• Community support is associated with better antiretroviral treatment outcomes in a resource-limited rural district in Malawi.

      Zachariah, R; Teck, R; Buhendwa, L; Fitzgerald, M; Labana, S; Chinji, C; Humblet, P; Harries, A D; Médecins Sans Frontières, Medical Department (Operational Research), Brussels Operational Center, 68 Rue de Gasperich, L-1617, Luxembourg, Belgium. zachariah@internet.lu (Elsevier, 2007-01)
      A study was carried in a rural district in Malawi among HIV-positive individuals placed on antiretroviral treatment (ART) in order to verify if community support influences ART outcomes. Standardized ART outcomes in areas of the district with and without community support were compared. Between April 2003 (when ART was started) and December 2004 a total of 1634 individuals had been placed on ART. Eight hundred and ninety-five (55%) individuals were offered community support, while 739 received no such support. For all patients placed on ART with and without community support, those who were alive and continuing ART were 96 and 76%, respectively (P<0.001); death was 3.5 and 15.5% (P<0.001); loss to follow-up was 0.1 and 5.2% (P<0.001); and stopped ART was 0.8 and 3.3% (P<0.001). The relative risks (with 95% CI) for alive and on ART [1.26 (1.21-1.32)], death [0.22 (0.15-0.33)], loss to follow-up [0.02 (0-0.12)] and stopped ART [0.23 (0.08-0.54)] were all significantly better in those offered community support (P<0.001). Community support is associated with a considerably lower death rate and better overall ART outcomes. The community might be an unrecognized and largely 'unexploited resource' that could play an important contributory role in countries desperately trying to scale up ART with limited resources.
    • Community-based antiretroviral therapy programs can overcome barriers to retention of patients and decongest health services in sub-Saharan Africa: a systematic review

      Decroo, Tom; Rasschaert, Freya; Telfer, Barbara; Remartinez, Daniel; Laga, Marie; Ford, Nathan; Médecins Sans Frontières, Av. Eduardo Mondlane 38 - CP 262, Tete, Mozambique. (Oxford University Press, 2013-09-05)
      In sub-Saharan Africa models of care need to adapt to support continued scale up of antiretroviral therapy (ART) and retain millions in care. Task shifting, coupled with community participation has the potential to address the workforce gap, decongest health services, improve ART coverage, and to sustain retention of patients on ART over the long-term. The evidence supporting different models of community participation for ART care, or community-based ART, in sub-Saharan Africa, was reviewed. In Uganda and Kenya community health workers or volunteers delivered ART at home. In Mozambique people living with HIV/AIDS (PLWHA) self-formed community-based ART groups to deliver ART in the community. These examples of community ART programs made treatment more accessible and affordable. However, to achieve success some major challenges need to be overcome: first, community programs need to be driven, owned by and embedded in the communities. Second, an enabling and supportive environment is needed to ensure that task shifting to lay staff and PLWHA is effective and quality services are provided. Finally, a long term vision and commitment from national governments and international donors is required. Exploration of the cost, effectiveness, and sustainability of the different community-based ART models in different contexts will be needed.
    • Community-Based Interventions to Improve and Sustain Antiretroviral Therapy Adherence, Retention in HIV Care and Clinical Outcomes in Low- and Middle-Income Countries for Achieving the UNAIDS 90-90-90 Targets

      Nachega, JB; Adetokunboh, O; Uthman, OA; Knowlton, AW; Altice, FL; Schechter, M; Galárraga, O; Geng, E; Peltzer, K; Chang, LW; et al. (Springer Link, 2016-07-30)
      Little is known about the effect of community versus health facility-based interventions to improve and sustain antiretroviral therapy (ART) adherence, virologic suppression, and retention in care among HIV-infected individuals in low- and middle-income countries (LMICs). We systematically searched four electronic databases for all available randomized controlled trials (RCTs) and comparative cohort studies in LMICs comparing community versus health facility-based interventions. Relative risks (RRs) for pre-defined adherence, treatment engagement (linkage and retention in care), and relevant clinical outcomes were pooled using random effect models. Eleven cohort studies and eleven RCTs (N = 97,657) were included. Meta-analysis of the included RCTs comparing community- versus health facility-based interventions found comparable outcomes in terms of ART adherence (RR = 1.02, 95 % CI 0.99 to 1.04), virologic suppression (RR = 1.00, 95 % CI 0.98 to 1.03), and all-cause mortality (RR = 0.93, 95 % CI 0.73 to 1.18). The result of pooled analysis from the RCTs (RR = 1.03, 95 % CI 1.01 to 1.06) and cohort studies (RR = 1.09, 95 % CI 1.03 to 1.15) found that participants assigned to community-based interventions had statistically significantly higher rates of treatment engagement. Two studies found community-based ART delivery model either cost-saving or cost-effective. Community- versus facility-based models of ART delivery resulted in at least comparable outcomes for clinically stable HIV-infected patients on treatment in LMICs and are likely to be cost-effective.
    • Community-supported models of care for people on HIV treatment in sub-Saharan Africa.

