Articles tagged as "Nigeria"

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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Linking cervical cancer prevention into infrastructure for HIV services in sub-Saharan Africa

Infrastructure requirements for human papillomavirus vaccination and cervical cancer screening in sub-Saharan Africa.

Sankaranarayanan R, Anorlu R, Sangwa-Lugoma G, Denny LA. Vaccine. 2013 Dec 29;31 Suppl 5:F47-52. doi: 10.1016/j.vaccine.2012.06.066.

The availability of both human papillomavirus (HPV) vaccination and alternative screening tests has greatly improved the prospects of cervical cancer prevention in sub-Saharan African (SSA) countries. The inclusion of HPV vaccine in the portfolio of new vaccines offered by the Global Alliance for Vaccines and Immunization (GAVI) to GAVI-eligible countries has vastly improved the chances of introducing HPV vaccination. Further investments to improve vaccine storage, distribution and delivery infrastructure and human resources of the Extended Programme of Immunization will substantially contribute to the faster introduction of HPV vaccination in SSA countries through both school- and campaign-based approaches. Alternative methods to cytology for the prevention of cervical cancer through the early detection and treatment of cervical cancer precursors have been extensively evaluated in the past 15 years, in Africa as well as in other low-resource settings. Visual inspection with 3-5% dilute acetic acid (VIA) and HPV testing are the two alternative screening methods that have been most studied, in both cross-sectional and randomised clinical trials. VIA is particularly suitable to low-resource settings; however, its efficacy in reducing cervical cancer is likely to be significantly lower than HPV testing. The introduction of VIA screening programmes will help develop the infrastructure that will, in turn, facilitate the introduction of affordable HPV testing in future. Links with the existing HIV/AIDS control programmes is another strategy to improve the infrastructure and screening services in SSA. Infrastructural requirements for an integrated approach aiming to vaccinate single-year cohorts of girls in the 9-13 years age-range and to screen women over 30 years of age using VIA or affordable rapid HPV tests are outlined in this manuscript.

Abstract access 

Editor’s notes: Infection with human papillomavirus (HPV) can lead to cervical cancer. HIV-positive women are more likely to acquire and have persistent HPV, so the high burden of HIV in sub-Saharan Africa (SSA) contributes to the burden of cervical cancer. This review article discusses the options for the prevention of cervical cancer in SSA. While this article is primarily focused on cervical cancer, it highlights the potential linkages of prevention activities with HIV/AIDS services with an emphasis on infrastructure to improve access to these services for women in SSA. The options for cervical cancer prevention in SSA include HPV vaccination, visual inspection tests, HPV DNA tests and cytology screening. These options and the infrastructure required for each are described in detail, and some of the barriers to delivery are highlighted. Treatment options are also described, including cryotherapy following visual inspection. 

Africa, Asia
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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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Intrauterine infections, but not obstetric complications, more common among pregnant women with HIV

HIV and the Risk of Direct Obstetric Complications: A Systematic Review and Meta-Analysis. 

Calvert C, Ronsmans C. PLoS One. 2013 Oct 4;8(10):e74848. doi:10.1371/journal.pone.0074848.

Background: Women of reproductive age in parts of sub-Saharan Africa are faced both with high levels of HIV and the threat of dying from the direct complications of pregnancy. Clinicians practicing in such settings have reported a high incidence of direct obstetric complications among HIV-infected women, but the evidence supporting this is unclear. The aim of this systematic review is to establish whether HIV-infected women are at increased risk of direct obstetric complications.

Methods and findings: Studies comparing the frequency of obstetric haemorrhage, hypertensive disorders of pregnancy, dystocia and intrauterine infections in HIV-infected and uninfected women were identified. Summary estimates of the odds ratio (OR) for the association between HIV and each obstetric complication were calculated through meta-analyses. In total, 44 studies were included providing 66 data sets; 17 on haemorrhage, 19 on hypertensive disorders, five on dystocia and 25 on intrauterine infections. Meta-analysis of the OR from studies including vaginal deliveries indicated that HIV-infected women had over three times the risk of a puerperal sepsis compared with HIV-uninfected women [pooled OR: 3.43, 95% confidence interval (CI): 2.00-5.85]; this figure increased to nearly six amongst studies only including women who delivered by caesarean (pooled OR: 5.81, 95% CI: 2.42-13.97). For other obstetric complications the evidence was weak and inconsistent.

