Articles tagged as "Europe"

Declines in HIV incidence and risk behaviours among drug users in Amsterdam

Drug Users in Amsterdam: Are They Still at Risk for HIV?

Nienke van der Knaap, Bart P. X. Grady, Maarten F. Schim van der Loeff, Titia Heijman, Arjen Speksnijder, Ronald Geskus, Maria Prins. PLoS One. 2013;8(3):e59125. doi: 10.1371/journal.pone.0059125. Epub 2013 Mar 18.

Background and Aims: To examine whether drug users (DU) in the Amsterdam Cohort Study (ACS) are still at risk for HIV, we studied trends in HIV incidence and injecting and sexual risk behaviour from 1986 to 2011.

Methods: The ACS is an open, prospective cohort study on HIV. Calendar time trends in HIV incidence were modelled using Poisson regression. Trends in risk behaviour were modelled via generalized estimating equations. In 2010, a screening for STI (chlamydia, gonorrhoea and syphilis) was performed. Determinants of unprotected sex were studied using logistic regression analysis.

Results: The HIV incidence among 1298 participants of the ACS with a total follow-up of 12,921 person-years (PY) declined from 6.0/100 PY (95% confidence interval [CI] 3.2–11.1) in 1986 to less than 1/100 PY from 1997 onwards. Both injection and sexual risk behaviour declined significantly over time. Out of 197 participants screened for STI in 2010–2011, median age 49 years (IQR 43–59), only 5 (2.5%) were diagnosed with an STI. In multivariable analysis, having a steady partner (aOR 4.1, 95% CI 1.6–10.5) was associated with unprotected sex. HIV-infected participants were less likely to report unprotected sex (aOR 0.07, 95% CI 0.02–0.37).

Conclusions: HIV incidence and injection risk behaviour declined from 1986 onwards. STI prevalence is low; unprotected sex is associated with steady partners and is less common among HIV-infected participants. These findings indicate a low transmission risk of HIV and STI, which suggests that DU do not play a significant role in the current spread of HIV in Amsterdam.

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Editor’s notes: Drug users are at high risk of HIV, both from the risk of HIV arising from sharing injecting paraphernalia, along with HIV risks from sexual behaviour – including the increased risk of unprotected sex associated with the use of cocaine and other stimulants, or if drug users work as commercial sex workers. Earlier research showed a decline in injecting risk behaviour up to 2005, but a remaining risk of HIV transmission from sexual risk behaviour. This analysis shows that risk from injecting has continued to decline. The prevalence of unprotected sex was substantial, but mainly associated with having a steady partner, and was less common in HIV-infected participants. Taken together, the findings indicate a low transmission risk of HIV and STI in this population cohort, and suggest that drug use no longer plays a significant role in the spread of HIV in Amsterdam. This is in contrast to the increasing levels of HIV infection among drug users in other Eastern European settings, and underscores the importance of effective harm reduction programmes for drug users.  

Europe
Netherlands
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If approved, once-daily dolutegravir could form part of an effective new option for treatment of HIV-1 in treatment-naive patients

Once-daily dolutegravir versus raltegravir in antiretroviral-naive adults with HIV-1 infection: 48 week results from the randomised, double-blind, non-inferiority SPRING-2 study.

Raffi F, Rachlis A, Stellbrink HJ, Hardy WD, Torti C, Orkin C, et al. SPRING-2 Study Group. Lancet. 2013 Mar 2;381(9868):735-43. doi: 10.1016/S0140-6736(12)61853-4. Epub 2013 Jan 8.

BACKGROUND: Dolutegravir (S/GSK1349572) is a once-daily HIV integrase inhibitor with potent antiviral activity and a favourable safety profile. We compared dolutegravir with HIV integrase inhibitor raltegravir, as initial treatment for adults with HIV-1.

