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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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Kehlenbrink S, Jobanputra K, Reddy A, Boulle P, Gomber A, Nugent R, Varma V, Nakayama AT, Ellman T. Diabetes Care in Humanitarian Settings. Endocrinol Metab Clin North Am 2023; 52:603-615. [PMID: 37865476 DOI: 10.1016/j.ecl.2023.05.010] [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: 10/23/2023]
Abstract
Despite the increasing prevalence of diabetes in populations experiencing humanitarian crisis, along with evidence that people living with diabetes are at higher risk for poor outcomes in a crisis, diabetes care is not routinely included in humanitarian health interventions. We here describe 4 factors that have contributed to the inequities and lack of diabetes inclusion in humanitarian programmes: (1) evolving paradigms in humanitarian health care, (2) complexities of diabetes service provision in humanitarian settings, (3) social and cultural challenges, and (4) lack of financing. We also outline opportunities and possible interventions to address these challenges and improve diabetes care among crisis-affected populations.
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Affiliation(s)
- Sylvia Kehlenbrink
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, 221 Longwood Avenue RFB-2, Boston, MA 02115, USA.
| | - Kiran Jobanputra
- Médecins Sans Frontières, Chancery Exchange, Lower Ground Floor, 10 Furnival Street, London EC4A 1AB, UK
| | - Amulya Reddy
- Médecins Sans Frontières, Chancery Exchange, Lower Ground Floor, 10 Furnival Street, London EC4A 1AB, UK
| | - Philippa Boulle
- Médecins Sans Frontières, Route de Ferney 140, Geneva 1202, Switzerland
| | - Apoorva Gomber
- Division of Global Health Equity, Brigham and Women's Hospital, Center for Integration Science, 75 Francis Street, Boston MA 02115, USA
| | - Rachel Nugent
- Department of Global Health, University of Washington, 3980 15th Avenue Northeast, Seattle, WA 98195, USA
| | - Vinod Varma
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Chemin du Pommier 40, 1218 Grand-Saconnex, Geneva, Switzerland
| | - Anna T Nakayama
- International Alliance for Diabetes Action, 101 South Hanley Road, Suite 800, Saint Louis, MO 63105, USA
| | - Tom Ellman
- Médecins Sans Frontières, 9th Floor, Zurich House, 70 Fox Street, Marshalltown, Johannesburg 2001, South Africa
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Bossard C, Chihana M, Nicholas S, Mauambeta D, Weinstein D, Conan N, Nicco E, Suzi J, OConnell L, Poulet E, Ellman T. HIV, sexual violence, and termination of pregnancy among adolescent and adult female sex workers in Malawi: A respondent-driven sampling study. PLoS One 2022; 17:e0279692. [PMID: 36584132 PMCID: PMC9803093 DOI: 10.1371/journal.pone.0279692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 12/13/2022] [Indexed: 12/31/2022] Open
Abstract
Female Sex Workers (FSWs) are a hard-to-reach and understudied population, especially those who begin selling sex at a young age. In one of the most economically disadvantaged regions in Malawi, a large population of women is engaged in sex work surrounding predominantly male work sites and transport routes. A cross-sectional study in February and April 2019 in Nsanje district used respondent driven sampling (RDS) to recruit women ≥13 years who had sexual intercourse (with someone other than their main partner) in exchange for money or goods in the last 30 days. A standardized questionnaire was filled in; HIV, syphilis, gonorrhea, and chlamydia tests were performed. CD4 count and viral load (VL) testing occurred for persons living with HIV (PLHIV). Among 363 study participants, one-quarter were adolescents 13-19 years (25.9%; n = 85). HIV prevalence was 52.6% [47.3-57.6] and increased with age: from 14.7% (13-19 years) to 87.9% (≥35 years). HIV status awareness was 95.2% [91.3-97.4], ART coverage was 98.8% [95.3-99.7], and VL suppression 83.2% [77.1-88.0], though adolescent FSWs were less likely to be virally suppressed than adults (62.8% vs. 84.4%). Overall syphilis prevalence was 29.7% [25.3-43.5], gonorrhea 9.5% [6.9-12.9], and chlamydia 12.5% [9.3-16.6]. 72.4% had at least one unwanted pregnancy, 17.9% had at least one abortion (40.1% of which were unsafe). Half of participants reported experiencing sexual violence (SV) (47.6% [42.5-52.7]) and more than one-tenth (14.2%) of all respondents experienced SV perpetrated by a police officer. Our findings show high levels of PLHIV-FSWs engaged in all stages of the HIV cascade of care. The prevalence of HIV, other STIs, unwanted pregnancy, unsafe abortion, and sexual violence remains extremely high. Peer-led approaches contributed to levels of ART coverage and HIV status awareness similar to those found in the general district population, despite the challenges and risks faced by FSWs.
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Affiliation(s)
- Claire Bossard
- Epicentre, Médecins Sans Frontières, Paris, France
- * E-mail:
| | | | | | | | | | | | - Elena Nicco
- OCB, Médecins Sans Frontières, Blantyre, Malawi
| | - Joel Suzi
- The Malawi National Aids Commission, Lilongwe, Malawi
| | - Lucy OConnell
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | | | - Tom Ellman
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
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Mangochi P, Bossard C, Catacutan C, Van Laeken D, Kwitonda C, Ortuno R, Chiwaula L, Meis M, Abura A, Furin J, Mpunga J, Goemare E, Ellman T, Garone D, Ferlazzo G, Isaakidis P. TB screening, prevention and treatment cascade in a Malawi prison. Int J Tuberc Lung Dis 2022; 26:956-962. [PMID: 36163657 DOI: 10.5588/ijtld.22.0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Incarcerated individuals, especially in high HIV and TB burden settings, are at increased risk of latent TB infection and/or TB disease. We implemented a comprehensive HIV-TB intervention in a Malawi prison and studied its feasibility.METHODS Between February and December 2019, consenting individuals underwent screening for HIV, TB infection and TB disease. HIV-positive individuals without TB disease were treated with a fixed-dose combination of isoniazid, cotrimoxazole and vitamin B6 (INH-CTX-B6). HIV-negative persons with TB infection received 12 weeks of isoniazid and rifapentine (3HP).RESULTS Of 1,546 consenting individuals, 1,498 (96.9%) were screened and 1,427 (92.3%) included in the analysis: 96.4% were male, the median age was 31 years (IQR 25-38). Twenty-nine (2.1%) participants were diagnosed with TB disease, of whom 89.7% started and 61.5% completed TB treatment. Of the 1,427 included, 341 (23.9%) were HIV-positive, of whom 98.5% on antiretroviral therapy and 95% were started on INH-CTX-B6. Among 1,086 HIV-negative participants, 1,015 (93.5%) underwent the tuberculin skin test (TST), 670 (65.9%) were TST-positive, 666 (99.4%) started 3HP and 570 (85.5%) completed 3HP treatment.CONCLUSION A comprehensive TB screening and treatment package among incarcerated individuals was acceptable and feasible, and showed high prevalence of HIV, TB disease and TB infection. Treatment uptake was excellent, but treatment completion needs to be improved. Greater investment in comprehensive HIV-TB services, including access to shorter TB regimens and follow-up upon release, is needed for incarcerated individuals.
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Affiliation(s)
- P Mangochi
- Médecins Sans Frontières (MSF), Blantyre, Malawi
| | | | - C Catacutan
- Médecins Sans Frontières (MSF), Blantyre, Malawi
| | - D Van Laeken
- Médecins Sans Frontières (MSF), Blantyre, Malawi
| | - C Kwitonda
- Médecins Sans Frontières (MSF), Blantyre, Malawi
| | - R Ortuno
- Médecins Sans Frontières (MSF), Blantyre, Malawi
| | - L Chiwaula
- Malawian Prison Health Service, Blantyre, Malawi
| | - M Meis
- KNCV Tuberculosis Foundation Challenge TB, The Hague, The Netherlands
| | - A Abura
- KNCV Tuberculosis Foundation Challenge TB, The Hague, The Netherlands
| | - J Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - J Mpunga
- National TB Control Programme, Blantyre, Malawi
| | - E Goemare
- Southern Africa Medical Unit, MSF, Cape Town, South Africa
| | - T Ellman
- Southern Africa Medical Unit, MSF, Cape Town, South Africa
| | | | - G Ferlazzo
- Southern Africa Medical Unit, MSF, Cape Town, South Africa
| | - P Isaakidis
- Southern Africa Medical Unit, MSF, Cape Town, South Africa, Clinical and Molecular Epidemiology Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
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Hacking D, Cassidy T, Ellman T, Steele SJ, Moore HA, Bermudez-Aza E, Nxiba X, Sopili E, Duran LT. HIV Self-testing Among Previously Diagnosed HIV-Positive People in Khayelitsha, South Africa: No Evidence of Harm but may Facilitate Re-engagement in ART Care. AIDS Behav 2022; 26:2891-2896. [PMID: 35235106 PMCID: PMC9372114 DOI: 10.1007/s10461-022-03586-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2021] [Indexed: 12/02/2022]
Abstract
In South Africa, where an estimated 34% of nearly 7-million HIV-positive people were not on antiretroviral therapy (ART) in 2019, innovative strategies to diagnose and link people to care are needed. HIV self-testing (HIVST) is one such strategy. However, there is concern that access to HIVST might result in re-testing among people on ART, with a risk of false negative results and disengagement from care. Between November 2017 and December 2018, HIVST kits were distributed at a private pharmacy and at HIV testing outreach events. Each participant was instructed to report their result via SMS and those who did not were followed-up telephonically 10 days later. Electronic medical records of participants were searched for evidence of HIV services 6 months before and after enrollment. Of 1482 participants, 163 (11%) were previously diagnosed HIV-positive prior to taking the test. Of these, 123 reported a result, however 87% reported a negative result. Of the 163 previously diagnosed, 84 were not in ART care prior to the test, with 15 (18%) linking to care post-test. Of 79 who were in ART care prior to the test, 76 (96%) remained in care, even though 51 (67%) had reported a negative result. Overall, 29% of participants reported their result via SMS, and 48% when telephoned. Despite efforts to dissuade them, some previously diagnosed HIV-positive utilised HIVST. For those disengaged from care this may facilitate re-engagement. Self-testing among those already in care, regardless of the reported result, did not disrupt their treatment, and their reasons for doing the test remain unclear.
