• 'I saw it as a second chance': A qualitative exploration of experiences of treatment failure and regimen change among people living with HIV on second- and third-line antiretroviral therapy in Kenya, Malawi and Mozambique

      Burns, R; Borges, J; Blasco, P; Vandenbulcke, A; Mukui, I; Magalasi, D; Molfino, L; Manuel, R; Schramm, B; Wringe, A (Taylor & Francis, 2019-01-11)
      Increasing numbers of people living with HIV (PLHIV) in sub-Saharan Africa are experiencing failure of first-line antiretroviral therapy and transitioning onto second-line regimens. However, there is a dearth of research on their treatment experiences. We conducted in-depth interviews with 43 PLHIV on second- or third-line antiretroviral therapy and 15 HIV health workers in Kenya, Malawi and Mozambique to explore patients' and health workers' perspectives on these transitions. Interviews were audio-recorded, transcribed and translated into English. Data were coded inductively and analysed thematically. In all settings, experiences of treatment failure and associated episodes of ill-health disrupted daily social and economic activities, and recalled earlier fears of dying from HIV. Transitioning onto more effective regimens often represented a second (or third) chance to (re-)engage with HIV care, with patients prioritising their health over other aspects of their lives. However, many patients struggled to maintain these transformations, particularly when faced with persistent social challenges to pill-taking, alongside the burden of more complex regimens and an inability to mobilise sufficient resources to accommodate change. Efforts to identify treatment failure and support regimen change must account for these patients' unique illness and treatment histories, and interventions should incorporate tailored counselling and social and economic support. Abbreviations: ART: Antiretroviral therapy; HIV: Human immunodeficiency virus; IDI: In-depth interview; MSF: Médecins Sans Frontières; PLHIV: People living with HIV.
    • "I take my pills every day, but then it goes up, goes down. I don't know what's going on": Perceptions of HIV virological failure in a rural context in Mozambique. A qualitative research study.

      Pulido Tarquino, IA; Venables, E; de Amaral Fidelis, JM; Giuliani, R; Decroo, T (Public Library of Science, 2019-06-17)
      BACKGROUND: HIV prevalence in Mozambique is estimated to be 13.2%. Routine viral load for HIV monitoring was first implemented in the rural area of Tete in 2014. Programmatic data showed an unexpected high proportion of high viral load results, with up to 40% of patients having a viral load above 1000 copies/ml. OBJECTIVES: This qualitative study aimed to explore perceptions about virological failure and viral load monitoring from the perspective of HIV positive patients on first-line antiretroviral therapy (ART) and health-care workers. METHODS: The study was conducted in seven rural communities in Changara-Marara district, Tete province, Mozambique. A total of 91 participants took part in in-depth interviews (IDIs) and focus group discussions (FGDs), including health-care workers (n = 18), patients on ART in individual care or Community Adherence Groups (CAGs) who experienced virological failure and virological re-suppression (n = 39) and CAG focal points (n = 34). Purposive sampling was used to select participants. Interviews and FGDs were conducted in Nhuengue and Portuguese. IDIs and FGDs were translated and transcribed before being coded and thematically analysed. RESULTS: Emergent themes showed that patients and health-care workers attributed great importance to viral load monitoring. A supressed viral load was viewed by participants as a predictor of good health and good adherence. However, some patients were confused and appeared distressed when confronted with virological failure. Viral load results were often little understood, especially when virological failure was detected despite good adherence. Inadequate explanations of causes of virological failure, delayed follow-up viral load results, repeated blood tests and lack of access to second-line ART resulted in reduced confidence in the effectiveness of ART, challenged the patient-provider relationship and disempowered patients and providers. CONCLUSION: In this rural context undetectable viral load is recognized as a predictor of good health by people living with HIV and health-care workers. However, a lack of knowledge and health system barriers caused different responses in patients and health-care workers. Adapted counselling strategies, accelerated viral load follow-up and second-line ART initiation in patients with virological failure need to be prioritized.
    • Idiopathic CD4+ T-lymphocytopenia with cryptococcal meningitis: first case report from Cambodia.

