• Loss to follow up from isoniazid preventive therapy among adults attending HIV voluntary counseling and testing sites in Uganda.

      Namuwenge, P M; Mukonzo, J K; Kiwanuka, N; Wanyenze, R; Byaruhanga, R; Bissell, K; Zachariah, R; Makerere University School of Public Health P.O. Box 7072 Kampala Uganda; AIDS Information Centre headquarters, P.O. Box 10446 Kampala, Uganda. (2012-02)
      Among HIV-infected adults attending non-governmental organization voluntary counseling and testing (VCT) sites in Uganda that provide a nine-month course of isoniazid preventive treatment (IPT), we report on loss to follow-up (LTFU) and its associated risk factors. The design was a retrospective cohort study of program data spanning a three year period (2006-2008). A total of 586 IPT patients were enrolled of whom 335 (57.1%) were females with a mean age of 34 years. Of those starting IPT, 341 (58.1%) were lost to follow-up, 197 (33.6%) completed IPT, 29 (4.9%) were discontinued and 19 (3.2%) died. The return rates at one, three, five and seven months were 78.0% (457), 62.1% (364), 52.9% (310) and 33.6% (197) respectively. Being less than 30 years of age, widowed, separated, or divorced were found to be associated with a higher risk of loss to follow-up. Sudden improvement in retention on IPT was observed between the years 2006 and 2007, although causes of the improvement are poorly understood hence the need for more research. At non-governmental VCT sites in Uganda, six out of ten individuals enrolled on IPT are lost to follow-up and efforts to reduce this attrition including systems strengthening might play a critical role in the success of IPT programs.
    • Low Incidence of Renal Dysfunction Among HIV-Infected Patients on a Tenofovir-Based First Line Antiretroviral Treatment Regimen in Myanmar

      Kyaw, Nang Thu Thu; Harries, Anthony D; Chinnakali, Palanivel; Antierens, Annick; Soe, Kyi Pyar; Woodman, Mike; Das, Mrinalini; Shetty, Sharmila; Zuu, Moe Khine Lwin; Htwe, Pyae Sone; Fernandez, Marcelo (Public Library of Science, 2015)
      Since 2004, Médecins Sans Frontières-Switzerland has provided treatment and care for people living with HIV in Dawei, Myanmar. Renal function is routinely monitored in patients on tenofovir (TDF)-based antiretroviral treatment (ART), and this provides an opportunity to measure incidence and risk factors for renal dysfunction.
    • Low lopinavir plasma or hair concentrations explain second-line protease inhibitor failures in a resource-limited setting.

      van Zyl, Gert Uves; van Mens, Thijs E; McIlleron, Helen; Zeier, Michele; Nachega, Jean B; Decloedt, Eric; Malavazzi, Carolina; Smith, Peter; Huang, Yong; van der Merwe, Lize; Gandhi, Monica; Maartens, Gary; Division of Medical Virology, Department of Pathology, NHLS Tygerberg and Stellenbosch University, Tygerberg, South Africa. guvz@sun.ac.za (2011-04)
      In resource-limited settings, many patients, with no prior protease inhibitor (PI) treatment on a second-line, high genetic barrier, ritonavir-boosted PI-containing regimen have virologic failure.
    • Low uptake of antiretroviral therapy after admission with human immunodeficiency virus and tuberculosis in KwaZulu-Natal, South Africa.

      Murphy, R A; Sunpath, H; Taha, B; Kappagoda, S; Maphasa, K T M; Kuritzkes, D R; Smeaton, L; Doctors Without Borders USA, New York, USA; McCord Hospital, South Africa; Harvard Medical School, Massachusetts, USA; Division of Infectious Disease and Geographic Medicine, California, USA; Zoe-Life, South Africa; Section of Retroviral Therapeutics, Massachusetts, USA; Centre for Biostatistics in AIDS Research, Massachusetts, USA (2010-07-01)
      A prospective cohort study was conducted among human immunodeficiency virus (HIV) infected in-patients with tuberculosis (TB) or other opportunistic infections (OIs) in South Africa to estimate subsequent antiretroviral therapy (ART) uptake and survival.
    • Malawi's contribution to "3 by 5": achievements and challenges

