• Access to CD4 Testing for Rural HIV Patients: Findings from a Cohort Study in Zimbabwe

      Vogt, Florian; Tayler-Smith, Katie; Bernasconi, Andrea; Makondo, Eliphas; Taziwa, Fabian; Moyo, Buhlebenkosi; Havazvidi, Liberty; Satyanarayana, Srinath; Manzi, Marcel; Khogali, Mohammed; Reid, Anthony (Public Library of Science, 2015-06-17)
      CD4 cell count measurement remains an important diagnostic tool for HIV care in developing countries. Insufficient laboratory capacity in rural Sub-Saharan Africa is frequently mentioned but data on the impact at an individual patient level are lacking. Urban-rural discrepancies in CD4 testing have not been quantified to date. Such evidence is crucial for public health planning and to justify new yet more expensive diagnostic procedures that could circumvent access constraints in rural areas.
    • Antiretroviral Therapy outcomes among adolescents and youth in rural Zimbabwe

      Bygrave, Helen; Mtangirwa, Judith; Ncube, Kwenzakwenkosi; Ford, Nathan; Kranzer, Katharina; Munyaradzi, Dhodho; Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa. Helen.bygrave@joburg.msf.org (2012-12-20)
      Around 2 million adolescents and 3 million youth are estimated to be living with HIV worldwide. Antiretroviral outcomes for this group appear to be worse compared to adults. We report antiretroviral therapy outcomes from a rural setting in Zimbabwe among patients aged 10-30 years who were initiated on ART between 2005 and 2008. The cohort was stratified into four age groups: 10-15 (young adolescents) 15.1-19 years (adolescents), 19.1-24 years (young adults) and 24.1-29.9 years (older adults). Survival analysis was used to estimate rates of deaths and loss to follow-up stratified by age group. Endpoints were time from ART initiation to death or loss to follow-up. Follow-up of patients on continuous therapy was censored at date of transfer, or study end (31 December 2008). Sex-adjusted Cox proportional hazards models were used to estimate hazard ratios for different age groups. 898 patients were included in the analysis; median duration on ART was 468 days. The risk of death were highest in adults compared to young adolescents (aHR 2.25, 95%CI 1.17-4.35). Young adults and adolescents had a 2-3 times higher risk of loss to follow-up compared to young adolescents. When estimating the risk of attrition combining loss to follow-up and death, young adults had the highest risk (aHR 2.70, 95%CI 1.62-4.52). This study highlights the need for adapted adherence support and service delivery models for both adolescents and young adults.
    • Clinical mentorship of nurse initiated antiretroviral therapy in Khayelitsha, South Africa: a quality of care assessment.

      Green, Ann; de Azevedo, Virginia; Patten, Gabriela; Davies, Mary-Ann; Ibeto, Mary; Cox, Vivian (Public Library of Science, 2014-06)
      To combat the AIDS epidemic and increase HIV treatment access, the South African government implemented a nurse-based, doctor-supported model of care that decentralizes administration of antiretroviral treatment (ART) for HIV positive patients through nurse initiated and managed ART. Médecins Sans Frontières (MSF) implemented a mentorship programme to ensure successful task-shifting, subsequently assessing the quality of clinical care provided by nurses.
    • Comparison of methods to correct survival estimates and survival regression analysis on a large HIV African cohort

      Henriques, Julie; Pujades-Rodriguez, Mar; McGuire, Megan; Szumilin, Elisabeth; Iwaz, Jean; Etard, Jean-François; Ecochard, René; Service de Biostatistique, Hospices Civils de Lyon, Lyon, France; Université de Lyon, Lyon, France; Université Lyon 1, Villeurbanne, France; Equipe Biostatistique-Santé, Centre National de la Recherche Scientifique-Unité Mixte de Recherche 5558 Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Epicentre, Paris, France; Médecins Sans Frontières, Paris, France; Institut de Recherche pour le Développement-Université de Montpellier Unité Mixte Internationale 233 TransVIHMI, Montpellier, France (PLoS, 2012)
      The evaluation of HIV treatment programs is generally based on an estimation of survival among patients receiving antiretroviral treatment (ART). In large HIV programs, loss to follow-up (LFU) rates remain high despite active patient tracing, which is likely to bias survival estimates and survival regression analyses.
    • Correcting for Mortality Among Patients Lost to Follow Up on Antiretroviral Therapy in South Africa: A Cohort Analysis

