• Abolishing user fees for children and pregnant women trebled uptake of malaria-related interventions in Kangaba, Mali.

      Ponsar, Frédérique; Van Herp, Michel; Zachariah, Rony; Gerard, Séco; Philips, Mit; Jouquet, Guillaume; Analysis and advocacy unit, Médecins sans Frontieres, Brussels Operational Centre, Brussels, Belgium. fredponsar@hotmail.com (2011-11)
      Malaria is the most common cause of morbidity and mortality in children under 5 in Mali. Health centres provide primary care, including malaria treatment, under a system of cost recovery. In 2005, Médecins sans Frontieres (MSF) started supporting health centres in Kangaba with the provision of rapid malaria diagnostic tests and artemisinin-based combination therapy. Initially MSF subsidized malaria tests and drugs to reduce the overall cost for patients. In a second phase, MSF abolished fees for all children under 5 irrespective of their illness and for pregnant women with fever. This second phase was associated with a trebling of both primary health care utilization and malaria treatment coverage for these groups. MSF's experience in Mali suggests that removing user fees for vulnerable groups significantly improves utilization and coverage of essential health services, including for malaria interventions. This effect is far more marked than simply subsidizing or providing malaria drugs and diagnostic tests free of charge. Following the free care strategy, utilization of services increased significantly and under-5 mortality was reduced. Fee removal also allowed for more efficient use of existing resources, reducing average cost per patient treated. These results are particularly relevant for the context of Mali and other countries with ambitious malaria treatment coverage objectives, in accordance with the United Nations Millennium Development Goals. This article questions the effectiveness of the current national policy, and the effectiveness of reducing the cost of drugs only (i.e. partial subsidies) or providing malaria tests and drugs free for under-5s, without abolishing other related fees. National and international budgets, in particular those that target health systems strengthening, could be used to complement existing subsidies and be directed towards effective abolition of user fees. This would contribute to increasing the impact of interventions on population health and, in turn, the effectiveness of aid.
    • Cost and cost-effectiveness of switching from d4T or AZT to a TDF-based first-line regimen in a resource-limited setting in rural Lesotho

      Jouquet, Guillaume; Bygrave, Helen; Kranzer, Katharina; Ford, Nathan; Gadot, Laurent; Lee, Janice; Hilderbrand, Katherine; Goemaere, Eric; Vlahakis, Natalie; Trivino, Laura; et al. (Lippincott Williams & Wilkins, 2011-11-01)
      Latest World Health Organization guidelines recommend shifting away from Stavudine (d4T)-based regimens due to severe side effects. However, widespread replacement of d4T by Tenofovir (TDF) or Zidovudine (AZT) is hampered by cost concerns.
    • Early initiation of antiretroviral therapy and associated reduction in mortality, morbidity and defaulting in a nurse-managed, community cohort in Lesotho.

      Ford, Nathan; Kranzer, Katharina; Hilderbrand, Katherine; Jouquet, Guillaume; Goemaere, Eric; Vlahakis, Nathalie; Triviño, Laura; Makakole, Lipontso; Bygrave, Helen; Médecins Sans Frontières, University of Cape Town, South Africa. Nathan.ford@msf.org (2010-11-13)
      INTRODUCTION: The latest WHO guidelines recommend initiating antiretroviral therapy (ART) at CD4 cell counts less than 350 cells/μl. However, donors and national governments are reluctant to support implementation owing to uncertainty regarding feasibility and relative benefit. Lesotho has supported earlier initiation since 2008. We assessed outcomes comparing early (CD4 cell counts >200 cells/μl) and late (CD4 cell counts ≤200 cells/μl) initiation. METHODS: We describe survival probability among patients initiating ART at CD4 cell counts 200 or less and more than 200 cells/μl and assess associations between baseline CD4 cell counts and mortality, morbidity, loss to follow-up and hospitalization using Cox regression adjusting for confounders identified a priori. RESULTS: Our analysis included 1177 patients; median age was 38 years and the majority (67%) were women. Median time on ART for the overall cohort was 506 days (interquartile range 396-608). Five hundred and thirty eight patients initiated ART at a CD4 cell count 200 cells/μl or less (interquartile range 54-160) and 639 patients initiated at CD4 cell count more than 200 cells/μl (interquartile range 238-321). In multivariate analysis, we found that patients initiating at CD4 cell count more than 200 cells/μl were 68% less likely to die (adjusted hazard ratio 0.32, 95% confidence interval 0.20-0.50), and 39% less likely to be lost to follow-up (adjusted hazard ratio 0.61, 95% confidence interval 0.43-0.87). Initiating ART at CD4 cell count more than 200 cells/μl was also associated with a 27% reduction in the rate of incident morbidity (adjusted hazard ratio 0.73, 95% confidence interval 0.65-0.82) and a 63% decreased rate of hospitalization (adjusted hazard ratio 0.37, 95% confidence interval 0.19-0.73). CONCLUSION: Earlier initiation is feasible in a low resource, high HIV prevalence setting, and provides important benefits in terms of reduced mortality, morbidity, retention and hospitalization. Donors should fully support the implementation of the latest WHO recommendations.
    • Feasibility and effectiveness of two community based HIV testing models in rural Swaziland

