Articles tagged as "Zambia"

Men at greater risk of not accessing antiretroviral treatment than women

Sex differentials in the uptake of antiretroviral treatment in Zambia.

Gari S, Martin-Hilber A, Malungo JR, Musheke M, Merten S. AIDS Care. 2014 Mar 25. [Epub ahead of print]

This study explores socio-structural factors that influence uptake of antiretroviral treatment (ART) in Zambia and assess differences between men and women. We conducted a case-control study nested in a community- and health facility-based survey, between September 2010 and February 2011. Cases were defined as HIV-positive individuals who, while eligible, never started ART and controls were HIV-positive individuals who were on ART. Cases and controls were matched by place of residence. We performed a conditional logistic regression analysis using a discrete logistic model stratified by sex. Overall, a significantly larger proportion of men (32.7%) than women (25.6%) did not uptake ART (Pearson chi2 = 5.9135; p = 0.015). In the crude analysis, poor health status and low self-efficacy were common factors associated with non-uptake in both sexes. After adjusting for covariates, men were more likely than women to refuse ART even though men's self-rated health was lower than women's. In general, the adjusted analysis suggests that HIV status disclosure affects uptake in both sexes but women's uptake of ART is largely hampered by poverty-related factors while for men, side effects and social pressure, probably associated with masculinity, are more important barriers. Alarmingly men's health seems to deteriorate until they start treatment, in contrast to women. Understanding gender differences in uptake and attitudes to ART is a crucial component to providing effective and appropriate health care to both men and women living with HIV/AIDS in Zambia.

Abstract access 

Editor’s notes: There have been observed differences in the uptake of antiretroviral therapy (ART) among men and women living with HIV, with men often at greater risk of not using ART than women. Previous research on this topic has suggested that this is due to the fact that women often have stronger links to community networks. Therefore, women have more information about the availability and accessibility of ART services. This study suggests that social and structural factors have different effects on men’s and women’s decisions to enrol in ART. The authors found that non-disclosure of HIV status was strongly associated with non-uptake of ART among both sexes.

Reasons for men not being on ART seemed to be related to ideas about masculinity while women were more likely to not enrol owing to financial factors. Women who participated in community activities and who were part of a cohesive network within their neighbourhoods, were at lower risk of not enrolling in ART than their counterparts. Conversely, men from discohesive neighbourhoods were at higher risk for non-uptake of ART. Anticipation of side effects and poor health status were associated with poor uptake among men. The authors suggest that this may be due to the fact that ill-health and spending time worrying about one’s health can be seen as signs of weakness among men. These findings are consistent with patterns of HIV treatment seeking behaviour as men usually tend to seek care when the disease is at a late stage, and when CD4 counts are particularly low.

The authors suggest that ART clinics and health centres are often seen as female spaces and so men might not feel comfortable accessing them. Strong social ties, especially in situations where poverty is persistent, appear to have a positive effect on uptake among women. On the other hand, this seems to have the opposite effect in men. This could be because of social pressures associated with masculinity. The authors conclude that HIV programming needs to reach out to men in order to avoid turning HIV into a ‘feminised epidemic’ and that programmes focusing on men need to be expanded. 

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

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

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

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

Abstract

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

Africa
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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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Late pharmacy refill identifies patients at risk of poor ART outcomes

Short communication: late refills during the first year of antiretroviral therapy predict mortality and program failure among HIV-infected adults in urban Zambia.

Vinikoor MJ, Schuttner L, Moyo C, Li M, Musonda P, Hachaambwa LM, Stringer JS, Chi BH. AIDS Res Hum Retroviruses 2014 Jan;30(1):74-7. doi: 10.1089/AID.2013.0167. Epub 2013 Aug 30.