METHODS: SPRING-2 is a 96 week, phase 3, randomised, double-blind, active-controlled, non-inferiority study that began on Oct 19, 2010, at 100 sites in Canada, USA, Australia, and Europe. Treatment-naive adults (aged ≥ 18 years) with HIV-1 infection and HIV-1 RNA concentrations of 1000 copies per mL or greater were randomly assigned (1:1) via a computer-generated randomisation sequence to receive either dolutegravir (50 mg once daily) or raltegravir (400 mg twice daily). Study drugs were given with coformulated tenofovir/emtricitabine or abacavir/lamivudine. Randomisation was stratified by screening HIV-1 RNA (≤ 100,000 copies per mL or >100,000 copies per mL) and nucleoside reverse transcriptase inhibitor backbone. Investigators were not masked to HIV-1 RNA results before randomisation. The primary endpoint was the proportion of participants with HIV-1 RNA less than 50 copies per mL at 48 weeks, with a 10% non-inferiority margin. Main secondary endpoints were changes from baseline in CD4 cell counts, incidence and severity of adverse events, changes in laboratory parameters, and genotypic or phenotypic evidence of resistance. Our primary analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01227824.

FINDINGS: 411 patients were randomly allocated to receive dolutegravir and 411 to receive raltegravir and received at least one dose of study drug. At 48 weeks, 361 (88%) patients in the dolutegravir group achieved an HIV-1 RNA value of less than 50 copies per mL compared with 351 (85%) in the raltegravir group (adjusted difference 2·5%; 95% CI -2·2 to 7·1). Adverse events were similar between treatment groups. The most common events were nausea (59 [14%] patients in the dolutegravir group vs 53 [13%] in the raltegravir group), headache (51 [12%] vs 48 [12%]), nasopharyngitis (46 [11%] vs 48 [12%]), and diarrhoea (47 [11%] in each group). Few patients had drug-related serious adverse events (three [<1%] vs five [1%]), and few had adverse events leading to discontinuation (ten [2%] vs seven [2%] in each group). CD4 cell counts increased from baseline to week 48 in both treatment groups by a median of 230 cells per μL. Rates of graded laboratory toxic effects were similar. We noted no evidence of treatment-emergent resistance in patients with virological failure on dolutegravir, whereas of the patients with virologic failure who received raltegravir, one (6%) had integrase treatment-emergent resistance and four (21%) had nucleoside reverse transcriptase inhibitors treatment-emergent resistance.

INTERPRETATION: The non-inferior efficacy and similar safety profile of dolutegravir compared with raltegravir means that if approved, combination treatment with once-daily dolutegravir and fixed-dose nucleoside reverse transcriptase inhibitors would be an effective new option for treatment of HIV-1 in treatment-naive patients.

FUNDING: ViiV Healthcare.

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Editor’s notes: Integrase inhibitors are a novel and potent class of antiretroviral drug, however their role in first line therapy has yet to be clearly defined. Use of the two FDA approved integrase inhibitors, raltegravir and elvitegravir, has been limited by the need for twice-daily dosing and the requirement for boosting respectively. Dolutegravir, evaluated in the SPRING-2 study, has a very favourable pharmacokinetic profile which allows once-daily dosing without the need for boosting. Planned co-formulation with ABC/3TC further increases the attractiveness of dolutegravir as a treatment option in treatment-naive patients. In this head to head study dolutegravir was non-inferior to raltegravir in terms of the primary endpoint (viral suppression at 48 weeks), and was well tolerated. Additionally, no evidence of drug resistance was found in the small number of patients with virological failure on dolutegravir treatment, in keeping with prior evidence suggesting a high genetic barrier to resistance. But as the accompanying Lancet editorial noted, some important questions remain unanswered. The study population of predominantly white males and the fact that most study participants had non-advanced disease, with a median baseline CD4 count of 359 cells/µL, makes extrapolation of the results to the areas of the world with the highest disease burdens difficult. Further studies in populations more representative of the global HIV epidemic are needed, but the results of the SPRING study suggest that dolutegravir will be a useful addition to the ART repertoire.

Europe, Northern America, Oceania
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HIV infection increases mortality among HIV-positive pregnant women

The contribution of HIV to pregnancy-related mortality: a systematic review and meta-analysis.

