Articles tagged as "Zambia"

Hunger hinders antiretroviral therapy adherence

Does food insecurity undermine adherence to antiretroviral therapy? A systematic review.

Singer AW, Weiser SD, McCoy SI. AIDS Behav. 2014 Aug 6. [Epub ahead of print]

A growing body of research has identified food insecurity as a barrier to antiretroviral therapy (ART) adherence. We systematically reviewed and summarized the quantitative literature on food insecurity or food assistance and ART adherence. We identified nineteen analyses from eighteen distinct studies examining food insecurity and ART adherence. Of the thirteen studies that presented an adjusted effect estimate for the relationship between food insecurity and ART adherence, nine found a statistically significant association between food insecurity and sub-optimal ART adherence. Four studies examined the association between food assistance and ART adherence, and three found that ART adherence was significantly better among food assistance recipients than non-recipients. Across diverse populations, food insecurity is an important barrier to ART adherence, and food assistance appears to be a promising intervention strategy to improve ART adherence among persons living with HIV. Additional research is needed to determine the effectiveness and cost-effectiveness of food assistance in improving ART adherence and other clinical outcomes among people living with HIV in the era of widespread and long-term treatment.

Abstract access 

Editor’s notes: A number of qualitative studies have found that a lack of food is given as a reason for non-adherence to anti-retroviral therapy (ART). The authors wanted to see if quantitative studies on food security and adherence supported this view. As with many systematic reviews the number of quantitative studies included in the final analysis was small: fourteen. However, the majority of these studies did find an association between the availability of food and adherence. The authors very carefully describe the difference methods used to measure both food security and ART adherence.  These findings show both the wide range of methods used for measurement and definitions of adherence and food security, which made comparisons difficult. So, while the authors did find that food insecurity is a barrier to adherence, they could not say why. Given that food insecurity may be a threat to adherence for the some of the increasing numbers of people starting ART, further research is urgently needed. We need to understand more about the association between food and ART adherence. 

  • share
0 comments.

Improving linkage to pre-antiretroviral therapy care and antiretroviral therapy initiation

Interventions to improve or facilitate linkage to or retention in pre-ART (HIV) care and initiation of ART in low- and middle-income settings--a systematic review.

Govindasamy D, Meghij J, Kebede Negussi E, Clare Baggaley R, Ford N, Kranzer K. J Int AIDS Soc. 2014 Aug 1;17(1):19032. doi: 10.7448/IAS.17.1.19032. eCollection 2014.

Introduction: Several approaches have been taken to reduce pre-antiretroviral therapy (ART) losses between HIV testing and ART initiation in low- and middle-income countries, but a systematic assessment of the evidence has not yet been undertaken. The aim of this systematic review is to assess the potential for interventions to improve or facilitate linkage to or retention in pre-ART care and initiation of ART in low- and middle-income settings.

Methods: An electronic search was conducted on Medline, Embase, Global Health, Web of Science and conference databases to identify studies describing interventions aimed at improving linkage to or retention in pre-ART care or initiation of ART. Additional searches were conducted to identify on-going trials on this topic, and experts in the field were contacted. An assessment of the risk of bias was conducted. Interventions were categorized according to key domains in the existing literature.

Results: A total of 11 129 potentially relevant citations were identified, of which 24 were eligible for inclusion, with the majority (n=21) from sub-Saharan Africa. In addition, 15 on-going trials were identified. The most common interventions described under key domains included: health system interventions (i.e. integration in the setting of antenatal care); patient convenience and accessibility (i.e. point-of-care CD4 count (POC) testing with immediate results, home-based ART initiation); behaviour interventions and peer support (i.e. improved communication, patient referral and education) and incentives (i.e. food support). Several interventions showed favourable outcomes: integration of care and peer supporters increased enrolment into HIV care, medical incentives increased pre-ART retention, POC CD4 testing and food incentives increased completion of ART eligibility screening and ART initiation. Most studies focused on the general adult patient population or pregnant women. The majority of published studies were observational cohort studies, subject to an unclear risk of bias.

