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Euvrard J, Timmerman V, Keene CM, Phelanyane F, Heekes A, Rice BD, Grimsrud A, Ehrenkranz P, Boulle A. The cyclical cascade of HIV care: Temporal care engagement trends within a population-wide cohort. PLoS Med 2024; 21:e1004407. [PMID: 38728361 DOI: 10.1371/journal.pmed.1004407] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 04/22/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND The traditional HIV treatment cascade aims to visualise the journey of each person living with HIV from diagnosis, through initiation on antiretroviral therapy (ART) to treatment success, represented by virological suppression. This representation has been a pivotal tool in highlighting and quantifying sequential gaps along the care continuum. There is longstanding recognition, however, that this may oversimplify the complexity of real-world engagement with HIV services in settings with mature high-burden HIV epidemics. A complementary "cyclical" cascade has been proposed to represent the processes of disengagement at different points on the care continuum, with multiple pathways to re-engagement, although the feasibility of implementing this at scale has been uncertain. This study aimed to populate, refine, and explore the utility of a cyclical representation of the HIV cascade, using routine data from a high-burden HIV setting. METHODS AND FINDINGS This observational cohort study leveraged person-level data on all people living with HIV in the Western Cape (WC), South Africa, who accessed public health services in the 2 years prior to 31 December 2023. Programme data from disease registers were complemented by data from pharmacy and laboratory systems. At study closure, 494 370 people were included, constituting 93% of those of those estimated to be living with HIV in the province, of whom 355 104 were on ART. Substantial disengagement from HIV care was evident at every point on the cascade. Early treatment emerged as a period of higher risk of disengagement, but it did not account for the majority of disengagement. Almost all those currently disengaged had prior experience of treatment. While re-engagement was also common, overall treatment coverage had increased slowly over 5 years. The transition to dolutegravir-based regimens was dramatic with good virological outcomes for those in care, notwithstanding a clearly discernible impact of the Coronavirus Disease 2019 (COVID-19) pandemic on viral load (VL) testing. People currently engaged and disengaged in care are similar with respect to age and gender. Those who died or disengaged recently were previously distributed across a range of cascade statuses, and a substantial proportion of those newly initiating and re-initiating treatment were no longer on treatment 6 months later. The main limitation of this study was incomplete evidence of HIV testing, linkage to HIV-specific services, and out-of-facility mortality. CONCLUSIONS Using routine data, it was possible to populate and automate a cyclical cascade of HIV care that continuously captured the nonlinear care journeys of individuals living with HIV. In this generalised mature HIV epidemic, most people are treatment experienced. Disengagement is common and occurs at various points along the cascade, making it challenging to identify high-impact intervention opportunities. While historical HIV cascades remain valuable for target setting and service monitoring, they can be complemented with insights from more detailed cyclical cascades.
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Affiliation(s)
- Jonathan Euvrard
- School of Public Health, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Venessa Timmerman
- School of Public Health, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Claire Marriott Keene
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Florence Phelanyane
- School of Public Health, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Alexa Heekes
- School of Public Health, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Brian D Rice
- School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anna Grimsrud
- HIV Programmes and Advocacy, IAS-the International AIDS Society, Cape Town, South Africa
| | - Peter Ehrenkranz
- Global Health, Bill & Melinda Gates Foundation, Seattle, Washington State, United States of America
| | - Andrew Boulle
- School of Public Health, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
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Phillips TK, Kassanjee R, Maxwell N, Anderson K, Johnson L, Moolla H, Myer L, Chi BH, Euvrard J, Boulle A, Davies M, Cornell M, de Waal R. ART history prior to conception: trends and association with postpartum disengagement from HIV care in Khayelitsha, South Africa (2013-2019): a retrospective cohort study. J Int AIDS Soc 2024; 27:e26236. [PMID: 38566482 PMCID: PMC10988117 DOI: 10.1002/jia2.26236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 03/12/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION In recent years, the expansion of HIV treatment eligibility has resulted in an increase in people with antiretroviral therapy (ART) experience prior to pregnancy but little is known about postpartum engagement in care in this population. We examined differences in disengagement from HIV care after delivery by maternal ART history before conception. METHODS We analysed data from people living with HIV (aged 15-49) in Khayelitsha, South Africa, with ≥1 live birth between April 2013 and March 2019. We described trends over time in ART history prior to estimated conception, classifying ART history groups as: (A) on ART with no disengagement (>270 days with no evidence of HIV care); (B) returned before pregnancy following disengagement; (C) restarted ART in pregnancy after disengagement; and (D) ART new start in pregnancy. We used Kaplan-Meier curves and proportional-hazards models (adjusted for maternal age, number of pregnancy records and year of delivery) to examine the time to disengagement from delivery to 2 years postpartum. RESULTS Among 7309 pregnancies (in 6680 individuals), the proportion on ART (A) increased from 19% in 2013 to 41% in 2019. The proportions of those who returned (B) and restarted (C) increased from 2% to 13% and from 2% to 10%, respectively. There was a corresponding decline in the proportion of new starts (D) from 77% in 2013 to 36% in 2019. In the first recorded pregnancy per person in the study period, 26% (95% CI 25-27%) had disengaged from care by 1 year and 34% (95% CI 33-36%) by 2 years postpartum. Individuals who returned (B: aHR 2.10, 95% CI 1.70-2.60), restarted (C: aHR 3.32, 95% CI 2.70-4.09) and newly started ART (D: aHR 2.41, 95% CI 2.12-2.74) had increased hazards of postpartum disengagement compared to those on ART (A). CONCLUSIONS There is a growing population of people with ART experience prior to conception and postpartum disengagement varies substantially by ART history. Antenatal care presents an important opportunity to understand prior ART experiences and an entry into interventions for strengthened engagement in HIV care.
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Affiliation(s)
- Tamsin Kate Phillips
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
- Division of Epidemiology & BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Reshma Kassanjee
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Nicola Maxwell
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Kim Anderson
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Leigh Johnson
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Haroon Moolla
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Landon Myer
- Division of Epidemiology & BiostatisticsSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Benjamin H. Chi
- Department of Obstetrics and GynecologySchool of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
- Department of Health and WellnessProvincial Government of the Western CapeCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
- Department of Health and WellnessProvincial Government of the Western CapeCape TownSouth Africa
| | - Mary‐Ann Davies
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
- Department of Health and WellnessProvincial Government of the Western CapeCape TownSouth Africa
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Renee de Waal
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public HealthUniversity of Cape TownCape TownSouth Africa
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van Vollenhoven H, Kalk E, Kroon SM, Maseko T, Phelanyane F, Euvrard J, Fourie L, le Roux N, Nongena P. Effects of the COVID-19 pandemic on early infant diagnosis of HIV in Cape Town, South Africa. South Afr J HIV Med 2024; 25:1542. [PMID: 38628908 PMCID: PMC11019036 DOI: 10.4102/sajhivmed.v25i1.1542] [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] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/19/2023] [Indexed: 04/19/2024] Open
Abstract
Background In South Africa, infants who are HIV-exposed are tested for HIV at birth and 10 weeks of age. The COVID-19 pandemic lockdown restrictions resulted in reduced access to healthcare services and uncertain impact on early infant HIV testing. Objectives To describe the effects of the COVID-19 pandemic lockdown restrictions on early infant HIV testing and diagnosis in Cape Town, South Africa. Method This retrospective cohort study compares HIV-exposed infants born during the first COVID-19 pandemic lockdown (2020) to those born in the same period the year before (2019). Laboratory and other data were abstracted from the Provincial Health Data Centre. Results A total of 2888 infants were included: 1474 born in 2020 and 1413 in 2019. Compared to 2019, there was an increase in the 10-week HIV polymerase chain reaction (PCR) uptake in 2020 (71% vs. 60%, P < 0.001). There was also an increase in the proportion of infants who demised without 10-week testing or were lost to follow-up in 2020 compared to 2019 (8% vs. 5%, P = 0.017). Differences detected in birth HIV PCR positivity rates between the two groups (1.1% vs. 0.5%, P = 0.17) did not reach statistical significance; however, a significant increase in vertical transmission of HIV by 10 weeks old was found in the 2020 cohort (1.2% vs. 0.5%. P = 0.046). Conclusion Vertical transmission of HIV at 10 weeks increased in the Cape Town Metropolitan during the initial COVID-19 lockdown. There was also an increase in the proportion of deaths without testing by 10 weeks in the 2020 group.
