• Providing HIV care in the aftermath of Kenya's post-election violence Medecins Sans Frontieres' lessons learned January - March 2008.

      Reid, T; van Engelgem, I; Telfer, B; Manzi, M; MSF Brussels, rue Dupre 94, Brussels 1090, Belgium. tony.reid@brussels.msf.org. (2008-12)
      ABSTRACT: Kenya's post-election violence in early 2008 created considerable problems for health services, and in particular, those providing HIV care. It was feared that the disruptions in services would lead to widespread treatment interruption. MSF had been working in the Kibera slum for 10 years and was providing antiretroviral therapy to 1800 patients when the violence broke out. MSF responded to the crisis in a number of ways and managed to keep HIV services going. Treatment interruption was less than expected, and MSF profited from a number of "lessons learned" that could be applied to similar contexts where a stable situation suddenly deteriorates.
    • Providing universal access to antiretroviral therapy in Thyolo, Malawi through task shifting and decentralization of HIV/AIDS care.

      Bemelmans, Marielle; Van Den Akker, Thomas; Ford, Nathan; Philips, Mit; Zachariah, Rony; Harries, Anthony; Schouten, Erik; Hermann, Katharina; Mwagomba, Beatrice; Massaquoi, Moses; et al. (2010-12)
      Objective  To describe how district-wide access to HIV/AIDS care was achieved and maintained in Thyolo District, Malawi. Method  In mid-2003, the Ministry of Health and Médecins Sans Frontières developed a model of care for Thyolo district (population 587 455) based on decentralization of care to health centres and community sites and task shifting. Results  After delegating HIV testing and counseling to lay counsellors, uptake of testing increased from 1300 tests per month in 2003 to 6500 in 2009. Shifting responsibility for antiretroviral therapy (ART) initiations to non-physician clinicians almost doubled ART enrolment, with a majority of initiations performed in peripheral health centres. By the end 2009, 23 261 people had initiated ART of whom 11 042 received ART care at health-centre level. By the end of 2007, the universal access targets were achieved, with nearly 9000 patients alive and on ART. The average annual cost for achieving these targets was €2.6 per inhabitant/year. Conclusion  The Thyolo programme has demonstrated the feasibility of district-wide access to ART in a setting with limited resources for health. Expansion and decentralization of HIV/AIDS service-capacity to the primary care level, combined with task shifting, resulted in increased access to HIV services with good programme outcomes despite staff shortages.
    • Provision of antiretroviral therapy in South Africa: the nuts and bolts

      Bekker, Linda-Gail; Venter, Francois; Cohen, Karen; Goemare, Eric; Van Cutsem, Gilles; Boulle, Andrew; Wood, Robin (International Medical Press, 2014-10-13)
      Public sector antiretroviral provision had a slow start in South Africa despite a raging epidemic and a World AIDS conference that shed significant public light on the disparities of therapy access globally. This was largely due to political prevarication in the midst of AIDS denialism. There has been an unprecedented expansion in the HIV treatment programme since 2008. As a result, South Africa now has the largest number of patients on antiretroviral drugs in the world, and South African life expectancy has increased by more than a decade. However, this has led to a number of fiscal, logistic and operational challenges that the country must face as the treatment programme continues to expand. Challenges include increasing detection within communities, linkage and retention in care, while strengthening operational support functions such as consistent drug supply, health staffing and infrastructure, diagnostic services, programme monitoring and sustainable financing. As a middle-income country, albeit with marked income inequality, and the heaviest HIV burden in the world, South Africa is a test case of whether a large-scale public health programme can boast of success in the face of numerous other health-system challenges.
    • Provision of antiretroviral treatment in conflict settings: the experience of Médecins Sans Frontières