Conclusions: Findings suggest that streamlining services to minimize patient visits, providing adequate medical and peer support, and providing incentives may decrease attrition, but the quality of the current evidence base is low. Few studies have investigated combined interventions, or assessed the impact of interventions across the HIV cascade. Results from on-going trials investigating POC CD4 count testing, patient navigation, rapid ART initiation and mobile phone technology may fill the quality of evidence gap. Further high-quality studies on key population groups are required, with interventions informed by previously reported barriers to care.

 Abstract  Full-text [free] access 

Editor’s notes: To maximise the impact of antiretroviral therapy (ART), people living with HIV should be diagnosed as early as possible, after acquiring HIV infection. They should be enrolled and retained in pre-ART care, initiated on ART and retained in ART care. And at the same time ensuring long-term adherence to achieve and maintain viral load suppression.

This review focuses on the first few steps in the treatment cascade. The authors review the evidence for activities that enhance the linkage from HIV testing to pre-ART care, retain people in pre-ART care and enhance the linkage to ART initiation. Streamlining services to minimize patient visits, providing adequate medical and peer support, and providing incentives appear to decrease attrition between HIV testing and ART initiation. However, the authors point out that most of the included studies looked at the effect of a single activity on a single point, in the continuum of care. There is a gap in evidence of the effect of combined activities and programmes across the continuum of care.

With the clear trend towards the earliest possible initiation of ART, the pre-ART care period will become much shorter. However there will be need for activities to improve immediate linkage from a positive test result, to ART initiation and ART care.

Health care delivery
Africa, Asia
  • share
0 comments.

How can we improve the UNAIDS modes of transmission model?

The HIV modes of transmission model: a systematic review of its findings and adherence to guidelines.

Shubber Z, Mishra S, Vesga JF, Boily MC. J Int AIDS Soc. 2014 Jun 23;17:18928. doi: 10.7448/IAS.17.1.18928. eCollection 2014.

Introduction: The HIV Modes of Transmission (MOT) model estimates the annual fraction of new HIV infections (FNI) acquired by different risk groups. It was designed to guide country-specific HIV prevention policies. To determine if the MOT produced context-specific recommendations, we analyzed MOT Results by region and epidemic type, and explored the factors (e.g. data used to estimate parameter inputs, adherence to guidelines) influencing the differences.

Methods: We systematically searched MEDLINE, EMBASE and UNAIDS reports, and contacted UNAIDS country directors for published MOT Results from MOT inception (2003) to 25 September 2012.

Results: We retrieved four journal articles and 20 UNAIDS reports covering 29 countries. In 13 countries, the largest FNI (range 26 to 63%) was acquired by the low-risk group and increased with low-risk population size. The FNI among female sex workers (FSWs) remained low (median 1.3%, range 0.04 to 14.4%), with little variability by region and epidemic type despite variability in sexual behaviour. In India and Thailand, where FSWs play an important role in transmission, the FNI among FSWs was 2 and 4%, respectively. In contrast, the FNI among men who have sex with men (MSM) varied across regions (range 0.1 to 89%) and increased with MSM population size. The FNI among people who inject drugs (PWID, range 0 to 82%) was largest in early-phase epidemics with low overall HIV prevalence. Most MOT studies were conducted and reported as per guidelines but data quality remains an issue.

Conclusions: Although countries are generally performing the MOT as per guidelines, there is little variation in the FNI (except among MSM and PWID) by region and epidemic type. Homogeneity in MOT FNI for FSWs, clients and low-risk groups may limit the utility of MOT for guiding country-specific interventions in heterosexual HIV epidemics.

 Abstract  Full-text [free] access

Editor’s notes: In 2002, the HIV Modes of Transmission model (MoT) was developed by UNAIDS to inform and focus, country-specific HIV prevention policies. The idea behind the model was to use simple mathematical modelling approaches, in combination with country specific data, to predict what the distribution of new HIV infection may look like. In this way, countries would be able to better focus their HIV response. Since its development and through 2012, the MoT has been applied in 29 countries, with the findings being used in many settings to shape priorities. In this study, the authors assess the degree to which the MoT produces different outputs in different epidemic contexts. They explore whether there are key parameters in the model that seem to drive similarities and/or differences in projections between countries. Surprisingly, across a broad range of epidemic settings, they found limited variability in the predicted annual fraction of new HIV infections (FNI) acquired by female sex workers (FSW) (0.04-14.4%). There were higher levels of variability between countries in the projected fraction of new HIV infections among men who have sex with men (0.01-89%) and people who inject drugs (0-82%).

