Articles tagged as "15 million accessing treatment"

A novel approach to increase Early Infant Diagnosis of HIV

If you text them, they will come: using the HIV infant tracking system to improve early infant diagnosis quality and retention in Kenya

Finocchario-Kessler S, Gautney BJ, Khamadi S, Okoth V, Goggin K, Spinler JK, Mwangi A, Kimanga D, Clark KF, Olungae HD, Preidis GA, Team HI. AIDS. 2014 Jul;28 Suppl 3:S313-21. doi: 10.1097/QAD.0000000000000332.

Objective: The objective of this study is to evaluate the impact of the HIV Infant Tracking System (HITSystem) for quality improvement of early infant diagnosis (EID) of HIV services.

Design and setting: This observational pilot study compared 12 months of historical pre-intervention EID outcomes at one urban and one peri-urban government hospital in Kenya to 12 months of intervention data to assess retention and time throughout the EID cascade of care.

Participants: Mother-infant pairs enrolled in EID at participating hospitals before (n = 320) and during (n = 523) the HITSystem pilot were eligible to participate.

Intervention: The HITSystem utilizes Internet-based coordination of the multistep PCR cycle, automated alerts to trigger prompt action from providers and laboratory technicians, and text messaging to notify mothers when results are ready or additional action is needed.

Main outcome measures: The main outcome measures were retention throughout EID services, meeting time-sensitive targets and improving results turn-around time, and increasing early antiretroviral therapy (ART) initiation among HIV-infected infants.

Results: The HITSystem was associated with an increase in the proportion of HIV-exposed infants retained in EID care at 9 months postnatal (45.1-93.0% urban; 43.2-94.1% peri-urban), a decrease in turn-around times between sample collection, PCR results and notification of mothers in both settings, and a significant increase in the proportion of HIV-infected infants started on antiretroviral therapy at each hospital (14 vs. 100% urban; 64 vs. 100% peri-urban).

Conclusion: The HITSystem maximizes the use of easily accessible technology to improve the quality and efficiency of EID services in resource-limited settings.

Abstract access

Editor’s notes: This study, based in Kenya uses a novel approach to improve EID and increase infant initiation of antiretroviral therapy (ART). Despite some limitations (being an observational study and using historical controls), the method not only increased the proportion of HIV-exposed infants retained in care but importantly also reduced turn-around times. Given the near universal access to mobile phones even in low resource settings, these findings are highly encouraging in this challenging area of HIV care delivery. The authors highlight that the novel system which integrates customised alerts (Internet and SMS-based) with dedicated prospective tracking of clients, successfully addresses multiple implementation barriers for the EID cascade of care. They further suggest that HITSystem implementation is feasible in remote areas, as it requires neither a continuous supply of electricity nor wire-based Internet access, provided site mobile broadband can be accessed. Such a system could also be beneficial for other areas of adherence support and further exploration is warranted.

Health care delivery
Africa
Kenya
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Converging epidemics of HIV and hypertension in Africa

Hypertension, kidney disease, HIV and antiretroviral therapy among Tanzanian adults: a cross-sectional study.

Peck RN, Shedafa R, Kalluvya S, Downs JA, Todd J, Suthanthiran M, Fitzgerald DW, Kataraihya JB. BMC Med. 2014 Jul 29;12(1):125. [Epub ahead of print]

Background: The epidemics of HIV and hypertension are converging in sub-Saharan Africa. Due to antiretroviral therapy (ART), more HIV-infected adults are living longer and gaining weight, putting them at greater risk for hypertension and kidney disease. The relationship between hypertension, kidney disease and long-term ART among African adults, though, remains poorly defined. Therefore, we determined the prevalences of hypertension and kidney disease in HIV-infected adults (ART-naive and on ART >2 years) compared to HIV-negative adults. We hypothesized that there would be a higher hypertension prevalence among HIV-infected adults on ART, even after adjusting for age and adiposity.

Methods: In this cross-sectional study conducted between October 2012 and April 2013, consecutive adults (>18 years old) attending an HIV clinic in Tanzania were enrolled in three groups: 1) HIV-negative controls, 2) HIV-infected, ART-naive, and 3) HIV-infected on ART for >2 years. The main study outcomes were hypertension and kidney disease (both defined by international guidelines). We compared hypertension prevalence between each HIV group versus the control group by Fisher’s exact test. Logistic regression was used to determine if differences in hypertension prevalence were fully explained by confounding.