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Ford N, Patten G, Rangaraj A, Davies MA, Meintjes G, Ellman T. Outcomes of people living with HIV after hospital discharge: a systematic review and meta-analysis. The Lancet HIV 2022; 9:e150-e159. [PMID: 35245507 PMCID: PMC8905089 DOI: 10.1016/s2352-3018(21)00329-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 12/03/2021] [Accepted: 12/13/2021] [Indexed: 12/19/2022]
Abstract
Background The identification and appropriate management of people with advanced HIV disease is a key component in the HIV response. People with HIV who are hospitalised are at a higher risk of death, a risk that might persist after discharge. The aims of this study were to estimate the frequency of negative post-discharge outcomes, and to determine risk factors for such outcomes in people with HIV. Methods Using a broad search strategy combining terms for hospital discharge and HIV infection, we searched MEDLINE via PubMed and Embase from Jan 1, 2003 to Nov 30, 2021 to identify studies reporting outcomes among people with HIV following discharge from hospital. We estimated pooled proportions of readmissions and deaths after hospital discharge using random-effects models. We also did subgroup analyses by setting, region, duration of follow-up, and advanced HIV status at admission, and sensitivity analyses to assess heterogeneity. Findings We obtained data from 29 cohorts, which reported outcomes of people living with HIV after hospital discharge in 92 781 patients. The pooled proportion of patients readmitted to hospital after discharge was 18·8% (95% CI 15·3–22·3) and 14·1% (10·8–17·3) died post-discharge. In sensitivity analyses, no differences were identified in the proportion of patients who were readmitted or died when comparing studies published before 2016 with those published after 2016. Post-discharge mortality was higher in studies from Africa (23·1% [16·5–29·7]) compared with the USA (7·5% [4·4–10·6]). For studies that reported both post-discharge mortality and readmission, the pooled proportion of patients who had this composite adverse outcome was 31·7% (23·9–39·5). Heterogeneity was moderate, and largely explained by patient status and linkage to care. Reported risk factors for readmission included low CD4 cell count at admission, longer length of stay, discharge against medical advice, and not linking to care following discharge; inpatient treatment with antiretroviral therapy (ART) during hospitalisation was protective of post-discharge mortality. Interpretation More than a quarter of patients with HIV had an adverse outcome after hospital discharge with no evidence of improvement in the past 15 years. This systematic review highlights the importance of ensuring post-discharge referral and appropriate management, including ART, to reduce mortality and readmission to hospital among this group of high-risk patients. Funding Bill & Melinda Gates Foundation. Translations For the French and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Nathan Ford
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO, Geneva, Switzerland; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Gabriela Patten
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Ajay Rangaraj
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO, Geneva, Switzerland
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Tom Ellman
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
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Cassidy T, Ntuli N, Kilani C, Malabi N, Rorwana B, Mutseyekwa T, O'Connell R, Steele SJ, Ndlovu Z, Ellman T, de Azevedo V, Pfaff C, Nelson A, Duran LT. Correction to: Delivering PrEP to Young Women in a Low-Income Setting in South Africa: Lessons for Providing Both Convenience and Support. AIDS Behav 2022; 26:160. [PMID: 34302284 DOI: 10.1007/s10461-021-03386-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Tali Cassidy
- Médecins Sans Frontières, Cape Town, South Africa.
- Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | | | | | | | | | | | | | | | | | - Tom Ellman
- Southern African Medical Unit, Cape Town, South Africa
| | | | - Colin Pfaff
- Médecins Sans Frontières, Cape Town, South Africa
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Abstract
Zibusiso Ndlovu and Tom Ellman discuss the potential value of task sharing in provision of testing for HIV and other infectious diseases.
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Affiliation(s)
- Zibusiso Ndlovu
- Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa
| | - Tom Ellman
- Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa
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Bossard C, Schramm B, Wanjala S, Jain L, Mucinya G, Opollo V, Wiesner L, van Cutsem G, Poulet E, Szumilin E, Ellman T, Maman D. High Prevalence of NRTI and NNRTI Drug Resistance Among ART-Experienced, Hospitalized Inpatients. J Acquir Immune Defic Syndr 2021; 87:883-888. [PMID: 33852504 PMCID: PMC8191469 DOI: 10.1097/qai.0000000000002689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients hospitalized with advanced HIV have a high mortality risk. We assessed viremia and drug resistance among differentiated care services and explored whether expediting the switching of failing treatments may be justified. SETTING Hospitals in the Democratic Republic of (DRC) Congo (HIV hospital) and Kenya (general hospital including HIV care). METHODS Viral load (VL) testing and drug resistance (DR) genotyping were conducted for HIV inpatients ≥15 years, on first-line antiretroviral therapy (ART) for ≥6 months, and CD4 ≤350 cells/µL. Dual-class DR was defined as low-, intermediate-, or high-level DR to at least 1 nucleoside reverse transcriptase inhibitor and 1 non-nucleoside reverse transcriptase inhibitor. ART regimens were considered ineffective if dual-class DR was detected at viral failure (VL ≥1000 copies/mL). RESULTS Among 305 inpatients, 36.7% (Kenya) and 71.2% (DRC) had VL ≥1000 copies/mL, of which 72.9% and 73.7% had dual-class DR. Among viral failures on tenofovir disoproxil fumarate (TDF)-based regimens, 56.1% had TDF-DR and 29.8% zidovudine (AZT)-DR; on AZT regimens, 71.4% had AZT-DR and 61.9% TDF-DR, respectively. Treatment interruptions (≥48 hours during past 6 months) were reported by 41.7% (Kenya) and 56.7% (DRC). Approximately 56.2% (Kenya) and 47.4% (DRC) on TDF regimens had tenofovir diphosphate concentrations <1250 fmol/punch (suboptimal adherence). Among viral failures with CD4 <100 cells/µL, 76.0% (Kenya) and 84.6% (DRC) were on ineffective regimens. CONCLUSIONS Many hospitalized, ART-experienced patients with advanced HIV were on an ineffective first-line regimen. Addressing ART failure promptly should be integrated into advanced disease care packages for this group. Switching to effective second-line medications should be considered after a single high VL on non-nucleoside reverse transcriptase inhibitor-based first-line if CD4 ≤350 cells/µL or, when VL is unavailable, among patients with CD4 ≤100 cells/µL.
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Affiliation(s)
| | | | | | | | | | - Valarie Opollo
- Kenya Medical Research Institute/Center for Global Health Research, Kisumu, Kenya;
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa;
| | - Gilles van Cutsem
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa;
- Center for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa; and
| | | | | | - Tom Ellman
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa;
| | - David Maman
- Epicentre, Médecins Sans Frontières, Paris, France;
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Carnimeo V, Pulido Tarquino IA, Fuentes S, Vaz D, Molfino L, Tamayo Antabak N, Cuco RM, Couto A, Lobo S, de Amaral Fidelis J, Mulassua JS, Ciglenecki I, Ellman T, Schramm B. High level of HIV drug resistance informs dolutegravir roll-out and optimized NRTI backbone strategy in Mozambique. JAC Antimicrob Resist 2021; 3:dlab050. [PMID: 34223118 PMCID: PMC8209982 DOI: 10.1093/jacamr/dlab050] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/21/2021] [Indexed: 11/16/2022] Open
Abstract
Background HIV drug resistance (HIV-DR) is rising in sub-Saharan Africa in both ART-naive and ART-experienced patients. Objectives To estimate the level of acquired DR (ADR) and pre-treatment DR (PDR) across selected urban and rural sites in Southern Africa, in Mozambique. Methods We conducted two cross-sectional surveys among adult HIV patients (October 2017–18) assessing ADR and PDR. In the (ADR) survey, those on NNRTI-based first-line ART for ≥6 months were recruited (three sites). In the PDR survey, those ART-naive or experienced with ≥3 months of treatment interruption prior were enrolled (eight sites). Results Among 1113 ADR survey participants 83% were receiving tenofovir (TDF)/lamivudine (3TC)/efavirenz (EFV). The median time on ART was 4.5 years (Maputo) and 3.2 years (Tete), 8.3% (95% CI 6.2%-10.6%, Maputo) and 15.5% (Tete) had a VL ≥ 1000 copies/mL, among whom 66% and 76.4% had NNRTI+NRTI resistance, and 52.8% and 66.7% had 3TC+TDF-DR. Among those on TDF regimens, 31.1% (Maputo) and 42.2% (Tete) were still TDF susceptible, whereas 24.4% and 11.5% had TDF+zidovudine (ZDV)-DR. Among those on ZDV regimens, 25% and 54.5% had TDF+ZDV-DR. The PDR survey included 735 participants: NNRTI-PDR was 16.8% (12.0–22.6) (Maputo) and 31.2% (26.2–36.6) (Tete), with a higher proportion (≥50%) among those previously on ART affected by PDR. Conclusions In Mozambique, viral failure was driven by NNRTI and NRTI resistance, with NRTI DR affecting backbone options. NNRTI-PDR levels surpassed the WHO 10% ‘alert’ threshold. Replacing NNRTI first-line drugs is urgent, as is frequent viral load monitoring and resistance surveillance. Changing NRTI backbones when switching to second-line regimens may need reconsideration.
