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Schomaker M, Kerschberger B, Boulle A. Is Same-Day Antiretroviral Therapy Initiation Beneficial? Methodological Aspects when Comparing Observational and Randomized Studies. Clin Infect Dis 2024; 78:800-801. [PMID: 37542467 DOI: 10.1093/cid/ciad459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/03/2023] [Indexed: 08/07/2023] Open
Affiliation(s)
- Michael Schomaker
- Department of Statistics, Ludwig-Maximilians University, Munich, Germany
| | - Bernhard Kerschberger
- Médecins Sans Frontières, Operational Centre Geneva, Mbabane, Eswatini
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, Faculty of Health Sciences, University of Cape Town, South Africa
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Mukooza E, Schausberger B, Mmema N, Dlamini V, Aung A, Kerschberger B, Ciglenecki I, Dube L, Wringe A. "It is still very little; I cannot pass it on": a qualitative study of experiences of diagnosis and treatment of acute HIV infection in Eswatini. AIDS Care 2024; 36:308-313. [PMID: 37552882 DOI: 10.1080/13548506.2023.2235275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 07/06/2023] [Indexed: 08/10/2023]
Abstract
Acute and early HIV infection (AEHI) is rarely diagnosed in sub-Saharan Africa, despite its potential contribution to incidence reduction. This qualitative study in Eswatini explored the experiences of health workers, people diagnosed with AEHI, and their partners towards AEHI diagnosis, to inform its scale-up. In-depth interviews were undertaken with 11 women and four men diagnosed with AEHI. Three patients' partners were interviewed about their understanding of AEHI and six health workers were interviewed about experiences of delivering AEHI services. Data were coded inductively and analysed iteratively following the principles of grounded theory. Experiences with AEHI diagnoses were shaped by (i) understanding the nature and consequences of AEHI, and (ii) social norms that influence disclosure and sexual behaviour. AEHI was a new concept for health workers who struggled to explain it to patients, leading to some confusion over their HIV status and misunderstandings around its high transmissibility and prognosis. Disclosure tended to occur to primary partners, if at all, limiting the ability to provide partner services, and one relationship breakdown was reported. If AEHI diagnosis and care interventions are to realise their full potential, it will be essential to reinforce the accompanying counselling sessions and closely monitor for potential social harms.
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Affiliation(s)
| | | | | | | | - Aung Aung
- Médecins sans Frontières (OCG), Mbabane, Eswatini
| | | | | | - Lenhle Dube
- Eswatini National Aids Programme (ENAP), Mbabane, Eswatini
| | - Alison Wringe
- London School of Hygiene and Tropical Medicine (LSHTM), London, UK
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Kerschberger B, Vambe D, Schomaker M, Mabhena E, Daka M, Dlamini T, Ngwenya S, Mamba B, Nxumalo B, Sibanda J, Dube S, Dlamini LM, Mukooza E, Ellman T, Ciglenecki I. Sustained high fatality during TB therapy amid rapid decline in TB mortality at population level: A retrospective cohort and ecological analysis from Shiselweni, Eswatini. Trop Med Int Health 2024; 29:192-205. [PMID: 38100203 DOI: 10.1111/tmi.13961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
OBJECTIVES Despite declining TB notifications in Southern Africa, TB-related deaths remain high. We describe patient- and population-level trends in TB-related deaths in Eswatini over a period of 11 years. METHODS Patient-level (retrospective cohort, from 2009 to 2019) and population-level (ecological analysis, 2009-2017) predictors and rates of TB-related deaths were analysed in HIV-negative and HIV-coinfected first-line TB treatment cases and the population of the Shiselweni region. Patient-level TB treatment data, and population and HIV prevalence estimates were combined to obtain stratified annual mortality rates. Multivariable Poisson regressions models were fitted to identify patient-level and population-level predictors of deaths. RESULTS Of 11,883 TB treatment cases, 1302 (11.0%) patients died during treatment: 210/2798 (7.5%) HIV-negative patients, 984/8443 (11.7%) people living with HIV (PLHIV), and 108/642 (16.8%) patients with unknown HIV-status. The treatment case fatality ratio remained above 10% in most years. At patient-level, fatality risk was higher in PLHIV (aRR 1.74, 1.51-2.02), and for older age and extra-pulmonary TB irrespective of HIV-status. For PLHIV, fatality risk was higher for TB retreatment cases (aRR 1.38, 1.18-1.61) and patients without antiretroviral therapy (aRR 1.70, 1.47-1.97). It decreases with increasing higher CD4 strata and the programmatic availability of TB-LAM testing (aRR 0.65, 0.35-0.90). At population-level, mortality rates decreased 6.4-fold (-147/100,000 population) between 2009 (174/100,000) and 2017 (27/100,000), coinciding with a decline in TB treatment cases (2785 in 2009 to 497 in 2017). Although the absolute decline in mortality rates was most pronounced in PLHIV (-826/100,000 vs. HIV-negative: -23/100,000), the relative population-level mortality risk remained higher in PLHIV (aRR 4.68, 3.25-6.72) compared to the HIV-negative population. CONCLUSIONS TB-related mortality rapidly decreased at population-level and most pronounced in PLHIV. However, case fatality among TB treatment cases remained high. Further strategies to reduce active TB disease and introduce improved TB therapies are warranted.
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Affiliation(s)
- Bernhard Kerschberger
- Médecins sans Frontières, Mbabane, Eswatini
- Médecins sans Frontières/Ärzte ohne Grenzen, Vienna Evaluation Unit, Vienna, Austria
| | - Debrah Vambe
- National TB Control Programme (NTCP), Manzini, Eswatini
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Statistics, Ludwig-Maximilians University Munich, Munich, Germany
| | | | | | | | | | - Bheki Mamba
- National TB Control Programme (NTCP), Manzini, Eswatini
| | | | - Joyce Sibanda
- National TB Control Programme (NTCP), Manzini, Eswatini
| | - Sisi Dube
- National TB Control Programme (NTCP), Manzini, Eswatini
| | | | | | - Tom Ellman
- Médecins sans Frontières, Cape Town, South Africa
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Schaefer R, Amparo da Costa Leite PH, Silva R, Abdool Karim Q, Akolo C, Cáceres CF, Dourado I, Green K, Hettema A, Hoornenborg E, Jana S, Kerschberger B, Mahler H, Matse S, McManus H, Molina JM, Reza-Paul S, Azwa I, Shahmanesh M, Taylor D, Vega-Ramirez H, Veloso VG, Baggaley R, Dalal S. Kidney function in tenofovir disoproxil fumarate-based oral pre-exposure prophylaxis users: a systematic review and meta-analysis of published literature and a multi-country meta-analysis of individual participant data. Lancet HIV 2022; 9:e242-e253. [PMID: 35271825 PMCID: PMC8964504 DOI: 10.1016/s2352-3018(22)00004-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Previous WHO guidance on tenofovir disoproxil fumarate-based oral pre-exposure prophylaxis (PrEP) suggests measuring creatinine levels at PrEP initiation and regularly afterwards, which might represent barriers to PrEP implementation and uptake. We aimed to systematically review published literature on kidney toxicity among tenofovir disoproxil fumarate-based oral PrEP users and conducted an individual participant data meta-analysis (IPDMA) on kidney function among PrEP users in a global implementation project dataset. METHODS In this systematic review and meta-analysis we searched PubMed up to June 30, 2021, for randomised controlled trials (RCTs) or cohort studies that reported on graded kidney-related adverse events among oral PrEP users (tenofovir disoproxil fumarate-based PrEP alone or in combination with emtricitabine or lamivudine). We extracted summary data and conducted meta-analyses with random-effects models to estimate relative risks of grade 1 and higher and grade 2 and higher kidney-related adverse events, measured by elevated serum creatinine or decline in estimated creatinine clearance or estimated glomerular filtration rate. The IPDMA included (largely unpublished) individual participant data from 17 PrEP implementation projects and two RCTs. Estimated baseline creatinine clearance and creatinine clearance change after initiation were described by age, gender, and comorbidities. We used random-effects regressions to estimate the risk in decline of creatinine clearance to less than 60 mL/min. FINDINGS We identified 62 unique records and included 17 articles reporting on 11 RCTs with 13 523 participants in meta-analyses. PrEP use was associated with increased risk of grade 1 and higher kidney adverse events (pooled odds ratio [OR] 1·49, 95% CI 1·22-1·81; I2=25%) and grade 2 and higher events (OR 1·75, 0·68-4·49; I2=0%), although the grade 2 and higher association was not statistically significant and events were rare (13 out of 6764 in the intervention group vs six out of 6782 in the control group). The IPDMA included 18 676 individuals from 15 countries (1453 [7·8%] from RCTs) and 79 (0·42%) had a baseline estimated creatinine clearance of less than 60 mL/min (increasing proportions with increasing age). Longitudinal analyses included 14 368 PrEP users and 349 (2·43%) individuals had a decline to less than 60 mL/min creatinine clearance, with higher risks associated with increasing age and baseline creatinine clearance of 60·00-89·99 mL/min (adjusted hazard ratio [aHR] 8·49, 95% CI 6·44-11·20) and less than 60 mL/min (aHR 20·83, 12·83-33·82). INTERPRETATION RCTs suggest that risks of kidney-related adverse events among tenofovir disoproxil fumarate-based oral PrEP users are increased but generally mild and small. Our global PrEP user analysis found varying risks by age and baseline creatinine clearance. Kidney function screening and monitoring might focus on older individuals, those with baseline creatinine clearance of less than 90 mL/min, and those with kidney-related comorbidities. Less frequent or optional screening among younger individuals without kidney-related comorbidities may reduce barriers to PrEP implementation and use. FUNDING Unitaid, Bill & Melinda Gates Foundation, WHO.
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Affiliation(s)
- Robin Schaefer
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland.
| | | | - Ronaldo Silva
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Quarraisha Abdool Karim
- CAPRISA, Nelson R Mandela School of Medicine; University of KwaZulu-Natal, Durban, South Africa
| | | | - Carlos F Cáceres
- Centro de Investigación Interdisciplinaria en Sexualidad, SIDA y Sociedad, Universidad Cayetano Heredia, Lima, Peru
| | - Inês Dourado
- Collective Health Institute, Federal University of Bahia, Brazil
| | | | | | - Elske Hoornenborg
- Center for Sexual Health, Department of Infectious Diseases, Public Health Service Amsterdam, Amsterdam, Netherlands
| | | | | | | | | | - Hamish McManus
- The Kirby Institute, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Jean-Michel Molina
- Department of Infectious Diseases, St-Louis and Lariboisière Hospitals, University of Paris, INSERM U944, Paris, France
| | - Sushena Reza-Paul
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada; Ashodaya Samithi, Mysuru, India
| | - Iskandar Azwa
- Infectious Diseases Unit, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Institute for Global Health, University College London, London, UK
| | | | - Hamid Vega-Ramirez
- National Institute of Psychiatry Ramon de la Fuente Muñiz, Mexico City, Mexico
| | - Valdiléa G Veloso
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Rachel Baggaley
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - Shona Dalal
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
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Kerschberger B, Aung A, Mpala Q, Ntshalintshali N, Mamba C, Schomaker M, Tombo ML, Maphalala G, Sibandze D, Dube L, Kashangura R, Mthethwa-Hleza S, Telnov A, de la Tour R, Gonzalez A, Calmy A, Ciglenecki I. Predicting, Diagnosing, and Treating Acute and Early HIV Infection in a Public Sector Facility in Eswatini. J Acquir Immune Defic Syndr 2021; 88:506-517. [PMID: 34483294 PMCID: PMC8575170 DOI: 10.1097/qai.0000000000002794] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/12/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The lack of acute and early HIV infection (AEHI) diagnosis and care contributes to high HIV incidence in resource-limited settings. We aimed to assess the yield of AEHI, predict and diagnose AEHI, and describe AEHI care outcomes in a public sector setting in Eswatini. SETTING This study was conducted in Nhlangano outpatient department from March 2019 to March 2020. METHODS Adults at risk of AEHI underwent diagnostic testing for AEHI with the quantitative Xpert HIV-1 viral load (VL) assay. AEHI was defined as the detection of HIV-1 VL on Xpert and either an HIV-seronegative or HIV-serodiscordant third-generation antibody-based rapid diagnostic test (RDT) result. First, the cross-sectional analysis obtained the yield of AEHI and established a predictor risk score for the prediction of AEHI using Lasso logistic regression. Second, diagnostic accuracy statistics described the ability of the fourth-generation antibody/p24 antigen-based Alere HIV-Combo RDT to diagnose AEHI (vs Xpert VL testing). Third, we described acute HIV infection care outcomes of AEHI-positive patients using survival analysis. RESULTS Of 795 HIV-seronegative/HIV-serodiscordant outpatients recruited, 30 (3.8%, 95% confidence interval: 2.6% to 5.3%) had AEHI. The predictor risk score contained several factors (HIV-serodiscordant RDT, women, feeling at risk of HIV, swollen glands, and fatigue) and had sensitivity and specificity of 83.3% and 65.8%, respectively, to predict AEHI. The HIV-Combo RDT had sensitivity and specificity of 86.2% and 99.9%, respectively, to diagnose AEHI. Of 30 AEHI-positive patients, the 1-month cumulative treatment initiation was 74% (95% confidence interval: 57% to 88%), and the 3-month viral suppression (<1000 copies/mL) was 87% (67% to 98%). CONCLUSION AEHI diagnosis and care seem possible in resource-limited settings.