Calvert C, Ronsmans PC. AIDS. 2013 Feb 25. [Epub ahead of print]

Whilst much is known about the contribution of HIV to adult mortality, remarkably little is known about the mortality attributable to HIV during pregnancy. In this paper the proportion of pregnancy-related deaths attributable to HIV based on empirical data was estimated from a systematic review of the strength of association between HIV and pregnancy-related mortality. Studies comparing mortality during pregnancy and the postpartum in HIV-infected and uninfected women were included. Summary estimates of the relative and attributable risks for the association between HIV and pregnancy-related mortality were calculated through meta-analyses. Varying estimates of HIV prevalence were used to predict the impact of the HIV epidemic on pregnancy-related mortality at the population level. 23 studies were included (17 from sub-Saharan Africa). Meta-analysis of the risk ratios (RR) indicated that HIV-infected women had eight times the risk of a pregnancy-related death compared with HIV-uninfected women (pooled RR: 7.74, 95% CI 5.37-11.16). The excess mortality attributable to HIV among HIV-infected pregnant and postpartum women was 994 per 100,000 pregnant women. We predict that 12% of all deaths during pregnancy and up to one year postpartum are attributable to HIV/AIDS in regions with a prevalence of HIV among pregnant women of 2%. This figure rises to 50% in regions with a prevalence of 15%.  The substantial excess of pregnancy-related mortality associated with HIV highlights the importance of integrating HIV and reproductive health services in areas of high HIV prevalence and pregnancy-related mortality.

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Editor’s notes: Millennium Development Goals include commitments to reduce maternal mortality. While HIV is a leading cause of death among women of reproductive age in sub-Saharan Africa, the contribution of HIV infection to overall maternal mortality is Africa has been less described. This analysis of this study indicates that a significant proportion of maternal deaths is due to HIV. While the contribution of HIV to maternal mortality is high in relatively low prevalence settings, it is remarkably and tragically high in high prevalence countries such as is seen in southern Africa: with an estimated 50% of maternal deaths due to HIV infection when prevalence is 15%. This modeling highlights the ongoing essential need to prevent new HIV infections if the MDGs will be met.

Epidemiology, Gender
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Harm reduction among drug users dramatically reduces new HIV and Hepatitis C virus infections

Decline in incidence of HIV and Hepatitis C virus infection among injecting drug users in Amsterdam; evidence for harm reduction?

de Vos AS, van der Helm JJ, Matser A, Prins M, Kretzschmar ME. Addiction. 2013 Jan 24. doi: 10.1111/add.12125. [Epub ahead of print]

In Amsterdam HIV prevalence has nearly halved among injecting drug users since 1990. Hepatitis C Virus (HCV) prevalence also declined, HIV and HCV incidence dropped to nearly zero. The authors examined possible explanations for these time trends, among which the implementation of harm reduction measures aimed at reducing risk behavior of IDU. Individual-based modeling of the spread of HIV and HCV was used. Information about demographic parameters was obtained from the Amsterdam Cohort Study (ACS) among drug users. The model included changes in inflow of new IDU and death-rates over time, the latter dependent on age and time since HIV-seroconversion. Different scenarios of risk behavior were considered. Simulated HIV and HCV incidence and prevalence were compared with ACS data. Assuming harm reduction measures had led to strong decrease in risk-behavior over time improved the model fit (squared residuals decreased by 30%). Substantial incidence and HIV prevalence decline were reproduced by incorporating demographic changes in the model. In particular, lowered disease spread might be a result of depletion of high-risk IDU among those at risk for disease, and a decrease in the number of high-risk individuals in the population due to HIV-related mortality. Marked decreases in HIV and HCV in Amsterdam since 1990 could be partly due to harm reduction measures; however, they may also be largely attributable to changes in the IDU population. Future research aimed at quantifying the benefits of interventions should not neglect the impact of natural epidemic progression and demographic changes.

Abstract access 

Editor’s notes: This article from Amsterdam highlights the impressive information that HIV and HCV incidence has dropped nearly to zero among drug users. Modeling exercises indicate that it is a challenge to attribute the cause of these results, however clearly harm reduction measures have been widely implemented, beyond the level seen in many other countries where drug users are a key population at risk for HIV acquisition.