      Libamba, Edwin; Makombe, Simon D; Harries, Anthony D; Schouten, Erik J; Yu, Joseph Kwong-Leung; Pasulani, Olesi; Mhango, Eustice; Aberle-Grasse, John; Hochgesang, Mindy; Limbambala, Eddie; Lungu, Douglas; Clinical HIV Unit, Ministry of Health, Lilongwe, Malawi; HIV Coordinator, Ministry of Health, Lilongwe, Malawi; Taiwan Medical Mission, Mzuzu Central Hospital, Mzuzu, Malawi; Médecins sans Frontières Belgium, Thyolo District Hospital, Malawi; Lighthouse Clinic, Lilongwe, Malawi; Centres for Disease Control, Lilongwe office, Malawi; WHO country office, Lilongwe, Malawi; Department of Clinical Services, Ministry of Health, Lilongwe, Malawi (2007-02-01)
      PROBLEM: Many resource-poor countries have started scaling up antiretroviral therapy (ART). While reports from individual clinics point to successful implementation, there is limited information about progress in government institutions at a national level. APPROACH: Malawi started national ART scale-up in 2004 using a structured approach. There is a focus on one generic, fixed-dose combination treatment with stavudine, lamivudine and nevirapine. Treatment is delivered free of charge to eligible patients with HIV and there is a standardized system for recruiting patients, monthly follow-up, registration, monitoring and reporting of cases and outcomes. All treatment sites receive quarterly supervision and evaluation. LOCAL SETTING: In January 2004, there were nine public sector facilities delivering ART to an estimated 4 000 patients. By December 2005, there were 60 public sector facilities providing free ART to 37,840 patients using national standardized systems. Analysis of quarterly cohort treatment outcomes at 12 months showed 80% of patients were alive, 10% dead, 9% lost to follow-up and 1% had stopped treatment. LESSONS LEARNED: Achievements were the result of clear national ART guidelines, implementing partners working together, an intensive training schedule focused on clinical officers and nurses, a structured system of accrediting facilities for ART delivery, quarterly supervision and monitoring, and no stock-outs of antiretroviral drugs. The main challenges are to increase the numbers of children, pregnant women and patients with tuberculosis being started on ART, and to avert high early mortality and losses to follow-up. The capacity of the health sector to cope with escalating case loads and to scale up prevention alongside treatment will determine the future success of ART delivery in Malawi.
    • Management of BU-HIV co-infection

      O'Brien, D P; Ford, N; Vitoria, M; Christinet, V; Comte, E; Calmy, A; Stienstra, Y; Eholie, S; Asiedu, K (2014-06-20)
      Buruli Ulcer (BU)-HIV co-infection is an important emerging management challenge for BU disease. Limited by paucity of scientific studies, guidance for management of this co-infection has been lacking.
    • [Management of HIV/AIDS patients in Kompong Cham, Cambodia]

      Allemand-Sourrieu, J; Gazin, P; Moreau, J; Programme MSF-France de traitement du sida au Cambodge. allemandjulie@yahoo.fr (2007-02)
      In 2003 the NGO Médecins sans Frontières started an anti-viral drug treatment program for HIV/AIDS patients in the regional hospital of Kompong Cham, Cambodia. In 2005 a total of 1100 adults and 149 children were on the active list. Sixty percent of new patients were at WHO stages 3 or 4. Compliance with HAART was high after 24 months. Access to second-line regimens is discussed.
    • Managing Advanced HIV Disease in a Public Health Approach.

      Ford, N; Meintjes, G; Calmy, A; Bygrave, H; Migone, C; Vitoria, M; Penazzato, M; Vojnov, L; Doherty, M (Oxford University Press, 2018-03-04)
      In 2017, the World Health Organization (WHO) published guidelines for the management of advanced human immunodeficiency virus (HIV) disease within a public health approach. Recent data suggest that more than a third of people starting antiretroviral therapy (ART) do so with advanced HIV disease, and an increasing number of patients re-present to care at an advanced stage of HIV disease following a period of disengagement from care. These guidelines recommend a standardized package of care for adults, adolescents, and children, based on the leading causes of morbidity and mortality: tuberculosis, severe bacterial infections, cryptococcal meningitis, toxoplasmosis, and Pneumocystis jirovecii pneumonia. A package of targeted interventions to reduce mortality and morbidity was recommended, based on results of 2 recent randomized trials that both showed a mortality reduction associated with delivery of a simplified intervention package. Taking these results and existing recommendations into consideration, WHO recommends that a package of care be offered to those presenting with advanced HIV disease; depending on age and CD4 cell count, the package may include opportunistic infection screening and prophylaxis, including fluconazole preemptive therapy for those who are cryptococcal antigen positive and without evidence of meningitis. Rapid ART initiation and intensified adherence interventions should also be proposed to everyone presenting with advanced HIV disease.
    • The marriage of science and optimized HIV care in resource-limited settings

      Calmy, A; Pizzocolo, C; Pizarro, L; Brücker, G; Murphy, R; Katlama, C; Strategies in Resource-Limited Settings Working Group; Campaign for Access to Essential Medicines, Médecins Sans Frontières, Geneva; Geneva University, Geneva, Switzerland; Solidarité Théapeutique et Initiatives contre le Sida, Paris; Université Paris 11, Faculté de Médicine Paris-Sud, Le Kremlin-Bicêtre, Paris; Université Pierre et Marie Curie, Paris, France (2008-11-12)
    • Mean CD4 cell count changes in patients failing a first-line antiretroviral therapy in resource-limited settings.

