, and their vulnerability related to older populations and higher rates of non-communicable diseases. We have also identified that the burden of the pandemic is also variable among high- and middle-income countries due to differences in the governance of the pandemic, fragmentation of health systems, and socio-economic inequities. Conclusion The COVID-19 pandemic demonstrates that every country remains vulnerable to public health emergencies. The aspiration towards a healthier and safer society requires that countries develop and implement a coherent and context-specific national strategy, improve governance of public health emergencies, build the capacity of their (public) health systems, minimize fragmentation, and tackle upstream structural issues, including socio-economic inequities. This is possible through a primary health care approach, which ensures provision of universal and equitable promotive, preventive and curative services, through whole-of-government and whole-of-society approaches.
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Affiliation(s)
- Yibeltal Assefa
- School of Public Health, the University of Queensland, Brisbane, Australia.
| | - Charles F Gilks
- School of Public Health, the University of Queensland, Brisbane, Australia
| | - Simon Reid
- School of Public Health, the University of Queensland, Brisbane, Australia
| | | | - Dereje Gedle Gete
- School of Public Health, the University of Queensland, Brisbane, Australia
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14
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Bell SFE, Lemoire J, Debattista J, Redmond AM, Driver G, Durkin I, Coffey L, Warner M, Howard C, Williams OD, Gilks CF, Dean JA. Online HIV Self-Testing (HIVST) Dissemination by an Australian Community Peer HIV Organisation: A Scalable Way to Increase Access to Testing, Particularly for Suboptimal Testers. Int J Environ Res Public Health 2021; 18:ijerph182111252. [PMID: 34769771 PMCID: PMC8583017 DOI: 10.3390/ijerph182111252] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 11/16/2022]
Abstract
HIV self-testing (HIVST) introduces opportunities for screening in non-conventional settings, and addresses known testing barriers. This study involved the development and evaluation of a free online HIVST dissemination service hosted by a peer-led, community-based organisation with on-site, peer-facilitated HIV testing, and established referral and support programs for people newly diagnosed with HIV to determine whether this model was feasible and acceptable for engaging MSM, particularly among infrequent and naive HIV-testers, or those living in remote and rural areas. Between December 2016 and April 2018, 927 kits were ordered by 794 individuals, the majority of whom were men who have sex with men (MSM) (62%; 494), having condomless sex (50%; 392), or living outside a major city (38%; 305). Very few (5%; 39) sought the available pre-test peer contact, despite 45% (353) being naive HIV-testers. This study demonstrates that online HIVST dissemination is acceptable and feasible for engaging at-risk suboptimal testers, including those unwilling to test elsewhere (19%; 47/225). With half (50%; 403) unwilling to buy a kit, our study suggests that HIVST will need to be subsidized (cost-neutral to users) to enhance population coverage and access.
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Affiliation(s)
- Sara Fiona Elisabeth Bell
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston 4006, Australia; (S.F.E.B.); (O.D.W.); (C.F.G.)
| | - Jime Lemoire
- Queensland Positive People, East Brisbane 4169, Australia; (J.L.); (A.M.R.); (G.D.); (I.D.); (L.C.); (M.W.); (C.H.)
| | - Joseph Debattista
- Metro North Public Health Unit, Metro North Hospital and Health Service, Windsor 4030, Australia;
| | - Andrew M. Redmond
- Queensland Positive People, East Brisbane 4169, Australia; (J.L.); (A.M.R.); (G.D.); (I.D.); (L.C.); (M.W.); (C.H.)
- Royal Brisbane and Women’s Hospital, Metro North Hospital and Health Service, Herston 4006, Australia
| | - Glen Driver
- Queensland Positive People, East Brisbane 4169, Australia; (J.L.); (A.M.R.); (G.D.); (I.D.); (L.C.); (M.W.); (C.H.)
| | - Izriel Durkin
- Queensland Positive People, East Brisbane 4169, Australia; (J.L.); (A.M.R.); (G.D.); (I.D.); (L.C.); (M.W.); (C.H.)
| | - Luke Coffey
- Queensland Positive People, East Brisbane 4169, Australia; (J.L.); (A.M.R.); (G.D.); (I.D.); (L.C.); (M.W.); (C.H.)
| | - Melissa Warner
- Queensland Positive People, East Brisbane 4169, Australia; (J.L.); (A.M.R.); (G.D.); (I.D.); (L.C.); (M.W.); (C.H.)
| | - Chris Howard
- Queensland Positive People, East Brisbane 4169, Australia; (J.L.); (A.M.R.); (G.D.); (I.D.); (L.C.); (M.W.); (C.H.)
| | - Owain David Williams
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston 4006, Australia; (S.F.E.B.); (O.D.W.); (C.F.G.)
| | - Charles F. Gilks
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston 4006, Australia; (S.F.E.B.); (O.D.W.); (C.F.G.)
| | - Judith Ann Dean
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston 4006, Australia; (S.F.E.B.); (O.D.W.); (C.F.G.)
- Correspondence: ; Tel.: +61-7-3346-4876 or +61-417768940
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15
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Engstrom T, Waller M, Mullens AB, Durham J, Debattista J, Wenham K, Bell SFE, Ariana A, Gu Z, Daken K, Dingle K, Gilks CF, Williams OD, Dean JA. STI and HIV knowledge and testing: a comparison of domestic Australian-born, domestic overseas-born and international university students in Australia. Sex Health 2021; 18:346-348. [PMID: 34412769 DOI: 10.1071/sh21055] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/21/2021] [Indexed: 11/23/2022]
Abstract
University students usually consist of young people from culturally and linguistically diverse backgrounds, and a group recognised as being at increased risk of STI. This study found lower levels of STI knowledge and STI testing among international students and to a lesser extent, domestic overseas-born students, compared with domestic Australian-born students. International students exhibited lower risk sexual behaviour but were more likely to have had a HIV test than domestic students. This diversity in sexual health knowledge, sexual health services utilisation and sexual experience indicates the need for a variety of public health approaches to improve sexual health.
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Affiliation(s)
- Teyl Engstrom
- School of Public Health, Faculty of Medicine, The University of Queensland,Herston Campus, 288 Herston Road, Herston, Qld 4006, Australia; and Corresponding author.
| | - Michael Waller
- School of Public Health, Faculty of Medicine, The University of Queensland,Herston Campus, 288 Herston Road, Herston, Qld 4006, Australia
| | - Amy B Mullens
- School of Psychology and Counselling, Centre for Health Research, University of Southern Queensland, Ipswich Campus, 11 Salisbury Road, Ipswich, Qld 4305, Australia
| | - Jo Durham
- School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove Campus, Victoria Park Road, Kelvin Grove, Qld 4059, Australia
| | - Joseph Debattista
- Metro North Public Health Unit, Metro North Hospital and Health Service, Bryden Street, Windsor, Qld 4030, Australia
| | - Kathryn Wenham
- School of Health and Behavioural Sciences, University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, Qld 4556, Australia
| | - Sara F E Bell
- School of Public Health, Faculty of Medicine, The University of Queensland,Herston Campus, 288 Herston Road, Herston, Qld 4006, Australia
| | - Armin Ariana
- School of Medicine and Dentistry, Griffith University, Gold Coast Campus, Parklands Drive, Southport, Qld 4222, Australia
| | - Zhihong Gu
- Ethnic Communities Council of Queensland, 253 Boundary Street, West End, Qld 4101, Australia
| | - Kirstie Daken
- School of Psychology and Counselling, Centre for Health Research, University of Southern Queensland, Ipswich Campus, 11 Salisbury Road, Ipswich, Qld 4305, Australia
| | - Kaeleen Dingle
- School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove Campus, Victoria Park Road, Kelvin Grove, Qld 4059, Australia
| | - Charles F Gilks
- School of Public Health, Faculty of Medicine, The University of Queensland,Herston Campus, 288 Herston Road, Herston, Qld 4006, Australia
| | - Owain D Williams
- School of Public Health, Faculty of Medicine, The University of Queensland,Herston Campus, 288 Herston Road, Herston, Qld 4006, Australia
| | - Judith A Dean
- School of Public Health, Faculty of Medicine, The University of Queensland,Herston Campus, 288 Herston Road, Herston, Qld 4006, Australia
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Abstract
OBJECTIVES Pyomyositis, an acute bacterial infection of skeletal muscle usually resulting in abscess formation, is well recognised in tropical regions where it can account for up to 4% of adult surgical admissions. It is increasingly being reported from high-income temperate countries. Pyomyositis occurs across all ages and in both sexes. Mortality ranges from 1% to 23%. Many risk factors have been suggested. We aimed to identify factors associated with pyomyositis. METHODS We undertook a systematic review and meta-analysis, using PubMed, EMBASE, Scopus and the Cochran Library and hand-searching published papers. The random-effects model meta-analysis was used to calculate pooled estimated odd ratios with the corresponding 95% confidence interval. RESULTS All studies in the systematic review (n = 25) and the meta-analysis (n = 12) were hospital-based. Seven only included children. Relatively few studies have been published in the last decade, the majority of which are from high-income temperate settings. Staphylococcus aureus was the main organism isolated. Males under the age of 20 predominated, and mortality of up to 20% was reported. Factors associated with pyomyositis were HIV infection (OR = 4.82; 95% CI: 1.67-13.92) and fulfilling an AIDS surveillance definition (OR = 6.08; 95% CI: 2.79-13.23). CONCLUSIONS Our meta-analysis indicated significant associations between pyomyositis infection and HIV/AIDS. Major gaps in our understanding of the epidemiology, pathogenesis, clinical presentation, and outcome remain, highlighting the need for further research and more systematic studies. Pyomyositis merits consideration as a neglected tropical disease.
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Affiliation(s)
- Chamnab Ngor
- School of Public Health, The University of Queensland, Brisbane, Qld, Australia.,School of Public Health, The National Institute of Public Health, Phnom Penh, Cambodia
| | - Lisa Hall
- School of Public Health, The University of Queensland, Brisbane, Qld, Australia
| | - Judith A Dean
- School of Public Health, The University of Queensland, Brisbane, Qld, Australia
| | - Charles F Gilks
- School of Public Health, The University of Queensland, Brisbane, Qld, Australia
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17
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Assefa Y, Gilks CF, van de Pas R, Reid S, Gete DG, Van Damme W. Reimagining global health systems for the 21st century: lessons from the COVID-19 pandemic. BMJ Glob Health 2021; 6:e004882. [PMID: 33906846 PMCID: PMC8088119 DOI: 10.1136/bmjgh-2020-004882] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/16/2021] [Accepted: 04/17/2021] [Indexed: 12/24/2022] Open
Affiliation(s)
- Yibeltal Assefa
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Charles F Gilks
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Remco van de Pas
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Simon Reid
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Dereje Gedle Gete
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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18
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Williams OD, Dean JA, Crothers A, Gilks CF, Gow J. Economic evaluation of alternative testing regimes and settings to detect undiagnosed HIV in Australia. BMC Health Serv Res 2021; 21:30. [PMID: 33413386 PMCID: PMC7789789 DOI: 10.1186/s12913-020-06040-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 12/21/2020] [Indexed: 11/26/2022] Open
Abstract
Background The study aimed to estimate the comparative costs per positive diagnosis of previously undetected HIV in three testing regimes: conventional; parallel and point of care (POC) testing. The regimes are analysed in six testing settings in Australia where infection is concentrated but with low prevalence. Methods A cost model was developed to highlight the trade-offs between test and economic efficiency from a provider perspective. First, an estimate of the number of tests needed to find a true (previously undiagnosed) positive diagnosis was made. Second, estimates of the average cost per positive diagnosis in whole of population (WoP) and men who have sex with men (MSM) was made, then third, aggregated to the total cost for diagnosis of all undetected infections. Results Parallel testing is as effective as conventional testing, but more economically efficient. POC testing provide two significant advantages over conventional testing: they screen out negatives effectively at comparatively lower cost and, with confirmatory testing of reactive results, there is no loss in efficiency. The average and total costs per detection in WoP are prohibitive, except for Home Self Testing. The diagnosis in MSM is cost effective in all settings, but especially using Home Self Testing when the individual assumes the cost of testing. Conclusions This study illustrates the trade-offs between economic and test efficiency and their interactions with population(s) prevalence. The efficient testing regimes and settings are presently under or not funded in Australia. Home Self Testing has the potential to dramatically increase testing rates at very little cost. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-06040-5.
