Articles tagged as "Cameroon"

Increasing HIV-testing in men: what works?

Systematic review of strategies to increase men's HIV-testing in sub-Saharan Africa

Hensen B, Taoka S, Lewis JJ, Weiss HA, Hargreaves J. AIDS. 2014 Jul; DOI:10.1097/QAD.0000000000000395

Objective: This systematic review summarizes evidence on the effectiveness of strategies to increase men's HIV-testing in sub-Saharan Africa.

Methods: Medline, EmBase, Africa-Wide Information and Global Health were searched. Cluster and individually randomized trials evaluating interventions to increase the proportion of adults (≥15 years) testing for HIV were eligible if they were conducted in sub-Saharan Africa, included men in the study population, and reported HIV-testing data by sex. References were independently screened.

Findings: Of the 1 852 references, 15 papers including 16 trials were eligible. Trials were judged too heterogeneous to combine in meta-analysis. Three interventions invited men to attend antenatal care-based HIV-testing via pregnant partners, of which two showed a significant effect on partner-testing. One intervention invited men to HIV-test through pregnant partners and showed an increase in HIV-testing when it was offered in bars compared with health facilities. A trial of notification to partners of newly diagnosed HIV-positive people showed an increase in testing where notification was by healthcare providers compared with notification by the patient. Three interventions reached men already at health facilities and eight reported the effects of community-based HIV-testing. Mobile-testing had a significant effect on HIV-testing compared with standard voluntary counselling and testing. Home-based testing also had a significant effect, but reached smaller numbers of men than mobile-testing.

Discussion: Interventions to encourage HIV-testing can increase men's levels of HIV-testing. Community-based programmes in particular had a large effect on population levels of HIV-testing. More data on costs and potential population impact of these approaches over different time-horizons would aid policy-makers in planning resource allocation to increase male HIV-testing.

Abstract access 

Editor’s notes: Approaches to increase rates of HIV-testing among men are urgently needed as uptake of HIV-testing in men remains lower than in women across sub-Saharan Africa. This systematic review identified published randomised controlled trials evaluating the impact of programmes to increase HIV-testing among men in sub-Saharan Africa. Few programmes focus on men specifically but some, like mobile testing, can have a substantial effect on HIV testing compared with standard voluntary counselling and testing. In addition, to be of direct benefit to men, increased HIV-testing among men is likely to lead to increased uptake among women and improved adherence to prevention of mother-to-child transmission. To increase men’s HIV-testing at a population level, country and time-specific combinations of available strategies are likely to be required. Along with additional research to determine whether these strategies encourage repeat-testing by high-risk HIV-negative men.

HIV testing
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WHO clinical staging misses a significant proportion of antiretroviral therapy eligible individuals

Diagnostic accuracy of the WHO clinical staging system for defining eligibility for ART in sub-Saharan Africa: a systematic review and meta-analysis.

Munthali C, Taegtmeyer M, Garner PG, Lalloo DG, Squire SB, Corbett EL, Ford N, MacPherson P. J Int AIDS Soc. 2014 Jun 12;17:18932. doi: 10.7448/IAS.17.1.18932. eCollection 2014.

Introduction: The World Health Organization (WHO) recommends that HIV-positive adults with CD4 count ≤500 cells/mm3 initiate antiretroviral therapy (ART). In many countries of sub-Saharan Africa, CD4 count is not widely available or consistently used and instead the WHO clinical staging system is used to determine ART eligibility. However, concerns have been raised regarding its discriminatory ability to identify patients eligible to start ART. We therefore reviewed the accuracy of WHO stage 3 or 4 assessment in identifying ART eligibility according to CD4 count thresholds for ART initiation.

Methods: We systematically searched PubMed and Global Health databases and conference abstracts using a comprehensive strategy for studies that compared the Results of WHO clinical staging with CD4 count thresholds. Studies performed in sub-Saharan Africa and published in English between 1998 and 2013 were eligible for inclusion according to our predefined study protocol. Two authors independently extracted data and assessed methodological quality and risk of bias using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) tool. Summary estimates of sensitivity and specificity were derived for each CD4 count threshold and hierarchical summary receiver operator characteristic curves were plotted.

