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Mutale W, Herce ME. Closing the gap in paediatric HIV infections: how available tools and technology can accelerate progress towards ending AIDS by 2030. Lancet 2024; 403:1313-1315. [PMID: 38484754 DOI: 10.1016/s0140-6736(24)00366-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 04/08/2024]
Affiliation(s)
- Wilbroad Mutale
- Department of Health Policy and Management, University of Zambia School of Public Health, Lusaka, Zambia; Southern Africa Institute for Collaborative Research and Innovation Organisation, Lusaka, Zambia.
| | - Michael E Herce
- Implementation Science Unit, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Narayan A, Salindri AD, Keshavjee S, Muyoyeta M, Velen K, Rueda ZV, Croda J, Charalambous S, García-Basteiro AL, Shenoi SV, Gonçalves CCM, Ferreira da Silva L, Possuelo LG, Aguirre S, Estigarribia G, Sequera G, Grandjean L, Telisinghe L, Herce ME, Dockhorn F, Altice FL, Andrews JR. Prioritizing persons deprived of liberty in global guidelines for tuberculosis preventive treatment. PLoS Med 2023; 20:e1004288. [PMID: 37788448 PMCID: PMC10547494 DOI: 10.1371/journal.pmed.1004288] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
In this Policy Forum piece, Aditya Narayan and colleagues discuss the challenges and opportunities for tuberculosis preventive treatment in carceral settings.
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Affiliation(s)
- Aditya Narayan
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Argita D. Salindri
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Salmaan Keshavjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Monde Muyoyeta
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Kavindhran Velen
- Implementation Division, The Aurum Institute, Johannesburg, South Africa
| | - Zulma V. Rueda
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
- Research Department, School of Medicine, Universidad Pontificia Bolivariana, Medellin, Colombia
| | - Julio Croda
- School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, Brazil
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, United States of America
- Oswaldo Cruz Foundation, Campo Grande, Brazil
| | - Salome Charalambous
- Implementation Division, The Aurum Institute, Johannesburg, South Africa
- Wits School of Public Health, Johannesburg, South Africa
| | - Alberto L. García-Basteiro
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Manhiça Health Research Center, Maputo, Mozambique
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Barcelona, Spain
| | - Sheela V. Shenoi
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, United States of America
| | | | | | - Lia G. Possuelo
- Department of Life Sciences, Santa Cruz do Sul University, Santa Cruz do Sul, Brazil
| | - Sarita Aguirre
- National Tuberculosis Control Program, Ministry of Public Health and Social Welfare (MSPyBS), Asunción, Paraguay
| | | | - Guillermo Sequera
- Department of Public Health, Facultad de Ciencias Médicas, Universidad Nacional de Asunción, Asunción, Paraguay
| | - Louis Grandjean
- Department of Infection, Immunity and Inflammation, Institute of Child Health, University College London, London, United Kingdom
| | - Lily Telisinghe
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Michael E. Herce
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Fernanda Dockhorn
- Ministry of Health, Health and Environmental Surveillance Secretariat, General Coordination for Tuberculosis, Endemic Mycoses and Non-Tuberculous Mycobacteria Surveillance, Brasília, (DF) Brazil
| | - Frederick L. Altice
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Jason R. Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, United States of America
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Mulholland GE, Herce ME, Okech BA, Jeremiah K, Bahemuka UM, Kwena ZA, Nanyonjo G, Seeley J, Pettifor A, Emch M, Weir SS, Edwards JK. Clinic presentation delay and tuberculosis treatment outcomes in the Lake Victoria region of East Africa: A multi-site prospective cohort study. PLOS Glob Public Health 2023; 3:e0002259. [PMID: 37647287 PMCID: PMC10468066 DOI: 10.1371/journal.pgph.0002259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 07/17/2023] [Indexed: 09/01/2023]
Abstract
In the Lake Victoria region of East Africa, little is known about delays between tuberculosis (TB) symptom onset and presentation at a clinic. Associations between clinic presentation delay and TB treatment outcomes are also poorly understood. In 2019, we abstracted data from routine TB treatment records for all adults (n = 776) initiating TB treatment in a 6-month period across 12 health facilities near Lake Victoria. We interviewed 301 cohort members and assessed whether they experienced a clinic presentation delay longer than 6 weeks. We investigated potential clinical and demographic correlates of clinic presentation delay and examined the association between clinic presentation delay and an unfavorable TB treatment outcome (death, loss to follow-up, or treatment failure). Clinic presentation delay was common, occurring among an estimated 54.7% (95% CI: 48.9%, 61.2%) of cohort members, though no specific correlates were identified. Clinic presentation delay was slightly associated with unfavorable TB treatment outcomes. The 180-day risk of an unfavorable outcome was 14.2% (95% CI: 8.0%, 20.4%) among those with clinic presentation delay, compared to 12.7% (95% CI: 5.1%, 20.3%) among those presenting earlier. Multi-level community-based interventions may be necessary to reduce clinic presentation delays in communities near Lake Victoria.
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Affiliation(s)
- Grace E Mulholland
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Michael E Herce
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Kidola Jeremiah
- Mwanza Research Centre, National Institute for Medical Research, Mwanza, Tanzania
| | - Ubaldo M Bahemuka
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | | | | | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
- Global Health and Development Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Audrey Pettifor
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Michael Emch
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Sharon S Weir
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Jessie K Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Mulholland GE, Herce ME, Bahemuka UM, Kwena ZA, Jeremiah K, Okech BA, Bukusi E, Okello ES, Nanyonjo G, Ssetaala A, Seeley J, Emch M, Pettifor A, Weir SS, Edwards JK. Geographic mobility and treatment outcomes among people in care for tuberculosis in the Lake Victoria region of East Africa: A multi-site prospective cohort study. PLOS Glob Public Health 2023; 3:e0001992. [PMID: 37276192 PMCID: PMC10241360 DOI: 10.1371/journal.pgph.0001992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 05/04/2023] [Indexed: 06/07/2023]
Abstract
Geographic mobility may disrupt continuity of care and contribute to poor clinical outcomes among people receiving treatment for tuberculosis (TB). This may occur especially where health services are not well coordinated across international borders, particularly in lower and middle income country settings. In this work, we describe mobility and the relationship between mobility and unfavorable TB treatment outcomes (i.e., death, loss to follow-up, or treatment failure) among a cohort of adults who initiated TB treatment at one of 12 health facilities near Lake Victoria. We abstracted data from health facility records for all 776 adults initiating TB treatment during a 6-month period at the selected facilities in Kenya, Tanzania, and Uganda. We interviewed 301 cohort members to assess overnight travel outside one's residential district/sub-county. In our analyses, we estimated the proportion of cohort members traveling in 2 and 6 months following initiation of TB treatment, explored correlates of mobility, and examined the association between mobility and an unfavorable TB treatment outcome. We estimated that 40.7% (95% CI: 33.3%, 49.6%) of people on treatment for TB traveled overnight at least once in the 6 months following treatment initiation. Mobility was more common among people who worked in the fishing industry and among those with extra-pulmonary TB. Mobility was not strongly associated with other characteristics examined, however, suggesting that efforts to improve TB care for mobile populations should be broad ranging. We found that in this cohort, people who were mobile were not at increased risk of an unfavorable TB treatment outcome. Findings from this study can help inform development and implementation of mobility-competent health services for people with TB in East Africa.
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Affiliation(s)
- Grace E. Mulholland
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Michael E. Herce
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Ubaldo M. Bahemuka
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | | | - Kidola Jeremiah
- Mwanza Intervention Trials Unit, Mwanza Research Centre, National Institute for Medical Research, Mwanza, Tanzania
| | | | | | - Elialilia S. Okello
- Mwanza Intervention Trials Unit, Mwanza Research Centre, National Institute for Medical Research, Mwanza, Tanzania
| | | | - Ali Ssetaala
- UVRI-IAVI HIV Vaccine Program Limited, Entebbe, Uganda
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
- Global Health and Development Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Michael Emch
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Audrey Pettifor
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Sharon S. Weir
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Jessie K. Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Pry JM, Mwila C, Kapesa H, Mulabe M, Frimpong C, Moono M, Savory T, Bolton-Moore C, Herce ME, Iyer S. Estimating potential silent transfer using baseline viral load measures among people presenting as new to HIV care in Lusaka, Zambia: a cross-sectional study. BMJ Open 2023; 13:e070384. [PMID: 37230517 DOI: 10.1136/bmjopen-2022-070384] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVES To estimate potential silent transfer using baseline viral load measures among individuals presenting as new to HIV care in routine HIV clinical settings in Lusaka, Zambia. DESIGN Cross-sectional study. SETTING Two large, urban government-operated health facilities supported by the Centre for Infectious Disease Research in Zambia. PARTICIPANTS A total of 248 participants with an incident positive HIV rapid test. OUTCOME MEASURES The primary outcome measure was HIV viral suppression at baseline (i.e., potential silent transfer), defined as having a viral load ≤1000 RNA copies(c)/mL at the time of initiating HIV care. We also examined viral suppression at ≤60 c/mL. METHODS We surveyed and measured baseline HIV viral load as part of the national recent infection testing algorithm among people living with HIV (PLWH) presenting as new to care. Using mixed effects Poisson regression, we identified characteristics among PLWH associated with potential silent transfer. RESULTS Among the 248 PLWH included, 63% were women with median age of 30, and 66 (27% (66/248)) had viral suppression at ≤1000 c/mL and 53 (21% (53/248)) at ≤60 c/mL thresholds, respectively. Participants aged 40+ years had a significantly higher adjusted prevalence of potential silent transfer (adjusted prevalence ratio (aPR): 2.10; 95% CI: 2.08, 2.13) compared with participants aged 18-24 years. Participants reporting no formal education had a significantly higher adjusted prevalence of potential silent transfer (aPR: 1.63; 95% CI: 1.52, 1.75) compared with those completing primary education. Among 57 potential silent transfers who completed a survey, 44 (77%) indicated having tested positive previously at ≥1 of 38 clinics in Zambia. CONCLUSIONS The high proportion of PLWH with potential silent transfer points to clinic shopping and/or co-enrolment at multiple care sites simultaneously, suggesting an opportunity to improve care continuity at the time of HIV care entry.
