• "We Are Part of a Family". Benefits and Limitations of Community ART Groups (CAGs) in Thyolo, Malawi: a Qualitative Study

      Pellecchia, U; Baert, S; Nundwe, S; Bwanali, A; Zamadenga, B; Metcalf, CA; Bygrave, H; Daho, S; Ohler, L; Chibwandira, B; et al. (International AIDS Society, 2017-03-28)
      In 2012 Community ART Groups (CAGs), a community-based model of antiretroviral therapy (ART) delivery were piloted in Thyolo District, Malawi as a way to overcome patient barriers to accessing treatment, and to decrease healthcare workers' workload. CAGs are self-formed groups of patients on ART taking turns to collect ART refills for all group members from the health facility. We conducted a qualitative study to assess the benefits and challenges of CAGs from patients' and healthcare workers' (HCWs) perspectives.
    • Weight evolution in HIV-1 infected women in Rwanda after stavudine substitution due to lipoatrophy: comparison of zidovudine with tenofovir/abacavir.

      van Griensven, J; Zachariah, R; Rasschaert, F; Atté, E F; Reid, T; Médecins Sans Frontières, 7089 Kigali, Rwanda. (2009-02-01)
      This cohort study was conducted amongst female patients manifesting lipoatrophy while receiving stavudine-containing first-line antiretroviral treatment regimens at two urban health centres in Rwanda. The objectives were to assess weight evolution after stavudine substitution and to describe any significant difference in weight evolution when zidovudine or tenofovir/abacavir was used for substitution. All adult patients on stavudine-containing first-line regimens who developed lipoatrophy (diagnosed using a lipodystrophy case definition study-based questionnaire) and whose treatment regimen was changed were included (n=114). In the most severe cases stavudine was replaced with tenofovir or abacavir (n=39), and in the remainder with zidovudine (n=75). For patients changed to zidovudine a progressive weight loss was seen, while those on tenofovir/abacavir showed a progressive weight increase from six months. The between-group difference in weight evolution was significant from nine months (difference at 12 months: 2.3kg, P=0.02). These differences were confirmed by follow-up lipoatrophy scores. In multivariate analysis, substitution with tenofovir/abacavir remained significantly associated with weight gain. This is the first study in Africa assessing weight gain as a proxy for recovery after stavudine substitution due to lipoatrophy, providing supporting evidence that tenofovir/abacavir is superior to zidovudine. The weight loss with zidovudine might justify earlier substitution and access to better alternatives like tenofovir/abacavir.
    • Weight gain at 3 months of antiretroviral therapy is strongly associated with survival: evidence from two developing countries

      Madec, Yoann; Szumilin, Elisabeth; Genevier, Christine; Ferradini, Laurent; Balkan, Suna; Pujades, Mar; Fontanet, Arnaud; Unité d'Epidémiologie des Maladies Emergentes, Institut Pasteur, Paris, France; Medecins Sans Frontieres, Paris, France; Medecins Sans Frontieres, Nairobi, Kenya; Infectious Diseases Department, Khmero-Soviet Friendship Hospital, Phnom Penh, Cambodia; Epicentre, Paris, France (2009-04-27)
      BACKGROUND: In developing countries, access to laboratory tests remains limited, and the use of simple tools such as weight to monitor HIV-infected patients treated with antiretroviral therapy should be evaluated. METHODS: Cohort study of 2451 Cambodian and 2618 Kenyan adults who initiated antiretroviral therapy between 2001 and 2007. The prognostic value of weight gain at 3 months of antiretroviral therapy on 3-6 months mortality, and at 6 months on 6-12 months mortality, was investigated using Poisson regression. RESULTS: Mortality rates [95% confidence interval (CI)] between 3 and 6 months of antiretroviral therapy were 9.9 (7.6-12.7) and 13.5 (11.0-16.7) per 100 person-years in Cambodia and Kenya, respectively. At 3 months, among patients with initial body mass index less than or equal to 18.5 kg/m (43% of the study population), mortality rate ratios (95% CI) were 6.3 (3.0-13.1) and 3.4 (1.4-8.3) for those with weight gain less than or equal to 5 and 5-10%, respectively, compared with those with weight gain of more than 10%. At 6 months, weight gain was also predictive of subsequent mortality: mortality rate ratio (95% CI) was 7.3 (4.0-13.3) for those with weight gain less than or equal to 5% compared with those with weight gain of more than 10%. CONCLUSION: Weight gain at 3 months is strongly associated with survival. Poor compliance or undiagnosed opportunistic infections should be investigated in patients with initial body mass index less than or equal to 18.5 and achieving weight gain less than or equal to 10%.
    • Weight loss after the first year of stavudine-containing antiretroviral therapy and its association with lipoatrophy, virological failure, adherence and CD4 counts at primary health care level in Kigali, Rwanda.