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Affiliation(s)
| | | | - S Fuentes
- Epicentre, Paris, France.,Médecins Sans Frontières Belgium, Mozambique Mission
| | - D Vaz
- Médecins Sans Frontières Switzerland, Mozambique Mission
| | - L Molfino
- Médecins Sans Frontières Switzerland, Mozambique Mission
| | | | - R M Cuco
- National Directorate of Public Health, Ministry of Health, Maputo, Mozambique
| | - A Couto
- Ministry of Health of Mozambique, Maputo, Mozambique
| | - S Lobo
- Health Directorate of Maputo, Maputo, Mozambique
| | | | | | | | - T Ellman
- Médecins Sans Frontières, Southern Africa Medical Unit (SAMU), South Africa
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Abstract
OBJECTIVE To identify any medical or public health rationale for claims that the time to act is now. DESIGN Pseudo-systematic review. DATA SOURCES PubMed. STUDY SELECTION Studies that included the claim "time is now" in the title, with or without exclamation marks. No language or date restriction was applied. RESULTS 512 articles were included for review. No relationship was identified between time to act and disease burden, severity, or specialty. Claims that the time to act was Christmas were almost entirely without basis. A clustering of claims that it is time to act in the first quarter of the year suggested a possible association with New Year's resolutions. CONCLUSIONS Now is as good a time as any.
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Affiliation(s)
- Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, University of Cape Town, Observatory 7925, South Africa
| | - Grania Brigden
- Department of Tuberculosis, International Union Against Tuberculosis and Lung Disease, Geneva, Switzerland
| | - Tom Ellman
- South African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Edward J Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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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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13
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Ndlovu Z, Massaquoi L, Bangwen NE, Batumba JN, Bora RU, Mbuaya J, Nzadi R, Ntabugi N, Kisaka P, Manciya G, Moudashirou R, Pangani H, Mangochi P, Makoko R, Van Laeken D, Kwitonda C, Ronoh Y, Kuwenyi K, Ortuno R, Mangwanya D, Zvidzai E, Mupepe T, Zinyowera S, Fajardo E, Ellman T. Diagnostic performance and usability of the VISITECT CD4 semi-quantitative test for advanced HIV disease screening. PLoS One 2020; 15:e0230453. [PMID: 32243435 PMCID: PMC7122771 DOI: 10.1371/journal.pone.0230453] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 03/01/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, a third of people starting antiretroviral therapy and majority of patients returning to HIV-care after disengagement, present with advanced HIV disease (ADH), and are at high risk of mortality. Simplified and more affordable point-of-care (POC) diagnostics are required to increase access to prompt CD4 cell count screening for ambulatory and asymptomatic patients. The Visitect CD4 Lateral Flow Assay (LFA) is a disposable POC test, providing a visually interpreted result of above or below 200 CD4cells/mm3. This study evaluated the diagnostic performance of this index test. METHODS Consenting patients above 18years of age and eligible for CD4 testing were enrolled in Nsanje district hospital (Malawi), Gutu mission hospital (Zimbabwe) and Centre hopitalier de Kabinda (DRC). A total of 708 venous blood samples were tested in the index test and in the BD FACSCount assay (reference test method) in the laboratories (Phase 1) to determine diagnostic accuracy. A total of 433 finger-prick (FP) samples were tested on the index test at POC by clinicians (Phase 2) and a self-completed questionnaire was administered to all testers to explore usability of the index test. RESULTS Among 708 patients, 67.2% were female and median CD4 was 297cells/mm3. The sensitivity of the Visitect CD4 LFA using venous blood in the laboratory was 95.0% [95% CI: 91.3-97.5] and specificity was 81.9% [95% CI: 78.2-85.2%]. Using FP samples, the sensitivity of the Visitect CD4 LFA was 98.3% [95% CI: 95.0-99.6] and specificity was 77.2% [95% CI: 71.6-82.2%]. Usability of the Visitect CD4 LFA was high across the study sites with 97% successfully completed tests. Due to the required specific multiple incubation and procedural steps during the Visitect CD4 LFA testing, few health workers (7/26) were not confident to manage testing whilst multi-tasking in their clinical work. CONCLUSIONS Visitect CD4 LFA is a promising test for decentralized CD4 screening in resource-limited settings, without access to CD4 testing and and it can trigger prompt management of patients with AHD. Lay health cadres should be considered to conduct Visitect CD4 LFA testing in PHCs as well as coordinating all other POC quality assurance.
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Affiliation(s)
- Zibusiso Ndlovu
- Southern Africa Medical Unit, Médecins Sans Frontiéres, Cape Town, South Africa
| | - Lamin Massaquoi
- Médecins Sans Frontiéres, Kinshasa, Democratic Republic of Congo
| | | | - John N. Batumba
- Médecins Sans Frontiéres, Kinshasa, Democratic Republic of Congo
| | - Rachelle U. Bora
- Médecins Sans Frontiéres, Kinshasa, Democratic Republic of Congo
| | - Joelle Mbuaya
- Médecins Sans Frontiéres, Kinshasa, Democratic Republic of Congo
| | - Roger Nzadi
- Médecins Sans Frontiéres, Kinshasa, Democratic Republic of Congo
| | - Nadine Ntabugi
- Médecins Sans Frontiéres, Kinshasa, Democratic Republic of Congo
| | - Patrick Kisaka
- Médecins Sans Frontiéres, Kinshasa, Democratic Republic of Congo
| | - Gisele Manciya
- Médecins Sans Frontiéres, Kinshasa, Democratic Republic of Congo
| | | | | | | | | | | | | | | | | | | | | | | | | | - Sekesai Zinyowera
- National Microbiology Reference Laboratory, Ministry of Health and Child Care, Harare, Zimbabwe
| | | | - Tom Ellman
- Southern Africa Medical Unit, Médecins Sans Frontiéres, Cape Town, South Africa
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14
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Chihana ML, Huerga H, Van Cutsem G, Ellman T, Goemaere E, Wanjala S, Masiku C, Szumilin E, Etard JF, Maman D, Davies MA. Distribution of advanced HIV disease from three high HIV prevalence settings in Sub-Saharan Africa: a secondary analysis data from three population-based cross-sectional surveys in Eshowe (South Africa), Ndhiwa (Kenya) and Chiradzulu (Malawi). Glob Health Action 2020; 12:1679472. [PMID: 31679482 PMCID: PMC6844432 DOI: 10.1080/16549716.2019.1679472] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Despite substantial progress in antiretroviral therapy (ART) scale up, some people living with HIV (PLHIV) continue to present with advanced HIV disease, contributing to ongoing HIV-related morbidity and mortality.Objective: We aimed to quantify population-level estimates of advanced HIV from three high HIV prevalence settings in Sub-Saharan Africa.Methods: Three cross-sectional surveys were conducted in (Ndhiwa (Kenya): September-November 2012), (Chiradzulu (Malawi): February-May 2013) and (Eshowe (South Africa): July-October 2013). Eligible individuals 15-59 years old who consented were interviewed at home followed by rapid HIV test and CD4 count test if tested HIV-positive. Advanced HIV was defined as CD4 < 200 cells/µl. We used logistic regression to identify patient characteristics associated with advanced HIV.Results: Among 18,991 (39.2% male) individuals, 4113 (21.7%) tested HIV-positive; 385/3957 (9.7% (95% Confidence Interval [CI]: 8.8-10.7)) had advanced HIV, ranging from 7.8% (95%CI 6.4-9.5) Chiradzulu (Malawi) to 11.8% (95%CI 9.8-14.2) Ndhiwa (Kenya). The proportion of PLHIV with advanced disease was higher among men 15.3% (95% CI 13.2-17.5) than women 7.5% (95%CI 6.6-8.6) p < 0.001. Overall, 62.7% of all individuals with advanced HIV were aware of their HIV status and 40.3% were currently on ART. Overall, 65.6% of individuals not on ART had not previously been diagnosed with HIV, while only 29.6% of those on ART had been on ART for ≥6 months. Individuals with advanced HIV disease were more likely to be men (adjusted Odds Ratio [aOR]; 2.1 (95%CI 1.7-2.6), and more likely not to be on ART (aOR; 1.7 (95%CI 1.3-2.1).Conclusion: In our study, about 1 in 10 PLHIV had advanced HIV with nearly 40% of them unaware of their HIV status. However, a substantial proportion of patients with advanced HIV were established on ART. Our findings suggest the need for a dual focus on alternative testing strategies to identify PLHIV earlier as well as improving ART retention.
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Affiliation(s)
- Menard L Chihana
- Epicentre, Cape Town, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Gilles Van Cutsem
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,MSF Southern Africa Medical Unit (SAMU), Cape Town, South Africa
| | - Tom Ellman
- MSF Southern Africa Medical Unit (SAMU), Cape Town, South Africa
| | - Eric Goemaere
- MSF Southern Africa Medical Unit (SAMU), Cape Town, South Africa
| | | | | | | | - Jean-Francois Etard
- International Research Unit (UMI), IRD UMI 233, INSERM U1175, Montpellier University, TransVIHMI, Montpellier, France
| | - David Maman
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,MSF Nairobi, Nairobi, Kenya
| | - Mary-Ann Davies
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Ford N, Geng E, Ellman T, Orrell C, Ehrenkranz P, Sikazwe I, Jahn A, Rabkin M, Ayisi Addo S, Grimsrud A, Rosen S, Zulu I, Reidy W, Lejone T, Apollo T, Holmes C, Kolling AF, Phate Lesihla R, Nguyen HH, Bakashaba B, Chitembo L, Tiriste G, Doherty M, Bygrave H. Emerging priorities for HIV service delivery. PLoS Med 2020; 17:e1003028. [PMID: 32059023 PMCID: PMC7021280 DOI: 10.1371/journal.pmed.1003028] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Nathan Ford and co-authors discuss global priorities in the provision of HIV prevention and treatment services.