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Affiliation(s)
- Hendrike van Vollenhoven
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Emma Kalk
- School of Public Health, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
| | - Stuart M. Kroon
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Tafadzwa Maseko
- Family Medicine and Population Health (FAMPOP), Department of Epidemiology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Florence Phelanyane
- Health Intelligence Directorate, Western Cape Department of Health, Cape Town, South Africa
| | - Jonathan Euvrard
- Health Intelligence Directorate, Western Cape Department of Health, Cape Town, South Africa
| | - Lezanne Fourie
- Department of Neonatology, Mowbray Maternity Hospital, Cape Town, South Africa
| | - Nicolene le Roux
- HIV/AIDS, STI’s and Tuberculosis Directorate (HAST), New Somerset Hospital, Cape Town, South Africa
| | - Phumza Nongena
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Trickey A, Johnson LF, Fung F, Bonifacio R, Iwuji C, Biraro S, Bosomprah S, Chirimuta L, Euvrard J, Fatti G, Fox MP, Von Groote P, Gumulira J, Howard G, Jennings L, Kiragga A, Muula G, Tanser F, Wagener T, Low A, Vickerman P. Associations of inter-annual rainfall decreases with subsequent HIV outcomes for persons with HIV on antiretroviral therapy in Southern Africa: a collaborative analysis of cohort studies. BMC Infect Dis 2023; 23:889. [PMID: 38114912 PMCID: PMC10731689 DOI: 10.1186/s12879-023-08902-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/13/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Periods of droughts can lead to decreased food security, and altered behaviours, potentially affecting outcomes on antiretroviral therapy (ART) among persons with HIV (PWH). We investigated whether decreased rainfall is associated with adverse outcomes among PWH on ART in Southern Africa. METHODS Data were combined from 11 clinical cohorts of PWH in Lesotho, Malawi, Mozambique, South Africa, Zambia, and Zimbabwe, participating in the International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA-SA) collaboration. Adult PWH who had started ART prior to 01/06/2016 and were in follow-up in the year prior to 01/06/2016 were included. Two-year rainfall from June 2014 to May 2016 at the location of each HIV centre was summed and ranked against historical 2-year rainfall amounts (1981-2016) to give an empirical relative percentile rainfall estimate. The IeDEA-SA and rainfall data were combined using each HIV centre's latitude/longitude. In individual-level analyses, multivariable Cox or generalized estimating equation regression models (GEEs) assessed associations between decreased rainfall versus historical levels and four separate outcomes (mortality, CD4 counts < 200 cells/mm3, viral loads > 400 copies/mL, and > 12-month gaps in follow-up) in the two years following the rainfall period. GEEs were used to investigate the association between relative rainfall and monthly numbers of unique visitors per HIV centre. RESULTS Among 270,708 PWH across 386 HIV centres (67% female, median age 39 [IQR: 32-46]), lower rainfall than usual was associated with higher mortality (adjusted Hazard Ratio: 1.18 [95%CI: 1.07-1.32] per 10 percentile rainfall rank decrease) and unsuppressed viral loads (adjusted Odds Ratio: 1.05 [1.01-1.09]). Levels of rainfall were not strongly associated with CD4 counts < 200 cell/mm3 or > 12-month gaps in care. HIV centres in areas with less rainfall than usual had lower numbers of PWH visiting them (adjusted Rate Ratio: 0.80 [0.66-0.98] per 10 percentile rainfall rank decrease). CONCLUSIONS Decreased rainfall could negatively impact on HIV treatment behaviours and outcomes. Further research is needed to explore the reasons for these effects. Interventions to mitigate the health impact of severe weather events are required.
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Affiliation(s)
- Adam Trickey
- Population Health Sciences, University of Bristol, Bristol, UK.
| | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Fai Fung
- Department of Civil Engineering, University of Bristol, Bristol, UK
- UK Meteorological Office, Exeter, UK
| | - Rogerio Bonifacio
- Climate and Earth Observation Unit, Research Assessment and Monitoring Division, World Food Programme HQ, Rome, Italy
| | - Collins Iwuji
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Global Health Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Samuel Biraro
- ICAP at Columbia University, Nakasero, Kampala, Uganda
| | - Samuel Bosomprah
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Biostatistics, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | | | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Geoffrey Fatti
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health and Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Per Von Groote
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Guy Howard
- Department of Civil Engineering and Cabot Institute of the Environment, University of Bristol, Bristol, UK
| | - Lauren Jennings
- Desmond Tutu Health Foundation, Institute of Infectious Diseases and Molecular Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Agnes Kiragga
- Research Division, African Population and Health Research Center, Nairobi, Kenya
| | - Guy Muula
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Frank Tanser
- Centre for Epidemic Response and Innovation, School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Thorsten Wagener
- Institute of Environmental Science and Geography, University of Potsdam, Potsdam, Germany
| | - Andrea Low
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK
- NIHR Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol, Bristol, UK
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Keene CM, Euvrard J, Amico KR, Ragunathan A, English M, McKnight J, Orrell C. Conceptualising engagement with HIV care for people on treatment: the Indicators of HIV Care and AntiRetroviral Engagement (InCARE) Framework. BMC Health Serv Res 2023; 23:435. [PMID: 37143067 PMCID: PMC10161576 DOI: 10.1186/s12913-023-09433-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 04/14/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND As the crisis-based approach to HIV care evolves to chronic disease management, supporting ongoing engagement with HIV care is increasingly important to achieve long-term treatment success. However, 'engagement' is a complex concept and ambiguous definitions limit its evaluation. To guide engagement evaluation and development of interventions to improve HIV outcomes, we sought to identify critical, measurable dimensions of engagement with HIV care for people on treatment from a health service-delivery perspective. METHODS We used a pragmatic, iterative approach to develop a framework, combining insights from researcher experience, a narrative literature review, framework mapping, expert stakeholder input and a formal scoping review of engagement measures. These inputs helped to refine the inclusion and definition of important elements of engagement behaviour that could be evaluated by the health system. RESULTS The final framework presents engagement with HIV care as a dynamic behaviour that people practice rather than an individual characteristic or permanent state, so that people can be variably engaged at different points in their treatment journey. Engagement with HIV care for those on treatment is represented by three measurable dimensions: 'retention' (interaction with health services), 'adherence' (pill-taking behaviour), and 'active self-management' (ownership and self-management of care). Engagement is the product of wider contextual, health system and personal factors, and engagement in all dimensions facilitates successful treatment outcomes, such as virologic suppression and good health. While retention and adherence together may lead to treatment success at a particular point, this framework hypothesises that active self-management sustains treatment success over time. Thus, evaluation of all three core dimensions is crucial to realise the individual, societal and public health benefits of antiretroviral treatment programmes. CONCLUSIONS This framework distils a complex concept into three core, measurable dimensions critical for the maintenance of engagement. It characterises elements that the system might assess to evaluate engagement more comprehensively at individual and programmatic levels, and suggests that active self-management is an important consideration to support lifelong optimal engagement. This framework could be helpful in practice to guide the development of more nuanced interventions that improve long-term treatment success and help maintain momentum in controlling a changing epidemic.
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Affiliation(s)
- Claire M Keene
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - K Rivet Amico
- Health Behaviour and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Ayesha Ragunathan
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mike English
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jacob McKnight
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Catherine Orrell
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Patten G, Sipambo N, Technau KG, Euvrard J, Ford N, Davies MA. Ongoing High Prevalence of Severe Immune Suppression Among Children in South Africa. J Acquir Immune Defic Syndr 2023; 92:273-280. [PMID: 36729553 PMCID: PMC9974841 DOI: 10.1097/qai.0000000000003137] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 11/14/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Among children in Southern Africa severe immune suppression (SIS) has declined, but most continue to initiate antiretroviral therapy (ART) with SIS. SETTING Using data from South Africa, we describe SIS at ART start and on ART between 2007 and 2020, among children <5 years with a CD4%/cell count at ART start and ≥1 subsequent measure. METHODS Gap in care was defined as >9 months without a recorded visit. We defined SIS according to age and CD4%/cell count. A multistate model was used to estimate transition probabilities between 5 states: SIS on ART; Stable, not SIS; Early Gap, commencing <9 months from ART start; Late Gap, commencing ≥9 months on ART; and Death. RESULTS Among 2536 children, 70% had SIS at ART start, and 36% experienced SIS on ART. An increasing proportion were age <1 year at ART initiation (2007-2009: 43% to 2013-2020: 55%). Increasingly, SIS on ART occurred after a gap, in those with SIS on ART for >1 year, and after a period of unknown immune status. Later year of ART initiation was associated with reduced transition from SIS on ART to Stable. Infants and those initiating ART with SIS were more likely to transition from Stable to SIS. Viremia strongly predicted death from both the on ART states. CONCLUSIONS Increasingly SIS occurred among ART-experienced children. Those starting ART with SIS and during infancy remained especially vulnerable to SIS once on treatment. Managing ART in these children may be more complex and further reducing AIDS-related mortality is likely to remain challenging.
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Affiliation(s)
- Gabriela Patten
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Nosisa Sipambo
- Harriet Shezi Children’s Clinic, Chris Hani Baragwanath Academic Hospital, Department of Paediatrics & Child Health, University of Witwatersrand, Johannesburg
| | - Karl-Günter Technau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
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Patten GE, Euvrard J, Anderegg N, Boulle A, Arendse KD, von der Heyden E, Ford N, Davies MA. Advanced HIV disease and engagement in care among patients on antiretroviral therapy in South Africa: results from a multi-state model. AIDS 2023; 37:513-522. [PMID: 36695361 PMCID: PMC9881824 DOI: 10.1097/qad.0000000000003442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Despite improved access to antiretroviral therapy (ART) for people with HIV (PWH), HIV continues to contribute considerably to morbidity and mortality. Increasingly, advanced HIV disease (AHD) is found among PWH who are ART-experienced. DESIGN Using a multi-state model we examined associations between engagement with care and AHD on ART in South Africa. METHODS Using data from IeDEA Southern Africa, we included PWH from South Africa, initiating ART from 2004 to 2017 aged more than 5 years with a CD4+ cell count at ART start and at least one subsequent measure. We defined a gap as no visit for at least 18 months. Five states were defined: 'AHD on ART' (CD4+ cell count <200 cells/μl), 'Clinically Stable on ART' (CD4+ cell count ≥200 or if no CD4+ cell count, viral load <1000 copies/ml), 'Early Gap' (commencing ≤18 months from ART start), 'Late Gap' (commencing >18 months from ART start) and 'Death'. RESULTS Among 32 452 PWH, men and those aged 15-25 years were more likely to progress to unfavourable states. Later years of ART start were associated with a lower probability of transitioning from AHD to clinically stable, increasing the risk of death following AHD. In stratified analyses, those starting ART with AHD in later years were more likely to re-engage in care with AHD following a gap and to die following AHD on ART. CONCLUSION In more recent years, those with AHD on ART were more likely to die, and AHD at re-engagement in care increased. To further reduce HIV-related mortality, efforts to address the challenges facing these more vulnerable patients are needed.
