• Association between older age and adverse outcomes on antiretroviral therapy: a cohort analysis of programme data from nine countries.

      Greig, Jane; Casas, Esther C; O'Brien, Daniel P; Mills, Edward J; Ford, Nathan; Médecins Sans Frontières, London, UK. jane.greig@london.msf.org (2012-07-31)
      Recent studies have highlighted the increased risk of adverse outcomes among older patients on antiretroviral therapy (ART). We report on the associations between older age and adverse outcomes in HIV/AIDS antiretroviral programmes across 17 programmes in sub-Saharan Africa.
    • A biregional survey and review of first-line treatment failure and second-line paediatric antiretroviral access and use in Asia and southern Africa

      Van Cutsem, G; Saphonn, V; Saramony, S; Vibol, U; Zhang, FJ; Han, N; Saghayam, S; Kurniati, N; Muktiarti, D; Fong, SM; Thien, M; Nik Yusoff, NK; Hai, LC; Razali, K; TREAT Asia/amfAR - The Foundation for AIDS Research, Bangkok, Thailand. annette.sohn@treatasia.org (BioMed Central, 2011-04-08)
      To better understand the need for paediatric second-line antiretroviral therapy (ART), an ART management survey and a cross-sectional analysis of second-line ART use were conducted in the TREAT Asia Paediatric HIV Observational Database and the IeDEA Southern Africa (International Epidemiologic Databases to Evaluate AIDS) regional cohorts.
    • Cascade of HIV Care and Population Biral Suppression in a High-Burden Region of Kenya

      Maman, D; Zeh, C; Mukui, I; Kirubi, B; Masson, S; Opolo, V; Szumilin, E; Riche, B; Etard, JF (Lippincott Williams & Wilkins, 2015-07-31)
      Direct measurement of antiretroviral treatment (ART) program indicators essential for evidence-based planning and evaluation - especially HIV incidence, population viral load, and ART eligibility - is rare in sub-Saharan Africa.
    • CD4 count slope and mortality in HIV-infected patients on antiretroviral therapy: multicohort analysis from South Africa

      Hoffmann, Christopher J; Schomaker, Michael; Fox, Matthew P; Mutevedzi, Portia; Giddy, Janet; Prozesky, Hans; Wood, Robin; Garone, Daniela B; Egger, Matthias; Boulle, Andrew; Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA. choffmann@jhmi.edu (Lippincott Williams & Wilkins, 2013-05-01)
      In many resource-limited settings monitoring of combination antiretroviral therapy (cART) is based on the current CD4 count, with limited access to HIV RNA tests or laboratory diagnostics. We examined whether the CD4 count slope over 6 months could provide additional prognostic information.
    • CD4 Testing at Clinics to Assess Eligibility for Antiretroviral Therapy

      Lumala, R; van den Akker, T; Metcalf, CA; Diggle, E; Zamadenga, B; Mbewa, K; Akkeson, A (College of Medicine, University of Malawi, 2012-06-01)
      In 2011, the Ministry of Health raised the CD4 threshold for antiretroviral therapy (ART) eligibility from <250 cells/µl and <350 cells/µl, but at the same time only 8.8% of facilities in Malawi with HIV services provided CD4 testing. We conducted a record review at 10 rural clinics in Thyolo District to assess the impact of introducing CD4 testing on identifying patients eligible for ART.
    • Clinical screening for HIV in a health centre setting in urban Kenya: an entry point for voluntary counselling, HIV testing and early diagnosis of HIV infection?

      Arendt, V; Mossong, J; Zachariah, R; Inwani, C; Farah, B; Robert, I; Waelbrouck, A; Fonck, K; Médecins Sans Frontières, Mission Kenya, Brussels Operational Centre, Brussels, Belgium. (2007-01)
      A study was conducted among patients attending a public health centre in Nairobi, Kenya in order to (a) verify the prevalence of HIV, (b) identify clinical risk factors associated with HIV and (c) determine clinical markers for clinical screening of HIV infection at the health centre level. Of 304 individuals involved in the study,107(35%) were HIV positive. A clinical screening algorithm based on four clinical markers, namely oral thrush, past or present TB, past or present herpes zoster and prurigo would pick out 61 (57%) of the 107 HIV-positive individuals. In a resource-poor setting, introducing a clinical screening algorithm for HIV at the health centre level could provide an opportunity for targeting voluntary counselling and HIV testing, and early access to a range of prevention and care interventions.
    • Effectiveness of a PMTCT programme in rural Western Kenya.