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Affiliation(s)
| | - Aung Aung
- Médecins Sans Frontières (OCG), Mbabane, Eswatini
| | | | | | | | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa;
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT—University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria;
| | | | | | | | - Lenhle Dube
- Ministry of Health (SNAP), Mbabane, Eswatini
| | | | | | - Alex Telnov
- Médecins Sans Frontières (OCG), Geneva, Switzerland;
| | | | - Alan Gonzalez
- Médecins Sans Frontières (OCG), Geneva, Switzerland;
| | - Alexandra Calmy
- HIV/AIDS Unit, Division of Infectious Diseases, Geneva University Hospitals Geneva, Switzerland; and
- Institute of Global Health, University of Geneva, Geneva, Switzerland.
| | - Iza Ciglenecki
- Médecins Sans Frontières (OCG), Geneva, Switzerland;
- Institute of Global Health, University of Geneva, Geneva, Switzerland.
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6
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Schausberger B, Mmema N, Dlamini V, Dube L, Aung A, Kerschberger B, Ciglenecki I, Vambe D, Mukooza E, Wringe A. "We have to learn to cooperate with each other": a qualitative study to explore integration of traditional healers into the provision of HIV self-testing and tuberculosis screening in Eswatini. BMC Health Serv Res 2021; 21:1314. [PMID: 34872563 PMCID: PMC8648147 DOI: 10.1186/s12913-021-07323-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Traditional healing plays an important role in healthcare in Eswatini, and innovative collaborations with traditional healers may enable hard-to-reach men to access HIV and tuberculosis diagnostic services. This study explored attitudes towards integration of traditional healers into the provision of HIV self-testing kits and sputum collection containers. METHODS A qualitative study was conducted in 2019-2020 in Shiselweni region, Eswatini. Eight male traditional healers were trained on HIV and tuberculosis care including distribution of HIV self-testing kits and sputum collection containers. Attitudes towards the intervention were elicited through in-depth interviews with the eight traditional healers, ten clients, five healthcare workers and seven focus group discussions with community members. Interviews and group discussions were conducted in SiSwati, audio-recorded, translated and transcribed into English. Data were coded inductively and analysed thematically. RESULTS 81 HIV self-testing kits and 24 sputum collection containers were distributed by the healers to 99 clients, with 14% of participants reporting a reactive HIV self-test result. The distribution of sputum containers did not result in any tuberculosis diagnoses, as samples were refused at health centres. Traditional healers perceived themselves as important healthcare providers, and after training, were willing and able to distribute HIV self-test kits and sputum containers to clients. Many saw themselves as peers who could address barriers to health-seeking among Swazi men that reflected hegemonic masculinities and patriarchal attitudes. Traditional healers were considered to provide services that were private, flexible, efficient and non-judgemental, although some clients and community members expressed concerns over confidentiality breaches. Attitudes among health workers were mixed, with some calling for greater collaboration with traditional healers and others expressing doubts about their potential role in promoting HIV and tuberculosis services. Specifically, many health workers did not accept sputum samples collected outside health facilities. CONCLUSIONS Offering HIV self-testing kits and sputum containers through traditional healers led to high HIV yields, but no TB diagnoses. The intervention was appreciated by healers' clients, due to the cultural literacy of traditional healers and practical considerations. Scaling-up this approach could bridge testing gaps if traditional healers are supported, but procedures for receiving sputum samples at health facilities need further strengthening.
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Affiliation(s)
| | | | | | - Lenhle Dube
- Eswatini National AIDS Program, Mbabane, Eswatini
| | - Aung Aung
- Médecins sans Frontières, Mbabane, Eswatini
| | | | | | | | | | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel St, London, UK.
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Kerschberger B, Boulle A, Kuwengwa R, Ciglenecki I, Schomaker M. The Impact of Same-Day Antiretroviral Therapy Initiation Under the World Health Organization Treat-All Policy. Am J Epidemiol 2021; 190:1519-1532. [PMID: 33576383 PMCID: PMC8327202 DOI: 10.1093/aje/kwab032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 01/27/2021] [Accepted: 02/09/2021] [Indexed: 12/18/2022] Open
Abstract
Rapid initiation of antiretroviral therapy (ART) is recommended for people living with human immunodeficiency virus (HIV), with the option to start treatment on the day of diagnosis (same-day ART). However, the effect of same-day ART remains unknown in realistic public sector settings. We established a cohort of ≥16-year-old patients who initiated first-line ART under a treat-all policy in Nhlangano (Eswatini) during 2014-2016, either on the day of HIV care enrollment (same-day ART) or 1-14 days thereafter (early ART). Directed acyclic graphs, flexible parametric survival analysis, and targeted maximum likelihood estimation (TMLE) were used to estimate the effect of same-day-ART initiation on a composite unfavorable treatment outcome (loss to follow-up, death, viral failure, treatment switch). Of 1,328 patients, 839 (63.2%) initiated same-day ART. The adjusted hazard ratio of the unfavorable outcome was higher, 1.48 (95% confidence interval: 1.16, 1.89), for same-day ART compared with early ART. TMLE suggested that after 1 year, 28.9% of patients would experience the unfavorable outcome under same-day ART compared with 21.2% under early ART (difference: 7.7%; 1.3%-14.1%). This estimate was driven by loss to follow-up and varied over time, with a higher hazard during the first year after HIV care enrollment and a similar hazard thereafter. We found an increased risk with same-day ART. A limitation was that possible silent transfers that were not captured.
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Affiliation(s)
- Bernhard Kerschberger
- Correspondence to Dr. Bernhard Kerschberger, Médecins Sans Frontières, Mantsholo Road 325, Mbabane, Eswatini (e-mail: )
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Bjertrup PJ, Mmema N, Dlamini V, Ciglenecki I, Mpala Q, Matse S, Kerschberger B, Wringe A. PrEP reminds me that I am the one to take responsibility of my life: a qualitative study exploring experiences of and attitudes towards pre-exposure prophylaxis use by women in Eswatini. BMC Public Health 2021; 21:727. [PMID: 33853575 PMCID: PMC8048211 DOI: 10.1186/s12889-021-10766-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/30/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pre-exposure-prophylaxis (PrEP) has been heralded for its potential to put women in control of preventing HIV infection, but uptake and continuation rates have been disappointing in high-incidence settings in sub-Saharan Africa. We explored structural and social factors that influenced PrEP use among young women and pregnant or breastfeeding women in rural Eswatini. METHODS We conducted two in-depth interviews with ten women on PrEP, and one-time in-depth interviews with fourteen women who declined or discontinued PrEP. Interviews covered decision-making processes around PrEP initiation and experiences with pill-taking. In-depth interviews were conducted with nine health workers, covering experiences in delivering PrEP services, and two focus group discussions were held with men to elicit their perceptions of PrEP. Interviews and discussions were audio-recorded, translated, transcribed and analysed thematically, using an inductive approach. RESULTS PrEP initiation and use were experienced by many women as empowering them to take control of their health and well-being, and stay HIV free, facilitating them to realise their aspirations relating to motherhood and educational attainment. However, the social norms that defined relationship dynamics with partners or family members either undermined or promoted this empowerment potential. In particular, young women were rarely supported by family members to take PrEP unless it was perceived to be for protecting an unborn child. Stigmatisation of pill-taking through its associations with HIV and the burden of daily pill-taking also contributed to PrEP discontinuation. CONCLUSIONS Unlike many prevention tools, PrEP enabled women to achieve a sense of control over their lives. Nevertheless, women's agency to continue and adhere to PrEP was influenced by social and structural factors including gender norms, family expectations of young women, relationship dynamics and stigma related to HIV. Future interventions should address these barriers to promote PrEP use among sexually-active women.
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Affiliation(s)
- Pia Juul Bjertrup
- Médecins Sans Frontières, Mbabane, Eswatini
- Department of Anthropology, University of Copenhagen, Øster Farimagsgade 5, 1353 Copenhagen, Denmark
| | | | | | | | | | - Sindy Matse
- Eswatini National AIDS Programme, Ministry of Health, Mbabane, Eswatini
| | | | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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9
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Beckert P, Sanchez-Padilla E, Merker M, Dreyer V, Kohl TA, Utpatel C, Köser CU, Barilar I, Ismail N, Omar SV, Klopper M, Warren RM, Hoffmann H, Maphalala G, Ardizzoni E, de Jong BC, Kerschberger B, Schramm B, Andres S, Kranzer K, Maurer FP, Bonnet M, Niemann S. MDR M. tuberculosis outbreak clone in Eswatini missed by Xpert has elevated bedaquiline resistance dated to the pre-treatment era. Genome Med 2020; 12:104. [PMID: 33239092 PMCID: PMC7687760 DOI: 10.1186/s13073-020-00793-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/27/2020] [Indexed: 12/20/2022] Open
Abstract
Background Multidrug-resistant (MDR) Mycobacterium tuberculosis complex strains not detected by commercial molecular drug susceptibility testing (mDST) assays due to the RpoB I491F resistance mutation are threatening the control of MDR tuberculosis (MDR-TB) in Eswatini. Methods We investigate the evolution and spread of MDR strains in Eswatini with a focus on bedaquiline (BDQ) and clofazimine (CFZ) resistance using whole-genome sequencing in two collections ((1) national drug resistance survey, 2009–2010; (2) MDR strains from the Nhlangano region, 2014–2017). Results MDR strains in collection 1 had a high cluster rate (95%, 117/123 MDR strains) with 55% grouped into the two largest clusters (gCL3, n = 28; gCL10, n = 40). All gCL10 isolates, which likely emerged around 1993 (95% highest posterior density 1987–1998), carried the mutation RpoB I491F that is missed by commercial mDST assays. In addition, 21 (53%) gCL10 isolates shared a Rv0678 M146T mutation that correlated with elevated minimum inhibitory concentrations (MICs) to BDQ and CFZ compared to wild type isolates. gCL10 isolates with the Rv0678 M146T mutation were also detected in collection 2. Conclusion The high clustering rate suggests that transmission has been driving the MDR-TB epidemic in Eswatini for three decades. The presence of MDR strains in Eswatini that are not detected by commercial mDST assays and have elevated MICs to BDQ and CFZ potentially jeopardizes the successful implementation of new MDR-TB treatment guidelines. Measures to limit the spread of these outbreak isolates need to be implemented urgently.
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Affiliation(s)
- Patrick Beckert
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Parkallee 1, 23845, Borstel, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany
| | | | - Matthias Merker
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Parkallee 1, 23845, Borstel, Germany
| | - Viola Dreyer
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Parkallee 1, 23845, Borstel, Germany
| | - Thomas A Kohl
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Parkallee 1, 23845, Borstel, Germany
| | - Christian Utpatel
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Parkallee 1, 23845, Borstel, Germany
| | - Claudio U Köser
- Department of Genetics, University of Cambridge, Cambridge, UK
| | - Ivan Barilar
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Parkallee 1, 23845, Borstel, Germany
| | - Nazir Ismail
- Centre for Tuberculosis, National TB Reference Laboratory, WHO TB Supranational Laboratory Network, National Institute for Communicable Diseases/National Health Laboratory Services, Johannesburg, South Africa.,Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa.,Department of Internal Medicine, University of Witwatersrand, Johannesburg, South Africa
| | - Shaheed Vally Omar
- Centre for Tuberculosis, National TB Reference Laboratory, WHO TB Supranational Laboratory Network, National Institute for Communicable Diseases/National Health Laboratory Services, Johannesburg, South Africa
| | - Marisa Klopper
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Robin M Warren
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Harald Hoffmann
- SYNLAB Gauting, Gauting, Germany, IML red GmbH, Institute of Microbiology and Laboratory Medicine, WHO Supranational Reference Laboratory of TB, Gauting, Germany
| | - Gugu Maphalala
- National Tuberculosis Reference Laboratory (NTRL), Ministry of Health, Mbabane, Swaziland
| | - Elisa Ardizzoni
- Mycobacteriology Unit, Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bouke C de Jong
- Mycobacteriology Unit, Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | - Sönke Andres
- National and WHO Supranational Reference Center for Mycobacteria, Research Center Borstel, Borstel, Germany
| | - Katharina Kranzer
- National and WHO Supranational Reference Center for Mycobacteria, Research Center Borstel, Borstel, Germany.,London School of Hygiene and Tropical Medicine, London, United Kingdom of Great Britain and Northern Ireland, UK
| | - Florian P Maurer
- National and WHO Supranational Reference Center for Mycobacteria, Research Center Borstel, Borstel, Germany.,Eppendorf, Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg, Hamburg, Germany
| | - Maryline Bonnet
- Epicentre, Paris, France.,IRD UMI233/ INSERM U1175/Université de Montpellier, Montpellier, France
| | - Stefan Niemann
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Parkallee 1, 23845, Borstel, Germany. .,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany. .,National and WHO Supranational Reference Center for Mycobacteria, Research Center Borstel, Borstel, Germany. .,Biochemistry & Microbiology, School of Medicine, University of Namibia, Windhoek, Namibia.