We evaluated the association of the number of late antiretroviral therapy (ART) refills with patient outcomes in a large public-sector human immunodeficiency virus treatment program in Lusaka, Zambia. Using pharmacy data routinely collected during 2004-2010, we calculated the number of late refills during the initial year of ART. We used multivariable Cox proportional hazard regression to examine the association between the number of late refills and death or program failure (i.e., death, loss to follow-up, or program withdrawal) >12 months after ART initiation, with and without stratification by the medication possession ratio (MPR) during the initial year of ART. Of 53 015 adults who received ART for ≥12 months (median follow-up duration, 86.1 months; interquartile range, 53.2-128.2 months), 26 847 (50.6%) had 0 late refills, 16 762 (31.6%) had 1, 6 505 (12.3%) had 2, and 2,901 (5.5%) had ≥3. Kaplan-Meier analysis revealed that ≥3 late refills was associated with a greater mortality risk than 1 and 2 late refills (p<0.001, by the log-rank test). The mortality risk was greater for patients with 2 late refills [adjusted hazard ratio (HR), 1.17; 95% confidence interval (CI), 0.99-1.38] or ≥3 late refills (adjusted HR, 1.51; 95% CI, 1.23-1.87), compared with that for patients with 0-1 late refills. Program failure was associated with ≥2 late refills. An MPR of <80% was associated with similar increases in mortality risk across late-refill strata. Monitoring late refills during the initial period of ART may help resource- and time-constrained clinics identify patients at risk for program failure.

Abstract access 

Editor’s notes: As antiretroviral therapy roll-out continues and the number of patients being followed up increases, strategies to promote retention in care which are feasible to use in busy clinics will become ever more important. Identifying patients at higher risk of loss to follow-up, who might benefit from more intensive support, is difficult. Adherence measures based on pharmacy refill data are attractive because they are objective, are predictive of virologic outcomes, use routinely-collected data, and do not place an additional burden on clinic staff.

This study covered over 50 000 patients taking antiretroviral therapy for more than 12 months in Zambia. Findings show that an increasing number of late pharmacy refills in the first year on antiretroviral therapy predicted death, and a composite outcome comprising death and loss from programme, measured after 12 months on treatment. These data support the use of pharmacy refill records to identify patients who may need additional support. Further research is needed to establish how best to combine early identification of risk with effective measures to maximise retention in care.

Africa
Zambia
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Low cost intervention package increases follow-up testing rates among couples attending voluntary HIV counselling and testing (VCT)

Predictors of first follow-up HIV testing for couples' voluntary HIV counseling and testing in Ndola, Zambia.

Czaicki NL, Davitte J, Siangonya B, Kastner R, Ahmed N, Khu NH, Kuo WH, Abdallah J, Wall KM, Tichacek A, Inambao M, Simpungwe K, Thior I, Allen S J Acquir Immune Defic Syndr. 2013 Dec 8. [Epub ahead of print]

Introduction: We describe predictors of first follow-up testing for concordant negative and discordant couples seeking joint voluntary HIV counseling and testing in Ndola, Zambia, where cohabiting couples account for an estimated two-thirds of incident HIV infections.

Methods: Demographic and serostatus data were collected from couples' voluntary HIV testing and counseling (CVCT) and follow-up testing services implemented in government clinics. We calculated follow-up testing rates by serostatus and compared rates before and after the introduction of a Good Health Package (GHP).

Results: The follow-up testing rate from May 2011 to December 2012 was 12.2% for concordant negative (M-F-) couples and 24.5% for discordant (M+F- or M-F+) couples. Significant predictors of follow-up testing in multivariate analyses included increasing man's (aOR=1.02 per year) and woman's (aOR=1.02) age, the man being HIV+ (aOR=2.57), and the woman being HIV+ (aOR=1.89). The man (aOR=1.29) and the couple (aOR=1.22) having been previously tested for HIV were predictive of follow-up testing among concordant negative couples. Introduction of a GHP increased follow-up testing among discordant (aOR=2.93) and concordant negative (aOR=2.06) couples.