The differences in the MoT projections were largely dependent on whether the country in question was categorised as having a concentrated / low-level epidemic, versus generalised epidemic, as defined by UNAIDS. Differences also arose depending upon whether ‘low risk groups’ were also included in the model. Indeed, for 22 of the 25 studies that included a low-risk group, this group was predicted to have a large annual fraction of new HIV infections (11.8-62.9%). This phenomenon arose, not because of high transmission rates in this group (in comparison to others such as MSM or PWIDs) but because these ‘low risk groups’ are large. They are one third of the total population. These findings may be misleading, as the projected high fraction of transmission is dependent on the assumption that everyone in this ‘low risk group’ does have some risk.

It appears that although the MoT was designed to address an important need, it is likely to have limited utility to guide programming in heterosexually driven epidemics.  To address this limitation, UNAIDS is supporting the HIV Modelling Consortium in their development of a revised MoT model that takes into better consideration risk categorization, data constraints and programmatic needs. The revised model is currently undergoing field testing and will be available for country use in 2015.

Africa, Asia, Europe, Latin America
  • share
0 comments.

WHO-recommended second-line ART regimen is safe and effective in Africa

Assessment of second-line antiretroviral regimens for HIV therapy in Africa.

Paton NI, Kityo C, Hoppe A, Reid A, Kambugu A, Lugemwa A, van Oosterhout JJ, Kiconco M, Siika A, Mwebaze R, Abwola M, Abongomera G, Mweemba A, Alima H, Atwongyeire D, Nyirenda R, Boles J, Thompson J, Tumukunde D, Chidziva E, Mambule I, Arribas JR, Easterbrook PJ, Hakim J, Walker AS, Mugyenyi P, EARNEST Trial Team. N Engl J Med. 2014 Jul 17;371(3):234-47. doi: 10.1056/NEJMoa1311274.

Background: The efficacy and toxic effects of nucleoside reverse-transcriptase inhibitors (NRTIs) are uncertain when these agents are used with a protease inhibitor in second-line therapy for human immunodeficiency virus (HIV) infection in resource-limited settings. Removing the NRTIs or replacing them with raltegravir may provide a benefit.

Methods: In this open-label trial in sub-Saharan Africa, we randomly assigned 1 277 adults and adolescents with HIV infection and first-line treatment failure to receive a ritonavir-boosted protease inhibitor (lopinavir-ritonavir) plus clinician-selected NRTIs (NRTI group, 426 patients), a protease inhibitor plus raltegravir in a superiority comparison (raltegravir group, 433 patients), or protease-inhibitor monotherapy after 12 weeks of induction therapy with raltegravir in a noninferiority comparison (monotherapy group, 418 patients). The primary composite end point, good HIV disease control, was defined as survival with no new World Health Organization stage 4 events, a CD4+ count of more than 250 cells per cubic millimeter, and a viral load of less than 10 000 copies per milliliter or 10 000 copies or more with no protease resistance mutations at week 96 and was analyzed with the use of imputation of data (</=4%).

Results: Good HIV disease control was achieved in 60% of the patients (mean, 255 patients) in the NRTI group, 64% of the patients (mean, 277) in the raltegravir group (P=0.21 for the comparison with the NRTI group; superiority of raltegravir not shown), and 55% of the patients (mean, 232) in the monotherapy group (noninferiority of monotherapy not shown, based on a 10-percentage-point margin). There was no significant difference in rates of grade 3 or 4 adverse events among the three groups (P=0.82). The viral load was less than 400 copies per milliliter in 86% of patients in the NRTI group, 86% in the raltegravir group (P=0.97), and 61% in the monotherapy group (P<0.001).

Conclusions: When given with a protease inhibitor in second-line therapy, NRTIs retained substantial virologic activity without evidence of increased toxicity, and there was no advantage to replacing them with raltegravir. Virologic control was inferior with protease-inhibitor monotherapy.