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10
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Asgary R, Staderini N, Mthethwa-Hleta S, Lopez Saavedra PA, Garcia Abrego L, Rusch B, Marie Luce T, Rusike Pasipamire L, Ndlangamandla M, Beideck E, Kerschberger B. Evaluating smartphone strategies for reliability, reproducibility, and quality of VIA for cervical cancer screening in the Shiselweni region of Eswatini: A cohort study. PLoS Med 2020; 17:e1003378. [PMID: 33211691 PMCID: PMC7676712 DOI: 10.1371/journal.pmed.1003378] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 10/08/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Cervical cancer is among the most common preventable cancers with the highest morbidity and mortality. The World Health Organization (WHO) recommends visual inspection of the cervix with acetic acid (VIA) as cervical cancer screening strategy in resource-poor settings. However, there are barriers to the sustainability of VIA programs including declining providers' VIA competence without mentorship and quality assurances and challenges of integration into primary healthcare. This study seeks to evaluate the impact of smartphone-based strategies in improving reliability, reproducibility, and quality of VIA in humanitarian settings. METHODS AND FINDINGS We implemented smartphone-based VIA that included standard VIA training, adapted refresher, and 6-month mHealth mentorship, sequentially, in the rural Shiselweni region of Eswatini. A remote expert reviewer provided diagnostic and management feedback on patients' cervical images, which were reviewed weekly by nurses. Program's outcomes, VIA image agreement rates, and Kappa statistic were compared before, during, and after training. From September 1, 2016 to December 31, 2018, 4,247 patients underwent screening; 247 were reviewed weekly by a VIA diagnostic expert. Of the 247, 128 (49%) were HIV-positive; mean age was 30.80 years (standard deviation [SD]: 7.74 years). Initial VIA positivity of 16% (436/2,637) after standard training gradually increased to 25.1% (293/1,168), dropped to an average of 9.7% (143/1,469) with a lowest of 7% (20/284) after refresher in 2017 (p = 0.001), increased again to an average of 9.6% (240/2,488) with a highest of 17% (17/100) before the start of mentorship, and dropped to an average of 8.3% (134/1,610) in 2018 with an average of 6.3% (37/591) after the start of mentorship (p = 0.019). Overall, 88% were eligible for and 68% received cryotherapy the same day: 10 cases were clinically suspicious for cancer; however, only 5 of those cases were confirmed using punch biopsy. Agreement rates with the expert reviewer for positive and negative cases were 100% (95% confidence interval [CI]: 79.4% to 100%) and 95.7% (95% CI: 92.2% to 97.9%), respectively, with negative predictive value (NPV) (100%), positive predictive value (PPV) (63.5%), and area under the curve of receiver operating characteristics (AUC ROC) (0.978). Kappa statistic was 0.74 (95% CI; 0.58 to 0.89); 0.64 and 0.79 at 3 and 6 months, respectively. In logistic regression, HIV and age were associated with VIA positivity (adjusted Odds Ratio [aOR]: 3.53, 95% CI: 1.10 to 11.29; p = 0.033 and aOR: 1.06, 95% CI: 1.0004 to 1.13; p = 0.048, respectively). We were unable to incorporate a control arm due to logistical constraints in routine humanitarian settings. CONCLUSIONS Our findings suggest that smartphone mentorship provided experiential learning to improve nurses' competencies and VIA reliability and reproducibility, reduced false positive, and introduced peer-to-peer education and quality control services. Local collaboration; extending services to remote populations; decreasing unnecessary burden to screened women, providers, and tertiary centers; and capacity building through low-tech high-yield screening are promising strategies for scale-up of VIA programs.
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Affiliation(s)
- Ramin Asgary
- Medecins Sans Frontieres, Geneva, Switzerland
- George Washington University, Washington, District of Columbia, United States of America
- Weill Cornell Medical College, New York, New York, United States of America
- * E-mail:
| | | | | | | | | | | | | | | | | | - Elena Beideck
- Weill Cornell Medical College, New York, New York, United States of America
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11
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Kerschberger B, Schomaker M, Jobanputra K, Kabore SM, Teck R, Mabhena E, Mthethwa-Hleza S, Rusch B, Ciglenecki I, Boulle A. HIV programmatic outcomes following implementation of the 'Treat-All' policy in a public sector setting in Eswatini: a prospective cohort study. J Int AIDS Soc 2020; 23:e25458. [PMID: 32128964 PMCID: PMC7054447 DOI: 10.1002/jia2.25458] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/04/2019] [Accepted: 01/22/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The Treat-All policy - antiretroviral therapy (ART) initiation irrespective of CD4 cell criteria - increases access to treatment. Many ART programmes, however, reported increasing attrition and viral failure during treatment expansion, questioning the programmatic feasibility of Treat-All in resource-limited settings. We aimed to describe and compare programmatic outcomes between Treat-All and standard of care (SOC) in the public sectors of Eswatini. METHODS This is a prospective cohort study of ≥16-year-old HIV-positive patients initiated on first-line ART under Treat-All and SOC in 18 health facilities of the Shiselweni region, from October 2014 to March 2016. SOC followed the CD4 350 and 500 cells/mm3 treatment eligibility thresholds. Kaplan-Meier estimates were used to describe crude programmatic outcomes. Multivariate flexible parametric survival models were built to assess associations of time from ART initiation with the composite unfavourable outcome of all-cause attrition and viral failure. RESULTS Of the 3170 patients, 1888 (59.6%) initiated ART under Treat-All at a median CD4 cell count of 329 (IQR 168 to 488) cells/mm3 compared with 292 (IQR 161 to 430) (p < 0.001) under SOC. Although crude programme retention at 36 months tended to be lower under Treat-All (71%) than SOC (75%) (p = 0.002), it was similar in covariate-adjusted analysis (adjusted hazard ratio [aHR] 1.06, 95% CI 0.91 to 1.23). The hazard of viral suppression was higher for Treat-All (aHR 1.12, 95% CI 1.01 to 1.23), while the hazard of viral failure was comparable (Treat-All: aHR 0.89, 95% CI 0.53 to 1.49). Among patients with advanced HIV disease (n = 1080), those under Treat-All (aHR 1.13, 95% CI 0.88 to 1.44) had a similar risk of an composite unfavourable outcome to SOC. Factors increasing the risk of the composite unfavourable outcome under both interventions were aged 16 to 24 years, being unmarried, anaemia, ART initiation on the same day as HIV care enrolment and CD4 ≤ 100 cells/mm3 . Under Treat-All only, the risk of the unfavourable outcome was higher for pregnant women, WHO III/IV clinical stage and elevated creatinine. CONCLUSIONS Compared to SOC, Treat-All resulted in comparable retention, improved viral suppression and comparable composite outcomes of retention without viral failure.
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Affiliation(s)
- Bernhard Kerschberger
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Kiran Jobanputra
- The Manson Unit, Médecins Sans Frontières, London, United Kingdom
| | - Serge M Kabore
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | - Roger Teck
- The Manson Unit, Médecins Sans Frontières, London, United Kingdom
| | - Edwin Mabhena
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | | | - Barbara Rusch
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Iza Ciglenecki
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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12
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Vambe D, Kay AW, Furin J, Howard AA, Dlamini T, Dlamini N, Shabangu A, Hassen F, Masuku S, Maha O, Wawa C, Mafukidze A, Altaye K, Sikhondze W, Gwitima T, Keus K, Simelane T, Kerschberger B. Bedaquiline and delamanid result in low rates of unfavourable outcomes among TB patients in Eswatini. Int J Tuberc Lung Dis 2020; 24:1095-1102. [DOI: 10.5588/ijtld.20.0082] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: Since 2015, Eswatini has been scaling up bedaquiline (BDQ) and delamanid (DLM) based drug-resistant TB treatment regimens under programmatic conditions.OBJECTIVE: Identification of factors associated with treatment outcomes in patients receiving BDQ and/or
DLM either as a new treatment initiation or drug substitution.DESIGN: This is a retrospective cohort study of patients receiving BDQ and/or DLM in Eswatini between March 2015 and October 2018. We describe factors associated with unfavourable treatment outcomes (death, lost to follow-up,
treatment failure and amplification of resistance) and culture conversion using multivariable flexible parametric survival and competing-risks regression analyses.RESULTS: Of 352 patients receiving BDQ and/or DLM, 7.8% and 21.2% had an unfavourable treatment outcome at 6 and 24
months, respectively. Predictors were age ≥ 60 years (adjusted hazard ratio aHR 4.49, 95%CI 1.61–12.57) vs. age 20–39 years, and a treatment regimen combining both drugs (aHR 4.49, 95%CI 1.61–12.57) vs. BDQ only. The probability of culture conversion was increased for
two health facilities and patients with a poly resistance profile (adjusted sub-hazard ratio 2.01, 95%CI 1.13–3.59) vs. multidrug resistance.CONCLUSION: Single use of BDQ or DLM was associated with low rates of unfavourable outcomes, suggesting that these medications may be
effectively adopted at scale under routine programmatic conditions. Combined use of BDQ and DLM was a risk factor for unfavourable outcomes and should prompt for collection of more data on the combined use of these medications.
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Affiliation(s)
- D. Vambe
- Eswatini National Tuberculosis Control Programme, Manzini, Eswatini
| | - A. W. Kay
- Baylor College of Medicine, Houston, TX, USA, Baylor Children´s Foundation, Mbabane, Eswatini
| | - J. Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
| | - A. A. Howard
- ICAP at Columbia University, New York, NY, Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - T. Dlamini
- Eswatini National Tuberculosis Control Programme, Manzini, Eswatini
| | - N. Dlamini
- Eswatini National Tuberculosis Control Programme, Manzini, Eswatini
| | | | - F. Hassen
- National TB Referral Hospital, Manzini
| | - S. Masuku
- Eswatini National Tuberculosis Control Programme, Manzini, Eswatini
| | - O. Maha
- Eswatini National Tuberculosis Control Programme, Manzini, Eswatini, Matsapha Comprehensive Care Clinic, Manzini
| | - C. Wawa
- Eswatini National Tuberculosis Control Programme, Manzini, Eswatini, Mankanyane Hospital, Manzini
| | | | - K. Altaye
- ICAP at Columbia University, Mbabane
| | - W. Sikhondze
- Eswatini National Tuberculosis Control Programme, Manzini, Eswatini
| | | | - K. Keus
- Médecins Sans Frontières (MSF) Operational Centre Amsterdam, Manzini
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13
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Walker C, Burtscher D, Myeni J, Kerschberger B, Schausberger B, Rusch B, Dlamini N, Whitehouse K. "They have been neglected for a long time": a qualitative study on the role and recognition of rural health motivators in the Shiselweni region, Eswatini. Hum Resour Health 2020; 18:66. [PMID: 32958066 PMCID: PMC7504860 DOI: 10.1186/s12960-020-00504-9] [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] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 08/18/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Community health workers (CHWs) are increasingly engaged to address human resource shortages and fill primary healthcare gaps. In Eswatini, a cadre of CHWs called Rural Health Motivators (RHM) was introduced in 1976 to respond to key public health challenges. However, the emergence of health needs, particularly HIV/TB, has been met with inadequate programme amendments, and the role of RHMs has become marginalised following the addition of other CHWs supported by non-governmental organisations. This study was implemented to understand the role of RHMs in decentralised HIV/TB activities. In this paper, we explore the findings in relation to the recognition of RHMs and the programme. METHODS This exploratory qualitative study utilised individual in-depth interviews, group and focus group discussions, participatory methods (utilising a game format) and observations. Participants were purposively selected and comprised RHM programme implementers, community stakeholders and local and non-governmental personnel. Data collection took place between August and September 2019. Interviews were conducted in English or siSwati and transcribed. SiSwati interviews were translated directly into English. All interviews were audio-recorded, manually coded and thematically analysed. Data was validated through methodical triangulation. RESULTS Suboptimal organisational structure and support, primarily insufficient training and supervision for activities were factors identified through interviews and observation activities. Significant confusion of the RHM role was observed, with community expectations beyond formally endorsed tasks. Community participants expressed dissatisfaction with receiving health information only, preferring physical assistance in the form of goods. Additionally, gender emerged as a significant influencing factor on the acceptability of health messages and the engagement of RHMs with community members. Expectations and structurally limiting factors shape the extent to which RHMs are recognised as integral to the health system, at all social and organisational levels. CONCLUSIONS Findings highlight the lack of recognition of RHMs and the programme at both community and national levels. This, along with historical neglect, has hindered the capacity of RHMs to successfully contribute to positive health outcomes for rural communities. Renewed attention and support mechanisms for this cadre are needed. Clarification of the RHM role in line with current health challenges and clearer role parameters is essential.
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Affiliation(s)
| | - Doris Burtscher
- Vienna Evaluation Unit/Anthropology, Médecins Sans Frontières, Vienna, Austria
| | - John Myeni
- Prevention and Promotion Programme, Ministry of Health, Mbabane, Eswatini
| | | | | | | | | | - Katherine Whitehouse
- Luxembourg Operational Research Unit (LuxOr), Médecins Sans Frontières, Brussels, Belgium
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14
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Burtscher D, Juul Bjertrup P, Vambe D, Dlamini V, Mmema N, Ngwenya S, Rusch B, Kerschberger B. 'She is like my mother': Community-based care of drug-resistant tuberculosis in rural Eswatini. Glob Public Health 2020; 16:911-923. [PMID: 32816634 DOI: 10.1080/17441692.2020.1808039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients with drug-resistant tuberculosis (DR-TB) have received community-based care in Eswatini since 2009. Trained and compensated community treatment supporters (CTSs) provide directly observed therapy (DOT), injectables and psychological support. We examined the acceptability of this model of care among DR-TB patients, including the perspective of family members of DR-TB patients and their CTSs in relation to the patient's experience of care and quality of life. This qualitative research was conducted in rural Eswatini in February 2018. DR-TB patients, CTSs and family members participated in in-depth interviews, paired interviews, focus group discussions and PhotoVoice. Data were thematically analysed and coded, and themes were extracted. Methodological triangulation enhanced the interpretation. All patients and CTSs and most family members considered community-based DR-TB care to be supportive. Positive aspects were emotional support, trust and dedicated individual care, including enabling practical, financial and social factors. Concerns were related to social and economic problems within the family and fears about infection risks for the family and the CTSs. Community-based DR-TB care was acceptable to patients, family members and CTSs. To reduce family members' fears of TB infection, information and sensitisation within the family and constant follow-up appear crucial.