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Affiliation(s)
- Nathan Ford
- Department HIV & Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
- * E-mail:
| | - Elvin Geng
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
| | - Tom Ellman
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Catherine Orrell
- Department of Medicine, Faculty of Health Sciences, Cape Town, South Africa
| | - Peter Ehrenkranz
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Miriam Rabkin
- ICAP, Columbia University Mailman School of Public Health, New York, New York, United States of America
| | | | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Isaac Zulu
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - William Reidy
- ICAP, Columbia University Mailman School of Public Health, New York, New York, United States of America
| | - Thabo Lejone
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
| | - Tsitsi Apollo
- Ministry of Health and Child Care Zimbabwe, Harare, Zimbabwe
| | - Charles Holmes
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Georgetown University, Washington, DC, United States of America
| | - Ana Francisca Kolling
- Department of Surveillance, Prevention and Control of STIs, HIV/AIDS and Viral Hepatitis, Ministry of Health, Brasilia, Brazil
| | | | - Huu Hai Nguyen
- Treatment and Care Department, Viet Nam Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam
| | | | | | - Ghion Tiriste
- Department HIV, World Health Organization, Addis Ababa, Ethiopia
| | - Meg Doherty
- Department HIV & Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Helen Bygrave
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
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Holmes CB, Rabkin M, Ford N, Preko P, Rosen S, Ellman T, Ehrenkranz P. Tailored HIV programmes and universal health coverage. Bull World Health Organ 2019; 98:87-94. [PMID: 32015578 PMCID: PMC6986224 DOI: 10.2471/blt.18.223495] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 06/08/2019] [Accepted: 09/06/2019] [Indexed: 12/15/2022] Open
Abstract
Improvements in geospatial health data and tailored human immunodeficiency virus (HIV) testing, prevention and treatment have led to greater microtargeting of the HIV response, based on location, risk, clinical status and disease burden. These approaches show promise for achieving control of the HIV epidemic. At the same time, United Nations Member States have committed to achieving broader health and development goals by 2030, including universal health coverage (UHC). HIV epidemic control will facilitate UHC by averting the need to commit ever-increasing resources to HIV services. Yet an overly targeted HIV response could also distort health systems, impede integration and potentially threaten broader health goals. We discuss current approaches to achieving both UHC and HIV epidemic control, noting potential areas of friction between disease-specific microtargeting and integrated health systems, and highlighting opportunities for convergence that could enhance both initiatives. Examples of these programmatic elements that could be better aligned include: improved information systems with unique identifiers to track and monitor individuals across health services and the life course; strengthened subnational data use; more accountable supply chains that supply a broad range of services; and strengthened community-based services and workforces. We argue that the response both to HIV and to broader health threats should use these areas of convergence to increase health systems efficiency and mitigate the harm of any potential decrease in health funding. Further investments in implementation and monitoring of these programme elements will be needed to make progress towards both UHC and HIV epidemic control.
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Affiliation(s)
- Charles B Holmes
- Georgetown University School of Medicine, 3900 Reservoir Rd NW, Washington, DC 20007, United States of America (USA)
| | - Miriam Rabkin
- ICAP at Columbia University, Mailman School of Public Health, New York, USA
| | - Nathan Ford
- Department of HIV and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Peter Preko
- ICAP at Columbia University, Mailman School of Public Health, New York, USA
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa
| | - Tom Ellman
- Medical Department, Médecins Sans Frontières, Cape Town, South Africa
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17
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Moore HA, Metcalf CA, Cassidy T, Hacking D, Shroufi A, Steele SJ, Duran LT, Ellman T. Investigating the addition of oral HIV self-tests among populations with high testing coverage - Do they add value? Lessons from a study in Khayelitsha, South Africa. PLoS One 2019; 14:e0215454. [PMID: 31048859 PMCID: PMC6497254 DOI: 10.1371/journal.pone.0215454] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 09/27/2018] [Accepted: 04/03/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction HIV self-testing (HIVST) offers a useful addition to HIV testing services and enables individuals to test privately. Despite recommendations to the contrary, repeat HIV testing is frequent among people already on anti-retroviral treatment (ART) and there are concerns that oral self-testing might lead to false negative results. A study was conducted in Khayelitsha, South Africa, to assess feasibility and uptake of HIVST and linkage-to-care following HIVST. Methods Participants were recruited at two health facilities from 1 March 2016 to 31 March 2017. People under 18 years, or with self-reported previously-diagnosed HIV infection, were excluded. Participants received an OraQuick Rapid HIV-1/2 Antibody kit, and reported their HIVST results by pre-paid text message (SMS) or by returning to the facility. Those not reporting within 7 days were contacted by phone. Electronic and paper-based clinical and laboratory records were retrospectively examined for all participants to identify known HIV outcomes, after matching for name, date of birth, and sex. These findings were compared with self-reported HIVST results where available. Results Of 639 participants, 401 (62.8%) self-reported a negative HIVST result, 27 (4.2%) a positive result, and 211 (33.0%) did not report. The record search identified that of the 401 participants self-reporting a negative HIVST result, 19 (4.7%) were already known to be HIV positive; of the 27 self-reporting positive, 12 (44%) were known HIV positive. Overall, records showed 57/639 (8.9%) were HIV positive of whom 39/57 (68.4%) had previously-diagnosed infection and 18/57 (31.6%) newly-diagnosed infection. Of the 428 participants who self-reported a result, 366 (85.5%) reported by SMS. Conclusions HIVST can improve HIV testing uptake and linkage to care. SMS is acceptable for reporting HIVST results but negative self-reports by participants may be unreliable. Use of HIVST by individuals on ART is frequent despite recommendations to the contrary and its implications need further consideration.
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Affiliation(s)
- Hazel Ann Moore
- Médecins Sans Frontières, Khayelitsha Project, Cape Town, South Africa
- * E-mail:
| | - Carol A. Metcalf
- Médecins Sans Frontières, Khayelitsha Project, Cape Town, South Africa
| | - Tali Cassidy
- Médecins Sans Frontières, Khayelitsha Project, Cape Town, South Africa
- Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Damian Hacking
- Médecins Sans Frontières, Khayelitsha Project, Cape Town, South Africa
| | - Amir Shroufi
- Médecins Sans Frontières, Cape Town, South Africa
| | | | | | - Tom Ellman
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
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18
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Chihana ML, Huerga H, Van Cutsem G, Ellman T, Wanjala S, Masiku C, Szumilin E, Etard JF, Davies MA, Maman D. Impact of "test and treat" recommendations on eligibility for antiretroviral treatment: Cross sectional population survey data from three high HIV prevalence countries. PLoS One 2018; 13:e0207656. [PMID: 30475865 PMCID: PMC6261019 DOI: 10.1371/journal.pone.0207656] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 11/05/2018] [Indexed: 12/02/2022] Open
Abstract
Background Latest WHO guidelines recommend starting HIV-positive individuals on antiretroviral therapy treatment (ART) regardless of CD4 count. We assessed additional impact of adopting new WHO guidelines. Methods We used data of individuals aged 15–59 years from three HIV population surveys conducted in 2012 (Kenya) and 2013 (Malawi and South Africa). Individuals were interviewed at home followed by rapid HIV and CD4 testing if tested HIV-positive. HIV-positive individuals were classified as “eligible for ART” if (i) had ever been initiated on ART or (ii) were not yet on ART but met the criteria for starting ART based on country’s guidelines at the time of the survey (Kenya–CD4< = 350 cells/μl and WHO Stage 3 or 4 disease, Malawi as for Kenya plus lifelong ART for all pregnant and breastfeeding women, South Africa as for Kenya plus ART for pregnant and breastfeeding women until cessation of breastfeeding). Findings Of 18,991 individuals who tested, 4,113 (21.7%) were HIV-positive. Using country’s ART eligibility guidelines at the time of the survey, the proportion of HIV-infected individuals eligible for ART was 60.0% (95% CI: 57.2–62.7) (Kenya), 73.4% (70.8–75.8) (South Africa) and 80.1% (77.3–82.6) (Malawi). Applying WHO 2013 guidelines (eligibility at CD4< = 500 and Option B+ for pregnant and breastfeeding women), the proportions eligible were 82.0% (79.8–84.1) (Kenya), 83.7% (81.5–85.6) (South Africa) and 87.6% (85.0–89.8) (Malawi). Adopting “test and treat” would mean a further 18.0% HIV-positive individuals (Kenya), 16.3% (South Africa) and 12.4% (Malawi) would become eligible. In all countries, about 20% of adolescents (aged 15–19 years), became eligible for ART moving from WHO 2013 to “test and treat” while no differences by sex were observed. Conclusion Countries that have already implemented 2013 WHO recommendations, the burden of implementing “test and treat” would be small. Youth friendly programmes to help adolescents access and adhere to treatment will be needed.