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Affiliation(s)
- Gabriela E Patten
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Nanina Anderegg
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | | | | | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
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Keene CM, Ragunathan A, Euvrard J, English M, McKnight J, Orrell C. Measuring patient engagement with HIV care in sub-Saharan Africa: a scoping study. J Int AIDS Soc 2022; 25:e26025. [PMID: 36285618 PMCID: PMC9597383 DOI: 10.1002/jia2.26025] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/27/2022] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Engagement with HIV care is a multi-dimensional, dynamic process, critical to maintaining successful treatment outcomes. However, measures of engagement are not standardized nor comprehensive. This undermines our understanding of the scope of challenges with engagement and whether interventions have an impact, complicating patient and programme-level decision-making. This study identified and characterized measures of engagement to support more consistent and comprehensive evaluation. METHODS We conducted a scoping study to systematically categorize measures the health system could use to evaluate engagement with HIV care for those on antiretroviral treatment. Key terms were used to search literature databases (Embase, PsychINFO, Ovid Global-Health, PubMed, Scopus, CINAHL, Cochrane and the World Health Organization Index Medicus), Google Scholar and stakeholder-identified manuscripts, ultimately including English evidence published from sub-Saharan Africa from 2014 to 2021. Measures were extracted, organized, then reviewed with key stakeholders. RESULTS AND DISCUSSION We screened 14,885 titles/abstracts, included 118 full-texts and identified 110 measures of engagement, categorized into three engagement dimensions ("retention," "adherence" and "active self-management"), a combination category ("multi-dimensional engagement") and "treatment outcomes" category (e.g. viral load as an end-result reflecting that engagement occurred). Retention reflected status in care, continuity of attendance and visit timing. Adherence was assessed by a variety of measures categorized into primary (prescription not filled) and secondary measures (medication not taken as directed). Active self-management reflected involvement in care and self-management. Three overarching use cases were identified: research to make recommendations, routine monitoring for quality improvement and strategic decision-making and assessment of individual patients. CONCLUSIONS Heterogeneity in conceptualizing engagement with HIV care is reflected by the broad range of measures identified and the lack of consensus on "gold-standard" indicators. This review organized metrics into five categories based on the dimensions of engagement; further work could identify a standardized, minimum set of measures useful for comprehensive evaluation of engagement for different use cases. In the interim, measurement of engagement could be advanced through the assessment of multiple categories for a more thorough evaluation, conducting sensitivity analyses with commonly used measures for more comparable outputs and using longitudinal measures to evaluate engagement patterns. This could improve research, programme evaluation and nuanced assessment of individual patient engagement in HIV care.
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Affiliation(s)
- Claire M. Keene
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Ayesha Ragunathan
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Mike English
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jacob McKnight
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Catherine Orrell
- Department of MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
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9
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Keene CM, Ragunathan A, Euvrard J, English M, McKnight J, Orrell C. Measuring patient engagement with HIV care in sub-Saharan Africa: a scoping study. J Int AIDS Soc 2022; 25:e26025. [PMID: 36285618 PMCID: PMC9597383 DOI: 10.1002/jia2.26025/full|10.1002/jia2.26025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/27/2022] [Indexed: 05/22/2023] Open
Abstract
INTRODUCTION Engagement with HIV care is a multi-dimensional, dynamic process, critical to maintaining successful treatment outcomes. However, measures of engagement are not standardized nor comprehensive. This undermines our understanding of the scope of challenges with engagement and whether interventions have an impact, complicating patient and programme-level decision-making. This study identified and characterized measures of engagement to support more consistent and comprehensive evaluation. METHODS We conducted a scoping study to systematically categorize measures the health system could use to evaluate engagement with HIV care for those on antiretroviral treatment. Key terms were used to search literature databases (Embase, PsychINFO, Ovid Global-Health, PubMed, Scopus, CINAHL, Cochrane and the World Health Organization Index Medicus), Google Scholar and stakeholder-identified manuscripts, ultimately including English evidence published from sub-Saharan Africa from 2014 to 2021. Measures were extracted, organized, then reviewed with key stakeholders. RESULTS AND DISCUSSION We screened 14,885 titles/abstracts, included 118 full-texts and identified 110 measures of engagement, categorized into three engagement dimensions ("retention," "adherence" and "active self-management"), a combination category ("multi-dimensional engagement") and "treatment outcomes" category (e.g. viral load as an end-result reflecting that engagement occurred). Retention reflected status in care, continuity of attendance and visit timing. Adherence was assessed by a variety of measures categorized into primary (prescription not filled) and secondary measures (medication not taken as directed). Active self-management reflected involvement in care and self-management. Three overarching use cases were identified: research to make recommendations, routine monitoring for quality improvement and strategic decision-making and assessment of individual patients. CONCLUSIONS Heterogeneity in conceptualizing engagement with HIV care is reflected by the broad range of measures identified and the lack of consensus on "gold-standard" indicators. This review organized metrics into five categories based on the dimensions of engagement; further work could identify a standardized, minimum set of measures useful for comprehensive evaluation of engagement for different use cases. In the interim, measurement of engagement could be advanced through the assessment of multiple categories for a more thorough evaluation, conducting sensitivity analyses with commonly used measures for more comparable outputs and using longitudinal measures to evaluate engagement patterns. This could improve research, programme evaluation and nuanced assessment of individual patient engagement in HIV care.
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Affiliation(s)
- Claire M. Keene
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Ayesha Ragunathan
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Mike English
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jacob McKnight
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Catherine Orrell
- Department of MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
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Kalk E, Heekes A, Slogrove AL, Phelanyane F, Davies MA, Myer L, Euvrard J, Kroon M, Petro G, Fieggen K, Stewart C, Rhoda N, Gebhardt S, Osman A, Anderson K, Boulle A, Mehta U. Cohort profile: the Western Cape Pregnancy Exposure Registry (WCPER). BMJ Open 2022; 12:e060205. [PMID: 35768089 PMCID: PMC9244673 DOI: 10.1136/bmjopen-2021-060205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
PURPOSE The Western Cape Pregnancy Exposure Registry (PER) was established at two public sector healthcare sentinel sites in the Western Cape province, South Africa, to provide ongoing surveillance of drug exposures in pregnancy and associations with pregnancy outcomes. PARTICIPANTS Established in 2016, all women attending their first antenatal visit at primary care obstetric facilities were enrolled and followed to pregnancy outcome regardless of the site (ie, primary, secondary, tertiary facility). Routine operational obstetric and medical data are digitised from the clinical stationery at the healthcare facilities. Data collection has been integrated into existing services and information platforms and supports routine operations. The PER is situated within the Provincial Health Data Centre, an information exchange that harmonises and consolidates all health-related electronic data in the province. Data are contributed via linkage across a unique identifier. This relationship limits the missing data in the PER, allows validation and avoids misclassification in the population-level data set. FINDINGS TO DATE Approximately 5000 and 3500 pregnant women enter the data set annually at the urban and rural sites, respectively. As of August 2021, >30 000 pregnancies have been recorded and outcomes have been determined for 93%. Analysis of key obstetric and neonatal health indicators derived from the PER are consistent with the aggregate data in the District Health Information System. FUTURE PLANS This represents significant infrastructure, able to address clinical and epidemiological concerns in a low/middle-income setting.
