Articles tagged as "Eliminate travel restrictions"

Towards the elimination of travel restrictions for people living with HIV

HIV-related travel restrictions: trends and country characteristics.

Chang F, Prytherch H, Nesbitt RC, Wilder-Smith A. Glob Health Action. 2013 Jun3;6:20472. doi: 10.3402/gha.v6i0.20472.

Introduction: Increasingly, HIV-seropositive individuals cross international borders. HIV-related restrictions on entry, stay, and residence imposed by countries have important consequences for this mobile population. Our aim was to describe the geographical distribution of countries with travel restrictions and to examine the trends and characteristics of countries with such restrictions.

Methods: In 2011, data presented to UNAIDS were used to establish a list of countries with and without HIV restrictions on entry, stay, and residence and to describe their geographical distribution. The following indicators were investigated to describe the country characteristics: population at mid-year, international migrants as a percentage of the population, Human Development Index, estimated HIV prevalence (age: 15–49), presence of a policy prohibiting HIV screening for general employment purposes, government and civil society responses to having non-discrimination laws/regulations which specify migrants/mobile populations, government and civil society responses to having laws/regulations/policies that present obstacles to effective HIV prevention, treatment, care, and support for migrants/mobile populations, Corruption Perception Index, and gross national income per capita.

Results: HIV-related restrictions exist in 45 out of 193 WHO countries (23%) in all regions of the world. We found that the Eastern Mediterranean and Western Pacific Regions have the highest proportions of countries with these restrictions. Our analyses showed that countries that have opted for restrictions have the following characteristics: smaller populations, higher proportions of migrants in the population, lower HIV prevalence rates, and lack of legislation protecting people living with HIV from screening for employment purposes, compared with countries without restrictions.

Conclusion: Countries with a high proportion of international migrants tend to have travel restrictions – a finding that is relevant to migrant populations and travel medicine providers alike. Despite international pressure to remove travel restrictions, many countries continue to implement these restrictions for HIV-positive individuals on entry and stay. Since 2010, the United States and China have engaged in high profile removals. This may be indicative of an increasing trend, facilitated by various factors, including international advocacy and the setting of a UNAIDS goal to halve the number of countries with restrictions by 2015.

Abstract   Full-text [free] access 

Editor’s notes: Travel restrictions for people living with HIV were adopted by many governments in the early years of the epidemic when little was known about the disease and when there was great fear regarding its spread. This study describes the situation of such restrictions as of 2011, and the geographical distribution of countries with restrictions. Restrictions were present in almost a quarter of WHO countries, with little change in the total of numbers in the past 20 years, despite high profile examples of the US and China removing travel restrictions.  Health practitioners working with mobile populations are well placed to advise and educate individuals who may be affected by these restrictions. Impacts on individual health include an increased risk of interrupted adherence to ARV medication, risk of deportation and detainment, which may limit access to treatment, and risk of psychological stress in travel/immigration process.

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Point of care testing

Effect of point-of-care CD4 cell count tests on retention of patients and rates of antiretroviral therapy initiation in primary health clinics: an observational cohort study

Jani IV, Sitoe NE, Alfai ER, Chongo PL, Quevedo JI, Rocha BM, Lehe JD, Peter TF, Lancet. 2011 Oct 29;378(9802):1572-9. Epub 2011 Sep 25