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Affiliation(s)
- Menard Laurent Chihana
- Centre for Infectious Diseases and Epidemiology, University of Cape Town, Cape Town, South Africa
- Epicentre, Cape Town, South Africa
- * E-mail:
| | | | - Gilles Van Cutsem
- Centre for Infectious Diseases and Epidemiology, University of Cape Town, Cape Town, South Africa
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Tom Ellman
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | | | | | | | - Jean Francois Etard
- Epicentre, Paris, France
- IRD UMI 233, INSERM U1175, Montpellier University, TransVIHMI, Montpellier, France
| | - Mary-Ann Davies
- Centre for Infectious Diseases and Epidemiology, University of Cape Town, Cape Town, South Africa
| | - David Maman
- Centre for Infectious Diseases and Epidemiology, University of Cape Town, Cape Town, South Africa
- Epicentre, Cape Town, South Africa
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Grebe E, Welte A, Johnson LF, van Cutsem G, Puren A, Ellman T, Etard JF, Huerga H. Population-level HIV incidence estimates using a combination of synthetic cohort and recency biomarker approaches in KwaZulu-Natal, South Africa. PLoS One 2018; 13:e0203638. [PMID: 30212513 PMCID: PMC6136757 DOI: 10.1371/journal.pone.0203638] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/26/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction There is a notable absence of consensus on how to generate estimates of population-level incidence. Incidence is a considerably more sensitive indicator of epidemiological trends than prevalence, but is harder to estimate. We used a novel hybrid method to estimate HIV incidence by age and sex in a rural district of KwaZulu-Natal, South Africa. Methods Our novel method uses an ‘optimal weighting’ of estimates based on an implementation of a particular ‘synthetic cohort’ approach (interpreting the age/time structure of prevalence, in conjunction with estimates of excess mortality) and biomarkers of ‘recent infection’ (combining Lag-Avidity, Bio-Rad Avidity and viral load results to define recent infection, and adapting the method for age-specific incidence estimation). Data were obtained from a population-based cross-sectional HIV survey conducted in Mbongolwane and Eshowe health service areas in 2013. Results Using the combined method, we find that age-specific HIV incidence in females rose rapidly during adolescence, from 1.33 cases/100 person-years (95% CI: 0.98,1.67) at age 15 to a peak of 5.01/100PY (4.14,5.87) at age 23. In males, incidence was lower, 0.34/100PY (0.00-0.74) at age 15, and rose later, peaking at 3.86/100PY (2.52-5.20) at age 30. Susceptible population-weighted average incidence in females aged 15-29 was estimated at 3.84/100PY (3.36-4.40), in males aged 15-29 at 1.28/100PY (0.68-1.50) and in all individuals aged 15-29 at 2.55/100PY (2.09-2.76). Using the conventional recency biomarker approach, we estimated HIV incidence among females aged 15-29 at 2.99/100PY (1.79-4.36), among males aged 15-29 at 0.87/100PY (0.22-1.60) and among all individuals aged 15-59 at 1.66/100PY (1.13-2.27). Discussion HIV incidence was very high in women aged 15-30, peaking in the early 20s. Men had lower incidence, which peaked at age 30. The estimates obtained from the hybrid method are more informative than those produced by conventional analysis of biomarker data, and represents a more optimal use of available data than either the age-continuous biomarker or synthetic cohort methods alone. The method is mainly useful at younger ages, where excess mortality is low and uncertainty in the synthetic cohort estimates is reasonably small. Conclusion Application of this method to large-scale population-based HIV prevalence surveys is likely to result in improved incidence surveillance over methods currently in wide use. Reasonably accurate and precise age-specific estimates of incidence are important to target better prevention, diagnosis and care strategies.
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Affiliation(s)
- Eduard Grebe
- DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- * E-mail:
| | - Alex Welte
- DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Leigh F. Johnson
- Centre for Infectious Diseases Epidemiology and Research (CIDER), University of Cape Town, Cape Town, South Africa
| | - Gilles van Cutsem
- Centre for Infectious Diseases Epidemiology and Research (CIDER), University of Cape Town, Cape Town, South Africa
- Médecins Sans Frontières, Cape Town, South Africa
| | - Adrian Puren
- National Institute for Communicable Diseases (NICD), National Health Laboratory Service, Johannesburg, South Africa
| | - Tom Ellman
- Médecins Sans Frontières, Cape Town, South Africa
| | - Jean-François Etard
- TransVIHMI, Institut de Recherche pour le Développement (IRD), Institut National de la Santé et de la Recherche Médicale (INSERM), Montpellier University, Montpellier, France
- Epicentre, Paris, France
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Huerga H, Van Cutsem G, Ben Farhat J, Puren A, Bouhenia M, Wiesner L, Dlamini L, Maman D, Ellman T, Etard JF. Progress towards the UNAIDS 90-90-90 goals by age and gender in a rural area of KwaZulu-Natal, South Africa: a household-based community cross-sectional survey. BMC Public Health 2018; 18:303. [PMID: 29499668 PMCID: PMC5833029 DOI: 10.1186/s12889-018-5208-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [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: 10/03/2017] [Accepted: 02/23/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The Joint United Nations Programme on HIV/AIDS (UNAIDS) has developed an ambitious strategy to end the AIDS epidemic. After eight years of antiretroviral therapy (ART) program we assessed progress towards the UNAIDS 90-90-90 targets in Mbongolwane and Eshowe, KwaZulu-Natal, South Africa. METHODS We conducted a cross-sectional household-based community survey using a two-stage stratified cluster probability sampling strategy. Persons aged 15-59 years were eligible. We used face-to-face interviewer-administered questionnaires to collect information on history of HIV testing and care. Rapid HIV testing was performed on site and venous blood specimens collected from HIV-positive participants for antiretroviral drug presence test, CD4 count and viral load. At the time of the survey the CD4 threshold for ART initiation was 350 cells/μL. We calculated progression towards the 90-90-90 UNAIDS targets by estimating three proportions: HIV positive individuals who knew their status (first 90), those diagnosed who were on ART (second 90), and those on ART who were virally suppressed (third 90). RESULTS We included 5649/6688 (84.5%) individuals. Median age was 26 years (IQR: 19-40), 62.3% were women. HIV prevalence was 25.2% (95% CI: 23.6-26.9): 30.9% (95% CI: 29.0-32.9) in women; 15.9% (95% CI: 14.0-18.0) in men. Overall progress towards the 90-90-90 targets was as follows: 76.4% (95% CI: 74.1-78.6) knew their status, 69.9% (95% CI: 67.0-72.7) of those who knew their status were on ART and 93.1% (95% CI: 91.0-94.8) of those on ART were virally suppressed. By sex, progress towards the 90-90-90 targets was: 79%-71%-93% among women; and 68%-68%-92% among men (p-values of women and men comparisons were < 0.001, 0.443 and 0.584 respectively). By age, progress was: 83%-75%-95% among individuals aged 30-59 years and 64%-58%-89% among those aged 15-29 years (p-values of age groups comparisons were < 0.001, < 0.001 and 0.011 respectively). CONCLUSIONS In this context of high HIV prevalence, significant progress has been achieved with regards to reaching the UNAIDS 90-90-90 targets. The third 90, viral suppression in people on ART, was achieved among women and men. However, gaps persist in HIV diagnosis and ART coverage particularly in men and individuals younger than 30 years. Achieving 90-90-90 is feasible but requires additional investment to reach youth and men.
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Affiliation(s)
- Helena Huerga
- Clinical Research, Epicentre, 8 rue Saint-Sabin, 75011 Paris, France
| | - Gilles Van Cutsem
- Medical Department, Médecins Sans Frontières, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Jihane Ben Farhat
- Clinical Research, Epicentre, 8 rue Saint-Sabin, 75011 Paris, France
| | - Adrian Puren
- National Institute for Communicable Diseases of the NHLS, Johannesburg, South Africa
| | - Malika Bouhenia
- Clinical Research, Epicentre, 8 rue Saint-Sabin, 75011 Paris, France
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Linda Dlamini
- Department of Health, District, Empangeni, Uthungulu, South Africa
| | - David Maman
- Clinical Research, Epicentre, 8 rue Saint-Sabin, 75011 Paris, France
| | - Tom Ellman
- Medical Department, Médecins Sans Frontières, Cape Town, South Africa
| | - Jean-François Etard
- Clinical Research, Epicentre, 8 rue Saint-Sabin, 75011 Paris, France
- IRD UMI 233, INSERM U1175, Université de Montpellier, Unité TransVIHMI, Montpellier, France
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Gils T, Bossard C, Verdonck K, Owiti P, Casteels I, Mashako M, Van Cutsem G, Ellman T. Stockouts of HIV commodities in public health facilities in Kinshasa: Barriers to end HIV. PLoS One 2018; 13:e0191294. [PMID: 29351338 PMCID: PMC5774776 DOI: 10.1371/journal.pone.0191294] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/01/2018] [Indexed: 11/22/2022] Open
Abstract
Stockouts of HIV commodities increase the risk of treatment interruption, antiretroviral resistance, treatment failure, morbidity and mortality. The study objective was to assess the magnitude and duration of stockouts of HIV medicines and diagnostic tests in public facilities in Kinshasa, Democratic Republic of the Congo. This was a cross-sectional survey involving visits to facilities and warehouses in April and May 2015. All zonal warehouses, all public facilities with more than 200 patients on antiretroviral treatment (ART) (high-burden facilities) and a purposive sample of facilities with 200 or fewer patients (low-burden facilities) in Kinshasa were selected. We focused on three adult ART formulations, cotrimoxazole tablets, and HIV diagnostic tests. Availability of items was determined by physical check, while stockout duration until the day of the survey visit was verified with stock cards. In case of ART stockouts, we asked the pharmacist in charge what the facility coping strategy was for patients needing those medicines. The study included 28 high-burden facilities and 64 low-burden facilities, together serving around 22000 ART patients. During the study period, a national shortage of the newly introduced first-line regimen Tenofovir-Lamivudine-Efavirenz resulted in stockouts of this regimen in 56% of high-burden and 43% of low-burden facilities, lasting a median of 36 (interquartile range 29-90) and 44 days (interquartile range 24-90) until the day of the survey visit, respectively. Each of the other investigated commodities were found out of stock in at least two low-burden and two high-burden facilities. In 30/41 (73%) of stockout cases, the commodity was absent at the facility but present at the upstream warehouse. In 30/57 (54%) of ART stockout cases, patients did not receive any medicines. In some cases, patients were switched to different ART formulations or regimens. Stockouts of HIV commodities were common in the visited facilities. Introduction of new ART regimens needs additional planning.
