Articles tagged as "Africa"

Biomedical prevention: not just antiretrovirals

Economics of antiretroviral treatment vs. circumcision for HIV prevention.

Bärnighausen T, Bloom DE, Humair S. Proc Natl Acad Sci U S A. 2012 Dec 6. [Epub ahead of print]

The HIV Prevention Trials Network (HPTN) 052 study, which showed the effectiveness of antiretroviral treatment in reducing HIV transmission, has been hailed as a "game changer" in the fight against HIV, prompting calls for scaling up treatment as prevention (TasP). However, it is unclear how TasP can be financed, given flat-lining support for global HIV programs. We assess whether TasP is indeed a game changer or if comparable benefits are obtainable at similar or lower cost by increasing coverage of medical male circumcision (MMC) and antiretroviral treatment (ART) at CD4 <350/μL. We develop a new mathematical model and apply it to South Africa, finding that high ART coverage combined with high MMC coverage provides approximately the same HIV incidence reduction as TasP, for $5 billion less over 2009-2020. MMC outperforms ART significantly in cost per infection averted ($1,096 vs. $6,790) and performs comparably in cost per death averted ($5,198 vs. $5,604). TasP is substantially less cost effective at $8,375 per infection and $7,739 per death averted. The prevention benefits of HIV treatment are largely reaped with high ART coverage. The most cost-effective HIV prevention strategy is to expand MMC coverage and then scale up ART, but the most cost-effective HIV-mortality reduction strategy is to scale up MMC and ART jointly. TasP is cost effective by commonly used absolute benchmarks but it is far less cost effective than MMC and ART. Given South Africa's current annual ART spending, the $5 billion in savings offered by MMC and ART over TasP in the next decade, for similar health benefits, challenges the widely hailed status of TasP as a game changer.

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Editor’s notes: The most significant evidence to have emerged in the field of ART in recent years has been the results of the HPTN 052 trial which demonstrated that ART can significantly reduce HIV transmission by up to 96% among people in HIV serodiscordant relationships. Other important advances include the use of ARVs in pre-exposure prophylaxis and accumulating evidence on the potential clinical benefit of ART initiation above 350 cells/µl. As a consequence, many have postulated – and modeling has been performed - that a “test and treat” strategy might become the way forward to shut down the HIV epidemic.

This vision, however, is hampered by different factors, the most important one being the fact that a large proportion of HIV-infected persons are unaware of their status. Studies to look at the potential impact of this strategy at the population level are underway in African settings (among others, by the ANRS, USAID, and NIH HPTN). The main concern, however, is that there shall be a minimum coverage threshold for this strategy to be effective in stopping the spread of HIV. In reality, just looking at efficacy data, considering all the biomedical prevention strategies that have been tested in a research and controlled settings, the situation in terms of prevention effect size, as of today, is the following: prime-boost vaccine (Thai RV144): 31%; tenofovir gel (Caprisa 004): 39%; TDF/FTC oral PrEP in MSM (Iprex): 44%; Male circumcision (Orange Farm): 57%; TDF/FTC in heterosexual (TDF2): 63%; TDF/FTC in serodiscordant partners (Partners PrEP): 73%; ART for serodiscordant couples (HPTN052): 96%.

The ideal way forward shall be to consider prevention as a combined approach, which includes more than one of the proven tools. Of course, a number of issues should be carefully taken into consideration: 1. Ensuring earlier knowledge of HIV status and access to ARV-based elements of combination prevention; and 2. Improving service delivery: continued and intensified provision of condoms, STI diagnosis and treatment, male circumcisions, counselling on risk reduction; effective linkage to HIV care following HIV testing and counselling; support and monitoring for long-term adherence and retention; consideration of human rights, ethics and community engagement; put in place key monitoring points: disinhibition and risk compensation; drug toxicity; drug resistance.

As far as treatment as prevention is concerned, a number of issues should still be addressed: are we sure of the treatment benefits of earlier ART initiation for the individual? Which might be the long term adverse effects of earlier treatment? Or of long term PrEP use? Are we helping the spread of viral resistance? Can we extrapolate the results to other groups? Beyond stable couples? Finally, how to prioritize and who is going to pay? This paper presents a mathematical model which compares the cost-effectiveness of two of the “most efficacious” tools of the biomedical prevention armamentarium: early treatment vs circumcision.  The latter method appears to be more cost-effective in terms of prevention effect. However, this modeling exercise does not take into consideration the immeasurable benefits of antiretroviral therapy for the health of the individual and of the society at large.

