Articles tagged as "Malawi"

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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Retention on antiretroviral therapy with “Option B+”: the Malawi experience

Retention in care under universal antiretroviral therapy for HIV-infected pregnant and breastfeeding women ('Option B+') in Malawi.

Tenthani L, Haas AD, Tweya H, Jahn A, van Oosterhout JJ, Chimbwandira F, Chirwa Z, Ng'ambi W, Bakali A, Phiri S, Myer L, Valeri F, Zwahlen M, Wandeler G, Keiser O; Ministry of Health in Malawi and IeDEA Southern Africa. AIDS. 2014 Feb 20;28(4):589-98. doi: 10.1097/QAD.0000000000000143

Objective: To explore the levels and determinants of loss to follow-up (LTF) under universal lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women ('Option B+') in Malawi.

Design, setting, and participants: We examined retention in care, from the date of ART initiation up to 6 months, for women in the Option B+ program. We analysed nationwide facility-level data on women who started ART at 540 facilities (n = 21 939), as well as individual-level data on patients who started ART at 19 large facilities (n = 11 534).

Results: Of the women who started ART under Option B+ (n = 21 939), 17% appeared to be lost to follow-up 6 months after ART initiation. Most losses occurred in the first 3 months of therapy. Option B+ patients who started therapy during pregnancy were five times more likely than women who started ART in WHO stage 3/4 or with a CD4 cell count 350 cells/µl or less, to never return after their initial clinic visit [odds ratio (OR) 5.0, 95% confidence interval (CI) 4.2-6.1]. Option B+ patients who started therapy while breastfeeding were twice as likely to miss their first follow-up visit (OR 2.2, 95% CI 1.8-2.8). LTF was highest in pregnant Option B+ patients who began ART at large clinics on the day they were diagnosed with HIV. LTF varied considerably between facilities, ranging from 0 to 58%.

Conclusion: Decreasing LTF will improve the effectiveness of the Option B+ approach. Tailored interventions, like community or family-based models of care could improve its effectiveness.

 Abstract access 

 Editor’s notes: “Option B+” refers to the strategy of starting combination antiretroviral therapy (ART) for pregnant women who are HIV positive, and then continuing ART lifelong. This strategy has many advantages from a programmatic perspective, including maintaining the mother’s health and reducing the risk of transmission in future pregnancies and to HIV-negative partners. Implementation of option B+ has increased ART coverage among pregnant women in Malawi, an important positive outcome. However, the full benefits of this strategy will only be realised if women remain in care and sustain virologic suppression. These data on retention are therefore important for programme managers.

Some 17% of women who started antiretroviral therapy during pregnancy were lost to follow-up by six months. Women starting ART during pregnancy were almost five times more likely never to return after the first visit, compared to women starting ART for their own health (based on a CD4 count below 350 or WHO stage three or four). These women are of particular concern because their loss from programme likely reflects a missed opportunity to prevent HIV transmission to their children. Effective strategies to maximise retention in care need to be identified and implemented.

On a methodological note, in this analysis, loss to follow-up was defined as missing a visit by more than 60 days, whereas WHO recommends a cut-off of 90 days. This illustrates the need for ART programmes to report standardised outcomes in order to facilitate comparisons.  

Africa
Malawi
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Pervasive geographic and transportation-related barriers to HIV services use in sub-Saharan Africa

Impact of geographic and transportation-related barriers on HIV outcomes in sub-Saharan Africa: a systematic review.

Lankowski AJ, Siedner MJ, Bangsberg DR, Tsai AC. AIDS Behav. 2014 Feb 23. [Epub ahead of print]

Difficulty obtaining reliable transportation to clinic is frequently cited as a barrier to HIV care in sub-Saharan Africa (SSA). Numerous studies have sought to characterize the impact of geographic and transportation-related barriers on HIV outcomes in SSA, but to date there has been no systematic attempt to summarize these findings. In this systematic review, we summarized this body of literature. We searched for studies conducted in SSA examining the following outcomes in the HIV care continuum: (1) voluntary counseling and testing, (2) pre-antiretroviral therapy (ART) linkage to care, (3) loss to follow-up and mortality, and (4) ART adherence and/or viral suppression. We identified 34 studies containing 52 unique estimates of association between a geographic or transportation-related barrier and an HIV outcome. There was an inverse effect in 23 estimates (44 %), a null association in 26 (50 %), and a paradoxical beneficial impact in 3 (6 %). We conclude that geographic and transportation-related barriers are associated with poor outcomes across the continuum of HIV care.