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Affiliation(s)
- Emma Kalk
- Centre for Infectious Disease Epidemiology & Research, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Alexa Heekes
- Centre for Infectious Disease Epidemiology & Research, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Health Intelligence Directorate, Western Cape Department of Health, Cape Town, South Africa
| | - Amy L Slogrove
- Ukwanda Centre for Rural Health, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
- Department of Paediatrics & Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Florence Phelanyane
- Centre for Infectious Disease Epidemiology & Research, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Health Intelligence Directorate, Western Cape Department of Health, Cape Town, South Africa
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology & Research, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Health Intelligence Directorate, Western Cape Department of Health, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology & Research, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Health Intelligence Directorate, Western Cape Department of Health, Cape Town, South Africa
| | - Max Kroon
- Department of Paediatrics & Child Health, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Neonatal Services, Mowbray Maternity Hospital, Cape Town, South Africa
| | - Greg Petro
- Department of Obstetrics & Gynaecology, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Maternity Services, New Somerset Hospital, Cape Town, South Africa
| | - Karen Fieggen
- Division of Human Genetics, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Medical Genetics Services, Groote Schuur Hospital, Cape Town, South Africa
| | - Chantal Stewart
- Department of Obstetrics & Gynaecology, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Maternity Services, Mowbray Maternity Hospital, Cape Town, South Africa
| | - Natasha Rhoda
- Department of Paediatrics & Child Health, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Neonatal Services, Mowbray Maternity Hospital, Cape Town, South Africa
| | - Stefan Gebhardt
- Department of Obstetrics & Gynaecology, Stellenbosch University, Stellenbosch, South Africa
- Maternity Services, Tygerberg Hospital, Cape Town, South Africa
| | - Ayesha Osman
- Department of Obstetrics & Gynaecology, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Maternity Services, Groote Schuur Hospital, Cape Town, South Africa
| | - Kim Anderson
- Centre for Infectious Disease Epidemiology & Research, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology & Research, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Health Intelligence Directorate, Western Cape Department of Health, Cape Town, South Africa
| | - Ushma Mehta
- Centre for Infectious Disease Epidemiology & Research, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
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11
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Nyakato P, Schomaker M, Fatti G, Tanser F, Euvrard J, Sipambo N, Fox MP, Haas AD, Yiannoutsos CT, Davies MA, Cornell M. Virologic non-suppression and early loss to follow up among pregnant and non-pregnant adolescents aged 15-19 years initiating antiretroviral therapy in South Africa: a retrospective cohort study. J Int AIDS Soc 2022; 25:e25870. [PMID: 35032096 PMCID: PMC8760609 DOI: 10.1002/jia2.25870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 12/20/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Older adolescents aged 15–19 years continue to have high rates of loss to follow up (LTFU), and high rates of virologic non‐suppression (VNS) compared to younger adolescents and adults. Adolescent females are at risk of pregnancy, which puts those living with HIV at a dual vulnerability. Our study assessed the factors associated with VNS and LTFU in older adolescents (including pregnant females) who initiated antiretroviral therapy (ART) in South Africa. Methods We included adolescents aged 15–19 years initiating ART between 2004 and 2019, with ≥ one viral load (VL) measurement between 4 and 24.5 months, and ≥ 6 months follow‐up, from six South African cohorts of the International epidemiology Databases to Evaluate AIDS‐Southern Africa (IeDEA‐SA). We defined VNS as VL ≥400 copies/ml and LTFU as not being in care for ≥180 days from ART start and not known as transferred out of the clinic or dead in the first 24 months on ART. We examined factors associated with VNS and LTFU using Fine&Gray competing risk models. Results We included a total of 2733 adolescents, 415 (15.2%) males, median (IQR) age at ART start of 18.6 (17.3, 19.4) years. Among females, 585/2318 (25.2%) were pregnant. Over the 24‐month follow‐up, 424 (15.5%) of all adolescents experienced VNS: range (11.1% pregnant females and 20.5% males). Over half of all adolescents were LTFU before any other event could occur. The hazard of VNS reduced with increasing age and CD4 count above 200 cells/μl at ART initiation among all adolescents having adjusted for all measured patient characteristics [adjusted sub‐distribution hazard ratio (aSHR) 19 vs. 15 years: 0.50 (95% CI: 0.36, 0.68), aSHR: >500 vs. ≤200 cells/μl: 0.22 (95% CI: 0.16, 0.31)]. The effect of CD4 count persisted in pregnant females. Increasing age and CD4 count >200 cells/μl were risk factors for LTFU among all adolescents. Conclusions Older adolescents had a high risk of LTFU shortly after ART start and a low risk of VNS, especially those initiating treatment during pregnancy. Interventions addressing adherence and retention should be incorporated into adolescent‐friendly services to prevent VNS and LTFU and endeavour to trace lost adolescents as soon as they are identified.
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Affiliation(s)
- Patience Nyakato
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Tyrol, Austria
| | - Geoffrey Fatti
- Kheth'Impilo AIDS-Free Living, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Frank Tanser
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Khayelitsha ART Programme and Medecins Sans Frontieres, Cape Town, South Africa
| | - Nosisa Sipambo
- Harriet Shezi Children's Clinic, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, Massachusetts, USA.,Health Economics & Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andreas D Haas
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Constantin T Yiannoutsos
- Department of Biostatistics, R.M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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12
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Han WM, Law MG, Egger M, Wools-Kaloustian K, Moore R, McGowan C, Kumarasamy N, Desmonde S, Edmonds A, Davies MA, Yiannoutsos C, Althoff KN, Cortes CP, Mohamed TJ, Jaquet A, Anastos K, Euvrard J, Castelnuovo B, Salters K, Coelho LE, Ekouevi DK, Eley B, Diero L, Zaniewski E, Ford N, Sohn AH, Kariminia A. Global estimates of viral suppression in children and adolescents and adults on antiretroviral therapy adjusted for missing viral load measurements: a multiregional, retrospective cohort study in 31 countries. Lancet HIV 2021; 8:e766-e775. [PMID: 34856180 PMCID: PMC8782625 DOI: 10.1016/s2352-3018(21)00265-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/12/2021] [Accepted: 09/16/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND As countries move towards the UNAIDS's 95-95-95 targets and with strong evidence that undetectable equals untransmittable, it is increasingly important to assess whether those with HIV who are receiving antiretroviral therapy (ART) achieve viral suppression. We estimated the proportions of children and adolescents and adults with viral suppression at 1, 2, and 3 years after initiating ART. METHODS In this retrospective cohort study, seven regional cohorts from the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium contributed data from individuals initiating ART between Jan 1, 2010, and Dec 31, 2019, at 148 sites in 31 countries with annual viral load monitoring. Only people with HIV who started ART after the time a site started routine viral load monitoring were included. Data up to March 31, 2020, were analysed. We estimated the proportions of children and adolescents (aged <18 years at ART initiation) and adults (aged ≥18 years at ART initiation) with viral suppression (viral load <1000 copies per mL) at 1, 2, and 3 years after ART initiation using an intention-to-treat approach and an adjusted approach that accounted for missing viral load measurements. FINDINGS 21 594 children and adolescents (11 812 [55%] female, 9782 [45%] male) from 106 sites in 22 countries and 255 662 adults (163 831 [64%] female, 91 831 [36%] male) from 143 sites in 30 countries were included. Using the intention-to-treat approach, the proportion of children and adolescents with viral suppression was 7303 (36%) of 20 478 at 1 year, 5709 (30%) of 19 135 at 2 years, and 4287 (24%) of 17 589 at 3 years after ART initiation; the proportion of adults with viral suppression was 106 541 (44%) of 240 600 at 1 year, 79 141 (36%) of 220 925 at 2 years, and 57 970 (29%) of 201 124 at 3 years after ART initiation. After adjusting for missing viral load measurements among those who transferred, were lost to follow-up, or who were in follow-up without viral load testing, the proportion of children and adolescents with viral suppression was 12 048 (64% [plausible range 43-81]) of 18 835 at 1 year, 10 796 (62% [41-77]) of 17 553 at 2 years, and 9177 (59% [38-91]) of 15 667 at 3 years after ART initiation; the proportion of adults with viral suppression was 176 964 (79% [53-80]) of 225 418 at 1 year, 145 552 (72% [48-79]) of 201 238 at 2 years, and 115 260 (65% [43-69]) of 178 458 at 3 years after ART initiation. INTERPRETATION Although adults with HIV are approaching the global target of 95% viral suppression, progress among children and adolescents is much slower. Substantial efforts are still needed to reach the viral suppression target for children and adolescents. FUNDING US National Institutes of Health.
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Affiliation(s)
- Win Min Han
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand.