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Affiliation(s)
- Tinne Gils
- Médecins sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa
| | - Claire Bossard
- Médecins sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa
| | | | - Philip Owiti
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Ilse Casteels
- Médecins sans Frontières, Operational Centre Brussels, Kinshasa, DRC
| | - Maria Mashako
- Médecins sans Frontières, Operational Centre Brussels, Kinshasa, DRC
| | - Gilles Van Cutsem
- Médecins sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa
| | - Tom Ellman
- Médecins sans Frontières, Southern Africa Medical Unit, Cape Town, South Africa
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Decroo T, Telfer B, Dores CD, White RA, Santos ND, Mkwamba A, Dezembro S, Joffrisse M, Ellman T, Metcalf C. Effect of Community ART Groups on retention-in-care among patients on ART in Tete Province, Mozambique: a cohort study. BMJ Open 2017; 7:e016800. [PMID: 28801427 PMCID: PMC5629627 DOI: 10.1136/bmjopen-2017-016800] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [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: 01/16/2023] Open
Abstract
OBJECTIVES Estimate the effect of participation in Community ART Groups (CAG) versus individual care on retention-in-care (RIC) on antiretroviral therapy (ART). DESIGN Retrospective cohort study. SETTING High levels of attrition (death or loss-to-follow-up (LTFU) combined) on ART indicate that delivery models need to adapt in sub-Saharan Africa. In 2008, patients more than 6 months on ART began forming CAG, and took turns to collect ART refills at the health facility, in Tete Province, Mozambique,. PARTICIPANTS 2406 adult patients, retained in care for at least 6 months after starting ART, during the study period (date of CAG introduction at the health facility-30 April 2012). METHODS Data up to 30 April 2012 were collected from patient records at eight health facilities. Survival analysis was used to compare RIC among patients in CAG and patients in individual care, with joining a CAG treated as an irreversible time-dependent variable. Multivariable Cox regression was used to estimate the effect of CAG on RIC, adjusted for age, sex and health facility type and stratified by calendar cohort. RESULTS 12-month and 24-monthRIC from the time of eligibility were, respectively, 89.5% and 82.3% among patients in individual care and 99.1% and 97.5% among those in CAGs (p<0.0001). CAG members had a greater than fivefold reduction in risk of dying or being LTFU (adjusted HR: 0.18, 95% CI 0.11 to 0.29). CONCLUSIONS Among patients on ART, RIC was substantially better among those in CAGs than those in individual care. This study confirms that patient-driven ART distribution through CAGs results in higher RIC among patients who are stable on ART.
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Affiliation(s)
- Tom Decroo
- Mission Mozambique, Médecins Sans Frontières, Operational Center Brussels, Tete, Mozambique
| | - Barbara Telfer
- Mission Mozambique, Médecins Sans Frontières, Operational Center Brussels, Tete, Mozambique
| | - Carla Das Dores
- Direcção Provincial de Saúde, Ministério da Saude de Moçambique, Tete, Moçambique
| | - Richard A White
- Department of Infectious Disease Epidemiology and Modelling, Norwegian Institute of Public Health, Oslo, Norway
| | - Natacha Dos Santos
- Mission Mozambique, Médecins Sans Frontières, Operational Center Brussels, Tete, Mozambique
| | - Alec Mkwamba
- Mission Mozambique, Médecins Sans Frontières, Operational Center Brussels, Tete, Mozambique
| | - Sergio Dezembro
- Mission Mozambique, Médecins Sans Frontières, Operational Center Brussels, Tete, Mozambique
| | - Mariano Joffrisse
- Mission Mozambique, Médecins Sans Frontières, Operational Center Brussels, Tete, Mozambique
| | - Tom Ellman
- Southern Africa Medical Unit, South Africa, Médecins Sans Frontières, Operational Center Brussels, Cape Town, South Africa
| | - Carol Metcalf
- Southern Africa Medical Unit, South Africa, Médecins Sans Frontières, Operational Center Brussels, Cape Town, South Africa
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Blaizot S, Huerga H, Riche B, Ellman T, Shroufi A, Etard JF, Ecochard R. Combined interventions to reduce HIV incidence in KwaZulu-Natal: a modelling study. BMC Infect Dis 2017; 17:522. [PMID: 28747167 PMCID: PMC5530541 DOI: 10.1186/s12879-017-2612-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 04/04/2017] [Accepted: 07/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Combined prevention interventions, including early antiretroviral therapy initiation, may substantially reduce HIV incidence in hyperendemic settings. Our aim was to assess the potential short-term impact of combined interventions on HIV spreading in the adult population of Mbongolwane and Eshowe (KwaZulu-Natal, South Africa) using sex- and age-specific scenarios, and age-targeted interventions. METHODS A mathematical model was used with data on adults (15-59 years) from the Mbongolwane and Eshowe HIV Impact in Population Survey to compare the effects of various interventions on the HIV incidence rate. These interventions included increase in antiretroviral therapy (ART) coverage with extended eligibility criteria, increase in voluntary medical male circumcision (VMMC), and implementation of pre-exposure prophylaxis (PrEP) among women. RESULTS With no additional interventions to the ones in place at the time of the survey (ART at CD4 < 350 and VMMC), incidence will decrease by 24% compared to the baseline rate. The implementation of "ART at CD4<500" or "ART for all" would reduce further the incidence rate by additional 8% and 15% respectively by 4 years and 20% and 34% by 10 years. Impacts would be higher with age-targeted scenarios than without. CONCLUSIONS In Mbongolwane and Eshowe, implementation of the new South African guidelines, recommending ART initiation regardless of CD4 count, would accelerate incidence reduction. In this setting, combining these guidelines, VMMC, and PrEP among young women could be an effective strategy in reducing the incidence to low levels.
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Affiliation(s)
- Stéphanie Blaizot
- Service de Biostatistique, Hospices Civils de Lyon, F-69003 Lyon, France
- Université de Lyon, F-69000 Lyon, France
- Université Lyon 1, F-69100 Villeurbanne, France
- CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100 Villeurbanne, France
| | | | - Benjamin Riche
- Service de Biostatistique, Hospices Civils de Lyon, F-69003 Lyon, France
- Université de Lyon, F-69000 Lyon, France
- Université Lyon 1, F-69100 Villeurbanne, France
- CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100 Villeurbanne, France
| | - Tom Ellman
- Médecins Sans Frontières, Cape Town, South Africa
| | - Amir Shroufi
- Médecins Sans Frontières, Cape Town, South Africa
| | - Jean-François Etard
- Epicentre, F-75011 Paris, France
- IRD UMI 233, INSERM U1175, Université de Montpellier, Unité TransVIHMI, F-34000 Montpellier, France
| | - René Ecochard
- Service de Biostatistique, Hospices Civils de Lyon, F-69003 Lyon, France
- Université de Lyon, F-69000 Lyon, France
- Université Lyon 1, F-69100 Villeurbanne, France
- CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100 Villeurbanne, France
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Grimsrud A, Bygrave H, Doherty M, Ehrenkranz P, Ellman T, Ferris R, Ford N, Killingo B, Mabote L, Mansell T, Reinisch A, Zulu I, Bekker LG. Reimagining HIV service delivery: the role of differentiated care from prevention to suppression. J Int AIDS Soc 2016; 19:21484. [PMID: 27914186 PMCID: PMC5136137 DOI: 10.7448/ias.19.1.21484] [Citation(s) in RCA: 229] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/11/2016] [Accepted: 11/18/2016] [Indexed: 11/15/2022] Open
Affiliation(s)
- Anna Grimsrud
- International AIDS Society, Cape Town, South Africa;
| | | | - Meg Doherty
- World Health Organization, Geneva, Switzerland
| | | | - Tom Ellman
- Médecins Sans Frontières, Cape Town, South Africa
| | - Robert Ferris
- United States Agency for International Development, Washington, DC, USA
| | - Nathan Ford
- World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | | | - Lynette Mabote
- AIDS Rights Alliance of Southern Africa, Cape Town, South Africa
| | - Tara Mansell
- International AIDS Society, Cape Town, South Africa
| | - Annette Reinisch
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | - Isaac Zulu
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Linda-Gail Bekker
- International AIDS Society, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
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Martínez Pérez G, Cox V, Ellman T, Moore A, Patten G, Shroufi A, Stinson K, Van Cutsem G, Ibeto M. 'I Know that I Do Have HIV but Nobody Saw Me': Oral HIV Self-Testing in an Informal Settlement in South Africa. PLoS One 2016; 11:e0152653. [PMID: 27044006 PMCID: PMC4820175 DOI: 10.1371/journal.pone.0152653] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 03/17/2016] [Indexed: 12/02/2022] Open
Abstract
Reaching universal HIV-status awareness is crucial to ensure all HIV-infected patients access antiretroviral treatment (ART) and achieve virological suppression. Opportunities for HIV testing could be enhanced by offering self-testing in populations that fear stigma and discrimination when accessing conventional HIV Counselling and Testing (HCT) in health care facilities. This qualitative research aims to examine the feasibility and acceptability of unsupervised oral self-testing for home use in an informal settlement of South Africa. Eleven in-depth interviews, two couple interviews, and two focus group discussions were conducted with seven healthcare workers and thirteen community members. Thematic analysis was done concurrently with data collection. Acceptability to offer home self-testing was demonstrated in this research. Home self-testing might help this population overcome barriers to accepting HCT; this was particularly expressed in the male and youth groups. Nevertheless, pilot interventions must provide evidence of potential harm related to home self-testing, intensify efforts to offer quality counselling, and ensure linkage to HIV/ART-care following a positive self-test result.