Europe
Netherlands
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Adverse events associated with nevirapine use in pregnancy

Adverse events associated with nevirapine use in pregnancy: a systematic review and meta-analysis.

Ford N, Calmy A, Andrieux-Meyer I, Hargreaves S, Mills EJ, Shubber Z. AIDS. 2013 Jan 5. [Epub ahead of print]

The risk of adverse drug events associated with nevirapine is suggested to be greater in pregnant women. The authors conducted a systematic review and meta-analysis of severe adverse events in HIV-positive women who initiated NVP while pregnant. Six databases were searched for studies reporting adverse events among HIV-positive pregnant women who had received nevirapine-based antiretroviral therapy for at least seven days. Data were pooled by the fixed-effects method. Twenty studies (3582 pregnant women) from 14 countries were included in the final review. The pooled proportion of patients experiencing a severe hepatotoxic event was 3.6% (95%CI 2.4-4.8%), severe rash was experienced by 3.3% of patients (95%CI 2.1-4.5%), and 6.2% (95%CI 4.0-8.4%) of patients discontinued nevirapine due to an adverse event. These results were comparable to frequencies observed in the general adult patient population, and to frequencies reported in non-pregnant women within the same cohort. For pregnant women with a CD4 cell count >250 cells/mm there was a non-significant tendency towards an increased likelihood of cutaneous events overall (OR 1.1, 95%CI 0.8-1.6) and severe cutaneous adverse events (OR 1.4, 95%CI 0.8-2.4) and consequently an increased risk of toxicity-driven regimen substitution (OR 1.7, 95%CI 1.1-2.6). These results suggest that the frequency of adverse events associated with nevirapine use in pregnant women, while high, is no higher than reported for nevirapine in the general adult population. Pregnant women with a high CD4 count may be at increased risk of adverse events, but evidence supporting this association is weak.

Abstract access 

Editor’s notes: The selection of antiretroviral drug regimens has been particularly challenging for HIV-positive pregnant women. Adverse events are less frequent for men and women with efavirenz use compared to nevirapine, and increasingly efavirenz is a preferred choice. However, due to concerns about the safety of efavirenz in pregnancy, nevirapine continues to be widely used as a component of antiretroviral treatment for pregnant women. However, there have been suggestions that HIV-positive pregnant women have higher rates of nevirapine-associated adverse events, especially for those women with high CD4, compared to non-pregnant women on nevirapine. This meta-analysis of 20 studies did demonstrate a relatively high frequency of adverse events in women who use nevirapine, but not at rates higher than among non-pregnant women on HIV treatment with nevirapine. The data about efavirenz safety for the fetus is being carefully reviewed to elucidate if widespread use of efavirenz is preferable to nevirapine during pregnancy.

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Comparing adverse effects of nevirapine and efavirenz

Adverse events associated with nevirapine and efavirenz-based first-line antiretroviral therapy: a systematic review and meta-analysis.

Shubber Z, Calmy A, Andrieux-Meyer I, Vitoria M, Renaud-Thery F, Shaffer N, Hargreaves S, Mills EJ, Ford N. AIDS. 2013 Jan 22. [Epub ahead of print]

Since 2002, the World Health Organization has recommended either nevirapine (NVP) or efavirenz (EFV) as part of first-line antiretroviral therapy. These two drugs are known to have differing toxicity profiles, but the clinical importance of these toxicities overall is not well established. The authors systematically reviewed adverse events among treatment-naïve HIV-positive adults and children receiving either NVP or EFV as part of first-line antiretroviral therapy. The primary outcome was drug discontinuation as a result of any adverse event; specific toxicities were evaluated as secondary outcomes. Point estimates and 95% confidence intervals (95% CI) were calculated and proportions and odds ratios (OR) pooled using fixed-effects meta-analysis. Data was reviewed on 26446 adult and 3975 children from 8 randomized trials and 26 prospective cohorts. Overall, adults on NVP were more than two times more likely to discontinue treatment due to any adverse event compared to patients on EFV (OR 2.2, 95%CI 1.9-2.6). Severe hepatotoxicity (OR 3.3, 95%CI 2.5-4.2), severe skin toxicity (OR 3.9, 95%CI 2.5-5.4), and severe hypersensitivity reactions (OR 2.4, 95%CI 1.9-2.9) were more likely to occur among patients on NVP. Patients receiving EFV were more likely to experience severe CNS-events (OR 3.4, 95%CI 2.1-5.4). Similar associations were seen in children. Compared to NVP, EFV is associated with a lower frequency of severe adverse events, in particular treatment discontinuations. This finding supports a move towards efavirenz-based therapy as the preferred first-line treatment regimen for HIV treatment within a public health approach.

