• Targeting CD4 testing to a clinical subgroup of patients could limit unnecessary CD4 measurements, premature antiretroviral treatment and costs in Thyolo District, Malawi.

      Zachariah, R; Teck, R; Ascurra, O; Humblet, P; Harries, A D; Médecins sans Frontières, Medical Department (Operational Research HIV-TB), Brussels Operational Center, 94 Rue Dupre, Brussels, Belgium. zachariah@internet.lu (Elsevier, 2006-01)
      Malawi offers antiretroviral treatment (ART) to all HIV-positive adults who are clinically classified as being in WHO clinical stage III or IV without 'universal' CD4 testing. This study was conducted among such adults attending a rural district hospital HIV/AIDS clinic (a) to determine the proportion who have CD4 counts >or=350 cells/microl, (b) to identify risk factors associated with such CD4 counts and (c) to assess the validity and predictive values of possible clinical markers for CD4 counts >or=350 cells/microl. A CD4 count >or=350 cells/microl was found in 36 (9%) of 401 individuals who are thus at risk of being placed prematurely on ART. A body mass index (BMI) >22 kg/m(2), the absence of an active WHO indicator disease at the time of presentation for ART, and a total lymphocyte count >1,200 cells/microl were significantly associated with such a CD4 count. The first two of these variables could serve as clinical markers for selecting subgroups of patients who should undergo CD4 testing. In a resource-limited district setting, assessing the BMI and checking for active opportunistic infections are routine clinical procedures that could be used to target CD4 measurements, thereby minimising unnecessary CD4 measurements, unnecessary (too early) treatment and costs.
    • Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa.

      Zachariah, R; Ford, N; Philips, M; Lynch, S; Massaquoi, M; Janssens, V; Harries, A D; Médecins Sans Frontières, Medical Department, Brussels Operational Center, Rue de Gasperich, Luxembourg. zachariah@internet.lu (Published by Elsevier, 2009-06)
      Sub-Saharan Africa is facing a crisis in human health resources due to a critical shortage of health workers. The shortage is compounded by a high burden of infectious diseases; emigration of trained professionals; difficult working conditions and low motivation. In particular, the burden of HIV/AIDS has led to the concept of task shifting being increasingly promoted as a way of rapidly expanding human resource capacity. This refers to the delegation of medical and health service responsibilities from higher to lower cadres of health staff, in some cases non-professionals. This paper, drawing on Médecins Sans Frontières' experience of scaling-up antiretroviral treatment in three sub-Saharan African countries (Malawi, South Africa and Lesotho) and supplemented by a review of the literature, highlights the main opportunities and challenges posed by task shifting and proposes specific actions to tackle the challenges. The opportunities include: increasing access to life-saving treatment; improving the workforce skills mix and health-system efficiency; enhancing the role of the community; cost advantages and reducing attrition and international 'brain drain'. The challenges include: maintaining quality and safety; addressing professional and institutional resistance; sustaining motivation and performance and preventing deaths of health workers from HIV/AIDS. Task shifting should not undermine the primary objective of improving patient benefits and public health outcomes.
    • Task-Sharing of HIV Care and ART Initiation: Evaluation of a Mixed-Care Non-Physician Provider Model for ART Delivery in Rural Malawi