      O'Brien, Daniel P; Venis, Sarah; Greig, Jane; Shanks, Leslie; Ellman, Tom; Sabapathy, Kalpana; Frigati, Lisa; Mills, Clair; Public Health Department, Médecins Sans Frontières, Amsterdam, Netherlands; 2Department of Infectious Diseases, Geelong Hospital, Geelong, Australia; Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia; Médecins Sans Frontières, London, UK; School of Child and Adolescent Health, Red Cross Childrens' Hospital, Capetown, South Africa; Te Kupenga Hauora Maori, Faculty of Medical and Health Sciences,University of Auckland, Auckland, New Zealand (2010-06-17)
      ABSTRACT: INTRODUCTION: Many countries ravaged by conflict have substantial morbidity and mortality attributed to HIV/AIDS yet HIV treatment is uncommonly available. Universal access to HIV care cannot be achieved unless the needs of populations in conflict-affected areas are addressed. METHODS: From 2003 Médecins Sans Frontières introduced HIV care, including antiretroviral therapy, into 24 programmes in conflict or post-conflict settings, mainly in sub-Saharan Africa. HIV care and treatment activities were usually integrated within other medical activities. Project data collected in the Fuchia software system were analysed and outcomes compared with ART-LINC data. Programme reports and other relevant documents and interviews with local and headquarters staff were used to develop lessons learned. RESULTS: In the 22 programmes where ART was initiated, more than 10,500 people were diagnosed with HIV and received medical care, and 4555 commenced antiretroviral therapy, including 348 children. Complete data were available for adults in 20 programmes (n = 4145). At analysis, 2645 (64%) remained on ART, 422 (10%) had died, 466 (11%) lost to follow-up, 417 (10%) transferred to another programme, and 195 (5%) had an unclear outcome. Median 12-month mortality and loss to follow-up were 9% and 11% respectively, and median 6-month CD4 gain was 129 cells/mm 3.Patient outcomes on treatment were comparable to those in stable resource-limited settings, and individuals and communities obtained significant benefits from access to HIV treatment. Programme disruption through instability was uncommon with only one program experiencing interruption to services, and programs were adapted to allow for disruption and population movements. Integration of HIV activities strengthened other health activities contributing to health benefits for all victims of conflict and increasing the potential sustainability for implemented activities. CONCLUSIONS: With commitment, simplified treatment and monitoring, and adaptations for potential instability, HIV treatment can be feasibly and effectively provided in conflict or post-conflict settings.
    • Public health. Getting HIV treatment to the most people.

      Lynch, Sharonann; Ford, Nathan; van Cutsem, Gilles; Bygrave, Helen; Janssens, Bart; Decroo, Tom; Andrieux-Meyer, Isabelle; Roberts, Teri; Balkan, Suna; Casas, Esther; et al. (2012-07-20)
    • Public-health and individual approaches to antiretroviral therapy: township South Africa and Switzerland compared.

      Keiser, O; Orrell, C; Egger, M; Wood, R; Brinkhof, M W G; Furrer, H; Van Cutsem, G; Ledergerber, B; Boulle, A; Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland. (PLoS, 2008-07-08)
      BACKGROUND: The provision of highly active antiretroviral therapy (HAART) in resource-limited settings follows a public health approach, which is characterised by a limited number of regimens and the standardisation of clinical and laboratory monitoring. In industrialized countries doctors prescribe from the full range of available antiretroviral drugs, supported by resistance testing and frequent laboratory monitoring. We compared virologic response, changes to first-line regimens, and mortality in HIV-infected patients starting HAART in South Africa and Switzerland. METHODS AND FINDINGS: We analysed data from the Swiss HIV Cohort Study and two HAART programmes in townships of Cape Town, South Africa. We included treatment-naïve patients aged 16 y or older who had started treatment with at least three drugs since 2001, and excluded intravenous drug users. Data from a total of 2,348 patients from South Africa and 1,016 patients from the Swiss HIV Cohort Study were analysed. Median baseline CD4+ T cell counts were 80 cells/mul in South Africa and 204 cells/mul in Switzerland. In South Africa, patients started with one of four first-line regimens, which was subsequently changed in 514 patients (22%). In Switzerland, 36 first-line regimens were used initially, and these were changed in 539 patients (53%). In most patients HIV-1 RNA was suppressed to 500 copies/ml or less within one year: 96% (95% confidence interval [CI] 95%-97%) in South Africa and 96% (94%-97%) in Switzerland, and 26% (22%-29%) and 27% (24%-31%), respectively, developed viral rebound within two years. Mortality was higher in South Africa than in Switzerland during the first months of HAART: adjusted hazard ratios were 5.90 (95% CI 1.81-19.2) during months 1-3 and 1.77 (0.90-3.50) during months 4-24. CONCLUSIONS: Compared to the highly individualised approach in Switzerland, programmatic HAART in South Africa resulted in similar virologic outcomes, with relatively few changes to initial regimens. Further innovation and resources are required in South Africa to both achieve more timely access to HAART and improve the prognosis of patients who start HAART with advanced disease.
    • A qualitative assessment of a community antiretroviral therapy group model in Tete, Mozambique

