• 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 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.
    • Errors Generated by a Point-Of-Care CD4+ T-Lymphocyte Analyser: a Retrospective Observational Study in Nine Countries

      Fajardo, E; Metcalf, C; Piriou, E; Gueguen, M; Maman, D; Chaillet, P; Cox, V; Rumaney, MB; Tunggal, S; Kosack, C; et al. (World Health Organization, 2015-09-01)
      To estimate the proportion of invalid results generated by a CD4+ T-lymphocyte analyser used by Médecins Sans Frontières (MSF) in field projects and identify factors associated with invalid results.
    • HIV Testing and Retention in Care of Infants Born to HIV- Infected Women Enrolled in 'Option B+', Thyolo, Malawi

      Martínez Pérez, G; Metcalf, C; Garone, D; Coulborn, R; Harries, A D; Hedt-Gauthier, B; Murowa, M; Mwenelupembe, GS; Van den Bergh, R; Triviño Durán, L (International Union Against Tuberculosis and Lung Disease, 2014-06-21)
      Prevention of mother-to-child transmission 'Option B+' originated in Malawi in 2011 to prevent new infections in infants exposed to the human immunodeficiency virus (HIV). We assessed 12-month programme retention and HIV testing uptake among infants born to HIV-infected mothers from September 2011 to June 2012 in Thyolo District Hospital. Of 513 infants, 368 (71.7%) remained in care at 12 months. Altogether, 412 (80.3%) underwent HIV DNA polymerase chain reaction testing, with 267 (52.0%) tested at 6-12 weeks, and 255 (49.7%) underwent rapid HIV testing, with 144 (28.1%) tested at 12 months. Eighty-eight (17.2%) infants had both tests as scheduled. Measures are needed to improve adherence to national testing protocols.
    • The Last and First Frontier--Emerging Challenges for HIV Treatment and Prevention in the First week of Life With Emphasis on Premature and Low Birth Weight Infants

      Cotton, MF; Holgate, S; Nelson, A; Rabie, H; Wedderburn, C; Mirochnick, M (International AIDS Society, 2015-12-02)
      There is new emphasis on identifying and treating HIV in the first days of life and also an appreciation that low birth weight (LBW) and preterm delivery (PTD) frequently accompany HIV-related pregnancy. Even in the absence of HIV, PTD and LBW contribute substantially to neonatal and infant mortality. HIV-exposed and -infected infants with these characteristics have received little attention thus far. As HIV programs expand to meet the 90-90-90 target for ending the HIV pandemic, attention should focus on newborn infants, including those delivered preterm or of LBW.
    • 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; et al. (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.
    • Outcomes of a remote, decentralized health center-based HIV/AIDS antiretroviral program in Zambia, 2003 to 2007

      Elema, R; Mills, C; Yun, O; Lokuge, K; Ssonko, C; Nyirongo, N; Mtonga, V; Zulu, H; Tu, D; Verputten, M; et al. (2009-02-11)
      A cross-sectional study of patients living with HIV/ AIDS treated during 2003 to 2007 in decentralized, rural health centers in Zambia was performed to measure virological outcomes after 12 months of antiretroviral therapy and identify factors associated with virological failure. Data from 228 patients who started antiretroviral therapy >12 months prior were analyzed. In all, 93% received stavudine + lamivudine + nevirapine regimens, and median antiretroviral therapy duration was 23.5 months (interquartile range 20-28). Of the 205 patients tested for viral load, 177 (86%) had viral load <1000 copies/mL. Probability of developing virological failure (viral load >1000 copies/mL) was 8.9% at 24 months and 19.6% at 32 months. Predictors for virological failure were <100% adherence, body mass index <18.5 kg/m(2), and women <40 years old. Of those with virological failure who underwent 3 to 6 months of intensive adherence counseling, 45% obtained virological success. In a remote, resource-limited setting in decentralized health centers, virological and immunological assessments of patients on antiretroviral therapy >12 months showed that positive health outcomes are achievable.
    • Scale-up of Routine Viral Load Testing in Resource-Poor Settings: Current and Future Implementation Challenges

      Roberts, T; Cohn, J; Bonner, K; Hargreaves, S (Oxford University Press, 2016-04-15)
      Despite immense progress in antiretroviral therapy (ART) scale-up, many people still lack access to basic standards of care, with our ability to meet the Joint United Nations Programme on HIV/AIDS 90-90-90 treatment targets for HIV/AIDS dependent on dramatic improvements in diagnostics. The World Health Organization recommends routine monitoring of ART effectiveness using viral load (VL) testing at 6 months and every 12 months, to monitor treatment adherence and minimize failure, and will publish its VL toolkit later this year. However, the cost and complexity of VL is preventing scale-up beyond developed countries and there is a lack of awareness among clinicians as to the long-term patient benefits and its role in prolonging the longevity of treatment programs. With developments in this diagnostic field rapidly evolving-including the recent improvements for accurately using dried blood spots and the imminent appearance to the market of point-of-care technologies offering decentralized diagnosis-we describe current barriers to VL testing in resource-limited settings. Effective scale-up can be achieved through health system and laboratory system strengthening and test price reductions, as well as tackling multiple programmatic and funding challenges.
    • Sustainable HIV Treatment in Africa Through Viral-Load-Informed Differentiated Care

      Phillips, A; Shroufi, A; Vojnov, L; Cohn, J; Roberts, T; Ellman, T; Bonner, K; Rousseau, C; Garnett, G; Cambiano, V; et al. (Nature Publishing Group, 2015-12-03)
      There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy in sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for clinical assessment. The clinic costs are comparable with the costs of the drugs themselves and CD4 counts are measured every 6 months, but patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes, a transition to more cost-effective delivery of antiretroviral therapy is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (the viral load) provides a direct measure of the current treatment effect. Viral-load-informed differentiated care is a means of tailoring care so that those with suppressed viral load visit the clinic less frequently and attention is focussed on those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach to measuring viral load in many countries is to collect dried blood spot samples for testing in regional laboratories; however, there have been concerns over the sensitivity and specificity of this approach to define treatment failure and the delay in returning results to the clinic. We use modelling to synthesize evidence and evaluate the cost-effectiveness of viral-load-informed differentiated care, accounting for limitations of dried blood sample testing. We find that viral-load-informed differentiated care using dried blood sample testing is cost-effective and is a recommended strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of point-of-care viral load tests that may become available in the future.
    • Viral load monitoring in resource-limited settings: a medical and public health priority.

      Ford, Nathan; Roberts, Teri; Calmy, Alexandra; Medecins Sans Frontieres, Geneva, Switzerland; Centre for Infectious Disease Epidemiology and Research, University of Cape Town; HIV/AIDS Unit, Infectious Disease Service, Geneva University Hospital, Geneva, Switzerland. (2012-08-24)
    • Viral Load Versus CD4⁺ Monitoring and 5-Year Outcomes of Antiretroviral Therapy in HIV-Positive Children in Southern Africa: a Cohort-Based Modelling Study

      Salazar-Vizcaya, L; Keiser, O; Karl, T; Davies, MA; Haas, Andreas D; Blaser, N; Cox, V; Eley, B; Rabie, H; Moultrie, H; et al. (Lippincott Williams & Wilkins, 2014-10-23)
      Many paediatric antiretroviral therapy (ART) programmes in Southern Africa rely on CD4⁺ to monitor ART. We assessed the benefit of replacing CD4⁺ by viral load monitoring.