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Affiliation(s)
- Jake M Pry
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Public Health Sciences, University of California Davis School of Medicine, Sacramento, California, USA
| | - Chilambwe Mwila
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Herbert Kapesa
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Musunge Mulabe
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Christiana Frimpong
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Misinzo Moono
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Theodora Savory
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Disease, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Michael E Herce
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Shilpa Iyer
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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Smith HJ, Herce ME, Mwila C, Chisenga P, Yenga C, Chibwe B, Mai V, Kashela L, Nanyagwe M, Hatwiinda S, Moonga CN, Musheke M, Lungu Y, Sikazwe I, Topp SM. Experiences of Justice-Involved People Transitioning to HIV Care in the Community After Prison Release in Lusaka, Zambia: A Qualitative Study. Glob Health Sci Pract 2023; 11:GHSP-D-22-00444. [PMID: 37116925 PMCID: PMC10141426 DOI: 10.9745/ghsp-d-22-00444] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 03/15/2023] [Indexed: 04/30/2023]
Abstract
INTRODUCTION In sub-Saharan Africa (SSA), incarcerated people experience a higher HIV burden than the general population. While access to HIV care and treatment for incarcerated people living with HIV (PLHIV) in SSA has improved in some cases, little is known about their transition to and post-release experience with care in the community. To address this gap, we conducted a qualitative study to describe factors that may influence post-release HIV care continuity in Zambia. METHODS In March-December 2018, we recruited study participants from a larger prospective cohort study following incarcerated and newly released PLHIV at 5 correctional facilities in 2 provinces in Zambia. We interviewed 50 participants immediately before release; 27 (54%) participated in a second interview approximately 6 months post-release. Demographic and psychosocial data were collected through a structured survey. RESULTS The pre-release setting was strongly influenced by the highly structured prison environment and assumptions about life post-release. Participants reported accessible HIV services, a destigmatizing environment, and strong informal social supports built through comradery among people facing the same trying detention conditions. Contrary to their pre-release expectations, during the immediate post-release period, participants struggled to negotiate the health system while dealing with unexpected stressors. Long-term engagement in HIV care was possible for participants with strong family support and a high level of self-efficacy. CONCLUSION Our study highlights that recently released PLHIV in Zambia face acute challenges in meeting their basic subsistence needs, as well as social isolation, which can derail linkage to and retention in community HIV care. Releasees are unprepared to face these challenges due to a lack of community support services. To improve HIV care continuity in this population, new transitional care models are needed that develop client self-efficacy, facilitate health system navigation, and pragmatically address structural and psychosocial barriers like poverty, gender inequality, and substance use.
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Affiliation(s)
- Helene J Smith
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Michael E Herce
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - Chilambwe Mwila
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Peter Chisenga
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Chisenga Yenga
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Besa Chibwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Vivien Mai
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Lillian Kashela
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Mirriam Nanyagwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sisa Hatwiinda
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Clement N Moonga
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Maurice Musheke
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Yotam Lungu
- Zambia Correctional Service, Government of the Republic of Zambia, Lusaka, Zambia
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia
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Charalambous S, Velen K, Rueda Z, Croda J, Herce ME, Shenoi SV, Altice FL, Muyoyeta M, Telisinghe L, Grandjean L, Keshavjee S, Andrews JR. Scaling up evidence-based approaches to tuberculosis screening in prisons. Lancet Public Health 2023; 8:e305-e310. [PMID: 36780916 DOI: 10.1016/s2468-2667(23)00002-6] [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] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/09/2022] [Accepted: 12/20/2022] [Indexed: 02/12/2023]
Abstract
People deprived of liberty have among the highest rates of tuberculosis globally. The incidence of tuberculosis is ten times greater than the incidence of tuberculosis in the general population. In 2021, WHO updated its guidance to strongly recommend systematic screening for tuberculosis in prisons and penitentiary systems. Which case-finding strategies should be adopted, and how to effectively implement these strategies in these settings, will be crucial questions facing ministries of health and justice. In this Viewpoint, we review the evidence base for tuberculosis screening and diagnostic strategies in prisons, highlighting promising approaches and knowledge gaps. Drawing upon past experiences of implementing active case-finding and care programmes in settings with a high tuberculosis burden, we discuss challenges and opportunities for improving the tuberculosis diagnosis and treatment cascade in these settings. We argue that improved transparency in reporting of tuberculosis notifications and outcomes in prisons and renewed focus and resourcing from WHO and other stakeholders will be crucial for building the commitment and investments needed from countries to address the continued crisis of tuberculosis in prisons.
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Affiliation(s)
- Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, Wits University, Johannesburg, South Africa; Division of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, CT, USA.
| | | | - Zulma Rueda
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MT, Canada; School of Medicine, Universidad Pontificia Bolivariana, Medellin, Colombia
| | - Julio Croda
- Division of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, CT, USA; Departamento de Clínica Médica, Universidade Federal de Mato Grosso do Sul, Campo Grande, Brazil; Fiocruz Mato Grosso do Sul, Campo Grade, Brazil
| | - Michael E Herce
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sheela V Shenoi
- Division of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, CT, USA; Section of Infectious Diseases, School of Medicine, Yale University, New Haven, CT, USA; University of Malaya, Centre of Excellence on Research in AIDS, Kuala Lumpur, Malaysia
| | - Frederick L Altice
- Division of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, CT, USA; Section of Infectious Diseases, School of Medicine, Yale University, New Haven, CT, USA; University of Malaya, Centre of Excellence on Research in AIDS, Kuala Lumpur, Malaysia
| | - Monde Muyoyeta
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Lily Telisinghe
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Louis Grandjean
- Department of Infection, Immunity and Inflammation, Institute of Child Health, University College London, UK
| | - Salmaan Keshavjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
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Lindsay B, Nyirongo N, Mwango L, Toeque MG, Masumba C, Litongola JP, Sikanyika J, Kabombo H, Moyo M, Siachibila S, Mudenda J, Tembo K, Olowski P, Olufunso A, Muchinda E, Musonda B, Okuku J, Mwila A, Moonga CN, Herce ME, Claassen CW. Initial implementation of HIV pre-exposure prophylaxis for people who are incarcerated in Zambia: a cross-sectional observational study. Lancet HIV 2023; 10:e24-e32. [PMID: 36243018 DOI: 10.1016/s2352-3018(22)00220-x] [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] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND There are over 23 000 incarcerated people in Zambia, a population which has higher HIV prevalence than the general population yet has no access to HIV prevention. To evaluate the feasibility of HIV pre-exposure prophylaxis (PrEP) implementation in Zambian criminal justice facilities, we offered PrEP services to incarcerated people and aimed to describe early implementation outcomes. METHODS In this cross-sectional observational study, we implemented a PrEP programme between Oct 1, 2020, and March 31, 2021, supporting 16 criminal justice facilities in four Zambian provinces. Before implementation, we held stakeholder engagement meetings with Zambia Correctional Service officials to discuss PrEP benefits, and trained Zambia Correctional Service health-care workers in PrEP management using the national PrEP training package. People who were incarcerated and screened positive for substantial HIV risk by use of a standardised HIV risk assessment tool were offered voluntary HIV testing and counselling. Those who tested positive were linked to antiretroviral therapy, and those who tested negative and met national HIV prevention eligibility criteria were offered PrEP. We assessed PrEP uptake and used descriptive statistics to characterise programme beneficiaries and the cascade of PrEP services. FINDINGS During the study period, we reached 12 367 people older than 15 years with HIV risk assessment and counselling, including 11 794 (95·4%) men and 573 (4·6%) women. Of these, 2610 people received HIV testing, with 357 (13·7%) testing HIV positive; positivity was significantly higher in women (20·6%) than men (13·2%, p=0·011). 1276 people were identified as HIV negative and PrEP eligible. Of these, 1190 (93·3%) initiated PrEP. The age group with the highest proportion reached and initiated on PrEP was those aged 25-29 years, representing 19·2% (2377 of 12 367) of all people reached and 24·1% (287 of 1190) of those who initiated PrEP. INTERPRETATION Delivery of PrEP to people who are incarcerated is feasible with adequate resourcing and support to the criminal justice health system, and can result in high uptake among eligible individuals. Further assessment is needed of PrEP persistence and adherence, and the perceptions of people who are incarcerated regarding their HIV risk and preferences for combination HIV prevention services. FUNDING US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.
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Affiliation(s)
- Brianna Lindsay
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia; Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Nasho Nyirongo
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | | | - Mona Gekanju Toeque
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia; Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | | | | | | | | | | | - Kalima Tembo
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Pawel Olowski
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | | | | | - Bupe Musonda
- Department of Public Health, Ministry of Health, Lusaka, Zambia
| | - Jackson Okuku
- US Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Annie Mwila
- US Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Clement N Moonga
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Michael E Herce
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia; Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - Cassidy W Claassen
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia; Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
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9
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Edwards JK, Donastorg Y, Zadrozny S, Hileman S, Gómez H, Seamans MJ, Herce ME, Ramírez E, Barrington C, Weir S. A Two-stage Approach for Rapid Assessment of the Proportion Achieving Viral Suppression Using Routine Clinical Data. Epidemiology 2022; 33:642-649. [PMID: 35648416 PMCID: PMC9378579 DOI: 10.1097/ede.0000000000001513] [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: 11/26/2022]
Abstract
BACKGROUND Improving viral suppression among people with HIV reduces morbidity, mortality, and transmission. Accordingly, monitoring the proportion of patients with a suppressed viral load is important to optimizing HIV care and treatment programs. But viral load data are often incomplete in clinical records. We illustrate a two-stage approach to estimate the proportion of treated people with HIV who have a suppressed viral load in the Dominican Republic. METHODS Routinely collected data on viral load and patient characteristics were recorded in a national database, but 74% of patients on treatment at the time of the study did not have a recent viral load measurement. We recruited a subset of these patients for a rapid assessment that obtained additional viral load measurements. We combined results from the rapid assessment and main database using a two-stage weighting approach and compared results to estimates obtained using standard approaches to account for missing data. RESULTS Of patients with recent routinely collected viral load data, 60% had a suppressed viral load. Results were similar after applying standard approaches to account for missing data. Using the two-stage approach, we estimated that 77% (95% confidence interval [CI] = 74, 80) of those on treatment had a suppressed viral load. CONCLUSIONS When assessing the proportion of people on treatment with a suppressed viral load using routinely collected data, applying standard approaches to handle missing data may be inadequate. In these settings, augmenting routinely collected data with data collected through sampling-based approaches could allow more accurate and efficient monitoring of HIV treatment program effectiveness.
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Affiliation(s)
- Jessie K. Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Yeycy Donastorg
- Instituto Dermatológico y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Sabrina Zadrozny
- Frank Porter Graham Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Hoisex Gómez
- Instituto Dermatológico y Cirugia de Piel, Santo Domingo, Dominican Republic
| | | | - Michael E. Herce
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Edwin Ramírez
- Servicio Nacional de Salud, Santo Domingo, Dominican Republic
| | - Clare Barrington
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sharon Weir
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
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10
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Mukora R, Smith HJ, Herce ME, Chimoyi L, Hausler H, Fielding KL, Charalambous S, Hoffmann CJ. Costs of implementing universal test and treat in three correctional facilities in South Africa and Zambia. PLoS One 2022; 17:e0272595. [PMID: 36006967 PMCID: PMC9409581 DOI: 10.1371/journal.pone.0272595] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 07/21/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction
Universal test and treat (UTT) is a population-based strategy that aims to ensure widespread HIV testing and rapid antiretroviral therapy (ART) for all who have tested positive regardless of CD4 count to decrease HIV incidence and improve health outcomes. Little is known about the specific resources required to implement UTT in correctional facilities for incarcerated people. The primary aim of this study was to describe the resources used to implement UTT and to provide detailed costing to inform UTT scale-up in similar settings.
Methods
The costing study was a cross-sectional descriptive study conducted in three correctional complexes, Johannesburg Correctional Facility in Johannesburg (>4000 inmates) South Africa, and Brandvlei (~3000 inmates), South Africa and Lusaka Central (~1400 inmates), Zambia. Costing was determined through a survey conducted between September and December 2017 that identified materials and labour used for three separate components of UTT: HIV testing services (HTS), ART initiation, and ART maintenance. Our study participants were staff working in the correctional facilities involved in any activity related to UTT implementation. Unit costs were reported as cost per client served while total costs were reported for all clients seen over a 12-month period.