Conclusion: A low-cost GHP including prevention, screening, and treatment for common causes of morbidity and mortality resulted in increased follow-up testing rates among HIV discordant and concordant negative couples. Overall follow-up testing rates remain low and efforts to increase these rates are necessary in order to ensure linkage to combination prevention, reduce HIV transmission within couples and identify seroconversions promptly. Further investigation of low-cost sustainable incentives and other factors influencing follow-up HIV testing for couples is needed.

Abstract access

Editor's notes: Couples’ voluntary HIV counselling and testing (CVCT) offers a promising route for reaching high-risk individuals in sub-Saharan Africa, where heterosexual transmission predominates. Though found to be cost-effective in research settings, CVCT’s impact is limited by low rates of follow-up counselling. The investigators here analysed data from 10 806 couples attending CVCT services around Ndola, Zambia, of whom 12% were HIV-discordant couples and 88% were HIV-negative concordant. Follow-up visits were scheduled for three to eight weeks after the initial CVCT visit. Only 13.6% of couples attended this visit. The most substantial predictor for follow up for all couples was the presence of the Good Health Practice package of prevention, screening and treatment services at the clinic, which was associated with a doubling of the follow-up rate. These results provide further justification for integrating HIV services into primary health care services - and vice versa - and the benefits possible for multiple health conditions with this approach.

Africa
Zambia
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Safety of tenofovir during pregnancy

Safety of tenofovir during pregnancy for the mother and fetus: a systematic review.

Wang L, Kourtis AP, Ellington S, Legardy-Williams J, Bulterys M. Clin Infect Dis. 2013 Dec;57(12):1773-81. doi: 10.1093/cid/cit601. Epub 2013 Sep 17.

Tenofovir disoproxil fumarate (TDF) safety during pregnancy has important public health implications. This review summarizes TDF safety during pregnancy, focusing on pregnancy outcomes, congenital anomaly risk, and other potential toxicities on neonates. Although information is limited, TDF appears to be safe during pregnancy. In 6 studies of human immunodeficiency virus type 1 (and/or hepatitis B virus)-infected women receiving TDF during pregnancy, adverse events were mild to moderate; none were considered to be TDF-related. Five studies that followed in utero TDF-exposed infants showed no increased risk of growth or bone abnormalities. One study showed slightly lower infant height at age 1 year, but the significance is unclear. The Antiretroviral Pregnancy Registry database, with 1 800 pregnancies exposed to TDF in the first trimester, does not indicate increased congenital anomaly risk with TDF exposure. More evidence collected prospectively, ideally with bone density measurements and randomized trial design, will be optimal to determine the effects of antenatal TDF exposure on children's health.

Abstract  Full-text [free] access

Editor’s notes: Tenofovir is a well-tolerated antiretroviral drug which is effective against HIV and hepatitis B. Due to these favourable characteristics and its once-daily dosing, tenofovir is increasingly used in clinical practice. As a result, more women are exposed to this drug at conception and during pregnancy. Tenofovir is classified by the US Food and Drug Administration as a pregnancy category B drug. This means that there is insufficient evidence to determine risk in humans. The authors of this paper provide the reader with an updated systematic review of the safety of tenofovir in pregnancy. Amongst the studies looking at adverse events in infants and mothers, no serious adverse events occurred which were attributed to tenofovir. Likewise, no study identified an increased risk of growth or bone abnormalities in infants up to two years of age. These studies need to be interpreted with caution as many studies had small sample sizes and in some studies the duration of exposure to tenofovir was short (single dose-seven days). Arguably, the most reassuring evidence comes from the antiretroviral pregnancy registry database report, which showed no increased risk of congenital anomalies amongst 1 800 infants exposed to tenofovir in utero. This systematic literature review notes the paucity of available evidence to guide decision-making and highlights the need for further studies to determine the risk to humans of tenofovir exposure during pregnancy.

HIV Treatment
Africa, Asia, Europe, Northern America
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Response to measles vaccination in children on antiretroviral therapy

Changes in measles serostatus among HIV-infected Zambian children initiating antiretroviral therapy before and after the 2010 measles outbreak and supplemental immunization activities.