      Calmy, Alexandra; Balestre, Eric; Bonnet, Fabrice; Boulle, Andrew; Sprinz, Eduardo; Wood, Robin; Delaporte, Eric; Messou, Eugène; McIntyre, James; El Filali, Kamal Marhoum; Schechter, Mauro; Kumarasamy, N; Bangsberg, David; McPhail, Patrick; Van Der Borght, Stefaan; Zala, Carlos; Egger, Matthias; Thiébaut, Rodolphe; Dabis, François; HIV Unit, Geneva University Hospital, Geneva, Switzerland. acalmy@gmail.com (BMC, 2012-12)
      Changes in CD4 cell counts are poorly documented in individuals with low or moderate-level viremia while on antiretroviral treatment (ART) in resource-limited settings. We assessed the impact of on-going HIV-RNA replication on CD4 cell count slopes in patients treated with a first-line combination ART.
    • 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; Dalmau, D (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.
    • Monitoring of antiretroviral therapy and mortality in HIV programmes in Malawi, South Africa and Zambia: mathematical modelling study

      Estill, Janne; Egger, Matthias; Johnson, Leigh F; Gsponer, Thomas; Wandeler, Gilles; Davies, Mary-Ann; Boulle, Andrew; Wood, Robin; Garone, Daniela; Stringer, Jeffrey S A; Hallett, Timothy B; Keiser, Olivia; Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland. jestill@ispm.unibe.ch (Public Library of Science, 2013-02-28)
      Mortality in patients starting antiretroviral therapy (ART) is higher in Malawi and Zambia than in South Africa. We examined whether different monitoring of ART (viral load [VL] in South Africa and CD4 count in Malawi and Zambia) could explain this mortality difference.
    • Monitoring the response to antiretroviral therapy in resource-poor settings: the Malawi model.

      Harries, A D; Gomani, P; Teck, R; de Teck, O; Bakali, E; Zachariah, R; Libamba, E; Mwansambo, A; Salaniponi, F; Mpazanje, R; National Tuberculosis Control Programme, Ministry of Health and Population, P.O. Box 30377, Lilongwe, Malawi. adharries@malawi.net (2004-12)
      With assistance from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), Malawi is scaling-up the delivery of antiretroviral (ARV) therapy to HIV-positive eligible patients. The country has developed National ARV Treatment Guidelines, which emphasize a structured and standardized approach for all aspects of ARV delivery, including monitoring and evaluation. Using the successful DOTS model adapted by National TB Control Programmes throughout the world, Malawi has developed a system of quarterly ARV cohort and cumulative ARV quarterly analyses. Thyolo district, in the southern region of Malawi, has been using this system since April 2003. This paper describes the standardized ARV treatment regimens and the treatment outcomes used in Thyolo to assess the impact of treatment, the registration and monitoring systems and how the cohort analyses are carried out. Data are presented for case registration and treatment outcome for the first quarterly cohort (April to June) and the combined cohorts (April to June and July to September). Such quarterly analyses may be useful for districts and Ministries of Health in assessing ARV delivery, although the burden of work involved in calculating the numbers may become large once ARV delivery systems have been established for several years.
    • Monitoring the South African National Antiretroviral Treatment Programme, 2003-2007: the IeDEA Southern Africa collaboration.