Results
The cost of HIV testing services (HTS) per client was $ 92.12 at Brandvlei, $ 73.82 at Johannesburg, and $ 65.15 at Lusaka. The largest cost driver for HIV testing at Brandvlei were staff costs at 55.6% of the total cost, while at Johannesburg (56.5%) and Lusaka (86.6%) supplies were the largest contributor. The cost per client initiated on ART was $917 for Brandvlei, $421.8 for Johannesburg, and $252.1 for Lusaka. The activity cost drivers were adherence counselling at Brandvlei (59%), and at Johannesburg and Lusaka it was the actual ART initiation at 75.6% and 75.8%, respectively. The annual unit cost for ART maintenance was $2,640.6 for Brandvlei, $710 for Johannesburg, and $385.5 for Lusaka. The activity cost drivers for all three facilities were side effect monitoring, and initiation of isoniazid preventive treatment (IPT), cotrimoxazole, and fluconazole, with this comprising 44.7% of the total cost at Brandvlei, 88.9% at Johannesburg, and 50.5% at Lusaka.
Conclusion
Given the needs of this population, the opportunity to reach inmates at high risk for HIV, and overall national and global 95-95-95 goals, the UTT policies for incarcerated individuals are of vital importance. Our findings provide comparator costing data and highlight key drivers of UTT cost by facility.
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Affiliation(s)
- Rachel Mukora
- The Aurum Institute, Aurum House, The Ridge, Johannesburg, South Africa
- * E-mail:
| | - Helene J. Smith
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia
| | - Michael E. Herce
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Lucy Chimoyi
- The Aurum Institute, Aurum House, The Ridge, Johannesburg, South Africa
| | | | - Katherine L. Fielding
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Salome Charalambous
- The Aurum Institute, Aurum House, The Ridge, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Christopher J. Hoffmann
- The Aurum Institute, Aurum House, The Ridge, Johannesburg, South Africa
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
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11
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Tembo T, Dale H, Muttau N, Itoh M, Williamson D, Mwamba C, Manasyan A, Beard RS, Cox MH, Herce ME. “Testing Can Be Done Anywhere”: A Qualitative Assessment of Targeted Community-Based Point-of-Care Early Infant Diagnosis of HIV in Lusaka, Zambia. Glob Health Sci Pract 2022; 10:GHSP-D-21-00723. [PMID: 36332072 PMCID: PMC9242615 DOI: 10.9745/ghsp-d-21-00723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 04/26/2022] [Indexed: 11/23/2022]
Abstract
Community-based point-of-care testing is an acceptable, appropriate, and feasible strategy for improving access to HIV diagnostic services for high-risk HIV-exposed infants. Introduction: Delayed HIV diagnosis in HIV-exposed infants (HEIs) results in missed opportunities for early antiretroviral therapy (ART), causing significant morbidity and mortality. Early infant diagnosis (EID) depends on the availability of accessible and reliable testing services. We explored the acceptability, appropriateness, and feasibility of deploying a targeted community-based point-of-care (POC) EID testing model (i.e., “community POC model”) to reach high-risk mother-infant pairs (MIPs) in Lusaka, Zambia. Methods: We conducted in-depth interviews with a purposive sample of health care workers, study staff, and caregivers in high-risk MIPs at 6 health facilities included in a larger implementation research study evaluating the community POC model. We defined “high-risk MIPs” as mothers who did not receive antenatal testing or an attended delivery or infants who missed EID testing milestones. Interviews were audio-recorded, translated, and transcribed verbatim in English. Content and thematic analysis were done using NVivo 10 software. Results: Health care workers (n=20) and study staff (n=12) who implemented the community POC model noted that the portability and on-screen prompts of the POC platform made it mobile and easy to use, but maintenance and supply chain management were key to field operations. Respondents also felt that the community POC model reached more infants who had never had EID testing, allowing them to find infants with HIV infection and immediately initiate them on ART. Caregivers (n=22) found the community POC model acceptable, provided that privacy could be ensured because the service was convenient and delivered close to home. Conclusion: We demonstrate the acceptability, appropriateness, and feasibility of implementing the community POC model in Zambia, while identifying potential challenges related to client privacy and platform field operations. The community POC model may represent a promising strategy to further facilitate active HIV case finding and linkage to ART for children with undiagnosed HIV infection in the community.
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Affiliation(s)
- Tannia Tembo
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.
| | - Helen Dale
- U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Nobutu Muttau
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Megumi Itoh
- U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Albert Manasyan
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - R Suzanne Beard
- U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Michael E Herce
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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12
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Rutstein SE, Matoga M, Chen JS, Mathiya E, Ndalema B, Nyirenda N, Bonongwe N, Taoloka S, Chagomerana M, Tegha G, Hosseinipour MC, Herce ME, Jere E, Krysiak R, Hoffman IF. Integrating enhanced HIV pre-exposure prophylaxis into a sexually transmitted infection clinic in Lilongwe (ePrEP STI): A prospective cohort study (Preprint). JMIR Res Protoc 2022; 11:e37395. [DOI: 10.2196/37395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 09/20/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022] Open
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13
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Pry JM, Sikombe K, Mody A, Iyer S, Mutale J, Vlahakis N, Savory T, Wa Mwanza M, Mweebo K, Mwila A, Mwale C, Mukumbwa-Mwenechanya M, Kerkhoff AD, Sikazwe I, Bolton Moore C, Mwamba D, Geng EH, Herce ME. Mitigating the effects of COVID-19 on HIV treatment and care in Lusaka, Zambia: a before-after cohort study using mixed effects regression. BMJ Glob Health 2022; 7:e007312. [PMID: 35078810 PMCID: PMC8795923 DOI: 10.1136/bmjgh-2021-007312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/04/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The Zambian Ministry of Health (MoH) issued COVID-19 mitigation guidance for HIV care immediately after the first COVID-19 case was confirmed in Zambia on 18 March 2020. The Centre for Infectious Disease Research in Zambia implemented MoH guidance by: 1) extending antiretroviral therapy (ART) refill duration to 6 multi-month dispensation (6MMD) and 2) task-shifting communication and mobilisation of those in HIV care to collect their next ART refill early. We assessed the impact of COVID-19 mitigation guidance on HIV care 3 months before and after guidance implementation. METHODS We reviewed all ART pharmacy visit data in the national HIV medical record for PLHIV in care having ≥1 visit between 1 January-30 June 2020 at 59 HIV care facilities in Lusaka Province, Zambia. We undertook a before-after evaluation using mixed-effects Poisson regression to examine predictors and marginal probability of early clinic return (pharmacy visit >7 days before next appointment), proportion of late visit (>7 days late for next appointment) and probability of receiving a 6MMD ART refill. RESULTS A total of 101 371 individuals (64% female, median age 39) with 130 486 pharmacy visits were included in the analysis. We observed a significant increase in the adjusted prevalence ratio (4.63; 95% CI 4.45 to 4.82) of early return before compared with after guidance implementation. Receipt of 6MMD increased from a weekly mean of 47.9% (95% CI 46.6% to 49.2%) before to 73.4% (95% CI 72.0% to 74.9%) after guidance implementation. The proportion of late visits (8-89 days late) was significantly higher before (18.8%, 95% CI17.2%to20.2%) compared with after (15.1%, 95% CI13.8%to16.4%) guidance implementation . CONCLUSIONS Timely issuance and implementation of COVID-19 mitigation guidance involving task-shifted patient communication and mobilisation alongside 6MMD significantly increased early return to ART clinic, potentially reducing interruptions in HIV care during a global public health emergency.
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Affiliation(s)
- Jake M Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Kombatende Sikombe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Aaloke Mody
- Department of Internal Medicine, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Shilpa Iyer
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Jacob Mutale
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Natalie Vlahakis
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Theodora Savory
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Mwanza Wa Mwanza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Keith Mweebo
- Division of Global HIV & Tuberculosis, Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Annie Mwila
- Division of Global HIV & Tuberculosis, Centers for Disease Control and Prevention, Lusaka, Zambia
| | | | | | - Andrew D Kerkhoff
- University of California San Francisco, San Francisco, California, USA
- San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Infectious Disease, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Daniel Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Elvin H Geng
- Department of Internal Medicine, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Michael E Herce
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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14
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Chimoyi L, Smith H, Hausler H, Fielding K, Hoffmann CJ, Herce ME, Charalambous S. Delivery of TB preventive therapy to incarcerated people living with HIV in southern African correctional facilities. Public Health Action 2021; 11:171-173. [PMID: 34956843 DOI: 10.5588/pha.21.0056] [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: 06/06/2021] [Accepted: 11/06/2021] [Indexed: 11/10/2022] Open
Abstract
TB preventive treatment (TPT) is recommended for high-risk and hard-to-reach populations such as incarcerated people living with HIV (PLHIV). To assess implementation of TPT delivery in correctional settings, we conducted an exploratory analysis of data from a multisite cohort study in South Africa and Zambia. From 975 participants, 648 were screened for TB, and 409 initiated TPT mostly within a month after initiation of antiretroviral therapy (190/409, 46.5%). We observed a median gap of one month (IQR 0.6-4.7) in TPT delivery to incarcerated PLHIV. Future research should examine standardised quality improvement tools and new strategies such as short-course regimens to improve TPT initiation in this population.
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Affiliation(s)
- L Chimoyi
- The Aurum Institute, Parktown, Johannesburg, South Africa
| | - H Smith
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - H Hausler
- TB HIV Care, Cape Town, South Africa
| | - K Fielding
- London School of Tropical Hygiene & Medicine, London, UK
| | - C J Hoffmann
- The Aurum Institute, Parktown, Johannesburg, South Africa.,Johns Hopkins University, Baltimore, MD, USA
| | - M E Herce
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - S Charalambous
- The Aurum Institute, Parktown, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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15
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Ostermann J, Yelverton V, Smith HJ, Nanyangwe M, Kashela L, Chisenga P, Mai V, Mwila C, Herce ME. Preferences for transitional HIV care among people living with HIV recently released from prison in Zambia: a discrete choice experiment. J Int AIDS Soc 2021; 24:e25805. [PMID: 34648690 PMCID: PMC8516367 DOI: 10.1002/jia2.25805] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 07/30/2021] [Indexed: 02/06/2023] Open
Abstract
Introduction No studies from sub‐Saharan Africa have attempted to assess HIV service delivery preferences among incarcerated people living with HIV as they transition from prisons to the community (“releasees”). We conducted a discrete choice experiment (DCE) to characterize releasee preferences for transitional HIV care services in Zambia to inform the development of a differentiated service delivery model to promote HIV care continuity for releasees. Methods Between January and October 2019, we enrolled a consecutive sample of 101 releasees from a larger cohort prospectively following 296 releasees from five prisons in Zambia. We administered a DCE eliciting preferences for 12 systematically designed choice scenarios, each presenting three hypothetical transitional care options. Options combined six attributes: (1) clinic type for post‐release HIV care; (2) client focus of healthcare workers; (3) transitional care model type; (4) characteristics of transitional care provider; (5) type of transitional care support; and (6) HIV status disclosure support. We analysed DCE choice data using a mixed logit model, with coefficients describing participants’ average (“mean”) preferences for each option compared to the standard of care and their distributions describing preference variation across participants. Results Most DCE participants were male (n = 84, 83.2%) and had completed primary school (n = 54, 53.5%), with 29 (28.7%) unemployed at follow‐up. Participants had spent an average of 8.2 months in the community prior to the DCE, with 18 (17.8%) reporting an intervening episode of re‐incarceration. While we observed significant preference variation across participants (p < 0.001 for most characteristics), releasees were generally averse to clinics run by community‐based organizations versus government antiretroviral therapy clinics providing post‐release HIV care (mean preference = –0.78, p < 0.001). On average, releasees most preferred livelihood support (mean preference = 1.19, p < 0.001) and HIV care support (mean preference = 1.00, p < 0.001) delivered by support groups involving people living with HIV (mean preference = 1.24, p < 0.001). Conclusions We identified preferred characteristics of transitional HIV care that can form the basis for differentiated service delivery models for prison releasees. Such models should offer client‐centred care in trusted clinics, provide individualized HIV care support delivered by support groups and/or peer navigators, and strengthen linkages to programs providing livelihood support.
