Articles tagged as "United Republic of Tanzania"

HIV prevention is successful among refugees and displaced persons

Changes in HIV-related behaviours, knowledge and testing among refugees and surrounding national populations: A multicountry study.

Dahab M, Spiegel PB, Njogu PM, Schilperoord M. AIDS Care. 2013 Jan 10 [Epub ahead of print]

To the authors’ knowledge, there is currently no published data on the prevalence of risky sex over time as displaced populations settle into long-term post-emergency refugee camps. To measure trends in HIV-related behaviours, the authors conducted a series of cross-sectional HIV behavioural surveillance surveys among refugees and surrounding community residents living in Kenya, Tanzania and Uganda, at baseline in 2004/2005 and at follow-up in 2010/2011. Participants were selected using two-stage cluster sampling, except in the Tanzanian refugee camp where systematic random sampling was employed. Participants had to reside in a selected household for more than weeks and aged between 15 and 49 years. 11,582 participants (6448 at baseline and 5134 at follow-up) were interviewed in three camps and their surrounding communities. The prevalence of multiple sexual partnerships ranged between 10.1 and 32.6% at baseline and 4.2 and 20.1% at follow-up, casual partnerships ranged between 8.0 and 33.2% at baseline and 3.5 and 17.4% at follow-up, and transactional partnerships between 1.1 and 14.0% at baseline and 0.8 and 12.0% at follow-up. The prevalence of multiple partnerships and casual sex in the Kenyan and Ugandan camps was not higher than among nationals. To the authors’ knowledge these data are the first to describe and compare trends in the prevalence of risky sex among conflict-affected populations and nationals living nearby. The large reductions in risky sexual partnerships are promising and possibly indicative of the success of HIV prevention programs. However, evaluation of specific prevention programmes remains necessary to assess which, and to what extent, specific activities contributed to behavioural change. Notably, refugees had lower levels of multiple and casual sexual partnerships than nationals in Kenya and Uganda and thus should not automatically be assumed to have higher levels of risky sexual behaviours than neighbouring nationals elsewhere.

Abstract access 

Editor’s notes: Whatever assumptions are made, there has been limited knowledge regarding HIV risk among long term displaced people compared to non-displaced people in surrounding communities. This study notes that frequency of multiple partnerships and ‘risky’ sex did not differ between these two groups. It is important that HIV prevention service providers understand their specific community rather than make assumptions about behavior. However, additional data beyond behavior must be examined to estimate risk of acquisition of HIV infection, such as community level HIV prevalence.  

Africa
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Adverse events associated with nevirapine use in pregnancy

Adverse events associated with nevirapine use in pregnancy: a systematic review and meta-analysis.

Ford N, Calmy A, Andrieux-Meyer I, Hargreaves S, Mills EJ, Shubber Z. AIDS. 2013 Jan 5. [Epub ahead of print]

The risk of adverse drug events associated with nevirapine is suggested to be greater in pregnant women. The authors conducted a systematic review and meta-analysis of severe adverse events in HIV-positive women who initiated NVP while pregnant. Six databases were searched for studies reporting adverse events among HIV-positive pregnant women who had received nevirapine-based antiretroviral therapy for at least seven days. Data were pooled by the fixed-effects method. Twenty studies (3582 pregnant women) from 14 countries were included in the final review. The pooled proportion of patients experiencing a severe hepatotoxic event was 3.6% (95%CI 2.4-4.8%), severe rash was experienced by 3.3% of patients (95%CI 2.1-4.5%), and 6.2% (95%CI 4.0-8.4%) of patients discontinued nevirapine due to an adverse event. These results were comparable to frequencies observed in the general adult patient population, and to frequencies reported in non-pregnant women within the same cohort. For pregnant women with a CD4 cell count >250 cells/mm there was a non-significant tendency towards an increased likelihood of cutaneous events overall (OR 1.1, 95%CI 0.8-1.6) and severe cutaneous adverse events (OR 1.4, 95%CI 0.8-2.4) and consequently an increased risk of toxicity-driven regimen substitution (OR 1.7, 95%CI 1.1-2.6). These results suggest that the frequency of adverse events associated with nevirapine use in pregnant women, while high, is no higher than reported for nevirapine in the general adult population. Pregnant women with a high CD4 count may be at increased risk of adverse events, but evidence supporting this association is weak.