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Affiliation(s)
| | - Vivian Cox
- Médecins Sans Frontières Khayelitsha, Cape Town, South Africa
| | - Tom Ellman
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Ann Moore
- Médecins Sans Frontières Khayelitsha, Cape Town, South Africa
| | - Gabriela Patten
- Médecins Sans Frontières Khayelitsha, Cape Town, South Africa
| | - Amir Shroufi
- Médecins Sans Frontières, Cape Town, South Africa
| | - Kathryn Stinson
- Médecins Sans Frontières Khayelitsha, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Maryrene Ibeto
- Médecins Sans Frontières Khayelitsha, Cape Town, South Africa
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Ford N, Shubber Z, Meintjes G, Grinsztejn B, Eholie S, Mills EJ, Davies MA, Vitoria M, Penazzato M, Nsanzimana S, Frigati L, O'Brien D, Ellman T, Ajose O, Calmy A, Doherty M. Causes of hospital admission among people living with HIV worldwide: a systematic review and meta-analysis. The Lancet HIV 2015; 2:e438-44. [DOI: 10.1016/s2352-3018(15)00137-x] [Citation(s) in RCA: 174] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 07/01/2015] [Accepted: 07/15/2015] [Indexed: 12/16/2022]
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Jobanputra K, Parker LA, Azih C, Okello V, Maphalala G, Kershberger B, Khogali M, Lujan J, Antierens A, Teck R, Ellman T, Kosgei R, Reid T. Factors associated with virological failure and suppression after enhanced adherence counselling, in children, adolescents and adults on antiretroviral therapy for HIV in Swaziland. PLoS One 2015; 10:e0116144. [PMID: 25695494 PMCID: PMC4335028 DOI: 10.1371/journal.pone.0116144] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [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: 08/24/2014] [Accepted: 12/03/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION This study explores factors associated with virological detectability, and viral re-suppression after enhanced adherence counselling, in adults and children on antiretroviral therapy (ART) in Swaziland. METHODS This descriptive study used laboratory data from 7/5/2012 to 30/9/2013, which were linked with the national ART database to provide information on time on ART and CD4 count; information on enhanced adherence counselling was obtained from file review in health facilities. Multivariable logistic regression was used to explore the relationship between viral load, gender, age, time on ART, CD4 count and receiving (or not receiving) enhanced adherence counselling. RESULTS From 12,063 patients undergoing routine viral load monitoring, 1941 (16%) had detectable viral loads. Children were more likely to have detectable viral loads (AOR 2.6, 95%CI 1.5-4.5), as were adolescents (AOR 3.2, 95%CI 2.2-4.8), patients with last CD4<350 cells/µl (AOR 2.2, 95%CI 1.7-2.9) or WHO Stage 3/4 disease (AOR 1.3, 95%CI 1.1-1.6), and patients on ART for longer (AOR 1.1, 95%CI 1.1-1.2). At retesting, 450 (54% of those tested) showed viral re-suppression. Children were less likely to re-suppress (AOR 0.2, 95%CI 0.1-0.7), as were adolescents (AOR 0.3, 95%CI 0.2-0.8), those with initial viral load> 1000 copies/ml (AOR 0.3, 95%CI 0.1-0.7), and those with last CD4<350 cells/µl (AOR 0.4, 95%CI 0.2-0.7). Receiving (or not receiving) enhanced adherence counselling was not associated with likelihood of re-suppression. CONCLUSIONS Children, adolescents and those with advanced disease were most likely to have high viral loads and least likely to achieve viral suppression at retesting; receiving adherence counselling was not associated with higher likelihood of viral suppression. Although the level of viral resistance was not quantified, this study suggests the need for ART treatment support that addresses the adherence problems of younger people; and to define the elements of optimal enhanced adherence support for patients of all ages with detectable viral loads.
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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 ART Program, Ministry of Health, Mbabane, Swaziland
| | - Velephi Okello
- Swaziland National ART Program, Ministry of Health, Mbabane, Swaziland
| | - Gugu Maphalala
- Swaziland National Reference Laboratory, Mbabane, Swaziland
| | | | - Mohammed Khogali
- Médecins Sans Frontières (Operational Research Unit), Luxembourg, Luxembourg
| | - Johnny Lujan
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Annick Antierens
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Roger Teck
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Tom Ellman
- Médecins Sans Frontières (Southern Africa Medical Unit), Cape Town, South Africa
| | - Rose Kosgei
- Médecins Sans Frontières (Operational Research Unit), Luxembourg, Luxembourg
| | - Tony Reid
- Médecins Sans Frontières (Operational Research Unit), Luxembourg, Luxembourg
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Affiliation(s)
- Tom Ellman
- From the Southern Africa Medical Unit, Médecins sans Frontières, Cape Town, South Africa
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Biot M, Saranchuk P, Ellman T, Bygrave H, Bemelmans M. Change to patient-centred terminology in tuberculosis: an important step, but what about the treatment strategies? [Correspondence]. Int J Tuberc Lung Dis 2012; 16:1559-60. [DOI: 10.5588/ijtld.12.0466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- M. Biot
- Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
| | - P. Saranchuk
- Médecins Sans Frontières, South African Medical Unit, Cape Town, South Africa
| | - T. Ellman
- Médecins Sans Frontières, South African Medical Unit, Cape Town, South Africa
| | - H. Bygrave
- Médecins Sans Frontières, South African Medical Unit, Cape Town, South Africa
| | - M. Bemelmans
- Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
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O'Brien DP, Venis S, Greig J, Shanks L, Ellman T, Sabapathy K, Frigati L, Mills C. Provision of antiretroviral treatment in conflict settings: the experience of Médecins Sans Frontières. Confl Health 2010; 4:12. [PMID: 20553624 PMCID: PMC2911421 DOI: 10.1186/1752-1505-4-12] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 06/17/2010] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Many countries ravaged by conflict have substantial morbidity and mortality attributed to HIV/AIDS yet HIV treatment is uncommonly available. Universal access to HIV care cannot be achieved unless the needs of populations in conflict-affected areas are addressed. METHODS From 2003 Médecins Sans Frontières introduced HIV care, including antiretroviral therapy, into 24 programmes in conflict or post-conflict settings, mainly in sub-Saharan Africa. HIV care and treatment activities were usually integrated within other medical activities. Project data collected in the Fuchia software system were analysed and outcomes compared with ART-LINC data. Programme reports and other relevant documents and interviews with local and headquarters staff were used to develop lessons learned. RESULTS In the 22 programmes where ART was initiated, more than 10,500 people were diagnosed with HIV and received medical care, and 4555 commenced antiretroviral therapy, including 348 children. Complete data were available for adults in 20 programmes (n = 4145). At analysis, 2645 (64%) remained on ART, 422 (10%) had died, 466 (11%) lost to follow-up, 417 (10%) transferred to another programme, and 195 (5%) had an unclear outcome. Median 12-month mortality and loss to follow-up were 9% and 11% respectively, and median 6-month CD4 gain was 129 cells/mm 3.Patient outcomes on treatment were comparable to those in stable resource-limited settings, and individuals and communities obtained significant benefits from access to HIV treatment. Programme disruption through instability was uncommon with only one program experiencing interruption to services, and programs were adapted to allow for disruption and population movements. Integration of HIV activities strengthened other health activities contributing to health benefits for all victims of conflict and increasing the potential sustainability for implemented activities. CONCLUSIONS With commitment, simplified treatment and monitoring, and adaptations for potential instability, HIV treatment can be feasibly and effectively provided in conflict or post-conflict settings.
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Affiliation(s)
- Daniel P O'Brien
- Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands
- Department of Infectious Diseases, Geelong Hospital, Geelong, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia
| | - Sarah Venis
- Manson Unit, Médecins Sans Frontières, London, UK
| | - Jane Greig
- Manson Unit, Médecins Sans Frontières, London, UK
| | - Leslie Shanks
- Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands
| | - Tom Ellman
- Manson Unit, Médecins Sans Frontières, London, UK
| | - Kalpana Sabapathy
- Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands
| | - Lisa Frigati
- Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands
- School of Child and Adolescent Health, Red Cross Childrens' Hospital, Capetown, South Africa
| | - Clair Mills
- Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands
- Te Kupenga Hauora Maori, Faculty of Medical and Health Sciences,University of Auckland, Auckland, New Zealand
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Yun O, Lima MA, Ellman T, Chambi W, Castillo S, Flevaud L, Roddy P, Parreño F, Albajar Viñas P, Palma PP. Feasibility, drug safety, and effectiveness of etiological treatment programs for Chagas disease in Honduras, Guatemala, and Bolivia: 10-year experience of Médecins Sans Frontières. PLoS Negl Trop Dis 2009; 3:e488. [PMID: 19582142 PMCID: PMC2700957 DOI: 10.1371/journal.pntd.0000488] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [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: 04/17/2009] [Accepted: 06/17/2009] [Indexed: 12/04/2022] Open
Abstract
Background Chagas disease (American trypanosomiasis) is a zoonotic or anthropozoonotic disease caused by the parasite Trypanosoma cruzi. Predominantly affecting populations in poor areas of Latin America, medical care for this neglected disease is often lacking. Médecins Sans Frontières/Doctors Without Borders (MSF) has provided diagnostic and treatment services for Chagas disease since 1999. This report describes 10 years of field experience in four MSF programs in Honduras, Guatemala, and Bolivia, focusing on feasibility protocols, safety of drug therapy, and treatment effectiveness. Methodology From 1999 to 2008, MSF provided free diagnosis, etiological treatment, and follow-up care for patients <18 years of age seropositive for T. cruzi in Yoro, Honduras (1999–2002); Olopa, Guatemala (2003–2006); Entre Ríos, Bolivia (2002–2006); and Sucre, Bolivia (2005–2008). Essential program components guaranteeing feasibility of implementation were information, education, and communication (IEC) at the community and family level; vector control; health staff training; screening and diagnosis; treatment and compliance, including family-based strategies for early detection of adverse events; and logistics. Chagas disease diagnosis was confirmed by testing blood samples using two different diagnostic tests. T. cruzi-positive patients were treated with benznidazole as first-line treatment, with appropriate counseling, consent, and active participation from parents or guardians for daily administration of the drug, early detection of adverse events, and treatment withdrawal, when necessary. Weekly follow-up was conducted, with adverse events recorded to assess drug safety. Evaluations of serological conversion were carried out to measure treatment effectiveness. Vector control, entomological surveillance, and health education activities were carried out in all projects with close interaction with national and regional programs. Results Total numbers of children and adolescents tested for T. cruzi in Yoro, Olopa, Entre Ríos, and Sucre were 24,471, 8,927, 7,613, and 19,400, respectively. Of these, 232 (0.9%), 124 (1.4%), 1,475 (19.4%), and 1,145 (5.9%) patients, respectively, were diagnosed as seropositive. Patients were treated with benznidazole, and early findings of seroconversion varied widely between the Central and South American programs: 87.1% and 58.1% at 18 months post-treatment in Yoro and Olopa, respectively; 5.4% by up to 60 months in Entre Ríos; and 0% at an average of 18 months in Sucre. Benznidazole-related adverse events were observed in 50.2% and 50.8% of all patients treated in Yoro and Olopa, respectively, and 25.6% and 37.9% of patients in Entre Ríos and Sucre, respectively. Most adverse events were mild and manageable. No deaths occurred in the treatment population. Conclusions These results demonstrate the feasibility of implementing Chagas disease diagnosis and treatment programs in resource-limited settings, including remote rural areas, while addressing the limitations associated with drug-related adverse events. The variability in apparent treatment effectiveness may reflect differences in patient and parasite populations, and illustrates the limitations of current treatments and measures of efficacy. New treatments with improved safety profiles, pediatric formulations of existing and new drugs, and a faster, reliable test of cure are all urgently needed. Chagas disease was discovered 100 years ago by the Brazilian physician Carlos Chagas. Predominantly affecting poor populations throughout Latin America, recognition and treatment of this parasitic disease are often neglected. Since 1999, the international medical humanitarian aid organization Médecins Sans Frontières (Doctors Without Borders) has offered diagnostic and therapeutic care for Chagas disease, and here we describe four of our programs in Honduras, Guatemala, and Bolivia, 1999–2008. The earliest programs focused on treating young children and in subsequent programs expanded up to 18 years of age. We identified six program components essential for project viability: information, education, and communication; vector control; health staff training; screening and diagnosis; treatment and compliance; and logistics. The number of children and adolescents screened for Chagas disease ranged from over 7,500 to nearly 25,000 in each program. Early analysis of cure rates ranged widely: from 87% and 58%, respectively, in Honduras and Guatemala, to 0%–5% in Bolivia. No deaths occurred in any of the programs, though drug-related side effects were observed in a quarter to half of all patients. Through our findings and experience, we discuss the feasibility, safety, and effectiveness of treatment programs for Chagas disease in resource-limited settings.