      Rasschaert, Freya; Telfer, Barbara; Lessitala, Faustino; Decroo, Tom; Remartinez, Daniel; Biot, Marc; Candrinho, Baltazar; Mbofana, Francisco; Van Damme, Wim (Public Library of Science, 2014-03-20)
      To improve retention on ART, Médecins Sans Frontières, the Ministry of Health and patients piloted a community-based antiretroviral distribution and adherence monitoring model through Community ART Groups (CAG) in Tete, Mozambique. By December 2012, almost 6000 patients on ART had formed groups of whom 95.7% were retained in care. We conducted a qualitative study to evaluate the relevance, dynamic and impact of the CAG model on patients, their communities and the healthcare system.
    • A qualitative investigation of adherence to nutritional therapy in malnourished adult AIDS patients in Kenya

      Dibari, Filippo; Bahwere, Paluku; Le Gall, Isabelle; Guerrero, Saul; Mwaniki, David; Seal, Andrew; Valid International, Oxford, UK; UCL Centre for International Health and Development, Institute of Child Health, London, UK; MSF-France, Nairobi, Kenya/Paris, France; Centre for Public Health, Kenya Medical Research Institute, KEMRI/CPHR, Nairobi, Kenya; Academy for Educational Development/Regional Office for Eastern and Central Africa, Nairobi, Kenya (Cambridge University Press, 2011-02-04)
      To understand factors affecting the compliance of malnourished, HIV-positive adults with a nutritional protocol using ready-to-use therapeutic food (RUTF; Plumpy'nut®).
    • Rationing antiretroviral therapy in Africa--treating too few, too late.

      Ford, N; Mills, E; Calmy, A; Medical unit, Médecins sans Frontières, and School of Public Health and Family Medicine, University of Cape Town, South Africa. (2009-04-30)
    • Reasons for loss to follow-up among mothers registered in a prevention-of-mother-to-child transmission program in rural Malawi

      Bwirire, L; Fitzgerald, M; Zachariah, R; Chikafa, V; Massaquoi, M; Moens, M; Kamoto, K; Schouten, E (Elsevier, 2008-05-16)
    • Reasons for unsatisfactory acceptance of antiretroviral treatment in the urban Kibera slum, Kenya.

      Unge, C; Johansson, A; Zachariah, R; Some, D; Van Engelgem, I; Ekstrom, A M; Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. christianunge@gmail.com (Taylor & Francis, 2008-02)
      The aim of this study was to explore why patients in the urban Kibera slum, Nairobi, Kenya, offered free antiretroviral treatment (ART) at the Médecins Sans Frontièrs (MSF) clinic, choose not to be treated despite signs of AIDS. Qualitative semi-structured interviews were conducted with 26 patients, 9 men and 17 women. Six main reasons emerged for not accepting ART: a) fear of taking medication on an empty stomach due to lack of food; b) fear that side-effects associated with ART would make one more ill; c) fear of disclosure and its possible negative repercussions; d) concern for continuity of treatment and care; e) conflicting information from religious leaders and community, and seeking alternative care (e.g. traditional medicine); f) illiteracy making patients unable to understand the information given by health workers.
    • Reflections on a decade of delivering PMTCT in Khayelitsha, South Africa