      Augusto, E; Raguenaud, M E; Kim, C; Mony, M; Isaakidis, P; Médecins Sans Frontières Belgium, Phnom Penh, Cambodia MSFB-Phnom-Penh-Med@brussels.msf.org. (2009-07)
      We report on a patient with cryptococcal meningitis with CD4+ T-lymphocytopenia and no evidence of HIV infection.
    • Immunovirological outcomes and resistance patterns at 4 years of antiretroviral therapy use in HIV-infected patients in Cambodia

      Pujades-Rodríguez, Mar; Schramm, Birgit; Som, Leakena; Nerrienet, Eric; Narom, Prak; Chanchhaya, Ngeth; Ferradini, Laurent; Balkan, Suna; Epicentre, Paris, France; Medecins Sans Frontieres, Phnom Penh, Cambodia; HIV⁄Hepatitis Laboratory, Pasteur Institute, Phnom Penh, Cambodia; Khmero-Sovietic Friendship Hospital, Phnom Penh, Cambodia; Medecins Sans Frontieres, Paris, France (2011-02-01)
      Objectives  To report immunovirological outcomes and resistance patterns in adults treated with triple combination antiretroviral therapy (cART) for 4 years in an HIV programme of Phnom Penh, Cambodia. Methods  It is a longitudinal study and cross-sectional evaluation of adults receiving cART for 4 years. CD4 cell counts and HIV-1 RNA were quantified, and resistance patterns were determined. Drug-related toxicity was assessed by clinicians and through laboratory testing. Results  After 4 years of cART start, the cumulative probability of retention in care was 0.80 and survival among patients not lost to follow-up was 0.85. A total of 349 patients (98% of eligible) participated in the cross-sectional evaluation. Ninety per cent were receiving first-line therapy, 29% stavudine- and 58% zidovudine-containing regimens (compared with 94% and 3% at cART initiation). Ninety-three per cent of patients were clinically asymptomatic, and severe lipodystrophy and dyslipidemia were diagnosed in 7.2% and 4.0%, respectively. Good treatment adherence was reported by 83% of patients. Median CD4 T-cell count was 410 cells/μl [IQR 290-511], and 90% of patients had >200 cells/μl. Only 15 (4%) patients had detectable HIV viral load (eight had <200 CD4 cells/μl), five had thymidine analogue mutations, and nine were resistant to two drug classes. In an intention-to-treat analysis, 26.1% (95% CI 22.0-30.5) of patients had failed first-line therapy. Conclusions  In this Cambodian cohort of adults who started cART at an advanced stage of HIV disease, we observed good clinical and immunovirological outcomes and self-reported treatment adherence at 4 years of therapy.
    • Immunovirological response to combined antiretroviral therapy and drug resistance patterns in children: 1- and 2-year outcomes in rural Uganda.

      Ahoua, Laurence; Guenther, Gunar; Rouzioux, Christine; Pinoges, Loretxu; Anguzu, Paul; Taburet, Anne-Marie; Balkan, Suna; Olson, David M; Olaro, Charles; Pujades-Rodríguez, Mar; et al. (BioMed Central, 2011-07-26)
      Children living with HIV continue to be in urgent need of combined antiretroviral therapy (ART). Strategies to scale up and improve pediatric HIV care in resource-poor regions, especially in sub-Saharan Africa, require further research from these settings. We describe treatment outcomes in children treated in rural Uganda after 1 and 2 years of ART start.
    • Impact and programmatic implications of routine viral load monitoring in Swaziland

      Jobanputra, Kiran; Parker, Lucy Anne; Azih, Charles; Okello, Velephi; Maphalala, Gugu; Jouquet, Guillaume; Kerschberger, Bernhard; Mekeidje, Calorine; Cyr, Joanne; Mafikudze, Arnold; et al. (Lippincott Williams & Wilkins, 2014-05-28)
      To assess the programmatic quality (coverage of testing, counselling and retesting), cost, and outcomes (viral suppression, treatment decisions), of routine viral load (VL) monitoring in Swaziland.
    • Impact of "test and treat" recommendations on eligibility for antiretroviral treatment: Cross sectional population survey data from three high HIV prevalence countries.