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Affiliation(s)
- Owain D Williams
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Judith A Dean
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Anna Crothers
- School of Medicine, Griffith University, Nathan, Australia
| | - Charles F Gilks
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Jeff Gow
- School of Commerce, University of Southern Queensland, Toowoomba, Queensland, 4350, Australia. .,School of Accounting, Economics and Finance, University of KwaZulu-Natal, Durban, South Africa.
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19
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Assefa Y, Hill PS, Gilks CF, Damme WV, van de Pas R, Woldeyohannes S, Reid S. Global health security and universal health coverage: Understanding convergences and divergences for a synergistic response. PLoS One 2020; 15:e0244555. [PMID: 33378383 PMCID: PMC7773202 DOI: 10.1371/journal.pone.0244555] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 12/13/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Global health security (GHS) and universal health coverage (UHC) are key global health agendas which aspire for a healthier and safer world. However, there are tensions between GHS and UHC strategy and implementation. The objective of this study was to assess the relationship between GHS and UHC using two recent quantitative indices. METHODS We conducted a macro-analysis to determine the presence of relationship between GHS index (GHSI) and UHC index (UHCI). We calculated Pearson's correlation coefficient and the coefficient of determination. Analyses were performed using IBM SPSS Statistics Version 25 with a 95% level of confidence. FINDINGS There is a moderate and significant relationship between GHSI and UHCI (r = 0.662, p<0.001) and individual indices of UHCI (maternal and child health and infectious diseases: r = 0.623 (p<0.001) and 0.594 (p<0.001), respectively). However, there is no relationship between GHSI and the non-communicable diseases (NCDs) index (r = 0.063, p>0.05). The risk of GHS threats a significant and negative correlation with the capacity for GHS (r = -0.604, p<0.001) and the capacity for UHC (r = -0.792, p<0.001). CONCLUSION The aspiration for GHS will not be realized without UHC; hence, the tension between these two global health agendas should be transformed into a synergistic solution. We argue that strengthening the health systems, in tandem with the principles of primary health care, and implementing a "One Health" approach will progressively enable countries to achieve both UHC and GHS towards a healthier and safer world that everyone aspires to live in.
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Affiliation(s)
- Yibeltal Assefa
- School of Public Health, the University of Queensland, Brisbane, Australia
| | - Peter S. Hill
- School of Public Health, the University of Queensland, Brisbane, Australia
| | - Charles F. Gilks
- School of Public Health, the University of Queensland, Brisbane, Australia
| | | | | | | | - Simon Reid
- School of Public Health, the University of Queensland, Brisbane, Australia
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20
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Dean JA, Bell SFE, Coffey L, Debattista J, Badman S, Redmond AM, Whiley DM, Lemoire J, Williams OD, Howard C, Gilks CF. Improved sensitivity from pooled urine, pharyngeal and rectal specimens when using a molecular assay for the detection of chlamydia and gonorrhoea near point of care. Sex Transm Infect 2020; 97:471-472. [PMID: 33188137 DOI: 10.1136/sextrans-2020-054835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/25/2020] [Indexed: 11/03/2022] Open
Affiliation(s)
- Judith Ann Dean
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Sara Fiona Elizabeth Bell
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Luke Coffey
- RAPID, Queensland Positive People, Brisbane, Queensland, Australia
| | - Joseph Debattista
- Metro North Public Health Unit, Metro North Hospital and Health Service, Windsor, Queensland, Australia
| | - Steven Badman
- The Kirby Insitute, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew M Redmond
- RAPID, Queensland Positive People, Brisbane, Queensland, Australia.,Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - David M Whiley
- Centre for Clinical Research, The University of Queensland, Herston, Queensland, Australia.,Pathology Queensland, Queensland Health, Herston, Queensland, Australia
| | - Jime Lemoire
- RAPID, Queensland Positive People, Brisbane, Queensland, Australia
| | - Owain David Williams
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Chris Howard
- RAPID, Queensland Positive People, Brisbane, Queensland, Australia
| | - Charles F Gilks
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
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21
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Assefa Y, Hill PS, Gilks CF, Admassu M, Tesfaye D, Van Damme W. Primary health care contributions to universal health coverage, Ethiopia. Bull World Health Organ 2020; 98:894-905A. [PMID: 33293750 PMCID: PMC7716108 DOI: 10.2471/blt.19.248328] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 02/06/2023] Open
Abstract
Many global health institutions, including the World Health Organization, consider primary health care as the path towards achieving universal health coverage (UHC). However, there remain concerns about the feasibility and effectiveness of this approach in low-resource countries. Ethiopia has been implementing the primary health-care approach since the mid-1970s, with primary health care at the core of the health system since 1993. Nevertheless, comprehensive and systemic evidence on the practice and role of primary health care towards UHC is lacking in Ethiopia. We made a document review of publicly available qualitative and quantitative data. Using the framework of the Primary Health Care Performance Initiative we describe and analyse the practice of primary health care and identify successes and challenges. Implementation of the primary health-care approach in Ethiopia has been possible through policies, strategies and programmes that are aligned with country priorities. There has been a diagonal approach to disease control programmes along with health-systems strengthening, community empowerment and multisectoral action. These strategies have enabled the country to increase health services coverage and improve the population’s health status. However, key challenges remain to be addressed, including inadequate coverage of services, inequity of access, slow health-systems transition to provide services for noncommunicable diseases, inadequate quality of care, and high out-of-pocket expenditure. To resolve gaps in the health system and beyond, the country needs to improve its domestic financing for health and target disadvantaged locations and populations through a precision public health approach. These challenges need to be addressed through the whole sustainable development agenda.
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Affiliation(s)
- Yibeltal Assefa
- School of Public Health, The University of Queensland, 266 Herston Road, Herston, QLD 4006, Brisbane, Australia
| | - Peter S Hill
- School of Public Health, The University of Queensland, 266 Herston Road, Herston, QLD 4006, Brisbane, Australia
| | - Charles F Gilks
- School of Public Health, The University of Queensland, 266 Herston Road, Herston, QLD 4006, Brisbane, Australia
| | - Mengesha Admassu
- International Institute of Primary Health Care, Addis Ababa, Ethiopia
| | - Dessalegn Tesfaye
- United States Agency for International Development, Addis Ababa, Ethiopia
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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22
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Assefa Y, Gilks CF. Ending the epidemic of HIV/AIDS by 2030: Will there be an endgame to HIV, or an endemic HIV requiring an integrated health systems response in many countries? Int J Infect Dis 2020; 100:273-277. [PMID: 32920236 DOI: 10.1016/j.ijid.2020.09.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 11/30/2022] Open
Abstract
The third Sustainable Development Goal (SDG-3) has a target to end the epidemic of HIV/AIDS by 2030 (Project 2030). This will be achieved when the number of new HIV infections and 'AIDS-related deaths' decline by 90% between 2010 and 2030. So far, the rate of drop in AIDS-related deaths is on track, whereas the rate of drop in new HIV infections is off track to achieve Project 2030. Even if Project 2030 was achieved, HIV would be an endemic health problem. Hence, HIV prevention and control programmes cannot close down for the foreseeable future. This rather demands a paradigm shift from a fully vertical to an integrated health systems response that provides services according to disease burden towards universal health coverage. This will ensure the sustainability of HIV services in the post-2030 era. These all entail unrelenting political commitment, and increased and sustainable funding from both national and global sources.
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Affiliation(s)
- Yibeltal Assefa
- School of Public Health, the University of Queensland, Brisbane, Australia.
| | - Charles F Gilks
- School of Public Health, the University of Queensland, Brisbane, Australia
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23
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Woldeyohannes SM, Perkins NR, Baker P, Gilks CF, Knibbs LD, Reid SA. Q fever vaccine efficacy and occupational exposure risk in Queensland, Australia: A retrospective cohort study. Vaccine 2020; 38:6578-6584. [PMID: 32798141 DOI: 10.1016/j.vaccine.2020.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 07/28/2020] [Accepted: 08/03/2020] [Indexed: 11/18/2022]
Abstract
Q-VAX® is a vaccine used to prevent Q fever. Administration of the vaccine is complicated by the need to ensure, using intradermal and serological tests, that individuals have no prior immunity. Previous studies suggest that the vaccine is highly efficacious and long-lasting in adults. However, there has been no systematic follow-up of vaccine efficacy and the longevity of immunity using population-level data. We aimed to investigate the vaccine failure rate and duration of immunity in previously vaccinated individuals. We formulated a retrospective cohort study design within a linked data. We used a Q fever vaccination registry linked to Q fever notifications and hospital admissions (1991-2016) in the state of Queensland, which has Australia's highest incidence of Q fever. Q-VAX® failure was defined as occurrence of Q fever > 14 days' after vaccination. The incidence of Q fever in vaccinated and unvaccinated individuals was 5.40 (95% CI: 3.65, 7.72) and 89.50 (95% CI: 70.50, 112.00]) per 100,000 person-years of follow-up, respectively. The hazard ratio (HR) for Q fever was 0.07 (95% CI: 0.04, 0.10) in non-immune vaccinated compared with immune unvaccinated individuals. The overall vaccine effectiveness was found to be 94.37% suggesting that Q-VAX® is highly effective at preventing Q fever. However, the greater incidence observed in unvaccinated individuals considered immune during the pre-vaccination screening may suggest that pre-vaccination screening is sub-optimal among this study population.