South Africa
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Getting to zero: from option B to option B+

Cost-effectiveness of World Health Organization 2010 Guidelines for Prevention of Mother-to-Child HIV Transmission in Zimbabwe.

Ciaranello AL, Perez F, Engelsmann B, Walensky RP, Mushavi A, Rusibamayila A, Keatinge J, Park JE, Maruva M, Cerda R, Wood R, Dabis F, Freedberg KA. Clin Infect Dis. 2012 Nov 30. [Epub ahead of print]

Background. In 2010, the World Health Organization (WHO) released revised guidelines for prevention of mother-to-child human immunodeficiency virus (HIV) transmission (PMTCT). We projected clinical impacts, costs, and cost-effectiveness of WHO-recommended PMTCT strategies in Zimbabwe.

Methods. We used Zimbabwean data in a validated computer model to simulate a cohort of pregnant, HIV-infected women (mean age, 24 years; mean CD4 count, 451 cells/µL; subsequent 18 months of breastfeeding). We simulated guideline-concordant care for 4 PMTCT regimens: single-dose nevirapine (sdNVP); WHO-recommended Option A, WHO-recommended Option B, and Option B+ (lifelong maternal 3-drug antiretroviral therapy regardless of CD4).

Outcomes included maternal and infant life expectancy (LE) and lifetime healthcare costs (2008 US dollars [USD]). Incremental cost-effectiveness ratios (ICERs, in USD per year of life saved [YLS]) were calculated from combined (maternal + infant) discounted costs and LE.

Results. Replacing sdNVP with Option A increased combined maternal and infant LE from 36.97 to 37.89 years and would reduce lifetime costs from $5760 to $5710 per mother-infant pair. Compared with Option A, Option B further improved LE (38.32 years), and saved money within 4 years after delivery ($5630 per mother-infant pair). Option B+ (LE, 39.04 years; lifetime cost, $6620 per mother-infant pair) improved maternal and infant health, with an ICER of $1370 per YLS compared with Option B.

Conclusions. Replacing sdNVP with Option A or Option B will improve maternal and infant outcomes and save money; Option B increases health benefits and decreases costs compared with Option A. Option B+ further improves maternal outcomes, with an ICER (compared with Option B) similar to many current HIV-related healthcare interventions.

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Editor's notes: This very important paper tackles one of the aspects (the differential cost-effectiveness of different interventions) of the current debate around prevention of mother to child transmission. Particularly for women with CD4 cells higher than 350 (below this level, triple therapy is already the rule) progressively switching from option A (AZT/3TC plus single dose nevirapine) to option B or B+ (starting triple therapy as soon as diagnosed and continue it for life) is considered by many countries the way forward, and may soon be translated in the new WHO guidelines. Advantages of option B+ may include: a) the simplification of regimen and service delivery; b) the harmonization with ART programmes; c) the potential use of once daily, single-pill, fixed dose combinations; and d) the independence from CD4 testing for initial decision. In addition, option B+ can assure protection against MTCT in future pregnancies and may prevent sexual transmission to serodiscordant partners. Finally, it avoids the danger of stopping and starting ARV drugs and there is probably a benefit to the mother's health (because of early ART). When comparing the cost-effectiveness of the different options and looking at them in a clinical perspective, the paper suggests that the health benefit of option B+ clearly outweigh the marginal augmentation of its cost as compared with option B.

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15 million on antiretrovirals by 2015: drug resistance

HIV drug resistance surveillance in low- and middle-income countries: 2004 to 2010.

Bertagnolio S, Parkin N, Jordan M. J Int AIDS Soc. 2012 Nov 11;15 Suppl 4:18083.

Background: At the end of 2011, over 8 million people were receiving antiretroviral therapy (ART) in low- and middle-income countries (LMIC), a 26-fold increase from 2003. Some degree of HIV drug resistance (HIVDR) will emerge among populations on combination ART even when high levels of adherence are achieved. In 2004, the World Health Organization (WHO) initiated global HIVDR surveillance to monitor emergence and transmission of HIVDR in countries scaling-up ART.

Methods: WHO HIVDR surveillance strategy was designed to inform public health decision-making regarding choice of ART and to identify ART programme factors which could be adjusted to minimize HIVDR emergence. The strategy includes (1) surveillance of transmitted HIVDR (TDR) in recently infected populations, (2) surveillance of acquired HIVDR (ADR) in populations on ART and (3) monitoring of early warning indicators (EWI) of HIVDR which are ART programme factors favouring HIVDR emergence. Surveys used standardized protocols. Epidemiological and sequence data were quality assured.

