• HIV epidemic and cascade of care in 12 east African rural fishing communities: results from a population-based survey in Uganda

      Burgos-Soto, J; Farhat, JB; Alley, I; Ojuka, P; Mulogo, E; Kise-Sete, T; Bouhenia, M; Salumu, L; Mathela, R; Langendorf, C; et al. (BMC, 2020-06-19)
      Background In East Africa, fishing communities are considered most-at-risk populations for the acquisition of HIV. We estimated HIV prevalence and assessed progress towards the UNAIDS 90–90-90 targets along the HIV treatment cascade in 12 fishing communities surrounding Lakes Edward and George, Uganda. Methods We conducted a cross-sectional household-based survey between September and November 2016. All adults between 15 and 69 years old were eligible to participate. Children below 15 years old were eligible for HIV testing if either parent was HIV-positive. Viral load testing was done for all HIV-infected individuals. Logistic regression models adjusted for sociodemographic-behavioral variables were used to assess the association between occupation and HIV positivity. Results Overall, 1738 adults (959 women, 779 men) and 148 children were included. Adult inclusion rate was 96.0%. Of the men, 58% reported to be fishermen. The HIV-prevalence among adults was 17.5% (95%CI: 15.8–19.4) and 6.1% (95%CI: 3.1–11.4) among HIV-exposed children. HIV prevalence was higher among women than among men (20.9% vs. 13.5%, p < 0.001). Among men, fishermen had a higher HIV prevalence (18.7%; 95%CI: 15.1–22.3) and a higher risk of being HIV-positive (aOR: 4.2; 95%CI: 2.0–9.1) than men of other occupations (p < 0.001). Progress towards the UNAIDS 90–90-90 targets was as follows: 86.5% (95%CI: 82.3–90.1%) of the HIV-positive participants were diagnosed, 98.7% (95%CI: 96.1–99.6%) of those aware were on antiretroviral therapy (ART), and 87.3% (95%CI: 82.3–91.0%) of those on ART were virally suppressed. Overall, 73% of all HIV-positive individuals were virally suppressed. Viral suppression was lower among individuals 15–24 years (45.5%) than among those 25–44 years (74.0%) and 45–69 years (85.0%), p < 0.001. Fishermen did not to have significant differences in the HIV cascade of care compared to men with other occupations. Conclusions HIV prevalence was high in these fishing communities, particularly among women and fishermen. Important progress has been made along the HIV treatment cascade, and the UNAIDS goal for viral suppression in population was achieved. However, gaps remain and HIV care strategies focusing on young people are urgently needed. HIV preventive interventions should target particularly women, young people and fishermen though HIV preventive and care services should remain available to the whole fishing communities.
    • HIV Misdiagnosis in Sub-Saharan Africa: Performance of Diagnostic Algorithms at Six Testing Sites

      Kosack, C; Shanks, L; Beelaert, G; Benson, T; Savane, A; Ng'ang'a, A; Andre, B; Zahinda, J; Fransen, K; Page, A (International AIDS Society, 2017-07-03)
      We evaluated the diagnostic accuracy of HIV testing algorithms at six programmes in five sub-Saharan African countries.
    • 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.
    • HIV prevention, care, and treatment in two prisons in Thailand.

      Wilson, D; Ford, N; Ngammee, V; Chua, A; Kyaw, M K K; Médecins Sans Frontières, Bangkapi, Bangkok, Thailand. (Public Library of Science, 2007-06)
    • HIV programmatic outcomes following implementation of the 'Treat-All' policy in a public sector setting in Eswatini: a prospective cohort study