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Affiliation(s)
- Doris Burtscher
- Médecins Sans Frontières/Ärzte ohne Grenzen, Vienna Evaluation Unit/Anthropology, Wien, Austria
| | | | - Debrah Vambe
- National Tuberculosis Control Program (NTCP), Manzini, Swaziland
| | | | | | | | - Barbara Rusch
- Médecins Sans Frontières, Operational Centre Geneva, Geneva, Switzerland
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15
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Ndlovu Z, Burton R, Stewart R, Bygrave H, Roberts T, Fajardo E, Mataka A, Szumilin E, Kerschberger B, Van Cutsem G, Ellman T. Framework for the implementation of advanced HIV disease diagnostics in sub-Saharan Africa: programmatic perspectives. Lancet HIV 2020; 7:e514-e520. [PMID: 32473102 DOI: 10.1016/s2352-3018(20)30101-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/16/2020] [Accepted: 03/23/2020] [Indexed: 01/21/2023]
Abstract
Patients with advanced HIV disease have a high risk of mortality, mainly from tuberculosis and cryptococcal meningitis. The advanced HIV disease management package recommended by WHO, which includes diagnostics, therapeutics, and patient psychosocial support, is barely implemented in many different countries. Here, we present a framework for the implementation of advanced HIV disease diagnostics. Laboratory and point-of-care-based reflex testing, coupled with provider-initiated requested testing, for cryptococcal antigen and urinary Mycobacterium tuberculosis lipoarabinomannan antigen, should be done for all patients with CD4+ cell counts of 200 cells per μL or less. Implementation of the advanced HIV disease package should be encouraged within primary health-care facilities and task shifting of testing to lay cadres could facilitate access to rapid results. Implementation of differentiated antiretroviral therapy delivery models can allow clinicians enough time to focus on the management of patients with advanced HIV disease. Efficient up-referral and post-discharge systems, including the development of patient-centric advanced HIV disease literacy, are also crucial. Implementation of the advanced HIV disease package is feasible at all health-care levels, and it should be part of the core of the global response towards ending AIDS as a public health threat.
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Affiliation(s)
- Zibusiso Ndlovu
- Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa.
| | - Rosie Burton
- Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa
| | | | - Helen Bygrave
- Médecins Sans Frontières, Access Campaign, Geneva, Switzerland
| | - Teri Roberts
- Médecins Sans Frontières, Access Campaign, Geneva, Switzerland
| | | | - Anafi Mataka
- African Society for Laboratory Medicine, Addis Ababa, Ethiopia
| | | | | | - Gilles Van Cutsem
- Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Tom Ellman
- Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa
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16
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Pasipamire L, Nesbitt RC, Dube L, Mabena E, Nzima M, Dlamini M, Rugongo N, Maphalala N, Obulutsa TA, Ciglenecki I, Kerschberger B. Implementation of community and facility-based HIV self-testing under routine conditions in southern Eswatini. Trop Med Int Health 2020; 25:723-731. [PMID: 32219945 PMCID: PMC7317513 DOI: 10.1111/tmi.13396] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objectives WHO recommends HIV self‐testing (HIVST) as an additional approach to HIV testing services. The study describes the strategies used during phase‐in of HIVST under routine conditions in Eswatini (formerly Swaziland). Methods Between May 2017 and January 2018, assisted and unassisted oral HIVST was offered at HIV testing services (HTS) sites to people aged ≥ 16 years. Additional support tools were available, including a telephone hotline answered 24/7, HIVST demonstration videos and printed educational information about HIV prevention and care services. Demographic characteristics of HIVST users were described and compared with standard blood‐based HTS in the community. HIVST results were monitored with follow‐up phone calls and the hotline. Results During the 9‐month period, 1895 people accessed HIVST and 2415 HIVST kits were distributed. More people accessed HIVST kits in the community (n = 1365, 72.0%) than at health facilities (n = 530, 28.0%). The proportion of males and median age among those accessing HIVST and standard HTS in the community were similar (49.3%, 29 years HIVST vs. 48.7%, 27 years standard HTS). In total, 34 (3.9%) reactive results were reported from 938 people with known HIVST results; 32.4% were males, and median age was 30 years (interquartile range 25–36). Twenty‐one (62%) patients were known to have received confirmatory blood‐based HTS; of these, 20 (95%) had concordant reactive results and 19 (95%) were linked to HIV care at a clinic. Conclusion Integration of HIVST into existing HIV facility‐ and community‐based testing strategies in Eswatini was found to be feasible, and HIVST has been adopted by national testing bodies in Eswatini.
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Affiliation(s)
| | - Robin C Nesbitt
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | - Lenhle Dube
- Eswatini National AIDS Programme (ENAP), Ministry of Health, Mbabane, Eswatini
| | - Edwin Mabena
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | - Muzi Nzima
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | - Mduduzi Dlamini
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | - Nozizwe Rugongo
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | | | | | - Iza Ciglenecki
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
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17
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Horter S, Seeley J, Bernays S, Kerschberger B, Lukhele N, Wringe A. Dissonance of Choice: Biomedical and Lived Perspectives on HIV Treatment-Taking. Med Anthropol 2020; 39:675-688. [PMID: 32078396 DOI: 10.1080/01459740.2020.1720981] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Treat-all recommends prompt treatment initiation for those diagnosed HIV positive, requiring adaptations to individuals' behavior and practice. Drawing on data from a longitudinal qualitative study in Eswatini, we examine the choice to initiate treatment when asymptomatic, the dissonance between the biomedical logic surrounding Treat-all and individuals' conceptions of treatment necessity, and the navigation over time of ongoing engagement with care. We reflect on the perspectives of healthcare workers, responsible for implementing Treat-all and holding a duty of care for their patients. We explore how the potentially differing needs and priorities of individuals and the public health agenda are navigated and reconciled. Rationalities regarding treatment-taking extend beyond the biomedical realm, requiring adjustments to sense of self and identity, and decision-making that is situated and socially embedded. Sense of choice and ownership for this process is important for individuals' engagement with treatment and care.
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Affiliation(s)
- Shona Horter
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine , London, UK.,Research Department, Medecins Sans Frontieres , Nhlangano, Swaziland
| | - Janet Seeley
- Global Health and Development, London School of Hygiene and Tropical Medicine , London, UK.,MRC/UVRI Uganda Research Unit On AIDS , Entebbe, Uganda
| | - Sarah Bernays
- The University of Sydney School of Public Health , Sydney, Australia
| | | | | | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine , London, UK
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18
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Kerschberger B, Jobanputra K, Schomaker M, Kabore SM, Teck R, Mabhena E, Lukhele N, Rusch B, Boulle A, Ciglenecki I. Feasibility of antiretroviral therapy initiation under the treat-all policy under routine conditions: a prospective cohort study from Eswatini. J Int AIDS Soc 2019; 22:e25401. [PMID: 31647613 PMCID: PMC6812490 DOI: 10.1002/jia2.25401] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 01/03/2019] [Accepted: 09/03/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The World Health Organization recommends the Treat-All policy of immediate antiretroviral therapy (ART) initiation, but questions persist about its feasibility in resource-poor settings. We assessed the feasibility of Treat-All compared with standard of care (SOC) under routine conditions. METHODS This prospective cohort study from southern Eswatini followed adults from HIV care enrolment to ART initiation. Between October 2014 and March 2016, Treat-All was offered in one health zone and SOC according to the CD4 350 and 500 cells/mm3 treatment eligibility thresholds in the neighbouring health zone, each of which comprised one secondary and eight primary care facilities. We used Kaplan-Meier estimates, multivariate flexible parametric survival models and standardized survival curves to compare ART initiation between the two interventions. RESULTS Of the 1726 (57.3%) patients enrolled under Treat-All and 1287 (42.7%) under SOC, cumulative three-month ART initiation was higher under Treat-All (91%) than SOC (74%; p < 0.001) with a median time to ART of 1 (IQR 0 to 14) and 10 (IQR 2 to 117) days respectively. Under Treat-All, ART initiation was higher in pregnant women (vs. non-pregnant women: adjusted hazard ratio (aHR) 1.96, 95% confidence interval (CI) 1.70 to 2.26), those with secondary education (vs. no formal education: aHR 1.48, 95% CI 1.12 to 1.95), and patients with an HIV-positive diagnosis before care enrolment (aHR 1.22, 95% CI 1.10 to 1.36). ART initiation was lower in patients attending secondary care facilities (aHR 0.64, 95% CI 0.58 to 0.72) and for CD4 351 to 500 when compared with CD4 201 to 350 cells/mm3 (aHR 0.84, 95% CI 0.72 to 1.00). ART initiation varied over time for TB cases, with lower hazard during the first two weeks after HIV care enrolment and higher hazards thereafter. Of patients with advanced HIV disease (n = 1085; 36.0%), crude 3-month ART initiation was similar in both interventions (91% to 92%) although Treat-All initiated patients more quickly during the first month after HIV care enrolment. CONCLUSIONS ART initiation was high under Treat-All and without evidence of de-prioritization of patients with advanced HIV disease. Additional studies are needed to understand the long-term impact of Treat-All on patient outcomes.
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Affiliation(s)
- Bernhard Kerschberger
- Médecins Sans Frontières (Operational Centre Geneva)MbabaneEswatini
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | | | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Institute of Public Health, Medical Decision Making and HealthTechnology AssessmentMedical Informatics and TechnologyUMIT – University for Health SciencesHall in TirolAustria
| | - Serge M Kabore
- Médecins Sans Frontières (Operational Centre Geneva)MbabaneEswatini
| | - Roger Teck
- The Manson UnitMédecins Sans FrontièresLondonUnited Kingdom
| | - Edwin Mabhena
- Médecins Sans Frontières (Operational Centre Geneva)MbabaneEswatini
| | | | - Barbara Rusch
- Médecins Sans Frontières (Operational Centre Geneva)GenevaSwitzerland
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Iza Ciglenecki
- Médecins Sans Frontières (Operational Centre Geneva)GenevaSwitzerland
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Kerschberger B, Telnov A, Yano N, Cox H, Zabsonre I, Kabore SM, Vambe D, Ngwenya S, Rusch B, Tombo ML, Ciglenecki I. Successful expansion of community-based drug-resistant TB care in rural Eswatini - a retrospective cohort study. Trop Med Int Health 2019; 24:1243-1258. [PMID: 31390108 PMCID: PMC6851784 DOI: 10.1111/tmi.13299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives Provision of drug‐resistant tuberculosis (DR‐TB) treatment is scarce in resource‐limited settings. We assessed the feasibility of ambulatory DR‐TB care for treatment expansion in rural Eswatini. Methods Retrospective patient‐level data were used to evaluate ambulatory DR‐TB treatment provision in rural Shiselweni (Eswatini), from 2008 to 2016. DR‐TB care was either clinic‐based led by nurses or community‐based at the patient's home with involvement of community treatment supporters for provision of treatment to patients with difficulties in accessing facilities. We describe programmatic outcomes and used multivariate flexible parametric survival models to assess time to adverse outcomes. Both care models were costed in supplementary analyses. Results Of 698 patients initiated on DR‐TB treatment, 57% were women and 84% were HIV‐positive. Treatment initiations increased from 27 in 2008 to 127 in 2011 and decreased thereafter to 51 in 2016. Proportionally, community‐based care increased from 19% in 2009 to 77% in 2016. Treatment success was higher for community‐based care (79%) than clinic‐based care (68%, P = 0.002). After adjustment for covariate factors among adults (n = 552), the risk of adverse outcomes (death, loss to follow‐up, treatment failure) in community‐based care was reduced by 41% (adjusted hazard ratio 0.59, 95% CI: 0.39–0.91). Findings were supported by sensitivity analyses. The care provider's per‐patient costs for community‐based (USD13 345) and clinic‐based (USD12 990) care were similar. Conclusions Ambulatory treatment outcomes were good, and community‐based care achieved better treatment outcomes than clinic‐based care at comparable costs. Contextualised DR‐TB care programmes are feasible and can support treatment expansion in rural settings.
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Affiliation(s)
| | - Alex Telnov
- Medecins Sans Frontieres (Operational Centre Geneva), Geneva, Switzerland
| | - Nanako Yano
- Clinton Health Access Initiative, Mbabane, Eswatini
| | - Helen Cox
- Institute of Infectious Diseases and Molecular Medicine, Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Cape Town, South Africa
| | - Inoussa Zabsonre
- Medecins Sans Frontieres (Operational Centre Geneva), Mbabane, Eswatini
| | | | - Debrah Vambe
- National TB Control Programme, Manzini, Eswatini
| | | | - Barbara Rusch
- Medecins Sans Frontieres (Operational Centre Geneva), Geneva, Switzerland
| | - Marie Luce Tombo
- Medecins Sans Frontieres (Operational Centre Geneva), Mbabane, Eswatini
| | - Iza Ciglenecki
- Medecins Sans Frontieres (Operational Centre Geneva), Geneva, Switzerland
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Kerschberger B, Schomaker M, Telnov A, Vambe D, Kisyeri N, Sikhondze W, Pasipamire L, Ngwenya SM, Rusch B, Ciglenecki I, Boulle A. Decreased risk of HIV-associated TB during antiretroviral therapy expansion in rural Eswatini from 2009 to 2016: a cohort and population-based analysis. Trop Med Int Health 2019; 24:1114-1127. [PMID: 31310029 PMCID: PMC6852273 DOI: 10.1111/tmi.13290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Objectives This paper assesses patient‐ and population‐level trends in TB notifications during rapid expansion of antiretroviral therapy in Eswatini which has an extremely high incidence of both TB and HIV. Methods Patient‐ and population‐level predictors and rates of HIV‐associated TB were examined in the Shiselweni region in Eswatini from 2009 to 2016. Annual population‐level denominators obtained from projected census data and prevalence estimates obtained from population‐based surveys were combined with individual‐level TB treatment data. Patient‐ and population‐level predictors of HIV‐associated TB were assessed with multivariate logistic and multivariate negative binomial regression models. Results Of 11 328 TB cases, 71.4% were HIV co‐infected and 51.8% were women. TB notifications decreased fivefold between 2009 and 2016, from 1341 to 269 cases per 100 000 person‐years. The decline was sixfold in PLHIV vs. threefold in the HIV‐negative population. Main patient‐level predictors of HIV‐associated TB were recurrent TB treatment (adjusted odds ratio [aOR] 1.40, 95% confidence interval [CI]: 1.19–1.65), negative (aOR 1.31, 1.15–1.49) and missing (aOR 1.30, 1.11–1.53) bacteriological status and diagnosis at secondary healthcare level (aOR 1.18, 1.06–1.33). Compared with 2009, the probability of TB decreased for all years from 2011 (aOR 0.69, 0.58–0.83) to 2016 (aOR 0.54, 0.43–0.69). The most pronounced population‐level predictor of TB was HIV‐positive status (adjusted incidence risk ratio 19.47, 14.89–25.46). Conclusions This high HIV‐TB prevalence setting experienced a rapid decline in TB notifications, most pronounced in PLHIV. Achievements in HIV‐TB programming were likely contributing factors.
