• Challenge and co-operation: civil society activism for access to HIV treatment in Thailand.

      Ford, N; Wilson, D; Cawthorne, P; Kumphitak, A; Kasi-Sedapan, S; Kaetkaew, S; Teemanka, S; Donmon, B; Preuanbuapan, C; Médecins Sans Frontières, Bangkok, Thailand. david.wilson.thai@gmail.com (Published by Wiley-Blackwell, 2009-03)
      Civil society has been a driving force behind efforts to increase access to treatment in Thailand. A focus on HIV medicines brought civil society and non-governmental and government actors together to fight for a single cause, creating a platform for joint action on practical issues to improve care for people with HIV/AIDS (PHA) within the public health system. The Thai Network of People with HIV/AIDS, in partnership with other actors, has provided concrete support for patients and for the health system as a whole; its efforts have contributed significantly to the availability of affordable generic medicines, early treatment for opportunistic infections, and an informed and responsible approach towards antiretroviral treatment that is critical to good adherence and treatment success. This change in perception of PHA from 'passive receiver' to 'co-provider' of health care has led to improved acceptance and support within the healthcare system. Today, most PHA in Thailand can access treatment, and efforts have shifted to supporting care for excluded populations.
    • Editorial: The AIDS crisis, cost-effectiveness and academic activism.

      Boelaert, M; Van Damme, W; Meessen, B; Van der Stuyft, P (2002-12)
    • Factors Associated with HIV Status Awareness and Linkage to Care Following Home Based Testing in Rural Malawi

      Maman, D; Ben-Farhat, J; Chilima, B; Masiku, C; Salumu, L; Ford, N; Mendiharat, P; Szumilin, E; Masson, S; Etard, JF; et al. (Wiley-Blackwell, 2016-10)
    • 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.
    • High acceptability of voluntary counselling and HIV-testing but unacceptable loss to follow up in a prevention of mother-to-child HIV transmission programme in rural Malawi: scaling-up requires a different way of acting.

      Manzi, M; Zachariah, R; Teck, R; Buhendwa, L; Kazima, J; Bakali, E; Firmenich, P; Humblet, P; Médecins sans Frontières-Luxembourg, Thyolo district, Luxembourg, Malawi. m.manzi@belgacom.net (Wiley-Blackwell, 2005-12)
      SETTING: Thyolo District Hospital, rural Malawi. OBJECTIVES: In a prevention of mother-to-child HIV transmission (PMTCT) programme, to determine: the acceptability of offering 'opt-out' voluntary counselling and HIV-testing (VCT); the progressive loss to follow up of HIV-positive mothers during the antenatal period, at delivery and to the 6-month postnatal visit; and the proportion of missed deliveries in the district. DESIGN: Cohort study. METHODS: Review of routine antenatal, VCT and PMTCT registers. RESULTS: Of 3136 new antenatal mothers, 2996 [96%, 95% confidence interval (CI): 95-97] were pre-test counselled, 2965 (95%, CI: 94-96) underwent HIV-testing, all of whom were post-test counselled. Thirty-one (1%) mothers refused HIV-testing. A total of 646 (22%) individuals were HIV-positive, and were included in the PMTCT programme. Two hundred and eighty-eight (45%) mothers and 222 (34%) babies received nevirapine. The cumulative loss to follow up (n=646) was 358 (55%, CI: 51-59) by the 36-week antenatal visit, 440 (68%, CI: 64-71) by delivery, 450 (70%, CI: 66-73) by the first postnatal visit and 524 (81%, CI: 78-84) by the 6-month postnatal visit. This left just 122 (19%, CI: 16-22) of the initial cohort still in the programme. The great majority (87%) of deliveries occurred at peripheral sites where PMTCT was not available. CONCLUSIONS: In a rural district hospital setting, at least 9 out of every 10 mothers attending antenatal services accepted VCT, of whom approximately one-quarter were HIV-positive and included in the PMTCT programme. The progressive loss to follow up of more than three-quarters of this cohort by the 6-month postnatal visit demands a 'different way of acting' if PMTCT is to be scaled up in our setting.
    • HIV-1 drug resistance testing at second-line regimen failure in Arua, Uganda: avoiding unnecessary switch to an empiric third-line.