      Chihana, ML; Huerga, H; Van Cutsem, G; Ellman, T; Wanjala, S; Masiku, C; Szumilin, E; Etard, JF; Davies, M; Maman, D (PLOS, 2018-01-01)
      Background Latest WHO guidelines recommend starting HIV-positive individuals on antiretroviral therapy treatment (ART) regardless of CD4 count. We assessed additional impact of adopting new WHO guidelines. Methods We used data of individuals aged 15–59 years from three HIV population surveys conducted in 2012 (Kenya) and 2013 (Malawi and South Africa). Individuals were interviewed at home followed by rapid HIV and CD4 testing if tested HIV-positive. HIV-positive individuals were classified as “eligible for ART” if (i) had ever been initiated on ART or (ii) were not yet on ART but met the criteria for starting ART based on country’s guidelines at the time of the survey (Kenya–CD4< = 350 cells/μl and WHO Stage 3 or 4 disease, Malawi as for Kenya plus lifelong ART for all pregnant and breastfeeding women, South Africa as for Kenya plus ART for pregnant and breastfeeding women until cessation of breastfeeding). Findings Of 18,991 individuals who tested, 4,113 (21.7%) were HIV-positive. Using country’s ART eligibility guidelines at the time of the survey, the proportion of HIV-infected individuals eligible for ART was 60.0% (95% CI: 57.2–62.7) (Kenya), 73.4% (70.8–75.8) (South Africa) and 80.1% (77.3–82.6) (Malawi). Applying WHO 2013 guidelines (eligibility at CD4< = 500 and Option B+ for pregnant and breastfeeding women), the proportions eligible were 82.0% (79.8–84.1) (Kenya), 83.7% (81.5–85.6) (South Africa) and 87.6% (85.0–89.8) (Malawi). Adopting “test and treat” would mean a further 18.0% HIV-positive individuals (Kenya), 16.3% (South Africa) and 12.4% (Malawi) would become eligible. In all countries, about 20% of adolescents (aged 15–19 years), became eligible for ART moving from WHO 2013 to “test and treat” while no differences by sex were observed. Conclusion Countries that have already implemented 2013 WHO recommendations, the burden of implementing “test and treat” would be small. Youth friendly programmes to help adolescents access and adhere to treatment will be needed. Go to: Introduction HIV remains one of the biggest contributors to mortality and morbidity in the world with most deaths occurring in the Sub-Saharan Africa (SSA)[1]. Despite freely available treatment for HIV/AIDS over the past decade, only (66.0%) of people living with HIV in eastern and southern part of SSA were on treatment in 2017 [2]. The World Health Organisation (WHO) 2013 treatment guidelines for starting HIV-positive people on antiretroviral therapy (ART) were CD4< = 500 cells/μl and for pregnant women to commence ART regardless of CD4 cell count [3]. In 2015 the WHO guidelines changed to starting every HIV-positive person on ART regardless of CD4 cell count[4] (the so-called “test and treat” approach) although some countries have not yet implemented these recommendations. With only half the population of HIV-positive individuals on treatment, containing the spread of HIV remains a challenge with only small declines in incidence[5]. However, more evidence is becoming available on the benefits of undetectable viral load and early ART initiation on mortality and morbidity[6–8] and on lowering the risk of transmission[9–13], bringing hope on how further spreading of the disease can be contained through a “test and treat” approach. However, adopting the new WHO guidelines may have challenges such as costs associated with more people on ART, infrastructure, human resources and how to monitor everyone started on ART to ensure that they adhere to medication[4]. This makes it difficult for countries to transition if they do not know what to expect if they move to test and treat. To plan properly for transitioning to the new WHO guidelines, countries need to know the number, proportion, age and sex distribution of the additional HIV-positive individuals that will need to start ART. Most studies on the impact of change in ART guidelines on eligibility have been based on mathematical modeling [14, 15] which can easily over or underestimate results depending on the model assumptions. Other studies however, have used population data, for example in Kenya, a study that estimated the impact of change in treatment guidelines using nationally representative Kenya AIDS indicator survey data fell short of measuring the differential impact of the new WHO guidelines on age and sex[16]. Our aim therefore, was to measure the impact of a “test and treat” policy on eligibility, stratified by sex and age, using population data from three countries (Kenya, Malawi and South Africa) at different stages of implementing previous WHO guidelines.
    • Impact of HIV on the Severity of Buruli Ulcer Disease: Results of a Retrospective Study in Cameroon