      Van Cutsem, Gilles; Ford, Nathan; Hildebrand, Katherine; Goemaere, Eric; Mathee, Shaheed; Abrahams, Musaed; Coetzee, David; Boulle, Andrew; Médecins Sans Frontières, South Africa; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa, Department of Health, Provincial Government of the Western Cape, South Africa (2011-02-17)
      Loss to follow-up (LTF) challenges the reporting of antiretroviral treatment (ART) programmes, since it encompasses patients alive but lost to programme and deaths misclassified as LTF. We describe LTF before and after correction for mortality in a primary care ART programme with linkages to the national vital registration system.
    • Early adherence to antiretroviral medication as a predictor of long-term HIV virological suppression: five-year follow up of an observational cohort.

      Ford, Nathan; Darder, Marta; Spelman, Tim; Maclean, Emi; Mills, Edward; Boulle, Andrew; Médecins Sans Frontières, Cape Town, South Africa. nathan.ford@joburg.msf.org (2010-05)
      OBJECTIVE: Previous studies have demonstrated a cross-sectional relationship between antiretroviral adherence and HIV virological suppression. We assessed the predictive value of baseline adherence in determining long-term virological failure. DESIGN: We assessed baseline adherence via an adherence questionnaire between administered to all consenting patients attending antiretroviral clinics in Khayelitsha township, South Africa, between May 2002 and March 2004. Virological status was ascertained after five years of follow up and multivariate analysis used to model associations of baseline variables and medication adherence with time to viral suppression or failure. RESULTS: Our adherence cohort comprised 207 patients, among whom 72% were female. Median age was 30 years and median CD4 count at initiation was 55 cells/mm(3). We found no statistically significant differences between baseline characteristics and early adherence groups. Multivariate analysis adjusting for baseline CD4 and age found that patients with suboptimal baseline adherence had a hazard ratio of 2.82 (95% CI 1.19-6.66, p = 0.018) for progression to virological failure compared to those whose baseline adherence was considered optimal. CONCLUSIONS: Our longitudinal study provides further confirmation of adherence as a primary determinant of subsequent confirmed virological failure, and serves as a reminder of the importance of initial early investments in adherence counseling and support as an effective way to maximize long-term treatment success.
    • The Effect of Complete Integration of HIV and TB Services on Time to Initiation of Antiretroviral Therapy: A Before-After Study.

      Kerschberger, Bernhard; Hilderbrand, Katherine; Boulle, Andrew M; Coetzee, David; Goemaere, Eric; De Azevedo, Virginia; Van Cutsem, Gilles; Médecins sans Frontières, Khayelitsha, Cape Town, South Africa; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; South African Medical Unit, Médecins sans Frontières, Johannesburg, South Africa; City of Cape Town, Health Directorate, Khayelitsha, South Africa. (2012-10)
      Studies have shown that early ART initiation in TB/HIV co-infected patients lowers mortality. One way to implement earlier ART commencement could be through integration of TB and HIV services, a more efficient model of care than separate, vertical programs. We present a model of full TB/HIV integration and estimate its effect on time to initiation of ART.
    • Effectiveness of Patient Adherence Groups as a model of care for stable patients on Antiretroviral Therapy in Khayelitsha, Cape Town, South Africa

      Luque-Fernandez, Miguel Angel; Van Cutsem, Gilles; Goemaere, Eric; Hilderbrand, Katherine; Schomaker, Michael; Mantangana, Nompumelelo; Mathee, Shaheed; Dubula, Vuyiseka; Ford, Nathan; Hernán, Miguel A; Boulle, Andrew; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa (2013-02-13)
      Innovative models of care are required to cope with the ever-increasing number of patients on antiretroviral therapy in the most affected countries. This study, in Khayelitsha, South Africa, evaluates the effectiveness of a group-based model of care run predominantly by non-clinical staff in retaining patients in care and maintaining adherence.
    • Estimation and Short-Term Prediction of the Course of the HIV Epidemic Using Demographic and Health Survey Methodology-Like Data