      Stinson, Kathryn; Giddy, Janet; Cox, Vivian; Burton, Rosie; Ibeto, Maryirene; Cragg, Carol; Van Cutsem, Gilles; Hilderbrand, Katherine; Boulle, Andrew; Coetzee, David; et al. (Health & Medical Publishing Group, 2014-03-25)
    • Reframing HIV Care: Putting People at the Centre of Antiretroviral Delivery

      Duncombe, Chris; Rosenblum, Scott; Hellmann, Nicholas; Holmes, Charles; Wilkinson, Lynne; Biot, Marc; Bygrave, Helen; Hoos, David; Garnett, Geoff (Wiley-Blackwell, 2015-01-13)
      The delivery of HIV care in the initial rapid scale-up of HIV care and treatment was based on existing clinic-based models, which are common in highly resourced settings and largely undifferentiated for individual needs. A new framework for treatment based on variable intensities of care tailored to the specific needs of different groups of individuals across the cascade of care is proposed here. Service intensity is characterized by four delivery components: (1) types of services delivered, (2) location of service delivery, (3) provider of health services, and (4) frequency of health services. How these components are developed into a service delivery framework will vary across countries and populations, with the intention being to improve acceptability and care outcomes. The goal of getting more people on treatment before they become ill will necessitate innovative models of delivering both testing and care. As HIV programs expand treatment eligibility, many people entering care will not be "patients" but healthy, active and productive members of society.(1) In order to take the framework to scale, it will be important to: (1) define which individuals can be served by an alternative delivery framework; (2) strengthen health systems that support decentralization, integration and task shifting; (3) make the supply chain more robust; and (4) invest in data systems for patient tracking and for program monitoring and evaluation. This article is protected by copyright. All rights reserved.
    • Refused and referred-persistent stigma and discrimination against people living with HIV/AIDS in Bihar: a qualitative study from India

      Nair, M; Kumar, P; Harshana, A; Kazmi, S; Pandey, S; Burza, S; Moreto-Planas, L (British Medical Journal BMJ, 2019-11-25)
      OBJECTIVES: This study aimed to explore barriers to accessing care, if any, among people living with HIV/AIDS (PLHA) in two districts of Bihar. We also aimed to assess attitudes towards PLHA among healthcare providers and community members. DESIGN: This qualitative study used an exploratory study design through thematic analysis of semistructured, in-depth interviews. SETTING: Two districts were purposively selected for the study, namely the capital Patna and a peripheral district located approximately 100 km from Patna, in order to glean insights from a diverse sample of respondents. PARTICIPANTS: Our team purposively selected 71 participants, including 35 PLHA, 10 community members and 26 healthcare providers. RESULTS: The overarching theme that evolved from these data through thematic coding identified that enacted stigma and discrimination interfere with each step in the HIV care continuum for PLHA in Bihar, India, especially outside urban areas. The five themes that contributed to these results include: perception of HIV as a dirty illness at the community level; non-consensual disclosure of HIV status; reliance on identifying PLHA to guide procedures and resistance to universal precautions; refusal to treat identified PLHA and referrals to other health centres for treatment; and inadequate knowledge and fear among health providers with respect to HIV transmission. CONCLUSIONS: The continued presence of discriminatory and stigmatising attitudes towards PLHA negatively impacts both disclosure of HIV status as well as access to care and treatment. We recognise a pressing need to improve the knowledge of HIV transmission, and implement universal precautions across all health facilities in the state, not just to reduce stigma and discrimination but also to ensure proper infection control. In order to improve treatment adherence and encourage optimal utilisation of services, it is imperative that the health system invest more in stigma reduction in Bihar and move beyond more ineffective, punitive approaches.
    • Registration problems for antiretrovirals in Africa.