      McGuire, Megan; Ben Farhat, Jihane; Pedrono, Gaelle; Szumilin, Elisabeth; Heinzelmann, Annette; Chinyumba, Yamikani Ntakwile; Goossens, Sylvie; Makombe, Simon; Pujades-Rodríguez, Mar (2013-09-16)
      Background: Expanding access to antiretroviral therapy (ART) in sub-Saharan Africa requires implementation of alternative care delivery models to traditional physician-centered approaches. This longitudinal analysis compares outcomes of patients initiated on antiretroviral therapy (ART) by non-physician and physician providers. Methods: Adults (≥15 years) initiating ART between September 2007 and March 2010, and with >1 follow-up visit were included and classified according to the proportion of clinical visits performed by nurses or by clinical officers(≥80% of visits). Multivariable Poisson models were used to compare 2-year program attrition (mortality and lost to follow-up) and mortality by type of provider. In sensitivity analyses only patients with less severe disease were included. Results: A total of 10,112 patients contributed 14,012 person-years to the analysis: 3386 (33.5%) in the clinical officer group, 1901 (18.8%) in the nurse care group and 4825 (47.7%) in the mixed care group. Overall 2-year program retention was 81.8%. Attrition was lower in the mixed care and higher in the clinical officer group, compared to the nurse group (adjusted incidence rate ratio [aIRR]=0.54, 95%CI 0.45-0.65; and aIRR=3.03, 95%CI 2.56-3.59,respectively). While patients initiated on ART by clinical officers in the mixed care group had lower attrition(aIRR=0.36, 95%CI 0.29-0.44) than those in the overall nurse care group; no differences in attrition were found between patients initiated on ART by nurses in the mixed care group and those included in the nurse group (aIRR=1.18, 95%CI 0.95-1.47). Two-year mortality estimates were aIRR=0.72, 95%CI 0.49-1.09 and aIRR=5.04,95%CI 3.56-7.15, respectively. Slightly higher estimates were observed when analyses were restricted to patients with less severe disease. Conclusion: The findings of this study support the use of a mixed care model with well trained and regularly supervised nurses and medical assistants to provide HIV care in countries with high HIV prevalence.
    • Temporal changes in programme outcomes among adult patients initiating antiretroviral therapy across South Africa, 2002-2007.

      Cornell, Morna; Grimsrud, Anna; Fairall, Lara; Fox, Matthew P; van Cutsem, Gilles; Giddy, Janet; Wood, Robin; Prozesky, Hans; Mohapi, Lerato; Graber, Claire; Egger, Matthias; Boulle, Andrew; Myer, Landon; Centre for Infectious Disease Epidemiology & Research, University of Cape Town, South Africa. morna@global.co.za (2010-09-10)
      OBJECTIVE: Little is known about the temporal impact of the rapid scale-up of large antiretroviral therapy (ART) services on programme outcomes. We describe patient outcomes [mortality, loss-to-follow-up (LTFU) and retention] over time in a network of South African ART cohorts. DESIGN: Cohort analysis utilizing routinely collected patient data. METHODS: Analysis included adults initiating ART in eight public sector programmes across South Africa, 2002-2007. Follow-up was censored at the end of 2008. Kaplan-Meier methods were used to estimate time to outcomes, and proportional hazards models to examine independent predictors of outcomes. RESULTS: Enrolment (n = 44 177, mean age 35 years; 68% women) increased 12-fold over 5 years, with 63% of patients enrolled in the past 2 years. Twelve-month mortality decreased from 9% to 6% over 5 years. Twelve-month LTFU increased annually from 1% (2002/2003) to 13% (2006). Cumulative LTFU increased with follow-up from 14% at 12 months to 29% at 36 months. With each additional year on ART, failure to retain participants was increasingly attributable to LTFU compared with recorded mortality. At 12 and 36 months, respectively, 80 and 64% of patients were retained. CONCLUSION: Numbers on ART have increased rapidly in South Africa, but the programme has experienced deteriorating patient retention over time, particularly due to apparent LTFU. This may represent true loss to care, but may also reflect administrative error and lack of capacity to monitor movements in and out of care. New strategies are needed for South Africa and other low-income and middle-income countries to improve monitoring of outcomes and maximize retention in care with increasing programme size.
    • Temporal Trends in the Characteristics of Children at Antiretroviral Therapy Initiation in Southern Africa: The IeDEA-SA Collaboration

      Davies, Mary-Ann; Phiri, Sam; Wood, Robin; Wellington, Maureen; Cox, Vivian; Bolton-Moore, Carolyn; Timmerman, Venessa; Moultrie, Harry; Ndirangu, James; Rabie, Helena; Technau, Karl; Giddy, Janet; Maxwell, Nicola; Boulle, Andrew; Keiser, Olivia; Egger, Matthias; Eley, Brian (Public Library of Science, 2013-12-09)
    • Tenofovir in second-line ART in Zambia and South Africa: collaborative analysis of cohort studies.