| | - Matthew G Law
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Richard Moore
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Catherine McGowan
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nagalingesawaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site, The Voluntary Health Services, Chennai, India
| | | | - Andrew Edmonds
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mary-Ann Davies
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Keri N Althoff
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Claudia P Cortes
- Fundación Arriaran-Facultad de Medicina Universidad de Chile, Santiago, Chile
| | | | - Antoine Jaquet
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development, UMR 1219, Bordeaux, France
| | - Kathryn Anastos
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jonathan Euvrard
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Kate Salters
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada
| | - Lara Esteves Coelho
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Didier K Ekouevi
- Program PAC-CI, Abidjan, Côte d'Ivoire; Bordeaux Population Health (UMR1219), Bordeaux, France
| | - Brian Eley
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Lameck Diero
- Department of Medicine, Moi University School of Medicine and Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Elizabeth Zaniewski
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nathan Ford
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; HIV/AIDS Department and Global Hepatitis Program, WHO, Geneva, Switzerland
| | - Annette H Sohn
- TREAT Asia/amfAR, The Foundation for AIDS Research, Bangkok, Thailand
| | - Azar Kariminia
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
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13
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Boulle A, Davies MA, Hussey H, Ismail M, Morden E, Vundle Z, Zweigenthal V, Mahomed H, Paleker M, Pienaar D, Tembo Y, Lawrence C, Isaacs W, Mathema H, Allen D, Allie T, Bam JL, Buddiga K, Dane P, Heekes A, Matlapeng B, Mutemaringa T, Muzarabani L, Phelanyane F, Pienaar R, Rode C, Smith M, Tiffin N, Zinyakatira N, Cragg C, Marais F, Mudaly V, Voget J, Davids J, Roodt F, van Zyl Smit N, Vermeulen A, Adams K, Audley G, Bateman K, Beckwith P, Bernon M, Blom D, Boloko L, Botha J, Boutall A, Burmeister S, Cairncross L, Calligaro G, Coccia C, Corin C, Daroowala R, Dave JA, De Bruyn E, De Villiers M, Deetlefs M, Dlamini S, Du Toit T, Endres W, Europa T, Fieggan G, Figaji A, Frankenfeld P, Gatley E, Gina P, Govender E, Grobler R, Gule MV, Hanekom C, Held M, Heynes A, Hlatswayo S, Hodkinson B, Holtzhausen J, Hoosain S, Jacobs A, Kahn M, Kahn T, Khamajeet A, Khan J, Khan R, Khwitshana A, Knight L, Kooverjee S, Krogscheepers R, Kruger JJ, Kuhn S, Laubscher K, Lazarus J, Le Roux J, Lee Jones S, Levin D, Maartens G, Majola T, Manganyi R, Marais D, Marais S, Maritz F, Maughan D, Mazondwa S, Mbanga L, Mbatani N, Mbena B, Meintjes G, Mendelson M, Möller E, Moore A, Ndebele B, Nortje M, Ntusi N, Nyengane F, Ofoegbu C, Papavarnavas N, Peter J, Pickard H, Pluke K, Raubenheimer PJ, Robertson G, Rozmiarek J, Sayed A, Scriba M, Sekhukhune H, Singh P, Smith E, Soldati V, Stek C, van den berg R, van der Merwe LR, Venter P, Vermooten B, Viljoen G, Viranna S, Vogel J, Vundla N, Wasserman S, Zitha E, Lomas-Marais V, Lombard A, Stuve K, Viljoen W, Basson DV, Le Roux S, Linden-Mars E, Victor L, Wates M, Zwanepoel E, Ebrahim N, Lahri S, Mnguni A, Crede T, de Man M, Evans K, Hendrikse C, Naude J, Parak M, Szymanski P, Van Koningsbruggen C, Abrahams R, Allwood B, Botha C, Botha MH, Broadhurst A, Claasen D, Daniel C, Dawood R, du Preez M, Du Toit N, Erasmus K, Koegelenberg CFN, Gabriel S, Hugo S, Jardine T, Johannes C, Karamchand S, Lalla U, Langenegger E, Louw E, Mashigo B, Mhlana N, Mnqwazi C, Moodley A, Moodley D, Moolla S, Mowlana A, Nortje A, Olivier E, Parker A, Paulsen C, Prozesky H, Rood J, Sabela T, Schrueder N, Sithole N, Sithole S, Taljaard JJ, Titus G, Van Der Merwe T, van Schalkwyk M, Vazi L, Viljoen AJ, Yazied Chothia M, Naidoo V, Wallis LA, Abbass M, Arendse J, Armien R, Bailey R, Bello M, Carelse R, Forgus S, Kalawe N, Kariem S, Kotze M, Lucas J, McClaughlin J, Murie K, Najjaar L, Petersen L, Porter J, Shaw M, Stapar D, Williams M, Aldum L, Berkowitz N, Girran R, Lee K, Naidoo L, Neumuller C, Anderson K, Begg K, Boerlage L, Cornell M, de Waal R, Dudley L, English R, Euvrard J, Groenewald P, Jacob N, Jaspan H, Kalk E, Levitt N, Malaba T, Nyakato P, Patten G, Schneider H, Shung King M, Tsondai P, Van Duuren J, van Schaik N, Blumberg L, Cohen C, Govender N, Jassat W, Kufa T, McCarthy K, Morris L, Hsiao NY, Marais R, Ambler J, Ngwenya O, Osei-Yeboah R, Johnson L, Kassanjee R, Tamuhla T. Risk Factors for Coronavirus Disease 2019 (COVID-19) Death in a Population Cohort Study from the Western Cape Province, South Africa. Clin Infect Dis 2021; 73:e2005-e2015. [PMID: 32860699 PMCID: PMC7499501 DOI: 10.1093/cid/ciaa1198] [Citation(s) in RCA: 300] [Impact Index Per Article: 100.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Risk factors for coronavirus disease 2019 (COVID-19) death in sub-Saharan Africa and the effects of human immunodeficiency virus (HIV) and tuberculosis on COVID-19 outcomes are unknown. METHODS We conducted a population cohort study using linked data from adults attending public-sector health facilities in the Western Cape, South Africa. We used Cox proportional hazards models, adjusted for age, sex, location, and comorbidities, to examine the associations between HIV, tuberculosis, and COVID-19 death from 1 March to 9 June 2020 among (1) public-sector "active patients" (≥1 visit in the 3 years before March 2020); (2) laboratory-diagnosed COVID-19 cases; and (3) hospitalized COVID-19 cases. We calculated the standardized mortality ratio (SMR) for COVID-19, comparing adults living with and without HIV using modeled population estimates. RESULTS Among 3 460 932 patients (16% living with HIV), 22 308 were diagnosed with COVID-19, of whom 625 died. COVID-19 death was associated with male sex, increasing age, diabetes, hypertension, and chronic kidney disease. HIV was associated with COVID-19 mortality (adjusted hazard ratio [aHR], 2.14; 95% confidence interval [CI], 1.70-2.70), with similar risks across strata of viral loads and immunosuppression. Current and previous diagnoses of tuberculosis were associated with COVID-19 death (aHR, 2.70 [95% CI, 1.81-4.04] and 1.51 [95% CI, 1.18-1.93], respectively). The SMR for COVID-19 death associated with HIV was 2.39 (95% CI, 1.96-2.86); population attributable fraction 8.5% (95% CI, 6.1-11.1). CONCLUSIONS While our findings may overestimate HIV- and tuberculosis-associated COVID-19 mortality risks due to residual confounding, both living with HIV and having current tuberculosis were independently associated with increased COVID-19 mortality. The associations between age, sex, and other comorbidities and COVID-19 mortality were similar to those in other settings.
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Affiliation(s)
| | - Andrew Boulle
- Health Impact Assessment, Western Cape Government: Health
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Mary-Ann Davies
- Health Impact Assessment, Western Cape Government: Health
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Hannah Hussey
- Health Impact Assessment, Western Cape Government: Health
- School of Public Health and Family Medicine, University of Cape Town
| | - Muzzammil Ismail
- Health Impact Assessment, Western Cape Government: Health
- School of Public Health and Family Medicine, University of Cape Town
| | - Erna Morden
- Health Impact Assessment, Western Cape Government: Health
- School of Public Health and Family Medicine, University of Cape Town
| | - Ziyanda Vundle
- Health Impact Assessment, Western Cape Government: Health
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University
| | - Virginia Zweigenthal
- Health Impact Assessment, Western Cape Government: Health
- School of Public Health and Family Medicine, University of Cape Town
| | - Hassan Mahomed
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University
- Metro Health Services, Western Cape Government: Health
| | - Masudah Paleker
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University
- Metro Health Services, Western Cape Government: Health
| | - David Pienaar
- Rural Health Services, Western Cape Government: Health
| | - Yamanya Tembo
- School of Public Health and Family Medicine, University of Cape Town
- Rural Health Services, Western Cape Government: Health
| | - Charlene Lawrence
- Communicable Disease Sub-Directorate, Western Cape Government: Health
| | - Washiefa Isaacs
- Communicable Disease Sub-Directorate, Western Cape Government: Health
| | - Hlengani Mathema
- Communicable Disease Sub-Directorate, Western Cape Government: Health
- National Institute for Communicable Diseases, National Health Laboratory Service, South Africa
| | - Derick Allen
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Taryn Allie
- Health Impact Assessment, Western Cape Government: Health
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Jamy-Lee Bam
- Health Impact Assessment, Western Cape Government: Health
| | - Kasturi Buddiga
- Health Impact Assessment, Western Cape Government: Health
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Pierre Dane
- Health Impact Assessment, Western Cape Government: Health
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Alexa Heekes
- Health Impact Assessment, Western Cape Government: Health
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Boitumelo Matlapeng
- Health Impact Assessment, Western Cape Government: Health
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Themba Mutemaringa
- Health Impact Assessment, Western Cape Government: Health
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Luckmore Muzarabani
- Health Impact Assessment, Western Cape Government: Health
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Florence Phelanyane
- Health Impact Assessment, Western Cape Government: Health
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Rory Pienaar
- Health Impact Assessment, Western Cape Government: Health
| | - Catherine Rode
- Health Impact Assessment, Western Cape Government: Health
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Mariette Smith
- Health Impact Assessment, Western Cape Government: Health
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Nicki Tiffin
- Health Impact Assessment, Western Cape Government: Health
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
- Wellcome Centre for Infectious Disease Research in Africa, University of Cape Town
- Division of Computational Biology, University of Cape Town
| | - Nesbert Zinyakatira
- Health Impact Assessment, Western Cape Government: Health
- School of Public Health and Family Medicine, University of Cape Town
| | - Carol Cragg
- Health Programmes Directorate, Western Cape Government: Health
| | - Frederick Marais
- Health Programmes Directorate, Western Cape Government: Health
- Faculty of Health Sciences, North West University
| | - Vanessa Mudaly
- School of Public Health and Family Medicine, University of Cape Town
- Health Programmes Directorate, Western Cape Government: Health
| | | | - Jody Davids
- George Hospital, Western Cape Government: Health
| | | | | | | | - Kevin Adams
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Gordon Audley
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Kathleen Bateman
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Peter Beckwith
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Marc Bernon
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Dirk Blom
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Linda Boloko
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Jean Botha
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Adam Boutall
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Sean Burmeister
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Lydia Cairncross
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Gregory Calligaro
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Cecilia Coccia
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Chadwin Corin
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Remy Daroowala
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Joel A Dave
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Elsa De Bruyn
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Martin De Villiers
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Mimi Deetlefs
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Sipho Dlamini
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Thomas Du Toit
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Wilhelm Endres
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Tarin Europa
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Graham Fieggan
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Anthony Figaji
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Petro Frankenfeld
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Elizabeth Gatley
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Phindile Gina
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Evashan Govender
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Rochelle Grobler
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Manqoba Vusumuzi Gule
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Christoff Hanekom
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Michael Held
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Alana Heynes
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Sabelo Hlatswayo
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Bridget Hodkinson
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | | | - Shakeel Hoosain
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Ashely Jacobs
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Miriam Kahn
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Thania Kahn
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Arvin Khamajeet
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Joubin Khan
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Riaasat Khan
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Alicia Khwitshana
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Lauren Knight
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Sharita Kooverjee
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Rene Krogscheepers
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Jean Jacque Kruger
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Suzanne Kuhn
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Kim Laubscher
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - John Lazarus
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Jacque Le Roux