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Editor’s notes: As increased progress is being made towards universal access to treatment, increased attention is being addressed towards retention in care and on treatment. Simpler, less toxic regimens have been a cornerstone of the Treatment 2.0 initiative of UNAIDS and WHO. Nevirapine has been widely utilized as an essential component of three drug antiretroviral therapy, in part due to low cost and safety at a population level. While efavirenz does have a greater incidence of central nervous system side effects (many of them manageable with supportive treatment), the overall discontinuation rate is significantly lower than with nevirapine. This data in combination with the continued reduction in efavirenz price, and incorporation into combination pill form, supports the move towards increased use of efavirenz for first line antiretroviral therapy.

HIV Treatment
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HIV / HCV co-infection: an emerging threat for eastern Europe and central Asia

Effect of HCV Infection on Cause-Specific Mortality following HIV Seroconversion Before and After 1997.

van der Helm J, Geskus R, Sabin C, Meyer L, Del Amo J, Chêne G, Dorrucci M, Muga R, Porter K, Prins M; CASCADE collaboration in EuroCoord. Gastroenterology. 2012 Dec 21. pii: S0016-5085(12)01852-5. [Epub ahead of print]

Background and aims: Individuals with HIV infection are frequently also infected with hepatitis C virus (HCV) (co-infection), but little is known about its effects on progression of HIV-associated disease. We aimed to determine the effects of co-infection on mortality from HIV and/or AIDS, and hepatitis or liver disease, adjusting for duration of HIV infection.

Methods: We analyzed data from the 16 cohorts of the Concerted Action on Seroconversion to AIDS and Death in Europe (CASCADE) Collaboration that included information on HCV infection and cause of death. A competing risks proportional sub-distribution hazards model was used to evaluate the effect of HCV infection on the following causes of death: HIV- and/or AIDS-related, hepatitis- or liver-related, natural, and non-natural.

Results: Of 9164 individuals with HIV infection and a known date of seroconversion, 2015 (22.0%) were also infected with HCV. Of 718 deaths, 395 (55.0%) were due to HIV infection and/or AIDS, and 39 (5.4%) to hepatitis or liver-related disease. Among individuals infected with only HIV or with co-infection, the mortality from HIV infection and/or AIDS-related causes and hepatitis or liver disease decreased significantly after 1997, when combination antiretroviral therapy (cART) became widely available. However, after 1997, HIV and/or AIDS-related mortality was higher among co-infected individuals than those with only HIV infection in each risk group: injection-drug use (adjusted hazard ratio [aHR], 2.43; 95% confidence interval [CI], 1.14-5.20), sex between men and women or hemophilia (aHR, 3.43; 95% CI, 1.70-6.93) and sex between men (aHR, 3.11; 95% CI, 1.49-6.48). Compared to individuals infected with only HIV, co-infected individuals had higher risk of death from hepatitis or liver disease.

Conclusions: Based on analysis of data from the CASCADE Collaboration, since 1997, when cART became widely available, individuals co-infected with HIV and HCV have had a higher risk of death from HIV and/or AIDS, and from hepatitis or liver disease, than patients infected with only HIV. It is necessary to evaluate the effects of HCV therapy on HIV progression.