      van Griensven, Johan; Zachariah, Rony; Mugabo, Jules; Reid, Tony; Médecins Sans Frontières, Operational Centre Brussels, Medical Department, Duprestraat 94, 1090 Brussels, Belgium. jvgrie@yahoo.com (2010-12)
      This study was conducted among 609 adults on stavudine-based antiretroviral treatment (ART) for at least one year at health center level in Kigali, Rwanda to (a) determine the proportion who manifest weight loss after one year of ART (b) examine the association between such weight loss and a number of variables, namely: lipoatrophy, virological failure, adherence and on-treatment CD4 count and (c) assess the validity and predictive values of weight loss to identify patients with lipoatrophy. Weight loss after the first year of ART was seen in 62% of all patients (median weight loss 3.1 kg/year). In multivariate analysis, weight loss was significantly associated with treatment-limiting lipoatrophy (adjusted effect/kg/year -2.0 kg, 95% confidence interval -0.6;-3.4 kg; P<0.01). No significant association was found with virological failure or adherence. Higher on-treatment CD4 cell counts were protective against weight loss. Weight loss that was persistent, progressive and/or chronic was predictive of lipoatrophy, with a sensitivity and specificity of 72% and 77%, and positive and negative predictive values of 30% and 95%. In low-income countries, measuring weight is a routine clinical procedure that could be used to filter out individuals with lipoatrophy on stavudine-based ART, after alternative causes of weight loss have been ruled out.
    • When to start antiretroviral therapy in resource-limited settings: a human rights analysis.

      Ford, Nathan; Calmy, Alexandra; Hurst, Samia; Médecins Sans Frontières, Cape Town, South Africa. nathan.ford@joburg.msf.org. (2010-06)
      ABSTRACT: BACKGROUND: Recent evidence from developed and developing countries shows clear clinical and public health benefit to starting antiretroviral therapy (ART) earlier. While discussions about when to start ART have often focused on the clinical risks and benefits, the main issue is one of fair limit-setting. We applied a human rights framework to assess a policy of early treatment initiation according to the following criteria: public-health purpose; likely effectiveness; specificity; human rights burdens and benefits; potential for less restrictive approaches; and fair administration. DISCUSSION: According to our analysis, a policy of earlier ART initiation would better serve both public health and human rights objectives. We highlight a number of policy approaches that could be taken to help meet this aim, including increased international financial support, alternative models of care, and policies to secure the most affordable sources of appropriate antiretroviral drugs. SUMMARY: Widespread implementation of earlier ART initiation is challenging in resource-limited settings. Nevertheless, rationing of essential medicines is a restriction of human rights, and the principle of least restriction serves to focus attention on alternative measures such as adapting health service models to increase capacity, decreasing costs, and seeking additional international funding. Progressive realisation using well-defined steps will be necessary to allow for a phased implementation as part of a framework of short-term targets towards nationwide policy adoption, and will require international technical and financial support.
    • Where do HIV-infected adolescents go after transfer? - Tracking transition/transfer of HIV-infected adolescents using linkage of cohort data to a health information system platform

      Davies, MA; Tsondai, P; Tiffin, N; Eley, B; Rabie, H; Euvrard, J; Orrell, C; Prozesky, H; Wood, R; Cogill, D; et al. (Wiley, 2017-03-16)
      To evaluate long-term outcomes in HIV-infected adolescents, it is important to identify ways of tracking outcomes after transfer to a different health facility. The Department of Health (DoH) in the Western Cape Province (WCP) of South Africa uses a single unique identifier for all patients across the health service platform. We examined adolescent outcomes after transfer by linking data from four International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA-SA) cohorts in the WCP with DoH data.
    • Who Needs to Be Targeted for HIV Testing and Treatment in KwaZulu-Natal? Results From a Population-Based Survey

      Huerga, H; Van Cutsem, G; Ben Farhat, J; Reid, M; Bouhenia, M; Maman, D; Wiesner, L; Etard, JF; Ellman, T (Lippincott Williams & Wilkins, 2016-12-01)
      Identifying gaps in HIV testing and treatment is essential to design specific strategies targeting those not accessing HIV services. We assessed the prevalence and factors associated with being HIV untested, unaware, untreated, and virally unsuppressed in KwaZulu-Natal, South Africa.
    • Women's Knowledge and Perception of Male Circumcision Before and After Its Roll-Out in the South African Township of Orange Farm from Community-Based Cross-Sectional Surveys

      Maraux, B; Lissouba, P; Rain-Taljaard, R; Taljaard, D; Bouscaillou, J; Lewis, D; Puren, A; Auvert, B (Public Library of Science, 2017-03-24)
      The roll-out of medical male circumcision (MC) is progressing in Southern and Eastern Africa. Little is known about the effect of this roll-out on women. The objective of this study was to assess the knowledge and perceptions of women regarding MC in a setting before and after the roll-out. This study was conducted in the South African township of Orange Farm where MC prevalence among men increased from 17% to 53% in the period 2008-2010. Data from three community-based cross sectional surveys conducted in 2007, 2010 and 2012 among 1258, 1197 and 2583 adult women, respectively were studied. In 2012, among 2583 women, 73.7% reported a preference for circumcised partners, and 87.9% knew that circumcised men could become infected with HIV. A total of 95.8% preferred to have their male children circumcised. These three proportions increased significantly during the roll-out. In 2007, the corresponding values were 64.4%, 82.9% and 80.4%, respectively. Among 2581 women having had sexual intercourse with circumcised and uncircumcised men, a majority (55.8%, 1440/2581) agreed that it was easier for a circumcised man to use a condom, 20.5% (530/2581) disagreed; and 23.07 (611/2581) did not know. However, some women incorrectly stated that they were fully (32/2579; 1.2%; 95%CI: 0.9% to 1.7%) or partially (233/2579; 9.0%; 95%CI: 8.0% to 10.2%) protected when having unprotected sex with a circumcised HIV-positive partner. This study shows that the favorable perception of women and relatively correct knowledge regarding VMMC had increased during the roll-out of VMMC. When possible, women should participate in the promotion of VMMC although further effort should be made to improve their knowledge.
    • 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)