      Wandeler, Gilles; Keiser, Olivia; Mulenga, Lloyd; Hoffmann, Christopher J; Wood, Robin; Chaweza, Thom; Brennan, Alana; Prozesky, Hans; Garone, Daniela; Giddy, Janet; Chimbetete, Cleophas; Boulle, Andrew; Egger, Matthias; Division of International and Environmental Health, Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, CH-3012 Bern, Switzerland. gwandeler@ispm.unibe.ch (2012-09-01)
      Tenofovir (TDF) is increasingly used in second-line antiretroviral treatment (ART) in sub-Saharan Africa. We compared outcomes of second-line ART containing and not containing TDF in cohort studies from Zambia and the Republic of South Africa (RSA).
    • They call it "patient selection" in Khayelitsha: the experience of Médecins Sans Frontières-South Africa in enrolling patients to receive antiretroviral treatment for HIV/AIDS

      Fox, Renée C; Goemaere, Eric; University of Pennsylvania, Philadelphia, USA; Médecins Sans Frontières (MSF) - South Africa (2006-05-02)
    • "They Just Come, Pick and Go." The Acceptability of Integrated Medication Adherence Clubs for HIV and Non Communicable Disease (NCD) Patients in Kibera, Kenya

      Venables, E; Edwards, JK; Baert, S; Etienne, W; Khabala, K; Bygrave, H (Public Library of Science, 2016-10-20)
      The number of people on antiretroviral therapy (ART) for the long-term management of HIV in low- and middle-income countries (LMICs) is continuing to increase, along with the prevalence of Non-Communicable Diseases (NCDs). The need to provide large volumes of HIV patients with ART has led to significant adaptations in how medication is delivered, but access to NCD care remains limited in many contexts. Medication Adherence Clubs (MACs) were established in Kibera, Kenya to address the large numbers of patients requiring chronic HIV and/or NCD care. Stable NCD and HIV patients can now collect their chronic medication every three months through a club, rather than through individual clinic appointments.
    • A three-tier framework for monitoring antiretroviral therapy in high HIV burden settings

      Osler, Meg; Hilderbrand, Katherine; Hennessey, Claudine; Arendse, Juanita; Goemaere, Eric; Ford, Nathan; Boulle, Andrew (International AIDS Society, 2014-04)
      The provision of antiretroviral therapy (ART) in low and middle-income countries is a chronic disease intervention of unprecedented magnitude and is the dominant health systems challenge for high-burden countries, many of which rank among the poorest in the world. Substantial external investment, together with the requirement for service evolution to adapt to changing needs, including the constant shift to earlier ART initiation, makes outcome monitoring and reporting particularly important. However, there is growing concern at the inability of many high-burden countries to report on the outcomes of patients who have been in care for various durations, or even the number of patients in care at a particular point in time. In many instances, countries can only report on the number of patients ever started on ART. Despite paper register systems coming under increasing strain, the evolution from paper directly to complex electronic medical record solutions is not viable in many contexts. Implementing a bridging solution, such as a simple offline electronic version of the paper register, can be a pragmatic alternative. This paper describes and recommends a three-tiered monitoring approach in low- and middle-income countries based on the experience implementing such a system in the Western Cape province of South Africa. A three-tier approach allows Ministries of Health to strategically implement one of the tiers in each facility offering ART services. Each tier produces the same nationally required monthly enrolment and quarterly cohort reports so that outputs from the three tiers can be aggregated into a single database at any level of the health system. The choice of tier is based on context and resources at the time of implementation. As resources and infrastructure improve, more facilities will transition to the next highest and more technologically sophisticated tier. Implementing a three-tier monitoring system at country level for pre-antiretroviral wellness, ART, tuberculosis and mother and child health services can be an efficient approach to ensuring system-wide harmonization and accurate monitoring of services, including long term retention in care, during the scale-up of electronic monitoring solutions.
    • Time to AIDS from 1992 to 1999 in HIV-1-Infected Subjects with Known Date of Infection.