Abstract access

Editor's notes: Globally, 25-33% of people living with HIV (PLHIV) are co-infected with the hepatitis C virus (HCV). HCV in PLHIV is associated with significantly faster rates progression of fibrosis resulting in substantially increased liver morbidity. As shown by this paper based on data from a very large number of cohort studies, liver disease has emerged as a leading cause of death in people living with both HIV and HCV in Europe. Indeed, liver failure is now the most common cause of death in PLHIV in Southern Europe and will soon become a major concern in eastern / central Europe, in countries where the HIV epidemic is rapidly spreading in people who inject drugs, while the prevalence of HCV co-infection is less common in Sub-Saharan Africa, where HBV co-infection is more widespread.

Results of numerous cohort studies have recently emerged to prove that earlier antiretroviral therapy is able to slow liver disease progression and the worsening of liver fibrosis, and that this also correlates with mortality. The right time to start antiretroviral therapy in this population is not supported by a sufficient amount of controlled studies. However, there is some consensus that HCV co-infected persons with CD4 below 500 µL should start antiretroviral therapy.

A huge number of new anti-HCV agents (the so-called direct acting agents [DAA]) are under clinical development and two of them have been already licensed. The use of these new drugs, in combination between them or in association with currently available drugs - pegylated interferon and ribavirin - may be able to dramatically increase the rate of sustained virological response, and the subsequent "cure" of HCV infection. Not enough data are available yet on the use of these new drugs in the treatment of liver disease of people living with both HIV and HCV, but it is almost certain that sooner or later this will become the standard in western countries.  However, the current cost of the new drugs and of the new combination therapies for HCV will definitely create, again, a dramatic inequality between co-infected patients living in countries able to afford these costs and patients living in countries with limited resources.

Comorbidity, HIV Treatment
Europe
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Persons left behind: transgender women

Worldwide burden of HIV in transgender women: a systematic review and meta-analysis.

Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Lancet Infect Dis. 2012 Dec 20. pii: S1473-3099(12)70315-8. [Epub ahead of print]

Background: Previous systematic reviews have identified a high prevalence of HIV infection in transgender women in the USA and in those who sell sex (compared with both female and male sex workers). However, little is known about the burden of HIV infection in transgender women worldwide. We aimed to better assess the relative HIV burden in all transgender women worldwide.

Methods: We did a systematic review and meta-analysis of studies that assessed HIV infection burdens in transgender women that were published between Jan 1, 2000, and Nov 30, 2011. Meta-analysis was completed with the Mantel-Haenszel method, and random-effects modelling was used to compare HIV burdens in transgender women with that in adults in the countries for which data were available.

Findings: Data were only available for countries with male-predominant HIV epidemics, which included the USA, six Asia-Pacific countries, five in Latin America, and three in Europe. The pooled HIV prevalence was 19·1% (95% CI 17·4-20·7) in 11 066 transgender women worldwide. In 7197 transgender women sampled in ten low-income and middle-income countries, HIV prevalence was 17·7% (95% CI 15·6-19·8). In 3869 transgender women sampled in five high-income countries, HIV prevalence was 21·6% (95% CI 18·8-24·3). The odds ratio for being infected with HIV in transgender women compared with all adults of reproductive age across the 15 countries was 48·8 (95% CI 21·2-76·3) and did not differ for those in low-income and middle-income countries compared with those in high-income countries.

Interpretation: Our findings suggest that transgender women are a very high burden population for HIV and are in urgent need of prevention, treatment, and care services. The meta-analysis showed remarkable consistency and severity of the HIV disease burden among transgender women.

Abstract access

Editor’s notes: This paper systematically reviews studies on the prevalence of HIV infection among transgender women in different countries from three continents. Results unfortunately show that there is a dramatic consistency in HIV prevalence data, which reach peaks often above 20%, irrespective of the financial context of the countries where transgenders live. In addition, there is a common theme: risk factors including stigma, discrimination and marginalisation are all factors which dramatically increase the risk of becoming infected by HIV. Not only are transgender women probably the group with the highest risk of acquiring the infection, but they are also in urgent need of prevention, possibly including pre- and post-exposure prophylaxis, and of tailored support and care. But these might not be enough, if marginalisation is supported in some countries with a legal environment contradicting international human rights frameworks.

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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.

Abstract access

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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