      Cornell, Morna; Technau, Karl; Fairall, Lara; Wood, Robin; Moultrie, Harry; van Cutsem, Gilles; Giddy, Janet; Mohapi, Lerato; Eley, Brian; MacPhail, Patrick; Prozesky, Hans; Rabie, Helena; Davies, Mary-Ann; Maxwell, Nicola; Boulle, Andrew; Infectious Disease Epidemiology Unit, School of Public Health and Family Medicine, University of Cape Town. morna@global.co.za (2009-09)
      OBJECTIVES: To introduce the combined South African cohorts of the International epidemiologic Databases to Evaluate AIDS Southern Africa (IeDEA-SA) collaboration as reflecting the South African national antiretroviral treatment (ART) programme; to characterise patients accessing these services; and to describe changes in services and patients from 2003 to 2007. DESIGN AND SETTING: Multi-cohort study of 11 ART programmes in Gauteng, Western Cape, Free State and KwaZulu-Natal. SUBJECTS: Adults and children (<16 years old) who initiated ART with > or =3 antiretroviral drugs before 2008. RESULTS: Most sites were offering free treatment to adults and children in the public sector, ranging from 264 to 17,835 patients per site. Among 45,383 adults and 6,198 children combined, median age (interquartile range) was 35.0 years (29.8-41.4) and 42.5 months (14.7-82.5), respectively. Of adults, 68% were female. The median CD4 cell count was 102 cells/microl (44-164) and was lower among males than females (86, 34-150 v. 110, 50-169, p<0.001). Median CD4% among children was 12% (7-17.7). Between 2003 and 2007, enrolment increased 11-fold in adults and 3-fold in children. Median CD4 count at enrolment increased for all adults (67-111 cells/microl, p<0.001) and for those in stage IV (39-89 cells/microl, p<0.001). Among children <5 years, baseline CD4% increased over time (11.5-16.0%, p<0.001). CONCLUSIONS: IeDEA-SA provides a unique opportunity to report on the national ART programme. The study describes dramatically increased enrolment over time. Late diagnosis and ART initiation, especially of men and children, need attention. Investment in sentinel sites will ensure good individual-level data while freeing most sites to continue with simplified reporting.
    • Mortality and Clinical Outcomes in Children Treated With Antiretroviral Therapy in Four African Vertical Programs During The First Decade of Paediatric HIV Care, 2001-2010

      Ben-Farhat, J; Schramm, B; Nicolay, N; Wanjala, S; Szumilin, E; Balkan, S; Pujades-Rodríguez, M (Wiley-Blackwell, 2016-12-19)
      To assess mortality and clinical outcomes in children treated with antiretroviral therapy in four African vertical programs between 2001 and 2010.
    • Mortality by baseline CD4 cell count among HIV patients initiating antiretroviral therapy: evidence from a large cohort in Uganda

      Mills, Edward J; Bakanda, Celestin; Birungi, Josephine; Mwesigwa, Robert; Chan, Keith; Ford, Nathan; Hogg, Robert S; Cooper, Curtis; Faculty of Health Sciences, University of Ottawa, Ottawa, Canada; The AIDS Support Organization (TASO), Headquarters, Kampala, Uganda; British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada; Médecins Sans Frontiers (MSF), Geneva, Switzerland; Division of Infectious Diseases, The Ottawa Hospital, Ottawa, Canada (Lippincott Williams & Wilkins, 2011-03-27)
      Evaluations of CD4 cell count and other prognostic factors on the survival of HIV patients in sub-Saharan Africa are extremely limited. Funders have been reticent to recommend earlier initiation of treatment. We aimed to examine the effect of baseline CD4 cell count on mortality using data from HIV patients receiving combination antiretroviral therapy (cART) in Uganda.
    • Mortality in Patients with HIV-1 Infection Starting Antiretroviral Therapy in South Africa, Europe, or North America: A Collaborative Analysis of Prospective Studies

      Boulle, Andrew; Schomaker, Michael; May, Margaret T; Hogg, Robert S; Shepherd, Bryan E; Monge, Susana; Keiser, Olivia; Lampe, Fiona C; Giddy, Janet; Ndirangu, James; Garone, Daniela; Fox, Matthew; Ingle, Suzanne M; Reiss, Peter; Dabis, Francois; Costagliola, Dominique; Castagna, Antonella; Ehren, Kathrin; Campbell, Colin; Gill, M John; Saag, Michael; Justice, Amy C; Guest, Jodie; Crane, Heidi M; Egger, Matthias; Sterne, Jonathan A C (2014-09-09)
      High early mortality in patients with HIV-1 starting antiretroviral therapy (ART) in sub-Saharan Africa, compared to Europe and North America, is well documented. Longer-term comparisons between settings have been limited by poor ascertainment of mortality in high burden African settings. This study aimed to compare mortality up to four years on ART between South Africa, Europe, and North America.
    • Mortality in the first six months among HIV-positive and HIV-negative patients empirically treated for tuberculosis.