Abstract  Full-text [free] access

Editor’s notes: Over the coming years, increasing numbers of individuals taking antiretroviral therapy (ART) in sub-Saharan Africa will develop treatment failure and require second-line treatment.  There is an urgent need to find the most cost-effective, tolerable and safe standardised second-line regimen for this setting.  The Europe-Africa Research Network for Evaluation of Second-Line Therapy (EARNEST) trial set out to assess whether alternative ART regimens (excluding the nucleoside reverse transcriptase inhibitor [NRTI] backbone) are more efficacious and less toxic than the WHO-recommended second-line regimen of a boosted protease inhibitor (PI) and two NRTIs.  The setting of the trial is typical of most antiretroviral programmes in Africa, with no routine viral load monitoring, and the second-line NRTI backbone selected without genotypic resistance testing. 

Participants in this study had extensive NRTI resistance. Despite this, there was substantial residual NRTI activity, and, by week  96, the WHO-recommended regimen of a boosted PI and two NRTIs was as good as the alternative regimen of a boosted PI and raltegravir, and better than PI monotherapy.  It is worth pointing out that although “good HIV disease control” was achieved in only 60% of study participants in the NRTI arm, this composite outcome required study participants to have had a CD4 count ≥250 cells per mm3 at week 96.  The 60% achieving “good HIV disease control” in the NRTI arm therefore reflects the low baseline CD4 cell counts (median CD4 count 72) at the time of switch to second-line therapy rather than treatment efficacy with regard to virologic suppression (VL<400 copies/ml), which was achieved in some 86% of people.

Further research will be needed to determine whether this second-line regimen continues to be effective in maintaining good HIV disease control through virologic suppression in the longer term.  

HIV Treatment
Africa
Kenya, Malawi, Uganda, Zambia, Zimbabwe
  • share
0 comments.

Increasing HIV-testing in men: what works?

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

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

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

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

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

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

Abstract access 

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

HIV testing
Africa
  • share
0 comments.

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

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

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

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

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

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

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

Abstract  Full-text [free] access  

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

Africa
  • share
0 comments.

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

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

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

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

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

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

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

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

Abstract  Full-text [free] access

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

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

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

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

Africa, Asia, Europe, Latin America
  • share
0 comments.

Systematic review highlights gaps in depression research in sub-Saharan Africa

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

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

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

Design: Systematic review and meta-analysis.

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

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

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

Abstract access 

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

Africa
  • share
0 comments.

High levels of acceptability and safety profile of a disposable device for adult voluntary medical male circumcision

Randomized controlled trial of the Shang ring versus conventional surgical techniques for adult male circumcision: safety and acceptability.

Sokal DC, Li PS, Zulu R, Awori QD, Combes SL, Simba RO, Lee R, Hart C, Perchal P, Hawry HJ, Bowa K, Goldstein M, Barone MA. J Acquir Immune Defic Syndr. 2014 Apr 1;65(4):447-55. doi: 10.1097/QAI.0000000000000061.

Objective: To compare clinical profiles of Shang Ring versus conventional circumcisions.

Design: Parallel group open-label randomized controlled trial with one-to-one allocations in 2 sites.

Methods: We enrolled HIV-negative men aged 18-54 years in Homa Bay, Kenya, and Lusaka, Zambia and followed them at 2, 7, 14, 21, 28, 42, and 60 days after Shang Ring versus conventional circumcision. We compared the duration of surgery, postoperative pain using a visual analog scale, adverse events rates, time to complete wound healing by clinical assessment, participant acceptability, and provider preferences between circumcision groups.

Results: We randomized 200 men to each group; 197 and 201 contributed to the Shang Ring and conventional surgery analyses, respectively. Adverse event rates were similar between groups. Pain scores at most time points were similar, however, the Shang Ring group reported higher scores for worst pain during erections (3.5 +/- 1.9 vs. 2.3 +/- 1.7; P < 0.001). Significantly more men were satisfied with the cosmetic appearance following Shang Ring male circumcision (MC), 95.7% versus 85.9% (P = 0.02) in Kenya, and 96.8% versus 71.3% (P < 0.01) in Zambia. Although median time to complete wound healing was 43 days in both groups, conventional circumcisions healed on average 5.2 days sooner (P < 0.001). Shang Ring procedures took one-third the time of conventional MC, 7 versus 20 minutes. All circumcision providers preferred the Shang Ring.