Results: Among HIV-negative adults, 25/153 (16.3%) had hypertension (similar to recent community survey data). HIV-infected adults on ART had a higher prevalence of hypertension (43/150 (28.7%), P=0.01) and a higher odds of hypertension even after adjustment (odds ratio (OR)= 2.19 (1.18 to 4.05), P=0.01 in the best model). HIV-infected, ART-naive adults had a lower prevalence of hypertension (8/151 (5.3%), P= 0.003) and a lower odds of hypertension after adjustment (OR 0.35 (0.15 to 0.84), P= 0.02 in the best model). Awareness of hypertension was 25% among hypertensive adults in all three groups. Kidney disease was common in all three groups (25.6% to 41.3%) and strongly associated with hypertension (P <0.001 for trend); among hypertensive participants, 50/76 (65.8%) had microalbuminuria and 20/76 (26.3%) had an estimated glomerular filtration rate (eGFR) <60 versus 33/184 (17.9%) and 16/184 (8.7%) participants with normal blood pressure.

Conclusions: HIV-infected adults on ART >2 years had two-fold greater odds of hypertension than HIV-negative controls. HIV-infected adults with hypertension were rarely aware of their diagnosis but often have evidence of kidney disease. Intensive hypertension screening and education are needed in HIV-clinics in sub-Saharan Africa. Further studies should determine if chronic, dysregulated inflammation may accelerate hypertension in this population.

Abstract  Full-text [free] access

Editor’s notes: The prevalence of both hypertension and HIV in sub-Saharan Africa is the highest among any region in the world. Hypertension is a leading risk factor for disease and accounts for nearly 10 million deaths a year. As antiretroviral therapy (ART) coverage has increased, infection-related mortality rates have substantially declined. Increased life-expectancy and weight gain among people taking ART may “unmask” an epidemic of hypertension in sub-Saharan Africa, where, unlike other global regions, the blood pressure of adults continues to rise.

This study showed a high prevalence of hypertension among HIV-positive adults taking ART for two or more years. The prevalence was nearly double that among HIV-negative adults, even after adjusting for age, sex and adiposity. In contrast, the prevalence of hypertension among ART-naïve adults was significantly lower than that among HIV-negative adults. There was no association between use of the first line antiretroviral drugs and hypertension, suggesting that the high prevalence of drugs cannot be explained by the type of drugs used to treat HIV infection.

Of concern, only 25% of hypertensive adults were aware of their condition. Among HIV-positive adults on ART, some 75% of those with hypertension were undiagnosed, some 85% were untreated and more than 95% were uncontrolled. Importantly, hypertension was strongly associated with kidney disease. Given that this is a cross-sectional study, it is not clear whether hypertension preceded kidney disease or vice versa.

Given the high prevalence of hypertension among HIV-positive peoples and that HIV is now a treatable, chronic condition, HIV care provides an opportunity for management of hypertension and should be considered as an integral aspect of HIV care. Studies are needed to understand the role of HIV and ART in causing hypertension, so that appropriate management strategies can be developed.

Comorbidity, HIV Treatment
Africa
United Republic of Tanzania
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Different strokes for different folks with HIV testing and counselling

Four models of HIV counselling and testing: utilization and test results in South Africa

Mabuto T, Latka MH, Kuwane B, Churchyard GJ, Charalambous S, Hoffmann CJ. PLoS One. 2014 Jul 11. DOI: 10.1371/journal.pone.0102267

Background: HIV Counselling and Testing (HCT) is the point-of-entry for pathways of HIV care and prevention. However, HCT is not reaching many who are HIV infected and this may be related to the HCT provision model. We describe HCT utilization and HIV diagnosis using four models of HCT delivery: clinic-based, urban mobile, rural mobile, and stand-alone.

Methods: Using cross-sectional data from routine HCT provided in South Africa, we described client characteristics and HIV test results from information collected during service delivery between January 2009 and June 2012.

Results: 118 358 clients received services at clinic-based units, 18 597; stand-alone, 28 937; urban mobile, 38 840; and rural mobile, 31 984. By unit, clients were similar in terms of median age (range 28-31), but differed in sex distribution, employment status, prior testing, and perceived HIV risk. Urban mobile units had the highest proportion of male clients (52%). Rural mobile units reached the highest proportion of clients with no prior HCT (61%) and reporting no perceived HIV risk (64%). Overall, 10 862 clients (9.3%) tested HIV-positive.