Abstract

Editor’s notes: This systematic review focuses on the importance of structural barriers to uptake of HIV treatment and care. Specifically, these are the association between geographic and transportation-related barriers and poor outcomes among HIV positive persons. Most of the quantitative and qualitative evidence reviewed in this paper (from 66 studies in sub-Saharan Africa) support the authors’ hypothesis that geographic and transportation-related barriers contribute to poor outcomes in HIV-positive individuals at all points along the continuum of HIV care. These were indexed in terms of voluntary counselling and testing, pre- antiretroviral therapy linkage to care, loss to follow-up, and adherence and/or viral suppression. A lack of association between these barriers and HIV services use was more common in studies where the study had clear limitations. For example, the use of self-reported as opposed to objective measures of exposures, small sample sizes, and the lack of control for confounding variables. The study has important policy implications related to the decentralisation of HIV treatment and care services, point-of-care services delivery, the provision of transportation stipends, the simplification of management protocols, and the reduction in the frequency of follow up visits.

Africa
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Simplifying clinical antiretroviral therapy eligibility assessment

A novel community health worker tool outperforms WHO clinical staging for assessment of antiretroviral therapy eligibility in a resource-limited setting.

Macpherson P, Lalloo DG, Thindwa D, Webb EL, Squire SB, Chipungu GA, Desmond N, Makombe SD, Taegtmeyer M, Choko AT, Corbett EL. J Acquir Immune Defic Syndr. 2014 Feb 1;65(2):e74-8. doi: 10.1097/QAI.0b013e3182a20e74.

The accuracy of a novel community health worker antiretroviral therapy eligibility assessment tool was examined in community members in Blantyre, Malawi. Nurses independently performed World Health Organization (WHO) staging and CD4 counts. One hundred ten (55.6%) of 198 HIV-positive participants had a CD4 count of <350 cells per cubic millimeter. The community health worker tool significantly outperformed WHO clinical staging in identifying CD4 count of <350 cells per cubic millimeter in terms of sensitivity (41% vs. 19%), positive predictive value (75% vs. 68%), negative predictive values (53% vs. 47%), and area under the receiver-operator curve (0.62 vs. 0.54; P = 0.017). Reliance on WHO staging is likely to result in missed and delayed antiretroviral therapy initiation.

 Abstract access 

Editor’s notes: Antiretroviral Therapy (ART) eligibility assessment has been identified as one of the bottlenecks in the HIV care cascade that limits and/or delays progression of patients to starting ART. Laboratory-based CD4 count testing requires more than one visit and is unavailable in many settings. WHO staging is difficult and time-consuming for many health care workers to use. Simplified eligibility tools are needed to simplify both facility-based and community-based ART initiation. This study found that a clinical tool incorporating a series of simple questions had greater accuracy than WHO staging, for identifying those eligible for ART, when used by community health care workers in Malawi. 

Africa
Malawi
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HIV, antiretroviral therapy and presentation of TB

The effect of HIV and antiretroviral therapy on characteristics of pulmonary tuberculosis in northern Malawi: a cross-sectional study

Munthali L, Khan PY, Mwaungulu NJ, Chilongo F, Floyd S, Kayange M, Glynn JR, French N, Crampin AC. BMC Infect Dis. 2014 Feb 25;14(1):107. doi: 10.1186/1471-2334-14-107.

Background: HIV infection reduces the likelihood that individuals with pulmonary tuberculosis are smear positive and that they have cavitatory disease. Antiretroviral therapy (ART) may shift the pattern of disease to be more similar to that of HIV negative patients. This would aid diagnosis - which often depends on sputum smears - but would also increase infectiousness. We assessed the effect of HIV and ART on smear positivity and cavitatory disease in laboratory-confirmed pulmonary TB patients.

Methods: Three sputum samples were collected per pulmonary TB suspect and were examined using microscopy and culture. Chest radiographs were available for a subset of patients as part of another study. The effect of HIV and ART status on sputum smear positivity and lung cavitation were evaluated using multivariable logistic regression.

Results: Of 1 024 laboratory-confirmed pulmonary TB patients who were identified between January 2005 and December 2011, 766 had HIV and ART status available. Positive sputum smears were significantly more common among HIV negative individuals than HIV positive individuals (adjusted OR = 2.91, 95% CI 1.53 - 5.55). Compared to those HIV positive but not on ART, patients on ART were more likely to be smear positive (adjusted OR = 2.33, 95% CI 1.01 - 5.39) if they had been on ART ≤ 6 months, but only slightly more likely to be smear positive (adjusted OR = 1.43, 95% CI 0.68 - 2.99) if they were on ART > 6 months. HIV negative patients were more likely than HIV positive patients to have cavitatory disease (adjusted OR = 1.97, 95% CI 1.20 - 3.23). Patients on ART > 6 months had a slight increase in cavitatory disease compared to HIV positive patients not on ART (adjusted OR = 1.68, CI 0.78 - 3.63).