      Blaizot, Stéphanie; Riche, Benjamin; Maman, David; Mukui, Irene; Kirubi, Beatrice; Etard, Jean-François; Ecochard, René (Public Library of Science, 2015-06-19)
      Mathematical models have played important roles in the understanding of epidemics and in the study of the impacts of various behavioral or medical measures. However, modeling accurately the future spread of an epidemic requires context-specific parameters that are difficult to estimate because of lack of data. Our objective is to propose a methodology to estimate context-specific parameters using Demographic and Health Survey (DHS)-like data that can be used in mathematical modeling of short-term HIV spreading.
    • Evaluation of Clinical and Immunological Markers for predicting Virological Failure in a HIV/AIDS treatment cohort in Busia, Kenya

      Ferreyra, Cecilia; Yun, Oliver; Eisenberg, Nell; Alonso, Elena; Khamadi, Ashimosi S; Mwau, Matilu; Mugendi, Martha Kihara; Alvarez, Ana; Velilla, Elena; Flevaud, Laurence; Arnedo, Mireia; Dalmau, David; Roddy, Paul; Bernasconi, Andrea; Palma, Pedro Pablo; Médecins Sans Frontières, Operational Center Barcelona Athens, Barcelona, Spain. cecilia.ferreyra@barcelona.msf.org (2012-11-21)
      In resource-limited settings where viral load (VL) monitoring is scarce or unavailable, clinicians must use immunological and clinical criteria to define HIV virological treatment failure. This study examined the performance of World Health Organization (WHO) clinical and immunological failure criteria in predicting virological failure in HIV patients receiving antiretroviral therapy (ART).
    • Factors Associated with Virological Failure and Suppression after Enhanced Adherence Counselling, in Children, Adolescents and Adults on Antiretroviral Therapy for HIV in Swaziland

      Jobanputra, Kiran; Parker, Lucy Anne; Azih, Charles; Okello, Velephi; Maphalala, Gugu; Kershberger, Bernard; Khogali, Mohammed; Lujan, Johnny; Antierens, Annick; Teck, Roger; Ellman, Tom; Kosgei, Rose; Reid, Tony (Public Library of Science, 2015-02-19)
      This study explores factors associated with virological detectability, and viral re-suppression after enhanced adherence counselling, in adults and children on antiretroviral therapy (ART) in Swaziland.
    • False positive HIV diagnoses in resource limited settings: operational lessons learned for HIV programmes

      Shanks, Leslie; Klarkowski, Derryck; O'Brien, Daniel P; Médecins Sans Frontières, Amsterdam, The Netherlands. (Public Library of Science, 2013-03-20)
      Access to HIV diagnosis is life-saving; however the use of rapid diagnostic tests in combination is vulnerable to wrongly diagnosing HIV infection when both screening tests give a false positive result. Misclassification of HIV patients can also occur due to poor quality control, administrative errors and lack of supervision and training of staff. Médecins Sans Frontières discovered in 2004 that HIV negative individuals were enrolled in some HIV programmes. This paper describes the result of an audit of three sites to review testing practices, implement improved testing algorithms and offer re-testing to clients enrolled in the HIV clinic.
    • First-Line Antiretroviral Drug Discontinuations in Children

      Fortuin-de Smidt, M; de Waal, R; Cohen, K; Technau, KG; Stinson, K; Maartens, G; Boulle, A; Igumbor, EU; Davies, MA (Public Library of Science, 2017-02-13)
      There are a limited number of paediatric antiretroviral drug options. Characterising the long term safety and durability of different antiretrovirals in children is important to optimise management of HIV infected children and to determine the estimated need for alternative drugs in paediatric regimens. We describe first-line antiretroviral therapy (ART) durability and reasons for discontinuations in children at two South African ART programmes, where lopinavir/ritonavir has been recommended for children <3 years old since 2004, and abacavir replaced stavudine as the preferred nucleoside reverse transcriptase inhibitor in 2010.
    • Impact of HIV-Associated Conditions on Mortality in People Commencing Anti-Retroviral Therapy in Resource Limited Settings