      Christinet, Vanessa; Rossel, Ludovic; Serafini, Micaela; Delhumeau, Cecile; Odermatt, Peter; Ciaffi, Laura; Nomo, Alain-Bertrand; Nkemenang, Patrick; Antierens, Annick; Comte, Eric; et al. (Oxford University Press, 2014-04-26)
      Background: Buruli ulcer (BU) is the third most common mycobacterial disease after tuberculosis and leprosy and is particularly frequent in rural West and Central Africa. However, the impact of HIV infection on BU severity and prevalence remains unclear. Methods: This was a retrospective study of data collected at the Akonolinga district hospital, Cameroon, from 1 January 2002 to 27 March 2013. HIV prevalence among BU patients was compared to regional HIV prevalence. Baseline characteristics of BU patients were compared between HIV-negative and HIV-positive patients, and according to CD4 cell count strata in the latter group. BU time-to-healing was assessed in different CD4 count strata and factors associated with BU main lesion size at baseline were identified. Results: HIV prevalence among BU patients was significantly higher than the regional estimated prevalence in each group (children, 4.00% vs 0.68% [P < .001]; men, 17.0% vs 4.7% [P < .001]; women, 36.0% vs 8.0% [P < .001]). HIV-positive individuals had a more severe form of BU with an increased severity in those with a higher level of immunosuppression. Low CD4 cell count was significantly associated with a larger main lesion size (beta-coefficient, -0.50; P = .015; 95% confidence interval [CI], -0.91 – 0.10). BU time-to-healing was more than double in patients with a CD4 cell count below 500 cell/mm3 (hazard ratio, 2.39; P = .001, 95% CI, 1.44 - 3.98). Conclusion: HIV-positive patients are at higher risk for BU. HIV-induced immunosuppression appears to have an impact on BU clinical presentation and disease evolution.
    • 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; et al. (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.
    • The impact of lay counselors on HIV testing rates: Quasi-experimental evidence from lay counselor redeployment in KwaZulu-Natal, South Africa

      Hu, J; Geldsetzer, P; Steele, SJ; Matthews, P; Ortblad, K; Solomon, T; Shroufi, A; van Cutsem, G; Tanser, F; Wyke, S; et al. (Lippincott Williams & Wilkins, 2018-06-14)
      This study aimed to determine the causal effect of the number of lay counselors employed at a primary care clinic in rural South Africa on the number of clinic-based HIV tests performed.
    • Impact of point-of-care CD4 testing on linkage to HIV care: a systematic review

      Wynberg, Elke; Cooke, Graham; Shroufi, Amir; Reid, Steven D; Ford, Nathan (International AIDS Society, 2014-01-20)
      Introduction: Point-of-care testing for CD4 cell count is considered a promising way of reducing the time to eligibility assessment for antiretroviral therapy (ART) and of increasing retention in care prior to treatment initiation. In this review, we assess the available evidence on the patient and programme impact of point-of-care CD4 testing. Methods: We searched nine databases and two conference sites (up until 26 October 2013) for studies reporting patient and programme outcomes following the introduction of point-of-care CD4 testing. Where appropriate, results were pooled using random-effects methods. Results: Fifteen studies, mainly from sub-Saharan Africa, were included for review, providing evidence for adults, adolescents, children and pregnant women. Compared to conventional laboratory-based testing, point-of-care CD4 testing increased the likelihood of having CD4 measured [odds ratio (OR) 4.1, 95% CI 3.5-4.9, n=2] and receiving a CD4 result (OR 2.8, 95% CI 1.5-5.6, n=6). Time to being tested was significantly reduced, by a median of nine days; time from CD4 testing to receiving the result was reduced by as much as 17 days. Evidence for increased treatment initiation was mixed. Discussion: The results of this review suggest that point-of-care CD4 testing can increase retention in care prior to starting treatment and can also reduce time to eligibility assessment, which may result in more eligible patients being initiated on ART.
    • Impact of variability in adherence to HIV antiretroviral therapy on the immunovirological response and mortality

      Boussari, Olayidé; Subtil, Fabien; Genolini, Christophe; Bastard, Mathieu; Iwaz, Jean; Fonton, Noël; Etard, Jean-François; Ecochard, René (BioMed Central (Springer Science), 2015-02-05)
      Several previous studies have shown relationships between adherence to HIV antiretroviral therapy (ART) and the viral load, the CD4 cell count, or mortality. However, the impact of variability in adherence to ART on the immunovirological response does not seem to have been investigated yet.
    • Impact on ART initiation of point-of-care CD4 testing at HIV diagnosis among HIV-positive youth in Khayelitsha, South Africa