      Kerschberger, B; Schomaker, M; Jobanputra, K; Kabore, SM; Teck, R; Mabhena, E; Mthethwa-Hleza, S; Rusch, B; Ciglenecki, I; Boulle, A (Wiley, 2020-03-03)
      INTRODUCTION: The Treat-All policy - antiretroviral therapy (ART) initiation irrespective of CD4 cell criteria - increases access to treatment. Many ART programmes, however, reported increasing attrition and viral failure during treatment expansion, questioning the programmatic feasibility of Treat-All in resource-limited settings. We aimed to describe and compare programmatic outcomes between Treat-All and standard of care (SOC) in the public sectors of Eswatini. METHODS: This is a prospective cohort study of ≥16-year-old HIV-positive patients initiated on first-line ART under Treat-All and SOC in 18 health facilities of the Shiselweni region, from October 2014 to March 2016. SOC followed the CD4 350 and 500 cells/mm3 treatment eligibility thresholds. Kaplan-Meier estimates were used to describe crude programmatic outcomes. Multivariate flexible parametric survival models were built to assess associations of time from ART initiation with the composite unfavourable outcome of all-cause attrition and viral failure. RESULTS: Of the 3170 patients, 1888 (59.6%) initiated ART under Treat-All at a median CD4 cell count of 329 (IQR 168 to 488) cells/mm3 compared with 292 (IQR 161 to 430) (p < 0.001) under SOC. Although crude programme retention at 36 months tended to be lower under Treat-All (71%) than SOC (75%) (p = 0.002), it was similar in covariate-adjusted analysis (adjusted hazard ratio [aHR] 1.06, 95% CI 0.91 to 1.23). The hazard of viral suppression was higher for Treat-All (aHR 1.12, 95% CI 1.01 to 1.23), while the hazard of viral failure was comparable (Treat-All: aHR 0.89, 95% CI 0.53 to 1.49). Among patients with advanced HIV disease (n = 1080), those under Treat-All (aHR 1.13, 95% CI 0.88 to 1.44) had a similar risk of an composite unfavourable outcome to SOC. Factors increasing the risk of the composite unfavourable outcome under both interventions were aged 16 to 24 years, being unmarried, anaemia, ART initiation on the same day as HIV care enrolment and CD4 ≤ 100 cells/mm3 . Under Treat-All only, the risk of the unfavourable outcome was higher for pregnant women, WHO III/IV clinical stage and elevated creatinine. CONCLUSIONS: Compared to SOC, Treat-All resulted in comparable retention, improved viral suppression and comparable composite outcomes of retention without viral failure.
    • 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.
    • HIV testing and retention in care of infants born to HIV-infected women enrolled in 'Option B+', Thyolo, Malawi

      Perez, G. Martinez; Metcalf, C.; Garone, D.; Coulborn, R.; Harries, A. D.; Hedt-Gauthier, B.; Murowa, M.; Mwenelupembe, G. S.; Van den Bergh, R.; Duran, L. Triviño (The Union, 2014-06-21)
    • HIV treatment in a conflict setting: outcomes and experiences from Bukavu, Democratic Republic of the Congo.

      Culbert, H; Tu, D; O'Brien, D; Ellman, T; Mills, C; Ford, N; Amisi, T; Chan, K; Venis, S; Médecins Sans Frontières-Holland, Amsterdam, The Netherlands. (Public Library of Science, 2007-05)
    • HIV viral load algorithm

      Shroufi, A; van Cutsem, G; Phillips, A; Maman, D; Murphy, R; Duncan, K; Cambiano, V; Bansi-Matharu, L (Ovid Technologies (Wolters Kluwer Health), 2020-01)
      Letter to the Editor | No Abstract
    • HIV Viral Load as an Independent Risk Factor for Tuberculosis in South Africa: Collaborative Analysis of Cohort Studies

      Fenner, L; Atkinson, A; Boulle, A; Fox, M; Prozesky, H; Zürcher, K; Ballif, M; Furrer, H; Zwahlen, M; Davies, M; et al. (International AIDS Society, 2017-06-23)
      Chronic immune activation due to ongoing HIV replication may lead to impaired immune responses against opportunistic infections such as tuberculosis (TB). We studied the role of HIV replication as a risk factor for incident TB after starting antiretroviral therapy (ART).
    • HIV Viral Load Monitoring in Resource-Limited Regions: Optional or Necessary?

      Calmy, A; Ford, N; Hirschel, B; Reynolds, S; Lynen, L; Goemaere, E; Garcia de la Vega, F; Perrin, L; Rodriguez, W; Medecins sans Frontieres, Access to Medicines Campaign, Geneva, 1211, Switzerland. acalmy@gmail.com (Published by: Infectious Diseases Society of America, 2007-01-01)
      Although it is a standard practice in high-income countries, determination of the human immunodeficiency virus (HIV) load is not recommended in developing countries because of the costs and technical constraints. As more and more countries establish capacity to provide second-line therapy, and as costs and technological constraints associated with viral load testing decrease, the question of whether determination of the viral load is necessary deserves attention. Viral load testing could increase in importance as a guide for clinical decisions on when to switch to second-line treatment and on how to optimize the duration of the first-line treatment regimen. In addition, the viral load is a particularly useful tool for monitoring adherence to treatment, performing sentinel surveillance, and diagnosing HIV infection in children aged <18 months. Rather than considering viral load data to be an unaffordable luxury, efforts should be made to ensure that viral load testing becomes affordable, simple, and easy to use in resource-limited settings.
    • HIV-1 drug resistance testing at second-line regimen failure in Arua, Uganda: avoiding unnecessary switch to an empiric third-line.