      Tassie, J M; Grabar, S; Lancar, R; Deloumeaux, J; Bentata, M; Costagliola, D; Institut National de la Santé et de la Recherche Médicale SC4, Faculté de Médecine, St. Antoine Université Pierre et Marie Curie, Paris, France; Epicentre, Paris, France. (2002-05-01)
      To estimate the change in AIDS incubation time during three periods characterized by different availability of antiretroviral treatments, data from the French Hospital Database on HIV of 4702 HIV-1-positive subjects with a documented date of infection were analyzed. Times from seroconversion to AIDS were compared in three periods: period 1 from January 1992 to June 1995 (monotherapy); period 2 from July 1995 to June 1996 (dual therapy); and period 3 from July 1996 to June 1999 (triple therapy). Nonparametric survival analyses were performed to account for staggered entries in the database and during each period. From periods 1 to 3, antiretroviral treatments were initiated earlier after infection, more subjects were treated, and the nature of regimens changed (25.6% of subjects were treated with monotherapy in period 1, 34.6% were treated with dual therapy in period 2, and 53.4% were treated with triple therapy in period 3). Compared with period 1, the relative hazard (RH) of AIDS was 0.31 in period 3 (95% confidence interval [CI]: 0.24-0.39). When comparing period 3 with period 2, the RH of AIDS was 0.36 (CI: 0.29-0.45). Assuming a log normal distribution, the median time to AIDS was estimated as 8.0 years in period 1 (CI: 6.0-10.6), 9.8 years in period 2 (CI: 8.5, 11.2), and 20.0 years in period 3 (CI: 17.1-23.3). This lengthening in time to AIDS from 1992 to 1999 was particularly marked in the period after the introduction of triple therapy, including protease inhibitors.
    • Time to initiation of antiretroviral therapy among patients with HIV-associated tuberculosis in Cape Town, South Africa

      Lawn, Stephen D; Campbell, Lucy; Kaplan, Richard; Boulle, Andrew; Cornell, Morna; Kerschberger, Bernhard; Morrow, Carl; Little, Francesca; Egger, Matthias; Wood, Robin; The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Department of Statistical Sciences, Faculty of Science, University of Cape Town, South Africa; School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Medecins Sans Frontieres, Cape Town, South Africa; Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland (Lippincott Williams & Wilkins, 2011-06-01)
      We studied the time interval between starting tuberculosis treatment and commencing antiretroviral treatment (ART) in HIV-infected patients (n = 1433; median CD4 count 71 cells per microliter, interquartile range: 32-132) attending 3 South African township ART services between 2002 and 2008. The overall median delay was 2.66 months (interquartile range: 1.58-4.17). In adjusted analyses, delays varied between treatment sites but were shorter for patients with lower CD4 counts and those treated in more recent calendar years. During the most recent period (2007-2008), 4.7%, 19.7%, and 51.1% of patients started ART within 2, 4, and 8 weeks of tuberculosis treatment, respectively. Operational barriers must be tackled to permit further acceleration of ART initiation as recommended by 2010 WHO ART guidelines.
    • Timeliness of Clinic Attendance is a good predictor of Virological Response and Resistance to Antiretroviral drugs in HIV-infected patients

      Bastard, Mathieu; Pinoges, Loretxu; Balkan, Suna; Szumilin, Elisabeth; Ferreyra, Cecilia; Pujades-Rodriguez, Mar; Epicentre, Paris, France. mathieu.bastard@geneva.msf.org (2012-11-07)
      Ensuring long-term adherence to therapy is essential for the success of HIV treatment. As access to viral load monitoring and genotyping is poor in resource-limited settings, a simple tool to monitor adherence is needed. We assessed the relationship between an indicator based on timeliness of clinic attendance and virological response and HIV drug resistance.
    • Tough choices: tenofovir, tenders and treatment

      Ford, N; Gray, A; Venter, F (South African Medical Association, 2008-06-04)
      Scaling up antiretroviral therapy (ART) in developing countries would not have been possible without market competition, which has driven down the price of standard first-line ARV drugs from more than US$12,000 per person per year in 2000 to US$99 today. However, access to new, second-line ARVs remains largely restricted to originator (patented) drugs. This causes significant challenges in countries where access to newer drugs is becoming inceasingly important as programmes mature and face challenges related to drug toxicity and resistance. Toxicity, in particular, has emerged as a major reason for individual drug switches and regimen changes, and is strongly implicated in decreasing adherence.
    • Towards a Patent Pool for HIV Medicines: The Background

      Childs, Michelle; Campaign for Access to Essential Medicines, Médecins Sans Frontières, Geneva, Switzerland (2010-07-01)
      Recent WHO guidelines for antiretroviral therapy recommend switching to less toxic, but more expensive medicines for first-line and second-line ART, raising questions about the financial sustainability of many AIDS treatment programmes. At the same time, many key generic producing countries such as India now grant pharmaceutical product patents so competition between multiple manufacturers will not be able to play the role it has in bringing down the price of newer drugs.Overcoming these patent barriers will require a range of solutions, such as restricting patentability criteria, or compulsory licensing. One additional systematic solution is provided by the patent pool, a collective solution to the management of patent rights, initially presented by Médecins Sans Frontières to the French Foreign Ministry and subsequently the UNITAID Executive Board in 2006.A patent pool must not be implemented at any costs, but answer medical needs, be based on economic realities and meet the access needs of the developing world, including middle-income countries.
    • Towards More Accurate HIV Testing in Sub-Saharan Africa: a Multi-Site Evaluation of HIV RDTs and Risk Factors For False Positives