Results: Fifteen studies met the inclusion criteria, including 25 032 participants from 14 countries. Most studies assessed individuals attending ART clinics prior to treatment initiation. WHO clinical stage 3 or 4 disease had a sensitivity of 60% (95% CI: 45-73%, Q=914.26, p<0.001) and specificity of 73% (95% CI: 60-83%, Q=1439.43, p<0.001) for a CD4 threshold of ≤200 cells/mm3 (11 studies); sensitivity and specificity for a threshold of CD4 count ≤350 cells/mm3 were 45% (95% CI: 26-66%, Q=1607.31, p<0.001) and 85% (95% CI: 69-93%, Q=896.70, p<0.001), respectively (six studies). For the threshold of CD4 count ≤500 cells/mm3 sensitivity was 14% (95% CI: 13-15%) and specificity was 95% (95% CI: 94-96%) (one study).

Conclusions: When used for individual treatment decisions, WHO clinical staging misses a high proportion of individuals who are ART eligible by CD4 count, with sensitivity falling as CD4 count criteria rises. Access to accurate, accessible, robust and affordable CD4 count testing methods will be a pressing need for as long as ART initiation decisions are based on criteria other than seropositivity.

Abstract  Full-text [free] access  

Editor’s notes: This study highlights the major shortcomings of WHO clinical staging when identifying antiretroviral therapy (ART) eligible individuals, with decreasing sensitivity of clinical staging for eligibility at higher CD4 thresholds. There remains limited access to CD4 count testing in many settings in sub-Saharan Africa. The individual and public health benefit of earlier ART initiation will not be achieved unless strategies other than WHO clinical staging are implemented. Access to affordable, quality assured CD4 count testing in all ART initiation clinics may never be feasible in the most resource-constrained settings. Universal treatment, removing the need for CD4 count testing, may be the way to ensure that eligible individuals are started on ART in a timely way.

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Integrating HIV, malaria and diarrhoea prevention is far more efficient than vertical programmes

Scaling up integrated prevention campaigns for global health: costs and cost-effectiveness in 70 countries. 

Marseille E, Jiwani A, Raut A, Verguet S, Walson J, Kahn JG. BMJ Open. 2014 Jun 26;4(6):e003987. doi: 10.1136/bmjopen-2013-003987.

Objective: This study estimated the health impact, cost and cost-effectiveness of an integrated prevention campaign (IPC) focused on diarrhoea, malaria and HIV in 70 countries ranked by per capita disability-adjusted life-year (DALY) burden for the three diseases.

Methods: We constructed a deterministic cost-effectiveness model portraying an IPC combining counselling and testing, cotrimoxazole prophylaxis, referral to treatment and condom distribution for HIV prevention; bed nets for malaria prevention; and provision of household water filters for diarrhoea prevention. We developed a mix of empirical and modelled cost and health impact estimates applied to all 70 countries. One-way, multiway and scenario sensitivity analyses were conducted to document the strength of our findings. We used a healthcare payer's perspective, discounted costs and DALYs at 3% per year and denominated cost in 2012 US dollars.

Primary and secondary outcomes: The primary outcome was cost-effectiveness expressed as net cost per DALY averted. Other outcomes included cost of the IPC; net IPC costs adjusted for averted and additional medical costs and DALYs averted.

Results: Implementation of the IPC in the 10 most cost-effective countries at 15% population coverage would cost US$583 million over 3 years (adjusted costs of US$398 million), averting 8.0 million DALYs. Extending IPC programmes to all 70 of the identified high-burden countries at 15% coverage would cost an adjusted US$51.3 billion and avert 78.7 million DALYs. Incremental cost-effectiveness ranged from US$49 per DALY averted for the 10 countries with the most favourable cost-effectiveness to US$119, US$181, US$335, US$1 692 and US$8 340 per DALY averted as each successive group of 10 countries is added ordered by decreasing cost-effectiveness.

Conclusions: IPC appears cost-effective in many settings, and has the potential to substantially reduce the burden of disease in resource-poor countries. This study increases confidence that IPC can be an important new approach for enhancing global health.

Abstract  Full-text [free] access

Editor’s notes: Increasingly governments and policy makers are seeking to identify how to invest resources most effectively, to achieve multiple health and development outcomes. This paper presents a cost-effectiveness analysis of an integrated campaign to prevent diarrhoea, malaria and HIV.  