Conclusions: The higher risk of intrauterine infections in HIV-infected pregnant and postpartum women may require targeted strategies involving the prophylactic use of antibiotics during labour. However, as the huge excess of pregnancy-related mortality in HIV-infected women is unlikely to be due to a higher risk of direct obstetric complications, reducing this mortality will require non obstetric interventions involving access to ART in both pregnant and non-pregnant women.

Abstract  Full-text [free] access

Editor’s notes: Women with HIV are thought to have a higher risk of adverse outcomes during pregnancy. This review is valuable in summarizing available data on this topic. Many of the included studies predated the wide availability of antiretroviral therapy. There was a clear association between HIV infection and intrauterine infections, but not with the other obstetric complications, e.g., obstetric haemorrhage, hypertensive disorders of pregnancy, dystocia, examined in the review. Considering individual conditions analysed, HIV infection was associated with antepartum haemorrhage, (but not postpartum haemorrhage). It was also found to be associated with pregnancy-induced hypertension (but not pre-eclampsia or eclampsia), and uterine rupture or prolonged labour (but not other complications of dystocia). The authors note that the studies were generally of low quality, and there were too few studies to examine the effect of antiretroviral therapy on these complications.  

Given the excess of intrauterine infections in women with HIV, the authors suggest that these might be preventable with prophylactic antibiotics. Overall, where causes of maternal mortality are documented, pregnant women with HIV are more likely to die of non-pregnancy related infections, than of obstetric complications. Specifically, non-pregnancy related infections are tuberculosis, pneumonia or meningitis. Pregnant women living with HIV need access to antenatal services and a skilled attendant at delivery. But, the top priority with respect to reducing maternal mortality is effective antiretroviral therapy.

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Patient expenditures for TB care are impoverishing and may prevent access to care

Household catastrophic payments for tuberculosis care in Nigeria: incidence, determinants, and policy implications for universal health coverage.

Ukwaja KN, Alobu I, Abimbola S, Hopewell PC. Infect Dis Poverty. 2013 Sep17;2(1):21. [Epub ahead of print]

Background: Studies on costs incurred by patients for tuberculosis (TB) care are limited as these costs are reported as averages, and the economic impact of the costs is estimated based on average patient/household incomes. Average expenditures do not represent the poor because they spend less on treatment compared to other economic groups. Thus, the extent to which TB expenditures risk sending households into, or further into, poverty and its determinants, is unknown. We assessed the incidence and determinants of household catastrophic payments for TB care in rural Nigeria.

Methods: Data used were obtained from a survey of 452 pulmonary TB patients sampled from three rural health facilities in Ebonyi State, Nigeria. Using household direct costs and income data, we analyzed the incidence of household catastrophic payments using, as thresholds, the traditional >10% of household income and the >=40% of non-food income, as recommended by the World Health Organization. We used logistic regression analysis to identify the determinants of catastrophic payments.

Results: Average direct household costs for TB were US$157 or 14% of average annual incomes. The incidence of catastrophic payment was 44%; with 69% and 15% of the poorest and richest household income-quartiles experiencing catastrophic activity, respectively. Independent determinants of catastrophic payments were: age >40 years (adjusted odds ratio [aOR] 3.9; 95% confidence interval [CI], 2.0, 7.8), male gender (aOR 3.0; CI 1.8, 5.2), urban residence (aOR 3.8; CI 1.9, 7.7), formal education (aOR 4.7; CI 2.5, 8.9), care at a private facility (aOR 2.9; 1.5, 5.9), poor household (aOR 6.7; CI 3.7, 12), household where the patient is the primary earner (aOR 3.8; CI 2.2, 6.6]), and HIV co-infection (aOR 3.1; CI 1.7, 5.6).

Conclusions: Current cost-lowering strategies are not enough to prevent households from incurring catastrophic out-of-pocket payments for TB care. Financial and social protection interventions are needed for identified at-risk groups, and community-level interventions may reduce inefficiencies in the care-seeking pathway. These observations should inform post-2015 TB strategies and influence policy-making on health services that are meant to be free of charge.