Abstract access 

Editor’s notes: The selection of antiretroviral drug regimens has been particularly challenging for HIV-positive pregnant women. Adverse events are less frequent for men and women with efavirenz use compared to nevirapine, and increasingly efavirenz is a preferred choice. However, due to concerns about the safety of efavirenz in pregnancy, nevirapine continues to be widely used as a component of antiretroviral treatment for pregnant women. However, there have been suggestions that HIV-positive pregnant women have higher rates of nevirapine-associated adverse events, especially for those women with high CD4, compared to non-pregnant women on nevirapine. This meta-analysis of 20 studies did demonstrate a relatively high frequency of adverse events in women who use nevirapine, but not at rates higher than among non-pregnant women on HIV treatment with nevirapine. The data about efavirenz safety for the fetus is being carefully reviewed to elucidate if widespread use of efavirenz is preferable to nevirapine during pregnancy.

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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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TB among children living with HIV

Incident tuberculosis and risk factors among HIV-infected children in Dar es Salaam, Tanzania.

Li N, Manji KP, Spiegelman D, Muya A, Mwiru RS, Liu E, Chalamilla G, Fawzi WW, Duggan C. AIDS. 2013 Jan 22. [Epub ahead of print]

This article describes the burden of pediatric tuberculosis (TB) in a HIV-infected population and explores the demographic and clinical factors associated with the occurrence of pediatric TB through a longitudinal analysis of a cohort of HIV-infected children. The endpoint of the study was clinically diagnosed TB. Cox proportional hazard regression was used to explore the predictors of incident TB among HIV-infected children under age 15 years after enrollment into the HIV program. The cohort comprised of 5040 children [median age: 5 years, interquartile range (IQR): 1-9 years]. During a median follow-up of 0.8 (IQR: 0.1-2.5) years, 376 out of 5040 children met the case definition for TB. The overall incidence of TB was 5.2/100 person-years. In multivariate analyses, older age at enrollment [relative risk (RR): 1.7, 95%, confidence interval (CI): 1.5-1.8], severe wasting (RR: 1.8, 95% CI: 1.3-2.5), severe immune-suppression (RR: 2.6, 95% CI: 1.8-3.8), anemia (RR: 1.4, 95% CI: 1.0-1.9) and World Health Organization (WHO) stage IV (RR: 4.5, 95% CI: 2.4-8.5) were all independently associated with a higher risk of TB. In addition, the use of antiretroviral drugs for more than 180 days reduced the risk of TB by 70% (RR: 0.3, 95% CI: 0.2-0.4). ART use is strongly associated with a reduced risk of tuberculosis among HIV-infected children, and should therefore be included in HIV care and treatment programs. Trials of interventions designed to improve the nutritional and hematologic status of these children should also be performed.

Abstract access 

Editor’s notes: Antiretroviral therapy reduces the incidence of tuberculosis for children, as well as for adults, living with HIV. While diagnosis of tuberculosis can be particularly challenging in children, the quite high incidence of active TB (10% in one year) in this study highlights the importance of proactive clinical screening and laboratory diagnosis, and provides additional evidence to the importance ART initiation as a measure that reduces the risk of TB.

Avoid TB deaths
Africa
United Republic of Tanzania
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Decentralizing pediatric HIV care and treatment into primary care centers

Decentralization of pediatric HIV Care and Treatment in Five sub-Saharan African Countries.

Fayorsey RN, Saito S, Carter RJ, Gusmao E, Frederix K, Koech-Keter E, Tene G, Panya M, Abrams EJ. J Acquir Immune Defic Syndr. 2013 Jan 18. [Epub ahead of print]

In resource-limited settings, decentralization of HIV care and treatment is a cornerstone of universal care and rapid scale-up. We compared trends in pediatric enrollment and outcomes at primary (PHF) versus secondary/tertiary health facilities (SHFs). Using aggregate program data reported quarterly from 274 public facilities in Kenya, Lesotho, Mozambique, Rwanda and Tanzania from January 2008- March 2010 trends were examined in the number of children < 15 years of age initiating antiretroviral treatment (ART) by facility type. Clinic-level lost to follow-up (LTFU) and mortality per 100 person years (PYs) on ART during the period by facility type were compared. During the two year period, 17,155 children enrolled in HIV care and 8,475 initiated ART in 182 (66%) PHFs and 92(34%) SHFs. PHFs increased from 56 to 182, while SHFs increased from 72 to 92 sites. SHFs accounted for 71% of children initiating ART; however, the proportion of children initiating ART each quarter at PHFs increased from 17% (129) to 44% (463) in conjunction with an increase in PHFs during observation period. The average LTFU and mortality rates for children on ART were 9.8/100PYs and 5.2/100PYs, respectively at PHFs and 20.2/100PYs and 6.0/100PYs at SHFs. Adjusted models show PHFs associated with lower LTFU (Adjusted Rate Ratio, ARR=0.55; p=0.022) and lower mortality (ARR=0.66; p=0.028). The expansion of pediatric services to PHFs has resulted in increased numbers of children on ART. Early findings suggest lower rates of LTFU and mortality at PHFs. Successful scale-up will require further expansion of pediatric services within PHFs.