Conclusion: HIV infection is associated with less smear positivity and cavitation in pulmonary TB patients. Among HIV positive patients, the use of ART shifts the presentation of disease towards that seen in HIV-negative individuals, which facilitates diagnosis but which also could increase infectiousness.

Abstract Full-text [free] access

Editor’s notes: Attenuation of immune responses to Mycobacterium tuberculosis reduces pulmonary immunopathology in patients with HIV co-infection. This decreases the risk of pulmonary cavitation and of testing sputum smear positive on microscopy. Having confirmed these associations, this study further demonstrated that antiretroviral therapy (ART) reverses this association. ART was associated with increased risk of pulmonary cavitation and sputum smear-positivity, likely reflecting restoration of immunopathology. TB cases developing during ART may therefore be more infectious, which has important implications for TB transmission risk.

Avoid TB deaths
Africa
Malawi
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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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Provider-initiated partner notification of HIV is potentially cost-effective in sub-Saharan Africa

Cost-effectiveness of provider-based HIV partner notification in urban Malawi.

Rutstein SE, Brown LB, Biddle AK, Wheeler SB, Kamanga G, Mmodzi P, Nyirenda N, Mofolo I, Rosenberg NE, Hoffman IF, Miller WC. Health Policy Plan 2014 Jan;29(1):115-26. doi: 10.1093/heapol/czs140. Epub 2013 Jan 15.

Provider-initiated partner notification for HIV effectively identifies new cases of HIV in sub-Saharan Africa, but is not widely implemented. Our objective was to determine whether provider-based HIV partner notification strategies are cost-effective for preventing HIV transmission compared with passive referral. We conducted a cost-effectiveness analysis using a decision-analytic model from the health system perspective during a 1-year period. Costs and outcomes of all strategies were estimated with a decision-tree model. The study setting was an urban sexually transmitted infection clinic in Lilongwe, Malawi, using a hypothetical cohort of 5 000 sex partners of 3 500 HIV-positive index cases. We evaluated three partner notification strategies: provider notification (provider attempts to notify indexes' locatable partners), contract notification (index given 1 week to notify partners then provider attempts notification) and passive referral (index is encouraged to notify partners, standard of care). Our main outcomes included cost (US dollars) per transmission averted, cost per new case identified and cost per partner tested. Based on estimated transmissions in a 5 000-person cohort, provider and contract notification averted 27.9 and 27.5 new infections, respectively, compared with passive referral. The incremental cost-effectiveness ratio (ICER) was $3 560 per HIV transmission averted for contract notification compared with passive referral. Provider notification was more expensive and slightly more effective than contract notification, yielding an ICER of $51 421 per transmission averted. ICERs were sensitive to the proportion of partners not contacted, but likely HIV positive and the probability of transmission if not on antiretroviral therapy. The costs per new case identified were $36 (provider), $18 (contract) and $8 (passive). The costs per partner tested were $19 (provider), $9 (contract) and $4 (passive). We conclude that, in this population, provider-based notification strategies are potentially cost-effective for identifying new cases of HIV. These strategies offer a simple, effective and easily implementable opportunity to control HIV transmission.

Abstract access 

Editor’s notes: Partner notification of HIV status is a way to identify new HIV cases and prevent transmission. Provider-initiated partner notification has had success in high-income countries, but is not widely implemented in sub-Saharan Africa. This study is the first cost-effectiveness analysis of provider-initiated partner notification in sub-Saharan Africa. The authors use a decision-tree model based on trial data from Malawi, to identify the incremental cost-effectiveness of provider notification, and contract notification, against the current standard of care (passive referral). 

The findings of this study indicate that provider referral may be a cost-effective and affordable way to identify new HIV cases and link patients to care earlier. The cost per infection averted as compared to passive referral ($3 560 for contract notification and $4 106 for provider notification) compares favourably with that of using nevirapine for prevention of mother-to-child transmission of HIV. Further research into the possible costs of adverse outcomes from provider notification (including dissolution of partnership or violence) is needed.

Africa
Malawi
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Pre-antiretroviral therapy losses to care: no time to lose

Adults receiving HIV care before the start of antiretroviral therapy in sub-Saharan Africa: patient outcomes and associated risk factors.