Rainwater-Lovett K, Nkamba HC, Mubiana-Mbewe M, Bolton-Moore C, Moss WJ. J Infect Dis. 2013 Dec 1;208(11):1747-55. doi: 10.1093/infdis/jit404. Epub 2013 Aug 2.

Background: In 2010, Zambia had a large measles outbreak, providing an opportunity to measure changes in measles serostatus following highly active antiretroviral therapy (HAART), exposure to measles virus, and revaccination among children infected with human immunodeficiency virus (HIV).

Methods: A prospective cohort study of 169 HIV-infected Zambian children aged 9-60 months with a history of measles vaccination was conducted to characterize the effects of HAART and revaccination on measles immunoglobulin G (IgG) serostatus by enzyme immunoassay.

Results: Prior to the measles outbreak, only 23% of HIV-infected children were measles IgG seropositive at HAART initiation. After adjusting for 6-month changes in baseline age and 5% changes in nadir CD4+ T-cell percentage, HAART was not associated with measles IgG seroconversion. However, 18 of 19 children seroconverted after revaccination. Eight children seroconverted during the outbreak without revaccination and were likely exposed to wild-type measles virus, but none were reported to have had clinical measles.

Conclusions: Immune reconstitution after HAART initiation did not restore protective levels of measles IgG antibodies, but almost all children developed protective antibody levels after revaccination. Some previously vaccinated HIV-infected children had serological evidence of exposure to wild-type measles virus without a reported history of measles.

Abstract access 

Editor’s notes: Successful immunisation campaigns in Africa resulted in >90% decline in measles cases by 2008. However, maintenance of high levels of population immunity and surveillance are vital to prevent outbreaks. HIV-positive children have lower response rates to measles vaccination and a poorer qualitative response to the vaccine compared to HIV-negative children. This study showed that less than 50% of vaccinated HIV-positive children had protective antibody levels. Immune reconstitution after starting antiretroviral therapy (ART) did not have any effect to restore protective antibody levels to measles virus. But, revaccination did result in most children seroconverting (i.e. developing protective measles antibodies).

With the scale up of ART, HIV-associated mortality has declined substantially. However, immune reconstitution does not restore protection against these infections. Further, the increased survival due to ART also results in an accumulation of HIV-positive children susceptible to diseases such as measles. The findings of this study would support revaccination of HIV-positive children not only for individual protection but also for measles elimination.

Avoid TB deaths
Africa
Zambia
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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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Congenital CMV infection in Zambia – further population-based studies needed

High rates of congenital cytomegalovirus (CMV) infections linked with maternal HIV infection among neonatal admissions at a large referral centre in sub-Saharan Africa.

Mwaanza N, Chilukutu L, Tembo J, Kabwe M, Musonda K, Kapasa M, Chabala C, Sinyangwe S, Mwaba P, Zumla A, Bates M. Clin Infect Dis. 2013 Nov 21. [Epub ahead of print]

Congenital cytomegalovirus (CMV) infection is the major infectious cause of birth defects and hearing loss globally. There is a growing recognition of the potential clinical impact of congenital CMV infections in high seroprevalence settings.

Methods: A cross-sectional study of neonatal admissions at a large referral centre in sub-Saharan Africa to determine the prevalence of both symptomatic and asymptomatic congenital CMV infection. Real Time PCR was used to screen DNA-extracted from sera, urine and saliva, and an ELISA assay was used to screen sera for anti-CMV IgM. Multivariate binary logistic regression was used to identify risk factors associated with increased odds of congenital CMV infection.

Results: Congenital CMV was detected in 3.8% (15/395) of neonates. Among these cases 40% (6/15) presented with jaundice, one of which also had petechiae. Congenital CMV infection was detected in 11.4% (9/79) [6.1-20.3%] of neonates born to HIV-infected mothers and both maternal HIV (OR 6.661 [2.126-20.876], p=0.001) and jaundice (OR 5.701 [1.776-18.306], p=0.003) were independently linked with significantly increased odds of congenital CMV infection.