Abstract access 

Editor’s notes: Early during treatment scale up pediatric ART remained a referral clinic intervention, limiting the enrollment of children and disrupting efforts to provide ‘one-stop’ visits for families with adults and children living with HIV. Barriers such as provider discomfort with pediatric ART have been addressed by increased training efforts as well as a public health approach of algorithm-based treatment. Increasingly pediatric ART is being provided in the same sites and by the same providers as other primary health services.

Africa
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Addressing barriers to universal access: focus on the pre-ART phase

Quantifying and addressing losses along the continuum of care for people living with HIV infection in sub-Saharan Africa: a systematic review.

Kranzer K, Govindasamy D, Ford N, Johnston V, Lawn SD. J Int AIDS Soc. 2012 Nov 19;15(2):17383.

Introduction: Recent years have seen an increasing recognition of the need to improve access and retention in care for people living with HIV/AIDS. This review aims to quantify patients along the continuum of care in sub-Saharan Africa and review possible interventions.

Methods: We defined the different steps making up the care pathway and quantified losses at each step between acquisition of HIV infection and retention in care on antiretroviral therapy (ART). We conducted a systematic review of data from studies conducted in sub-Saharan Africa and published between 2000 and June 2011 for four of these steps and performed a meta-analysis when indicated; existing data syntheses were used for the remaining two steps.

Results: The World Health Organization estimates that only 39% of HIV-positive individuals are aware of their status. Among patients who know their HIV-positive status, just 57% (95% CI, 48 to 66%) completed assessment of ART eligibility. Of eight studies using an ART eligibility threshold of≤200 cells/µL, 41% of patients (95% CI, 27% to 55%) were eligible for treatment, while of six studies using an ART eligibility threshold of≤350 cells/µL, 57% of patients (95% CI, 50 to 63%) were eligible. Of those not yet eligible for ART, the median proportion remaining in pre-ART care was 45%. Of eligible individuals, just 66% (95% CI, 58 to 73%) started ART and the proportion remaining on therapy after three years has previously been estimated as 65%. However, recent studies highlight that this is not a simple linear pathway, as patients cycle in and out of care. Published studies of interventions have mainly focused on reducing losses at HIV testing and during ART care, whereas few have addressed linkage and retention during the pre-ART period.

Conclusions: Losses occur throughout the care pathway, especially prior to ART initiation, and for some patients this is a transient event, as they may re-engage in care at a later time. However, data regarding interventions to address this issue are scarce. Research is urgently needed to identify effective solutions so that a far greater proportion of infected individuals can benefit from long-term ART.

Abstract access


 

Who Starts? Factors Associated with Starting Antiretroviral Therapy among Eligible Patients in Two, Public HIV Clinics in Lilongwe, Malawi. 

Feldacker C, Johnson D, Hosseinipour M, Phiri S, Tweya H. PLoS One. 2012;7(11):e50871. Epub 2012 Nov 30.

Background: Lighthouse Trust operates two, public, integrated HIV clinics, Lighthouse (LH) and Martin Preuss Center (MPC), in Lilongwe, Malawi. Approximately 20% of patients eligible for antiretroviral therapy (ART) do not start ART. We explore individual and geographic factors that influence whether ART-eligible patients initiate ART.

Methods: Adult patients eligible for ART between 2008-2011 were included. Analysis was stratified by clinic. Using logistic regression, we evaluated factors associated with initiating ART including gender, age, body mass index (BMI), employment, tuberculosis (TB), eligible at initial registration, WHO stage, CD4, months in pre-ART care (from initial registration to eligibility date), and patient neighborhood distance to clinic.

Results: Of 14,216 study patients, 4841 were from LH; 9285 were from MPC. At LH and MPC, respectively, median age was 34.2 and 33.8 years; median BMI was 22.0 and 20.6; and median distance was 5.6 and 4.9 Km. In multivariate models, odds of starting ART was highest among those older than 35 years and those eligible for ART based on WHO stages 3-4 vs. those in WHO stages 1-2 with CD4<250. Patients with 1-12 months in pre-ART were at least 11 times more likely to start ART than peers with less pre-ART time. At LH, living 2.5-5 Km from the clinic increased the likelihood of starting ART over patients living closer.