      Marshall, Catherine S; Curtis, Andrea J; Spelman, Tim; O'Brien, Daniel P; Greig, Jane; Shanks, Leslie; du Cros, Philipp; Casas, Esther C; da Fonseca, Marcio Silveira; Athan, Eugene; Elliott, Julian H; Infectious Diseases Unit, Alfred Hospital, Melbourne, Australia. catherine.marshall@nt.gov.au (PLoS, 2013-07)
      To identify associations between specific WHO stage 3 and 4 conditions diagnosed after ART initiation and all cause mortality for patients in resource-limited settings (RLS). DESIGN, SETTING: Analysis of routine program data collected prospectively from 25 programs in eight countries between 2002 and 2010.
    • Incidence of WHO stage 3 and 4 conditions following initiation of Anti-Retroviral Therapy in resource limited settings

      Curtis, Andrea J; Marshall, Catherine S; Spelman, Tim; Greig, Jane; Elliot, Julian H; Shanks, Leslie; Du Cros, Philipp; Casas, Esther C; Da Fonseca, Marcio Silveria; O'Brien, Daniel P; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (2012-12-20)
      To determine the incidence of WHO clinical stage 3 and 4 conditions during early anti-retroviral therapy (ART) in resource limited settings (RLS).
    • Is There a Need for Viral Load Testing to Assess Treatment Failure in HIV-Infected Patients Who Are about to Change to Tenofovir-Based First-Line Antiretroviral Therapy? Programmatic Findings from Myanmar

      Thiha, N; Chinnakali, P; Harries, AD; Shwe, M; Balathandan, TP; Thein Than Tun, S; Das, M; Tin, HH; Yi, Y; Babin, FX; Lwin, TT; Clevenbergh, PA (Public Library of Science, 2016-08-09)
      WHO recommends that stavudine is phased out of antiretroviral therapy (ART) programmes and replaced with tenofovir (TDF) for first-line treatment. In this context, the Integrated HIV Care Program, Myanmar, evaluated patients for ART failure using HIV RNA viral load (VL) before making the change. We aimed to determine prevalence and determinants of ART failure in those on first-line treatment.
    • Low Incidence of Renal Dysfunction Among HIV-Infected Patients on a Tenofovir-Based First Line Antiretroviral Treatment Regimen in Myanmar

      Kyaw, Nang Thu Thu; Harries, Anthony D; Chinnakali, Palanivel; Antierens, Annick; Soe, Kyi Pyar; Woodman, Mike; Das, Mrinalini; Shetty, Sharmila; Zuu, Moe Khine Lwin; Htwe, Pyae Sone; Fernandez, Marcelo (Public Library of Science, 2015)
      Since 2004, Médecins Sans Frontières-Switzerland has provided treatment and care for people living with HIV in Dawei, Myanmar. Renal function is routinely monitored in patients on tenofovir (TDF)-based antiretroviral treatment (ART), and this provides an opportunity to measure incidence and risk factors for renal dysfunction.
    • Monitoring of antiretroviral therapy and mortality in HIV programmes in Malawi, South Africa and Zambia: mathematical modelling study

      Estill, Janne; Egger, Matthias; Johnson, Leigh F; Gsponer, Thomas; Wandeler, Gilles; Davies, Mary-Ann; Boulle, Andrew; Wood, Robin; Garone, Daniela; Stringer, Jeffrey S A; Hallett, Timothy B; Keiser, Olivia; Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland. jestill@ispm.unibe.ch (Public Library of Science, 2013-02-28)
      Mortality in patients starting antiretroviral therapy (ART) is higher in Malawi and Zambia than in South Africa. We examined whether different monitoring of ART (viral load [VL] in South Africa and CD4 count in Malawi and Zambia) could explain this mortality difference.
    • Mortality reduction associated with HIV/AIDS care and antiretroviral treatment in rural Malawi: evidence from registers, coffin sales and funerals.