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Affiliation(s)
- Solomon M Woldeyohannes
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Queensland 4006, Australia; School of Veterinary Science, Faculty of Science, The University of Queensland, Gatton, Queensland, Australia.
| | - Nigel R Perkins
- School of Veterinary Science, Faculty of Science, The University of Queensland, Gatton, Queensland, Australia
| | - Peter Baker
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Queensland 4006, Australia
| | - Charles F Gilks
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Queensland 4006, Australia
| | - Luke D Knibbs
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Queensland 4006, Australia
| | - Simon A Reid
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Queensland 4006, Australia
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24
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Assefa Y, Hill PS, Van Damme W, Dean J, Gilks CF. Leaving no one behind: lessons from implementation of policies for universal HIV treatment to universal health coverage. Global Health 2020; 16:17. [PMID: 32093771 PMCID: PMC7038514 DOI: 10.1186/s12992-020-00549-4] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 02/13/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The third Sustainable Development Goal (SDG - 3) aims to ensure healthy lives and promote well-being for all at all ages. SDG-3 has a specific target on universal health coverage (UHC), which emphasizes the importance of all people and communities having access to quality health services without risking financial hardship. The objective of this study is to review progress towards UHC using antiretroviral treatment (ART) as a case study. METHODS We used a mixed-methods design including qualitative and quantitative approaches. We reviewed and synthesised the evidence on the evolution of the WHO HIV treatment guidelines between 2002 and 2019. We calculated ART coverage over time by gender, age group, and location. We also estimated ART coverage differences and ratios. FINDINGS ART guidelines have evolved from "treating the sickest" to "treating all". ART coverage increased globally from under 7% in 2005 to 62% in 2018. There have been successes in increasing ART coverage in all populations and locations. However, progress varies by population and location in many regions. There is inequity in ART coverage: women (68%) versus men (55%), and adults (62%) versus children (54%). This inequity has widened over time, and with expanded ART eligibility criteria. On the other hand, data from at least one high-burden country (Ethiopia) shows that inequity among regions has narrowed over time due to the improvements in the primary health care systems and implementation of the public health approach in the country. CONCLUSION ART coverage has increased at global, regional and national levels to all population groups. However, the gains have not been equitable among locations and populations. Policies towards universality may widen the inequity in resource-limited settings unless countries take precautions and "put the last first". We argue that primary health care and public health approaches, with multi-sectoral actions and community engagement, are vital to minimize inequity, achieve UHC and leave no one behind.
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Affiliation(s)
- Yibeltal Assefa
- School of Public Health, the University of Queensland, Brisbane, Australia
| | - Peter S. Hill
- School of Public Health, the University of Queensland, Brisbane, Australia
| | | | - Judith Dean
- School of Public Health, the University of Queensland, Brisbane, Australia
| | - Charles F. Gilks
- School of Public Health, the University of Queensland, Brisbane, Australia
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25
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Lazarou M, Fitzgerald L, Warner M, Downing S, Williams OD, Gilks CF, Russell D, Dean JA. Australian interdisciplinary healthcare providers' perspectives on the effects of broader pre-exposure prophylaxis (PrEP) access on uptake and service delivery: a qualitative study. Sex Health 2020; 17:485-492. [PMID: 33292927 DOI: 10.1071/sh20156] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/18/2020] [Indexed: 12/15/2022]
Abstract
Background The addition of pre-exposure prophylaxis (PrEP) for HIV prevention to the Australian Government-subsidised Pharmaceutical Benefits Scheme (PBS) enables any doctor or nurse practitioner to prescribe it and has increased accessibility options. However, understanding of Australian healthcare providers' (HCP) knowledge and preparedness to prescribe PrEP remains limited. METHODS Semistructured interviews, conducted before PBS listing (October 2016-April 2017), explored PrEP knowledge and prescription experiences of 51 multidisciplinary HCPs involved with the Queensland Pre-Exposure Prophylaxis Demonstration study. RESULTS Thematic analysis revealed that participants viewed PrEP as a necessary HIV prevention option, but there was concern about confusing prevention messages and potential risk compensation. Clinical capacity, stigma, cultural norms, rural access and PrEP-associated costs were identified as barriers to access and uptake. Some of these barriers may be addressed by the PBS listing; nonetheless, there was strong specialist concern about the preparedness of general practitioners without sexual health experience to prescribe PrEP. Participants identified a need to educate all HCPs, implement multidisciplinary supply models and provide timely access to PrEP for vulnerable populations and those ineligible for Medicare (Australia's universal healthcare insurance system). CONCLUSIONS Although PrEP listing on the PBS addressed structural barriers to access, this study highlights the role of nurses and other interdisciplinary healthcare workers in the provision of PrEP in addressing the sociocultural barriers that still affect the access of certain populations to HIV prevention measures. These findings will inform further professional training as PrEP is more widely accessed and requested outside specialist sexual health services. Future work is needed to ensure that the primary healthcare workforce is prepared to provide competent and safe access to PrEP across diverse locations and population groups.
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Affiliation(s)
- Mattea Lazarou
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston Campus, 288 Herston Road, Herston, Qld 4006, Australia
| | - Lisa Fitzgerald
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston Campus, 288 Herston Road, Herston, Qld 4006, Australia
| | - Melissa Warner
- Blood Borne Virus and Sexually Transmissible Infection Unit, Communicable Disease Branch, Queensland Health, Butterfield Street, Herston, Qld 4006, Australia
| | - Sandra Downing
- College of Public Health, Medical and Veterinary Sciences, Division of Tropical Health and Medicine, James Cook University, 1 James Cook Drive, Douglas, Qld 4811, Australia
| | - Owain D Williams
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston Campus, 288 Herston Road, Herston, Qld 4006, Australia
| | - Charles F Gilks
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston Campus, 288 Herston Road, Herston, Qld 4006, Australia
| | - Darren Russell
- Cairns Sexual Health Service, Cairns and Hinterland Hospital and Health Service, 381 Sheridan Street, Cairns North, Qld 4870, Australia; and College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Douglas, Qld 4811, Australia
| | - Judith A Dean
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston Campus, 288 Herston Road, Herston, Qld 4006, Australia; and Corresponding author.
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26
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Badman SG, Bell SFE, Dean JA, Lemoire J, Coffey L, Debattista J, Redmond AM, Williams OD, Gilks CF, Whiley DM. Reduced sensitivity from pooled urine, pharyngeal and rectal specimens when using a molecular assay for the detection of chlamydia and gonorrhoea near the point of care. Sex Health 2020; 17:15-21. [PMID: 31945307 DOI: 10.1071/sh19028] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 09/12/2019] [Indexed: 11/23/2022]
Abstract
Background The aim of this study was to compare the performance of pooled self-collected urogenital, pharyngeal and anorectal specimens to that of individual specimen results for the molecular detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) near the point of care (POC) for diagnostic sensitivity. METHODS Clients (mostly men who have sex with men) attending an urban community testing service and three sex-on-premises venues in Brisbane, Australia, were offered CT and NG testing by trained lay providers. Participants provided three self-collected specimens (urine, pharyngeal and rectal) for testing by GeneXpert (Cepheid, Sunnyvale, CA, USA). If any of the individual specimens from a participant were positive, all three specimens were pooled and retested. RESULTS Of the 388 participants who provided three individual anatomical specimens, 76 (19.6%) were found to be positive for CT and/or NG at one or more sites. The pooling approach failed to detect five CT rectal and four NG pharyngeal infections. The overall performance (sensitivity) of the pooling approach compared with individual specimen testing and Cohen's κ were 90.0% and 0.86 respectively for CT and 89.7% and 0.89 respectively for NG. CONCLUSIONS Reduced sensitivity was observed when using pooled specimens for the detection of CT and NG using GeneXpert near the POC, similar to results reported in laboratory-based CT and NG pooling studies. These data suggest specimen pooling is feasible near to the POC, potentially saving time and costs when screening at-risk populations for CT and NG. Our data also suggest a reduction in pooled urine could improve overall test sensitivity.
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Affiliation(s)
- Steven G Badman
- The Kirby Institute, Level 6, Wallace Wurth Building, High Street, UNSW Sydney, Randwick, NSW 2032, Australia; and Corresponding author.
| | - Sara F E Bell
- School of Public Health, The University of Queensland, 288 Herston Road, Herston, Qld 4006, Australia
| | - Judith A Dean
- School of Public Health, The University of Queensland, 288 Herston Road, Herston, Qld 4006, Australia
| | - Jime Lemoire
- RAPID, Queensland Positive People, 21 Manilla Street, East Brisbane, Qld 4169, Australia
| | - Luke Coffey
- RAPID, Queensland Positive People, 21 Manilla Street, East Brisbane, Qld 4169, Australia
| | - Joseph Debattista
- Metro North Public Health Unit, Bryden Street, Windsor, Qld 4030, Australia
| | - Andrew M Redmond
- RAPID, Queensland Positive People, 21 Manilla Street, East Brisbane, Qld 4169, Australia; and Infectious Diseases Services, Royal Brisbane and Women's Hospital, Herston, Qld 4029, Australia
| | - Owain D Williams
- School of Public Health, The University of Queensland, 288 Herston Road, Herston, Qld 4006, Australia
| | - Charles F Gilks
- School of Public Health, The University of Queensland, 288 Herston Road, Herston, Qld 4006, Australia
| | - David M Whiley
- Centre for Clinical Research, The University of Queensland, Building 71/918, Royal Brisbane and Women's Hospital Campus, Herston, Qld 4029, Australia; and Pathology Queensland, Level 4, Block 7, Royal Brisbane and Women's Hospital, Herston, Qld 4006, Australia
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27
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Bell SFE, Coffey L, Debattista J, Badman SG, Redmond AM, Whiley DM, Lemoire J, Williams OD, Howard C, Gilks CF, Dean JA. Peer-delivered point-of-care testing for Chlamydia trachomatis and Neisseria gonorrhoeae within an urban community setting: a cross-sectional analysis. Sex Health 2020; 17:359-367. [PMID: 32731917 DOI: 10.1071/sh19233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 06/11/2020] [Indexed: 11/23/2022]
Abstract
Background The advent of fully automated nucleic acid amplification test (NAAT) technology brings new public health opportunities to provide Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) point-of-care testing (POCT) in non-traditional settings. METHODS This pilot study evaluated the integration of the CT/NG Xpert diagnostic assay into an urban peer-led community setting providing HIV and syphilis POCT. A comprehensive protocol of testing, result notification, referral and follow up, managed by peer test facilitators, was undertaken. RESULTS Over 67 weeks, there were 4523 occasions of CT/NG testing using urine, oropharyngeal and anorectal samples with 25.7% (803) of the 3123 unique participants returning for repeat testing. The prevalence of CT and NG was 9.5% and 5.4% respectively. Where CT and or NG infection was detected, 98.4% (604/614) of participants were successfully notified of detected infection and referred for treatment. Evaluation Survey responses (11.4%, 516/4523) indicated a substantial proportion of respondents (27.1%, 140/516) 'would not have tested anywhere else'. Of note, 17.8% (92/516) of participants reported no previous CT/NG test and an additional 17.8% (92/516) reported testing more than 12 months ago. A total of 95.9% (495/516) of participants 'Strongly agreed' or 'Agreed' to being satisfied with the service. CONCLUSION The project successfully demonstrated an acceptable and feasible model for a peer-delivered community-led service to provide targeted molecular CT/NG POCT. This model offers capacity to move beyond the traditional pathology and STI testing services and establish community-led models that build trust and increase testing rates for key populations of epidemiological significance.
