• The Continuing Burden of Advanced HIV Disease Over 10 Years of Increasing Antiretroviral Therapy Coverage in South Africa.

      Osler, M; Hilderbrand, K; Goemaere, E; Ford, N; Smith, M; Meintjes, G; Kruger, J; Govender, NP; Boulle, A (Oxford University Press, 2018-03-04)
      BACKGROUND: Antiretroviral treatment (ART) has been massively scaled up to decrease human immunodeficiency virus (HIV)-related morbidity, mortality, and HIV transmission. However, despite documented increases in ART coverage, morbidity and mortality have remained substantial. This study describes trends in the numbers and characteristics of patients with very advanced HIV disease in the Western Cape, South Africa. METHODS: Annual cross-sectional snapshots of CD4 distributions were described over 10 years, derived from a province-wide cohort of all HIV patients receiving CD4 cell count testing in the public sector. Patients with a first CD4 count <50 cells/µL in each year were characterized with respect to prior CD4 and viral load testing, ART access, and retention in ART care. RESULTS: Patients attending HIV care for the first time initially constituted the largest group of those with CD4 count <50 cells/µL, dropping proportionally over the decade from 60.9% to 26.7%. By contrast, the proportion who were ART experienced increased from 14.3% to 56.7%. In patients with CD4 counts <50 cells/µL in 2016, 51.8% were ART experienced, of whom 76% could be confirmed to be off ART or had recent viremia. More than half who were ART experienced with a CD4 count <50 cells/µL in 2016 were men, compared to approximately one-third of all patients on ART in the same year. CONCLUSIONS: Ongoing HIV-associated morbidity now results largely from treatment-experienced patients not being in continuous care or not being fully virologically suppressed. Innovative interventions to retain ART patients in effective care are an essential priority for the ongoing HIV response.
    • High Proportions of Patients With Advanced HIV Are Antiretroviral Therapy Experienced: Hospitalization Outcomes From 2 Sub-Saharan African Sites

      Ousley, J; Niyibizi, AA; Wanjala, S; Vandenbulcke, A; Kirubi, B; Omwoyo, W; Price, J; Salumu, L; Szumilin, E; Spiers, S; et al. (Oxford University Press, 2018-03-04)
      Human immunodeficiency virus (HIV) remains an important cause of hospitalization and death in low- and middle- income countries. Yet morbidity and in-hospital mortality patterns remain poorly characterized, with prior antiretroviral therapy (ART) exposure and treatment failure status largely unknown.
    • HIV Viral Load Monitoring in Resource-Limited Regions: Optional or Necessary?

      Calmy, A; Ford, N; Hirschel, B; Reynolds, S; Lynen, L; Goemaere, E; Garcia de la Vega, F; Perrin, L; Rodriguez, W; Medecins sans Frontieres, Access to Medicines Campaign, Geneva, 1211, Switzerland. acalmy@gmail.com (Published by: Infectious Diseases Society of America, 2007-01-01)
      Although it is a standard practice in high-income countries, determination of the human immunodeficiency virus (HIV) load is not recommended in developing countries because of the costs and technical constraints. As more and more countries establish capacity to provide second-line therapy, and as costs and technological constraints associated with viral load testing decrease, the question of whether determination of the viral load is necessary deserves attention. Viral load testing could increase in importance as a guide for clinical decisions on when to switch to second-line treatment and on how to optimize the duration of the first-line treatment regimen. In addition, the viral load is a particularly useful tool for monitoring adherence to treatment, performing sentinel surveillance, and diagnosing HIV infection in children aged <18 months. Rather than considering viral load data to be an unaffordable luxury, efforts should be made to ensure that viral load testing becomes affordable, simple, and easy to use in resource-limited settings.
    • Managing Advanced HIV Disease in a Public Health Approach.

      Ford, N; Meintjes, G; Calmy, A; Bygrave, H; Migone, C; Vitoria, M; Penazzato, M; Vojnov, L; Doherty, M (Oxford University Press, 2018-03-04)
      In 2017, the World Health Organization (WHO) published guidelines for the management of advanced human immunodeficiency virus (HIV) disease within a public health approach. Recent data suggest that more than a third of people starting antiretroviral therapy (ART) do so with advanced HIV disease, and an increasing number of patients re-present to care at an advanced stage of HIV disease following a period of disengagement from care. These guidelines recommend a standardized package of care for adults, adolescents, and children, based on the leading causes of morbidity and mortality: tuberculosis, severe bacterial infections, cryptococcal meningitis, toxoplasmosis, and Pneumocystis jirovecii pneumonia. A package of targeted interventions to reduce mortality and morbidity was recommended, based on results of 2 recent randomized trials that both showed a mortality reduction associated with delivery of a simplified intervention package. Taking these results and existing recommendations into consideration, WHO recommends that a package of care be offered to those presenting with advanced HIV disease; depending on age and CD4 cell count, the package may include opportunistic infection screening and prophylaxis, including fluconazole preemptive therapy for those who are cryptococcal antigen positive and without evidence of meningitis. Rapid ART initiation and intensified adherence interventions should also be proposed to everyone presenting with advanced HIV disease.
    • A Retrospective Survey of HIV Drug Resistance Among Patients 1 Year After Initiation of Antiretroviral Therapy at 4 Clinics in Malawi

      Wadonda-Kabondo, N.; Hedt, B. L.; van Oosterhout, J. J.; Moyo, K.; Limbambala, E.; Bello, G.; Chilima, B.; Schouten, E.; Harries, A.; Massaquoi, M.; et al. (2012-05)
    • Symptomatic hyperlactatemia: lessons learned using a point-of-care device in a health care center- and nurse-based antiretroviral program in Rwanda.

      van Griensven, J; Atte, E; Reid, T (Published by: Infectious Diseases Society of America and University of Chicago Press, 2008-01-15)
    • Treatment Outcomes Stratified by Baseline Immunological Status Among Young Children Receiving Nonnucleoside Reverse-Transcriptase Inhibitor-Based Antiretroviral Therapy in Resource-Limited Settings.

      O'Brien, D P; Sauvageot, D; Olson, D; Schaeffer, M; Humblet, P; Pudjades, M; Ellman, T; Zachariah, R; Szumilin, E; Arnould, L; et al. (Published by: Infectious Diseases Society of America, 2007-05-01)
      A study of 568 children aged <5 years who commenced nonnucleoside reverse-transcriptase inhibitor-based antiretroviral therapy in resource-limited settings revealed good early outcomes. After 12 months of antiretroviral therapy, survival probability was 0.89 (95% confidence interval, 0.86-0.92), with no significant difference among children stratified on the basis of baseline immunological levels; 62% attained a CD4 cell percentage >25%, and 7% continued to have a CD4 cell percentage <15%.
    • Voluntary Community Human Immunodeficiency Virus Testing, Linkage, and Retention in Care Interventions in Kenya: Modeling the Clinical Impact and Cost-effectiveness

      Luong Nguyen, LB; Yazdanpanah, Y; Maman, D; Wanjala, S; Vandenbulcke, A; Price, J; Parker, RA; Hennequin, W; Mendiharat, P; Freedberg, KA (Oxford University Press, 2018-05-08)
      In southwest Kenya, the prevalence of human immunodeficiency virus (HIV) infection is about 25%. Médecins Sans Frontières has implemented a voluntary community testing (VCT) program, with linkage to care and retention interventions, to achieve the Joint United Nations Program on HIV and AIDS (UNAIDS) 90-90-90 targets by 2017. We assessed the effectiveness and cost-effectiveness of these interventions.