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Affiliation(s)
- Jan Ostermann
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA.,South Carolina SmartState Center for Healthcare Quality, University of South Carolina, Columbia, South Carolina, USA.,Center for Health Policy & Inequalities Research, Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Valerie Yelverton
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Helene J Smith
- Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.,School of Public Health & Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Mirriam Nanyangwe
- Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Lillian Kashela
- Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Peter Chisenga
- Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Vivien Mai
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Chilambwe Mwila
- Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Michael E Herce
- Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.,Institute for Global Health & Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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16
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Herce ME, Chagomerana MB, Zalla LC, Carbone NB, Chi BH, Eliya MT, Phiri S, Topp SM, Kim MH, Wroe EB, Chilangwa C, Chinkonde J, Mofolo IA, Hosseinipour MC, Edwards JK. Community-facility linkage models and maternal and infant health outcomes in Malawi's PMTCT/ART program: A cohort study. PLoS Med 2021; 18:e1003780. [PMID: 34534213 PMCID: PMC8516224 DOI: 10.1371/journal.pmed.1003780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 10/14/2021] [Accepted: 08/23/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, 3 community-facility linkage (CFL) models-Expert Clients, Community Health Workers (CHWs), and Mentor Mothers-have been widely implemented to support pregnant and breastfeeding women (PBFW) living with HIV and their infants to access and sustain care for prevention of mother-to-child transmission of HIV (PMTCT), yet their comparative impact under real-world conditions is poorly understood. METHODS AND FINDINGS We sought to estimate the effects of CFL models on a primary outcome of maternal loss to follow-up (LTFU), and secondary outcomes of maternal longitudinal viral suppression and infant "poor outcome" (encompassing documented HIV-positive test result, LTFU, or death), in Malawi's PMTCT/ART program. We sampled 30 of 42 high-volume health facilities ("sites") in 5 Malawi districts for study inclusion. At each site, we reviewed medical records for all newly HIV-diagnosed PBFW entering the PMTCT program between July 1, 2016 and June 30, 2017, and, for pregnancies resulting in live births, their HIV-exposed infants, yielding 2,589 potentially eligible mother-infant pairs. Of these, 2,049 (79.1%) had an available HIV treatment record and formed the study cohort. A randomly selected subset of 817 (40.0%) cohort members underwent a field survey, consisting of a questionnaire and HIV biomarker assessment. Survey responses and biomarker results were used to impute CFL model exposure, maternal viral load, and early infant diagnosis (EID) outcomes for those missing these measures to enrich data in the larger cohort. We applied sampling weights in all statistical analyses to account for the differing proportions of facilities sampled by district. Of the 2,049 mother-infant pairs analyzed, 62.2% enrolled in PMTCT at a primary health center, at which time 43.7% of PBFW were ≤24 years old, and 778 (38.0%) received the Expert Client model, 640 (31.2%) the CHW model, 345 (16.8%) the Mentor Mother model, 192 (9.4%) ≥2 models, and 94 (4.6%) no model. Maternal LTFU varied by model, with LTFU being more likely among Mentor Mother model recipients (adjusted hazard ratio [aHR]: 1.45; 95% confidence interval [CI]: 1.14, 1.84; p = 0.003) than Expert Client recipients. Over 2 years from HIV diagnosis, PBFW supported by CHWs spent 14.3% (95% CI: 2.6%, 26.1%; p = 0.02) more days in an optimal state of antiretroviral therapy (ART) retention with viral suppression than women supported by Expert Clients. Infants receiving the Mentor Mother model (aHR: 1.24, 95% CI: 1.01, 1.52; p = 0.04) and ≥2 models (aHR: 1.44, 95% CI: 1.20, 1.74; p < 0.001) were more likely to undergo EID testing by age 6 months than infants supported by Expert Clients. Infants receiving the CHW and Mentor Mother models were 1.15 (95% CI: 0.80, 1.67; p = 0.44) and 0.84 (95% CI: 0.50, 1.42; p = 0.51) times as likely, respectively, to experience a poor outcome by 1 year than those supported by Expert Clients, but not significantly so. Study limitations include possible residual confounding, which may lead to inaccurate conclusions about the impacts of CFL models, uncertain generalizability of findings to other settings, and missing infant medical record data that limited the precision of infant outcome measurement. CONCLUSIONS In this descriptive study, we observed widespread reach of CFL models in Malawi, with favorable maternal outcomes in the CHW model and greater infant EID testing uptake in the Mentor Mother model. Our findings point to important differences in maternal and infant HIV outcomes by CFL model along the PMTCT continuum and suggest future opportunities to identify key features of CFL models driving these outcome differences.
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Affiliation(s)
- Michael E. Herce
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Maganizo B. Chagomerana
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
| | - Lauren C. Zalla
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Benjamin H. Chi
- Division of Global Women’s Health, Department of Obstetrics & Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Michael T. Eliya
- Department of HIV and AIDS, Ministry of Health, Government of the Republic of Malawi, Lilongwe, Malawi
| | - Sam Phiri
- Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
- Lighthouse Trust, Lilongwe, Malawi
| | - Stephanie M. Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland, Australia
| | - Maria H. Kim
- Baylor International Pediatrics AIDS Initiative, Texas Children’s Hospital, Houston, Texas, United States of America
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America
| | - Emily B. Wroe
- Division of Global Health Equity, Department of Medicine, Brigham & Women’s Hospital, Boston, Massachusetts, United States of America
- Abwenzi Pa Za Umoyo/Partners In Health—Malawi, Neno, Malawi
| | | | | | | | - Mina C. Hosseinipour
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
| | - Jessie K. Edwards
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Hosseinipour MC, Innes C, Naidoo S, Mann P, Hutter J, Ramjee G, Sebe M, Maganga L, Herce ME, deCamp AC, Marshall K, Dintwe O, Andersen-Nissen E, Tomaras GD, Mkhize N, Morris L, Jensen R, Miner MD, Pantaleo G, Ding S, Van Der Meeren O, Barnett SW, McElrath MJ, Corey L, Kublin JG. Phase 1 Human Immunodeficiency Virus (HIV) Vaccine Trial to Evaluate the Safety and Immunogenicity of HIV Subtype C DNA and MF59-Adjuvanted Subtype C Envelope Protein. Clin Infect Dis 2021; 72:50-60. [PMID: 31900486 PMCID: PMC7823071 DOI: 10.1093/cid/ciz1239] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/01/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The Pox-Protein Public-Private Partnership is performing a suite of trials to evaluate the bivalent subtype C envelope protein (TV1.C and 1086.C glycoprotein 120) vaccine in the context of different adjuvants and priming agents for human immunodeficiency virus (HIV) type 1 (HIV-1) prevention. METHODS In the HIV Vaccine Trials Network 111 trial, we compared the safety and immunogenicity of DNA prime followed by DNA/protein boost with DNA/protein coadministration injected intramuscularly via either needle/syringe or a needle-free injection device (Biojector). One hundred thirty-two healthy, HIV-1-uninfected adults were enrolled from Zambia, South Africa, and Tanzania and were randomized to 1 of 6 arms: DNA prime, protein boost by needle/syringe; DNA and protein coadministration by needle/syringe; placebo by needle/syringe; DNA prime, protein boost with DNA given by Biojector; DNA and protein coadministration with DNA given by Biojector; and placebo by Biojector. RESULTS All vaccinations were safe and well tolerated. DNA and protein coadministration was associated with increased HIV-1 V1/V2 antibody response rate, a known correlate of decreased HIV-1 infection risk. DNA administration by Biojector elicited significantly higher CD4+ T-cell response rates to HIV envelope protein than administration by needle/syringe in the prime/boost regimen (85.7% vs 55.6%; P = .02), but not in the coadministration regimen (43.3% vs 48.3%; P = .61). CONCLUSIONS Both the prime/boost and coadministration regimens are safe and may be promising for advancement into efficacy trials depending on whether cellular or humoral responses are desired. CLINICAL TRIALS REGISTRATION South African National Clinical Trials Registry (application 3947; Department of Health [DoH] no. DOH-27-0715-4917) and ClinicalTrials.gov (NCT02997969).
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Affiliation(s)
- Mina C Hosseinipour
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Project-Malawi, Lilongwe, Malawi
| | | | - Sarita Naidoo
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Philipp Mann
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Julia Hutter
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Gita Ramjee
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | | | | | - Michael E Herce
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Allan C deCamp
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Kyle Marshall
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - One Dintwe
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Cape Town HVTN Immunology Laboratory, Cape Town, South Africa
| | - Erica Andersen-Nissen
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Cape Town HVTN Immunology Laboratory, Cape Town, South Africa
| | - Georgia D Tomaras
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nonhlanhla Mkhize
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Lynn Morris
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Ryan Jensen
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Maurine D Miner
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Giuseppe Pantaleo
- Division of Immunology and Allergy, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Song Ding
- EuroVacc Foundation, Lausanne, Switzerland
| | | | | | - M Juliana McElrath
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Lawrence Corey
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - James G Kublin
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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18
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Mwango LK, Stafford KA, Blanco NC, Lavoie MC, Mujansi M, Nyirongo N, Tembo K, Sakala H, Chipukuma J, Phiri B, Nzangwa C, Mwandila S, Nkwemu KC, Saadani A, Mwila A, Herce ME, Claassen CW. Index and targeted community-based testing to optimize HIV case finding and ART linkage among men in Zambia. J Int AIDS Soc 2021; 23 Suppl 2:e25520. [PMID: 32589360 PMCID: PMC7319128 DOI: 10.1002/jia2.25520] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Current healthcare systems fail to provide adequate HIV services to men. In Zambia, 25% of adult men living with HIV were unaware of their HIV status in 2018, and 12% of those who were unaware of their HIV statu were not receiving antiretroviral therapy (ART) due to pervasive barriers to HIV testing services (HTS) and linkage to ART. To identify men and key and priority populations living with HIV in Zambia, and link them to care and treatment, we implemented the Community Impact to Reach Key and Underserved Individuals for Treatment and Support (CIRKUITS) project. We present HTS and ART linkage results from the first year of CIRKUITS. METHODS CIRKUITS aimed to reach beneficiaries by training, mentoring, and deploying community health workers to provide index testing services and targeted community HTS. Community leaders and workplace supervisors were engaged to enable workplace HTS for men. To evaluate the effects of these interventions, we collected age- and sex-disaggregated routinely collected programme data for the first 12 months of the project (October 2018 to September 2019) across 37 CIRKUITS-supported facilities in three provinces. We performed descriptive statistics and estimated index cascades for indicators of interest, and used Chi square tests to compare indicators by age, sex, and district strata. RESULTS Over 12 months, CIRKUITS tested 38,255 persons for HIV, identifying 10,974 (29%) new people living with HIV, of whom 10,239 (93%) were linked to ART. Among men, CIRKUITS tested 18,336 clients and identified 4458 (24%) as HIV positive, linked 4132 (93%) to ART. Men who tested HIV negative were referred to preventative services. Of the men found HIV positive, and 13.0% were aged 15 to 24 years, 60.3% were aged 25 to 39, 20.9% were aged 40 to 49 and 5.8% were ≥50 years old. Index testing services identified 2186 (49%) of HIV-positive men, with a positivity yield of 40% and linkage of 88%. Targeted community testing modalities accounted for 2272 (51%) of HIV-positive men identified, with positivity yield of 17% and linkage of 97%. CONCLUSIONS Index testing and targeted community-based HTS are effective strategies to identify men living with HIV in Zambia. Index testing results in higher yield, but lower linkage and fewer absolute men identified compared to targeted community-based HTS.
