• Providing universal access to antiretroviral therapy in Thyolo, Malawi through task shifting and decentralization of HIV/AIDS care.

      Bemelmans, Marielle; Van Den Akker, Thomas; Ford, Nathan; Philips, Mit; Zachariah, Rony; Harries, Anthony; Schouten, Erik; Hermann, Katharina; Mwagomba, Beatrice; Massaquoi, Moses; et al. (2010-12)
      Objective  To describe how district-wide access to HIV/AIDS care was achieved and maintained in Thyolo District, Malawi. Method  In mid-2003, the Ministry of Health and Médecins Sans Frontières developed a model of care for Thyolo district (population 587 455) based on decentralization of care to health centres and community sites and task shifting. Results  After delegating HIV testing and counseling to lay counsellors, uptake of testing increased from 1300 tests per month in 2003 to 6500 in 2009. Shifting responsibility for antiretroviral therapy (ART) initiations to non-physician clinicians almost doubled ART enrolment, with a majority of initiations performed in peripheral health centres. By the end 2009, 23 261 people had initiated ART of whom 11 042 received ART care at health-centre level. By the end of 2007, the universal access targets were achieved, with nearly 9000 patients alive and on ART. The average annual cost for achieving these targets was €2.6 per inhabitant/year. Conclusion  The Thyolo programme has demonstrated the feasibility of district-wide access to ART in a setting with limited resources for health. Expansion and decentralization of HIV/AIDS service-capacity to the primary care level, combined with task shifting, resulted in increased access to HIV services with good programme outcomes despite staff shortages.
    • Risk factors for mortality in AIDS-associated Kaposi sarcoma in a primary care antiretroviral treatment program in Malawi

      Chu, Kathryn; Misinde, Dalitso; Massaquoi, Moses; Pasulani, Olesi; Mwagomba, Beatrice; Ford, Nathan; Zachariah, Rony (2010-04)
    • Short and long term retention in antiretroviral care in health facilities in rural Malawi and Zimbabwe.

      Rasschaert, Freya; Koole, Olivier; Zachariah, Rony; Lynen, Lut; Manzi, Marcel; Van Damme, Wim; Institute of Tropical Medicine, Nationale straat 155, Antwerpen 2000, Belgium. frasschaert@itg.be (2012-12)
      Despite the successful scale-up of ART services over the past years, long term retention in ART care remains a major challenge, especially in high HIV prevalence and resource-limited settings. This study analysed the short (<12 months) and long (>12 months) term retention on ART in two ART programmes in Malawi (Thyolo district) and Zimbabwe (Buhera district).
    • Six-Month Mortality among HIV-Infected Adults Presenting for Antiretroviral Therapy with Unexplained Weight Loss, Chronic Fever or Chronic Diarrhea in Malawi.

      van Lettow, Monique; Akesson, Ann; Martiniuk, Alexandra L C; Ramsay, Andrew; Chan, Adrienne K; Anderson, Suzanne T; Harries, Anthony D; Corbett, Elizabeth; Heyderman, Robert S; Zachariah, Rony; et al. (2012-11)
      In sub-Saharan Africa, early mortality is high following initiation of antiretroviral therapy (ART). We investigated 6-month outcomes and factors associated with mortality in HIV-infected adults being assessed for ART initiation and presenting with weight loss, chronic fever or diarrhea, and with negative TB sputum microscopy.
    • Strategies to improve patient retention on antiretroviral therapy in sub-Saharan Africa.

      Harries, Anthony D; Zachariah, Rony; Lawn, Stephen D; Rosen, Sydney; International Union against Tuberculosis and Lung Disease, Paris, France. adharries@theunion.org (2010-06)
      The scale-up of antiretroviral therapy (ART) has been one of the success stories of sub-Saharan Africa, where coverage has increased from about 2% in 2003 to more than 40% 5 years later. However, tempering this success is a growing concern about patient retention (the proportion of patients who are alive and remaining on ART in the health system). Based on the personal experience of the authors, 10 key interventions are presented and discussed that might help to improve patient retention. These are (1) the need for simple and standardized monitoring systems to track what is happening, (2) reliable ascertainment of true outcomes of patients lost to follow-up, (3) implementation of measures to reduce early mortality in patients both before and during ART, (4) ensuring uninterrupted drug supplies, (5) consideration of simple, non-toxic ART regimens, (6) decentralization of ART care to health centres and the community, (7) a reduction in indirect costs for patients particularly in relation to transport to and from clinics, (8) strengthening links within and between health services and the community, (9) the use of ART clinics to deliver other beneficial patient or family-orientated packages of care such as insecticide-treated bed nets, and (10) innovative (thinking 'out of the box') interventions. High levels of retention on ART are vital for individual patients, for credibility of programmes and for on-going resource and financial support.
    • Tracing patients on antiretroviral treatment lost-to-follow-up in an urban slum in India

      Errol, Lisa; Isaakidis, Petros; Zachariah, Rony; Ali, Mohammed; Pilankar, Gurudas; Maurya, Sanjana; Geraets, Claudia; Ladomirska, Joanna; Patel, Sunil; Reid, Tony (Blackwell, 2012-01)
    • Treatment outcomes in a cohort of Palestine refugees with diabetes mellitus followed through use of E-Health over 3 years in Jordan

      Khader, Ali; Ballout, Ghada; Shahin, Yousef; Hababeh, Majed; Farajallah, Loai; Zeidan, Wafaa; Abu-Zayed, Ishtaiwi; Kochi, Arata; Harries, Anthony D; Zachariah, Rony; et al. (John Wiley & Sons Ltd, 2014-02)
      The aim of this study was to use E-Health to report on 12-month, 24-month and 36-month outcomes and late-stage complications of a cohort of Palestine refugees with diabetes mellitus (DM) registered in the second quarter of 2010 in a primary healthcare clinic in Amman, Jordan.
    • Treatment outcomes in a cohort of patients with chronic hepatitis B and human immunodeficiency virus co-infection in Mumbai, India

      Isaakidis, Petros; Mansoor, Homa; Zachariah, Rony; Da Silva, Esdras A.; Varghese, Bhanumati; Deshpande, Alaka; Dal Molin, Tiago A.; Ladomirska, Joanna; Arnould, Line; Reid, Tony (2012-10)
    • Unacceptable attrition among WHO stages 1 and 2 patients in a hospital-based setting in rural Malawi: can we retain such patients within the general health system?