      Patten, Gabriela E M; Wilkinson, Lynne; Conradie, Karien; Isaakidis, Petros; Harries, Anthony D; Edginton, Mary E; De Azevedo, Virginia; van Cutsem, Gilles; MSF Khayelitsha, Cape Town, South Africa. gem.patten@gmail.com (2013-07-04)
      Despite the rapid expansion of antiretroviral therapy (ART) programmes in developing countries, pre-treatment losses from care remain a challenge to improving access to treatment. Youth and adolescents have been identified as a particularly vulnerable group, at greater risk of loss from both pre-ART and ART care. Point-of-care (POC) CD4 testing has shown promising results in improving linkage to ART care. In Khayelitsha township, South Africa, POC CD4 testing was implemented at a clinic designated for youth aged 12-25 years. We assessed whether there was an associated reduction in attrition between HIV testing, assessment for eligibility and ART initiation.
    • Implementation and Operational Research: Feasibility of Using Tuberculin Skin Test Screening for Initiation of 36-Month Isoniazid Preventive Therapy in HIV-Infected Patients in Resource-Constrained Settings

      Huerga, H; Mueller, Y; Ferlazzo, G; Mpala, Q; Bevilacqua, P; Vasquez, B; Noël Mekiedje, C; Ouattara, A; Mchunu, G; Weyenga, HO; et al. (Lippincott Williams & Wilkins, 2016-04-01)
      The tuberculin skin test (TST) can be used to identify HIV-infected people who would benefit the most from long-term isoniazid preventive therapy (IPT). However, in resource-constrained settings, implementation of the TST can be challenging. The objectives of this study were to assess the feasibility of implementing the TST for IPT initiation and to estimate the proportion of TST-positive incidence among HIV-positive patients in 2 high tuberculosis and HIV burden settings.
    • Implementation and outcomes of an active defaulter tracing system for HIV, prevention of mother to child transmission of HIV (PMTCT), and TB patients in Kibera, Nairobi, Kenya.

      Thomson, Kerry A; Cheti, Erastus O; Reid, Tony; Médecins Sans Frontières (MSF) Operational Centre Brussels, PO BOX 38897 Postal Code 00623, Parklands, Nairobi, Kenya. (2011-06)
      Retention of patients in long term care and adherence to treatment regimens are a constant challenge for HIV, prevention of mother to child transmission of HIV (PMTCT), and TB programmes in sub-Saharan Africa. This study describes the implementation and outcomes of an active defaulter tracing system used to reduce loss to follow-up (LTFU) among HIV, PMTCT, TB, and HIV/TB co-infected patients receiving treatment at three Médecins Sans Frontières clinics in the informal settlement of Kibera, Nairobi, Kenya. Patients are routinely contacted by a social worker via telephone, in-person visit, or both very soon after they miss an appointment. Patient outcomes identified through 1066 tracing activities conducted between 1 April 2008 and 31 March 2009 included: 59.4% returned to the clinic, 9.0% unable to return to clinic, 6.3% died, 4.7% refused to return to clinic, 4.5% went to a different clinic, and 0.8% were hospitalized. Fifteen percent of patients identified for tracing could not be contacted. LTFU among all HIV patients decreased from 21.2% in 2006 to 11.5% in 2009. An active defaulter tracing system is feasible in a resource poor setting, solicits feedback from patients, retains a mobile population of patients in care, and reduces LTFU among HIV, PMTCT, and TB patients.
    • Implementation of a comprehensive program including psycho-social and treatment literacy activities to improve adherence to HIV care and treatment for a pediatric population in Kenya.

      Van Winghem, J; Telfer, B; Reid, T; Ouko, J; Mutunga, A; Jama, Z; Vakil, S; Operational Cell Belgium, Médecins Sans Frontières, Nairobi, Kenya. vwjoelle@gmail.com (2008-12)
      BACKGROUND: To achieve good clinical outcomes with HAART, patient adherence to treatment and care is a key factor. Since the literature on how to care for pediatric HIV patients is limited, we describe here adherence interventions implemented in our comprehensive care program in a resource-limited setting in Kenya. METHODS: We based our program on factors reported to influence adherence to HIV care and treatment. We describe, in detail, our program with respect to how we adapted our clinical settings, implemented psycho-social support activities for children and their caregivers and developed treatment literacy for children and teenagers living with HIV/AIDS. RESULTS: This paper focused on the details of the program, with the treatment outcomes as secondary. However, our program appeared to have been effective; for 648 children under 15 years of age who were started on HAART, the Kaplan-Meier mortality survival estimate was 95.27% (95%CI 93.16-96.74) at 12 months after the time of initiation of HAART. CONCLUSION: Our model of pediatric HIV/AIDS care, focused on a child-centered approach with inclusion of caregivers and extended family, addressed the main factors influencing treatment adherence. It appeared to produce good results and is replicable in resource-limited settings.
    • Implementing a tenofovir-based first-line regimen in rural Lesotho: clinical outcomes and toxicities after two years.