Conclusion: Congenital and early infant CMV infections may have important consequences for child health in sub-Saharan Africa and other high HIV and CMV seroprevalence populations globally.

Abstract access

Editor’s notes: Congenital cytomegalovirus (CMV) can lead to hearing impairment and neurodevelopmental delay, but few studies have estimated the prevalence of congenital CMV infection in Sub-Saharan Africa. This may be because it has been assumed that clinical impact of congenital CMV is likely to be low, resulting primarily from maternal re-infections or reactivations of CMV. This study recruited from an inpatient neonatal population in Lusaka, Zambia, and found a high prevalence of congenital CMV (3.8%) in this population and a strong association with maternal HIV infection.  The number of cases was small but a substantial minority (40%) were symptomatic. Limitations of the study include selection biases due to the recruitment process, and lack of information on antiretroviral status of the mother. Despite these, the study highlights the need for further, population-based studies in high HIV prevalence settings to assess the prevalence and risk factors for congenital CMV more widely, including the role of ART and maternal viral shedding on risk of transmission. 

Africa
Zambia
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Persistent gender inequities in ART uptake and retention in sub-Saharan Africa – strategies needed to better engage men.

Differences Between HIV-Infected Men and Women in Antiretroviral Therapy Outcomes - Six African Countries, 2004-2012.

Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2013 Nov 29;62(47):946-52.

Evaluation of differences between human immunodeficiency virus (HIV)-infected men and women in antiretroviral therapy (ART) enrollment characteristics and outcomes might identify opportunities to improve ART program patient outcomes and prevention impact. During September 2008-February 2012, retrospective cohort studies to estimate attrition of enrollees (i.e. from death, stopping ART, or loss to follow-up) at 6-month intervals after ART initiation were completed among samples of adult men and women (defined as aged ≥15 years or aged ≥18 years) who initiated ART during 2004-2010 in six African countries: Côte d'Ivoire in western Africa; Swaziland, Mozambique, and Zambia in southern Africa; and Uganda and Tanzania in eastern Africa. Records for 13 175 ART enrollees were analyzed; sample sizes among the six countries ranged from 1 457 to 3 682. In each country, women comprised 61%-67% of ART enrollees. Median CD4 count range was 119-141 cells/µL for men and 137-161 cells/µL for women. Compared with women, a greater percentage of men initiated ART who had World Health Organization (WHO) HIV stage IV disease. In cohorts from western Africa and southern Africa, the risk for attrition was 15%-26% lower among women compared with men in multivariable analysis. However, in eastern Africa, differences between men and women in risk for attrition were not statistically significant. Research to identify country-specific causes for increased attrition and delayed initiation of care among men could identify strategies to improve ART program outcomes among men, which might contribute to prevention of new HIV infections in female partners.

Abstract   Full-text [free] access

Editor’s notes: Equitable access to treatment is a widely endorsed principle in all fields of medicine. This study on gender differences in the uptake and outcomes of antiretroviral therapy (ART) provides programme managers with the evidence to assess and possibly rectify any imbalance. The study is based on clinical cohort data from six geographically diverse African countries. The study found that (1) women account for the majority of patients on ART, (2) they are less likely to enrol with advanced HIV disease, and (3) they have lower attrition rates (mortality, loss to follow up, etc.), after adjusting for possible baseline predictors of survival such as the CD4 count. The first of the three findings may be related to higher eligibility rates in women, which is difficult to assess using clinical data alone. It may also be related to the evidence in favour of higher male attrition rates that was not as strong in the two East African sites. We also need to bear in mind that higher attrition may result from causes unrelated to HIV (see Sabin CA in this issue). Aside from these caveats, the results do indeed suggest that greater effort is necessary to engage men in HIV treatment and care programmes.  This will rectify the apparent imbalance in treatment uptake and outcomes, and it will also have implications for onward transmission to their (female) partners. 

Africa
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