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Affiliation(s)
- Sara F E Bell
- School of Public Health, The University of Queensland, Herston Campus, 288 Herston Road, Herston, Qld 4006, Australia
| | - Luke Coffey
- RAPID, Queensland Positive People, 21 Manilla Street, East Brisbane, Qld 4169, Australia
| | - Joseph Debattista
- Metro North Public Health Unit, Metro North Hospital and Health Service, Bryden Street, Windsor, Qld 4030, Australia
| | - Steven G Badman
- Kirby Institute, L6, Wallace Wurth Building, High Street, The University of New South Wales Sydney, Randwick, NSW 2032, Australia
| | - Andrew M Redmond
- RAPID, Queensland Positive People, 21 Manilla Street, East Brisbane, Qld 4169, Australia; and Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Butterfield St, Herston, Qld 4029, Australia
| | - David M Whiley
- Centre for Clinical Research, The University of Queensland, Building 71/918, Royal Brisbane and Women's Hospital Campus, Herston, Qld 4029, Australia; and Pathology Queensland, Block 7, Royal Brisbane and Women's Hospital, Herston, Qld 4029, Australia
| | - Jime Lemoire
- RAPID, Queensland Positive People, 21 Manilla Street, East Brisbane, Qld 4169, Australia
| | - Owain D Williams
- School of Public Health, The University of Queensland, Herston Campus, 288 Herston Road, Herston, Qld 4006, Australia
| | - Chris Howard
- RAPID, Queensland Positive People, 21 Manilla Street, East Brisbane, Qld 4169, Australia
| | - Charles F Gilks
- School of Public Health, The University of Queensland, Herston Campus, 288 Herston Road, Herston, Qld 4006, Australia
| | - Judith A Dean
- School of Public Health, The University of Queensland, Herston Campus, 288 Herston Road, Herston, Qld 4006, Australia; and Corresponding author.
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Gelaw YA, Williams G, Soares Magalhães RJ, Gilks CF, Assefa Y. HIV Prevalence Among Tuberculosis Patients in Sub-Saharan Africa: A Systematic Review and Meta-analysis. AIDS Behav 2019; 23:1561-1575. [PMID: 30607755 DOI: 10.1007/s10461-018-02386-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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] [Indexed: 12/31/2022]
Abstract
HIV associated tuberculosis (TB) morbidity and mortality is a major concern in sub-Saharan Africa. Understanding the level of HIV infection among TB patients is vital for adequate response. We conducted a systematic review and meta-analysis to estimate the prevalence of HIV in TB patients in sub-Saharan Africa. We searched PubMed, EMBASE, Web of Science and CINAHL databases. A meta-analysis with a random-effects model was performed. Potential sources of heterogeneity in the prevalence estimates were explored using meta-regression analysis. We identified 68 studies that collectively included 62,969 TB patients between 1990 and 2017. The overall estimate of HIV prevalence in TB patients was 31.8% (95% CI 27.8-36.1). There was substantial heterogeneity in the prevalence estimates in Southern, Central, Eastern, and Western sub-Saharan Africa regions (43.7, 41.3, 31.1 and 25.5%, respectively). We noted an apparent reduction in the estimate from 33.7% (95% CI 27.6-40.4) in the period before 2000 to 25.7% (95% CI 17.6-336.6) in the period after 2010. The Eastern and Southern sub-Saharan Africa region had higher prevalence [34.4% (95% CI 29.3-34.4)] than the Western and Central region [27.3% (95% CI 21.6-33.8)]. The prevalence of HIV in TB patients has declined over time in sub-Saharan Africa. We argue that this is due to strengthened HIV prevention and control response and enhanced TB/HIV collaborative activities. Countries and regions with high burdens of HIV and TB should strengthen and sustain efforts in order to achieve the goal of ending both HIV and TB epidemics in line with the Sustainable Development Goals.
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Affiliation(s)
- Yalemzewod Assefa Gelaw
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Brisbane, QLD, 4006, Australia.
- Institute of Public Health, College of Medicine and Health Science, University of Gondar, 196, Gondar, Ethiopia.
| | - Gail Williams
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Brisbane, QLD, 4006, Australia
| | - Ricardo J Soares Magalhães
- UQ Spatial Epidemiology Laboratory, Faculty of Science, School of Veterinary Science, The University of Queensland, Gatton, QLD, 4343, Australia
- Children's Health and Environment Program, Faculty of Medicine, Child Health Research Centre, The University of Queensland, Brisbane, QLD, 4101, Australia
| | - Charles F Gilks
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Brisbane, QLD, 4006, Australia
| | - Yibeltal Assefa
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Brisbane, QLD, 4006, Australia
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Woldeyohannes SM, Gilks CF, Baker P, Perkins NR, Reid SA. Seroprevlance of Coxiella burnetii among abattoir and slaughterhouse workers: A meta-analysis. One Health 2018; 6:23-28. [PMID: 30302365 PMCID: PMC6175780 DOI: 10.1016/j.onehlt.2018.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 09/22/2018] [Accepted: 09/22/2018] [Indexed: 12/12/2022] Open
Abstract
Q fever caused by the gram negative bacteria, Coxiella burnetii, is an occupational hazard for those who live and work in rural settings and those who are in contact with animals, especially abattoir and slaughterhouse workers. Australia is the only country to register a vaccine to prevent Q fever (Q-vax®, Seqirus, Australia) that is used in high risk populations. Seroprevalence studies conducted to determine the burden of Q fever (C. burnetii infection) in different settings have demonstrated high levels of heterogeneity with estimates of the percent positive ranging from 30% to 70%. There is a need for a more systematic evaluation of the findings of these studies in order to provide summary estimates of the seroprevalence in different settings. We searched for published articles using PubMed, MEDLINE-EMBASE, and Scopus databases using search terms obtained from an initial review of published reports of recent Q fever outbreaks. Data on the seroprevalence of C. burnetii infection (Q fever) was extracted from the selected studies and a random effects meta-analysis was performed with stratification by outbreak status, year, country and serological techniques used. Results were visualised with a forest plot with 95% CI and measures of heterogeneity (I 2) for the random effects model. A total of 19 articles that met the search criteria were included. The reported seroprevalence rate ranged from 4.7% to 91.7% among abattoir and slaughterhouse workers. No inter-group heterogeneity was observed (p = 0.956), supporting the pooling of all studies into one pooled measure. The pooled estimate of seropositivity for C. burnetii infection in people working in abattoirs and slaughterhouses was 26% (95% CI: 18-35%) regardless of the evidence of an "outbreak", the time of year or country. Seropositivity for C burnetii was independent of a person's age and years of occupational experience. Within abattoirs and slaughterhouses, slaughtering of cattle, sheep and goats are the most important risk factors associated with seropositivity and for those who showed over symptoms upon infection. We recommend that vaccination programmes are directed towards people employed in the meat processing industry to mitigate the significant health and economic impacts of Q fever.
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Affiliation(s)
- Solomon M. Woldeyohannes
- School of Public Health, The University of Queensland, Herston, Queensland 4006, Australia
- School of Veterinary Science, The University of Queensland, Gatton, Queensland 4343, Australia
| | - Charles F. Gilks
- School of Public Health, The University of Queensland, Herston, Queensland 4006, Australia
| | - Peter Baker
- School of Public Health, The University of Queensland, Herston, Queensland 4006, Australia
| | - Nigel R. Perkins
- School of Veterinary Science, The University of Queensland, Gatton, Queensland 4343, Australia
| | - Simon A. Reid
- School of Public Health, The University of Queensland, Herston, Queensland 4006, Australia
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Assefa Y, Gilks CF, Dean J, Tekle B, Lera M, Balcha TT, Getaneh Y, Van Damme W, Hill PS. Towards achieving the fast-track targets and ending the epidemic of HIV/AIDS in Ethiopia: Successes and challenges. Int J Infect Dis 2018; 78:57-64. [PMID: 30391417 DOI: 10.1016/j.ijid.2018.10.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 10/25/2018] [Accepted: 10/26/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Ethiopia has adopted the global plan to end the epidemic of HIV/AIDS. The aim of this study was to assess the progress made towards achieving this plan. METHODS A review and analysis of national population-based surveys, surveillance, and routine programme data was executed. The data analysis was conducted using Excel 2016 and Stata 14 (StataCorp LP, College Station, TX, USA). RESULTS Between 2011 and 2016, the number of HIV-related deaths dropped by 58%, while that of new HIV infections dropped by only 6%. Discriminatory attitudes declined significantly from 77.9% (95% confidence interval (CI) 77.3-78.4%) in 2011 to 41.5% (95% CI 40.6-42.4%) in 2016. Around 79% of adult people living with HIV (PLHIV) were aware of their HIV status; 90% of PLHIV who were aware of their HIV status were taking antiretroviral treatment (ART) and 88% of adult PLHIV on ART had viral suppression in 2016. The proportion of people aged 15-49 years who had ever been tested for HIV and had received results increased from 39.8% (95% CI 39.2-40.4%) in 2011 to 44.8% (95% CI 44.2-45.4%) in 2016. This proportion was very low among children below age 15 years at only 6.2% (95% CI 5.9-6.5%). Among regions, HIV testing coverage varied from 13% to 72%. Female sex workers had lower coverage for HIV testing (31%) and ART (70%) than the national average in the adult population. International funding for HIV dropped from more than US$ 1.3 billion in 2010-2012 to less than US$ 800 million in 2016-2018. CONCLUSIONS Ethiopia is on track to achieve the targets for HIV testing, ART, viral suppression, and AIDS-related deaths, but not for reductions in new HIV infections, discriminatory attitudes, and equity. Ending the epidemic of HIV/AIDS requires a combined response, including prevention and treatment, tailored to key populations and locations, as well as increased funding.
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Affiliation(s)
- Yibeltal Assefa
- School of Public Health, the University of Queensland, Brisbane, Australia.
| | - Charles F Gilks
- School of Public Health, the University of Queensland, Brisbane, Australia
| | - Judith Dean
- School of Public Health, the University of Queensland, Brisbane, Australia
| | - Betru Tekle
- United Nations Programme on HIV/AIDS, Kigali, Rwanda
| | - Meskele Lera
- Federal Ministry of Health, Addis Ababa, Ethiopia
| | | | - Yimam Getaneh
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Peter S Hill
- School of Public Health, the University of Queensland, Brisbane, Australia
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Bell SFE, Dean JA, Lemoire J, Debattista J, Driver G, Gilks CF, Redmond A, Williams OD. Integrated HIV self-testing (HIVST) service delivery in Queensland for policy and service development: study protocol. AIDS Care 2018; 31:207-215. [DOI: 10.1080/09540121.2018.1516859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
| | - Judith Ann Dean
- School of Public Health, The University of Queensland, Herston, Australia
| | - Jime Lemoire
- RAPID, Queensland Positive People, East Brisbane, Australia
| | - Joseph Debattista
- Metro North Public Health Unit, Metro North Hospital and Health Service, Windsor, Australia
| | - Glen Driver
- RAPID, Queensland Positive People, East Brisbane, Australia
| | - Charles F. Gilks
- School of Public Health, The University of Queensland, Herston, Australia
| | - Andrew Redmond
- RAPID, Queensland Positive People, East Brisbane, Australia
- Royal Brisbane and Women’s Hospital, Metro North Hospital and Health Service, Windsor, Australia
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Affiliation(s)
- Mark A Boyd
- University of Adelaide, Lyell McEwin Hospital, Adelaide, SA 5112, Australia.
| | - David A Cooper
- Kirby Institute, University of New South Wales Australia, NSW, Australia
| | - Charles F Gilks
- School of Public health, University of Queensland, Queensland, Australia
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Affiliation(s)
- Yibeltal Assefa
- School of Public Health, University of Queensland, QLD, Australia
| | - Charles F Gilks
- School of Public Health, University of Queensland, QLD, Australia.