Results: TDR: Eighty-two surveys were conducted in 30 countries in 2004 to 2010, assessing 3588 recently infected individuals. Pooled analysis indicates an overall prevalence of 3.1% TDR to at least one drug class, 1.6% to non-nucleoside reverse transcriptase inhibitor (NNRTI), 1.3% to nucleoside reverse transcriptase inhibitor (NRTI) and 0.7% to protease inhibitor (PI). Levels of NNRTI resistance, particularly in the areas surveyed in Africa, increased over time, reaching 3.4% (95% CI=1.8 to 5.2%) in 2009. Greater ART coverage was associated, though modestly, with increased prevalence of TDR to NNRTI (P-value adjusted for region=0.039). ADR: Thirty-six ADR surveys assessing 6370 people in 12 LMIC were conducted in 2007 to 2010. HIVDR prevalence to any drug among those initiating ART ranged from 4.8% (95% CI=3.8 to 6.0%) in 2007 to 6.8% (95% CI=4.8 to 9.0%) in 2010. Ninety per cent of patients alive and on therapy at 12 months achieved viral load <1000 c/µL. Among people with virological failure, 72% had HIVDR to at least one drug. EWI: EWIs were monitored at 2017 clinics in 50 countries assessing 131,686 people since 2004. Overall, 75% of clinics met the target of 100% of patients receiving appropriate ART; 69% of clinics met the <20% target for lost to follow-up at 12 months; and only 65% of clinics provided a continuous supply of ART during a 12-month period.

Conclusion: Expansion of ART in LMIC has resulted in an overall increase in HIVDR, particularly to NNRTI in Africa. EWIs reveal important gaps in service delivery and programme performance. While these data call for continued and improved scale up of surveillance, they also suggest that resistance is under control in the areas surveyed, and the majority of patients initiating or switching therapy are likely to respond to currently available first- and second-line therapy.

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Editor’s notes: At the beginning of the battle for access to treatment and care for people living with HIV in countries with limited resources, one of the most commonly used arguments against increasing access to ART was the potential for increasing levels of HIV drug resistance. This event could lead the benefits of greater access to treatment being compromised by the reduced effectiveness of the available drugs. The paper published by the WHO group leading the global surveillance of transmitted drug resistance (TDR) proves that higher levels of ART coverage are indeed associated with slightly increased levels of TDR. However, the evidence to date indicates that the increase has been modest during the recent scale up of ART in resource limited settings, and that resistance has not occurred at the levels that some predicted. The best way forward is to carefully consider the lessons learned from some inevitable mistakes at the beginning of the antiretroviral era, i.e., using drugs and combinations of insufficient potency, with poor tolerability profile and difficult to take. For too many years the cheapest drugs, not the best ones, have been brought to resource limited settings. The further scaling up of antiretroviral treatment will need quality drug combinations and, very probably, expanded availability of HIV-RNA monitoring.

HIV Treatment
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HIV care in resource limited settings: not just a matter of drugs

Clinic-Based Food Assistance is Associated with Increased Medication Adherence among HIV-Infected Adults on Long-Term Antiretroviral Therapy in Zambia.

Tirivayi N, Koethe JR, Groot W. J AIDS Clin Res. 2012;3(7):171. Epub 2012 Sep 24.

Background: There has been limited research to date on the effects of food assistance provided to HIV-infected adults in resource-constrained settings with a high prevalence of malnutrition and chronic food insecurity. We compare antiretroviral therapy (ART) adherence, weight gain, and CD4+ lymphocyte count change among HIV-infected adults enrolled in a clinic-based food assistance program in Lusaka, Zambia versus a control group of non-recipients.

Methods: We conducted a cohort study incorporating interviewer-administered surveys and retrospective clinical data to compare ART patients receiving food assistance with a control group of non-recipients. Medication adherence was assessed using pharmacy dispensation records. We use propensity score matching to assess the effect of food assistance on outcome measures.

Results: After 6 months, food assistance recipients (n=145) had higher ART adherence compared to non-recipients (n=147, 98.3% versus 88.8%, respectively; p<0.01), but no significant effects were observed for weight or CD4+ lymphocyte count change. The improvement in adherence rates was greater for participants on ART for less than 230 days, and those with BMI<18.5 kg/m(2), a higher HIV disease stage, or a CD4+ lymphocyte count ≤ 350 cells/μl.

Conclusions: Promoting optimal medication adherence among persons on ART is relevant to public health and the success of HIV control efforts. The provision of food assistance to HIV-infected adults on ART may have an incentivizing effect which can improve medication adherence, particularly among patients recently initiated on treatment and those with poor nutrition or advanced disease. The effects on body weight and immune reconstitution appear minimal.