      Bemelmans, Marielle; Baert, Saar; Goemaere, Eric; Wilkinson, Lynne; Vandendyck, Martin; van Cutsem, Gilles; Silva, Carlota; Perry, Sharon; Szumilin, Elisabeth; Gerstenhaber, Rodd; et al. (2014-08)
      Further scale-up of antiretroviral therapy (ART) to those in need while supporting the growing patient cohort on ART requires continuous adaptation of healthcare delivery models. We describe several approaches to manage stable patients on ART developed by Médecins Sans Frontières together with Ministries of Health in four countries in sub-Saharan Africa.
    • Comparative Effectiveness of Interventions to Improve the HIV Continuum of Care and HIV Preexposure Prophylaxis in Kenya: A Model-Based Analysis

      Luong Nguyen, LB; Freedberg, KA; Wanjala, S; Maman, D; Szumilin, E; Mendiharat, P; Yazdanpanah, Y (Oxford University Press, 2020-10-27)
      Background In Western Kenya up to one-quarter of the adult population was human immunodeficiency virus (HIV)-infected in 2012. The Ministry of Health, Médecins Sans Frontières, and partners implemented an HIV program that surpassed the 90-90-90 UNAIDS targets. In this generalized epidemic, we compared the effectiveness of preexposure prophylaxis (PrEP) with improving continuum of care. Methods We developed a dynamic microsimulation model to project HIV incidence and infections averted to 2030. We modeled 3 strategies compared to a 90-90-90 continuum of care base case: (1) scaling up the continuum of care to 95-95-95, (2) PrEP targeting young adults with 10% coverage, and (3) scaling up to 95-95-95 and PrEP combined. Results In the base case, by 2030 HIV incidence was 0.37/100 person-years. Improving continuum levels to 95-95-95 averted 21.5% of infections, PrEP averted 8.0%, and combining 95-95-95 and PrEP averted 31.8%. Sensitivity analysis showed that PrEP coverage had to exceed 20% to avert as many infections as reaching 95-95-95. Conclusions In a generalized HIV epidemic with continuum of care levels at 90-90-90, improving the continuum to 95-95-95 is more effective than providing PrEP. Continued improvement in the continuum of care will have the greatest impact on decreasing new HIV infections.
    • Comparison of methods to correct survival estimates and survival regression analysis on a large HIV African cohort

      Henriques, Julie; Pujades-Rodriguez, Mar; McGuire, Megan; Szumilin, Elisabeth; Iwaz, Jean; Etard, Jean-François; Ecochard, René; Service de Biostatistique, Hospices Civils de Lyon, Lyon, France; Université de Lyon, Lyon, France; Université Lyon 1, Villeurbanne, France; Equipe Biostatistique-Santé, Centre National de la Recherche Scientifique-Unité Mixte de Recherche 5558 Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France; Epicentre, Paris, France; Médecins Sans Frontières, Paris, France; Institut de Recherche pour le Développement-Université de Montpellier Unité Mixte Internationale 233 TransVIHMI, Montpellier, France (PLoS, 2012)
      The evaluation of HIV treatment programs is generally based on an estimation of survival among patients receiving antiretroviral treatment (ART). In large HIV programs, loss to follow-up (LFU) rates remain high despite active patient tracing, which is likely to bias survival estimates and survival regression analyses.
    • A Comparison of Self-report and Antiretroviral Detection to inform estimates of Antiretroviral Therapy Coverage, Viral Load Suppression and HIV incidence in Kwazulu-Natal, South Africa