Conclusions: Client characteristics varied by HCT model. Importantly, rural and urban mobile units reached more men, first-time testers, and clients who considered themselves to be at low risk for HIV.

Abstract  Full-text [free] access

Editor’s notes: This study compared cross-sectional data across four HIV Counselling and Testing (HCT) models during a two and half year time period in South Africa. The study took into account 121 038 individuals who were tested through the four models. Some data were not captured for all individuals. However, this relatively large sample provides valuable information about the characteristics of individuals who took up testing through each of the four models. The study reports strengths for each of the models: men were more likely to be reached through the rural and urban mobile units, as were first time testers and individuals who perceived themselves to be at lower risk for acquiring HIV. Overall, both the mobile units reached more people, with a higher proportion unemployed. However, the standalone model served more employed individuals and could easily refer within the clinic for other health issues. What is clear from this study is that there is a place for each of the models and that options matter for individuals to enable the system to reach as many as possible. One model cannot accommodate everyone. This is similar to the idea that options for contraception, and even more recently for HIV prevention, are important. People have different needs depending on who they are, where they live, and what they do. Providing options which serve the diversity of needs will allow for greater accessibility and acceptability of services. 

HIV testing
Africa
South Africa
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Getting high on treatment – a cause for concern

Whoonga and the abuse and diversion of antiretrovirals in Soweto, South Africa.

Rough K, Dietrich J, Essien T, Grelotti DJ, Bansberg DR, Gray G, Katz IT AIDS Behavior. 2014 Jul;18(7):1378-80. doi: 10.1007/s10461-013-0683-x.

Media reports have described recreational use of HIV antiretroviral medication in South Africa, but little has been written about this phenomenon in the scientific literature. We present original, qualitative data from eight semi-structured interviews that characterize recreational antiretroviral use in Soweto, South Africa. Participants reported that antiretrovirals, likely efavirenz, are crushed, mixed with illicit drugs (in a mixture known as whoonga), and smoked. They described medications being stolen from patients and expressed concern that antiretroviral abuse jeopardized the safety of both patients and users. Further studies are needed to understand the prevalence, patterns, and consequences of antiretroviral abuse and diversion.

Abstract access 

Editor’s notes: This short report is based on information provided by eight out of 43 participants of a study on decision making linked to HIV-treatment refusal.  The team did not, therefore, set out to gather data on the misuse of anti-retroviral drugs.  However, eight people volunteered information on the use of efavirenz to `get high’ by people in their communities.  The authors’ call for further research is timely with the move to `test and treat’. With more people who may not perceive themselves to be ill taking antiretroviral therapy, there may be an increased risk of drugs being sold on the black market for illicit use.

Africa
South Africa
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Home-based HIV testing improves health-seeking behaviour

The impact of home-based HIV counselling and testing on care-seeking and incidence of common infectious disease syndromes in rural western Kenya.

Bigogo G, Amolloh M, Laserson KF, Audi A, Aura B, Dalal W, Ackers M, Burton D, Breiman RF, Feikin DR. BMC Infect Dis. 2014 Jul 8;14(1):376. doi: 10.1186/1471-2334-14-376.

Background: In much of Africa, most individuals living with HIV do not know their status. Home-based counselling and testing (HBCT) leads to more HIV-infected people learning their HIV status. However, there is little data on whether knowing one's HIV-positive status necessarily leads to uptake of HIV care, which could in turn, lead to a reduction in the prevalence of common infectious disease syndromes.

Methods: In 2008, Kenya Medical Research Institute (KEMRI) in collaboration with the Centers for Disease Control and Prevention (CDC) offered HBCT to individuals (aged ≥13 years) under active surveillance for infectious disease syndromes in Lwak in rural western Kenya. HIV test results were linked to morbidity and healthcare-seeking data collected by field workers through bi-weekly home visits. We analyzed changes in healthcare seeking behaviors using proportions, and incidence (expressed as episodes per person-year) of acute respiratory illness (ARI), severe acute respiratory illness (SARI), acute febrile illness (AFI) and diarrhea among first-time HIV testers in the year before and after HBCT, stratified by their test result and if HIV-positive, whether they sought care at HIV Patient Support Centers (PSCs).