      Huerga, H; Ferlazzo, G; Wanjala, S; Bastard, M; Bevilacqua, P; Ardizzoni, E; Sitienei, J; Bonnet, M (BioMed Central, 2019-02-11)
      Empirical treatment of tuberculosis (TB) may be necessary in patients with negative or no Xpert MTB/RIF results. In a context with access to Xpert, we assessed mortality in the 6 months after the initial TB consultation among HIV-positive and HIV-negative patients who received empirical TB treatment or TB treatment based on bacteriological confirmation and we compared it with the mortality among those who did not receive TB treatment.
    • Mortality of patients lost to follow-up in antiretroviral treatment programmes in resource-limited settings: systematic review and meta-analysis

      Brinkhof, M; Pujades-Rodriguez, M; Egger, M; Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland; Epicentre, Médecins Sans Frontières, Paris, France; Department of Social Medicine, University of Bristol, Bristol, United Kingdom (2009-06-04)
      BACKGROUND: The retention of patients in antiretroviral therapy (ART) programmes is an important issue in resource-limited settings. Loss to follow up can be substantial, but it is unclear what the outcomes are in patients who are lost to programmes. METHODS AND FINDINGS: We searched the PubMed, EMBASE, Latin American and Caribbean Health Sciences Literature (LILACS), Indian Medlars Centre (IndMed) and African Index Medicus (AIM) databases and the abstracts of three conferences for studies that traced patients lost to follow up to ascertain their vital status. Main outcomes were the proportion of patients traced, the proportion found to be alive and the proportion that had died. Where available, we also examined the reasons why some patients could not be traced, why patients found to be alive did not return to the clinic, and the causes of death. We combined mortality data from several studies using random-effects meta-analysis. Seventeen studies were eligible. All were from sub-Saharan Africa, except one study from India, and none were conducted in children. A total of 6420 patients (range 44 to 1343 patients) were included. Patients were traced using telephone calls, home visits and through social networks. Overall the vital status of 4021 patients could be ascertained (63%, range across studies: 45% to 86%); 1602 patients had died. The combined mortality was 40% (95% confidence interval 33%-48%), with substantial heterogeneity between studies (P<0.0001). Mortality in African programmes ranged from 12% to 87% of patients lost to follow-up. Mortality was inversely associated with the rate of loss to follow up in the programme: it declined from around 60% to 20% as the percentage of patients lost to the programme increased from 5% to 50%. Among patients not found, telephone numbers and addresses were frequently incorrect or missing. Common reasons for not returning to the clinic were transfer to another programme, financial problems and improving or deteriorating health. Causes of death were available for 47 deaths: 29 (62%) died of an AIDS defining illness. CONCLUSIONS: In ART programmes in resource-limited settings a substantial minority of adults lost to follow up cannot be traced, and among those traced 20% to 60% had died. Our findings have implications both for patient care and the monitoring and evaluation of programmes.
    • Mortality reduction associated with HIV/AIDS care and antiretroviral treatment in rural Malawi: evidence from registers, coffin sales and funerals.

      Mwagomba, Beatrice; Zachariah, Rony; Massaquoi, Moses; Misindi, Dalitso; Manzi, Marcel; Mandere, Bester C; Bemelmans, Marielle; Philips, Mit; Kamoto, Kelita; Schouten, Eric J; Harries, A D; Thyolo District Health Services, Ministry of Health and Population, Thyolo, Malawi. (2010-05)
      BACKGROUND: To report on the trend in all-cause mortality in a rural district of Malawi that has successfully scaled-up HIV/AIDS care including antiretroviral treatment (ART) to its population, through corroborative evidence from a) registered deaths at traditional authorities (TAs), b) coffin sales and c) church funerals. METHODS AND FINDINGS: Retrospective study in 5 of 12 TAs (covering approximately 50% of the population) during the period 2000-2007. A total of 210 villages, 24 coffin workshops and 23 churches were included. There were a total of 18,473 registered deaths at TAs, 15781 coffins sold, and 2762 church funerals. Between 2000 and 2007, there was a highly significant linear downward trend in death rates, sale of coffins and church funerals (X(2) for linear trend: 338.4 P<0.0001, 989 P<0.0001 and 197, P<0.0001 respectively). Using data from TAs as the most reliable source of data on deaths, overall death rate reduction was 37% (95% CI:33-40) for the period. The mean annual incremental death rate reduction was 0.52/1000/year. Death rates decreased over time as the percentage of people living with HIV/AIDS enrolled into care and ART increased. Extrapolating these data to the entire district population, an estimated 10,156 (95% CI: 9786-10259) deaths would have been averted during the 8-year period. CONCLUSIONS: Registered deaths at traditional authorities, the sale of coffins and church funerals showed a significant downward trend over a 8-year period which we believe was associated with the scaling up HIV/AIDS care and ART.