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Affiliation(s)
- Oliver Yun
- Médecins Sans Frontières/Doctors Without Borders, New York, New York, United States of America
| | - M. Angeles Lima
- Médecins Sans Frontières, Operational Center Barcelona-Athens (OCBA), Barcelona, Spain
- * E-mail:
| | - Tom Ellman
- Médecins Sans Frontières/Médicos Sin Fronteras, La Paz, Bolivia
| | - Wilma Chambi
- Médecins Sans Frontières/Médicos Sin Fronteras, La Paz, Bolivia
| | - Sandra Castillo
- Médecins Sans Frontières/Médicos Sin Fronteras, La Paz, Bolivia
| | - Laurence Flevaud
- Médecins Sans Frontières, Operational Center Barcelona-Athens (OCBA), Barcelona, Spain
| | - Paul Roddy
- Médecins Sans Frontières, Operational Center Barcelona-Athens (OCBA), Barcelona, Spain
| | - Fernando Parreño
- Médecins Sans Frontières, Operational Center Barcelona-Athens (OCBA), Barcelona, Spain
| | - Pedro Albajar Viñas
- Laboratory of Parasitological Diseases, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro, Brazil
| | - Pedro Pablo Palma
- Médecins Sans Frontières, Operational Center Barcelona-Athens (OCBA), Barcelona, Spain
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Culbert H, Tu D, O'Brien DP, Ellman T, Mills C, Ford N, Amisi T, Chan K, Venis S. HIV treatment in a conflict setting: outcomes and experiences from Bukavu, Democratic Republic of the Congo. PLoS Med 2007; 4:e129. [PMID: 17535100 PMCID: PMC1880839 DOI: 10.1371/journal.pmed.0040129] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Providing HIV care in conflict settings involves additional obstacles to those generally encountered in other resource-limited settings, say Heather Culbert and colleagues.
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O'Brien DP, Sauvageot D, Olson D, Schaeffer M, Humblet P, Pudjades M, Ellman T, Zachariah R, Szumilin E, Arnould L, Read T. Treatment Outcomes Stratified by Baseline Immunological Status among Young Children Receiving Nonnucleoside Reverse-Transcriptase Inhibitor-Based Antiretroviral Therapy in Resource-Limited Settings. Clin Infect Dis 2007; 44:1245-8. [PMID: 17407046 DOI: 10.1086/513433] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2006] [Accepted: 01/20/2007] [Indexed: 11/03/2022] Open
Abstract
A study of 568 children aged <5 years who commenced nonnucleoside reverse-transcriptase inhibitor-based antiretroviral therapy in resource-limited settings revealed good early outcomes. After 12 months of antiretroviral therapy, survival probability was 0.89 (95% confidence interval, 0.86-0.92), with no significant difference among children stratified on the basis of baseline immunological levels; 62% attained a CD4 cell percentage >25%, and 7% continued to have a CD4 cell percentage <15%.
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Chhin S, Harwell JI, Bell JD, Rozycki G, Ellman T, Barnett JM, Ward H, Reinert SE, Pugatch D. Etiology of chronic diarrhea in antiretroviral-naive patients with HIV infection admitted to Norodom Sihanouk Hospital, Phnom Penh, Cambodia. Clin Infect Dis 2006; 43:925-32. [PMID: 16941378 DOI: 10.1086/507531] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2005] [Accepted: 06/08/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Although both human immunodeficiency virus (HIV) infection and diarrhea are considerable problems in Cambodia, there have not been any studies to determine the history, clinical presentation, and etiology of chronic diarrhea in patients with HIV infection in Cambodia. In this article, we present a case-control study involving 40 HIV-infected patients with chronic diarrhea and 40 HIV-infected patients without diarrhea. METHODS Clinical, demographic, and laboratory data were collected. Stool samples were examined for parasites, including Cryptosporidium species (by partial acid-fast stain), bacterial pathogens, and rotavirus. Samples from 10 case patients and 10 control subjects were also analyzed for Cryptosporidium species by polymerase chain reaction-restriction fragment-length polymorphism. RESULTS The median CD4(+) cell count was 11.5 cells/mm(3). A potential pathogen was found in 30 case patients (75%) and 29 control subjects (72.5%). Cryptosporidium was the most common pathogen, present in 16 case patients (40%) and 20 control subjects (53.3%). The presence of Cryptosporidium was confirmed by polymerase chain reaction-restriction fragment-length polymorphism, with a prevalence of 40% in each of the 2 groups of 10 subjects who were enrolled for Cryptosporidium evaluation. CONCLUSIONS Subjects in this cohort had severe immunosuppression. The prevalence of pathogens, including Cryptosporidium, was extremely high but did not differ significantly between the case patients with diarrhea and the control subjects without diarrhea. Further studies are needed to examine factors associated with Cryptosporidium carriage and the natural history of asymptomatic infection.
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Affiliation(s)
- Senya Chhin
- Department of Infectious Diseases, Preah Bat Norodom Sihanouk Hospital, Phnom Penh, Cambodia
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Ellman T, Ford N. Scaling up antiretroviral treatment in resource-poor settings. Lancet 2006; 368:445-6. [PMID: 16890818 DOI: 10.1016/s0140-6736(06)69140-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ellman T. Special Volume on Reformulation, dedicated to the memory of Saul Amarel, 1928–2002. ARTIF INTELL 2005. [DOI: 10.1016/j.artint.2004.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Affiliation(s)
- Tom Ellman
- Médecins Sans Frontières, London WC1R 5DJ, UK.
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Beesley R, Filteau S, Tomkins A, Doherty T, Ayles H, Reid A, Ellman T, Parton S. Impact of acute malaria on plasma concentrations of transferrin receptors. Trans R Soc Trop Med Hyg 2000; 94:295-8. [PMID: 10975004 DOI: 10.1016/s0035-9203(00)90329-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The acute-phase response to infection alters the plasma concentrations of most biochemical measures of iron status, rendering assessment of status difficult. Soluble transferrin receptors (TfR) may be an exception but have not been examined longitudinally during the major metabolic and inflammatory changes which occur during clinical malaria. Blood samples were collected daily during hospitalization, and again at a follow-up 2-6 weeks after discharge, from adult, mainly European, patients (n = 49) who developed uncomplicated Plasmodium falciparum malaria following visits to endemic areas. Parasitaemia and plasma concentrations of ferritin, TfR, C-reactive protein (CRP), alpha 1-acid glycoprotein (AGP) and alpha 1-antichymotrypsin (ACT) were measured. The concentrations of CRP, AGP and ACT correlated highly (P < 0.001) with each other and with plasma ferritin, and were significantly higher (P < 0.05) at all time points in hospital compared to the follow-up. TfR concentration correlated negatively and significantly (P < 0.05) with AGP and CRP but not with ACT or ferritin, and was significantly lower (around 30%) at all time points in hospital compared to follow-up, although in only 1 subject did it ever fall outside the normal reference range. In areas where both iron deficiency and clinical episodes of malaria are common, plasma TfR values need to be interpreted cautiously as indicators of iron status.
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Affiliation(s)
- R Beesley
- Institute of Child Health, London, UK
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