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Scott Lee Jones
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Dion Levin
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Gary Maartens
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Thina Majola
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Rodgers Manganyi
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - David Marais
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Suzaan Marais
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Francois Maritz
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Deborah Maughan
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Simthandile Mazondwa
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Luyanda Mbanga
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Nomonde Mbatani
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Bulewa Mbena
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Graeme Meintjes
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Marc Mendelson
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Ernst Möller
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Allison Moore
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Babalwa Ndebele
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Marc Nortje
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Ntobeko Ntusi
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Funeka Nyengane
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Chima Ofoegbu
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Nectarios Papavarnavas
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Jonny Peter
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Henri Pickard
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Kent Pluke
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Peter J Raubenheimer
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Gordon Robertson
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Julius Rozmiarek
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - A Sayed
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Matthias Scriba
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Hennie Sekhukhune
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Prasun Singh
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Elsabe Smith
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Vuyolwethu Soldati
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Cari Stek
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Robert van den berg
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Le Roux van der Merwe
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Pieter Venter
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Surgery, University of Cape Town
| | - Barbra Vermooten
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Gerrit Viljoen
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Santhuri Viranna
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Jonno Vogel
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Nokubonga Vundla
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Sean Wasserman
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | - Eddy Zitha
- Groote Schuur Hospital, Western Cape Government: Health
- Department of Medicine, University of Cape Town
| | | | | | - Katrin Stuve
- Department of Radiology, University of Cape Town
| | | | | | - Sue Le Roux
- Karl Bremer Hospital, Western Cape Government: Health
| | | | | | - Mark Wates
- Karl Bremer Hospital, Western Cape Government: Health
| | | | - Nabilah Ebrahim
- Khayelitsha District Hospital, Western Cape Government: Health
| | - Sa’ad Lahri
- Khayelitsha District Hospital, Western Cape Government: Health
| | - Ayanda Mnguni
- Khayelitsha District Hospital, Western Cape Government: Health
| | - Thomas Crede
- Mitchells Plain and Heideveld Hospitals, Western Cape Government: Health
| | - Martin de Man
- Mitchells Plain and Heideveld Hospitals, Western Cape Government: Health
- Division of Emergency Medicine, University of Cape Town
| | - Katya Evans
- Mitchells Plain and Heideveld Hospitals, Western Cape Government: Health
- Division of Emergency Medicine, University of Cape Town
| | - Clint Hendrikse
- Mitchells Plain and Heideveld Hospitals, Western Cape Government: Health
- Division of Emergency Medicine, University of Cape Town
| | - Jonathan Naude
- Mitchells Plain and Heideveld Hospitals, Western Cape Government: Health
| | - Moosa Parak
- Mitchells Plain and Heideveld Hospitals, Western Cape Government: Health
- Division of Emergency Medicine, University of Cape Town
| | - Patrick Szymanski
- Mitchells Plain and Heideveld Hospitals, Western Cape Government: Health
| | - Candice Van Koningsbruggen
- Mitchells Plain and Heideveld Hospitals, Western Cape Government: Health
- Division of Emergency Medicine, University of Cape Town
| | - Riezaah Abrahams
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Brian Allwood
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Christoffel Botha
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Matthys Henndrik Botha
- Tygerberg Hospital, Western Cape Government: Health
- Department of Obstetrics and Gyneacology, Stellenbosch University
| | - Alistair Broadhurst
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Dirkie Claasen
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Che Daniel
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Riyaadh Dawood
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Marie du Preez
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Nicolene Du Toit
- Tygerberg Hospital, Western Cape Government: Health
- Department of Obstetrics and Gyneacology, Stellenbosch University
| | - Kobie Erasmus
- Tygerberg Hospital, Western Cape Government: Health
- Emergency Medical Services, Western Cape Government
| | | | - Shiraaz Gabriel
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Susan Hugo
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Thabiet Jardine
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Clint Johannes
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Sumanth Karamchand
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Usha Lalla
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Eduard Langenegger
- Tygerberg Hospital, Western Cape Government: Health
- Department of Obstetrics and Gyneacology, Stellenbosch University
| | - Eize Louw
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Boitumelo Mashigo
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Nonte Mhlana
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Chizama Mnqwazi
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Ashley Moodley
- Tygerberg Hospital, Western Cape Government: Health
- Department of Obstetrics and Gyneacology, Stellenbosch University
| | - Desiree Moodley
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Saadiq Moolla
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Abdurasiet Mowlana
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Andre Nortje
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Elzanne Olivier
- Tygerberg Hospital, Western Cape Government: Health
- Department of Obstetrics and Gyneacology, Stellenbosch University
| | - Arifa Parker
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Chané Paulsen
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Hans Prozesky
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Jacques Rood
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Tholakele Sabela
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Neshaad Schrueder
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Nokwanda Sithole
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Sthembiso Sithole
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Jantjie J Taljaard
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Gideon Titus
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Tian Van Der Merwe
- Tygerberg Hospital, Western Cape Government: Health
- Department of Obstetrics and Gyneacology, Stellenbosch University
| | - Marije van Schalkwyk
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Luthando Vazi
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Abraham J Viljoen
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | - Mogamat Yazied Chothia
- Tygerberg Hospital, Western Cape Government: Health
- Department of Medicine, Stellenbosch University
| | | | - Lee Alan Wallis
- Emergency Medical Services, Western Cape Government
- Division of Emergency Medicine, University of Cape Town
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Linda Aldum
- City Health, Community Services and Health, City of Cape Town
| | | | - Raakhee Girran
- City Health, Community Services and Health, City of Cape Town
| | - Kevin Lee
- City Health, Community Services and Health, City of Cape Town
| | - Lenny Naidoo
- City Health, Community Services and Health, City of Cape Town
| | | | - Kim Anderson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Kerrin Begg
- School of Public Health and Family Medicine, University of Cape Town
| | - Lisa Boerlage
- School of Public Health and Family Medicine, University of Cape Town
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Renée de Waal
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Lilian Dudley
- Metro Health Services, Western Cape Government: Health
| | - René English
- Metro Health Services, Western Cape Government: Health
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Pam Groenewald
- South African Medical Research Council Burden of Disease Research Unit
| | - Nisha Jacob
- School of Public Health and Family Medicine, University of Cape Town
| | - Heather Jaspan
- Division of Immunology and Institute of Infectious Diseases and Molecular Medicine, University of Cape Town
| | - Emma Kalk
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | | | - Thoko Malaba
- School of Public Health and Family Medicine, University of Cape Town
| | - Patience Nyakato
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Gabriela Patten
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | | | | | - Priscilla Tsondai
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - James Van Duuren
- School of Public Health and Family Medicine, University of Cape Town
| | | | - Lucille Blumberg
- National Institute for Communicable Diseases, National Health Laboratory Service, South Africa
- University of Pretoria
| | - Cheryl Cohen
- National Institute for Communicable Diseases, National Health Laboratory Service, South Africa
- School of Public Health, University of Witwatersrand
| | - Nelesh Govender
- National Institute for Communicable Diseases, National Health Laboratory Service, South Africa
- School of Pathology, University of the Witwatersrand and School of Pathology, University of Cape Town
| | - Waasila Jassat
- National Institute for Communicable Diseases, National Health Laboratory Service, South Africa
| | - Tendesayi Kufa
- National Institute for Communicable Diseases, National Health Laboratory Service, South Africa
| | - Kerrigan McCarthy
- National Institute for Communicable Diseases, National Health Laboratory Service, South Africa
| | - Lynn Morris
- National Institute for Communicable Diseases, National Health Laboratory Service, South Africa
- University of Witwatersrand, South African Medical Research Council Antibody Immunity Research Unit and the Centre for the AIDS Programme in South Africa (CAPRISA)
| | - Nei-yuan Hsiao
- National Health Laboratory Service and Division of Virology, School of Pathology, University of Cape Town
| | - Ruan Marais
- National Health Laboratory Service and Division of Virology, School of Pathology, University of Cape Town
| | - Jon Ambler
- Wellcome Centre for Infectious Disease Research in Africa, University of Cape Town
| | - Olina Ngwenya
- Wellcome Centre for Infectious Disease Research in Africa, University of Cape Town
| | | | - Leigh Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Reshma Kassanjee
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Tsaone Tamuhla
- Division of Computational Biology, University of Cape Town
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14
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Zaniewski E, Dao Ostinelli CH, Chammartin F, Maxwell N, Davies M, Euvrard J, van Dijk J, Bosomprah S, Phiri S, Tanser F, Sipambo N, Muhairwe J, Fatti G, Prozesky H, Wood R, Ford N, Fox MP, Egger M. Trends in CD4 and viral load testing 2005 to 2018: multi-cohort study of people living with HIV in Southern Africa. J Int AIDS Soc 2020; 23:e25546. [PMID: 32640106 PMCID: PMC7343336 DOI: 10.1002/jia2.25546] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 05/06/2020] [Accepted: 05/19/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The World Health Organization (WHO) recommends a CD4 cell count before starting antiretroviral therapy (ART) to detect advanced HIV disease, and routine viral load (VL) testing following ART initiation to detect treatment failure. Donor support for CD4 testing has declined to prioritize access to VL monitoring. We examined trends in CD4 and VL testing among adults (≥15 years of age) starting ART in Southern Africa. METHODS We analysed data from 14 HIV treatment programmes in Lesotho, Malawi, Mozambique, South Africa, Zambia and Zimbabwe in 2005 to 2018. We examined the frequency of CD4 and VL testing, the percentage of adults with CD4 or VL tests, and among those having a test, the percentage starting ART with advanced HIV disease (CD4 count <200 cells/mm3 ) or failing to suppress viral replication (>1000 HIV-RNA copies/mL) after ART initiation. We used mixed effect logistic regression to assess time trends adjusted for age and sex. RESULTS Among 502,456 adults, the percentage with CD4 testing at ART initiation decreased from a high of 78.1% in 2008 to a low of 38.0% in 2017; the probability declined by 14% each year (odds ratio (OR) 0.86; 95% CI 0.86 to 0.86). Frequency of CD4 testing also declined. The percentage starting ART with advanced HIV disease declined from 83.3% in 2005 to 23.5% in 2018; each year the probability declined by 20% (OR 0.80; 95% CI 0.80 to 0.81). VL testing after starting ART varied; 61.0% of adults in South Africa and 10.7% in Malawi were tested, but fewer than 2% were tested in the other four countries. The probability of VL testing after ART start increased only modestly each year (OR 1.06; 95% CI 1.05 to 1.06). The percentage with unsuppressed VL was 8.6%. There was no evidence of a decrease in unsuppressed VL over time (OR 1.00; 95% CI 0.99 to 1.01). CONCLUSIONS CD4 cell counting declined over time, including testing at the start of ART, despite the fact that many patients still initiated ART with advanced HIV disease. Without CD4 testing and expanded VL testing many patients with advanced HIV disease and treatment failure may go undetected, threatening the effectiveness of ART in sub-Saharan Africa.