Conclusions: Safety profiles of the 2 techniques were similar, all MC providers preferred the Shang Ring technique, and study participants preferred the Shang Ring's cosmetic results. The Shang Ring should be considered for adult MC as programs scale-up.

Abstract access 

Editor’s notes: Rapid scale up of voluntary medical male circumcision (VMMC) is needed to impact on the HIV epidemic. The current goal is for 20 million VMMCs to be conducted in countries with generalised HIV epidemics by 2016. To achieve this, it is essential to examine alternative methods to conventional surgery. The Shang Ring is one such method, which is a disposable, single-use, minimally invasive device that has been widely used in China and is starting to be used in sub-Saharan Africa. This is one of the first larger scale randomised control trial comparing an adult VMMC device with conventional surgery. The results show very high levels of acceptability of the Shang Ring among both participants and providers, and a reassuring safety profile showing a similar risk of adverse events using the two methods.  However, the risk of a moderate/severe adverse event was higher in this study than in a previous trial of the Shang Ring in Uganda. This finding underscores that back-up services are needed in case of complications.

Africa
Kenya, Zambia
  • share
0 comments.

Real-world costing of HIV treatment in Zambia highlights difference between national guidelines and actual resource use

Retention in care, resource utilization, and costs for adults receiving antiretroviral therapy in Zambia: a retrospective cohort study.

Scott CA, Iyer HS, McCoy K, Moyo C, Long L, Larson BA, Rosen S. BMC Public Health. 2014 Mar 31;14(1):296. doi: 10.1186/1471-2458-14-296.

Background: Of the estimated 800 000 adults living with HIV in Zambia in 2011, roughly half were receiving antiretroviral therapy (ART). As treatment scale up continues, information on the care provided to patients after initiating ART can help guide decision-making. We estimated retention in care, the quantity of resources utilized, and costs for a retrospective cohort of adults initiating ART under routine clinical conditions in Zambia.

Methods: Data on resource utilization (antiretroviral [ARV] and non-ARV drugs, laboratory tests, outpatient clinic visits, and fixed resources) and retention in care were extracted from medical records for 846 patients who initiated ART at ≥15 years of age at six treatment sites between July 2007 and October 2008. Unit costs were estimated from the provider's perspective using site- and country-level data and are reported in 2011 USD.

Results: Patients initiated ART at a median CD4 cell count of 145 cells/μL. Fifty-nine percent of patients initiated on a tenofovir-containing regimen, ranging from 15% to 86% depending on site. One year after ART initiation, 75% of patients were retained in care. The average cost per patient retained in care one year after ART initiation was $243 (95% CI, $194-$293), ranging from $184 (95% CI, $172-$195) to $304 (95% CI, $290-$319) depending on site. Patients retained in care one year after ART initiation received, on average, 11.4 months' worth of ARV drugs, 1.5 CD4 tests, 1.3 blood chemistry tests, 1.4 full blood count tests, and 6.5 clinic visits with a doctor or clinical officer. At all sites, ARV drugs were the largest cost component, ranging from 38% to 84% of total costs, depending on site.

Conclusions: Patients initiate ART late in the course of disease progression and a large proportion drop out of care after initiation. The quantity of resources utilized and costs vary widely by site, and patients utilize a different mix of resources under routine clinical conditions than if they were receiving fully guideline-concordant care. Improving retention in care and guideline concordance, including increasing the use of tenofovir in first-line ART regimens, may lead to increases in overall treatment costs.

 Abstract  Full-text [free] access

Editor’s notes: This article highlights the importance of conducting ‘real-world’ economic evaluations for HIV-related services.  The authors found that practical implementation of national policy was not universal. This finding had important implications on the observed retention in care and cost of providing services. The observed use of some resources, e.g. drugs, for people retained in care, were lower than expected, while the number of clinical consultations was higher than recommended in the guidelines. These findings suggest that it may not be appropriate to assume that guidelines and practice will be identical for the purposes of programme planning and budgeting.  

Africa
Zambia
  • share
0 comments.