      Fily, F; Ayikobua, E; Ssemwanga, D; Nicholas, S; Kaleebu, P; Delaugerre, C; Pasquier, E; Amoros Quiles, I; Balkan, S; Schramm, B (Wiley-Blackwell, 2018-07-29)
      The number of patients on second-line antiretroviral therapy is growing, but data on HIV drug resistance patterns at failure in resource-constrained settings are scarce. We aimed to describe drug resistance and investigate the factors associated with extensive resistance to nucleoside/nucleotide reverse transcriptase inhibitors (NRTI), in patients failing second-line therapy in the HIV outpatient clinic at Arua Regional Referral Hospital, Uganda.
    • Implementation of community and facility-based HIV self-testing under routine conditions in southern Eswatini

      Pasipamire, L; Nesbitt, R; Dube, L; Mabena, E; Nzima, M; Dlamini, M; Rugongo, N; Maphalala, N; Obulutsa, TA; Ciglenecki, I; et al. (Wiley, 2020-03-27)
      OBJECTIVES: WHO recommends HIV self-testing (HIVST) as an additional approach to HIV testing services. The study describes the strategies used during phase-in of HIVST under routine conditions in Eswatini (formerly Swaziland). METHODS: Between May 2017 and January 2018, assisted and unassisted oral HIVST was offered at HIV testing services (HTS) sites to people aged ≥ 16 years. Additional support tools were available, including a telephone hotline answered 24/7, HIVST demonstration videos and printed educational information about HIV prevention and care services. Demographic characteristics of HIVST users were described and compared with standard blood-based HTS in the community. HIVST results were monitored with follow-up phone calls and the hotline. RESULTS: During the 9-month period, 1895 people accessed HIVST and 2415 HIVST kits were distributed. More people accessed HIVST kits in the community (n = 1365, 72.0%) than at health facilities (n = 530, 28.0%). The proportion of males and median age among those accessing HIVST and standard HTS in the community were similar (49.3%, 29 years HIVST vs. 48.7%, 27 years standard HTS). In total, 34 (3.9%) reactive results were reported from 938 people with known HIVST results; 32.4% were males, and median age was 30 years (interquartile range 25-36). Twenty-one (62%) patients were known to have received confirmatory blood-based HTS; of these, 20 (95%) had concordant reactive results and 19 (95%) were linked to HIV care at a clinic. CONCLUSION: Integration of HIVST into existing HIV facility- and community-based testing strategies in Eswatini was found to be feasible, and HIVST has been adopted by national testing bodies in Eswatini.
    • Incidence, risk factors and causes of death in an HIV care programme with a large proportion of injecting drug users.

      Spillane, Heidi; Nicholas, Sarala; Tang, Zhirong; Szumilin, Elisabeth; Balkan, Suna; Pujades-Rodriguez, Mar; Médecins Sans Frontières, Nanning, China;Epicentre, Paris, France; Guangxi Centre for Disease Control, Nanning, China; Médecins Sans Frontières, Paris, France. (2012-08-05)
      Objectives  To identify factors influencing mortality in an HIV programme providing care to large numbers of injecting drug users (IDUs) and patients co-infected with hepatitis C (HCV). Methods  A longitudinal analysis of monitoring data from HIV-infected adults who started antiretroviral therapy (ART) between 2003 and 2009 was performed. Mortality and programme attrition rates within 2 years of ART initiation were estimated. Associations with individual-level factors were assessed with multivariable Cox and piece-wise Cox regression. Results  A total of 1671 person-years of follow-up from 1014 individuals was analysed. Thirty-four percent of patients were women and 33% were current or ex-IDUs. 36.2% of patients (90.8% of IDUs) were co-infected with HCV. Two-year all-cause mortality rate was 5.4 per 100 person-years (95% CI, 4.4-6.7). Most HIV-related deaths occurred within 6 months of ART start (36, 67.9%), but only 5 (25.0%) non-HIV-related deaths were recorded during this period. Mortality was higher in older patients (HR = 2.50; 95% CI, 1.42-4.40 for ≥40 compared to 15-29 years), and in those with initial BMI < 18.5 kg/m(2) (HR = 3.38; 95% CI, 1.82-5.32), poor adherence to treatment (HR = 5.13; 95% CI, 2.47-10.65 during the second year of therapy), or low initial CD4 cell count (HR = 4.55; 95% CI, 1.54-13.41 for <100 compared to ≥100 cells/μl). Risk of death was not associated with IDU status (P = 0.38). Conclusion  Increased mortality was associated with late presentation of patients. In this programme, death rates were similar regardless of injection drug exposure, supporting the notion that satisfactory treatment outcomes can be achieved when comprehensive care is provided to these patients.
    • Integrating tuberculosis and HIV care in the primary care setting in South Africa.