They developed a model to estimate the cost per disability adjusted life year (DALY) averted by this intervention, across 70 countries with high disease burden, assuming 15% coverage. The authors categorise countries by income level and their opportunity index (i.e. the opportunity to avert DALYs by having a high disease burden). The findings suggest that an integrated prevention campaign (IPC) could cost as little as US$7 per DALY averted in Guinea-Bissau, a low income, high opportunity country. As would be expected, the contribution of the different IPC components varied by country, depending on their relative disease burdens. This suggests that further focusing of activities within countries may further improve efficiency.

The model was also used to consider potential roll out strategies across counties. For this, countries were grouped into blocks of 10, and ordered with increasing incremental-cost effectiveness. The authors suggest that reaching the top 40 countries with IPC, even at just 15% coverage, could achieve far greater health benefits, with a substantially lower budget, than requested under PEPFAR for antiretroviral therapy alone.

This paper provides further evidence of the need for a more integrated approach to improve population health across disease areas.

Africa, Asia, Europe, Latin America
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Systematic review highlights gaps in depression research in sub-Saharan Africa

Reliability and validity of depression assessment among persons with HIV in sub-Saharan Africa: systematic review and meta-analysis.

Tsai AC. J Acquir Immune Defic Syndr. 2014 May 21. [Epub ahead of print]

Objectives: To systematically review the reliability and validity of instruments used to screen for major depressive disorder or assess depression symptom severity among persons with HIV in sub-Saharan Africa.

Design: Systematic review and meta-analysis.

Methods: A systematic evidence search protocol was applied to seven bibliographic databases. Studies examining the reliability and/or validity of depression assessment tools were selected for inclusion if they were based on data collected from HIV-positive adults in any African member state of the United Nations. Random-effects meta-analysis was employed to calculate pooled estimates of depression prevalence. In a subgroup of studies of criterion-related validity, the bivariate random-effects model was used to calculate pooled estimates of sensitivity and specificity.

Results: Of 1 117 records initially identified, I included 13 studies of 5 373 persons with HIV in 7 sub-Saharan African countries. Reported estimates of Cronbach's alpha ranged from 0.63-0.95, and analyses of internal structure generally confirmed the existence of a depression-like construct accounting for a substantial portion of variance. The pooled prevalence of probable depression was 29.5% (95% CI, 20.5-39.4), while the pooled prevalence of major depressive disorder was 13.9% (95% CI, 9.7-18.6). The Center for Epidemiologic Studies-Depression scale was the most frequently studied instrument, with a pooled sensitivity of 0.82 (95% CI, 0.73-0.87) for detecting major depressive disorder.

Conclusions: Depression screening instruments yielded relatively high false positive rates. Overall, few studies described the reliability and/or validity of depression instruments in sub-Saharan Africa.

Abstract access 

Editor’s notes: This is the first systematic review of depression screening and diagnostic instruments among HIV-positive people in sub-Saharan Africa. The depression treatment gap for people living with HIV in high-income countries is considerable, and is likely to be even greater in sub-Saharan Africa. The eligible studies in this review were geographically concentrated in southern and eastern Africa. Prevalence of depression overall was high, but was substantially lower among people who had initiated HIV treatment than among people who had not. Additionally, depression prevalence estimates were twice as high when using screening tools rather than diagnostic criteria, indicating a high false positivity rate. This systematic review highlights critical areas for future research, particularly in validating depression screening tools and in expanding investigation of HIV and depression co-morbidity beyond South Africa and Uganda.

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Overcoming logistical barriers to implementing viral load testing


Systematic review of the use of dried blood spots for monitoring HIV viral load and for early infant diagnosis.

Smit PW, Sollis KA, Fiscus S, Ford N, Vitoria M, Essajee S, Barnett D, Cheng B, Crowe SM, Denny T, Landay A, Stevens W, Habiyambere V, Perriens JH, Peeling RW. PLoS One. 2014 Mar 6;9(3):e86461. doi: 10.1371/journal.pone.0086461. eCollection 2014.