Results: Of 9 613 individuals offered HBCT, 6 366 (66%) were first-time testers, 698 (11%) of whom were HIV-infected. One year after HBCT, 50% of HIV-infected persons had enrolled at PSCs - 92% of whom had started cotrimoxazole and 37% of those eligible for antiretroviral treatment had initiated therapy. Among HIV-infected persons enrolled in PSCs, AFI and diarrhea incidence decreased in the year after HBCT (rate ratio [RR] 0.84; 95% confidence interval [CI] 0.77 - 0.91 and RR 0.84, 95% CI 0.73 - 0.98, respectively). Among HIV-infected persons not attending PSCs and among HIV-uninfected persons, decreases in incidence were significantly lower. While decreases also occurred in rates of respiratory illnesses among HIV-positive persons in care, there were similar decreases in the other two groups.

Conclusions: Large scale HBCT enabled a large number of newly diagnosed HIV-infected persons to know their HIV status, leading to a change in care seeking behavior and ultimately a decrease in incidence of common infectious disease syndromes through appropriate treatment and care.

Abstract  Full-text [free] access

Editor’s notes: HIV testing is the entry point to HIV care and treatment. Despite increased availability of HIV treatment, many people in Africa still do not know their HIV status. Home-based counselling and testing (HBCT) has been used in some countries as a strategy to increase HIV testing rates.  However, the benefits of testing can only be fully realised if individuals who test HIV-positive are subsequently linked to care services.

In this study, 79% of individuals offered testing through a mass HBCT campaign accepted and 11% tested HIV-positive, showing that this is an effective strategy for improving HIV testing rates. By 24 months, only 58% of individuals who tested HIV-positive had enrolled into care. However, HBCT led to a change in health-seeking behaviour. This was demonstrated by an increase in proportion of clinic attendances for common infectious illnesses compared to the period before HBCT was implemented, among newly diagnosed HIV-positive persons who engaged in care. In addition, there was a significant decrease in incidence of common infectious disease among newly diagnosed HIV-positive persons; this is likely to be due to the use of cotrimoxazole prophylaxis and antiretroviral therapy following linkage to HIV care.

The main limitation of this study was that the differences in disease pre-and post-HBCT could be due to annual variations in disease burden, or due to other temporal factors. Notwithstanding this, the study does demonstrate that HBCT changed health-seeking behaviour, which in turn may reduce the incidence of common infectious disease.  As with all HIV testing strategies, in order to realise the full benefits of HBCT, it is crucial to ensure linkage to HIV care for individuals who test HIV-positive. 

Africa
Kenya
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Home initiation of ART may be valuable addition to services to achieve universal access to treatment

Effect of optional home initiation of HIV care following HIV self-testing on antiretroviral therapy initiation among adults in Malawi: a randomized clinical trial

MacPherson P, Lalloo DG, Webb EL, Maheswaran H, Choko AT, Makombe SD, Butterworth AE, van Oosterhout JJ, Desmond N, Thindwa D, Squire SB, Hayes RJ, Corbett EL Journal of the American Medical Association. 2014 Jul 23-30;312(4):372-9. doi: 10.1001/jama.2014.6493.

Importance: Self-testing for HIV infection may contribute to early diagnosis of HIV, but without necessarily increasing antiretroviral therapy (ART) initiation.

Objective: To investigate whether offering optional home initiation of HIV care after HIV self-testing might increase demand for ART initiation, compared with HIV self-testing accompanied by facility-based services only.

Design, setting, and participants: Cluster randomized trial conducted in Blantyre, Malawi, between January 30 and November 5, 2012, using restricted 1:1 randomization of 14 community health worker catchment areas. Participants were all adult (≥16 years) residents (n = 16 660) who received access to home HIV self-testing through resident volunteers. This was a second-stage randomization of clusters allocated to the HIV self-testing group of a parent trial.

Interventions: Clusters were randomly allocated to facility-based care or optional home initiation of HIV care (including 2 weeks of ART if eligible) for participants reporting positive HIV self-test results.

Main outcomes and measures: The pre-planned primary outcome compared between groups the proportion of all adult residents who initiated ART within the first 6 months of HIV self-testing availability. Secondary outcomes were uptake of HIV self-testing, reporting of positive HIV self-test results, and rates of loss from ART at 6 months.