Abstract access 

Editor’s notes: Household health care expenditures can often push households into poverty. These payments, known as catastrophic payments, mean that households are giving up the consumption of basic goods and services to pay for health care.  This study uses individual level data on health care expenditures for TB services and income levels, to examine the extent to which TB involves catastrophic payments in Nigeria.  Although TB services are subsidized and supposed to be free, this survey confirms this is not the case with patients paying most frequently for drugs, laboratory tests and transport.   Of particular concern is the high level of pre-diagnostic costs; that the poor are more vulnerable and the situation is exacerbated for those with HIV co-infection. The findings are important for policy makers trying to improve access to TB care, HIV care and access to health care in general. They emphasize the importance of prepayment schemes to facilitate access to health care when individuals are at their most in need.  

Africa
Nigeria
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Scope for improvements to the UNAIDS model of Modes of Transmission

Can the UNAIDS modes of transmission model be improved?: a comparison of the original and revised model projections using data from a setting in West Africa.

Prudden HJ, Watts CH, Vickerman P, Bobrova N, Heise L, Ogungbemi MK, Momah A,  Blanchard JF, Foss AM. AIDS. 2013 Aug 6. [Epub ahead of print]

Objective:  The UNAIDS Modes of Transmission Model (MoT) is a user-friendly model, developed to predict the distribution of new HIV infections among different subgroups. The model has been used in 29 countries to guide interventions. However, there is the risk that the simplification inherent in the MoT produces misleading findings. Using input data from Nigeria, we compare projections from the MoT with those from a revised model that incorporates additional heterogeneity.

Methods:  We revised the MoT to explicitly incorporate brothel and street-based sex-work, transactional sex, and HIV-discordant couples. Both models were parameterized using behavioural and epidemiological data from Cross River State, Nigeria. Model projections were compared, and the robustness of the revised model projections to different model assumptions, was investigated.

Results:  The original MoT predicts 21% of new infections occur in most-at-risk-populations (MARPs), compared with 45% (40-75%, 95% Crl) once additional heterogeneity and updated parameterization is incorporated. Discordant couples, a subgroup previously not explicitly modelled, are predicted to contribute a third of new HIV infections. In addition, the new findings suggest that women engaging in transactional sex may be an important but previously less recognised risk group, with 16% of infections occurring in this subgroup.

Conclusion:  The MoT is an accessible model that can inform intervention priorities. However, the current model may be potentially misleading, with our comparisons in Nigeria suggesting that the model lacks resolution, making it challenging for the user to correctly interpret the nature of the epidemic. Our findings highlight the need for a formal review of the MoT.

Abstract access

Editor’s notes: This innovative study modifies the UNAIDS Modes of Transmission (MoT) model, which is used to estimate the distribution of new HIV infections in different population subgroups, with the findings being used to prioritize interventions. The revised model incorporates subgroups to the original population groupings – for example, the category of “female sex workers” is further divided into “brothel based” and “non-brothel based” sex workers; and inclusion of “transactional sex” and discordant couples.  The addition of new categories means that this revised model requires more data. The revised model changed the authors’ conclusions about the epidemic in the example setting of Cross River State, Nigeria, suggesting that the original MoT model may underestimate the importance of different vulnerable groups, including girls involved in transactional sex.  Overall, the paper suggests a need to review the MoT model to assess whether further refinement would improve the reliability of the model projections. The HIV Modelling Consortium is currently working on a revision of the MoT model.

Africa
Nigeria
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Better virological outcomes with efavirenz compared to nevirapine

Outcomes for efavirenz versus nevirapine-containing regimens for treatment of HIV-1 infection: a systematic review and meta-analysis.

Pillay P, Ford N, Shubber Z, Ferrand RA., PLoS One. 2013 Jul 22;8(7):e68995. doi: 10.1371/journal.pone.0068995. Print 2013

Introduction: There is conflicting evidence and practice regarding the use of the non-nucleoside reverse transcriptase inhibitors (NNRTI) efavirenz (EFV) and nevirapine (NVP) in first-line antiretroviral therapy (ART).

Methods: We systematically reviewed virological outcomes in HIV-1 infected, treatment-naive patients on regimens containing EFV versus NVP from randomised trials and observational cohort studies. Data sources include PubMed, Embase, the Cochrane Central Register of Controlled Trials and conference proceedings of the International AIDS Society, Conference on Retroviruses and Opportunistic Infections, between 1996 to May 2013. Relative risks (RR) and 95% confidence intervals were synthesized using random-effects meta-analysis. Heterogeneity was assessed using the I(2) statistic, and subgroup analyses performed to assess the potential influence of study design, duration of follow up, location, and tuberculosis treatment. Sensitivity analyses explored the potential influence of different dosages of NVP and different viral load thresholds.