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Affiliation(s)
- Linah K Mwango
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Kristen A Stafford
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Natalia C Blanco
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Marie-Claude Lavoie
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Morley Mujansi
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Nasho Nyirongo
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Kalima Tembo
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Henry Sakala
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | | | - Beauty Phiri
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Carol Nzangwa
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | - Susan Mwandila
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia
| | | | - Ahmed Saadani
- U.S. Center for Disease Control and Prevention, Lusaka, Zambia
| | - Annie Mwila
- U.S. Center for Disease Control and Prevention, Lusaka, Zambia
| | - Michael E Herce
- Institute for Global Health and Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Cassidy W Claassen
- Maryland Global Initiatives Corporation Zambia, Lusaka, Zambia.,Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
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19
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Chagomerana MB, Edwards JK, Zalla LC, Carbone NB, Banda GT, Mofolo IA, Hosseinipour MC, Herce ME. Timing of HIV testing among pregnant and breastfeeding women and risk of mother-to-child HIV transmission in Malawi: a sampling-based cohort study. J Int AIDS Soc 2021; 24:e25687. [PMID: 33749155 PMCID: PMC7982503 DOI: 10.1002/jia2.25687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 02/02/2021] [Accepted: 02/17/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Pregnant women living with HIV can achieve viral suppression and prevent HIV mother-to-child transmission (MTCT) with timely HIV testing and early ART initiation and maintenance. Although it is recommended that pregnant women undergo HIV testing early in antenatal care in Malawi, many women test positive during breastfeeding because they did not have their HIV status ascertained during pregnancy, or they tested negative during pregnancy but seroconverted postpartum. We sought to estimate the association between the timing of last positive HIV test (during pregnancy vs. breastfeeding) and outcomes of maternal viral suppression and MTCT in Malawi's PMTCT programme. METHODS We conducted a two-stage cohort study among mother-infant pairs in 30 randomly selected high-volume health facilities across five nationally representative districts of Malawi between 1 July 2016 and 30 June 2017. Log-binomial regression was used to estimate prevalence ratios (PR) and risk ratios (RR) for associations between timing of last positive HIV test (i.e. breastfeeding vs. pregnancy) and maternal viral suppression and MTCT, controlling for confounding using inverse probability weighting. RESULTS Of 822 mother-infant pairs who had available information on the timing of the last positive HIV test, 102 mothers (12.4%) had their last positive test during breastfeeding. Women who lived one to two hours (PR = 2.15; 95% CI: 1.29 to 3.58) or >2 hours (PR = 2.36; 95% CI: 1.37 to 4.10) travel time to the nearest health facility were more likely to have had their last positive HIV test during breastfeeding compared to women living <1 hour travel time to the nearest health facility. The risk of unsuppressed VL did not differ between women who had their last positive HIV test during breastfeeding versus pregnancy (adjusted RR [aRR] = 0.87; 95% CI: 0.48 to 1.57). MTCT risk was higher among women who had their last positive HIV test during breastfeeding compared to women who had it during pregnancy (aRR = 6.57; 95% CI: 3.37 to 12.81). CONCLUSIONS MTCT in Malawi occurred disproportionately among women with a last positive HIV test during breastfeeding. Testing delayed until the postpartum period may lead to higher MTCT. To optimize maternal and child health outcomes, PMTCT programmes should focus on early ART initiation and providing targeted testing, prevention, treatment and support to breastfeeding women.
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Affiliation(s)
- Maganizo B Chagomerana
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jessie K Edwards
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lauren C Zalla
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Godfrey T Banda
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | - Innocent A Mofolo
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Mina C Hosseinipour
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Michael E Herce
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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20
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Smith HJ, Topp SM, Hoffmann CJ, Ndlovu T, Charalambous S, Murray L, Kane J, Sikazwe I, Muyoyeta M, Herce ME. Addressing Common Mental Health Disorders Among Incarcerated People Living with HIV: Insights from Implementation Science for Service Integration and Delivery. Curr HIV/AIDS Rep 2021; 17:438-449. [PMID: 32779099 DOI: 10.1007/s11904-020-00518-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Despite evidence of disproportionate burden of HIV and mental health disorders among incarcerated people, scarce services exist to address common mental health disorders, including major depressive and anxiety disorders, post-traumatic stress disorder, and substance use disorders, among incarcerated people living with HIV (PLHIV) in sub-Saharan Africa (SSA). This paper aims to summarize current knowledge on mental health interventions of relevance to incarcerated PLHIV and apply implementation science theory to highlight strategies and approaches to deliver mental health services for PLHIV in correctional settings in SSA. RECENT FINDINGS Scarce evidence-based mental health interventions have been rigorously evaluated among incarcerated PLHIV in SSA. Emerging evidence from low- and middle-income countries and correctional settings outside SSA point to a role for cognitive behavioral therapy-based talking and group interventions implemented using task-shifting strategies involving lay health workers and peer educators. Several mental health interventions and implementation strategies hold promise for addressing common mental health disorders among incarcerated PLHIV in SSA. However, to deliver these approaches, there must first be pragmatic efforts to build corrections health system capacity, address human rights abuses that exacerbate HIV and mental health, and re-conceptualize mental health services as integral to quality HIV service delivery and universal access to primary healthcare for all incarcerated people.
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Affiliation(s)
- Helene J Smith
- Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | | | - Christopher J Hoffmann
- The Aurum Institute, Johannesburg, South Africa
- Johns Hopkins University, Baltimore, MD, USA
| | | | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa
- University of the Witwatersrand Johannesburg, Johannesburg, South Africa
| | | | | | - Izukanji Sikazwe
- Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Monde Muyoyeta
- Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Michael E Herce
- Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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21
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Herce ME, Hoffmann CJ, Fielding K, Topp SM, Hausler H, Chimoyi L, Smith HJ, Chetty-Makkan CM, Mukora R, Tlali M, Olivier AJ, Muyoyeta M, Reid SE, Charalambous S. Universal test-and-treat in Zambian and South African correctional facilities: a multisite prospective cohort study. Lancet HIV 2020; 7:e807-e816. [PMID: 32763152 DOI: 10.1016/s2352-3018(20)30188-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/29/2020] [Accepted: 05/05/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Despite the global scale-up of antiretroviral therapy (ART), incarcerated people have not benefited equally from test-and-treat recommendations for HIV. To improve access to ART for incarcerated people with HIV, we introduced a universal test-and-treat (UTT) intervention in correctional facilities in South Africa and Zambia, and aimed to assess UTT feasibility and clinical outcomes. METHODS Treatment as Prevention (TasP) was a multisite, mixed methods, implementation research study done at three correctional complexes in South Africa (Johnannesburg and Breede River) and Zambia (Lusaka). Here, we report the clinical outcomes for a prospective cohort of incarcerated individuals who were offered the TasP UTT intervention. Incarcerated individuals were eligible for inclusion if they were aged 18 years or older, with new or previously diagnosed HIV, not yet on ART, and were expected to remain incarcerated for 30 days or longer. To enable the implementation of UTT at the included correctional facilities, we first strengthened on-site HIV service delivery. All participants were offered same-day ART initiation, and had two study-specific follow-up visits scheduled to coincide with routine clinic visits at 6 and 12 months. The main outcomes were ART uptake, time from cohort enrolment to ART initiation, and retention in care and viral suppression at 6 and 12 months. We estimated the association between baseline demographic characteristics and time to ART initiation using Cox proportional hazard models, and, in a post-hoc analysis, we used logistic regression models to assess the association between demographic and clinical variables, including time to ART initiation, and the proportion of participants with a composite poor outcome (defined as viral load >50 copies per mL, or for participants with a missing viral load, lack of retention in care in the on-site ART programme) at 6 months. This study is registered at ClinicalTrials.gov, NCT02946762. FINDINGS Between June 23, 2016, and Dec 31, 2017, we identified 1562 incarcerated people with HIV, of whom 1389 (89%) were screened, 1021 (74%) met eligibility criteria, and 975 (95%) were enrolled and followed up to March 31, 2018. At the end of follow-up, 835 (86%) of 975 participants had started ART. Median time from enrolment to ART initiation was 0 days (IQR 0-8). Of 346 participants who remained incarcerated at 6 months, 327 (95%) were retained in care and 269 (78%) had a documented viral load, of whom 262 (97%) achieved viral suppression (<1000 copies per mL). The mortality rate among the 835 participants who had initiated ART was 1·9 per 100 person-years (95% CI 0·9-3·9). No statistically significant associations were identified between any baseline characteristics and time to ART initiation or composite poor outcome. INTERPRETATION UTT implementation is feasible in correctional settings, and can achieve levels of same-day ART uptake, retention in care, and viral suppression among incarcerated people with HIV that are comparable to those observed in community settings. FUNDING UK Department for International Development, Swedish International Development Cooperation Agency, Norwegian Agency for Development Cooperation.