      Fily, F; Ayikobua, E; Ssemwanga, D; Nicholas, S; Kaleebu, P; Delaugerre, C; Pasquier, E; Amoros Quiles, I; Balkan, S; Schramm, B (Wiley-Blackwell, 2018-07-29)
      The number of patients on second-line antiretroviral therapy is growing, but data on HIV drug resistance patterns at failure in resource-constrained settings are scarce. We aimed to describe drug resistance and investigate the factors associated with extensive resistance to nucleoside/nucleotide reverse transcriptase inhibitors (NRTI), in patients failing second-line therapy in the HIV outpatient clinic at Arua Regional Referral Hospital, Uganda.
    • HIV-1 viral load monitoring: an opportunity to reinforce treatment adherence in a resource-limited setting in Thailand.

      Wilson, D; Keiluhu, A K; Kogrum, S; Reid, T; Seriratana, N; Ford, N; KyawKyaw, M K; Talangsri, P; Taochalee, N; Médecins Sans Frontières, 28/36 Chokchai 4 Road, Ladphrao, Bangkok 10230, Thailand. (2008-12-23)
      This paper describes a program to increase patients' treatment literacy regarding viral load (VL) monitoring through patient education materials and a counseling protocol, implemented by peer counselors, in order to reinforce adherence to first-line treatment. VL monitoring and second-line antiretroviral treatment were introduced into an established first-line treatment program in a rural district hospital in Thailand. All patients (171 adults and 14 children) taking antiretroviral treatment for more than 6 months participated and those with detectable VL were targeted for additional adherence support. The main outcome measure recorded was the number of detectable results becoming undetectable after counseling. Four adults and one child had a persistently high VL and switched to second-line treatment. Of 51 adults (30%) with an initial low detectable VL, 47/51 identified likely explanations, usually linked with poor adherence. Following counseling, VL became undetectable in 45/51 cases and some patients could resolve long-standing psychosocial problems. We conclude that HIV-1 VL monitoring together with targeted counseling for patients with detectable VL can promote adherence to treatment, providing an opportunity to delay onset of HIV-1 resistance. When implemented with a patient-centered approach, it can be a very useful tool for psychosocial support.
    • HIV-associated Kaposi's sarcoma in Maputo, Mozambique: outcomes in a specialized treatment center, 2010-2015

      Fardhdiani, V; Molfino, L; Zamudio, AG; Manuel, R; Luciano, G; Ciglenecki, I; Rusch, B; Toutous Trellu, L; Coldiron, ME (BioMed Central, 2018-01-19)
      Kaposi's sarcoma (KS) is a common HIV-associated malignancy associated with disability, pain and poor outcomes. The cornerstone of its treatment is antiretroviral therapy, but advanced disease necessitates the addition of chemotherapy. In high-income settings, this often consists of liposomal anthracyclines, but in Mozambique, the first line includes conventional doxorubicin, bleomycin and vincristine, which is poorly-tolerated. Médecins Sans Frontières supports the Ministry of Health (MOH) in a specialized HIV and KS treatment center at the Centro de Referencia de Alto Maé in Maputo.
    • The HIV/AIDS epidemic in sub-Saharan Africa: thinking ahead on programmatic tasks and related operational research

      Zachariah, Rony; Van Damme, Wim; Arendt, Vic; Schmit, Jean; Harries, Anthony D (2011)
    • HIV/AIDS prevention and treatment.

      Goemaere, E; Ford, N; Benatar, S R (Elsevier, 2002-07-06)
    • Home-based HIV counseling and testing as a gateway to earlier initiation of antiretroviral therapy

      Mills, Edward J; Ford, Nathan; Faculty of Health Sciences, University of Ottawa, Canada; Médecins Sans Frontières, Geneva, Switzerland; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa (Oxford University Press, 2011-12-08)
    • How can the community contribute in the fight against HIV/AIDS and tuberculosis? An example from a rural district in Malawi.