Bastard M N, Szumilin N, Balkan E, Poulet E,  Pujades-Rodriguez, M. J Acquir Immune Defic Syndr 2013; 64(5):455-63

Background: Gaining understanding of the period before antiretroviral therapy (ART) is needed to improve treatment outcomes and to reduce HIV transmission. This study describes the cascade of enrollment in HIV care, pre-ART follow-up, and predictors of mortality and lost to follow-up (LTFU) before ART initiation.

Methods: We conducted a cohort study among HIV-infected adult patients not yet started on ART in 4 HIV sub-Saharan African programs. Patient follow-up began at enrollment and ended at the earliest of death, transfer-out, ART initiation, last visit date, or 60 months postenrollment. Risk factors for death and LTFU were investigated during the periods 0-6 and 6-60 months.

Results: A total of 55 789 patients (65.4% women) were included as follows: 44.2% in clinical stage 3 or 4, with median CD4 of 261 cells per microliter [interquartile range (IQR): 125-447]. Patient care started with a median of 3 days (IQR: 0-11) after HIV diagnosis, and 31 104 of 55 789 (55.8%) patients had CD4 counts performed within 1 month of enrollment. Of 47 283 patients with known ART eligibility status at enrollment, 36 969 (78.2%) patients required ART and 27 798 of 36 969 (75.7%) patients initiated therapy. Median follow-up was 2.5 months (IQR: 0.9-13.1). Mortality and LTFU rates were 3.9 per 100 person-years [95% confidence interval (CI): 3.7 to 4.1] and 28.3 per 100 person-years (95% CI: 27.8 to 28.8), respectively. Regardless of period, increased mortality and LTFU were associated with male, lower body mass index, advanced clinical stage, and lower CD4 cell count.

Conclusions: Short delays between HIV testing and care enrollment were observed in our HIV programs, but delays to determine ART eligibility were long. Interventions to initiate ART earlier, specifically targeted to men, are needed to improve patient retention in Africa.

Abstract access 

Editor’s notes: This large study from four sites in east Africa confirms the findings of other studies from sub-Saharan Africa which have documented substantial losses to care among patients during the care cascade, between the time of HIV testing and starting antiretroviral treatment (ART). The proportion of patients lost to follow-up was particularly striking and the strong association with disease stage suggests that this group may include many unascertained deaths. The need to strengthen and expedite each step of the care cascade is clear. 

Health care delivery
Africa
Kenya, Malawi, Uganda
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A multi-assay algorithm approach enables accurate estimation of HIV incidence from cross-sectional data

Development of Methods for Cross-Sectional HIV Incidence Estimation in a Large, Community Randomized Trial.

Laeyendecker O, Kulich M, Donnell D, Komárek A, Omelka M, Mullis CE, Szekeres G, Piwowar-Manning E, Fiamma A, Gray RH, Lutalo T, Morrison CS, Salata RA, Chipato T, Celum C, Kahle EM, Taha TE, Kumwenda NI, Karim QA, Naranbhai V, Lingappa JR, Sweat MD, Coates T, Eshleman SH. PLoS One. 2013 Nov 13;8(11):e78818. doi: 10.1371/journal.pone.0078818.

Background: Accurate methods of HIV incidence determination are critically needed to monitor the epidemic and determine the population level impact of prevention trials. One such trial, Project Accept, a Phase III, community-randomized trial, evaluated the impact of enhanced, community-based voluntary counseling and testing on population-level HIV incidence. The primary endpoint of the trial was based on a single, cross-sectional, post-intervention HIV incidence assessment.

Methods and findings: Test performance of HIV incidence determination was evaluated for 403 multi-assay algorithms [MAAs] that included the BED capture immunoassay [BED-CEIA] alone, an avidity assay alone, and combinations of these assays at different cutoff values with and without CD4 and viral load testing on samples from seven African cohorts (5,325 samples from 3,436 individuals with known duration of HIV infection [1 month to >10 years]). The mean window period (average time individuals appear positive for a given algorithm) and performance in estimating an incidence estimate (in terms of bias and variance) of these MAAs were evaluated in three simulated epidemic scenarios (stable, emerging and waning). The power of different test methods to detect a 35% reduction in incidence in the matched communities of Project Accept was also assessed. A MAA was identified that included BED-CEIA, the avidity assay, CD4 cell count, and viral load that had a window period of 259 days, accurately estimated HIV incidence in all three epidemic settings and provided sufficient power to detect an intervention effect in Project Accept.

Conclusions: In a Southern African setting, HIV incidence estimates and intervention effects can be accurately estimated from cross-sectional surveys using a MAA. The improved accuracy in cross-sectional incidence testing that a MAA provides is a powerful tool for HIV surveillance and program evaluation.