      Mwagomba, Beatrice; Zachariah, Rony; Massaquoi, Moses; Misindi, Dalitso; Manzi, Marcel; Mandere, Bester C; Bemelmans, Marielle; Philips, Mit; Kamoto, Kelita; Schouten, Eric J; Harries, A D; Thyolo District Health Services, Ministry of Health and Population, Thyolo, Malawi. (2010-05)
      BACKGROUND: To report on the trend in all-cause mortality in a rural district of Malawi that has successfully scaled-up HIV/AIDS care including antiretroviral treatment (ART) to its population, through corroborative evidence from a) registered deaths at traditional authorities (TAs), b) coffin sales and c) church funerals. METHODS AND FINDINGS: Retrospective study in 5 of 12 TAs (covering approximately 50% of the population) during the period 2000-2007. A total of 210 villages, 24 coffin workshops and 23 churches were included. There were a total of 18,473 registered deaths at TAs, 15781 coffins sold, and 2762 church funerals. Between 2000 and 2007, there was a highly significant linear downward trend in death rates, sale of coffins and church funerals (X(2) for linear trend: 338.4 P<0.0001, 989 P<0.0001 and 197, P<0.0001 respectively). Using data from TAs as the most reliable source of data on deaths, overall death rate reduction was 37% (95% CI:33-40) for the period. The mean annual incremental death rate reduction was 0.52/1000/year. Death rates decreased over time as the percentage of people living with HIV/AIDS enrolled into care and ART increased. Extrapolating these data to the entire district population, an estimated 10,156 (95% CI: 9786-10259) deaths would have been averted during the 8-year period. CONCLUSIONS: Registered deaths at traditional authorities, the sale of coffins and church funerals showed a significant downward trend over a 8-year period which we believe was associated with the scaling up HIV/AIDS care and ART.
    • Nevirapine-associated early hepatotoxicity: incidence, risk factors, and associated mortality in a primary care ART programme in South Africa.

      Chu, Kathryn M; Boulle, Andrew M; Ford, Nathan; Goemaere, Eric; Asselman, Valerie; Van Cutsem, Gilles; South African Medical Unit, Médecins Sans Frontières, Johannesburg, South Africa. kathryn.chu@joburg.msf.org (2010-02)
      BACKGROUND: The majority of antiretroviral treatment programmes in sub-Saharan Africa are scaling up antiretroviral treatment using a fixed dose first-line antiretroviral regimen containing stavudine, lamivudine, and nevirapine. One of the primary concerns with the use of this regimen is nevirapine-associated hepatotoxicity. METHODOLOGY/PRINCIPAL FINDINGS: Study participants were 1809 HIV-infected, antiretroviral naïve adults initiating nevirapine-based antiretroviral therapy between November 2002 and December 2006. The primary outcome was early hepatotoxicity. Secondary outcomes were associations with hepatotoxicity and mortality at six months. The cumulative proportion of early hepatotoxicity ranged from 1.0-2.0% giving an incidence-rate at 102 days of 3.6-7.6 per 100 person-years. Median time to hepatotoxicity was 32 (IQR 28-58) days. At 12 weeks, only 8% of patients had alanine aminotransferase monitoring at all the time-points recommended by national guidelines. No association was found between age, gender, baseline CD4 count, concurrent tuberculosis infection, prior participation in a prevention of mother-to-child-transmission program, or baseline weight and early hepatotoxicity. There was no association between early hepatotoxicity and mortality. CONCLUSIONS: The cumulative proportion of early hepatotoxicity in nevirapine based antiretroviral therapy was low in this resource-constrained setting. Hepatotoxicity was not associated with mortality. Frequent routine monitoring of alanine aminotransferase proved difficult to implement in this public sector primary care programme. Focused monitoring in the first month may be a more cost-effective and pragmatic option in settings with limited resources. Correlation with clinical signs and symptoms may allow future alanine aminotransferase testing to be dictated by clinical criteria.