Background: Dried blood spots (DBS) have been used as alternative specimens to plasma to increase access to HIV viral load (VL) monitoring and early infant diagnosis (EID) in remote settings. We systematically reviewed evidence on the performance of DBS compared to plasma for VL monitoring and EID.

Methods and findings: Thirteen peer reviewed HIV VL publications and five HIV EID papers were included. Depending on the technology and the viral load distribution in the study population, the percentage of DBS samples that are within 0.5 log of VL in plasma ranged from 52-100%. Because the input sample volume is much smaller in a blood spot, there is a risk of false negatives with DBS. Sensitivity of DBS VL was found to be 78-100% compared to plasma at VL below 1 000 copies/ml, but this increased to 100% at a threshold of 5 000 copies/ml. Unlike a plasma VL test which measures only cell free HIV RNA, a DBS VL also measures proviral DNA as well as cell-associated RNA, potentially leading to false positive results when using DBS. The systematic review showed that specificity was close to 100% at DBS VL above 5 000 copies/ml, and this threshold would be the most reliable for predicting true virologic failure using DBS. For early infant diagnosis, DBS has a sensitivity of 100% compared to fresh whole blood or plasma in all studies.  

Conclusions: Although limited data are available for EID, DBS offer a highly sensitive and specific sampling strategy to make viral load monitoring and early infant diagnosis more accessible in remote settings. A standardized approach for sampling, storing, and processing DBS samples would be essential to allow successful implementation.

Abstract    Full-text [free] access 

Editor’s notes: The World Health Organization recommends that viral load monitoring is used to confirm early infant diagnoses of HIV and to monitor people on antiretroviral therapy for treatment failure. However, viral load monitoring is expensive, technically complex and requires good laboratory infrastructure and highly trained staff. As a result few countries in resource-limited settings have been able to implement these guidelines.

This systematic review evaluates the performance of dried blood spots as compared to plasma for measuring viral load. Dried blood spots (DBS) are an alternative sampling strategy which could be used to overcome some of the logistical barriers to the widespread implementation of viral load testing. They can be performed by lay workers as there is no need for phlebotomy. Whole blood from a finger or heel prick is placed directly onto filter paper and once dried they can be stored with desiccant and transferred to the central laboratory at room temperature. The results of this systematic review confirm that DBS offer a highly sensitive and specific sampling strategy for early infant diagnosis and for detecting virologic failure at a viral load threshold of      >5 000 copies/ml. However, the authors’ stress that in order to compare different methodologies, standardised protocols for sampling, storing and processing samples are needed. DBS do provide a very promising strategy for increasing access to viral load monitoring. However if we are to see an impact on outcomes, the roll out of DBS will need to be accompanied by robust systems to ensure timely turn-around-times for results. Staff training and support to ensure that appropriate action is taken following a raised viral load, are also a must.

Africa, Asia, Europe
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Do text messaging activities promote adherence to antiretroviral therapy?


Text message intervention designs to promote adherence to antiretroviral therapy (ART): a meta-analysis of randomized controlled trials

Finitsis, D. J. P., J. A. Johnson, B. PLoS One. 2014 Feb 5;9(2):e88166. doi: 10.1371/journal.pone.0088166. eCollection 2014.

Background: The efficacy of antiretroviral therapy depends on patient adherence to a daily medication regimen, yet many patients fail to adhere at high enough rates to maintain health and reduce the risk of transmitting HIV. Given the explosive global growth of cellular-mobile phone use, text-messaging interventions to promote adherence are especially appropriate. This meta-analysis synthesized available text messaging interventions to promote antiretroviral therapy adherence in people living with HIV.

Methods: We performed Boolean searches of electronic databases, hand searches of recent year conference abstracts and reverse searches. Included studies (1) targeted antiretroviral therapy adherence in a sample of people living with HIV, (2) used a randomized-controlled trial design to examine a text messaging intervention, and (3) reported at least one adherence measurement or clinical outcome.

Results: Eight studies, including 9 interventions, met inclusion criteria. Text-messaging interventions yielded significantly higher adherence than control conditions (OR = 1.39; 95% CI = 1.18, 1.64). Sensitivity analyses of intervention characteristics suggested that studies had larger effects when interventions (1) were sent less frequently than daily, (2) supported bidirectional communication, (3) included personalized message content, and (4) were matched to participants' antiretroviral therapy dosing schedule. Interventions were also associated with improved viral load and/or CD4+ count (k = 3; OR = 1.56; 95% CI = 1.11, 2.20).