Results: Of 5011 citations retrieved, 38 reports of studies comprising 114 391 patients were included for review. EFV was significantly less likely than NVP to lead to virologic failure in both trials (RR 0.85 [0.73-0.99] I(2) = 0%) and observational studies (RR 0.65 [0.59-0.71] I(2) = 54%). EFV was more likely to achieve virologic success than NVP, though marginally significant, in both randomised controlled trials (RR 1.04 [1.00-1.08] I(2) = 0%) and observational studies (RR 1.06 [1.00-1.12] I(2) = 68%).

Conclusion: EFV-based first line ART is significantly less likely to lead to virologic failure compared to NVP-based ART. This finding supports the use of EFV as the preferred NNRTI in first-line treatment regimen for HIV treatment, particularly in resource limited settings.

Abstract  Full-text [free] access

Editor’s notes: Efavirenz and nevirapine are key antiretroviral agents, particularly in resource-limited settings. Nevirapine has been widely used, for reasons including safety during pregnancy and lower cost, despite lower potency and a higher risk of hepatotoxicity and severe allergic reactions, than with efavirenz. This article summarizes data on virological outcomes from clinical trials and observational cohort studies comparing efavirenz and nevirapine. The finding that efavirenz is associated with slightly better virological outcomes is not surprising but it is valuable to have the available data summarised. The result, along with recent recommendations allowing efavirenz to be taken throughout pregnancy, and price reductions, supports the move towards efavirenz-based fixed drug combinations as first-line antiretroviral treatment in resource-limited settings.

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Reproductive rights of women living with HIV

Community attitudes towards childbearing and abortion among HIV-positive women in Nigeria and Zambia.

Kavanaugh ML, Moore AM, Akinyemi O, Adewole I, Dzekedzeke K, Awolude O, Arulogun O. Cult Health Sex. 2013 Feb;15(2):160-74. doi: 10.1080/13691058.2012.745271. Epub 2012 Nov 23

Although stigma towards HIV-positive women for both continuing and terminating a pregnancy has been documented, to date few studies have examined relative stigma towards one outcome versus the other. This study seeks to describe community attitudes towards each of two possible elective outcomes of an HIV-positive woman's pregnancy - induced abortion or birth - to determine which garners more stigma and document characteristics of community members associated with stigmatising attitudes towards each outcome. Data come from community-based interviews with reproductive-aged men and women, 2401 in Zambia and 2452 in Nigeria. Bivariate and multivariate analyses revealed that respondents from both countries overwhelmingly favoured continued childbearing for HIV-positive pregnant women, but support for induced abortion was slightly higher in scenarios in which anti-retroviral therapy (ART) was unavailable. Zambian respondents held more stigmatising attitudes towards abortion for HIV-positive women than did Nigerian respondents. Women held more stigmatising attitudes towards abortion for HIV-positive women than men, particularly in Zambia. From a sexual and reproductive health and rights perspective, efforts to assist HIV-positive women in preventing unintended pregnancy and to support them in their pregnancy decisions when they do become pregnant should be encouraged in order to combat the social stigma documented in this paper.

Abstract access 

Editor’s notes: Women’s rights to make reproductive health choices extend fully to women living with HIV. The World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the Office of the High Commissioner on Human Rights (OHCHR) all affirm the reproductive rights of HIV-positive individuals to choose between continuing and terminating a pregnancy, calling for access to safe abortion services in countries where it is legal for individuals who choose the latter option. This study primarily focused on attitudes towards continued childbearing versus induced abortion in two relatively high prevalence countries, in particular in contexts where induced abortion is not generally viewed favorably. However it does reflect the continued interest overall in childbearing regardless of HIV status for many women. Interestingly, the findings also indicated greater favorability towards a continuation of pregnancy for women on ART – perhaps reflecting a growing understanding that effective PMTCT interventions significantly lower the risk of vertical HIV transmission.

Africa
Nigeria, Zambia
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Comparing adverse effects of nevirapine and efavirenz

Adverse events associated with nevirapine and efavirenz-based first-line antiretroviral therapy: a systematic review and meta-analysis.