Abstract  Full-text [free] access

Editor’s notes: This study explores a cross-sectional method to determine occurrence of new HIV infections in a population. This was done as an alternative to longitudinal follow-up of individuals which is onerous; or using changes in estimates of existing infections as an indication of rates of new infections, which is potentially less accurate. The methods described here could be invaluable for monitoring the HIV epidemic and in evaluating prevention initiatives. Challenges in estimating HIV incidence include finding a suitable window period i.e., long enough in order to detect recent infection from a given sample, but not so long that chronic infections are also detected; and the impact of HIV viral load, treatment duration and other factors on serological assays. The investigators examined multiple approaches to combine existing tools in simulated epidemic scenarios. They validated their findings using samples with known duration of infection and available CD4 count blood samples, from a number of established HIV prevention trials. Testing algorithms that included multiple assays were superior to single serologic assays; the incidence estimates obtained using multiple assays had lower bias and better precision. The optimal method was a 4-assay multi-assay algorithm (MAA) which could detect the ratio between incidence in the intervention and control communities of Project Accept more accurately than would have been obtained with 6 monthly follow-up of a cohort of participants. The main limitation of note was that sub-type D infections were frequently misclassified. The authors recommend that further research for subtype D endemic areas is required. 

Epidemiology, HIV testing
Africa
Botswana, Kenya, Malawi, South Africa, Uganda, Zimbabwe
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An integrated investment approach for women’s and children’s health

Advancing social and economic development by investing in women's and children's health: a new Global Investment Framework.

Stenberg K, Axelson H, Sheehan P, Anderson I, Gülmezoglu AM, Temmerman M, Mason E, Friedman HS, Bhutta ZA, Lawn JE, Sweeny K, Tulloch J, Hansen P, Chopra M, Gupta A, Vogel JP, Ostergren M, Rasmussen B, Levin C, Boyle C, Kuruvilla S, Koblinsky M, Walker N, de Francisco A, Novcic N, Presern C, Jamison D, Bustreo F; on behalf of the Study Group for the Global Investment Framework for Women's Children's Health. Lancet. 2013 Nov 18. doi: S0140-6736(13)62231-X. pii: 10.1016/S0140-6736(13)62231-X. [Epub ahead of print]

A new Global Investment Framework for Women's and Children's Health demonstrates how investment in women's and children's health will secure high health, social, and economic returns. We costed health systems strengthening and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and socioeconomic returns of these investments. Increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending.

Abstract access 

Editor’s notes: Over the past 20 years there have been substantial gains in maternal and child health (MCH). However, much still needs to be done – assuming a continuation of current rates of progress, there would nevertheless be shortfalls in the achievement of MDG 4 and 5 targets. Especially in sub-Saharan Africa, HIV is an important underlying cause of maternal and child ill health. This paper models the costs and benefits of an accelerated action on MCH, including for HIV, the prevention of mother to child HIV transmission; first line treatment for pregnant women; cotrimoxazole for children, and the provision of paediatric antiretroviral therapy (ART). These HIV services are complemented by health systems strengthening; increased family planning provision; and packages for malaria, immunisation, and child health. The paper is interesting for many reasons, including both the breadth of its intervention focus, and the detailed modelling of the likely health, social and economic benefits of such investments.

Although the direct HIV related benefits are not described in detail in the main paper, it is likely that these result both from increased contraceptive use (prong 2 for preventing vertical HIV transmission), as well as ART and cotrimoxazole provision. It also illustrates the potential value of developing a cross-disease investment approach, as a means to ensure that services effectively respond to the breadth of women’s and children’s health needs. This more ‘joined up’, integrated perspective on strategies for health investment can support core investments in health systems strengthening. It can also potentially achieve important cross-disease synergies, e.g., ensuring that a child who has not acquired HIV at birth does not then die from malaria. 

Africa, Asia, Latin America, Oceania
Afghanistan, Angola, Azerbaijan, Bangladesh, Benin, Bolivia, Botswana, Brazil, Burkina Faso, Burundi, Cambodia, Cameroon, Central African Republic, Chad, China, Comoros, Congo, Côte d'Ivoire, Democratic People's Republic of Korea, Democratic Republic of the Congo, Djibouti, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guatemala, Guinea, Guinea-Bissau, Haiti, India, Indonesia, Iraq, Kenya, Kyrgyzstan, Lao People's Democratic Republic, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mexico, Morocco, Mozambique, Myanmar, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Peru, Philippines, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Solomon Islands, Somalia, South Africa, Sudan, Swaziland, Tajikistan, Togo, Turkmenistan, Uganda, United Republic of Tanzania, Uzbekistan, Viet Nam, Yemen, Zambia, Zimbabwe
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