      Parker, Lucy Anne; Jobanputra, Kiran; Rusike, Lorraine; Mazibuko, Sikhathele; Okello, Velephi; Kerschberger, Bernhard; Jouquet, Guillaume; Cyr, Joanne; Teck, Roger (Wiley-Blackwell, 2015-03-07)
      To evaluate the feasibility (population reached, costs) and effectiveness (positivity rates, linkage to care) of two strategies of community-based HIV testing and counselling (HTC) in rural Swaziland.
    • Impact and programmatic implications of routine viral load monitoring in Swaziland

      Jobanputra, Kiran; Parker, Lucy Anne; Azih, Charles; Okello, Velephi; Maphalala, Gugu; Jouquet, Guillaume; Kerschberger, Bernhard; Mekeidje, Calorine; Cyr, Joanne; Mafikudze, Arnold; et al. (Lippincott Williams & Wilkins, 2014-05-28)
      To assess the programmatic quality (coverage of testing, counselling and retesting), cost, and outcomes (viral suppression, treatment decisions), of routine viral load (VL) monitoring in Swaziland.
    • Implementing a tenofovir-based first-line regimen in rural Lesotho: clinical outcomes and toxicities after two years.

      Bygrave, Helen; Ford, Nathan; van Cutsem, Gilles; Hilderbrand, Katherine; Jouquet, Guillaume; Goemaere, Eric; Vlahakis, Nathalie; Triviño, Laura; Makakole, Lipontso; Kranzer, Katharina; et al. (2011-03)
      The latest World Health Organization guidelines recommend replacing stavudine with tenofovir or zidovudine in first-line antiretroviral therapy in resource-limited settings. We report on outcomes and toxicities among patients on these different regimens in a routine treatment cohort in Lesotho.
    • Renal safety of a tenofovir-containing first line regimen: experience from an antiretroviral cohort in rural lesotho.

      Bygrave, Helen; Kranzer, Katharina; Hilderbrand, Katherine; Jouquet, Guillaume; Goemaere, Eric; Vlahakis, Nathalie; Triviño, Laura; Makakole, Lipontso; Ford, Nathan; Médecins Sans Frontières, Morija, Lesotho. (2011-03)
      Current guidelines contraindicate TDF use when creatinine clearance (CrCl) falls below 50 ml/min. We report prevalence of abnormal renal function at baseline and factors associated with abnormal renal function from a community cohort in Lesotho.
    • Trends in loss to follow-up among migrant workers on antiretroviral therapy in a community cohort in Lesotho.

      Bygrave, Helen; Kranzer, Katharina; Hilderbrand, Katherine; Whittall, Jonathan; Jouquet, Guillaume; Goemaere, Eric; Vlahakis, Nathalie; Triviño, Laura; Makakole, Lipontso; Ford, Nathan; et al. (2010-10-08)
      BACKGROUND: The provision of antiretroviral therapy (ART) to migrant populations raises particular challenges with respect to ensuring adequate treatment support, adherence, and retention in care. We assessed rates of loss to follow-up for migrant workers compared with non-migrant workers in a routine treatment programme in Morjia, Lesotho. DESIGN: All adult patients (≥18 years) initiating ART between January 1, 2008, and December 31, 2008, and followed up until the end of 2009, were included in the study. We described rates of loss to follow-up according to migrant status by Kaplan-Meier estimates, and used Poisson regression to model associations between migrant status and loss to follow-up controlling for potential confounders identified a priori. RESULTS: Our cohort comprised 1185 people, among whom 12% (148) were migrant workers. Among the migrant workers, median age was 36.1 (29.6-45.9) and the majority (55%) were male. We found no statistically significant differences between baseline characteristics and migrant status. Rates of lost to follow up were similar between migrants and non-migrants in the first 3 months but differences increased thereafter. Between 3 and 6 months after initiating antiretroviral therapy, migrants had a 2.78-fold increased rate of defaulting (95%CI 1.15-6.73); between 6 and 12 months the rate was 2.36 times greater (95%CI 1.18-4.73), whereas after 1 year the rate was 6.69 times greater (95%CI 3.18-14.09). CONCLUSIONS: Our study highlights the need for programme implementers to take into account the specific challenges that may influence continuity of antiretroviral treatment and care for migrant populations.