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Editor’s notes: The combination of infectious diseases and malnutrition is one of the most dramatic public health problems in sub-Saharan Africa. The relationship is negatively synergistic: malnutrition compromises natural immunity, leading to increased susceptibility to infection, more frequent and prolonged episodes and increased severity of disease. Likewise, infection can aggravate or precipitate malnutrition through decreased appetite and food intake, malabsorption, nutrient loss or increased metabolic needs. In addition, severe malnutrition often masks the signs and symptoms of infectious diseases, making prompt clinical diagnosis and early treatment very difficult. The overall impact of malnutrition on mortality from infectious diseases is devastating and it is therefore crucial that nutritional and HIV interventions be integrated. This observational study conducted in Zambia in a resource-limited setting, found a significant positive impact of food assistance on patients’ adherence to HIV medications. As the same authors suggest, further studies would be necessary to investigate the beneficial impact on retention to care of integrating nutritional supplementation and HIV care in resource-limited settings. Due to the relevance of this topic it would be sensible for countries to integrate nutritional aspects into HIV response plans, e.g., develop national guidelines on nutrition and HIV, and appoint nutrition focal points in national AIDS control committees.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Africa, Asia, Europe, Latin America
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Preventing new paediatric infections

Health facility characteristics and their relationship to coverage of PMTCT of HIV services across four African countries: The PEARL Study

Ekouevi DK, Stringer E, Coetzee D, Tih P, Creek T, Stinson K, Westfall AO, Welty T, Chintu N, Chi BH, Wilfert C, Shaffer N, Stringer J, Dabis F. PLoS One. 2012;7(1):e29823. Epub 2012 Jan 20

Health facility characteristics associated with effective prevention of mother-to-child transmission of HIV (PMTCT) coverage in sub-Saharan are poorly understood. Ekouevi and colleagues conducted surveys in health facilities with active PMTCT services in Cameroon, Cote d'Ivoire, South Africa, and Zambia. Data was compiled via direct observation and exit interviews. The authors constructed composite scores to describe provision of PMTCT services across seven topical areas: antenatal quality, PMTCT quality, supplies available, patient satisfaction, patient understanding of medication, and infrastructure quality. Pearson correlations and Generalized Estimating Equations (GEE) to account for clustering of facilities within countries were used to evaluate the relationship between the composite scores, total time of visit and select individual variables with PMTCT coverage among women delivering. Between July 2008 and May 2009, they collected data from 32 facilities; 78% were managed by the government health system. An opt-out approach for HIV testing was used in 100% of facilities in Zambia, 63% in Cameroon, and none in Côte d'Ivoire or South Africa. Using Pearson correlations, PMTCT coverage (median of 55%, (IQR: 33-68) was correlated with PMTCT quality score (rho = 0.51; p = 0.003); infrastructure quality score (rho = 0.43; p = 0.017); time spent at clinic (rho = 0.47; p = 0.013); patient understanding of medications score (rho = 0.51; p = 0.006); and patient satisfaction quality score (rho = 0.38; p = 0.031). PMTCT coverage was marginally correlated with the antenatal quality score (rho = 0.304; p = 0.091). Using GEE adjustment for clustering, the, antenatal quality score became more strongly associated with PMTCT coverage (p<0.001) and the PMTCT quality score and patient understanding of medications remained marginally significant. The authors observed a positive relationship between an antenatal quality score and PMTCT coverage but did not identify a consistent set of variables that predicted PMTCT coverage.

For abstract access click here. 

Editor’s note: The PEARL Study (PMTCT Effectiveness in Africa: Research and Linkages to Care) was conducted from 2007-2009 in 32 health facilities with PMTCT services in four countries: Cameroon (8), Cote d’Ivoire (9), South Africa (6), and Zambia (9). It found that coverage of single-dose nevirapine of both mother and baby was variable and reached only 55% overall. In this first study to do so systematically, the researchers assessed antenatal clinic and service characteristics to see if they would predict coverage. One factor stood out as distinguishing the worst-performing sites from the others and that was the lack of registers with PMTCT information. Although some other obvious variables were associated with coverage, variables related to general antenatal care were more predictive of PMTCT coverage. This supports the importance of strengthening health care in general in order to improve PMCTC coverage. But it does not in anyway decrease the need for quality assessments and creative improvements in PMTCT programmes themselves.

Cameroon, Côte d'Ivoire, South Africa, Zambia
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