      Tayler-Smith, Katie; Zachariah, Rony; Massaquoi, M; Massaquoi, M; Manzi, Marcel; Pasulani, Olesi; van den Akker, Thomas; Bemelmans, Marielle; Bauernfeind, Ariane; Mwagomba, Beatrice; et al. (2010-05)
      A study conducted among HIV-positive adults in WHO clinical stages 1 and 2 was followed up at Thyolo District Hospital (rural Malawi) to report on: (1) retention and attrition before and while on antiretroviral treatment (ART); and (2) the criteria used for initiating ART. Between June 2008 and January 2009, 1633 adults in WHO stages 1 and 2 were followed up for a total of 282 person-years. Retention in care at 1, 2, 3 and 6 months for those not on ART (n=1078) was 25, 18, 11 and 4% vs. 99, 97, 95 and 90% for patients who started ART (n=555, P=0.001). Attrition rates were 31 times higher among patients not started on ART compared with those started on ART (adjusted hazard ratio, 31.0, 95% CI 22-44). Ninety-two patients in WHO stage 1 or 2 were started on ART without the guidance of a CD4 count, and 11 were incorrectly started on ART with CD4 count > or = 250 cells/mm(3). In a rural district hospital setting in Malawi, attrition of individuals in WHO stages 1 and 2 is unacceptably high, and specific operational strategies need to be considered to retain such patients in the health system.
    • Using touchscreen electronic medical record systems to support and monitor national scale-up of antiretroviral therapy in Malawi.

      Douglas, Gerald P; Gadabu, Oliver J; Joukes, Sabine; Mumba, Soyapi; McKay, Michael V; Ben-Smith, Anne; Jahn, Andreas; Schouten, Erik J; Landis Lewis, Zach; van Oosterhout, Joep J; et al. (2010-09)
    • Very early mortality in patients starting antiretroviral treatment at primary health centres in rural Malawi.

      Zachariah, Rony; Harries, Katie; Moses, Massaquoi; Manzi, Marcel; Line, Arnould; Mwagomba, Beatrice; Harries, Anthony D; Medecins Sans Frontieres, Medical Department, Brussels, Belgium. zachariah@internet.lu (2009-07-15)
      OBJECTIVES: To report on the cumulative proportion of deaths occurring within 3 months of starting antiretroviral treatment (ART) and to identify factors associated with such deaths, among adults at primary health centres in a rural district of Malawi. METHODS: Retrospective cohort study: from June 2006 to April 2008, deaths occurring over a 3-month period were determined and risk factors examined. RESULTS: A total of 2316 adults (706 men and 1610 women; median age 35 years) were included in the analysis and followed up for a total of 1588 person-years (PY); 277 (12%) people died, of whom 206 (74%) people died within 3 months of initiating ART (cumulative incidence: 13.0; 95% confidence interval: 11.3-14.8 per 100 PY of follow-up). Significant risk factors associated with early deaths included male sex, WHO stage 4 disease, oesophageal or persistent oral candidiasis and unexplained presumed or measured weight loss >10%. One in every 3 patients who either died or was lost to follow up had unexplained weight loss >10%, and survival in this group was significantly different from patients without this condition. CONCLUSIONS: Seven in 10 individuals initiating ART at primary health centres die early. Specific groups of patients are at higher risk of such mortality and should receive priority attention, care and support.
    • Weight loss after the first year of stavudine-containing antiretroviral therapy and its association with lipoatrophy, virological failure, adherence and CD4 counts at primary health care level in Kigali, Rwanda.

      van Griensven, Johan; Zachariah, Rony; Mugabo, Jules; Reid, Tony; Médecins Sans Frontières, Operational Centre Brussels, Medical Department, Duprestraat 94, 1090 Brussels, Belgium. jvgrie@yahoo.com (2010-12)
      This study was conducted among 609 adults on stavudine-based antiretroviral treatment (ART) for at least one year at health center level in Kigali, Rwanda to (a) determine the proportion who manifest weight loss after one year of ART (b) examine the association between such weight loss and a number of variables, namely: lipoatrophy, virological failure, adherence and on-treatment CD4 count and (c) assess the validity and predictive values of weight loss to identify patients with lipoatrophy. Weight loss after the first year of ART was seen in 62% of all patients (median weight loss 3.1 kg/year). In multivariate analysis, weight loss was significantly associated with treatment-limiting lipoatrophy (adjusted effect/kg/year -2.0 kg, 95% confidence interval -0.6;-3.4 kg; P<0.01). No significant association was found with virological failure or adherence. Higher on-treatment CD4 cell counts were protective against weight loss. Weight loss that was persistent, progressive and/or chronic was predictive of lipoatrophy, with a sensitivity and specificity of 72% and 77%, and positive and negative predictive values of 30% and 95%. In low-income countries, measuring weight is a routine clinical procedure that could be used to filter out individuals with lipoatrophy on stavudine-based ART, after alternative causes of weight loss have been ruled out.