Conclusions: Text-messaging can support antiretroviral therapy adherence. Researchers should consider the adoption of less frequent messaging interventions with content and timing that is individually tailored and designed to evoke a reply from the recipient. Future research is needed in order to determine how best to optimize efficacy.

Abstract Full-text [free] access

Editor’s notes: Adherence to antiretroviral therapy (ART) is crucial for good clinical outcomes and for reducing the risk of onward HIV transmission. In the last decade, there has been a massive increase in cellular phone ownership. This provides a promising and potentially cost-effective approach to improving ART adherence through short messaging services (SMS). The World Health Organization guidelines recommend using SMS as part of a package of activities to support adherence to ART.

This meta-analysis examined how SMS can be optimally used to promote successful adherence. Eight randomised controlled trials from the USA, Brazil, Kenya and Cameroon investigated nine types of SMS activities. Studies used multiple methods to measure adherence including self-report, electronic drug monitoring and pill counts. Overall, text messaging significantly improved the average adherence outcome. Only three of the eight studies used virologic suppression as an outcome measure; importantly these studies did show an improvement in adherence. The study highlighted the components of SMS activities that were associated with the most effect on adherence. These included less frequent messaging than daily, personalised message content, SMS matched to dosing schedules and bidirectional communication between the care provider and the participant.

In summary, SMS is a promising activity for supporting adherence, although the effect on adherence is modest.  Several questions remain to be answered, namely the optimum way of operationalising this as an adherence support activity, its sustainability and its cost-effectiveness (given the modest effect size). Finally, a major limitation of ART adherence studies is the common use of non-biological measures of adherence, which do not always reflect virologic suppression. Virologic suppression is the most persuasive outcome for evaluations of programmes to improve adherence. 

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Promising results from integrating depression treatment with HIV care in Cameroon

Feasibility, safety, acceptability, and preliminary efficacy of measurement-based care depression treatment for HIV patients in Bamenda, Cameroon.

Pence, B. W. G., B. N. Atashili, J. O'Donnell, J. K. Kats, D. Whetten, K. Njamnshi, A. K. Mbu, T. Kefie, C. Asanji, S. Ndumbe, P. AIDS Behav. 2014 Feb 21. [Epub ahead of print]

Depression affects 18-30 % of HIV-infected patients in Africa and is associated with greater stigma, lower antiretroviral adherence, and faster disease progression. However, the region's health system capacity to effectively identify and treat depression is limited. Task-shifting models may help address this large mental health treatment gap. Measurement-Based Care (MBC) is a task-shifting model in which a Depression Care Manager guides a non-psychiatric (e.g., HIV) provider in prescribing and managing antidepressant treatment. We adapted MBC for depressed HIV-infected patients in Cameroon and completed a pilot study to assess feasibility, safety, acceptability, and preliminary efficacy. We enrolled 55 participants; all started amitriptyline 25-50 mg daily at baseline. By 12 weeks, most remained at 50 mg daily (range 25-125 mg). Median (interquartile range) PHQ-9 depressive severity scores declined from 13 (12-16) (baseline) to 2 (0-3) (week 12); 87 % achieved depression remission (PHQ-9 <5) by 12 weeks. Intervention fidelity was high: HIV providers followed MBC recommendations at 96 % of encounters. Most divergences reflected a failure to increase dose when indicated. No serious and few bothersome side effects were reported. Most suicidality (prevalence 62 % at baseline; 8 % at 12 weeks) was either passive or low-risk. Participant satisfaction was high (100 %), and most participants (89 %) indicated willingness to pay for medications if MBC were implemented in routine care. The adapted MBC intervention demonstrated high feasibility, safety, acceptability, and preliminary efficacy in this uncontrolled pilot study. Further research should assess whether MBC could improve adherence and HIV outcomes in this setting.

Abstract access

Editor’s notes: Task sharing for mental health care services has been shown effective for the general population in several low-income settings. However, its effectiveness for an HIV-positive population remains in question. By supervising HIV physicians in the provision of depression care, there is increased access to a critical mental health service.  In addition, there are likely to be positive effects for HIV treatment outcomes. The results of this study provide compelling grounds for further research, specifically for a randomized control trial of the Measurement-Based Care treatment protocol.