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Affiliation(s)
- Michael E Herce
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia; Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.
| | - Christopher J Hoffmann
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA; The Aurum Institute, Johannesburg, South Africa
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Douglas, QLD, Australia
| | | | | | - Helene J Smith
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Candice M Chetty-Makkan
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Mpho Tlali
- The Aurum Institute, Johannesburg, South Africa
| | | | - Monde Muyoyeta
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Stewart E Reid
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia; Department of Medicine, Division of Infectious Diseases, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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22
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Pry J, Chipungu J, Smith HJ, Bolton Moore C, Mutale J, Duran‐Frigola M, Savory T, Herce ME. Patient-reported reasons for declining same-day antiretroviral therapy initiation in routine HIV care settings in Lusaka, Zambia: results from a mixed-effects regression analysis. J Int AIDS Soc 2020; 23:e25560. [PMID: 32618137 PMCID: PMC7333172 DOI: 10.1002/jia2.25560] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 12/22/2019] [Revised: 05/14/2020] [Accepted: 06/04/2020] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION In the current "test and treat" era, HIV programmes are increasingly focusing resources on linkage to care and same-day antiretroviral therapy (ART) initiation to meet UNAIDS 95-95-95 targets. After observing sub-optimal treatment indicators in health facilities supported by the Centre for Infectious Disease Research in Zambia (CIDRZ), we piloted a "linkage assessment" tool in facility-based HIV testing settings to uncover barriers to same-day linkage to care and ART initiation among newly identified people living with HIV (PLHIV) and to guide HIV programme quality improvement efforts. METHODS The one-page, structured linkage assessment tool was developed to capture patient-reported barriers to same-day linkage and ART initiation using three empirically supported categories of barriers: social, personal and structural. The tool was implemented in three health facilities, two urban and one rural, in Lusaka, Zambia from 1 November 2017 to 31 January 2018, and administered to all newly identified PLHIV declining same-day linkage and ART. Individuals selected as many reasons as relevant. We used mixed-effects logistic regression modelling to evaluate predictors of citing specific barriers to same-day linkage and ART, and Fisher's Exact tests to assess differences in barrier citation by socio-demographics and HIV testing entry point. RESULTS A total of 1278 people tested HIV positive, of whom 126 (9.9%) declined same-day linkage and ART, reporting a median of three barriers per respondent. Of these 126, 71.4% were female. Females declining same-day ART were younger, on average, (median 28.5 years, interquartile range (IQR): 21 to 37 years) than males (median 34.5 years, IQR: 26 to 44 years). The most commonly reported barrier category was structural, "clinics were too crowded" (n = 33), followed by a social reason, "friends and family will condemn me" (n = 30). The frequency of citing personal barriers differed significantly across HIV testing point (χ2 p = 0.03). Significant predictors for citing ≥1 barrier to same-day ART were >50 years of age (OR: 12.59, 95% CI: 6.00 to 26.41) and testing at a rural facility (OR: 9.92, 95% CI: 4.98 to 19.79). CONCLUSIONS Given differences observed in barriers to same-day ART initiation reported across sex, age, testing point, and facility type, new, tailored counselling and linkage to care approaches are needed, which should be rigorously evaluated in routine programme settings.
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Affiliation(s)
- Jake Pry
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
- Division of Infectious DiseasesSchool of MedicineWashington UniversitySt. LouisMOUSA
| | - Jenala Chipungu
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | - Helene J Smith
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | - Carolyn Bolton Moore
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
- School of MedicineUniversity of AlabamaBirminghamALUSA
| | - Jacob Mutale
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | - Miquel Duran‐Frigola
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
- Joint IRB‐BSC‐CRG Program in Computational BiologyInstitute for Research in Biomedicine (IRB Barcelona)The Barcelona Institute of Science and TechnologyBarcelonaCataloniaSpain
| | - Theodora Savory
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
| | - Michael E Herce
- Implementation Science UnitCentre for Infectious Disease Research in Zambia (CIDRZ)LusakaZambia
- Institute for Global Health & Infectious DiseasesSchool of MedicineUniversity of North CarolinaChapel HillNCUSA
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23
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Virkud AV, Arimi P, Ssengooba F, Mulholland GE, Herce ME, Markiewicz M, Weir S, Edwards JK. Access to HIV prevention services in East African cross-border areas: a 2016-2017 cross-sectional bio-behavioural study. J Int AIDS Soc 2020; 23 Suppl 3:e25523. [PMID: 32602638 PMCID: PMC7325514 DOI: 10.1002/jia2.25523] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/11/2020] [Accepted: 04/23/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION East African cross-border areas are visited by mobile and vulnerable populations, such as men, female sex workers, men who have sex with men, truck drivers, fisher folks and young women. These groups may not benefit from traditional HIV prevention interventions available at the health facilities where they live, but may benefit from services offered at public venues identified as places where people meet new sexual partners (e.g. bars, nightclubs, transportation hubs and guest houses). The goal of this analysis was to estimate availability, access and uptake of prevention services by populations who visit these venues. METHODS We collected cross-sectional data using the Priorities for Local AIDS Control Efforts sampling method at cross-border locations near or along the land and lake borders of Kenya, Rwanda, Tanzania and Uganda from June 2016-February 2017. This bio-behavioural survey captured information from a probability sample of 11,428 individuals at 833 venues across all areas. Data were weighted using survey sampling weights and analysed using methods to account for the complex sampling design. RESULTS Among the 85.6% of persons who had access to condoms, 60.5% did not use a condom at their last anal or vaginal sexual encounter. Venues visited by high percentages of persons living with HIV were not more likely than other venues to offer condoms. In 12 of the 22 cross-border areas, male or female condoms were available at less than 33% of the venues visited by persons having difficulty accessing condoms. In 17 of the 22 cross-border areas, education outreach visits in the preceding six months occurred at less than 50% of the venues where participants had low effective use of condoms. CONCLUSIONS Individuals visiting venues in cross-border areas report poor access to and low effective use of condoms and other prevention services. Availability of HIV prevention services differed by venue and population type and cross-border area, suggesting opportunities for more granular targeting of HIV prevention interventions and transnational coordination of HIV programming.
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Affiliation(s)
- Arti V Virkud
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Peter Arimi
- U.S. Agency for International DevelopmentKenya/East Africa Regional MissionNairobiKenya
| | - Freddie Ssengooba
- College of Health SciencesSchool of Public HealthMakerere UniversityKampalaUganda
| | - Grace E Mulholland
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Michael E Herce
- Department of MedicineDivision of Infectious DiseasesUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Milissa Markiewicz
- MEASURE EvaluationCarolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Sharon Weir
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
- MEASURE EvaluationCarolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Jessie K Edwards
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
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Topp SM, Carbone NB, Tseka J, Kamtsendero L, Banda G, Herce ME. " Most of what they do, we cannot do!" How lay health workers respond to barriers to uptake and retention in HIV care among pregnant and breastfeeding mothers in Malawi. BMJ Glob Health 2020; 5:e002220. [PMID: 32561513 PMCID: PMC7304641 DOI: 10.1136/bmjgh-2019-002220] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/06/2020] [Accepted: 05/09/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In the era of Option B+ and 'treat all' policies for HIV, challenges to retention in care are well documented. In Malawi, several large community-facility linkage (CFL) models have emerged to address these challenges, training lay health workers (LHW) to support the national prevention of mother-to-child transmission (PMTCT) programme. This qualitative study sought to examine how PMTCT LHW deployed by Malawi's three most prevalent CFL models respond to known barriers to access and retention to antiretroviral therapy (ART) and PMTCT. METHODS We conducted a qualitative study, including 43 semi-structured interviews with PMTCT clients; 30 focus group discussions with Ministry of Health (MOH)-employed lay and professional providers and PMTCT LHWs; a facility CFL survey and 2-4 hours of onsite observation at each of 8 sites and in-depth interviews with 13 programme coordinators and MOH officials. Thematic analysis was used, combining inductive and deductive approaches. RESULTS Across all three models, PMTCT LHWs carried out a number of 'targeted' activities that respond directly to a range of known barriers to ART uptake and retention. These include: (i) fulfilling counselling and educational functions that responded to women's fears and uncertainties; (ii) enhancing women's social connectedness and participation in their own care and (iii) strengthening service function by helping clinic-based providers carry out duties more efficiently and effectively. Beyond absorbing workload or improving efficiency, however, PMTCT LHWs supported uptake and retention through foundational but often intangible work to strengthen CFL, including via efforts to strengthen facility-side responsiveness, and build community members' recognition of and trust in services. CONCLUSION PMTCT LHWs in each of the CFL models examined, addressed social, cultural and health system factors influencing client access to, and engagement with, HIV care and treatment. Findings underscore the importance of person-centred design in the 'treat-all' era and the contribution LHWs can make to this, but foreground the challenges of achieving person-centredness in the context of an under-resourced health system. Further work to understand the governance and sustainability of these project-funded CFL models and LHW cadres is now urgently required.
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Affiliation(s)
- Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | | | | | | | - Godfrey Banda
- University of North Carolina Project, Lilongwe, Malawi
| | - Michael E Herce
- Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel HIll, North Carolina, USA
- Implementation Science Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
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Zalla LC, Herce ME, Edwards JK, Michel J, Weir SS. The burden of HIV among female sex workers, men who have sex with men and transgender women in Haiti: results from the 2016 Priorities for Local AIDS Control Efforts (PLACE) study. J Int AIDS Soc 2019; 22:e25281. [PMID: 31287624 PMCID: PMC6615490 DOI: 10.1002/jia2.25281] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 04/05/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Despite the higher risk of HIV among female sex workers (FSWs), men who have sex with men (MSM) and transgender women (TGW), these populations are under-represented in the literature on HIV in Haiti. Here, we present the first nationally representative estimates of HIV prevalence and the first care and treatment cascade for FSWs, MSM and TGW in Haiti. We also examine the social determinants of HIV prevalence in these groups and estimate FSW and MSM population size in Haiti. METHODS Data were collected between April 2016 and February 2017 throughout the 10 geographical departments of Haiti. The Priorities for Local AIDS Control Efforts (PLACE) method was used to: (1) recruit participants for a behavioural survey; (2) provide rapid testing, counselling and linkage to care for syphilis and HIV; and (3) measure viral load using dried blood spots for participants testing HIV positive. RESULTS Study participants included 990 FSWs, 520 MSM and 109 TGW. HIV prevalence was estimated at 7.7% (95% CI 6.2%, 9.6%) among FSWs, 2.2% (0.9%, 5.3%) among MSM and 27.6% (5.0%, 73.5%) among TGW. Of participants who tested positive for syphilis, 17% of FSWs, 19% of MSM and 74% of TGW were co-infected with HIV. Economic instability and intimate partner violence (IPV) were significantly associated with HIV among MSM; food insecurity, economic instability and history of rape were significantly associated with HIV among TGW. Fewer than one-third of participants living with HIV knew their status, and more than a quarter of those who knew their status were not on treatment. While approximately four in five FSW and MSM participants on treatment for HIV were virally suppressed, viral suppression was less common among TGW participants at only 46%. CONCLUSIONS This study demonstrates a need for targeted interventions to prevent and treat HIV among key populations in Haiti. Potential high-impact interventions may include venue-based, peer navigator-led outreach and testing for HIV and syphilis and improving screening and case management for structural violence and IPV. TGW are in urgent need of such interventions due to our observations of alarmingly high HIV prevalence and low frequency of HIV viral suppression among TGW.