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Assefa Y, Gilks CF, Lynen L, Williams O, Hill PS, Tolera T, Malvia A, Van Damme W. Performance of the Antiretroviral Treatment Program in Ethiopia, 2005-2015: strengths and weaknesses toward ending AIDS. Int J Infect Dis 2017; 60:70-76. [PMID: 28533167 DOI: 10.1016/j.ijid.2017.05.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 05/11/2017] [Accepted: 05/11/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Ethiopia is one of the countries which has scaled up antiretroviral treatment (ART) over the past decade. This study reviews the performance of the ART program in Ethiopia during the past decade, and identifies successes and weaknesses toward ending AIDS in the country. METHODS A review and synthesis of data was conducted using multiple data sources: reports from all health facilities in Ethiopia to the Federal Ministry of Health, HIV/AIDS estimates and projections, and retrospective cohort and cross-sectional studies conducted between 2005/6 and 2014/15. FINDINGS The ART program has been successful over several critical areas: (1) ART coverage improved from 4% to 54%; (2) the median CD4 count/mm3 at the time of ART initiation increased from 125 in 2005/6 to 231 in 2012/13; (3) retention in care after 12 months on ART has increased from 82% to 92%. In spite of these successes, important challenges also remain: (1) ART coverage is not equitable: among regions (5.6%-93%), between children (25%) and adults (60%), and between female (54%) and male patients (69%); (2) retention in care is variable among regions (83%-94%); and, (3) the shift to second-line ART is slow and low (0·58%). INTERPRETATION The findings suggest that the ART program should sustain the successes and reflect on the shortcomings toward the goal of ending AIDS. It is important to capitalize on and calibrate the interventions and approaches utilized to scale up ART in the past. Analysis of the treatment cascade, in order to pinpoint the gaps and identify appropriate solutions, is commendable in this regard.
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Affiliation(s)
- Yibeltal Assefa
- The University of Queensland, School of Public Health, Brisbane, Australia; Ethiopian Public Health Institute, Addis Ababa, Ethiopia.
| | - Charles F Gilks
- The University of Queensland, School of Public Health, Brisbane, Australia
| | - Lutgarde Lynen
- Institute of Tropical Medicine, Department of Clinical Sciences, Antwerp, Belgium
| | - Owain Williams
- The University of Queensland, School of Public Health, Brisbane, Australia
| | - Peter S Hill
- The University of Queensland, School of Public Health, Brisbane, Australia
| | - Taye Tolera
- Federal Ministry of Health, Addis Ababa, Ethiopia
| | | | - Wim Van Damme
- Institute of Tropical Medicine, Department of Public Health, Antwerp, Belgium
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Ford D, Muzambi M, Nkhata MJ, Abongomera G, Joseph S, Ndlovu M, Mabugu T, Grundy C, Chan AK, Cataldo F, Kityo C, Seeley J, Katabira E, Gilks CF, Reid A, Hakim J, Gibb DM. Implementation of Antiretroviral Therapy for Life in Pregnant/Breastfeeding HIV+ Women (Option B+) Alongside Rollout and Changing Guidelines for ART Initiation in Rural Zimbabwe: The Lablite Project Experience. J Acquir Immune Defic Syndr 2017; 74:508-516. [PMID: 27984555 PMCID: PMC5751886 DOI: 10.1097/qai.0000000000001267] [Citation(s) in RCA: 16] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women (Option B+) was rolled out in Zimbabwe from 2014, with simultaneous raising of the CD4 treatment threshold to 500 cells per cubic millimeter in nonpregnant/breastfeeding adults and children 5 years and over. METHODS Lablite is an implementation project in Zimbabwe, Malawi, and Uganda evaluating ART rollout. Routine patient-level data were collected for 6 months before and 12 months after Option B+ rollout at a district hospital and 3 primary care facilities in Zimbabwe (2 with outreach ART and 1 with no ART provision before Option B+). RESULTS Between September 2013 and February 2015, there were 1686 ART initiations in the 4 facilities: 91% adults and 9% children younger than 15 years. In the 3 facilities with established ART, initiations rose from 300 during 6 months before Option B+ to 869 (2.9-fold) and 463 (1.5-fold), respectively, 0-6 months and 6-12 months after Option B+. Post-Option B+, an estimated 43% of pregnant/breastfeeding women needed ART for their own health, based on World Health Organization stage 3/4 or CD4 ≤350 per cubic millimeter (64% for CD4 ≤500). Seventy-four men (22%) and 123 nonpregnant/breastfeeding women (34%) initiated ART with CD4 >350 after the CD4 threshold increase. Estimated 12-month retention on ART was 79% (69%-87%) in Option B+ women (significantly lower in younger women, P = 0.01) versus 93% (91%-95%) in other adults (difference P < 0.001). CONCLUSIONS There were increased ART initiations in all patient groups after implementation of World Health Organization 2013 guidelines. Retention of Option B+ women was poorer than retention of other adults; younger women require attention because they are more likely to disengage from care.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Adrienne K Chan
- Dignitas International, Zomba, Malawi
- Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | | | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Janet Seeley
- MRC/UVRI Uganda Research Unit of AIDS, Entebbe, Uganda
| | - Elly Katabira
- Infectious Diseases Institute, Makerere University, Mulago, Uganda
| | - Charles F Gilks
- Infectious Diseases Institute, Makerere University, Mulago, Uganda
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Dolling DI, Goodall RL, Chirara M, Hakim J, Nkurunziza P, Munderi P, Eram D, Tumukunde D, Spyer MJ, Gilks CF, Kaleebu P, Dunn DT, Pillay D. The virological durability of first-line ART among HIV-positive adult patients in resource limited settings without virological monitoring: a retrospective analysis of DART trial data. BMC Infect Dis 2017; 17:160. [PMID: 28222702 PMCID: PMC5319022 DOI: 10.1186/s12879-017-2266-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 02/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Few low-income countries have virological monitoring widely available. We estimated the virological durability of first-line antiretroviral therapy (ART) after five years of follow-up among adult Ugandan and Zimbabwean patients in the DART study, in which virological assays were conducted retrospectively. METHODS DART compared clinically driven monitoring with/without routine CD4 measurement. Annual plasma viral load was measured on 1,762 patients. Analytical weights were calculated based on the inverse probability of sampling. Time to virological failure, defined as the first viral load measurement ≥200 copies/mL after 48 weeks of ART, was analysed using Kaplan-Meier plots and Cox regression models. RESULTS Overall, 65% of DART trial patients were female. Patients initiated first-line ART at a median (interquartile range; IQR) age of 37 (32-42) and with a median CD4 cell count of 86 (32-140). After 240 weeks of ART, patients initiating dual-class nucleoside reverse-transcriptase inhibitor (NRTI) -non-nucleoside reverse-transcriptase (NNRTI) regimens containing nevirapine + zidovudine + lamivudine had a lower incidence of virological failure than patients on triple-NRTI regimens containing tenofovir + zidovudine + lamivudine (21% vs 40%; hazard ratio (HR) =0.48, 95% CI:0.38-0.62; p < 0.0001). In multivariate analyses, female patients (HR = 0.79, 95% CI: 0.65-0.95; p = 0.02), older patients (HR = 0.73 per 10 years, 95% CI: 0.64-0.84; p < 0.0001) and patients with a higher pre-ART CD4 cell count (HR = 0.64 per 100 cells/mm3, 95% CI: 0.54-0.75; p < 0.0001) had a lower incidence of virological failure after adjusting for adherence to ART. No difference in failure rate between the two randomised monitoring strategies was observed (p= 0.25). CONCLUSIONS The long-term durability of virological suppression on dual-class NRTI-NNRTI first-line ART without virological monitoring is remarkable and is enabled by high-quality clinical management and a consistent drug supply. To achieve higher rates of virological suppression viral-load-informed differentiated care may be required. TRIAL REGISTRATION Prospectively registered on 18/10/2000 as ISRCTN13968779 .
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Affiliation(s)
| | | | | | | | | | | | - David Eram
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | | | | | - Charles F Gilks
- School of Population Health, University of Queensland, Brisbane, Australia
| | | | | | - Deenan Pillay
- Africa Centre for Health and Population Studies, University of KwaZulu Natal, Durban, South Africa
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Nkhata MJ, Muzambi M, Ford D, Chan AK, Abongomera G, Namata H, Mambule I, South A, Revill P, Grundy C, Mabugu T, Chiwaula L, Hakim J, Kityo C, Reid A, Katabira E, Sodhi S, Gilks CF, Gibb DM, Seeley J, Cataldo F. Shifting human resources for health in the context of ART provision: qualitative and quantitative findings from the Lablite baseline study. BMC Health Serv Res 2016; 16:660. [PMID: 27852291 PMCID: PMC5112633 DOI: 10.1186/s12913-016-1891-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lablite is an implementation project supporting and studying decentralized antiretroviral therapy (ART) rollout to rural communities in Malawi, Uganda and Zimbabwe. Task shifting is one of the strategies to deal with shortage of health care workers (HCWs) in ART provision. Evaluating Human Resources for Health (HRH) optimization is essential for ensuring access to ART. The Lablite project started with a baseline survey whose aim was to describe and compare national and intercountry delivery of ART services including training, use of laboratories and clinical care. METHODS A cross-sectional survey was conducted between October 2011 and August 2012 in a sample of 81 health facilities representing different regions, facility levels and experience of ART provision in Malawi, Uganda and Zimbabwe. Using a questionnaire, data were collected on facility characteristics, human resources and service provision. Thirty three (33) focus group discussions were conducted with HCWs in a subset of facilities in Malawi and Zimbabwe. RESULTS The survey results showed that in Malawi and Uganda, primary care facilities were run by non-physician clinical officers/medical assistants while in Zimbabwe, they were run by nurses/midwives. Across the three countries, turnover of staff was high especially among nurses. Between 10 and 20% of the facilities had at least one clinical officer/medical assistant leave in the 3 months prior to the study. Qualitative results show that HCWs in ART and non-ART facilities perceived a shortage of staff for all services, even prior to the introduction of ART provision. HCWs perceived the introduction of ART as having increased workload. In Malawi, the number of people on ART and hence the workload for HCWs has further increased following the introduction of Option B+ (ART initiation and life-long treatment for HIV positive pregnant and lactating women), resulting in extended working times and concerns that the quality of services have been affected. For some HCWs, perceived low salaries, extended working schedules, lack of training opportunities and inadequate infrastructure for service provision were linked to low job satisfaction and motivation. CONCLUSIONS ART has been decentralized to lower level facilities in the context of an ongoing HRH crisis and staff shortage, which may compromise the provision of high-quality ART services. Task shifting interventions need adequate resources, relevant training opportunities, and innovative strategies to optimize the operationalization of new WHO treatment guidelines which continue to expand the number of people eligible for ART.