      Azcoaga-Lorenzo, A; Ferreyra, C; Alvarez, A; Palma, P P; Velilla, E; del Amo, J; Medecins Sans Frontieres-Spain/Operational Centre Barcelona-Athens, Barcelona, Spain. azcoaga@yahoo.es (Taylor and Francis, 2011-03)
      We assess the coverage of a Prevention of Mother-to-child Transmission (PMTCT) programme in Busia (Kenya) from 1 January 2006 to 31 December 2008 and estimate the risk of transmission of HIV. We also estimate the odds of HIV transmission according to pharmacological intervention received. Programme coverage was estimated as the proportion of mother-baby pairs receiving any antiretroviral (ARV) regimen among all HIV-positive women attending services. We estimated the mother-to-child transmission (MTCT) rate and their 95% confidence interval (95%CI) using the direct method of calculation (intermediate estimate). A case-control study was established among all children born to HIV-positive mothers with information on outcome (HIV status of the babies) and exposure (data on pharmacological intervention). Cases were all HIV-positive children and controls were the HIV-negative ones. Exposure was defined as: (1) complete protocol: ARV prescribed according World Health Organisation recommendations; (2) partial protocol: does not meet criteria for complete protocol; and (3) no intervention: ARVs were not prescribed to both mother and child. Babies were tested using DNA Polymerase Chain Reaction at six weeks of life and six weeks after breastfeeding ceased. In the study period, 22,566 women accepted testing, 1668 were HIV positive (7.4%; 95%CI 7.05-7.73); 1036 (62%) registered in the programme and 632 were lost. Programme coverage was 40.4% (95%CI 37.9-42.7). Out of the 767 newborns, 28 (3.6%) died, 148 (19.3%) defaulted, 282 (36.7%) were administratively censored and 309 (40.2%) babies completed the follow-up as per protocol; 49 were HIV positive and MTCT risk was 15.86% (95%CI 11.6-20.1). The odds of having an HIV-positive baby was 4.6 times higher among pairs receiving a partial protocol compared to those receiving a complete protocol and 43 times higher among those receiving no intervention. Our data show a good level of enrolment but low global coverage rate. It demonstrates that ARV regimens can be implemented in low resource rural settings with marked decreases of MTCT. Increasing the coverage of PMTCT programmes remains the main challenge.
    • Highly Active Antiretroviral Therapy in Resource-Poor Settings: The Experience of Médecins Sans Frontières.

      Tassie, J M; Szumilin, E; Calmy, A; Goemaere, E; Epicentre, Paris, France. (2003-09-05)
      We describe the short-term results of highly active antiretroviral therapy (HAART) in seven projects in low and middle income countries. A total of 743 adults were included, and clinical, immunological and virological responses were analysed. At 6 months, outcomes were similar to those observed in western countries, and the probability of remaining on treatment was 94%. The challenge now is to extend access to HAART to the millions in urgent need.
    • HIV Prevalence and Demographic Risk Factors in Blood Donors.

      Zachariah, R; Harries, A D; Nkhoma, W; Arendt, V; Spielmann M P; Buhendwa, L; Chingi, C; Mossong, J; Medecins Sans Frontieres, Luxembourg, Blantyre, Malawi. (2002-02)
      OBJECTIVES: To estimate HIV prevalence in various blood donor populations, to identity sociodemographic risk factors associated with prevalent HIV and to assess the feasibility of offering routine voluntary counselling services to blood donors. DESIGN: Cross-sectional study. SETTING: Thyolo district, Malawi. METHODS: Data analysis involving blood donors who underwent voluntary counselling and HIV testing between January 1998 and July 2000. RESULTS: Crude HIV prevalence was 22%, while the age standardised prevalence (>15 years) was 17%. Prevalence was lowest among rural donors, students and in males of the age group 15-19 years. There was a highly significant positive association of HIV prevalence with increasing urbanisation. Significant risk factors associated with prevalence for both male and female donors included having a business-related occupation, living in a semi-urban or urban area and being in the age group 25-29 years for females and 30-34 years for males. All blood donors were pre-test counselled and 90% were post test counselled in 2000. CONCLUSIONS: HIV prevalence in blood donors was alarmingly high, raising important concerns on the potential dangers of HIV transmission through blood transfusions. Limiting blood transfusions, use of a highly sensitive screening test, and pre-donation selection of donors is important. The experience also shows that it is feasible to offer pre and post test counselling services for blood donors as an entry point for early diagnosis of asymptomatic HIV infection and, broader preventive strategies including the potential of early access to drugs, for the prevention of opportunistic infections.
    • Life expectancy of persons receiving combination antiretroviral therapy in low-income countries: a cohort analysis from Uganda