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Affiliation(s)
- Bernhard Kerschberger
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Institute of Public Health, Medical Decision Making and HealthTechnology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Alex Telnov
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Debrah Vambe
- National TB Control Program, Ministry of Health, Manzini, Eswatini
| | - Nicholas Kisyeri
- Eswatini National AIDS Programme, Ministry of Health, Mbabane, Eswatini
| | - Welile Sikhondze
- National TB Control Program, Ministry of Health, Manzini, Eswatini
| | | | | | - Barbara Rusch
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Iza Ciglenecki
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Kerschberger B, Schomaker M, Ciglenecki I, Pasipamire L, Mabhena E, Telnov A, Rusch B, Lukhele N, Teck R, Boulle A. Programmatic outcomes and impact of rapid public sector antiretroviral therapy expansion in adults prior to introduction of the WHO treat-all approach in rural Eswatini. Trop Med Int Health 2019; 24:701-714. [PMID: 30938037 PMCID: PMC6849841 DOI: 10.1111/tmi.13234] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objectives To assess long‐term antiretroviral therapy (ART) outcomes during rapid HIV programme expansion in the public sector of Eswatini (formerly Swaziland). Methods This is a retrospectively established cohort of HIV‐positive adults (≥16 years) who started first‐line ART in 25 health facilities in Shiselweni (Eswatini) between 01/2006 and 12/2014. Temporal trends in ART attrition, treatment expansion and ART coverage were described over 9 years. We used flexible parametric survival models to assess the relationship between time to ART attrition and covariates. Results Of 24 772 ART initiations, 6% (n = 1488) occurred in 2006, vs. 13% (n = 3192) in 2014. Between these years, median CD4 cell count at ART initiation increased (113–265 cells/mm3). The active treatment cohort expanded 8.4‐fold, ART coverage increased 8.0‐fold (7.1% in 2006 vs. 56.8% in 2014) and 12‐month crude ART retention improved from 71% to 86%. Compared with the pre‐decentralisation period (2006–2007), attrition decreased by 5% (adjusted hazard ratio [aHR] 0.95, 95% confidence interval 0.88–1.02) during HIV‐TB service decentralisation (2008–2010), by 17% (aHR 0.83, 0.75–0.92) during service consolidation (2011–2012), and by 20% (aHR 0.80, 0.71–0.90) during further treatment expansion (2013–2014). The risk of attrition was higher for young age, male sex, pathological baseline haemoglobin and biochemistry results, more toxic drug regimens, WHO III/IV staging and low CD4 cell count; access to a telephone was protective. Conclusions Programmatic outcomes improved during large expansion of the treatment cohort and increased ART coverage. Changes in ART programming may have contributed to better outcomes.
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Affiliation(s)
- Bernhard Kerschberger
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Iza Ciglenecki
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | | | - Edwin Mabhena
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini
| | - Alex Telnov
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Barbara Rusch
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | | | | | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Horter S, Bernays S, Thabede Z, Dlamini V, Kerschberger B, Pasipamire M, Rusch B, Wringe A. "I don't want them to know": how stigma creates dilemmas for engagement with Treat-all HIV care for people living with HIV in Eswatini. Afr J AIDS Res 2019; 18:27-37. [PMID: 30782082 DOI: 10.2989/16085906.2018.1552163] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
"Treat-all" programmes aim to improve clinical outcomes and to reduce HIV transmission through regular HIV testing and immediate offer of antiretroviral therapy (ART) for those diagnosed HIV-positive, irrespective of immunological status and symptoms of disease. Global narratives on the benefits of Treat-all anticipate reduced HIV-related stigma and increased "normalisation" of HIV with Treat-all implementation, whereby HIV is remoulded as a manageable, chronic condition where stigmatising symptoms can be concealed. Drawing on Goffman's stigma work, we aimed to investigate how stigma may influence the engagement of clinically asymptomatic people living with HIV (PLHIV) with Treat-all HIV care in Shiselweni, Eswatini (formerly Swaziland). This longitudinal research comprised 106 interviews conducted from August 2016 to September 2017, including repeated interviews with 30 PLHIV, and one-off interviews with 20 healthcare workers. Data were analysed thematically using NVivo 11, drawing upon principles of grounded theory to generate findings inductively from participants' accounts. Stigma was pervasive within the narratives of PLHIV, framing their engagement with treatment and care. Many asymptomatic PLHIV were motivated to initiate ART in order to maintain a "discreditable" status, by preventing the development of visible and exposing symptoms. However, engagement with treatment and care services could itself be exposing. PLHIV described the ways in which these "invisibilising" benefits and exposing risks of ART were continually assessed and navigated over time. Where the risk of exposure was deemed too great, this could lead to intermittent treatment-taking, and disengagement from care. Addressing HIV related stigma is crucial to the success of Treat-all, and should thus be a core component of HIV responses.
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Affiliation(s)
- Shona Horter
- a London School of Hygiene and Tropical Medicine , London , UK.,b Médecins sans Frontières/Doctors Without Borders , Nhlangano , Eswatini
| | - Sarah Bernays
- c Sydney School of Public Health , University of Sydney , Sydney , Australia
| | - Zanele Thabede
- b Médecins sans Frontières/Doctors Without Borders , Nhlangano , Eswatini
| | - Velibanti Dlamini
- b Médecins sans Frontières/Doctors Without Borders , Nhlangano , Eswatini
| | | | - Munyaradzi Pasipamire
- d Swaziland National AIDS Programme , Swaziland Ministry of Health , Mbabane , Eswatini
| | - Barbara Rusch
- e Médecins sans Frontières/Doctors without Borders , Geneva , Switzerland
| | - Alison Wringe
- a London School of Hygiene and Tropical Medicine , London , UK
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Horter S, Wringe A, Thabede Z, Dlamini V, Kerschberger B, Pasipamire M, Lukhele N, Rusch B, Seeley J. "Is it making any difference?" A qualitative study examining the treatment-taking experiences of asymptomatic people living with HIV in the context of Treat-all in Eswatini. J Int AIDS Soc 2019; 22:e25220. [PMID: 30697970 PMCID: PMC6351702 DOI: 10.1002/jia2.25220] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/26/2018] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Treat-all is being implemented in several African settings, in accordance with 2015 World Health Organisation guidelines. The factors known to undermine adherence to antiretroviral therapy (ART) may change in the context of Treat-all, where people living with HIV (PLHIV) increasingly initiate ART at earlier, asymptomatic stages of disease, soon after diagnosis. This paper aimed to examine the asymptomatic PLHIV's experiences engaging with early ART initiation under the Treat-all policy, including how they navigate treatment-taking over the longer term. METHODS A longitudinal qualitative study was conducted within a Médecins Sans Frontières/Ministry of Health Treat-all pilot in Shiselweni, southern Eswatini. The Treat-all pilot began in October 2014, adopted into national policy in October 2016. Participants were recruited purposively to include newly diagnosed, clinically asymptomatic PLHIV with a range of treatment-taking experiences, and healthcare workers (HCW) with various roles. This analysis drew upon a sub-sample of 17 PLHIV who had been on ART for at least 12 months, with mean 20 months on ART at first interview, and who undertook three interviews each. Additionally, 20 HCWs were interviewed once. Interviews were conducted from August 2016 to September 2017. Data were analysed thematically using coding, drawing upon principles of grounded theory, and aided by Nvivo 11. RESULTS It was important for PLHIV to perceive the need for treatment, and to have evidence of its effectiveness to motivate their treatment-taking, thereby supporting engagement with care. For some, coming to terms with a HIV diagnosis or re-interpreting past illnesses as signs of HIV could point to the need for ART to prevent health deterioration and prolong life. However, others doubted the accuracy of an HIV diagnosis and the need for treatment in the absence of symptoms or signs of ill health, with some experimenting with treatment-taking as a means of seeking evidence of their need for treatment and its effect. Viral load monitoring appeared important in offering a view of the effect of treatment on the level of the virus, thereby motivating continued treatment-taking. CONCLUSIONS These findings highlight the importance of PLHIV perceiving need for treatment and having evidence of the difference that ART is making to them for motivating treatment-taking. Patient support should be adapted to address these concerns, and viral load monitoring made routinely available within Treat-all care, with communication of suppressed results emphasized to patients.
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Affiliation(s)
- Shona Horter
- Médecins Sans FrontièresNhlanganoEswatini
- London School of Hygiene and Tropical MedicineLondonUK
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Kerschberger B, Mpala Q, Uribe PAD, Maphalala G, de la Tour R, Kalombola S, Bekele A, Chawinga T, Mliba M, Ntshalintshali N, Phugwayo N, Kabore SM, Goiri J, Dlamini S, Ciglenecki I, Fajardo E. Field suitability and diagnostic accuracy of the Biocentric® open real-time PCR platform for plasma-based HIV viral load quantification in Swaziland. BMC Infect Dis 2018; 18:570. [PMID: 30428850 PMCID: PMC6236955 DOI: 10.1186/s12879-018-3474-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 10/31/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Viral load (VL) testing is being scaled up in resource-limited settings. However, not all commercially available VL testing methods have been evaluated under field conditions. This study is one of a few to evaluate the Biocentric platform for VL quantification in routine practice in Sub-Saharan Africa. METHODS Venous blood specimens were obtained from patients eligible for VL testing at two health facilities in Swaziland from October 2016 to March 2017. Samples were centrifuged at two laboratories (LAB-1, LAB-2) to obtain paired plasma specimens for VL quantification with the national reference method and on the Biocentric platform. Agreement (correlation, Bland-Altman) and accuracy (sensitivity, specificity) indicators were calculated at the VL thresholds of 416 (2.62 log10) and 1000 (3.0 log10) copies/mL. Leftover samples from patients with discordant VL results were re-quantified and accuracy indicators recalculated. Logistic regression was used to compare laboratory performance. RESULTS A total of 364 paired plasma samples (LAB-1: n = 198; LAB-2: n = 166) were successfully tested using both methods. The correlation was high (R = 0.82, p < 0.01), and the Bland-Altman analysis showed a minimal mean difference (- 0.03 log10 copies/mL; 95% CI: -1.15 to 1.08). At the clinical threshold level of 3.0 log10 copies/mL, the sensitivity was 88.6% (95% CI: 78.7 to 94.9) and the specificity was 98.3% (95% CI: 96.1 to 99.4). Sensitivity was higher in LAB-1 (100%; 95% CI: 71.5 to 100) than in LAB-2 (86.4%; 95% CI: 75.0 to 94.0). Most upward (n = 8, 2.2%) and downward (n = 11, 3.0%) misclassifications occurred at the 2.62 log threshold, with LAB-2 having a 16 (95% CI: 2.26 to 113.27; p = 0.006) times higher odds of downward misclassification. After retesting of discordant leftover samples (n = 17), overall sensitivity increased to 93.5% (95% CI: 85.5 to 97.9) and 97.1% (95% CI: 90.1 to 99.7) at the 2.62 and 3.0 thresholds, and specificity increased to 98.6% (95% CI: 96.5 to 99.6) and 99.0% (95% CI: 97.0 to 99.8) respectively. CONCLUSIONS The test characteristics of the Biocentric platform were overall comparable to the national reference method for VL quantification. One laboratory tended to misclassify VL results downwards, likely owing to unmet training needs and lack of previous hands-on practice.