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Affiliation(s)
| | | | - Deborah Ford
- MRC Clinical Trials Unit at University College London, London, UK
| | - Adrienne K Chan
- Dignitas International, Zomba, Malawi.,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | | | | | - Ivan Mambule
- Infectious Diseases Institute, Makerere University, Mulago, Uganda
| | - Annabelle South
- MRC Clinical Trials Unit at University College London, London, UK
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Caroline Grundy
- MRC Clinical Trials Unit at University College London, London, UK
| | | | | | | | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | | | - Elly Katabira
- Infectious Diseases Institute, Makerere University, Mulago, Uganda
| | - Sumeet Sodhi
- Dignitas International, Zomba, Malawi.,Department of Family and Community Medicine, University of Toronto, Toronto, Canada.,Department of Family and Community Medicine, University Health Network, Toronto Western Hospital, Toronto, Canada
| | - Charles F Gilks
- School of Population Health, University of Queensland, St Lucia, Australia
| | - Diana M Gibb
- MRC Clinical Trials Unit at University College London, London, UK
| | - Janet Seeley
- MRC/UVRI Uganda Research Unit of AIDS, Entebbe, Uganda
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38
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French N, Gordon SB, Mwalukomo T, White SA, Mwafulirwa G, Longwe H, Mwaiponya M, Zijlstra EE, Molyneux ME, Gilks CF. A trial of a 7-valent pneumococcal conjugate vaccine in HIV-infected adults. Malawi Med J 2016; 28:115-122. [PMID: 27895845 PMCID: PMC5117001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Streptococcus pneumoniae is a leading and serious coinfection in adults with human immunodeficiency virus (HIV) infection, particularly in Africa. Prevention of this disease by vaccination with the current 23-valent polysaccharide vaccine is suboptimal. Protein conjugate vaccines offer a further option for protection, but data on their clinical efficacy in adults are needed. METHODS In this double-blind, randomized, placebo-controlled clinical efficacy trial, we studied the efficacy of a 7-valent conjugate pneumococcal vaccine in predominantly HIV-infected Malawian adolescents and adults who had recovered from documented invasive pneumococcal disease. Two doses of vaccine were given 4 weeks apart. The primary end point was a further episode of pneumococcal infection caused by vaccine serotypes or serotype 6A. RESULTS From February 2003 through October 2007, we followed 496 patients (of whom 44% were male and 88% were HIV-seropositive) for 798 person-years of observation. There were 67 episodes of pneumococcal disease in 52 patients, all in the HIV-infected subgroup. In 24 patients, there were 19 episodes that were caused by vaccine serotypes and 5 episodes that were caused by the 6A serotype. Of these episodes, 5 occurred in the vaccine group and 19 in the placebo group, for a vaccine efficacy of 74% (95% confidence interval [CI], 30 to 90). There were 73 deaths from any cause in the vaccine group and 63 in the placebo group (hazard ratio in the vaccine group, 1.18; 95% CI, 0.84 to 1.66). The number of serious adverse events within 14 days after vaccination was significantly lower in the vaccine group than in the placebo group (3 vs. 17, P = 0.002), and the number of minor adverse events was significantly higher in the vaccine group (41 vs. 13, P = 0.003). CONCLUSIONS The 7-valent pneumococcal conjugate vaccine protected HIV-infected adults from recurrent pneumococcal infection caused by vaccine serotypes or serotype 6A. (Current Controlled Trials number, ISRCTN54494731.).
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Affiliation(s)
- Neil French
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Karonga Prevention Study, London School of Hygiene and Tropical Medicine, Karonga, Malawi
| | - Stephen B Gordon
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Thandie Mwalukomo
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Sarah A White
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Gershom Mwafulirwa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Herbert Longwe
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Martin Mwaiponya
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Eduard E Zijlstra
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Malcolm E Molyneux
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Abstract
Self-Testing for HIV (HIVST) is widely recognised as a feasible and effective means of increasing rates of testing and detection of HIV, particularly in non-testing and infrequent testing populations. Currently in Australia, the only means of accessing this technology is to purchase unregulated products on-line. A search of available on-line distributers was purposefully performed from the perspective of an English-speaking individual, with no clinical background or specific understanding of HIV testing practices, seeking to determine their HIV status. Purchased kits were assessed against a structured extraction tool based on the Australian Therapeutic Goods Administration (TGA) HIV testing clinical performance guidelines. In total, eight HIVST kits were purchased from seven different distributers. Analysis of the purchased kits and linked websites revealed that none met the TGA's requirements for HIV testing kits intended for home use; none also conformed to the additional recommendations for information, quality and links to services developed from this study's review of HIVST associated literature. People seeking HIVST kits are able to purchase sub-standard products that ill-serve their needs, and do so at a time of great personal vulnerability. The fact that Australians are willing to purchase and use these sub-standard products indicates HIVST is in demand. Health policy and models of service are needed in order to ensure people have access to a safe and effective registered device at prices that enable equity of access to all Australians, particularly those most at risk of HIV. Other countries awaiting access to regulated HIVST devices also need to consider the potential implications. Collaboration between manufacturers, distributers, regulatory bodies, service providers and the community is needed globally in order to ensure HIVST is embedded into testing methods in a manner that does not disrupt but rather safely and effectively increases HIV testing rates.
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Affiliation(s)
- Owain David Williams
- a School of Public Health, Faculty of Medicine and Biomedical Sciences , The University of Queensland , Herston , Australia
| | - Judith Ann Dean
- a School of Public Health, Faculty of Medicine and Biomedical Sciences , The University of Queensland , Herston , Australia
| | - Kim Harting
- a School of Public Health, Faculty of Medicine and Biomedical Sciences , The University of Queensland , Herston , Australia
| | - Kate Bath
- a School of Public Health, Faculty of Medicine and Biomedical Sciences , The University of Queensland , Herston , Australia
| | - Charles F Gilks
- a School of Public Health, Faculty of Medicine and Biomedical Sciences , The University of Queensland , Herston , Australia
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Sutherland KA, Parry CM, McCormick A, Kapaata A, Lyagoba F, Kaleebu P, Gilks CF, Goodall R, Spyer M, Kityo C, Pillay D, Gupta RK. Correction: Evidence for Reduced Drug Susceptibility without Emergence of Major Protease Mutations following Protease Inhibitor Monotherapy Failure in the SARA Trial. PLoS One 2016; 11:e0157094. [PMID: 27254277 PMCID: PMC4890937 DOI: 10.1371/journal.pone.0157094] [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] [Indexed: 11/19/2022] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pone.0137834.].
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Ford D, Robins JM, Petersen ML, Gibb DM, Gilks CF, Mugyenyi P, Grosskurth H, Hakim J, Katabira E, Babiker AG, Walker AS. The Impact of Different CD4 Cell-Count Monitoring and Switching Strategies on Mortality in HIV-Infected African Adults on Antiretroviral Therapy: An Application of Dynamic Marginal Structural Models. Am J Epidemiol 2015; 182:633-43. [PMID: 26316598 PMCID: PMC4581589 DOI: 10.1093/aje/kwv083] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 03/27/2015] [Indexed: 12/14/2022] Open
Abstract
In Africa, antiretroviral therapy (ART) is delivered with limited laboratory monitoring, often none. In 2003–2004, investigators in the Development of Antiretroviral Therapy in Africa (DART) Trial randomized persons initiating ART in Uganda and Zimbabwe to either laboratory and clinical monitoring (LCM) or clinically driven monitoring (CDM). CD4 cell counts were measured every 12 weeks in both groups but were only returned to treating clinicians for management in the LCM group. Follow-up continued through 2008. In observational analyses, dynamic marginal structural models on pooled randomized groups were used to estimate survival under different monitoring-frequency and clinical/immunological switching strategies. Assumptions included no direct effect of randomized group on mortality or confounders and no unmeasured confounders which influenced treatment switch and mortality or treatment switch and time-dependent covariates. After 48 weeks of first-line ART, 2,946 individuals contributed 11,351 person-years of follow-up, 625 switches, and 179 deaths. The estimated survival probability after a further 240 weeks for post-48-week switch at the first CD4 cell count less than 100 cells/mm3 or non-Candida World Health Organization stage 4 event (with CD4 count <250) was 0.96 (95% confidence interval (CI): 0.94, 0.97) with 12-weekly CD4 testing, 0.96 (95% CI: 0.95, 0.97) with 24-weekly CD4 testing, 0.95 (95% CI: 0.93, 0.96) with a single CD4 test at 48 weeks (baseline), and 0.92 (95% CI: 0.91, 0.94) with no CD4 testing. Comparing randomized groups by 48-week CD4 count, the mortality risk associated with CDM versus LCM was greater in persons with CD4 counts of <100 (hazard ratio = 2.4, 95% CI: 1.3, 4.3) than in those with CD4 counts of ≥100 (hazard ratio = 1.1, 95% CI: 0.8, 1.7; interaction P = 0.04). These findings support a benefit from identifying patients immunologically failing first-line ART at 48 weeks.
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Affiliation(s)
- Deborah Ford
- Correspondence to Dr. Deborah Ford, MRC Clinical Trials Unit at UCL, University College London, Aviation House, 125 Kingsway, London WC2B 6NH, United Kingdom (e-mail: )
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Sutherland KA, Goodall RL, McCormick A, Kapaata A, Lyagoba F, Kaleebu P, Thiltgen G, Gilks CF, Spyer M, Kityo C, Pillay D, Dunn D, Gupta RK. Gag-Protease Sequence Evolution Following Protease Inhibitor Monotherapy Treatment Failure in HIV-1 Viruses Circulating in East Africa. AIDS Res Hum Retroviruses 2015; 31:1032-7. [PMID: 26258548 PMCID: PMC4675176 DOI: 10.1089/aid.2015.0138] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Around 2.5 million HIV-infected individuals failing first-line therapy qualify for boosted protease inhibitor (bPI)-based second-line therapy globally. Major resistance mutations are rarely present at treatment failure in patients receiving bPI and the determinants of failure in these patients remain unknown. There is evidence that Gag can impact PI susceptibility. Here, we have sequenced Gag-Protease before and following failure in 23 patients in the SARA trial infected with subtypes A, C, and D viruses. Before bPI, significant variation in Protease and Gag was observed at positions previously associated with PI exposure and resistance including Gag mutations L449P, S451N, and L453P and Protease K20I and L63P. Following PI failure, previously described mutations in Protease and Gag were observed, including those at the cleavage sites such as R361K and P453L. However, the emergence of clear genetic determinants of therapy failure across patients was not observed. Larger Gag sequence datasets will be required to comprehensively identify mutational correlates of bPI failure across subtypes.