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Affiliation(s)
- Lauren C Zalla
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Michael E Herce
- Division of Infectious DiseasesDepartment of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Jessie K Edwards
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | | | - Sharon S Weir
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
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Topp SM, Chetty-Makkan CM, Smith HJ, Chimoyi L, Hoffmann CJ, Fielding K, Reid SE, Olivier AJ, Hausler H, Herce ME, Charalambous S. "It's Not Like Taking Chocolates": Factors Influencing the Feasibility and Sustainability of Universal Test and Treat in Correctional Health Systems in Zambia and South Africa. Glob Health Sci Pract 2019; 7:189-202. [PMID: 31249019 PMCID: PMC6641809 DOI: 10.9745/ghsp-d-19-00051] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/09/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Sub-Saharan African correctional facilities concentrate large numbers of people who are living with HIV or at risk for HIV infection. Universal test and treat (UTT) is widely recognized as a promising approach to improve the health of individuals and a population health strategy to reduce new HIV infections. In this study, we explored the feasibility and sustainability of implementing UTT in correctional facilities in Zambia and South Africa. METHODS Nested within a UTT implementation research study, our qualitative evaluation of feasibility and sustainability used a case-comparison design based on data from 1 Zambian and 3 South African correctional facilities. Primary data from in-depth interviews with incarcerated individuals, correctional managers, health care providers, and policy makers were supplemented by public policy documents, study documentation, and implementation memos in both countries. Thematic analysis was informed by an empirically established conceptual framework for health system analysis. RESULTS Despite different institutional profiles, we were able to successfully introduce UTT in the South Africa and Zambian correctional facilities participating in the study. A supportive policy backdrop was important to UTT implementation and establishment in both countries. However, sustainability of UTT, defined as relevant government departments' capacity to independently plan, resource, and administer quality UTT, differed. South Africa's correctional facilities had existing systems to deliver and monitor chronic HIV care and treatment, forming a "scaffolding" for sustained UTT despite some human resources shortages and poorly integrated health information systems. Notwithstanding recent improvements, Zambia's correctional health system demonstrated insufficient material and technical capacity to independently deliver quality UTT. In the correctional facilities of both countries, inmate population dynamics and their impact on HIV-related stigma were important factors in UTT service uptake. CONCLUSION Findings demonstrate the critical role of policy directives, health service delivery systems, adequate resourcing, and population dynamics on the feasibility and likely sustainability of UTT in corrections in Zambia and South Africa.
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Affiliation(s)
- Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland, Australia. .,Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | | | - Helene J Smith
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | | | | | | | - Stewart E Reid
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.,Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, School of Medicine, Birmingham, AL, USA
| | | | | | - Michael E Herce
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.,Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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Carbone NB, Njala J, Jackson DJ, Eliya MT, Chilangwa C, Tseka J, Zulu T, Chinkonde JR, Sherman J, Zimba C, Mofolo IA, Herce ME. "I would love if there was a young woman to encourage us, to ease our anxiety which we would have if we were alone": Adapting the Mothers2Mothers Mentor Mother Model for adolescent mothers living with HIV in Malawi. PLoS One 2019; 14:e0217693. [PMID: 31173601 PMCID: PMC6555548 DOI: 10.1371/journal.pone.0217693] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 05/12/2019] [Indexed: 12/03/2022] Open
Abstract
Background Pregnant and post-partum adolescent girls and young women (AGYW) living with HIV in sub-Saharan Africa experience inferior outcomes along the prevention of mother-to-child transmission of HIV (PMTCT) cascade compared to their adult counterparts. Yet, despite this inequality in outcomes, scarce data from the region describe AGYW perspectives to inform adolescent-sensitive PMTCT programming. In this paper, we report findings from formative implementation research examining barriers to, and facilitators of, PMTCT care for HIV-infected AGYW in Malawi, and explore strategies for adapting the mothers2mothers (m2m) Mentor Mother Model to better meet AGYW service delivery-related needs and preferences. Methods Qualitative researchers conducted 16 focus group discussions (FGDs) in 4 Malawi districts with HIV-infected adolescent mothers ages 15–19 years categorized into two groups: 1) those who had experience with m2m programming (8 FGDs, n = 38); and 2) those who did not (8 FGDs, n = 34). FGD data were analyzed using thematic analysis to assess major and minor themes and to compare findings between groups. Results Median participant age was 17 years (interquartile range: 2 years). Poverty, stigma, food insecurity, lack of transport, and absence of psychosocial support were crosscutting barriers to PMTCT engagement. While most participants highlighted resilience and self-efficacy as motivating factors to remain in care to protect their own health and that of their children, they also indicated a desire for tailored, age-appropriate services. FGD participants indicated preference for support services delivered by adolescent HIV-infected mentor mothers who have successfully navigated the PMTCT cascade themselves. Conclusions HIV-infected adolescent mothers expressed a preference for peer-led, non-judgmental PMTCT support services that bridge communities and facilities to pragmatically address barriers of stigma, poverty, health system complexity, and food insecurity. Future research should evaluate implementation and health outcomes for adolescent mentor mother services featuring these and other client-centered attributes, such as provision of livelihood assistance and peer-led psychosocial support.
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Affiliation(s)
| | - Joseph Njala
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | - Debra J. Jackson
- UNICEF/New York, New York, New York, United States of America
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Michael T. Eliya
- Department of HIV and AIDS, Ministry of Health, Government of the Republic of Malawi, Lilongwe, Malawi
| | | | - Jennifer Tseka
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | - Tasila Zulu
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | | | | | - Chifundo Zimba
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | | | - Michael E. Herce
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Institute for Global Health & Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
- * E-mail:
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Herce ME, Muyoyeta M, Topp SM, Henostroza G, Reid SE. Coordinating the prevention, treatment, and care continuum for HIV-associated tuberculosis in prisons: a health systems strengthening approach. Curr Opin HIV AIDS 2018; 13:492-500. [PMID: 30222608 PMCID: PMC7705648 DOI: 10.1097/coh.0000000000000505] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 12/31/2022]
Abstract
PURPOSE OF REVIEW To advance a re-conceptualized prevention, treatment, and care continuum (PTCC) for HIV-associated tuberculosis (TB) in prisons, and to make recommendations for strengthening prison health systems and reducing HIV-associated TB morbidity and mortality throughout the cycle of pretrial detention, incarceration, and release. RECENT FINDINGS Despite evidence of increased HIV-associated TB burden in prisons compared to the general population, prisoners face entrenched barriers to accessing anti-TB therapy, antiretroviral therapy, and evidence-based HIV and TB prevention. New approaches, suitable for the complexities of healthcare delivery in prisons, have emerged that may address these barriers, and include: novel TB diagnostics, universal test and treat for HIV, medication-assisted treatment for opioid dependence, comprehensive transitional case management, and peer navigation, among others. SUMMARY Realizing ambitious international HIV and TB targets in prisons will only be possible by first addressing the root causes of the TB/HIV syndemic, which are deeply intertwined with human rights violations and weaknesses in prison health systems, and, second, fundamentally re-organizing HIV and TB services around a coordinated PTCC. Taking these steps can help ensure universal access to comprehensive, good-quality, free and voluntary TB/HIV prevention, treatment, and care, and advance efforts to strengthen health resourcing, staffing, information management, and primary care access within prisons.
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Affiliation(s)
- Michael E Herce
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Monde Muyoyeta
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland, Australia
| | - German Henostroza
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, School of Medicine, Birmingham, Alabama, USA
| | - Stewart E Reid
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, School of Medicine, Birmingham, Alabama, USA
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Herce ME, Miller WM, Bula A, Edwards JK, Sapalalo P, Lancaster KE, Mofolo I, Furtado MLM, Weir SS. Achieving the first 90 for key populations in sub-Saharan Africa through venue-based outreach: challenges and opportunities for HIV prevention based on PLACE study findings from Malawi and Angola. J Int AIDS Soc 2018; 21 Suppl 5:e25132. [PMID: 30033589 PMCID: PMC6055127 DOI: 10.1002/jia2.25132] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 05/18/2018] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Providing outreach HIV prevention services at venues (i.e. "hotspots") where people meet new sex partners can decrease barriers to HIV testing services (HTS) for key populations (KP) in sub-Saharan Africa (SSA). We offered venue-based HTS as part of bio-behavioural surveys conducted in urban Malawi and Angola to generate regional insights into KP programming gaps and identify opportunities to achieve the "first 90" for KP in SSA. METHODS From October 2016 to March 2017, we identified and verified 1054 venues in Luanda and Benguela, Angola and Zomba, Malawi and conducted bio-behavioural surveys at 166 using the PLACE method. PLACE interviews community informants to systematically identify public venues where KP can be reached and conducts bio-behavioural surveys at a stratified random sample of venues. We present survey results using summary statistics and multivariable modified Poisson regression modelling to examine associations between receipt of outreach worker-delivered HIV/AIDS education and HTS uptake. We applied sampling weights to estimate numbers of HIV-positive KP unaware of their status at venues. RESULTS We surveyed 959 female sex workers (FSW), 836 men who have sex with men (MSM), and 129 transgender women (TGW). An estimated 71% of HIV-positive KP surveyed were not previously aware of their HIV status, receiving a new HIV diagnosis through PLACE venue-based HTS. If venue-based HTS were implemented at all venues, 2022 HIV-positive KP (95% CI: 1649 to 2477) who do not know their status could be reached, including 1666 FSW (95% CI: 1397 to 1987), 274 MSM (95% CI: 160 to 374), and 82 TG (95% CI: 20 to 197). In multivariable analyses, FSW, MSM, and TGW who received outreach worker-delivered HIV/AIDS education were 3.15 (95% CI: 1.99 to 5.01), 3.12 (95% CI: 2.17 to 4.48), and 1.80 (95% CI: 0.67 to 4.87) times as likely, respectively, as those who did not to have undergone HTS within the last six months. Among verified venues, <=68% offered any on-site HIV prevention services. CONCLUSIONS Availability of HTS and other HIV prevention services was limited at venues. HIV prevention can be delivered at venues, which can increase HTS uptake and HIV diagnosis among individuals not previously aware of their status. Delivering venue-based HTS may represent an effective strategy to reach the "first 90" for KP in SSA.
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Affiliation(s)
- Michael E Herce
- Department of MedicineUNC Institute for Global Health & Infectious DiseasesUniversity of North Carolina at Chapel HillChapel HillNCUSA
- UNC Project—MalawiLilongweMalawi
| | - William M Miller
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | | | - Jessie K Edwards
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | | | - Kathryn E Lancaster
- Division of EpidemiologyCollege of Public HealthThe Ohio State UniversityColumbusOHUSA
| | | | | | - Sharon S Weir
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of EpidemiologyUniversity of North Carolina at Chapel HillChapel HillNCUSA
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Telisinghe L, Charalambous S, Topp SM, Herce ME, Hoffmann CJ, Barron P, Schouten EJ, Jahn A, Zachariah R, Harries AD, Beyrer C, Amon JJ. HIV and tuberculosis in prisons in sub-Saharan Africa. Lancet 2016; 388:1215-27. [PMID: 27427448 PMCID: PMC6182190 DOI: 10.1016/s0140-6736(16)30578-5] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Given the dual epidemics of HIV and tuberculosis in sub-Saharan Africa and evidence suggesting a disproportionate burden of these diseases among detainees in the region, we aimed to investigate the epidemiology of HIV and tuberculosis in prison populations, describe services available and challenges to service delivery, and identify priority areas for programmatically relevant research in sub-Saharan African prisons. To this end, we reviewed literature on HIV and tuberculosis in sub-Saharan African prisons published between 2011 and 2015, and identified data from only 24 of the 49 countries in the region. Where data were available, they were frequently of poor quality and rarely nationally representative. Prevalence of HIV infection ranged from 2·3% to 34·9%, and of tuberculosis from 0·4 to 16·3%; detainees nearly always had a higher prevalence of both diseases than did the non-incarcerated population in the same country. We identified barriers to prevention, treatment, and care services in published work and through five case studies of prison health policies and services in Zambia, South Africa, Malawi, Nigeria, and Benin. These barriers included severe financial and human-resource limitations and fragmented referral systems that prevent continuity of care when detainees cycle into and out of prison, or move between prisons. These challenges are set against the backdrop of weak health and criminal-justice systems, high rates of pre-trial detention, and overcrowding. A few examples of promising practices exist, including routine voluntary testing for HIV and screening for tuberculosis upon entry to South African and the largest Zambian prisons, reforms to pre-trial detention in South Africa, integration of mental health services into a health package in selected Malawian prisons, and task sharing to include detainees in care provision through peer-educator programmes in Rwanda, Zimbabwe, Zambia, and South Africa. However, substantial additional investments are required throughout sub-Saharan Africa to develop country-level policy guidance, build human-resource capacity, and strengthen prison health systems to ensure universal access to HIV and tuberculsosis prevention, treatment, and care of a standard that meets international goals and human rights obligations.