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Affiliation(s)
- Bernhard Kerschberger
- Medecins Sans Frontieres (OCG), P.O. Box 18, Eveni, Lot No. 331, Sheffield Road, Industrial Area, Mbabane, Swaziland.
| | - Qhubekani Mpala
- Medecins Sans Frontieres (OCG), P.O. Box 18, Eveni, Lot No. 331, Sheffield Road, Industrial Area, Mbabane, Swaziland
| | - Paola Andrea Díaz Uribe
- Medecins Sans Frontieres (OCG), P.O. Box 18, Eveni, Lot No. 331, Sheffield Road, Industrial Area, Mbabane, Swaziland
| | - Gugu Maphalala
- Ministry of Health (National Reference Laboratory), Mbabane, Swaziland
| | | | - Sydney Kalombola
- Medecins Sans Frontieres (OCG), P.O. Box 18, Eveni, Lot No. 331, Sheffield Road, Industrial Area, Mbabane, Swaziland
| | - Addis Bekele
- Medecins Sans Frontieres (OCG), P.O. Box 18, Eveni, Lot No. 331, Sheffield Road, Industrial Area, Mbabane, Swaziland
| | - Tiwonge Chawinga
- Medecins Sans Frontieres (OCG), P.O. Box 18, Eveni, Lot No. 331, Sheffield Road, Industrial Area, Mbabane, Swaziland
| | - Mukelo Mliba
- Medecins Sans Frontieres (OCG), P.O. Box 18, Eveni, Lot No. 331, Sheffield Road, Industrial Area, Mbabane, Swaziland
| | | | - Nomcebo Phugwayo
- Ministry of Health (National Reference Laboratory), Mbabane, Swaziland
| | - Serge Mathurin Kabore
- Medecins Sans Frontieres (OCG), P.O. Box 18, Eveni, Lot No. 331, Sheffield Road, Industrial Area, Mbabane, Swaziland
| | - Javier Goiri
- Medecins Sans Frontieres (OCG), Geneva, Switzerland
| | - Sindisiwe Dlamini
- Ministry of Health (National Reference Laboratory), Mbabane, Swaziland
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Etoori D, Ciglenecki I, Ndlangamandla M, Edwards CG, Jobanputra K, Pasipamire M, Maphalala G, Yang C, Zabsonre I, Kabore SM, Goiri J, Teck R, Kerschberger B. Successes and challenges in optimizing the viral load cascade to improve antiretroviral therapy adherence and rationalize second-line switches in Swaziland. J Int AIDS Soc 2018; 21:e25194. [PMID: 30350392 PMCID: PMC6198167 DOI: 10.1002/jia2.25194] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [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: 11/24/2017] [Accepted: 09/26/2018] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION As antiretroviral therapy (ART) is scaled up, more patients become eligible for routine viral load (VL) monitoring, the most important tool for monitoring ART efficacy. For HIV programmes to become effective, leakages along the VL cascade need to be minimized and treatment switching needs to be optimized. However, many HIV programmes in resource-constrained settings report significant shortfalls. METHODS From a public sector HIV programme in rural Swaziland, we evaluated the VL cascade of adults (≥18 years) on ART from the time of the first elevated VL (>1000 copies/mL) between January 2013 and June 2014 to treatment switching by December 2015. We additionally described HIV drug resistance for patients with virological failure. We used descriptive statistics and Kaplan-Meier estimates to describe the different steps along the cascade and regression models to determine factors associated with outcomes. RESULTS AND DISCUSSION Of 828 patients with a first elevated VL, 252 (30.4%) did not receive any enhanced adherence counselling (EAC). Six hundred and ninety-six (84.1%) patients had a follow-up VL measurement, and the predictors of receiving a follow-up VL were being a second-line patient (adjusted hazard ratio (aHR): 0.72; p = 0.051), Hlathikhulu health zone (aHR: 0.79; p = 0.013) and having received two EAC sessions (aHR: 1.31; p = 0.023). Four hundred and ten patients (58.9%) achieved VL re-suppression. Predictors of re-suppression were age 50 to 64 (adjusted odds ratio (aOR): 2.02; p = 0.015) compared with age 18 to 34 years, being on second-line treatment (aOR: 3.29; p = 0.003) and two (aOR: 1.66; p = 0.045) or three (aOR: 1.86; p = 0.003) EAC sessions. Of 278 patients eligible to switch to second-line therapy, 120 (43.2%) had switched by the end of the study. Finally, of 155 successfully sequenced dried blood spots, 144 (92.9%) were from first-line patients. Of these, 133 (positive predictive value: 92.4%) had resistance patterns that necessitated treatment switching. CONCLUSIONS Patients on ART with high VLs were more likely to re-suppress if they received EAC. Failure to re-suppress after counselling was predictive of genotypically confirmed resistance patterns requiring treatment switching. Delays in switching were significant despite the ability of the WHO algorithm to predict treatment failure. Despite significant progress in recent years, enhanced focus on quality care along the VL cascade in resource-limited settings is crucial.
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Affiliation(s)
- David Etoori
- Research DepartmentMédecins Sans FrontièresMbabaneSwaziland
- Department of Population HealthLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Iza Ciglenecki
- Research DepartmentMédecins Sans FrontièresGenevaSwitzerland
| | | | | | | | | | - Gugu Maphalala
- Swaziland National Reference Laboratory (NRL)Ministry of HealthMbabaneSwaziland
| | - Chunfu Yang
- Division of Global HIV/AIDSThe Centre for Disease ControlAtlantaGAUSA
| | | | - Serge M Kabore
- Research DepartmentMédecins Sans FrontièresMbabaneSwaziland
| | - Javier Goiri
- Research DepartmentMédecins Sans FrontièresGenevaSwitzerland
| | - Roger Teck
- Research DepartmentMédecins Sans FrontièresGenevaSwitzerland
- South African Medical UnitMédecins Sans FrontièresCape TownSouth Africa
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Pasipamire L, Nesbitt RC, Ndlovu S, Sibanda G, Mamba S, Lukhele N, Pasipamire M, Kabore SM, Rusch B, Ciglenecki I, Kerschberger B. Retention on ART and predictors of disengagement from care in several alternative community-centred ART refill models in rural Swaziland. J Int AIDS Soc 2018; 21:e25183. [PMID: 30225946 PMCID: PMC6141897 DOI: 10.1002/jia2.25183] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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: 03/13/2018] [Accepted: 08/10/2018] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION A broad range of community-centred care models for patients stable on anti-retroviral therapy (ART) have been proposed by the World Health Organization to better respond to patient needs and alleviate pressure on health systems caused by rapidly growing patient numbers. Where available, often a single alternative care model is offered in addition to routine clinical care. We operationalized several community-centred ART delivery care models in one public sector setting. Here, we compare retention in care and on ART and identify predictors of disengagement with care. METHODS Patients on ART were enrolled into three community-centred ART delivery care models in the rural Shiselweni region (Swaziland), from 02/2015 to 09/2016: Community ART Groups (CAGs), comprehensive outreach care and treatment clubs. We used Kaplan-Meier estimates to describe crude retention in care model and retention on ART (including patients who returned to clinical care). Multivariate Cox proportional hazard models were used to determine factors associated with all-cause attrition from care model and disengagement with ART. RESULTS A total of 918 patients were enrolled. CAGs had the most participants with 531 (57.8%). Median age was 44.7 years (IQR 36.3 to 54.4), 71.8% of patients were female, and 62.6% fulfilled eligibility criteria for community ART. The 12-month retention in ART was 93.7% overall; it was similar between model types (p = 0.52). A considerable proportion of patients returned from community ART to clinical care, resulting in lower 12 months retention in care model (82.2% overall); retention in care model was lowest in CAGs at 70.4%, compared with 86.3% in outreach and 90.4% in treatment clubs (p < 0.001). In multivariate Cox regression models, patients in CAGs had a higher risk of disengaging from care model (aHR 3.15, 95% CI 2.01 to 4.95, p < 0.001) compared with treatment clubs. We found, however, no difference in attrition in ART between alternative model types. CONCLUSIONS Concurrent implementation of three alternative community-centred ART models in the same region was feasible. Although a considerable proportion of patients returned back to clinical care, overall ART retention was high and should encourage programme managers to offer community-centred care models adapted to their specific setting.
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Etoori D, Kerschberger B, Staderini N, Ndlangamandla M, Nhlabatsi B, Jobanputra K, Mthethwa-Hleza S, Parker LA, Sibanda S, Mabhena E, Pasipamire M, Kabore SM, Rusch B, Jamet C, Ciglenecki I, Teck R. Challenges and successes in the implementation of option B+ to prevent mother-to-child transmission of HIV in southern Swaziland. BMC Public Health 2018; 18:374. [PMID: 29558896 PMCID: PMC5859825 DOI: 10.1186/s12889-018-5258-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 03/06/2018] [Indexed: 01/09/2023] Open
Abstract
Background Universal antiretroviral therapy (ART) for all pregnant/ breastfeeding women living with Human Immunodeficiency Virus (HIV), known as Prevention of mother-to child transmission of HIV (PMTCT) Option B+ (PMTCTB+), is being scaled up in most countries in Sub-Saharan Africa. In the transition to PMTCTB+, many countries face challenges with proper implementation of the HIV care cascade. We aimed to describe the feasibility of a PMTCTB+ approach in the public health sector in Swaziland. Methods Lifelong ART was offered to a cohort of HIV+ pregnant women aged ≥16 years at the first antenatal care (ANC1) visit in 9 public sector facilities, between 01/2013 and 06/2014. The study enrolment period was divided into 3 phases (early: 01–06/2013, mid: 07–12/2013 and late: 01–06/2014) to account for temporal trends. Kaplan-Meier estimates and Cox proportional-hazards regression models were applied for ART initiation and attrition analyses. Results Of 665 HIV+ pregnant women, 496 (74.6%) initiated ART. ART initiation increased in later study enrolment phases (mid: aHR: 1.41; later: aHR: 2.36), and decreased at CD4 ≥ 500 (aHR: 0.69). 52.9% were retained in care at 24 months. Attrition was associated with ANC1 in the third trimester (aHR: 2.37), attending a secondary care facility (aHR: 1.98) and ART initiation during later enrolment phases (mid aHR: 1.48; late aHR: 1.67). Of 373 women eligible, 67.3% received a first VL. 223/251 (88.8%) were virologically suppressed (< 1000 copies/mL). Of 670 infants, 53.6% received an EID test, 320/359 had a test result recorded and of whom 7 (2.2%) were HIV+. Conclusions PMTCTB+ was found to be feasible in this setting, with high rates of maternal viral suppression and low transmission to the infant. High treatment attrition, poor follow-up of mother-baby pairs and under-utilisation of VL and EID testing are important programmatic challenges.
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Affiliation(s)
- David Etoori
- Médecins Sans Frontières, Mbabane, Swaziland. .,London School of Hygiene and Tropical Medicine, London, UK.
| | | | | | | | - Bonisile Nhlabatsi
- Sexual and Reproductive Health Unit, Ministry of Health, Mbabane, Swaziland
| | | | | | - Lucy Anne Parker
- Médecins Sans Frontières, Geneva, Switzerland.,CIBER Epidemiología y Salud Pública, Universidad Miguel Hernández, Alicante, Spain
| | | | | | | | | | | | | | | | - Roger Teck
- Médecins Sans Frontières, Geneva, Switzerland.,South African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
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Mueller Y, Mpala Q, Kerschberger B, Rusch B, Mchunu G, Mazibuko S, Bonnet M. Adherence, tolerability, and outcome after 36 months of isoniazid-preventive therapy in 2 rural clinics of Swaziland: A prospective observational feasibility study. Medicine (Baltimore) 2017; 96:e7740. [PMID: 28858089 PMCID: PMC5585483 DOI: 10.1097/md.0000000000007740] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Although efficacy of 36 months isoniazid preventive therapy (IPT) among HIV-positive individuals has been proven in trial settings, outcome, tolerance, and adherence have rarely been evaluated in real-life settings.This is a prospective observational cohort study conducted in 2 primary care rural clinics in Swaziland.After negative tuberculosis symptom screening, patients either with the positive tuberculin skin test (TST) or after tuberculosis treatment were initiated on IPT for 144 weeks. In addition to routine clinic visits, adherence was assessed every semester.Of 288 eligible patients, 2 patients never started IPT (1 refusal, 1 contraindication), and 253 (87.8%), 234 (81.3%), and 228 (79.2%) were still on IPT after 48, 96, and 144 weeks, respectively (chiP = .01). Of 41 patients who interrupted IPT before 144 weeks, 21 defaulted (of which 17 also defaulted HIV care); 16 stopped because of adverse drug reactions; 2 were discontinued by clinicians' mistake and 1 because of TB symptoms. Five patients (1.7%) died of causes not related to IPT, 5 (1.7%) developed TB of which 2 were isoniazid-resistant, and 9 (3.1%) were transferred to another clinic. As an indicator of adherence, isoniazid could be detected in the urine during 86.3% (302/350) and 73.6% (248/337) of patient visits in the 2 clinics, respectively (chiP < .001).The routine implementation of IPT 36 months was feasible and good patient outcomes were achieved, with low TB incidence, good tolerance, and sustained adherence.