      Zachariah, R; Teck, R; Buhendwa, L; Labana, S; Chinji, C; Humblet, P; Harries, A D; Médecins sans Frontières, Medical Department (Operational Research), Brussels Operational Center, Belgium. zachariah@internet.lu (Elsevier, 2006-02)
      This paper describes (a) the experience of initiating community involvement in HIV/AIDS and tuberculosis (TB) activities in a rural district in Malawi and (b) some of the different ways in which the community is contributing in the fight against these two diseases and the outcomes of their involvement. During a 2-year period, a total of 21,358 (41%) of 52,510 HIV tests performed at voluntary counselling and HIV testing (VCT) sites in the district were conducted by lay community counsellors. A team of 465 community volunteers, 1,362 trained family caregivers and 9 community nurses provided care and support to 5,106 HIV-positive individuals, of whom 2,006 (39%) were in WHO stage III or IV. All those in WHO stage III or IV were on co-trimoxazole prophylaxis and 895 (45%) of these were also on antiretroviral treatment. A total of 2,714 TB patients, of whom 1627 (60%) were HIV-positive, also received care and support. A total of 1,694 orphans were trained in vocational skills. Twelve vegetable gardens and three maize farms were set up, and pre-school activities were organised for 900 orphans. Communities can play an important contributory role in reducing the burden of HIV/AIDS and TB and in mitigating its impact. Despite this, community resources in most settings are often under-exploited and their role remains undefined.
    • How developing world concerns need to be part of drug development plans: A case study of four emerging antiretrovirals

      van Roey, J; von Schoen-Angerer, T; Ford, N; Calmy, A; Médecins Sans Frontières, Campaign for Access to Essential Medecins, Geneva, Switzerland; Médecins Sans Frontières, Khayelitsha, South Africa; Geneva Teaching Hospital, Geneva, Switzerland (2008-07)
      Clinical trials are usually designed to meet registration requirements in developed countries, and do not always address key concerns for use in developing countries. Four late-stage investigational new drugs - rilpivirine, etravirine, raltegravir and maraviroc - show potential to improve antiretroviral therapy. However, a number of issues could limit their use in developing countries, including dose selection, treatment strategy, combination with other drugs, use in specific populations and reliance on expensive tests. Key research questions relevant for developing countries need to be answered early in the drug development process to ensure maximum benefit for the majority.
    • How labour intensive is a doctor-based delivery model for antiretroviral treatment (ART)? Evidence from an observational study in Siem Reap, Cambodia

      Van Damme, W; Kheang, S; Janssens, B; Kober, K; Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium. Médecins Sans Frontières–Belgium, Phnom Penh, Cambodia. (BioMed Central, 2007-05-01)
      BACKGROUND: Funding for scaling-up antiretroviral treatment (ART) in low-income countries has increased substantially, but the lack of human resources for health (HRH) is increasingly being identified as an important constraint for scaling-up ART. METHODS: In a clinic run by Médecins Sans Frontières in Siem Reap, Cambodia, we documented the use of doctor-time for ART in September 2004 and in August 2005, for different phases in ART (pre-ART, ART initiation, ART follow-up Year 1, & ART follow-up Year 2). Based on these observations and using a variety of assumptions for survival of patients on ART (between 90 and 95% annually) and for further reductions in doctor-time per patient (between 0 and 10% annually), we estimated the need for doctors for the period 2004 till 2013 in the Siem Reap clinic, and in a hypothetical district in sub-Saharan Africa. RESULTS: In the Siem Reap clinic, we found that from 2004 to 2005 the doctor-time needed per patient was reduced by between 14% and 33%, thanks to a reduction in number of visits per patient and shorter consultation times. In 2004, 2.06 full-time equivalent (FTE) doctors were needed for 522 patients on ART, and in 2005 this was slightly reduced to 1.97 FTE doctors for 911 patients on ART. By 2013, Siem Reap clinic will need between 2 and 5 FTE doctors for ART. In a district in sub-Saharan Africa with 200,000 inhabitants and 20% adult HIV prevalence, using a similar doctor-based ART delivery model, between 4 and 11 FTE doctors would be needed to cover 50% of ART needs. CONCLUSION: ART is labour intensive. Important reductions in doctor-time per patient can be realized during scaling-up. The doctor-based ART delivery model analysed seems adequate for Cambodia. However, for many districts in sub-Saharan Africa a doctor-based ART delivery model may be incompatible with their HRH constraints.