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Affiliation(s)
- Lilanganee Telisinghe
- Field Epidemiology Services, Public Health England, Bristol, UK; University of Bristol, Bristol, UK.
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Michael E Herce
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia; University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Peter Barron
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Andreas Jahn
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi; International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, USA
| | - Rony Zachariah
- Médecins Sans Frontières, Brussels Operational Centre, Operational Research Unit, Luxembourg City, Luxembourg
| | - Anthony D Harries
- International Union Against Tuberculosis and Lung Disease, Paris, France; London School of Hygiene & Tropical Medicine, London, UK
| | - Chris Beyrer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Joseph J Amon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Health and Human Rights Division, Human Rights Watch, New York, NY, USA
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Herce ME, Mtande T, Chimbwandira F, Mofolo I, Chingondole CK, Rosenberg NE, Lancaster KE, Kamanga E, Chinkonde J, Kumwenda W, Tegha G, Hosseinipour MC, Hoffman IF, Martinson FE, Stein E, van der Horst CM. Supporting Option B+ scale up and strengthening the prevention of mother-to-child transmission cascade in central Malawi: results from a serial cross-sectional study. BMC Infect Dis 2015; 15:328. [PMID: 26265222 PMCID: PMC4533797 DOI: 10.1186/s12879-015-1065-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 07/28/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We established Safeguard the Family (STF) to support Ministry of Health (MoH) scale-up of universal antiretroviral therapy (ART) for HIV-infected pregnant and breastfeeding women (Option B+) and to strengthen the prevention of mother-to-child transmission (PMTCT) cascade from HIV testing and counseling (HTC) through maternal ART provision and post-delivery early infant HIV diagnosis (EID). To these ends, we implemented the following interventions in 5 districts: 1) health worker training and mentorship; 2) couples' HTC and male partner involvement; 3) women's psychosocial support groups; and 4) health and laboratory system strengthening for EID. METHODS We conducted a serial cross-sectional study using facility-level quarterly (Q) program data and individual-level infant HIV-1 DNA PCR data to evaluate STF performance on PMTCT indicators for project years (Y) 1 (April-December 2011) through 3 (January-December 2013), and compared these results to national averages. RESULTS Facility-level uptake of HTC, ART, infant nevirapine prophylaxis, and infant DNA PCR testing increased significantly from quarterly baselines of 66 % (n/N = 32,433/48,804), 23 % (n/N = 442/1,958), 1 % (n/N = 10/1,958), and 52 % (n/N = 1,385/2,644) to 87 % (n/N = 39,458/45,324), 96 % (n/N = 2,046/2,121), 100 % (n/N = 2,121/2,121), and 62 % (n/N = 1,462/2,340), respectively, by project end (all p < 0.001). Quarterly HTC, ART, and infant nevirapine prophylaxis uptake outperformed national averages over years 2-3. While transitioning EID laboratory services to MoH, STF provided first-time HIV-1 DNA PCR testing for 2,226 of 11,261 HIV-exposed infants (20 %) tested in the MoH EID program in STF districts from program inception (Y2) through Y3. Of these, 78 (3.5 %) tested HIV-positive. Among infants with complete documentation (n = 608), median age at first testing decreased from 112 days (interquartile range, IQR: 57-198) in Y2 to 76 days (IQR: 46-152) in Y3 (p < 0.001). During Y3 (only year with national data for comparison), non-significantly fewer exposed infants tested HIV-positive (3.6 %) at first testing in STF districts than nationally (4.1 %) (p = 0.4). CONCLUSIONS STF interventions, integrated within the MoH Option B+ program, achieved favorable HTC, maternal ART, infant prophylaxis, and EID services uptake, and a low proportion of infants found HIV-infected at first DNA PCR testing. Continued investments are needed to strengthen the PMTCT cascade, particularly around EID.
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Affiliation(s)
- Michael E Herce
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. .,University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
| | - Tiwonge Mtande
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
| | - Frank Chimbwandira
- HIV Unit, Ministry of Health, Government of the Republic of Malawi, P.O. Box 30377, Lilongwe 3, Malawi.
| | - Innocent Mofolo
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
| | | | - Nora E Rosenberg
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. .,University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
| | - Kathy E Lancaster
- University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
| | - Esmie Kamanga
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
| | | | - Wiza Kumwenda
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
| | - Gerald Tegha
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
| | - Mina C Hosseinipour
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. .,University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
| | - Irving F Hoffman
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. .,University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
| | - Francis E Martinson
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. .,University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
| | - Eva Stein
- University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
| | - Charles M van der Horst
- Tidziwe Centre, UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi. .,University of North Carolina at Chapel Hill, 130 Mason Farm Rd. (Bioinformatics), CB# 7030, Chapel Hill, NC, 27599-7030, USA.
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Herce ME, Elmore SN, Kalanga N, Keck JW, Wroe EB, Phiri A, Mayfield A, Chingoli F, Beste JA, Tengatenga L, Bazile J, Krakauer EL, Rigodon J. Assessing and responding to palliative care needs in rural sub-Saharan Africa: results from a model intervention and situation analysis in Malawi. PLoS One 2014; 9:e110457. [PMID: 25313997 PMCID: PMC4197005 DOI: 10.1371/journal.pone.0110457] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 09/19/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Palliative care is rarely accessible in rural sub-Saharan Africa. Partners In Health and the Malawi government established the Neno Palliative Care Program (NPCP) to provide palliative care in rural Neno district. We conducted a situation analysis to evaluate early NPCP outcomes and better understand palliative care needs, knowledge, and preferences. METHODS Employing rapid evaluation methodology, we collected data from 3 sources: 1) chart review of all adult patients from the NPCP's first 9 months; 2) structured interviews with patients and caregivers; 3) semi-structured interviews with key stakeholders. RESULTS The NPCP enrolled 63 patients in its first 9 months. Frequent diagnoses were cancer (n = 50, 79%) and HIV/AIDS (n = 37 of 61, 61%). Nearly all (n = 31, 84%) patients with HIV/AIDS were on antiretroviral therapy. Providers registered 112 patient encounters, including 22 (20%) home visits. Most (n = 43, 68%) patients had documented pain at baseline, of whom 23 (53%) were treated with morphine. A majority (n = 35, 56%) had ≥1 follow-up encounter. Mean African Palliative Outcome Scale pain score decreased non-significantly between baseline and follow-up (3.0 vs. 2.7, p = 0.5) for patients with baseline pain and complete pain assessment documentation. Providers referred 48 (76%) patients for psychosocial services, including community health worker support, socioeconomic assistance, or both. We interviewed 36 patients referred to the NPCP after the chart review period. Most had cancer (n = 19, 53%) or HIV/AIDS (n = 10, 28%). Patients frequently reported needing income (n = 24, 67%) or food (n = 22, 61%). Stakeholders cited a need to make integrated palliative care widely available. CONCLUSIONS We identified a high prevalence of pain and psychosocial needs among patients with serious chronic illnesses in rural Malawi. Early NPCP results suggest that comprehensive palliative care can be provided in rural Africa by integrating disease-modifying treatment and palliative care, linking hospital, clinic, and home-based services, and providing psychosocial support that includes socioeconomic assistance.
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Affiliation(s)
- Michael E. Herce
- Department of Medicine, Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - Shekinah N. Elmore
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Noel Kalanga
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - James W. Keck
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - Emily B. Wroe
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Atupere Phiri
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - Alishya Mayfield
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Felix Chingoli
- Neno District Health Office, Neno District Hospital, Ministry of Health, Government of the Republic of Malawi, Neno, Malawi
| | - Jason A. Beste
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - Listern Tengatenga
- Neno District Health Office, Neno District Hospital, Ministry of Health, Government of the Republic of Malawi, Neno, Malawi
| | - Junior Bazile
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - Eric L. Krakauer
- Partners in Health, Boston, Massachusetts, United States of America
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Medicine, Division of Palliative Care, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jonas Rigodon
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
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Krupski T, Harding MA, Herce ME, Gulding KM, Stoler MH, Theodorescu D. The role of vascular endothelial growth factor in the tissue specific in vivo growth of prostate cancer cells. Growth Factors 2001; 18:287-302. [PMID: 11519827 DOI: 10.3109/08977190109029117] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Despite the fact that cancer cells can be found in many vascular beds, continued growth of the metastatic tumor focus exhibits a significant degree of 'organ tropism', with only certain organs exhibiting the ravages of metastatic disease. Since a limiting factor to the growth of metastases beyond 2 mm in diameter, may be a lack of angiogenesis, we sought to determine whether tumor overexpression of vascular endothelial growth factor (VEGF), a potent angiogenic factor related to prostate cancer metastasis, is causally related to organ specific tumor growth in a prostate cancer xenograft model. LnCaP-C4-2 is a subline of the human prostate cancer cell line LnCaP which unlike its parent, has a predilection for growth in bone, a common site for human prostate cancer metastasis. LnCaP-C4-2, is tumorigenic when injected intrafemorally in mice but requires co-injection of stromal components (Matrigel) to be tumorigenic in the subcutaneous site. Because of this site-specific tumorigenicity profile and relatively low VEGF mRNA and protein expression, this line was transfected with a full length cDNA encoding the 165 isoform of VEGF. Cells either overexpressing or not expressing the transfected gene were selected for study in vivo and in vitro. Overexpression of VEGF did not seem to affect in vitro cell growth. Such overexpression did affect tumorigenicity and in vivo tumor growth rates when cells were inoculated in the subcutaneus site. Interestingly, the dependency of subcutaneous tumorigenicity on Matrigel co-inoculation was still observed in cells overexpressing VEGF. In contrast to the impact that VEGF overexpression has on subcutaneous tumorigenicity, no such effect was observed when cells were inoculated in orthotopic/prostate (primary) or intrafemoral (metastatic) sites. In view of the importance of tumor-stromal interactions in growth of xenografts, we sought to determine if the host strain is important to the observed tumorigenicity effects of VEGF overexpression. No differences in subcutaneous tumorigenicity as a function of either Matrigel use or VEGF expression levels were observed when SCID/bg and RAG/pfp mouse strains were compared. In conclusion, our data indicate that the biological impact of prostate tumor VEGF overexpression is organ/site specific, leading to the speculation that it may play a part in the observed organ tropism of metastatic spread. In addition, these results highlight the importance of the tumor microenvironment in determining the biological impact of transfected and overexpressed genes in the study of tumor biology.
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Affiliation(s)
- T Krupski
- Department of Molecular Physiology and Biological Physics, University of Virginia, Health Sciences Center, Charlottesville, USA
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