Conclusions: Length of the pre-ART period is the most significant predictor of starting ART among eligible patients. Better understanding of motivation for retention in pre-ART care may reduce attrition along the treatment cascade.

Abstract access


 

Attrition from HIV Testing to Antiretroviral Therapy Initiation among Patients Newly Diagnosed with HIV in Haiti.

Noel E, Esperance M, McLaughlin M, Bertrand R, Devieux J, Severe P, Marcelin A, Nicotera J, Delcher C, Griswold M, Meredith G, Pape JW, Koenig SP. J Acquir Immune Defic Syndr. 2012 Dec 18. [Epub ahead of print]

Objective: We report rates and risk factors for attrition in the first cohort of patients followed through all stages from HIV testing to ART initiation.

Design: Cohort study of all patients diagnosed with HIV between January and June, 2009.

Methods: We calculated the proportion of patients who completed CD4 cell counts and initiated ART or remained in pre-ART care during two years of follow-up, and assessed predictors of attrition.

Results: Of 1,427 patients newly diagnosed with HIV, 680 (48%) either initiated ART or were retained in pre-ART care for the subsequent two years. One thousand eighty-three patients (76%) received a CD4 cell count and 973 (90%) returned for result; 297 (31%) had CD4 cell count <200 cells/µl and of these, 256 (86%) initiated ART. Among 429 patients with CD4 >350 cells/µl, 215 (50%) started ART or were retained in pre-ART care. Active TB was associated with lower odds of attrition prior to CD4 cell count (OR: 0.08; 95% CI: 0.03-0.25) but also higher odds of attrition prior to ART initiation (OR: 2.46; 95% CI: 1.29-4.71). Lower annual income (≤$US125) was associated with higher odds of attrition prior to CD4 cell count (OR 1.65; 95% CI: 1.25-2.19), and prior to ART initiation among those with CD4 cell count >350 cells/µl (OR: 1.74; 95% CI: 1.20-2.52).After tracking patients through a national database, the retention rate increased to only 57%.

Conclusion: Fewer than half of patients newly diagnosed with HIV initiate ART or remain in pre-ART care for two years in a clinic providing comprehensive services. Additional efforts to improve retention in pre-ART are critically needed.

Abstract access

Editor’s notes: The first of three papers presents a systematic review of the published data addressing the entire HIV care pathway, including HIV testing, pre-ART care comprising assessment of ART eligibility, retention in pre-ART care prior to ART eligibility, initiation of ART and retention in ART care. The second paper describes factors associated with ART initiation in a large cohort of patients in Malawi.The third paper presents the results of a prospective cohort study conducted at the GHESKIO clinic, the oldest and largest HIV testing facility in Haiti. GHESKIO tests nearly 30 000 patients per year for HIV, and follows patients from HIV testing through pre-ART care, ART initiation and follow-up. Their results show high rates of attrition at every step from HIV testing to ART initiation, losses occurring mainly prior to ART initiation with fewer than half of patients newly diagnosed with HIV initiating ART or remaining in pre-ART care. This is a vital study because it confirms the results of other relevant studies conducted in Africa, and highlights how the care pathway, especially prior to ART initiation is a global challenge. All research conducted in different parts of the world concur with the urgent need to address operational questions to improve the retention in pre-ART care (prior to ART eligibility and initiation).

All three papers raise a very sensitive issue, which has been poorly explored, the pre-ART care phase. Indeed, the current inclination towards earlier initiation of ART requires earlier diagnosis and regular monitoring until treatment eligibility. Poor pre-ART retention in care, or the failure to link patients from HIV testing to HIV care and retain them until they are eligible for ART, is a problem that has recently surfaced in the research literature. Without effective retention in pre-ART care – beginning with HIV testing and continuing until the first antiretrovirals are dispensed – even patients who have long been aware of their HIV status will access care only when seriously ill, which is often well after treatment eligibility. Unfortunately, only a handful of quantitative studies reporting on rates of pre-ART linkage and loss in sub-Saharan Africa have been published, and many of these are limited in the time periods and outcomes they consider. More operational research addressing the retention in care of individuals not yet eligible for ART is therefore essential. There appear to be several reasons for the poor showing of pre-ART care. Most patients during this stage are asymptomatic and may not perceive themselves to require medical care. Since little therapeutic care is offered during the pre-ART period, patients must take on faith that making the effort to come to the clinic for monitoring is worth the costs of doing so. Current approaches to providing care often require multiple clinic visits, e.g., to first provide a blood sample for a CD4 count and then return a week later to receive the results. Choosing to "wait and see what happens" may well be a preferred strategy for patients who lack resources for transport, risk losing employment by taking time off work, or fear being recognized as a client of an HIV clinic.  A number of interventions are being tried to improve retention in pre-ART care, though very few have been rigorously evaluated. Most interventions aim either to reduce the costs that patients perceive in seeking pre-ART care or increasing the perceived benefits of care. Interventions to reduce costs are more common and focus on structural changes in the delivery of care (fewer visits, more convenient locations, shorter waiting times, etc.). Interventions to increase benefits may offer more services at each visit (e.g., provision of cotrimoxazole or food parcels). There is little evidence so far as to whether these interventions will be effective. A possible way forward might also be the involvement of the local personnel such as community-based workers. Community may provide tangible support in increasing knowledge of HIV, obtain information about any changes or movements in patients’ lives, continue to follow patients in the social environment where they live, and support them to make periodic clinic visits.