      Coetzee, D; Hilderbrand, K; Goemaere, E; Matthys, F; Boelaert, M; Infectious Disease Research Unit, School of Public Health and Family Medicine, University of Cape Town, Observatory, South Africa. dcoetzee@cormack.uct.ac.za (2004-06)
      BACKGROUND: In many countries including South Africa, the increasing human immunodeficiency virus (HIV) and tuberculosis (TB) epidemics have impacted significantly on already weakened public health services. This paper reviews the scope, process and performance of the HIV and TB services in a primary care setting where antiretroviral therapy is provided, in Khayelitsha, South Africa, in order to assess whether there is a need for some form of integration. METHODS: The scope and process of both services were assessed through observations of the service and individual and group interviews with key persons. The performance was assessed by examining the 2001-2002 reports from the health information system and clinical data. RESULTS: The TB service is programme oriented to the attainment of an 85% cure rate amongst smear-positive patients while the HIV service has a more holistic approach to the patient with HIV. The TB service is part of a well-established programme that is highly standardized. The HIV service is in the pilot phase. There is a heavy load at both services and there is large degree of cross-referral between the two services. There are lessons that can be learnt from each service. There is an overlap of activities, duplication of services and under-utilization of staff. There are missed opportunities for TB and HIV prevention, diagnosis and management. CONCLUSIONS: The study suggests that there may be benefits to integrating HIV and TB services. Constraints to this process are discussed.
    • Predictive value of C-reactive protein for tuberculosis, bloodstream infection or death among HIV-infected individuals with chronic, non-specific symptoms and negative sputum smear microscopy.

      Bedell, RA; van Lettow, M; Meaney, C; Corbett, EL; Chan, AK; Heyderman, RS; Anderson, ST; Akesson, A; Kumwenda, M; Zachariah, R; et al. (Wiley-Blackwell, 2018-01-01)
      BACKGROUND: C-reactive protein (CRP) is an inflammatory biomarker that may identify patients at risk of infections or death. Mortality among HIV-infected persons commencing antiretroviral therapy (ART) is often attributed to tuberculosis (TB) or bloodstream infections (BSI). METHODS: In two district hospitals in southern Malawi, we recruited HIV-infected adults with one or more unexplained symptoms present for at least one month (weight loss, fever or diarrhoea) and negative expectorated sputum microscopy for TB. CRP determination for 452 of 469 (96%) participants at study enrolment was analysed for associations with TB, BSI or death to 120 days post-enrolment. RESULTS: Baseline CRP was significantly elevated among patients with confirmed or probable TB (52), BSI (50) or death (60) compared to those with no identified infection who survived at least 120 days (269). A CRP value of >10 mg/L was associated with confirmed or probable TB (adjusted odds ratio 5.7; 95% CI 2.6, 14.3; 87% sensitivity) or death by 30 days (adjusted odds ratio 9.2; 95% CI 2.2, 55.1; 88% sensitivity). CRP was independently associated with TB, BSI or death, but the prediction of these endpoints was enhanced by including haemoglobin (all outcomes), CD4 count (BSI, death) and whether ART was started (death) in logistic regression models. CONCLUSION: High CRP at the time of ART initiation is associated with TB, BSI and early mortality and so has potential utility for stratifying patients for intensified clinical and laboratory investigation and follow-up. They may also be considered for empirical treatment of opportunistic infections including TB.
    • Programmatic outcomes and impact of rapid public sector antiretroviral therapy expansion in adults prior to introduction of the WHO treat-all approach in rural Eswatini.

      Boulle, A; Teck, R; Lukhele, N; Rusch, B; Telnov, A; Mabhena, E; Pasipamire, L; Ciglenecki, I; Schomaker, M; Kerschberger, B (John Wiley & Sons, 2019-04-01)
      To assess long-term antiretroviral therapy (ART) outcomes during rapid HIV programme expansion in the public sector of Eswatini (formerly Swaziland). This is a retrospectively established cohort of HIV-positive adults (≥16 years) who started first-line ART in 25 health facilities in Shiselweni (Eswatini) between 01/2006 and 12/2014. Temporal trends in ART attrition, treatment expansion and ART coverage were described over 9 years. We used flexible parametric survival models to assess the relationship between time to ART attrition and covariates. Of 24 772 ART initiations, 6% (n = 1488) occurred in 2006, vs. 13% (n = 3192) in 2014. Between these years, median CD4 cell count at ART initiation increased (113-265 cells/mm Programmatic outcomes improved during large expansion of the treatment cohort and increased ART coverage. Changes in ART programming may have contributed to better outcomes.
    • Reframing HIV Care: Putting People at the Centre of Antiretroviral Delivery