      Mills, Edward J; Bakanda, Celestin; Birungi, Josephine; Chan, Keith; Ford, Nathan; Cooper, Curtis L; Nachega, Jean B; Dybul, Mark; Hogg, Robert S; University of Ottawa, Ottawa, Ontario, Canada; The AIDS Support Organization, Kampala, Uganda; British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada; Medecins Sans Frontieres, Geneva, Switzerland; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Centre for Infectious Disease Epidemiology and Research, University of Cape Town and Stellenbosch University, Cape Town, South Africa; The Ottawa Hospital, Ottawa, Ontario, Canada; Simon Fraser University, Burnaby, British Columbia, Canada; O’Neill Institute for National and Global Health Law, Georgetown University, Washington, DC (American College of Physicians, 2011-07-18)
      Little is known about the effect of combination antiretroviral therapy (cART) on life expectancy in sub-Saharan Africa.
    • Low uptake of antiretroviral therapy after admission with human immunodeficiency virus and tuberculosis in KwaZulu-Natal, South Africa.

      Murphy, R A; Sunpath, H; Taha, B; Kappagoda, S; Maphasa, K T M; Kuritzkes, D R; Smeaton, L; Doctors Without Borders USA, New York, USA; McCord Hospital, South Africa; Harvard Medical School, Massachusetts, USA; Division of Infectious Disease and Geographic Medicine, California, USA; Zoe-Life, South Africa; Section of Retroviral Therapeutics, Massachusetts, USA; Centre for Biostatistics in AIDS Research, Massachusetts, USA (2010-07-01)
      A prospective cohort study was conducted among human immunodeficiency virus (HIV) infected in-patients with tuberculosis (TB) or other opportunistic infections (OIs) in South Africa to estimate subsequent antiretroviral therapy (ART) uptake and survival.
    • Malawi's contribution to "3 by 5": achievements and challenges

      Libamba, Edwin; Makombe, Simon D; Harries, Anthony D; Schouten, Erik J; Yu, Joseph Kwong-Leung; Pasulani, Olesi; Mhango, Eustice; Aberle-Grasse, John; Hochgesang, Mindy; Limbambala, Eddie; Lungu, Douglas; Clinical HIV Unit, Ministry of Health, Lilongwe, Malawi; HIV Coordinator, Ministry of Health, Lilongwe, Malawi; Taiwan Medical Mission, Mzuzu Central Hospital, Mzuzu, Malawi; Médecins sans Frontières Belgium, Thyolo District Hospital, Malawi; Lighthouse Clinic, Lilongwe, Malawi; Centres for Disease Control, Lilongwe office, Malawi; WHO country office, Lilongwe, Malawi; Department of Clinical Services, Ministry of Health, Lilongwe, Malawi (2007-02-01)
      PROBLEM: Many resource-poor countries have started scaling up antiretroviral therapy (ART). While reports from individual clinics point to successful implementation, there is limited information about progress in government institutions at a national level. APPROACH: Malawi started national ART scale-up in 2004 using a structured approach. There is a focus on one generic, fixed-dose combination treatment with stavudine, lamivudine and nevirapine. Treatment is delivered free of charge to eligible patients with HIV and there is a standardized system for recruiting patients, monthly follow-up, registration, monitoring and reporting of cases and outcomes. All treatment sites receive quarterly supervision and evaluation. LOCAL SETTING: In January 2004, there were nine public sector facilities delivering ART to an estimated 4 000 patients. By December 2005, there were 60 public sector facilities providing free ART to 37,840 patients using national standardized systems. Analysis of quarterly cohort treatment outcomes at 12 months showed 80% of patients were alive, 10% dead, 9% lost to follow-up and 1% had stopped treatment. LESSONS LEARNED: Achievements were the result of clear national ART guidelines, implementing partners working together, an intensive training schedule focused on clinical officers and nurses, a structured system of accrediting facilities for ART delivery, quarterly supervision and monitoring, and no stock-outs of antiretroviral drugs. The main challenges are to increase the numbers of children, pregnant women and patients with tuberculosis being started on ART, and to avert high early mortality and losses to follow-up. The capacity of the health sector to cope with escalating case loads and to scale up prevention alongside treatment will determine the future success of ART delivery in Malawi.
    • Monitoring HIV Viral Load in Resource Limited Settings: Still a Matter of Debate?