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Affiliation(s)
- Elizabeth Zaniewski
- Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
| | - Cam H Dao Ostinelli
- Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
| | | | - Nicola Maxwell
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Mary‐Ann Davies
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | | | - Samuel Bosomprah
- Centre for Infectious Disease Research in ZambiaLusakaZambia
- Department of BiostatisticsSchool of Public HealthUniversity of GhanaAccraGhana
| | | | - Frank Tanser
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Lincoln International Institute for Rural HealthUniversity of LincolnLincolnUnited Kingdom
- School of Nursing and Public HealthUniversity of KwaZulu‐NatalDurbanSouth Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)University of KwaZulu‐NatalDurbanSouth Africa
| | - Nosisa Sipambo
- Chris Hani Baragwanath Academic HospitalJohannesburgSouth Africa
| | | | - Geoffrey Fatti
- Kheth’Impilo AIDS Free LivingCape TownSouth Africa
- Division of Epidemiology and BiostatisticsDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Hans Prozesky
- Division of Infectious DiseasesDepartment of MedicineStellenbosch UniversityCape TownSouth Africa
| | - Robin Wood
- Gugulethu ART Programme (Desmond Tutu HIV Centre)Cape TownSouth Africa
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Department of HIV/AIDS and Global Hepatitis ProgrammeWorld Health OrganizationGenevaSwitzerland
| | - Matthew P Fox
- Department of Global HealthBoston UniversityBostonMAUSA
- Department of EpidemiologyBoston UniversityBostonMAUSA
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Matthias Egger
- Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
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15
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Kehoe K, Boulle A, Tsondai PR, Euvrard J, Davies MA, Cornell M. Long-term virologic responses to antiretroviral therapy among HIV-positive patients entering adherence clubs in Khayelitsha, Cape Town, South Africa: a longitudinal analysis. J Int AIDS Soc 2020; 23:e25476. [PMID: 32406983 PMCID: PMC7224308 DOI: 10.1002/jia2.25476] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION In South Africa, an estimated 4.6 million people were accessing antiretroviral therapy (ART) in 2018. As universal Test and Treat is implemented, these numbers will continue to increase. Given the need for lifelong care for millions of individuals, differentiated service delivery models for ART services such as adherence clubs (ACs) for stable patients are required. In this study, we describe long-term virologic outcomes of patients who have ever entered ACs in Khayelitsha, Cape Town. METHODS We included adult patients enrolled in ACs in Khayelitsha between January 2011 and December 2016 with a recorded viral load (VL) before enrolment. Risk factors for an elevated VL (VL >1000 copies/mL) and confirmed virologic failure (two consecutive VLs >1000 copies/mL one year apart) were estimated using Cox proportional hazards models. VL completeness over time was assessed. RESULTS Overall, 8058 patients were included in the analysis, contributing 16,047 person-years of follow-up from AC entry (median follow-up time 1.7 years, interquartile range [IQR]:0.9 to 2.9). At AC entry, 74% were female, 46% were aged between 35 and 44 years, and the median duration on ART was 4.8 years (IQR: 3.0 to 7.2). Among patients virologically suppressed at AC entry (n = 8058), 7136 (89%) had a subsequent VL test, of which 441 (6%) experienced an elevated VL (median time from AC entry 363 days, IQR: 170 to 728). Older age (adjusted hazard ratio [aHR] 0.64, 95% confidence interval [CI] 0.46 to 0.88), more recent year of AC entry (aHR 0.76, 95% CI 0.68 to 0.84) and higher CD4 count (aHR 0.67, 95% CI 0.54 to 0.84) were protective against experiencing an elevated VL. Among patients with an elevated VL, 52% (150/291) with a repeat VL test subsequently experienced confirmed virologic failure in a median time of 112 days (IQR: 56 to 168). Frequency of VL testing was constant over time (82 to 85%), with over 90% of patients remaining virologically suppressed. CONCLUSIONS This study demonstrates low prevalence of elevated VLs and confirmed virologic failure among patients who entered ACs. Although ACs were expanded rapidly, most patients were well monitored and remained stable, supporting the continued rollout of this model.
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Affiliation(s)
- Kathleen Kehoe
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Khayelitsha ART Programme and Médecins Sans FrontièresCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Priscilla R Tsondai
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Khayelitsha ART Programme and Médecins Sans FrontièresCape TownSouth Africa
| | - Mary Ann Davies
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
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16
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Pillay T, Cornell M, Fox MP, Euvrard J, Fatti G, Technau KG, Sipambo N, Prozesky H, Eley B, Tanser F, Johnson LF. Recording of HIV viral loads and viral suppression in South African patients receiving antiretroviral treatment: a multicentre cohort study. Antivir Ther 2020; 25:257-266. [PMID: 32960187 DOI: 10.3851/imp3371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Viral suppression in patients on antiretroviral treatment (ART) is critical to reducing HIV transmission and HIV-related mortality. Although many studies have evaluated factors associated with viral suppression, few have assessed the extent to which missing viral load data may bias results. METHODS We included data on all patients starting ART from 2005 to 2019 in eight South African cohorts participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) collaboration. Multivariable logistic regression models were used to determine factors associated with having a viral load measurement within 2 months of a scheduled testing date and having a viral load <400 RNA copies/ml ('viral suppression'). In a sensitivity analysis, missing viral loads were imputed based on patients' clinical and demographic characteristics and outcomes. RESULTS Viral load tests were scheduled in 603,549 and 77,423 intervals in adults and children, respectively, but test results were recorded in only 40.7% and 41.2%, respectively. The proportion of recorded results suppressed was 85.7% in adults and 72.4% in children. After imputation of missing viral load measurements, viral suppression reduced slightly in adults (85.3%) and increased in children (73.2%). Predictors of virological suppression in adults, which included female sex, older age, higher baseline CD4+ T-cell count and recent testing year, were similar in the main analysis and after imputing missing viral loads. CONCLUSIONS Although viral load information was frequently missing in the South African setting, estimates of viral suppression and predictors of viral suppression did not change substantially after adjusting for missing data.