HIV testing, HIV Treatment
Africa, Latin America
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Integration of HIV and TB services: a model to shift from "vertical to horizontal"

Integrating tuberculosis and HIV services in low- and middle-income countries: a systematic review.

Legido-Quigley H, Montgomery CM, Khan P, Atun R, Fakoya A, Getahun H, Grant AD. Trop Med Int Health. 2012 Dec 10. [Epub ahead of print]

Objectives: Given the imperative to scale up integrated tuberculosis (TB) and HIV services in settings where both are of major public health importance, we aimed to synthesise knowledge concerning implementation of TB/HIV service integration.

Methods: Systematic review of studies describing a strategy to facilitate TB and HIV service integration, searching 15 bibliographic databases including Medline, Embase and the Cochrane library; and relevant conference abstracts.

Results: Sixty-three of 1936 peer-reviewed articles and 70 of 170 abstracts met our inclusion criteria. We identified five models: entry via TB service, with referral for HIV testing and care; entry via TB service, on-site HIV testing, and referral for HIV care; entry via HIV service with referral for TB screening and treatment; entry via HIV service, on-site TB screening, and referral for TB diagnosis and treatment; and TB and HIV services provided at a single facility. Referral-based models are most easily implemented, but referral failure is a key risk. Closer integration requires more staff training and additional infrastructure (e.g. private space for HIV counselling; integrated records). Infection control is a major concern. More integrated models hold potential efficiencies from both provider and user perspective. Most papers report 'outcomes' (e.g. proportion of TB patients tested for HIV); few report downstream 'impacts' such as outcomes of TB treatment or antiretroviral therapy. Very few studies address the perspectives of service users or staff, or costs or cost-effectiveness.

Conclusions: While scaling up integrated services, robust comparisons of the impacts of different models are needed using standardised outcome measures.

Abstract access

Editor’s notes:This study emphasizes the need to implement the most effective integrated services for the prevention and cure of HIV and TB.  TB remains one of the most deadly infectious diseases that dramatically impacts on people in sub-Saharan Africa and represent the major cause of death in those living with HIV in the region. In fact, the progressive weakening of the immune system in HIV-positive people increases the likelihood of contracting/reactivating tuberculosis. Already in 2004, the WHO published "A Interim Policy on TBV/HIV Collaborative Activities" with the purpose of providing a guide to establish integration of TB and HIV services, and to reduce the TB load in people living with HIV. An updated document "WHO policy on collaborative TB/HIV activities: guidelines for national programmes and other stakeholders" is now available. The document provides guidance for integrating care activities between TB and HIV health services. However, to put this paper into perspective, a consensus can be reached by saying that integration shall not just be about HIV and TB. Indeed, the old debate between "vertical approaches (e.g. disease focused)" and horizontal approaches (e.g. health systems focused) shall now be concluded and integration of services shall expand to care of other diseases, particularly when, at the horizon, an epidemic of chronic non-communicable diseases is slowly but surely rising in Africa. In summary, HIV is a chronic infection impacting the lifecycle; with periods of illness and wellness, with multiple clinical and psychosocial needs, requiring lifelong care and treatment with a secure supply of medicines and laboratory tests.

It is evident that HIV care may inform appropriate responses to other health threats which share the same demand for services, training of health care workers, support for adherence, infrastructure and equipment, programme management, drug and laboratory supplies, linkage to care and community involvement. In other words, there is a wide recognition of the spillover effect of HIV interventions towards health systems strengthening, not only to the benefit of other communicable diseases, but also of child and maternal health and of chronic non-communicable diseases (like diabetes, hypertension and cancer).

Africa, Asia, Europe, Latin America
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