      Huerga, H; Shiferie, F; Grebe, E; Giuliani, R; Farhat, JB; Van-Cutsem, G; Cohen, K (BioMed Central, 2017-09-29)
      Accurately identifying individuals who are on antiretroviral therapy (ART) is important to determine ART coverage and proportion on ART who are virally suppressed. ART is also included in recent infection testing algorithms used to estimate incidence. We compared estimates of ART coverage, viral load suppression rates and HIV incidence using ART self-report and detection of antiretroviral (ARV) drugs and we identified factors associated with discordance between the methods.
    • Comparison of Self-Reported Alcohol Consumption to Phosphatidylethanol Measurement among HIV-Infected Patients Initiating Antiretroviral Treatment in Southwestern Uganda

      Bajunirwe, Francis; Haberer, Jessica E; Boum, Yap; Hunt, Peter; Mocello, Rain; Martin, Jeffrey N; Bangsberg, David R; Hahn, Judith A (Public Library of Science, 2014-12-01)
      Alcohol consumption among HIV-infected patients may accelerate HIV disease progression or reduce antiretroviral therapy adherence. Self-reported alcohol use is frequently under-reported due to social desirability and recall bias. The aim of this study was to compare self-reported alcohol consumption to phosphatidylethanol (PEth), a biomarker of alcohol consumption, and to estimate the correlation between multiple measures of self-reported alcohol consumption with PEth.
    • Conceptions of Agency and Constraint for HIV-Positive Patients and Healthcare Workers to Support Long-Term Engagement With Antiretroviral Therapy Care in Khayelitsha, South Africa

      Stern, E; Colvin, C; Gxabagxaba, N; Schutz, C; Burton, R; Meintjes, G (Taylor & Francis, 2017-03-01)
      In the context of the optimism around antiretroviral therapy (ART) as prevention of HIV/AIDS, addressing the barriers to long-term ART adherence is critical. This is particularly important given the tendency to individualise or use a blame discourse when exploring why HIV-infected patients "fail" to adequately adhere to ART, and not sufficiently exploring contextual reasons for poor adherence that may require varying solutions. This study took place at three clinics and one hospital in Khayelitsha, South Africa, to document the contextual factors that challenged ART adherence in this community. Interviews were conducted with 20 HIV-infected patients who had defaulted on their ART and were subsequently admitted to Khayelitsha hospital for clinical complications, and 9 ART service providers including doctors, nurses and HIV counsellors. Interviews assessed the reasons patients defaulted on ART and explored ways this could be prevented. Data from both groups were analysed collectively using thematic analysis. While the interviews revealed a landscape of environmental risks threatening adherence to ART, all patients managed to overcome the identified barriers at some point in their treatment phase, indicating the fluidity of patients' needs and decision making. Patients reported that distrustful relationships with service providers could inhibit their understanding of ART and/or interrupt their follow-up at clinics. Patients described their rationale and agency underlying non-adherence, such as testing their bodies' physical limits without ART medication. The study speaks to the need to appreciate contextual social and structural barriers related to ART adherence, and how these are negotiated differently by specific sub-groups, to support an appropriate response. It is imperative to not solely emphasise loss to follow-up but also assess patients' subjective trajectory of their ART journey, decision making and agency with adhering to ART, their relations with healthcare workers, and how these dynamics are intertwined with broader constraints in health systems.
    • The Continuing Burden of Advanced HIV Disease Over 10 Years of Increasing Antiretroviral Therapy Coverage in South Africa.