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Affiliation(s)
| | | | | | | | | | | | - Maryline Bonnet
- Epicentre, Paris, France
- IRD UMI 233 TransVIHMI-UM—INSERM U1175, Montpellier, France
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Rhee SY, Varghese V, Holmes SP, Van Zyl GU, Steegen K, Boyd MA, Cooper DA, Nsanzimana S, Saravanan S, Charpentier C, de Oliveira T, Etiebet MAA, Garcia F, Goedhals D, Gomes P, Günthard HF, Hamers RL, Hoffmann CJ, Hunt G, Jiamsakul A, Kaleebu P, Kanki P, Kantor R, Kerschberger B, Marconi VC, D'amour Ndahimana J, Ndembi N, Ngo-Giang-Huong N, Rokx C, Santoro MM, Schapiro JM, Schmidt D, Seu L, Sigaloff KCE, Sirivichayakul S, Skhosana L, Sunpath H, Tang M, Yang C, Carmona S, Gupta RK, Shafer RW. Mutational Correlates of Virological Failure in Individuals Receiving a WHO-Recommended Tenofovir-Containing First-Line Regimen: An International Collaboration. EBioMedicine 2017; 18:225-235. [PMID: 28365230 PMCID: PMC5405160 DOI: 10.1016/j.ebiom.2017.03.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/07/2017] [Accepted: 03/17/2017] [Indexed: 11/29/2022] Open
Abstract
Tenofovir disoproxil fumarate (TDF) genotypic resistance defined by K65R/N and/or K70E/Q/G occurs in 20% to 60% of individuals with virological failure (VF) on a WHO-recommended TDF-containing first-line regimen. However, the full spectrum of reverse transcriptase (RT) mutations selected in individuals with VF on such a regimen is not known. To identify TDF regimen-associated mutations (TRAMs), we compared the proportion of each RT mutation in 2873 individuals with VF on a WHO-recommended first-line TDF-containing regimen to its proportion in a cohort of 50,803 antiretroviral-naïve individuals. To identify TRAMs specifically associated with TDF-selection pressure, we compared the proportion of each TRAM to its proportion in a cohort of 5805 individuals with VF on a first-line thymidine analog-containing regimen. We identified 83 TRAMs including 33 NRTI-associated, 40 NNRTI-associated, and 10 uncommon mutations of uncertain provenance. Of the 33 NRTI-associated TRAMs, 12 - A62V, K65R/N, S68G/N/D, K70E/Q/T, L74I, V75L, and Y115F - were more common among individuals receiving a first-line TDF-containing compared to a first-line thymidine analog-containing regimen. These 12 TDF-selected TRAMs will be important for monitoring TDF-associated transmitted drug-resistance and for determining the extent of reduced TDF susceptibility in individuals with VF on a TDF-containing regimen.
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Affiliation(s)
- Soo-Yon Rhee
- Department of Medicine, Stanford University, Stanford, CA 94305, USA.
| | - Vici Varghese
- Department of Medicine, Stanford University, Stanford, CA 94305, USA
| | - Susan P Holmes
- Department of Statistics, Stanford University, Stanford, CA 94305, USA
| | - Gert U Van Zyl
- Division of Medical Virology, Stellenbosch University, National Health Laboratory Service, Tygerberg 7505, South Africa
| | - Kim Steegen
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, WITS 2050, South Africa
| | - Mark A Boyd
- The Kirby Institute, UNSW, Sydney, NSW 2052, Australia
| | | | - Sabin Nsanzimana
- HIV/AIDS Division, Rwanda Biomedical Center, Kigali, P.O. Box 87, Rwanda
| | - Shanmugam Saravanan
- Y.R. Gaitonde Centre for AIDS Research and Education, Voluntary Health Services, Taramani, Chennai 600113, India
| | - Charlotte Charpentier
- Univ Paris Diderot, Sorbonne Paris Cité, IAME, UMR 1137, INSERM, F-75018 Paris, France; AP-HP, Hôpital Bichat-Claude Bernard, Laboratoire de Virologie, F-75018 Paris, France
| | - Tulio de Oliveira
- College of Health Sciences, University of KwaZulu-Natal, Durban 4041, South Africa
| | - Mary-Ann A Etiebet
- Institute of Human Virology, University of Maryland School of Medicine, MD 21201, USA
| | | | - Dominique Goedhals
- Department of Medical Microbiology and Virology, National Health Laboratory Service/University of the Free State, Bloemfontein 9301,South Africa
| | - Perpetua Gomes
- Laboratorio de Virologia, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon 1449-005, Portugal
| | - Huldrych F Günthard
- University Hospital Zurich, Institute of Medical Virology, University of Zurich, 8091 Zurich, Switzerland
| | - Raph L Hamers
- Amsterdam Institute for Global Health and Development, Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam, P.O. Box 22700, The Netherlands
| | | | - Gillian Hunt
- National Institute for Communicable Diseases, Sandringham, Johannesburg 2131, South Africa
| | | | | | - Phyllis Kanki
- Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Rami Kantor
- Division of Infectious Diseases, Alpert Medical School, Brown University, Providence, RI 02903, USA
| | | | - Vincent C Marconi
- Emory University School of Medicine, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | | | - Nicaise Ndembi
- Institute of Human Virology Nigeria, Abuja, Federal Capital Territory, P.O. Box 9396, Nigeria
| | - Nicole Ngo-Giang-Huong
- Institut de Recherche pour le Developpement (IRD), UMI 174 - PHPT, 13572 Marseilles, France
| | - Casper Rokx
- Department of Internal Medicine and Infectious Diseases, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | | | | | - Daniel Schmidt
- Department of Infectious Disease Epidemiology, HIV/AIDS, STI and Blood Born Infections, Robert Koch-Institute, 13353 Berlin, Germany
| | - Lillian Seu
- School of Medicine, University of Alabama at Birmingham, AL 35210, USA
| | - Kim C E Sigaloff
- Amsterdam Institute for Global Health and Development, Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam, P.O. Box 22700, The Netherlands
| | | | - Lindiwe Skhosana
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, WITS 2050, South Africa
| | - Henry Sunpath
- School of Clinical Sciences, University of KwaZulu- Natal, Durban 4041, South Africa
| | - Michele Tang
- Department of Medicine, Stanford University, Stanford, CA 94305, USA
| | - Chunfu Yang
- Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Port-au-Prince, Haiti
| | - Sergio Carmona
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, WITS 2050, South Africa
| | | | - Robert W Shafer
- Department of Medicine, Stanford University, Stanford, CA 94305, USA
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Gregson J, Kaleebu P, Marconi VC, van Vuuren C, Ndembi N, Hamers RL, Kanki P, Hoffmann CJ, Lockman S, Pillay D, de Oliveira T, Clumeck N, Hunt G, Kerschberger B, Shafer RW, Yang C, Raizes E, Kantor R, Gupta RK. Occult HIV-1 drug resistance to thymidine analogues following failure of first-line tenofovir combined with a cytosine analogue and nevirapine or efavirenz in sub Saharan Africa: a retrospective multi-centre cohort study. Lancet Infect Dis 2016; 17:296-304. [PMID: 27914856 PMCID: PMC5421555 DOI: 10.1016/s1473-3099(16)30469-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 10/06/2016] [Accepted: 10/14/2016] [Indexed: 01/08/2023]
Abstract
Background HIV-1 drug resistance to older thymidine analogue nucleoside reverse transcriptase inhibitor drugs has been identified in sub-Saharan Africa in patients with virological failure of first-line combination antiretroviral therapy (ART) containing the modern nucleoside reverse transcriptase inhibitor tenofovir. We aimed to investigate the prevalence and correlates of thymidine analogue mutations (TAM) in patients with virological failure of first-line tenofovir-containing ART. Methods We retrospectively analysed patients from 20 studies within the TenoRes collaboration who had locally defined viral failure on first-line therapy with tenofovir plus a cytosine analogue (lamivudine or emtricitabine) plus a non-nucleoside reverse transcriptase inhibitor (NNRTI; nevirapine or efavirenz) in sub-Saharan Africa. Baseline visits in these studies occurred between 2005 and 2013. To assess between-study and within-study associations, we used meta-regression and meta-analyses to compare patients with and without TAMs for the presence of resistance to tenofovir, cytosine analogue, or NNRTIs. Findings Of 712 individuals with failure of first-line tenofovir-containing regimens, 115 (16%) had at least one TAM. In crude comparisons, patients with TAMs had lower CD4 counts at treatment initiation than did patients without TAMs (60·5 cells per μL [IQR 21·0–128·0] in patients with TAMS vs 95·0 cells per μL [37·0–177·0] in patients without TAMs; p=0·007) and were more likely to have tenofovir resistance (93 [81%] of 115 patients with TAMs vs 352 [59%] of 597 patients without TAMs; p<0·0001), NNRTI resistance (107 [93%] vs 462 [77%]; p<0·0001), and cytosine analogue resistance (100 [87%] vs 378 [63%]; p=0·0002). We detected associations between TAMs and drug resistance mutations both between and within studies; the correlation between the study-level proportion of patients with tenofovir resistance and TAMs was 0·64 (p<0·0001), and the odds ratio for tenofovir resistance comparing patients with and without TAMs was 1·29 (1·13–1·47; p<0·0001) Interpretation TAMs are common in patients who have failure of first-line tenofovir-containing regimens in sub-Saharan Africa, and are associated with multidrug resistant HIV-1. Effective viral load monitoring and point-of-care resistance tests could help to mitigate the emergence and spread of such strains.
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Affiliation(s)
- John Gregson
- Department of Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Pontiano Kaleebu
- MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda; Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Vincent C Marconi
- Department of Global Health, Emory University Rollins School of Public Health, Emory University, Atlanta, GA, USA; Division of Infectious Diseases, Emory University School of Medicine, Emory University, Atlanta, GA, USA
| | - Cloete van Vuuren
- Division of Infectious Diseases, University of the Free State, and 3 Military Hospital, Bloemfontein, South Africa
| | | | - Raph L Hamers
- Amsterdam Institute for Global Health and Development, Department of Global Health, Academic Medical Center, University of Amsterdam, Netherlands
| | - Phyllis Kanki
- Department of Immunology and Infectious Disease, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Christopher J Hoffmann
- Aurum Institute, Johannesburg South Africa; Johns Hopkins University, Baltimore, MD, USA
| | | | - Deenan Pillay
- Department of Infection, University College London, London, UK; Africa Health Research Institute, KwaZulu Natal, South Africa
| | - Tulio de Oliveira
- Nelson R Mandela School of Medicine, School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa; Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Nathan Clumeck
- Saint-Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Gillian Hunt
- National Institute for Communicable Diseases, Sandringham, South Africa
| | | | - Robert W Shafer
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Chunfu Yang
- International Laboratory Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Elliot Raizes
- Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rami Kantor
- Division of Infectious Diseases, Alpert Medical School, Brown University, Providence, RI, USA
| | - Ravindra K Gupta
- Department of Infection, University College London, London, UK; Africa Health Research Institute, KwaZulu Natal, South Africa.