      Kosack, CS; Page, AL; Beelaert, G; Benson, T; Savane, A; Ng'ang'a, A; Andre, B; Zahinda, JP; Shanks, L; Fransen, K (International AIDS Society, 2017-03-22)
      Although individual HIV rapid diagnostic tests (RDTs) show good performance in evaluations conducted by WHO, reports from several African countries highlight potentially significant performance issues. Despite widespread use of RDTs for HIV diagnosis in resource-constrained settings, there has been no systematic, head-to-head evaluation of their accuracy with specimens from diverse settings across sub-Saharan Africa. We conducted a standardized, centralized evaluation of eight HIV RDTs and two simple confirmatory assays at a WHO collaborating centre for evaluation of HIV diagnostics using specimens from six sites in five sub-Saharan African countries.
    • Toxicity associated with stavudine dose reduction from 40 to 30 mg in first-line antiretroviral therapy.

      Pujades-Rodríguez, Mar; Dantony, Emmanuelle; Pinoges, Loretxu; Ecochard, René; Etard, Jean-François; Carrillo-Casas, Esther; Szumilin, Elisabeth; Clinical Research Department, Epicentre, Paris, France. mar.pujades@epicentre.msf.org (2011-11)
      To compare the incidence and timing of toxicity associated with the use of a reduced dose of stavudine from 40 to 30 mg in first-line antiretroviral therapy (ART) for HIV treatment and to investigate associated risk factors.
    • Tracing defaulters in HIV prevention of mother-to-child transmission programmes through community health workers: results from a rural setting in Zimbabwe.

      Vogt, Florian; Ferreyra, Cecilia; Bernasconi, Andrea; Ncube, Lewis; Taziwa, Fabian; Marange, Winnie; Wachi, David; Becher, Heiko (International AIDS Society, 2015-10)
      High retention in care is paramount to reduce vertical human immunodeficiency virus (HIV) infections in prevention of mother-to-child transmission (PMTCT) programmes but remains low in many sub-Saharan African countries. We aimed to assess the effects of community health worker-based defaulter tracing (CHW-DT) on retention in care and mother-to-child HIV transmission, an innovative approach that has not been evaluated to date.
    • Tracing patients on antiretroviral treatment lost-to-follow-up in an urban slum in India

      Errol, Lisa; Isaakidis, Petros; Zachariah, Rony; Ali, Mohammed; Pilankar, Gurudas; Maurya, Sanjana; Geraets, Claudia; Ladomirska, Joanna; Patel, Sunil; Reid, Tony (Blackwell, 2012-01)
    • Training clinicians treating HIV to diagnose cytomegalovirus retinitis

      Heiden, David; Tun, NiNi; Maningding, Ernest; Heiden, Matthew; Rose-Nussbaumer, Jennifer; Chan, Khin Nyein; Khizniak, Tamara; Yakubenko, Alexandra; Lewallen, Susan; Keenan, Jeremy D; Saranchuk, Peter (World Health Organization, 2014-12-01)
      Acquired immunodeficiency syndrome (AIDS)-related cytomegalovirus (CMV) retinitis continues to be a neglected source of blindness in resource-poor settings. The main issue is lack of capacity to diagnose CMV retinitis in the clinical setting where patients receive care and all other opportunistic infections are diagnosed.
    • Transmission Networks and Risk of HIV Infection in KwaZulu-Natal, South Africa: A Community-Wide Phylogenetic Study

      de Oliveira, T; Kharsany, ABM; Gräf, T; Cawood, C; Khanyile, D; Grobler, A; Puren, A; Madurai, S; Baxter, C; Karim, QA; Karim, SSA (Elsevier, 2016-11-30)
      The incidence of HIV infection in young women in Africa is very high. We did a large-scale community-wide phylogenetic study to examine the underlying HIV transmission dynamics and the source and consequences of high rates of HIV infection in young women in South Africa.