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Affiliation(s)
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Geoffrey Fatti
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Karl-Günter Technau
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Nosisa Sipambo
- Harriet Shezi Children's Clinic, University of the Witwatersrand, Johannesburg, South Africa
| | - Hans Prozesky
- Division of Infectious Diseases, Tygerberg Academic Hospital, University of Stellenbosch, Cape Town, South Africa
| | - Brian Eley
- Red Cross War Memorial Children's Hospital and the Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Frank Tanser
- Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK.,Africa Health Research Institute, Somkhele, KwaZulu-Natal, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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17
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de Beer S, Kalk E, Kroon M, Boulle A, Osler M, Euvrard J, Timmerman V, Davies M. A longitudinal analysis of the completeness of maternal HIV testing, including repeat testing in Cape Town, South Africa. J Int AIDS Soc 2020; 23:e25441. [PMID: 31997583 PMCID: PMC6989397 DOI: 10.1002/jia2.25441] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 12/04/2019] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The virtual elimination of mother-to-child transmission of HIV cannot be achieved without complete maternal HIV testing. The World Health Organization recommends that women in high HIV prevalent settings repeat HIV testing in the third trimester, and at delivery or directly thereafter. The Western Cape Province (South Africa) prevention of mother-to-child transmission (PMTCT) guidelines recommend a repeat maternal HIV test between 32 and 34 weeks gestation and at delivery in addition to testing at the first antenatal visit (ideally <20 weeks gestation). There are few published longitudinal studies on the uptake of initial and repeated maternal HIV testing programmes in sub-Saharan Africa. We aimed to investigate the implementation of initial and repeat maternal HIV testing guidelines in Cape Town, South Africa. METHODS Between 2013 and 2016 we established an electronic PMTCT register that consolidated routine data from a primary healthcare facility and its secondary and tertiary referral sites in Cape Town. This provided a longitudinal record for each participant, from first antenatal visit to delivery. Utilizing these data, we conducted a retrospective analysis investigating the completeness of maternal HIV testing according to the PMTCT HIV testing guidelines in Cape Town, and predictors of complete testing, from 2014 to 2016. RESULTS Among 8558 enrolled pregnant women, 7213 (84%) were not known to be HIV positive at their first visit and thus eligible for HIV testing; 91% of them received ≥1 HIV test during pregnancy/delivery. Testing at the first visit was 98% among the 85% of women who attended antenatal care. Among women eligible to receive all three recommended HIV tests, only 11% achieved all three tests. Delivery HIV testing completion among all women without an HIV-positive diagnosis was 23%. HIV prevalence at delivery was 21% and HIV incidence between first visit and delivery in those with ≥2 HIV tests was 0.2%. Women who enrolled after 2014 were more likely to receive the three recommended tests (aOR: 1.41; 95% CI: 1.10 to 1.81) and retest at delivery (aOR: 1.20; 95% CI: 1.05 to 1.39). CONCLUSIONS Implementation of maternal HIV testing in Cape Town improved between 2014 and 2016 but major gaps remain, particularly at delivery.
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Affiliation(s)
- Shani de Beer
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Emma Kalk
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Max Kroon
- Department of PaediatricsMowbray Maternity HospitalUniversity of Cape TownCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Meg Osler
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Venessa Timmerman
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Mary‐Ann Davies
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
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18
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Kalk E, Kroon M, Boulle A, Osler M, Euvrard J, Stinson K, Timmerman V, Davies M. Neonatal and infant diagnostic HIV-PCR uptake and associations during three sequential policy periods in Cape Town, South Africa: a longitudinal analysis. J Int AIDS Soc 2018; 21:e25212. [PMID: 30480373 PMCID: PMC6256843 DOI: 10.1002/jia2.25212] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 10/30/2018] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION To strengthen the early infant diagnosis (EID) programmes and timeously identify and treat HIV-infected infants, birth HIV-PCR for some/all infants has been recommended in the Western Cape, South Africa since 2014. Operational data on the implementation of such programmes in low- and middle-income countries are limited. METHODS Utilizing the electronic records platform at primary care facilities, we developed an electronic register which consolidated obstetric and HIV-related data, allowing us to track a cohort of HIV-infected/exposed mother/infant dyads longitudinally from antenatal care through delivery to infant HIV-PCR. We assessed guideline implementation and impact on EID of three sequential EID policies in a referral chain of facilities in Cape Town (primary-tertiary care). Birth HIV-PCR was indicated in period 1 if symptomatic; period 2 if meeting high-risk criteria for transmission; and period 3 for all HIV-exposed neonates. RESULTS We enrolled 2012 HIV-exposed infants; 89.2% had at least one HIV-PCR at any point. The majority of birth tests were performed in hospital versus primary care regardless of policy period. Almost half of all infants (47.9%) had at least one high-risk criterion for vertical infection; of these, 39.7% had a birth test. Infants with more risk factors were more likely to have birth EID. Receipt of a birth HIV-PCR significantly reduced the likelihood of receiving a follow-up test at six to ten weeks, even after adjusting for potential confounders (aOR 0.18 (0.12 to 0.26)). The proportion of infants tested at six to ten weeks old dropped from 92.9% (period 1) to 80.2% in period 3 and those receiving birth HIV-PCR increased, peaking at 67.4% during period 3. The proportion of positive birth tests was highest (2.9%) when birth tests were restricted to infants meeting high-risk criteria, with a low proportion positive for the first time at six to ten weeks. During period 3, the proportion positive at six to ten weeks was high (2.4%), highlighting the importance of follow-up to detect intrapartum and early postpartum infections. CONCLUSIONS Over all policy periods, EID guidelines were incompletely implemented across all levels of care but especially in primary care. Birth HIV-PCR reduced return for follow-up testing, such follow-up testing is critical for the effectiveness of the programme.
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Affiliation(s)
- Emma Kalk
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Max Kroon
- Department of PaediatricsMowbray Maternity HospitalUniversity of Cape TownCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Meg Osler
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Kathryn Stinson
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Venessa Timmerman
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Mary‐Ann Davies
- Centre for Infectious Disease Epidemiology & ResearchSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
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19
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Kaplan SR, Oosthuizen C, Stinson K, Little F, Euvrard J, Schomaker M, Osler M, Hilderbrand K, Boulle A, Meintjes G. Contemporary disengagement from antiretroviral therapy in Khayelitsha, South Africa: A cohort study. PLoS Med 2017; 14:e1002407. [PMID: 29112692 PMCID: PMC5675399 DOI: 10.1371/journal.pmed.1002407] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 09/12/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Retention in care is an essential component of meeting the UNAIDS "90-90-90" HIV treatment targets. In Khayelitsha township (population ~500,000) in Cape Town, South Africa, more than 50,000 patients have received antiretroviral therapy (ART) since the inception of this public-sector program in 2001. Disengagement from care remains an important challenge. We sought to determine the incidence of and risk factors associated with disengagement from care during 2013-2014 and outcomes for those who disengaged. METHODS AND FINDINGS We conducted a retrospective cohort study of all patients ≥10 years of age who visited 1 of the 13 Khayelitsha ART clinics from 2013-2014 regardless of the date they initiated ART. We described the cumulative incidence of first disengagement (>180 days not attending clinic) between 1 January 2013 and 31 December 2014 using competing risks methods, enabling us to estimate disengagement incidence up to 10 years after ART initiation. We also described risk factors for disengagement based on a Cox proportional hazards model, using multiple imputation for missing data. We ascertained outcomes (death, return to care, hospital admission, other hospital contact, alive but not in care, no information) after disengagement until 30 June 2015 using province-wide health databases and the National Death Registry. Of 39,884 patients meeting our eligibility criteria, the median time on ART to 31 December 2014 was 33.6 months (IQR 12.4-63.2). Of the total study cohort, 592 (1.5%) died in the study period, 1,231 (3.1%) formally transferred out, 987 (2.5%) were silent transfers and visited another Western Cape province clinic within 180 days, 9,005 (22.6%) disengaged, and 28,069 (70.4%) remained in care. Cumulative incidence of disengagement from care was estimated to be 25.1% by 2 years and 50.3% by 5 years on ART. Key factors associated with disengagement (age, male sex, pregnancy at ART start [HR 1.58, 95% CI 1.47-1.69], most recent CD4 count) and retention (ART club membership, baseline CD4) after adjustment were similar to those found in previous studies; however, notably, the higher hazard of disengagement soon after starting ART was no longer present after adjusting for these risk factors. Of the 9,005 who disengaged, the 2 most common initial outcomes were return to ART care after 180 days (33%; n = 2,976) and being alive but not in care in the Western Cape (25%; n = 2,255). After disengagement, a total of 1,459 (16%) patients were hospitalized and 237 (3%) died. The median follow-up from date of disengagement to 30 June 2015 was 16.7 months (IQR 11-22.4). As we included only patient follow-up from 2013-2014 by design in order to maximize the generalizability of our findings to current programs, this limited our ability to more fully describe temporal trends in first disengagement. CONCLUSIONS Twenty-three percent of ART patients in the large cohort of Khayelitsha, one of the oldest public-sector ART programs in South Africa, disengaged from care at least once in a contemporary 2-year period. Fifty-eight percent of these patients either subsequently returned to care (some "silently") or remained alive without hospitalization, suggesting that many who are considered "lost" actually return to care, and that misclassification of "lost" patients is likely common in similar urban populations. A challenge to meeting ART retention targets is developing, testing, and implementing program designs to target mobile populations and retain them in lifelong care. This should be guided by risk factors for disengagement and improving interlinkage of routine information systems to better support patient care across complex care platforms.
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Affiliation(s)
- Samantha R. Kaplan
- Yale School of Medicine, New Haven, Connecticut, United States of America
- * E-mail:
| | - Christa Oosthuizen
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kathryn Stinson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Médecins Sans Frontières (Southern Africa Medical Unit), Johannesburg, South Africa
| | - Francesca Little
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Meg Osler
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Katherine Hilderbrand
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Médecins Sans Frontières (Southern Africa Medical Unit), Johannesburg, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Graeme Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
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