Loss to follow-up of HIV-positive patients before initiation of antiretroviral therapy can exceed 50% in low-income settings and is a challenge to the scale-up of treatment. Jani and colleagues implemented point-of-care counting of CD4 cells in Mozambique and assessed the effect on loss to follow-up before immunological staging and treatment initiation. In this observational cohort study, data for enrolment into HIV management and initiation of antiretroviral therapy were extracted retrospectively from patients' records at four primary health clinics providing HIV treatment and point-of-care CD4 services. Loss to follow-up and the duration of each preparatory step before treatment initiation were measured and compared with baseline data from before the introduction of point-of-care CD4 testing. After the introduction of point-of-care CD4 the proportion of patients lost to follow-up before completion of CD4 staging dropped from 57% (278 of 492) to 21% (92 of 437) (adjusted odds ratio [OR] 0·2, 95% CI 0·15-0·27). Total loss to follow-up before initiation of antiretroviral treatment fell from 64% (314 of 492) to 33% (142 of 437) (OR 0·27, 95% CI 0·21-0·36) and the proportion of enrolled patients initiating antiretroviral therapy increased from 12% (57 of 492) to 22% (94 of 437) (OR 2·05, 95% CI 1·42-2·96). The median time from enrolment to antiretroviral therapy initiation reduced from 48 days to 20 days (p<0·0001), primarily because of a reduction in the median time taken to complete CD4 staging, which decreased from 32 days to 3 days (p<0·0001). Loss to follow-up between staging and antiretroviral therapy initiation did not change significantly (OR 0·84, 95% CI 0·49-1·45). Point-of-care CD4 testing enabled clinics to stage patients rapidly on-site after enrolment, which reduced opportunities for pretreatment loss to follow-up. As a result, more patients were identified as eligible for and initiated antiretroviral treatment. Point-of-care testing might therefore be an effective intervention to reduce pretreatment loss to follow-up.

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Editor’s note: The rate of loss to follow-up after antiretroviral therapy initiation in resource-constrained settings can be high in the first year but it is nowhere near as high as the loss to follow-up after HIV diagnosis and before treatment initiation. Weak referral links, distances to be travelled to clinics, and high mortality are important reasons. This is the first study to assess whether a diagnostic test could reduce pre-treatment losses to follow-up and the results are resounding. Point-of-care CD4 count using a fingerpick sample replaced a system in which blood samples were sent once a week for testing (median 10 days), patients returned for a staging visit once the results became available (median 17.5 days), and each part of this process took place at a different site (HIV testing, CD4 count blood draw, and staging consultation). 30% of patients had their CD4 test done on the same day they learned they had HIV infection and by 5 days, 90% had received point-of-care CD4 testing. 50% of patients were able to have their staging consultation on the day they completed CD4 count testing. About 21% of patients learned their HIV result, completed their point-of-care CD4 count testing, and had their staging consultation all on the same day. The median time from enrolment to clinical staging for treatment decisions in this study dropped ten-fold from 32 days to 3 days. This is an important contribution to efforts worldwide to increase the efficiency and sustainability of antiretroviral therapy programmes. Improving clinic workflow, developing flexible staffing models to accommodate spikes in patients testing HIV-positive, and other innovations can increase the impact of point-of-care diagnostics on reducing loss-to-follow up, increasing treatment initiation, and ultimately improving patient survival.

HIV testing
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Point of care testing

Detecting drug-resistant tuberculosis: the importance of rapid testing

Hoek KG, Van Rie A, van Helden PD, Warren RM, Victor TC, Mol Diagn Ther. 2011 Aug 1;15(4):189-94. doi: 10.2165/11593780-000000000-00000

Despite numerous intervention strategies, including the direct observed short-course treatment strategy and improved diagnostic methods, the incidence of multidrug-resistant and extensively drug-resistant tuberculosis (TB) continues to rise globally. Many treatment policies are based on the model that acquisition of drug resistance in already infected individuals drives the drug-resistant TB epidemic, hence the focus on drug-resistance testing of retreatment cases. However, molecular epidemiology and mathematical modelling suggest that the majority of multidrug-resistant TB cases are due to ongoing transmission of multidrug-resistant strains. This is most likely the result of diagnostic delay, thereby emphasizing the need for rapid diagnostics and comprehensive contact tracing, as well as active case finding. Current diagnosis of TB in low-income, high-burden regions relies on smear microscopy and clinical signs and symptoms. However, this smear-centred approach has many pitfalls, including low sensitivity in HIV patients and children, the inability of smear to reveal drug-resistance patterns, and the need for sampling on consecutive days. In order to address these limitations, efforts have been made to expand access to Mycobacterium tuberculosis culture and drug susceptibility testing. However, the slow growth rate of the causative agent, M. tuberculosis, contributes to significant diagnostic delay. Molecular-based diagnostic methods, targeting mutations that are known to confirm drug resistance, are capable of significantly reducing diagnostic delay. Two such methods, the line-probe assay and the real-time PCR-based Xpert® MTB/RIF assay, have been described. The latter test shows particular promise for smear-negative and extrapulmonary specimens. This may prove especially useful in settings where co-infection rates with HIV are high. However, since most research focuses on the performance of both of these assays, further investigations need to be done regarding the impact of the routine implementation of these assays on TB control programs and the cost effectiveness thereof.