      Ford, N; Darder, M; Médecins Sans Frontières, Khayelitsha, 7784 South Africa. Nathan.FORD@london.msf.org (Elsevier, 2006-03-11)
    • Reimagining HIV Service Delivery: The Role Of Differentiated Care From Prevention to Suppression

      Grimsrud, A; Bygrave, H; Doherty, M; Ehrenkranz, P; Ellman, T; Ferris, R; Ford, N; Killingo, B; Mabote, L; Mansell, T; et al. (International AIDS Society, 2016-12-01)
    • Relationship Between Time to Initiation of Antiretroviral Therapy and Treatment Outcomes: A Cohort Analysis of ART Eligible Adolescents in Zimbabwe

      Vogt, F; Rehman, AM; Kranzer, K; Nyathi, M; Van Griensven, J; Dixon, M; Ndebele, W; Gunguwo, H; Colebunders, R; Ndlovu, M; et al. (Lippincott Williams & Wilkins, 2017-04-01)
      Age-specific retention challenges make antiretroviral therapy (ART) initiation in adolescents difficult, often requiring a lengthy preparation process. This needs to be balanced against the benefits of starting treatment quickly. The optimal time to initiation duration in adolescents is currently unknown.
    • Renal safety of a tenofovir-containing first line regimen: experience from an antiretroviral cohort in rural lesotho.

      Bygrave, Helen; Kranzer, Katharina; Hilderbrand, Katherine; Jouquet, Guillaume; Goemaere, Eric; Vlahakis, Nathalie; Triviño, Laura; Makakole, Lipontso; Ford, Nathan; Médecins Sans Frontières, Morija, Lesotho. (2011-03)
      Current guidelines contraindicate TDF use when creatinine clearance (CrCl) falls below 50 ml/min. We report prevalence of abnormal renal function at baseline and factors associated with abnormal renal function from a community cohort in Lesotho.
    • Resistance profiles after different periods of exposure to a first-line antiretroviral regimen in a Cameroonian cohort of HIV type-1-infected patients.

      Soria, A; Porten, K; Fampou-Toundji, J; Galli, L; Mougnutou, R; Buard, V; Kfutwah, A; Vessière, A; Rousset, D; Teck, R; et al. (2009-08)
      BACKGROUND: The lack of HIV type-1 (HIV-1) viral load (VL) monitoring in resource-limited settings might favour the accumulation of resistance mutations and thus hamper second-line treatment efficacy. We investigated the factors associated with resistance after the initiation of antiretroviral therapy (ART) in the absence of virological monitoring. METHODS: Cross-sectional VL sampling of HIV-1-infected patients receiving first-line ART (nevirapine or efavirenz plus stavudine or zidovudine plus lamivudine) was carried out; those with a detectable VL were genotyped. RESULTS: Of the 573 patients undergoing VL sampling, 84 were genotyped. The mean number of nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) mutations increased with the duration of ART exposure (P=0.02). Multivariable analysis showed that patients with a CD4+ T-cell count < or =50 cells/mm(3) at ART initiation (baseline) had a higher mean number of both NRTI and non-NRTI (NNRTI) mutations than those with a baseline CD4+ T-cell count >50 cells/mm(3) (2.10 versus 0.56; P<0.0001; and 1.65 versus 0.76; P=0.005, respectively). A baseline CD4+ T-cell count < or =50 cells/mm(3) predicted > or =1 NRTI mutation (adjusted odds ratio [AOR] 7.49, 95% confidence interval [CI] 2.20-32.14), > or =1 NNRTI mutation (AOR 4.25, 95% CI 1.36-15.48), > or =1 thymidine analogue mutation (AOR 8.45, 95% CI 2.16-40.16) and resistance to didanosine (AOR 6.36, 95% CI 1.49-32.29) and etravirine (AOR 4.72, 95% CI 1.53-15.70). CONCLUSIONS: Without VL monitoring, the risk of drug resistance increases with the duration of ART and is associated with lower CD4+ T-cell counts at ART initiation. These data might help define strategies to preserve second-line treatment options in resource-limited settings.