      Arnedo, M; Alonso, E; Eisenberg, N; Ibáñez, L; Ferreyra, C; Jaén, A; Flevaud, L; Khamadi, S; Roddy, P; Gatell, JM; Dalmau, D (Public Library of Science, 2012-12-06)
      Consequences of lack of viral monitoring in predicting the effects of development of HIV drug resistance mutations during HAART in resource-limited settings (RLS) is still a matter of debate.
    • Mortality, AIDS-morbidity, and loss to follow-up by current CD4 cell count among HIV-1-infected adults receiving antiretroviral therapy in Africa and Asia: data from the ANRS 12222 collaboration

      Gabillard, Delphine; Lewden, Charlotte; Ndoye, Ibra; Moh, Raoul; Segeral, Olivier; Tonwe-Gold, Besigin; Etard, Jean-François; Pagnaroat, Men; Fournier-Nicolle, Isabelle; Eholié, Serge; Konate, Issouf; Minga, Albert; Mpoudi-Ngole, Eitel; Koulla-Shiro, Sinata; Zannou, Djimon Marcel; Anglaret, Xavier; Laurent, Christian (Lippincott Williams and Wilkins, 2013-04-15)
      In resource-limited countries, estimating CD4-specific incidence rates of mortality and morbidity among patients receiving antiretroviral therapy (ART) may help assess the effectiveness of care and treatment programmes, identify program weaknesses, and inform decisions.
    • A national survey of the impact of rapid scale-up of antiretroviral therapy on health-care workers in Malawi: effects on human resources and survival.

      Makombe, S D; Jahn, A; Tweya, H; Chuka, S; Yu, J K L; Hochgesang, M; Aberle-Grasse, J; Pasulani, O; Schouten, E J; Kamoto, K; Harries, A D; HIV Unit, Ministry of Health, Lilongwe, Malawi. (WHO, 2007-11)
      OBJECTIVE: To assess the human resources impact of Malawis rapidly growing antiretroviral therapy (ART) programme and balance this against the survival benefit of health-care workers who have accessed ART themselves. METHODS: We conducted a national cross-sectional survey of the human resource allocation in all public-sector health facilities providing ART in mid-2006. We also undertook a survival analysis of health-care workers who had accessed ART in public and private facilities by 30 June 2006, using data from the national ART monitoring and evaluation system. FINDINGS: By 30 June 2006, 59 581 patients had accessed ART from 95 public and 28 private facilities. The public sites provided ART services on 2.4 days per week on average, requiring 7% of the clinician workforce, 3% of the nursing workforce and 24% of the ward clerk workforce available at the facilities. We identified 1024 health-care workers in the national ART-patient cohort (2% of all ART patients). The probabilities for survival on ART at 6 months, 12 months and 18 months were 85%, 81% and 78%, respectively. An estimated 250 health-care workers lives were saved 12 months after ART initiation. Their combined work-time of more than 1000 staff-days per week was equivalent to the human resources required to provide ART at the national level. CONCLUSION: A large number of ART patients in Malawi are managed by a small proportion of the health-care workforce. Many health-care workers have accessed ART with good treatment outcomes. Currently, staffing required for ART balances against health-care workers lives saved through treatment, although this may change in the future.
    • Outcomes and safety of concomitant nevirapine and rifampicin treatment under programme conditions in Malawi.