Results: A significantly greater proportion of adults in the home group initiated ART (181/8 194, 2.2%) compared with the facility group (63/8 466, 0.7%; risk ratio [RR], 2.94, 95% CI, 2.10-4.12; P < .001). Uptake of HIV self-testing was high in both the home (5 287/8 194, 64.9%) and facility groups (4 433/8 466, 52.7%; RR, 1.23; 95% CI, 0.96-1.58; P = .10). Significantly more adults reported positive HIV self-test results in the home group (490/8 194 [6.0%] vs the facility group,   278/8 466 [3.3%]; RR, 1.86; 95% CI, 1.16-2.97; P = .006). After 6 months, 52 of 181 ART initiators (28.7%) and 15 of 63 ART initiators (23.8%) in the home and facility groups, respectively, were lost from ART (adjusted incidence rate ratio, 1.18; 95% CI, 0.62-2.25, P = .57).

Conclusions and relevance: Among Malawian adults offered HIV self-testing, optional home initiation of care compared with standard HIV care resulted in a significant increase in the proportion of adults initiating ART.

Abstract  Full-text [free] access 

Editor’s notes: This study extends the recent drive to bring HIV testing closer to individuals and away from facilities by offering the option of initiating ART at the door-step. There are many benefits of such a strategy for asymptomatic individuals, and the popularity is clear from the high uptake of self-testing in this and other studies. The higher self-report of HIV positivity in the home initiating group probably reflects favourable disclosure and low stigma related conditions for this subset of community members. It is noteworthy that a greater number of home initiators were lost-to-follow-up 6 months after initiating ART. The authors highlight that the difference was not statistically significant. Although the pooled retention across initiation groups was lower than national retention data i.e., ART retention at 6 months was 72% vs 80% in the Malawi national programme, it was still within the range seen in other programmes. Home initiation of ART may be a valuable addition to services in the drive towards universal access to treatment. 

Health care delivery
Africa
Malawi
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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
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High mortality in people taking antiretroviral therapy with delayed switching following virologic failure

Delayed switch of antiretroviral therapy after virologic failure associated with elevated mortality among HIV-infected adults in Africa.

Petersen ML, Tran L, Geng EH, Reynolds SJ, Kambugu A, Wood R, Bangsberg DR, Yiannoutsos CT, Deeks SG, Martin JN. AIDS. 2014 Jun 28. [Epub ahead of print].

Objective: Routine monitoring of plasma HIV RNA among HIV-infected patients on antiretroviral therapy (ART) is unavailable in many resource-limited settings. Alternative monitoring approaches correlate poorly with virologic failure and can substantially delay switch to second-line therapy. We evaluated the impact of delayed switch on mortality among patients with virologic failure in Africa.

Design: A cohort.

Methods: We examined patients with confirmed virologic failure on first-line nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimens from four cohorts with serial HIV RNA monitoring in Uganda and South Africa. Marginal structural models aimed to estimate the effect of delayed switch on mortality in a hypothetical trial in which switch time was randomly assigned. Inverse probability weights adjusted for measured confounders including time-updated CD4 cell count and HIV RNA.

Results: Among 823 patients with confirmed virologic failure, the cumulative incidence of switch 180 days after failure was 30% [95% confidence interval (95% CI 27-33]. The majority of patients (74%) had not failed immunologically (as defined by WHO criteria) by the time of virologic failure. Adjusted mortality was higher for individuals who remained on first-line therapy than for those who had switched [odds ratio (OR) 2.1, 95% CI 1.1-4.2]. Among those without immunologic failure, the relative harm of failure to switch was similar (OR 2.4; 95% CI 0.99-5.8) to that of the entire cohort, although of borderline statistical significance.

Conclusion: Among HIV-infected patients with confirmed virologic failure on first-line ART, remaining on first-line therapy led to an increase in mortality relative to switching. Our results suggest that detection and response to confirmed virologic failure could decrease mortality.

Abstract access 

Editor’s notes: The World Health Organization recommends scaling up access to routine viral load monitoring. This will enable healthcare workers to detect non-adherence and virologic failure earlier and to intervene to re-establish virologic control. This could be either on first-line antiretroviral therapy (ART) or by switching to second-line ART. If successful, this should limit the duration of viraemia, thereby limiting accumulation of resistance mutations and conserving future treatment options. The effect of viral load monitoring on mortality is less certain. To date, no randomised controlled trial has demonstrated a survival benefit of viral load monitoring over and above CD4 count monitoring. This may be due to study design - short follow-up time and intensive adherence support meant that few people experienced virologic failure. Previous observational studies described lower mortality in a South African cohort monitored using viral load monitoring as compared to a Malawian and Zambian cohort using CD4 count monitoring. However, subsequent mathematical modelling indicated that viral load monitoring only accounted for a small proportion of this difference. The rest was due to differences in resources, infrastructure and other unmeasured confounders. 