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CD4 counts at antiretroviral therapy start rising globally, but could do better!

Immunodeficiency at the start of combination antiretroviral therapy in low-,  middle-, and high-income countries.

The IeDEA and ART Cohort Collaborations. J Acquir Immune Defic Syndr 2014 Jan 1;65(1):e8-e16. doi: 10.1097/QAI.0b013e3182a39979.

Objective: To describe the CD4 cell count at the start of combination antiretroviral therapy (cART) in low-income (LIC), lower middle-income (LMIC), upper middle-income (UMIC), and high-income (HIC) countries.

Methods: Patients aged 16 years or older starting cART in a clinic participating in a multicohort collaboration spanning 6 continents (International epidemiological Databases to Evaluate AIDS and ART Cohort Collaboration) were eligible. Multilevel linear regression models were adjusted for age, gender, and calendar year; missing CD4 counts were imputed.

Results: In total, 379 865 patients from 9 LIC, 4 LMIC, 4 UMIC, and 6 HIC were included. In LIC, the median CD4 cell count at cART initiation increased by 83% from 80 to 145 cells/µL between 2002 and 2009. Corresponding increases in LMIC, UMIC, and HIC were from 87 to 155 cells/µL (76% increase), 88 to 135 cells/µL (53%), and 209 to 274 cells/µL (31%). In 2009, compared with LIC, median counts were 13 cells/µL [95% confidence interval (CI): -56 to +30] lower in LMIC, 22 cells/µL (-62 to +18) lower in UMIC, and 112 cells/µL (+75 to +149) higher in HIC. They were 23 cells/µL (95% CI: +18 to +28 cells/µL) higher in women than men. Median counts were 88 cells/µL (95% CI: +35 to +141 cells/µL) higher in countries with an estimated national cART coverage >80%, compared with countries with <40% coverage.

Conclusions: Median CD4 cell counts at the start of cART increased 2000-2009 but remained below 200 cells/µL in LIC and MIC and below 300 cells/µL in HIC. Earlier start of cART will require substantial efforts and resources globally.

Abstract access 

Editor’s notes: In this multi-cohort analysis spanning six continents, median CD4 counts at initiation of combination antiretroviral therapy were substantially higher in high-income compared to low- or middle-income countries. Median CD4 counts at initiation increased between 2002 and 2009 in most countries studied, but these increases were greater in low- and middle-income than high-income countries and were greater among men than women. Baseline CD4 counts in low- and middle-income countries were higher among countries with national antiretroviral therapy coverage of 80% or above. Nevertheless, despite the massive scale-up of antiretroviral therapy in low-income countries since 2002, the increases in median CD4 count at the start of antiretroviral therapy have been modest. Substantial efforts and resources are needed to achieve earlier implementation of antiretroviral therapy globally.

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Point of Care CD4 testing can improve gaps in the treatment cascade

Impact of point-of-care CD4 testing on linkage to HIV care: a systematic review

Wynberg E, Cooke G, Shroufi A, Reid SD, Ford N.J Int AIDS Soc 2014 Jan 20;17(1):18809. doi: 10.7448/IAS.17.1.18809. eCollection 2014.

Introduction: Point-of-care testing for CD4 cell count is considered a promising way of reducing the time to eligibility assessment for antiretroviral therapy (ART) and of increasing retention in care prior to treatment initiation. In this review, we assess the available evidence on the patient and programme impact of point-of-care CD4 testing.

Methods: We searched nine databases and two conference sites (up until 26 October 2013) for studies reporting patient and programme outcomes following the introduction of point-of-care CD4 testing. Where appropriate, results were pooled using random-effects methods.

Results: Fifteen studies, mainly from sub-Saharan Africa, were included for review, providing evidence for adults, adolescents, children and pregnant women. Compared to conventional laboratory-based testing, point-of-care CD4 testing increased the likelihood of having CD4 measured [odds ratio (OR) 4.1, 95% CI 3.5-4.9, n=2] and receiving a CD4 result (OR 2.8, 95% CI 1.5-5.6, n=6). Time to being tested was significantly reduced, by a median of nine days; time from CD4 testing to receiving the result was reduced by as much as 17 days. Evidence for increased treatment initiation was mixed.