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Affiliation(s)
| | - Ruth L. Goodall
- MRC Clinical Trials Unit at University College London, London, United Kingdom
| | | | - Anne Kapaata
- Uganda Research Unit on AIDS, Medical Research Council (MRC), Uganda Virus Research Institute, Entebbe, Uganda
| | - Fred Lyagoba
- Uganda Research Unit on AIDS, Medical Research Council (MRC), Uganda Virus Research Institute, Entebbe, Uganda
| | - Pontiano Kaleebu
- Uganda Research Unit on AIDS, Medical Research Council (MRC), Uganda Virus Research Institute, Entebbe, Uganda
| | | | - Charles F. Gilks
- School of Population Health, University of Queensland, Brisbane, Australia
| | - Moira Spyer
- MRC Clinical Trials Unit at University College London, London, United Kingdom
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Deenan Pillay
- University College London, London, United Kingdom
- Wellcome Trust Africa Centre for Health and Population Sciences, University of KwaZulu Natal, Mtubatuba, South Africa
| | - David Dunn
- MRC Clinical Trials Unit at University College London, London, United Kingdom
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Sutherland KA, Parry CM, McCormick A, Kapaata A, Lyagoba F, Kaleebu P, Gilks CF, Goodall R, Spyer M, Kityo C, Pillay D, Gupta RK. Evidence for Reduced Drug Susceptibility without Emergence of Major Protease Mutations following Protease Inhibitor Monotherapy Failure in the SARA Trial. PLoS One 2015; 10:e0137834. [PMID: 26382239 PMCID: PMC4575205 DOI: 10.1371/journal.pone.0137834] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/23/2015] [Indexed: 12/11/2022] Open
Abstract
Background Major protease mutations are rarely observed following failure with protease inhibitors (PI), and other viral determinants of failure to PI are poorly understood. We therefore characterized Gag-Protease phenotypic susceptibility in subtype A and D viruses circulating in East Africa following viral rebound on PIs. Methods Samples from baseline and treatment failure in patients enrolled in the second line LPV/r trial SARA underwent phenotypic susceptibility testing. Data were expressed as fold-change in susceptibility relative to a LPV-susceptible reference strain. Results We cloned 48 Gag-Protease containing sequences from seven individuals and performed drug resistance phenotyping from pre-PI and treatment failure timepoints in seven patients. For the six patients where major protease inhibitor resistance mutations did not emerge, mean fold-change EC50 to LPV was 4.07 fold (95% CI, 2.08–6.07) at the pre-PI timepoint. Following viral failure the mean fold-change in EC50 to LPV was 4.25 fold (95% CI, 1.39–7.11, p = 0.91). All viruses remained susceptible to DRV. In our assay system, the major PI resistance mutation I84V, which emerged in one individual, conferred a 10.5-fold reduction in LPV susceptibility. One of the six patients exhibited a significant reduction in susceptibility between pre-PI and failure timepoints (from 4.7 fold to 9.6 fold) in the absence of known major mutations in protease, but associated with changes in Gag: V7I, G49D, R69Q, A120D, Q127K, N375S and I462S. Phylogenetic analysis provided evidence of the emergence of genetically distinct viruses at the time of treatment failure, indicating ongoing viral evolution in Gag-protease under PI pressure. Conclusions Here we observe in one patient the development of significantly reduced susceptibility conferred by changes in Gag which may have contributed to treatment failure on a protease inhibitor containing regimen. Further phenotype-genotype studies are required to elucidate genetic determinants of protease inhibitor failure in those who fail without traditional resistance mutations whilst PI use is being scaled up globally.
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Affiliation(s)
| | - Chris M. Parry
- Uganda Research Unit on AIDS, Medical Research Council (MRC), Uganda Virus Research Institute, Entebbe, Uganda
| | | | - Anne Kapaata
- Uganda Research Unit on AIDS, Medical Research Council (MRC), Uganda Virus Research Institute, Entebbe, Uganda
| | - Fred Lyagoba
- Uganda Research Unit on AIDS, Medical Research Council (MRC), Uganda Virus Research Institute, Entebbe, Uganda
| | - Pontiano Kaleebu
- Uganda Research Unit on AIDS, Medical Research Council (MRC), Uganda Virus Research Institute, Entebbe, Uganda
| | - Charles F. Gilks
- School of Population Health, University of Queensland, Brisbane, Australia
| | - Ruth Goodall
- MRC Clinical Trials Unit at UCL, London, United Kingdom
| | - Moira Spyer
- MRC Clinical Trials Unit at UCL, London, United Kingdom
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Deenan Pillay
- University College London, London, United Kingdom
- Wellcome Trust Africa Centre for Health and Population Sciences, University of KwaZulu Natal, Mtubatuba, South Africa
- * E-mail: (DP); (RKG)
| | - Ravindra K. Gupta
- University College London, London, United Kingdom
- * E-mail: (DP); (RKG)
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Gomo ZAR, Hakim JG, Walker SA, Tinago W, Mandozana G, Kityo C, Munderi P, Katabira E, Reid A, Gibb DM, Gilks CF. Impact of second-line antiretroviral regimens on lipid profiles in an African setting: the DART trial sub-study. AIDS Res Ther 2014; 11:32. [PMID: 25320632 PMCID: PMC4197260 DOI: 10.1186/1742-6405-11-32] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 09/27/2014] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Increasing numbers of HIV-infected patients in sub-Saharan Africa are exposed to antiretroviral therapy (ART), but there are few data on lipid changes on first-line ART, and even fewer on second-line. METHODS DART was a randomized trial comparing monitoring strategies in Ugandan/Zimbabwean adults initiating first-line ART and switching to second-line at clinical/immunological failure. We evaluated fasting lipid profiles at second-line initiation and ≥48 weeks subsequently in stored samples from Zimbabwean patients switching before 18 September 2006. RESULTS Of 91 patients switched to second-line ART, 65(73%) had fasting samples at switch and ≥48 weeks, 14(15%) died or were lost <48 weeks, 10(11%) interrupted ART for >14 days and 2(2%) had no samples available. 56/65(86%) received ZDV/d4T + 3TC + TDF first-line, 6(9%) ZDV/d4T + 3TC + NVP and 3(5%) ZDV + 3TC with TDF and NVP. Initial second-line regimens were LPV/r + NNRTI in 27(41%), LPV/r + NNRTI + ddI in 33(50%) and LPV/r + TDF + ddI/3TC/ZDV in 6(9%). At second-line initiation median (IQR) TC, LDL-C, HDL-C and TG (mmol/L) were 3.3(2.8-4.0), 1.7(1.3-2.2), 0.7(0.6-0.9) and 1.1(0.8-1.9) respectively. Levels were significantly increased 48 weeks later, by mean (SE) +2.0(0.1), +1.1(0.1), +0.5(0.05) and +0.4(0.2) respectively (p < 0.001; TG p = 0.01). 3% at switch vs 25% 48 weeks later had TC >5.2 mmol/L; 3% vs 25% LDL-C >3.4 mmol/L and 91% vs 41% HDL-C <1.1 mmol/L (p < 0.001). Similar proportions had TG >1.8 mmol/L (0 vs 3%) and TC/HDL-C ≥5 (40% vs 33%) (p > 0.15). CONCLUSION Modest lipid elevations were observed in African patients on predominantly LPV/r + NNRTI-based second-line regimens. Routine lipid monitoring during second-line ART regimens may not be warranted in this setting but individual cardiovascular risk assessment should guide practice.
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Chan AK, Ford D, Namata H, Muzambi M, Nkhata MJ, Abongomera G, Mambule I, South A, Revill P, Grundy C, Mabugu T, Chiwaula L, Cataldo F, Hakim J, Seeley J, Kityo C, Reid A, Katabira E, Sodhi S, Gilks CF, Gibb DM. The Lablite project: a cross-sectional mapping survey of decentralized HIV service provision in Malawi, Uganda and Zimbabwe. BMC Health Serv Res 2014; 14:352. [PMID: 25138583 PMCID: PMC4148932 DOI: 10.1186/1472-6963-14-352] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 07/29/2014] [Indexed: 12/05/2022] Open
Abstract
Background In sub-Saharan Africa antiretroviral therapy (ART) is being decentralized from tertiary/secondary care facilities to primary care. The Lablite project supports effective decentralization in 3 countries. It began with a cross-sectional survey to describe HIV and ART services. Methods 81 purposively sampled health facilities in Malawi, Uganda and Zimbabwe were surveyed. Results The lowest level primary health centres comprised 16/20, 21/39 and 16/22 facilities included in Malawi, Uganda and Zimbabwe respectively. In Malawi and Uganda most primary health facilities had at least 1 medical assistant/clinical officer, with average 2.5 and 4 nurses/midwives for median catchment populations of 29,275 and 9,000 respectively. Primary health facilities in Zimbabwe were run by nurses/midwives, with average 6 for a median catchment population of 8,616. All primary health facilities provided HIV testing and counselling, 50/53 (94%) cotrimoxazole preventive therapy (CPT), 52/53 (98%) prevention of mother-to-child transmission of HIV (PMTCT) and 30/53 (57%) ART management (1/30 post ART-initiation follow-up only). All secondary and tertiary-level facilities provided HIV and ART services. In total, 58/81 had ART provision. Stock-outs during the 3 months prior to survey occurred across facility levels for HIV test-kits in 55%, 26% and 9% facilities in Malawi, Uganda and Zimbabwe respectively; for CPT in 58%, 32% and 9% and for PMTCT drugs in 26%, 10% and 0% of facilities (excluding facilities where patients were referred out for either drug). Across all countries, in facilities with ART stored on-site, adult ART stock-outs were reported in 3/44 (7%) facilities compared with 10/43 (23%) facility stock-outs of paediatric ART. Laboratory services at primary health facilities were limited: CD4 was used for ART initiation in 4/9, 5/6 and 13/14 in Malawi, Uganda and Zimbabwe respectively, but frequently only in selected patients. Routine viral load monitoring was not used; 6/58 (10%) facilities with ART provision accessed centralised viral loads for selected patients. Conclusions Although coverage of HIV testing, PMTCT and cotrimoxazole prophylaxis was high in all countries, decentralization of ART services was variable and incomplete. Challenges of staffing and stock management were evident. Laboratory testing for toxicity and treatment effectiveness monitoring was not available in most primary level facilities. Electronic supplementary material The online version of this article (doi:10.1186/1472-6963-14-352) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Deborah Ford
- MRC Clinical Trials Unit at University College London, London, U,K.