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Parker LA, Jobanputra K, Okello V, Nhlangamandla M, Mazibuko S, Kourline T, Kerschberger B, Pavlopoulos E, Teck R. Implementation and Operational Research: Barriers and Facilitators to Combined ART Initiation in Pregnant Women With HIV: Lessons Learnt From a PMTCT B+ Pilot Program in Swaziland. J Acquir Immune Defic Syndr 2015; 69:e24-30. [PMID: 25622060 PMCID: PMC4418786 DOI: 10.1097/qai.0000000000000537] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 11/26/2014] [Indexed: 12/05/2022]
Abstract
BACKGROUND In January 2013, Swaziland launched a prevention of mother-to-child transmission of HIV (PMTCT) B+ implementation study in rural Shiselweni. We aimed to identify patient and health service determinants of combined antiretroviral therapy (ART) initiation to help guide national implementation of PMTCT B+. METHODS This prospective cohort study uses routine data from registers and patient files in the PMTCT B+ pilot zone and a neighboring health zone where PMTCT A was the standard of care. All HIV-positive women not on combined ART at the first antenatal care visit between January 28, 2013 and December 31, 2013 were included. RESULTS 399 women from the PMTCT B+ zone and 183 from the PMTCT A zone are included. The overall proportion of women who had not started an antiretroviral intervention before 32 weeks' gestation was lower in the PMTCT A zone (13% vs 25%, P = 0.003), yet a higher proportion women with CD4 <350 initiated combined ART in the PMTCT B+ zone (86% vs 74%, P = 0.032). Within the PMTCT B+ pilot, initiation rates were highly variable between health facilities; while at patient level, ART initiation was significantly higher among women with CD4 <350 compared with CD4 >350 (80% vs 59%, P < 0.001). Among women with CD4 <350, those recorded as newly diagnosed were more likely to initiate combined ART. Although lower educational level and occupational barriers seemed to hinder combined ART initiation among women with CD4 >350, high proportions of missing socio-demographic data made it impossible to make any firm conclusions to this respect. CONCLUSIONS This study not only demonstrates challenges in initiating pregnant women on ART, but also identifies opportunities offered by PMTCT B+ for improving treatment initiation among women with lower CD4 counts.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Roger Teck
- Médecins sans Frontières, Geneva, Switzerland
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Parker LA, Jobanputra K, Rusike L, Mazibuko S, Okello V, Kerschberger B, Jouquet G, Cyr J, Teck R. Feasibility and effectiveness of two community-based HIV testing models in rural Swaziland. Trop Med Int Health 2015; 20:893-902. [PMID: 25753897 PMCID: PMC4672714 DOI: 10.1111/tmi.12501] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objectives To evaluate the feasibility (population reached, costs) and effectiveness (positivity rates, linkage to care) of two strategies of community-based HIV testing and counselling (HTC) in rural Swaziland. Methods Strategies used were mobile HTC (MHTC) and home-based HTC (HBHTC). Information on age, sex, previous testing and HIV results was obtained from routine HTC records. A consecutive series of individuals testing HIV-positive were followed up for 6 months from the test date to assess linkage to care. Results A total of 9 060 people were tested: 2 034 through MHTC and 7 026 through HBHTC. A higher proportion of children and adolescents (<20 years) were tested through HBHTC than MHTC (57% vs. 17%; P < 0.001). MHTC reached a higher proportion of adult men than HBHTC (42% vs. 39%; P = 0.015). Of 398 HIV-positive individuals, only 135 (34%) were enrolled in HIV care within 6 months. Of 42 individuals eligible for antiretroviral therapy, 22 (52%) started treatment within 6 months. Linkage to care was lowest among people who had tested previously and those aged 20–40 years. HBHTC was 50% cheaper (US$11 per person tested; $797 per individual enrolled in HIV care) than MHTC ($24 and $1698, respectively). Conclusion In this high HIV prevalence setting, a community-based testing programme achieved high uptake of testing and appears to be an effective and affordable way to encourage large numbers of people to learn their HIV status (particularly underserved populations such as men and young people). However, for community HTC to impact mortality and incidence, strategies need to be implemented to ensure people testing HIV-positive in the community are linked to HIV care. Objectifs Evaluer la faisabilité (population atteinte, coûts) et l'efficacité (taux de positivité, liaison aux soins) de deux stratégies de dépistage et conseil (DC) communautaire du VIH en zone rurale au Swaziland. Méthodes Les stratégies utilisées étaient des DC mobiles (DC-M) et le DC à domicile (DC-D). Les informations sur l’âge, le sexe, les tests précédents et les résultats VIH ont été obtenues à partir des dossiers de routine du DC. Une série d'individus séropositifs consécutifs a été suivie pendant six mois à partir de la date du test afin d’évaluer les liaisons aux soins. Résultats 9.060 personnes ont été testées: 2.034 par le biais du DC-M et 7026 par le biais du DC-D. Une plus grande proportion d'enfants et d'adolescents (<20 ans) ont été testés par le biais du DC-D que par celui du DC-M (57% vs 17%; p <0,001). Le DC-M a atteint une proportion plus élevée d'hommes adultes que le DC-D (42% vs 39%; p = 0,015). Des 398 personnes séropositives, seules 135 (34%) ont été inscrites à des soins VIH dans les 6 mois. De 42 personnes admissibles à la thérapie antirétrovirale, 22 (52%) ont commencé le traitement dans les 6 mois. Les liaisons avec les soins étaient plus faibles chez les personnes qui ont effectué un dépistage auparavant et celles âgées de 20 à 40 ans. Le DC-D était 50% moins cher (11 $ US par personne testée, 797 $ par personne inscrite dans les soins VIH) que le DC-M (24 $ et 1.698 $, respectivement). Conclusion Dans ce contexte à haute prévalence du VIH, un programme de dépistage communautaire a atteint une couverture élevée et semble être un moyen efficace et abordable pour encourager un grand nombre de personnes à connaître leur statut VIH (en particulier les populations mal desservies, telles que les hommes et les jeunes personnes). Cependant, afin que le DC communautaire ait un impact sur la mortalité et l'incidence, des stratégies doivent être mises en œuvre pour assurer que les personnes testées séropositives dans la communauté soient reliées aux soins du VIH. Objetivos Evaluar la viabilidad (población alcanzada, costes) y efectividad (tasas de positividad, vinculación al tratamiento) de dos estrategias comunitarias de asesoramiento y prueba para el VIH (APV) en zonas rurales de Suazilandia. Métodos Las estrategias utilizadas fueron la de APV en instalaciones clínicas móviles (APVM) y el APV realizado en el hogar (APVBH). Se obtuvo información sobre la edad, el sexo, la realización de pruebas anteriores y resultados de VIH de los informes rutinarios de APV. A una serie consecutiva de individuos que habían dado positivo en la prueba de VIH se les siguió durante 6 meses a partir del día de la prueba, con el fin de evaluar la conexión posterior a los cuidados y tratamiento adecuados. Resultados Se evaluaron 9,060 personas: 2,034 mediante APVM y 7,026 mediante APVBH. A una mayor proporción de niños y adolescentes (<20 años) se les realizó la prueba mediante APVBH que mediante APVM (57% vs. 17%; p<0.001). El APVM llegó a una mayor proporción de hombres adultos que el APVBH (42% vs. 39%; p=0.015). De 398 individuos VIH positivos, solo 135 (34%) estaban recibiendo atención y cuidados para el VIH después de 6 meses. De 42 individuos elegibles para Terapia Antirretroviral, 22 (52%) comenzaron el tratamiento dentro de los 6 meses siguientes a la prueba. La vinculación a los cuidados y atención para VIH posterior a la prueba era menor entre aquellos que habían dado previamente positivo y aquellos con edades entre 20-40 años. El APVBH era un 50% más barato (US$11 por persona a la que se le realizó la prueba, $797 por individuo recibiendo cuidados para VIH) que el APVM ($24 y $1698, respectivamente). Conclusión En este emplazamiento con una alta prevalencia de VIH, un programa de prueba para el VIH basado en la comunidad alcanzó un alto nivel de aceptación de la prueba, y parece ser una manera efectiva y económicamente asumible de animar a un gran número de personas a conocer su estatus de VIH (en particular población actualmente poco alcanzada como los hombres y personas jóvenes). Sin embargo, para que el APV comunitario tenga un impacto sobre la mortalidad y la incidencia, es necesario implementar estrategias apoyen el tratamiento, asegurando que las personas que dan positivo en la prueba son remitidas y reciben los cuidados adecuados.
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Affiliation(s)
| | | | | | | | | | | | | | - Joanne Cyr
- Médecins Sans Frontières, Geneva, Switzerland
| | - Roger Teck
- Médecins Sans Frontières, Geneva, Switzerland
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Jobanputra K, Parker LA, Azih C, Okello V, Maphalala G, Jouquet G, Kerschberger B, Mekeidje C, Cyr J, Mafikudze A, Han W, Lujan J, Teck R, Antierens A, van Griensven J, Reid T. Impact and programmatic implications of routine viral load monitoring in Swaziland. J Acquir Immune Defic Syndr 2014; 67:45-51. [PMID: 24872139 PMCID: PMC4149657 DOI: 10.1097/qai.0000000000000224] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 05/05/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the programmatic quality (coverage of testing, counseling, and retesting), cost, and outcomes (viral suppression, treatment decisions) of routine viral load (VL) monitoring in Swaziland. DESIGN Retrospective cohort study of patients undergoing routine VL monitoring in Swaziland (October 1, 2012 to March 31, 2013). RESULTS Of 5563 patients eligible for routine VL testing monitoring in the period of study, an estimated 4767 patients (86%) underwent testing that year. Of 288 patients with detectable VL, 210 (73%) underwent enhanced adherence counseling and 202 (70%) had a follow-up VL within 6 months. Testing coverage was slightly lower in children, but coverage of retesting was similar between and age groups and sexes. Of those with a follow-up test, 126 (62%) showed viral suppression. The remaining 78 patients had World Health Organization-defined virologic failure; 41 (53%) were referred by the doctor for more adherence counseling, and 13 (15%) were changed to second-line therapy, equating to an estimated rate of 1.2 switches per 100 patient-years. Twenty-four patients (32%) were transferred out, lost to follow-up, or not reviewed by doctor. The "fully loaded" cost of VL monitoring was $35 per patient-year. CONCLUSIONS Achieving good quality VL monitoring is feasible and affordable in resource-limited settings, although close supervision is needed to ensure good coverage of testing and counseling. The low rate of switch to second-line therapy in patients with World Health Organization-defined virologic failure seems to reflect clinician suspicion of ongoing adherence problems. In our study, the main impact of routine VL monitoring was reinforcing adherence rather than increasing use of second-line therapy.
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Affiliation(s)
- Kiran Jobanputra
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Swaziland
| | - Lucy Anne Parker
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Swaziland
| | - Charles Azih
- Swaziland National AIDS Program, Ministry of Health, Mbabane, Swaziland
| | - Velephi Okello
- Swaziland National AIDS Program, Ministry of Health, Mbabane, Swaziland
| | - Gugu Maphalala
- Swaziland National Reference Laboratory, Mbabane, Swaziland
| | - Guillaume Jouquet
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Swaziland
| | | | - Calorine Mekeidje
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Swaziland
| | - Joanne Cyr
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Swaziland
| | - Arnold Mafikudze
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Swaziland
| | - Win Han
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Swaziland
| | - Johnny Lujan
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Roger Teck
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Annick Antierens
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | | | - Tony Reid
- Médecins Sans Frontières (Operational Research Unit, MSF Luxembourg), Luxembourg
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Garone DB, Conradie K, Patten G, Cornell M, Goemaere W, Kunene J, Kerschberger B, Ford N, Boulle A, Van Cutsem G. High rate of virological re-suppression among patients failing second-line antiretroviral therapy following enhanced adherence support: A model of care in Khayelitsha, South Africa. South Afr J HIV Med 2013. [DOI: 10.4102/sajhivmed.v14i4.52] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Objective. To describe and evaluate the outcomes of a support programme for patients with virological failure while receiving second-line antiretroviral therapy (ART) in South Africa.Method. We described a comprehensive medical and counselling patient support programme for patients receiving secondline ART and with two consecutive viral loads (VLs) >1 000 copies/ml. Patients with >3 months follow-up and at least one VL measurement after inclusion in the programme were eligible for analysis.Results. Of 69 patients enrolled in the programme, 40 had at least one follow-up VL and no known drug resistance at enrolment; 27 (68%) of these re-suppressed while remaining on second-line ART following enhanced adherence support. The majority (18/27; 67%) achieved re-suppression within the first 3 months in the programme. Five patients with diagnosed second-line drug resistance achieved viral re-suppression (<400 copies/ml) after being switched to third-line ART. Seven patients (7/40; 18%) did not achieve viral re-suppression after 9 months in the programme: 6 with known adherence problems (4 without drug resistance on genotype) and 1 with a VL <1 000 copies/ml. Overall, 3 patients (4%) died, 3 (4%) were lost to follow-up and 2 (3%) were transferred out.Conclusion. Our experience from a routine programme demonstrates that with targeted adherence support, the majority of patients who were viraemic while receiving second-line ART returned to an undetectable VL within 3 months. By increasing the time receiving second-line ART and decreasing the need for genotypes and/or third-line ART, this intervention may reduce costs.
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Barnett W, Patten G, Kerschberger B, Conradie K, Garone DB, Van Cutsem G, Colvin CKJ. Perceived adherence barriers among patients failing second-line antiretroviral therapy in Khayelitsha, South Africa. South Afr J HIV Med 2013. [DOI: 10.4102/sajhivmed.v14i4.51] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background. The recent scale-up of antiretroviral therapy (ART) coverage in resource-limited settings has greatly improved access to treatment. However, increasing numbers of patients are failing first- and second-line ART.Objective. To examine factors affecting adherence to second-line ART from the perspective of clinic staff and patients, assessing both individual and structural perceived barriers.Methods. Research was conducted at a large primary care tuberculosis (TB)/HIV clinic in Khayelitsha, a peri-urban township in Cape Town, South Africa. Participants were drawn from a Médecins Sans Frontières-run programme to support patients failing second-line ART. A qualitative research approach was used, combining multiple methodologies including key informant interviews with staff (n=11), in-depth interviews with patients (n=10) and a Photovoice workshop (n=11). Responses and photographs were coded by content; data were transformed into variables and analysed accordingly.Results. Staff identified drinking, non-disclosure, not using condoms and pill fatigue as barriers to ART adherence, while patients identified side-effects, not using condoms and a lack of understanding concerning medication timing. With respect to service delivery, staff identified a need for continued counselling and educational support following ART initiation. Patients were concerned about missing medical records and poor staff attitudes in the clinic.Conclusion. These findings identify discrepancies between provider and patient perceptions of barriers to, and facilitators of adherence, as well as of service delivery solutions. This highlights the need for on-going counselling and education following ART initiation, improved quality of counselling, and improved methods to identify and address specific barriers concerning medication adherence.
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Kerschberger B, Hilderbrand K, Boulle AM, Coetzee D, Goemaere E, De Azevedo V, Van Cutsem G. The effect of complete integration of HIV and TB services on time to initiation of antiretroviral therapy: a before-after study. PLoS One 2012; 7:e46988. [PMID: 23071690 PMCID: PMC3465310 DOI: 10.1371/journal.pone.0046988] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 09/06/2012] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Studies have shown that early ART initiation in TB/HIV co-infected patients lowers mortality. One way to implement earlier ART commencement could be through integration of TB and HIV services, a more efficient model of care than separate, vertical programs. We present a model of full TB/HIV integration and estimate its effect on time to initiation of ART. METHODOLOGY/PRINCIPAL FINDINGS We retrospectively reviewed TB registers and clinical notes of 209 TB/HIV co-infected adults with a CD4 count <250 cells/µl and registered for TB treatment at one primary care clinic in a South African township between June 2008 and May 2009. Using Kaplan-Meier and Cox proportional hazard analysis, we compared time between initiation of TB treatment and ART for the periods before and after full, "one-stop shop" integration of TB and HIV services (in December 2009). Potential confounders were determined a priori through directed acyclic graphs. Robustness of assumptions was investigated by sensitivity analyses. The analysis included 188 patients (100 pre- and 88 post-integration), yielding 56 person-years of observation. Baseline characteristics of the two groups were similar. Median time to ART initiation decreased from 147 days (95% confidence interval [CI] 85-188) before integration of services to 75 days (95% CI 52-119) post-integration. In adjusted analyses, patients attending the clinic post-integration were 1.60 times (95% CI 1.11-2.29) more likely to have started ART relative to the pre-integration period. Sensitivity analyses supported these findings. CONCLUSIONS/SIGNIFICANCE Full TB/HIV care integration is feasible and led to a 60% increased chance of co-infected patients starting ART, while reducing time to ART initiation by an average of 72 days. Although these estimates should be confirmed through larger studies, they suggest that scale-up of full TB/HIV service integration in high TB/HIV prevalence settings may shorten time to ART initiation, which might reduce excess mortality and morbidity.
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Affiliation(s)
| | - Katherine Hilderbrand
- Médecins sans Frontières, Khayelitsha, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Andrew M. Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - David Coetzee
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Eric Goemaere
- South African Medical Unit, Médecins sans Frontières, Johannesburg, South Africa
| | | | - Gilles Van Cutsem
- Médecins sans Frontières, Khayelitsha, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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