      Bygrave, Helen; Ford, Nathan; van Cutsem, Gilles; Hilderbrand, Katherine; Jouquet, Guillaume; Goemaere, Eric; Vlahakis, Nathalie; Triviño, Laura; Makakole, Lipontso; Kranzer, Katharina; et al. (2011-03)
      The latest World Health Organization guidelines recommend replacing stavudine with tenofovir or zidovudine in first-line antiretroviral therapy in resource-limited settings. We report on outcomes and toxicities among patients on these different regimens in a routine treatment cohort in Lesotho.
    • Implementing antiretroviral therapy in rural communities: the Lusikisiki model of decentralized HIV/AIDS care.

      Bedelu, M; Ford, N; Hilderbrand, K; Reuter, H; Médecins Sans Frontières, Lusikisiki, South Africa. (Infectious Diseases Society of America, 2007-12-01)
      Health worker shortages are a major bottleneck to scaling up antiretroviral therapy (ART), particularly in rural areas. In Lusikisiki, a rural area of South Africa with a population of 150,000 serviced by 1 hospital and 12 clinics, Médecins Sans Frontières has been supporting a program to deliver human immunodeficiency virus (HIV) services through decentralization to primary health care clinics, task shifting (including nurse-initiated as opposed to physician-initiated treatment), and community support. This approach has allowed for a rapid scale-up of treatment with satisfactory outcomes. Although the general approach in South Africa is to provide ART through hospitals-which seriously limits access for many people, if not the majority of people-1-year outcomes in Lusikisiki are comparable in the clinics and hospital. The greater proximity and acceptability of services at the clinic level has led to a faster enrollment of people into treatment and better retention of patients in treatment (2% vs. 19% lost to follow-up). In all, 2200 people were receiving ART in Lusikisiki in 2006, which represents 95% coverage. Maintaining quality and coverage will require increased resource input from the public sector and full acceptance of creative approaches to implementation, including task shifting and community involvement.
    • Implications of Differentiated Care for Successful ART Scale-Up in a Concentrated HIV Epidemic in Yangon, Myanmar

      Mesic, A; Fontaine, J; Aye, T; Greig, J; Thwe, T; Moretó-Planas, L; Kliesckova, J; Khin, K; Zarkua, N; Gonzales, L; et al. (International AIDS Society, 2017-07-21)
      Introduction: National AIDS Programme in Myanmar has made significant progress in scaling up antiretroviral treatment (ART) services and recognizes the importance of differentiated care for people living with HIV. Indeed, long centred around the hospital and reliant on physicians, the country’s HIV response is undergoing a process of successful decentralization with HIV care increasingly being integrated into other health services as part of a systematic effort to expand access to HIV treatment. This study describes implementation of differentiated care in Médecins Sans Frontières (MSF)-supported programmes and reports its outcomes. Methods: A descriptive cohort analysis of adult patients on antiretroviral treatment was performed. We assessed stability of patients as of 31 December 2014 and introduced an intervention of reduced frequency of physicians’ consultations for stable patients, and fast tract ART refills. We measured a number of saved physician’s visits as the result of this intervention. Main outcomes, remained under care, death, lost to follow up, treatment failure, were assessed on 31 December 2015 and reported as rates for different stable groups. Results: On 31 December 2014, our programme counted 16, 272 adult patients enrolled in HIV care, of whom 80.34% were stable. The model allowed for an increase in the average number of patients one medical team could care for – from 745 patients in 2011 to 1, 627 in 2014 – and, thus, a reduction in the number of teams needed. An assessment of stable patients enrolled on ART one year after the implementation of the new model revealed excellent outcomes, aggregated for stable patients as 98.7% remaining in care, 0.4% dead, 0.8% lost to follow-up, 0.8% clinical treatment failure and 5.8% with immunological treatment failure. Conclusions: Implementation of a differentiated model reduced the number of visits between stable clients and physicians, reduced the medical resources required for treatment and enabled integrated treatment of the main co-morbidities. We hope that these findings will encourage other stakeholders to implement innovative models of HIV care in Myanmar, further expediting the scale up of ART services, the decentralization of treatment and the integration of care for the main HIV co-morbidities in this context.
    • Improving first-line antiretroviral therapy in resource-limited settings

      Ford, Nathan; Calmy, Alexandra (Wolters Kluwer Health | Lippincott Williams & Wilkins, 2010-01)