Discussion: The results of this review suggest that point-of-care CD4 testing can increase retention in care prior to starting treatment and can also reduce time to eligibility assessment, which may result in more eligible patients being initiated on ART.

Abstract   Full-text [free] access

Editor’s notes: A recent review from sub-Saharan Africa found that one quarter of patients are lost-to-care in the step between testing HIV positive and having a CD4 measurement done. The potential for point-of-care (PoC) CD4 testing to increase access to antiretroviral therapy (ART) is increasingly recognised. However, the effectiveness of PoC tests depends on effective implementation as well as technical accuracy. This comprehensive systematic review was undertaken to evaluate the programmatic impact of point-of-care (PoC) CD4 tests on the treatment cascade. It shows that compared with laboratory CD4 testing, the PoC tests can reduce time to eligibility assessment, retention in care prior to treatment initiation, and in some settings, increased initiation of ART upon eligibility. The review highlights some gaps in research in this area – all the 15 studies included were located in sub-Saharan Africa, only one of the studies included randomization, and few discussed training of staff on how to use the tests. Overall, this review adds to the evidence that PoC CD4 tests have a useful role to play in improving the treatment cascade. In particular, around time to eligibility assessment, but clearly needs to be used in conjunction with additional strategies to ensure successful linkage to care and retention in care.

HIV testing, HIV Treatment
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Large-scale partner notification of HIV is feasible in resource-poor settings

Scale-up and case-finding effectiveness of an HIV partner services program in Cameroon: an innovative HIV prevention intervention for developing countries.

Henley C, Forgwei G, Welty T, Golden M, Adimora A, Shields R, Muffih PT. Sex Transm Dis. 2013 Dec;40(12):909-14. doi: 10.1097/OLQ.0000000000000032.

Background: Partner services (PSs) are a long-standing component of HIV control programs in the United States and some parts of Europe. Small randomized trials suggest that HIV PS can be effective in identifying persons with undiagnosed HIV infection. However, the scalability and effectiveness of HIV PS in low-income countries are unknown.

Methods: We used data collected from 2009 to 2010 through a large HIV PS program in Cameroon to evaluate HIV PS in a developing country. HIV-positive index cases diagnosed in antenatal care, voluntary counseling and testing, and inpatient facilities were interviewed to collect information on their sexual partners. Partners were contacted via telephone or home visit to notify, test, and enroll those found to be HIV positive in medical care.

Results: Health advisors interviewed 1 462 persons with HIV infection during the evaluation period; these persons provided information about 1 607 sexual partners. Health advisors notified 1 347 (83.8%) of these partners, of whom 900 (66.8%) were HIV tested. Of partners tested, 451 (50.1%) were HIV positive, of whom 386 (85.6%) enrolled into HIV medical care. An average 3.2 index cases needed to be interviewed to identify 1 HIV case.

Conclusions: HIV PS can be successfully implemented in a developing country and is highly effective in identifying persons with HIV infection and linking them to care.

Abstract access 

Editor’s notes: Partner notification of HIV status is a way to increase uptake of testing, and uptake of and adherence to antiretroviral therapy (ART) through mutual disclosure and support. However, partner disclosure is challenging and not commonly implemented in high prevalence settings. This paper reports on the first large-scale study in Africa of the effectiveness of HIV partner services in identifying persons with undiagnosed HIV infection. Health advisors asked HIV-index cases to identify partners in the past three years – the index cases were assured that all information collected would be kept confidential and their identities would not be revealed. Of the 1 607 partners reported by HIV-positive index cases, most (92%) were notified by health advisors rather than the index case. Over half (56%) received HIV testing through the partner services, of whom 50% tested HIV positive and 86% of the HIV positive partners were enrolled into care. There were no reported cases of domestic violence resulting from the partner services. These findings demonstrate that it is possible to provide HIV partner services to a large number of persons diagnosed with HIV infection at antenatal clinics, voluntary counselling and testing services (VCT) and inpatient health facilities in sub-Saharan Africa. Further studies on the potential social harms and benefits associated with partner services, cost-effectiveness, and risk behaviour are needed.  

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