This study explored the impact on mortality of delayed switching following confirmed virologic failure. Among 7 975 people initiated on ART between 2002-2011, some 823 experienced confirmed virologic failure. As described by others, even in the context of routine viral load monitoring and access to second-line ART, marked delays in switching occur. The cumulative incidence of switching to second-line ART within six months of confirmed failure in this study was only 30%. Some of these ‘delays’ may have been due to the study definition of virologic failure. A lower viral load threshold was used in this study than was likely to have been used in the clinical guidelines.  Delays could also have been due to healthcare system factors such as delayed turn-around-time for results or difficulties in recalling people. However, healthcare worker factors, such as delayed switching to address adherence barriers or to avoid drug interactions, particularly with treatment for tuberculosis, are also likely to also have played a part. Regardless of the reasons for delays, after adjusting for measured confounders, mortality was higher for people who experienced delayed switching. Longer delay was associated with higher probability of death.

This study indicates that viral load monitoring alone may not be sufficient to reduce mortality. A greater understanding of the reasons for delays, together with innovative ways to ensure virologic failure is detected and managed in an effective, timely manner, is needed. 

HIV Treatment
Africa
South Africa, Uganda
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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
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Decentralization of HIV care and treatment services in Kenya

Decentralization of HIV care and treatment services in Central Province, Kenya. 

Reidy W, Sheriff M, Wang C, Hawken M, Koech E, Elul B, Kimanga D, Abrams E; for the Identifying Optimal Models of HIV Care in Africa: Kenya Consortium. J Acquir Immune Defic Syndr. 2014 Jun 26. [Epub ahead of print].

Background: Since 2006, the government of Kenya began decentralizing HIV care from secondary health facilities (SHF) to an expanded network including primary health facilities (PHF). We evaluated the impact of this strategy on enrollment, care, and outcomes among adult patients in Central Province, Kenya from 2006 to 2010.

Methods: We analyzed electronic patient-level data for 26 690 patients at 15 SHF and 22 PHF. Enrollment, patient and facility characteristics, and patterns in CD4+ testing, WHO staging, and ART initiation were compared between SHF and PHF. Survival analysis was used to estimate cumulative death and loss to follow-up (LTF) rates in PHF and SHF. Multivariate competing risks regression and Cox proportional hazards models were constructed to identify correlates of LTF and death.

Results: Enrollment in PHF increased mainly between 2007 and 2009, representing 5% and 25% of all new enrollments, respectively. CD4+ test provision and WHO staging, time to ART initiation, and CD4+ count at ART initiation were for the most part similar between PHF and SHF. In multivariate analyses, pre-ART patients enrolled in PHF had a lower risk of LTF than those enrolled in SHF (SHR=0.77, 95% CI: 0.61-0.96). No differences in risk of death among pre-ART patients, or in LTF or death among ART patients were observed.

Conclusion: Enrollment at PHF increased substantially during the period; death rates were comparable between PHF and SHF, while LTF among pre-ART patients was lower at PHF. This suggests that decentralization can be a successful strategy for expanding HIV care.

Abstract access 

Editor’s notes: As with many other countries in sub-Saharan Africa, Kenya has chosen the strategy of decentralisation of HIV services to peripheral health centres, to close the treatment gap.

The authors of this paper compared enrolment, people’ characteristics, and outcomes among nearly 27 000 people in HIV care at primary and secondary health facilities between 2006 and 2010. Over this period, the proportion of people living with HIV enrolled in care at primary health facilities increased substantially. People at primary health facilities had a somewhat healthier profile. This was possibly due to self-selection where sicker people refer themselves to secondary health facilities. No differences in mortality and loss to follow-up among people on antiretroviral therapy (ART) were observed between primary and secondary health facilities. Retention in care among people not yet on ART can be particularly challenging. So the finding that people in primary health facilities experienced lower loss to follow-up rates compared to people using secondary health facilities is useful evidence in support of decentralised care.

Decentralisation of care sometimes raises concerns that the quality of care may be less good when delivered by less specialised staff. This study compared quality of services such as assessment of people for ART eligibility and time to ART initiation. The authors found similar quality of services at primary and secondary health facilities. Interestingly people at primary health facilities were initiated earlier on ART after HIV diagnosis, possibly due to more frequent assessment of ART eligibility at these centres.

This large study is a useful addition to the evidence base supporting decentralised HIV care, with no evidence of loss of quality.

Health care delivery
Africa
Kenya
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