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Goodall RL, Dunn DT, Pattery T, van Cauwenberge A, Nkurunziza P, Awio P, Ndembi N, Munderi P, Kityo C, Gilks CF, Kaleebu P, Pillay D. Phenotypic and genotypic analyses to guide selection of reverse transcriptase inhibitors in second-line HIV therapy following extended virological failure in Uganda. J Antimicrob Chemother 2014; 69:1938-44. [PMID: 24633208 PMCID: PMC4054985 DOI: 10.1093/jac/dku052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objectives We investigated phenotypic and genotypic resistance after 2 years of first-line therapy with two HIV treatment regimens in the absence of virological monitoring. Methods NORA [Nevirapine OR Abacavir study, a sub-study of the Development of AntiRetroviral Therapy in Africa (DART) trial] randomized 600 symptomatic HIV-infected Ugandan adults (CD4 cell count <200 cells/mm3) to receive zidovudine/lamivudine plus abacavir (cABC arm) or nevirapine (cNVP arm). All virological tests were performed retrospectively, including resistance tests on week 96 plasma samples with HIV RNA levels ≥1000 copies/mL. Phenotypic resistance was expressed as fold-change in IC50 (FC) relative to wild-type virus. Results HIV-1 RNA viral load ≥1000 copies/mL at week 96 was seen in 58/204 (28.4%) cABC participants and 21/159 (13.2%) cNVP participants. Resistance results were available in 35 cABC and 17 cNVP participants; 31 (89%) cABC and 16 (94%) cNVP isolates had a week 96 FC below the biological cut-off for tenofovir (2.2). In the cNVP arm, 16/17 participants had resistance mutations synonymous with high-level resistance to nevirapine and efavirenz; FC values for etravirine were above the biological cut-off in 9 (53%) isolates. In multivariate regression models, K65R, Y115F and the presence of thymidine analogue-associated mutations were associated with increased susceptibility to etravirine in the cABC arm. Conclusions Our data support the use of tenofovir following failure of a first-line zidovudine-containing regimen and shed further light on non-nucleoside reverse transcriptase inhibitor hypersusceptibility.
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Affiliation(s)
| | - D T Dunn
- MRC Clinical Trials Unit, London, UK
| | | | | | - P Nkurunziza
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - P Awio
- Joint Clinical Research Centre, Kampala, Uganda
| | - N Ndembi
- Institute of Human Virology, Abuja, Nigeria
| | - P Munderi
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - C Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - C F Gilks
- School of Population Health, University of Queensland, Brisbane, Australia
| | - P Kaleebu
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - D Pillay
- Department of Infection, University College London, London, UK Centres for Infection, Public Health England, Colindale, UK
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Kityo C, Gibb DM, Gilks CF, Goodall RL, Mambule I, Kaleebu P, Pillay D, Kasirye R, Mugyenyi P, Walker AS, Dunn DT. High level of viral suppression and low switch rate to second-line antiretroviral therapy among HIV-infected adult patients followed over five years: retrospective analysis of the DART trial. PLoS One 2014; 9:e90772. [PMID: 24625508 PMCID: PMC3953124 DOI: 10.1371/journal.pone.0090772] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 02/05/2014] [Indexed: 12/24/2022] Open
Abstract
UNLABELLED In contrast to resource-rich countries, most HIV-infected patients in resource-limited countries receive treatment without virological monitoring. There are few long-term data, in this setting, on rates of viral suppression or switch to second-line antiretroviral therapy. The DART trial compared clinically driven monitoring (CDM) versus routine laboratory (CD4/haematology/biochemistry) and clinical monitoring (LCM) in HIV-infected adults initiating therapy. There was no virological monitoring in either study group during follow-up, but viral load was measured in Ugandan participants at trial closure. Two thousand three hundred and seventeen (2317) participants from this country initiated antiretroviral therapy with zidovudine/lamivudine plus tenofovir (n = 1717), abacavir (n = 300), or nevirapine (n = 300). Of 1896 (81.8%) participants who were alive and in follow-up at trial closure (median 5.1 years after therapy initiation), 1507 (79.5%) were on first-line and 389 (20.5%) on second-line antiretroviral therapy. The overall switch rate after the first year was 5.6 per 100 person-years; the rate was substantially higher in participants with low baseline CD4 counts (<50 cells/mm3). Among 1207 (80.1%) first-line participants with viral load measured, HIV RNA was <400 copies/ml in 963 (79.8%), 400-999 copies/ml in 37 (3.1%), 1,000-9,999 copies/ml in 110 (9.1%), and ≥10,000 copies/ml in 97 (8.0%). The proportion with HIV RNA <400 copies/ml was slightly lower (difference 7.1%, 95% CI 2.5 to 11.5%) in CDM (76.3%) than in LCM (83.4%). Among 252 (64.8%) second-line participants with viral load measured (median 2.3 years after switch), HIV RNA was <400 copies/ml in 226 (89.7%), with no difference between monitoring strategies. Low switch rates and high, sustained levels of viral suppression are achievable without viral load or CD4 count monitoring in the context of high-quality clinical care. TRIAL REGISTRATION ISRCTN13968779.
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Affiliation(s)
- Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Diana M. Gibb
- MRC Clinical Trials Unit at UCL, London, United Kingdom
| | - Charles F. Gilks
- School of Population Health, University of Queensland, Australia
| | | | | | | | | | | | | | | | - David T. Dunn
- MRC Clinical Trials Unit at UCL, London, United Kingdom
- * E-mail:
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Gupta RK, Goodall RL, Ranopa M, Kityo C, Munderi P, Lyagoba F, Mugarura L, Gilks CF, Kaleebu P, Pillay D. High rate of HIV resuppression after viral failure on first-line antiretroviral therapy in the absence of switch to second-line therapy. Clin Infect Dis 2013; 58:1023-6. [PMID: 24352348 PMCID: PMC3952602 DOI: 10.1093/cid/cit933] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In a randomized comparison of nevirapine or abacavir with zidovudine plus lamivudine, routine viral load monitoring was not performed, yet 27% of individuals with viral failure at week 48 experienced resuppression by week 96 without switching. This supports World Health Organization recommendations that suspected viral failure should trigger adherence counseling and repeat measurement before a treatment switch is considered.
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Walker AS, Prendergast AJ, Mugyenyi P, Munderi P, Hakim J, Kekitiinwa A, Katabira E, Gilks CF, Kityo C, Nahirya-Ntege P, Nathoo K, Gibb DM. Mortality in the year following antiretroviral therapy initiation in HIV-infected adults and children in Uganda and Zimbabwe. Clin Infect Dis 2012; 55:1707-18. [PMID: 22972859 PMCID: PMC3501336 DOI: 10.1093/cid/cis797] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [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] [Indexed: 12/19/2022] Open
Abstract
In low-income countries, children ≥4 years and adults with low CD4 count have equally high mortality risk in the 3 months after initiation of antiretroviral therapy, similar to that of untreated individuals. Bacterial infections play a major role; targeted interventions could have important benefits. Background. Adult mortality in the first 3 months on antiretroviral therapy (ART) is higher in low-income than in high-income countries, with more similar mortality after 6 months. However, the specific patterns of changing risk and causes of death have rarely been investigated in adults, nor compared with children in low-income countries. Methods. We used flexible parametric hazard models to investigate how mortality risks varied over the first year on ART in human immunodeficiency virus–infected adults (aged 18–73 years) and children (aged 4 months to 15 years) in 2 trials in Zimbabwe and Uganda. Results. One hundred seventy-nine of 3316 (5.4%) adults and 39 of 1199 (3.3%) children died; half of adult/pediatric deaths occurred in the first 3 months. Mortality variation over year 1 was similar; at all CD4 counts/CD4%, mortality risk was greatest between days 30 and 50, declined rapidly to day 180, then declined more slowly. One-year mortality after initiating ART with 0–49, 50–99 or ≥100 CD4 cells/μL was 9.4%, 4.5%, and 2.9%, respectively, in adults, and 10.1%, 4.4%, and 1.3%, respectively, in children aged 4–15 years. Mortality in children aged 4 months to 3 years initiating ART in equivalent CD4% strata was also similar (0%–4%: 9.1%; 5%–9%: 4.5%; ≥10%: 2.8%). Only 10 of 179 (6%) adult deaths and 1 of 39 (3%) child deaths were probably medication-related. The most common cause of death was septicemia/meningitis in adults (20%, median 76 days) and children (36%, median 79 days); pneumonia also commonly caused child deaths (28%, median 41 days). Conclusions. Children ≥4 years and adults with low CD4 values have remarkably similar, and high, mortality risks in the first 3 months after ART initiation in low-income countries, similar to cohorts of untreated individuals. Bacterial infections are a major cause of death in both adults and children; targeted interventions could have important benefits.
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Gilks CF, Walker AS, Dunn DT, Gibb DM, Kikaire B, Reid A, Musana H, Mambule I, Kasirye R, Robertson V, Ssali F, Spyer M, Pillay D, Yirrell D, Kaleebu P. Lopinavir/ritonavir monotherapy after 24 weeks of second-line antiretroviral therapy in Africa: a randomized controlled trial (SARA). Antivir Ther 2012; 17:1363-73. [PMID: 22814125 DOI: 10.3851/imp2253] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Boosted protease inhibitor (bPI) monotherapy (bPImono) potentially has substantial cost, safety and operational benefits. It has never been evaluated as second-line antiretroviral therapy (ART) in Africa. METHODS After 24 weeks of lopinavir/ritonavir-containing second-line therapy, DART participants were randomized to remain on combination therapy (CT), or change to bPImono maintenance (SARA trial; ISRCTN53817258). Joint primary end points were CD4(+) T-cell changes 24 weeks later and serious adverse events (SAEs); retrospectively assayed viral load (VL) was a secondary end point. Analyses were intention-to-treat. RESULTS A total of 192 participants were randomized to CT (n=95) or bPImono (n=97) and followed for median 60 weeks (IQR 45-84). Participants received median 4.0 years (IQR 3.5-4.4) first-line ART. Median CD4(+) T-cell count at first-line failure was 86 cells/mm(3) (47-136), increasing to 245 cells/mm(3) (173-325) after 24-week induction when 77% had VL<50 copies/ml. Overall, 44 (23%) were receiving second-line therapy with bPI and nucleoside reverse transcriptase inhibitors (NRTI) only, and 148 (77%) with bPI plus non-NRTI (NNRTI) with or without NRTI. At 24 weeks after randomization to CT versus bPImono, mean CD4(+) T-cell increase was 42 (CT, n=85) versus 49 cells/mm(3) (bPImono, n=88; adjusted difference 13 [95% CI -15, 43], P=0.37; non-inferior compared with predetermined non-inferiority margin [-33]). Virological suppression was greater for CT versus bPImono (trend P=0.009): 77% (70/91) versus 60% (56/94) were <50 copies/ml, and 5% (5) versus 14% (13) were ≥1,000 copies/ml, respectively. A total of 0 (0%) versus 5 (5%) participants had major protease inhibitor mutations and 3 (3%) versus 0 (0%) new NNRTI/NRTI mutations were detected during follow-up. Two participants (1 CT and 1 bPImono) died >24 weeks after randomization, and 5 (2 CT and 3 bPImono) experienced SAEs (P=0.51). CONCLUSIONS bPImono following a 24-week second-line induction was associated with similar CD4(+) T-cell response, but increased low-level viraemia, generally without protease inhibitor resistance. Longer-term trials are needed to provide definitive evidence about effectiveness in Africa.
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