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Editor’s note: Over two-thirds of multi-drug resistant tuberculosis (MDR-TB) cases are now believed to result from ongoing transmission of drug resistant virus rather than from acquiring drug resistance while being treated. Detecting this resistance at the time of TB diagnosis so that treatment regimens can be adjusted not only saves lives, it can save time and money while preventing onward transmission. This article tracks the development of molecular-based diagnostic methods leading to WHO’s recommendation in December 2010 to use the Xpert™ MTB/RIF real-time PCR (polymerase chain reaction) assay to detect simultaneously TB and resistance to rifampin, a key first-line TB drug. With countries such as South Africa introducing Xpert™ widely, it is time to determine the most cost-effective ways to use these new tools. The first step is to study the impact of routine implementation on treatment decisions and, most importantly, on treatment outcomes. In particular, will additional testing be needed for people living with HIV who have negative Xpert™ results since the test can miss 30% of smear-negative, culture-positive specimens? Operations research, phased implementation research and trials, and health economics studies are all needed – and the opportunity to conduct them is now.

HIV testing
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People living with HIV

Seroprevalence of HPV vaccine types 6, 11, 16 and 18 in HIV-infected women from South Africa, Brazil and Botswana

Firnhaber C, Evans D, Friedman-Khalili R, Willliams S, Michelow P, Matlhagela K, Wester C, Grinsztejn B, Lockman S. J Clin Virol. 2011 Nov;52(3):265-8. Epub 2011 Sep 9

Many resource limited settings suffer from high rates of both cervical cancer and HIV. Limited HPV serology data are available from resource limited settings; such data could help describe local patterns of Human Papilloma Virus infection and predict vaccine efficacy. To determine seropositivity to HPV types 6, 11, 16 and 18 in HIV-infected women from South Africa, Botswana, and Brazil. HPV serotyping for high-risk types 6, 11, 16 and 18 was performed on samples collected from HIV-infected women from 2003-2010 using competitive Luminex Immuno Assay (HPV-4cLIA). Firnhaber and colleagues examined the association between seropositivity to these HPV types and country of enrollment, CD4, HIV-1 RNA level, and Pap smear. HPV serology results were available for 487 HIV-infected women (157, 170 and 160 from South Africa, Botswana, and Brazil respectively). Approximately 65% of women had serum antibodies to one of the 4 HPV types and less than 3% of women had antibodies to all 4 serotypes. Approximately 30% women demonstrated antibodies to type 16 HPV. Rates of seropositivity to HPV 11, and HPV 16+18 varied significantly between countries. Statistical difference was also shown in women in different age categories in the different countries. There was no difference in serology results compared by CD4 count, HIV viral load or Pap smear results. These data suggest that the quadrivalent vaccine may be effective in preventing HPV infection in these countries.

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Editor’s note: Cervical cancer is the third most common cancer in women with an estimated 85% of the global burden experienced in resource-constrained settings. Lack of access to services that provide early diagnosis of cervical abnormalities through visual screening with acetic acid or PAP tests means that HPV (human papilloma virus) infection that is persistent can develop undetected into cervical cancer. WHO reports that in 2007, 275,000 women died of cervical cancer, a cancer that can be cured if caught early and that is now vaccine-preventable. The two vaccines now available prevent cervical cancer from developing from HPV infection. As this article reveals, it is incorrect to assume that women living with HIV in countries as diverse as South Africa, Brazil, and Botswana have already had HPV infection. Only 3% of women had antibodies to all four of the types included in the quadrivalent vaccine, meaning that only they would not benefit from vaccination. Fully 35% had no evidence in their serum of previous HPV infection and 60% had no evidence of previous infection with the high-risk HPV subtypes 16 and 18. A number of trials are now underway assessing the safety and immunogenicity of HPV vaccination among women with HIV who have varying CD4 count levels and their results will inform policy and programming. In the meantime, preventing HPV infection in the first place through vaccination before sexual debut makes most sense for girls and now for boys worldwide.

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