      Moses, M; Zachariah, R; Tayler-Smith, K; Misinde, D; Foncha, C; Manzi, M; Bauerfeind, A; Mwagomba, B; Kwanjana, J; Harries, A D; Médecins sans Frontières, Thyolo District, Thyolo, Malawi. (2010-02)
      SETTING: Thyolo District Hospital, rural Malawi. OBJECTIVES: To report on 1) clinical, immunological and virological outcomes and 2) safety among human immunodeficiency virus (HIV) infected patients with tuberculosis (TB) who received concurrent nevirapine (NVP) and rifampicin (RMP) based treatment. DESIGN: Retrospective cohort study. METHODS: Analysis of programme data, June-December 2007. RESULTS: Of a total of 156 HIV-infected TB patients who started NVP-based antiretroviral treatment, 136 (87%) completed TB treatment successfully, 16 (10%) died and 5 (4%) were transferred out. Mean body weight and CD4 gain (adults) were respectively 4.4 kg (95%CI 3.3-5.4) and 140 cells/mm(3) (95%CI 117-162). Seventy-four per cent of patients who completed TB treatment and had a viral load performed (n = 74) had undetectable levels (<50 copies/ml), while 17 (22%) had a viral load of 50-1000 copies/ml. Hepatotoxicity was present in 2 (1.3%) patients at baseline. Two patients developed Grade 2 and one developed Grade 3 alanine transaminase enzyme elevations during TB treatment (incidence rate per 10 years of follow-up 4.2, 95%CI 1.4-13.1). There were no reported deaths linked to hepatotoxicity. CONCLUSIONS: In a rural district in Malawi, concomitant NVP and RMP treatment is associated with good TB treatment outcomes and appears safe. Further follow-up of patients would be useful to ascertain the longer-term effects of this concurrent treatment.
    • Paediatric HIV care in sub-Saharan Africa: clinical presentation and 2-year outcomes stratified by age group

      Ben-Farhat, Jihane; Gale, Marianne; Szumilin, Elisabeth; Balkan, Suna; Poulet, Elisabeth; Pujades-Rodríguez, Mar (John Wiley & Sons Ltd, 2013-09)
      To examine age differences in mortality and programme attrition amongst paediatric patients treated in four African HIV programmes.
    • Preventing HIV-1: lessons from Mwanza and Rakai.

      Matthys, F; Boelaert, M (Elsevier, 1999-05-01)
    • The prevention of mother-to-child HIV transmission programme and infant feeding practices.

      Hilderbrand, K; Goemaere, E; Coetzee, D; Infectious Diseases and HIV/AIDS Epidemiology Unit, School of Public Health and Family Medicine, University of Cape Town. (2003-10)
      Since the first cases of HIV transmission through breast-feeding were documented, a fierce debate has raged on appropriate guidelines for infant feeding in resource-poor settings. A major problem is determining when it is safe and feasible to formula-feed, as breast-milk protects against other diseases. A cross-sectional survey of 113 women attending the programme for the prevention of mother-to-child transmission in Khayelitsha, Cape Town, was conducted. Over 95% of women on the programme formula-fed their infants and did not breast-feed at all. Seventy per cent of women said that their infant had never had diarrhoea, and only 3% of children had had two episodes of diarrhoea. Focus groups identified the main reasons for not breast-feeding given by women to their families and those around them. Formula feeding is safe and feasible in an urban environment where sufficient potable water is available.
    • Scaling-up co-trimoxazole prophylaxis in HIV-exposed and HIV-infected children in high HIV-prevalence countries.

      Zachariah, R; Harries, A D; Luo, C; Bachman, G; Graham, S M; Médecins Sans Frontières, Medical department (Operational Research), Brussels Operational Center, Brussels, Belgium. zachariah@internet.lu (Elsevier, 2007-10)
      Co-trimoxazole (trimethoprim-sulfamethoxazole) is a widely available antibiotic that substantially reduces HIV-related morbidity and mortality in both adults and children. Prophylaxis with co-trimoxazole is a recommended intervention of proven benefit that could serve not only as an initial step towards improving paediatric care in young children with limited access to antiretroviral treatment, but also as an important complement to antiretroviral therapy in resource-limited settings. Despite co-trimoxazole's known clinical benefits, the potential operational benefits, and favourable recommendations by WHO, UNAIDS, and UNICEF, its routine use in developing countries--particularly sub-Saharan Africa--has remained limited. Out of an estimated 4 million children in need of co-trimoxazole prophylaxis (HIV-exposed and HIV-infected), only 4% are currently receiving this intervention. We discuss some of the major barriers preventing the scale-up of co-trimoxazole prophylaxis for children in countries with a high prevalence of HIV and propose specific actions required to tackle these challenges.