Shubber Z, Calmy A, Andrieux-Meyer I, Vitoria M, Renaud-Thery F, Shaffer N, Hargreaves S, Mills EJ, Ford N. AIDS. 2013 Jan 22. [Epub ahead of print]

Since 2002, the World Health Organization has recommended either nevirapine (NVP) or efavirenz (EFV) as part of first-line antiretroviral therapy. These two drugs are known to have differing toxicity profiles, but the clinical importance of these toxicities overall is not well established. The authors systematically reviewed adverse events among treatment-naïve HIV-positive adults and children receiving either NVP or EFV as part of first-line antiretroviral therapy. The primary outcome was drug discontinuation as a result of any adverse event; specific toxicities were evaluated as secondary outcomes. Point estimates and 95% confidence intervals (95% CI) were calculated and proportions and odds ratios (OR) pooled using fixed-effects meta-analysis. Data was reviewed on 26446 adult and 3975 children from 8 randomized trials and 26 prospective cohorts. Overall, adults on NVP were more than two times more likely to discontinue treatment due to any adverse event compared to patients on EFV (OR 2.2, 95%CI 1.9-2.6). Severe hepatotoxicity (OR 3.3, 95%CI 2.5-4.2), severe skin toxicity (OR 3.9, 95%CI 2.5-5.4), and severe hypersensitivity reactions (OR 2.4, 95%CI 1.9-2.9) were more likely to occur among patients on NVP. Patients receiving EFV were more likely to experience severe CNS-events (OR 3.4, 95%CI 2.1-5.4). Similar associations were seen in children. Compared to NVP, EFV is associated with a lower frequency of severe adverse events, in particular treatment discontinuations. This finding supports a move towards efavirenz-based therapy as the preferred first-line treatment regimen for HIV treatment within a public health approach.

Abstract access 

Editor’s notes: As increased progress is being made towards universal access to treatment, increased attention is being addressed towards retention in care and on treatment. Simpler, less toxic regimens have been a cornerstone of the Treatment 2.0 initiative of UNAIDS and WHO. Nevirapine has been widely utilized as an essential component of three drug antiretroviral therapy, in part due to low cost and safety at a population level. While efavirenz does have a greater incidence of central nervous system side effects (many of them manageable with supportive treatment), the overall discontinuation rate is significantly lower than with nevirapine. This data in combination with the continued reduction in efavirenz price, and incorporation into combination pill form, supports the move towards increased use of efavirenz for first line antiretroviral therapy.

HIV Treatment
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Challenges in retention in long term care and treatment

Toward an understanding of disengagement from HIV treatment and care in sub-Saharan Africa: a qualitative study.

Ware NC, Wyatt MA, Geng EH, Kaaya SF, Agbaji OO, Muyindike WR, Chalamilla G, Agaba PA. PLoS Med. 2013 Jan;10 (1):e1001369. doi: 10.1371/journal.pmed.1001369. Epub 2013 Jan 8.

The rollout of antiretroviral therapy in sub-Saharan Africa has brought lifesaving treatment to millions of HIV-infected individuals. Treatment is lifelong, however, and to continue to benefit, patients must remain in care. Despite this, systematic investigations of retention have repeatedly documented high rates of loss to follow-up from HIV treatment programs. This paper introduces an explanation for missed clinic visits and subsequent disengagement among patients enrolled in HIV treatment and care programs in Africa. Eight-hundred-ninety patients enrolled in HIV treatment programs in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda who had extended absences from care were tracked for qualitative research interviews. Two-hundred-eighty-seven were located, and 91 took part in the study. Interview data were inductively analyzed to identify reasons for missed visits and to assemble them into a broader explanation of how missed visits may develop into disengagement. Findings reveal unintentional and intentional reasons for missing visits, along with reluctance to return to care following an absence. Disengagement is interpreted as a process through which missed visits and ensuing reluctance to return over time erode patients' subjective sense of connectedness to care. Missed visits are inevitable over a lifelong course of HIV care. Efforts to prevent missed clinic visits combined with moves to minimize barriers to re-entry into care are more likely than either approach alone to keep missed visits from turning into long-term disengagement.

Abstract access 

Editor’s notes: The focus on universal access to HIV treatment has, at times, lead to a unitary focus on numbers of new patients started on antiretroviral therapy. The rates of non-adherence and lost-to-care can reach sobering proportions the longer treatment is continued. Programmatic responses to these challenges are not always developed with a clear understanding of the patient’s perspective and the patient’s view of the obstacles to long term retention. The voices of people living with HIV need to be heard, and their description of the barriers they face will lead to structural responses that truly serve the need of the ‘client’.   

Epidemiology
Africa
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