      Duncombe, Chris; Rosenblum, Scott; Hellmann, Nicholas; Holmes, Charles; Wilkinson, Lynne; Biot, Marc; Bygrave, Helen; Hoos, David; Garnett, Geoff (Wiley-Blackwell, 2015-01-13)
      The delivery of HIV care in the initial rapid scale-up of HIV care and treatment was based on existing clinic-based models, which are common in highly resourced settings and largely undifferentiated for individual needs. A new framework for treatment based on variable intensities of care tailored to the specific needs of different groups of individuals across the cascade of care is proposed here. Service intensity is characterized by four delivery components: (1) types of services delivered, (2) location of service delivery, (3) provider of health services, and (4) frequency of health services. How these components are developed into a service delivery framework will vary across countries and populations, with the intention being to improve acceptability and care outcomes. The goal of getting more people on treatment before they become ill will necessitate innovative models of delivering both testing and care. As HIV programs expand treatment eligibility, many people entering care will not be "patients" but healthy, active and productive members of society.(1) In order to take the framework to scale, it will be important to: (1) define which individuals can be served by an alternative delivery framework; (2) strengthen health systems that support decentralization, integration and task shifting; (3) make the supply chain more robust; and (4) invest in data systems for patient tracking and for program monitoring and evaluation. This article is protected by copyright. All rights reserved.
    • Supervised Oral HIV Self-Testing is Accurate in Rural KwaZulu-Natal, South Africa

      Martínez Pérez, G; Steele, SJ; Govender, I; Arellano, G; Mkwamba, A; Hadebe, M; van Cutsem, G (Wiley-Blackwell, 2016-06)
      To achieve UNAIDS 90-90-90 targets, alternatives to conventional HIV testing models are necessary in South Africa to increase population awareness of their HIV status. One of the alternatives is oral mucosal transudates-based HIV self-testing (OralST). This study describes implementation of counsellor-introduced supervised OralST in a high HIV prevalent rural area.
    • Vital status of pre-ART and ART patients defaulting from care in rural Malawi

      McGuire, Megan; Munyenyembe, Tamika; Szumilin, Elisabeth; Heinzelmann, Annette; Le Paih, Mickael; Bouithy, Nenette; Pujades-Rodríguez, Mar; Médecins Sans Frontières, Chiradzulu, Malawi; Médecins Sans Frontières, Paris, France; Epicentre, Paris, France (2010-04-29)
      OBJECTIVES: To ascertain the outcome of pre-Antiretroviral therapy (ART) and ART patients defaulting from care and investigate reasons for defaulting. METHODS: Patients defaulting from HIV care in Chiradzulu between July 2004 and September 2007 were traced at last known home address. Deaths and moves were recorded, and patients found alive were interviewed. Defaulting was defined as missed last appointment by more than 1 month among patients of unknown vital status. RESULTS: A total of 1637 individuals were traced (54%-88% of eligible), 981 pre-ART and 656 ART patients. Of 694 pre-ART patients found, 49% had died (51% of adults and 38% of children), a median of 47 days after defaulting, and 14% had moved away. Of 451 ART patients found, 54% had died (54% of adults and 50% of children), a median of 52 days after defaulting, and 20% had moved away. Overall, 221 patients were interviewed (90% of those found alive), 42% had worked outside the district in the previous year; 49% of pre-ART and 19% of ART patients had not disclosed their HIV status to other household members. Main reasons for defaulting were stigma (43%), care dissatisfaction (34%), improved health (28%) and for ART discontinuation, poor understanding of disease or treatment (56%) and drug side effects (42%). CONCLUSION: This study in a rural African HIV programme reveals the dynamics related to health service access and use, and it provides information to correct programme mortality estimates for adults and children.
    • Zidovudine to prevent mother-to-infant HIV transmission in developing countries: a view from Thailand.

      Kumphitak, A; Cawthorne, P; Lakhonphol, S; Kasi-Sedapan, S; Sanaeha, S; Unchit, N; Wilson, D (1999-03)