      Osler, M; Hilderbrand, K; Goemaere, E; Ford, N; Smith, M; Meintjes, G; Kruger, J; Govender, NP; Boulle, A (Oxford University Press, 2018-03-04)
      BACKGROUND: Antiretroviral treatment (ART) has been massively scaled up to decrease human immunodeficiency virus (HIV)-related morbidity, mortality, and HIV transmission. However, despite documented increases in ART coverage, morbidity and mortality have remained substantial. This study describes trends in the numbers and characteristics of patients with very advanced HIV disease in the Western Cape, South Africa. METHODS: Annual cross-sectional snapshots of CD4 distributions were described over 10 years, derived from a province-wide cohort of all HIV patients receiving CD4 cell count testing in the public sector. Patients with a first CD4 count <50 cells/µL in each year were characterized with respect to prior CD4 and viral load testing, ART access, and retention in ART care. RESULTS: Patients attending HIV care for the first time initially constituted the largest group of those with CD4 count <50 cells/µL, dropping proportionally over the decade from 60.9% to 26.7%. By contrast, the proportion who were ART experienced increased from 14.3% to 56.7%. In patients with CD4 counts <50 cells/µL in 2016, 51.8% were ART experienced, of whom 76% could be confirmed to be off ART or had recent viremia. More than half who were ART experienced with a CD4 count <50 cells/µL in 2016 were men, compared to approximately one-third of all patients on ART in the same year. CONCLUSIONS: Ongoing HIV-associated morbidity now results largely from treatment-experienced patients not being in continuous care or not being fully virologically suppressed. Innovative interventions to retain ART patients in effective care are an essential priority for the ongoing HIV response.
    • The Continuing Value of CD4 Cell Count Monitoring for Differential HIV Care and Surveillance

      Rice, B; Boulle, A; Schwarcz, S; Shroufi, A; Rutherford, G; Hargreaves, J (JMIR Publications, 2019-03-20)
      The move toward universal provision of antiretroviral therapy and the expansion of HIV viral load monitoring call into question the ongoing value of CD4 cell count testing and monitoring. We highlight the role CD4 monitoring continues to have in guiding clinical decisions and measuring and evaluating the epidemiology of HIV. To end the HIV/AIDS epidemic, we require strategic information, which includes CD4 cell counts, to make informed clinical decisions and effectively monitor key surveillance indicators.
    • Correcting for Mortality Among Patients Lost to Follow Up on Antiretroviral Therapy in South Africa: A Cohort Analysis

      Van Cutsem, Gilles; Ford, Nathan; Hildebrand, Katherine; Goemaere, Eric; Mathee, Shaheed; Abrahams, Musaed; Coetzee, David; Boulle, Andrew; Médecins Sans Frontières, South Africa; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa, Department of Health, Provincial Government of the Western Cape, South Africa (2011-02-17)
      Loss to follow-up (LTF) challenges the reporting of antiretroviral treatment (ART) programmes, since it encompasses patients alive but lost to programme and deaths misclassified as LTF. We describe LTF before and after correction for mortality in a primary care ART programme with linkages to the national vital registration system.
    • Correcting mortality for loss to follow-up: a nomogram applied to antiretroviral treatment programmes in sub-Saharan Africa.

      Egger, Matthias; Spycher, Ben D; Sidle, John; Weigel, Ralf; Geng, Elvin H; Fox, Matthew P; MacPhail, Patrick; van Cutsem, Gilles; Messou, Eugène; Wood, Robin; et al. (2011-01)
      The World Health Organization estimates that in sub-Saharan Africa about 4 million HIV-infected patients had started antiretroviral therapy (ART) by the end of 2008. Loss of patients to follow-up and care is an important problem for treatment programmes in this region. As mortality is high in these patients compared to patients remaining in care, ART programmes with high rates of loss to follow-up may substantially underestimate mortality of all patients starting ART.
    • Cost and cost-effectiveness of switching from d4T or AZT to a TDF-based first-line regimen in a resource-limited setting in rural Lesotho

      Jouquet, Guillaume; Bygrave, Helen; Kranzer, Katharina; Ford, Nathan; Gadot, Laurent; Lee, Janice; Hilderbrand, Katherine; Goemaere, Eric; Vlahakis, Natalie; Trivino, Laura; et al. (Lippincott Williams & Wilkins, 2011-11-01)
      Latest World Health Organization guidelines recommend shifting away from Stavudine (d4T)-based regimens due to severe side effects. However, widespread replacement of d4T by Tenofovir (TDF) or Zidovudine (AZT) is hampered by cost concerns.
    • Cost-effectiveness of point-of-care viral load monitoring of antiretroviral therapy in resource-limited settings: mathematical modelling study

      Estill, Janne; Egger, Matthias; Blaser, Nello; Vizcaya, Luisa Salazar; Garone, Daniela; Wood, Robin; Campbell, Jennifer; Hallett, Timothy B; Keiser, Olivia; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland. jestill@ispm.unibe.ch (Wolters Kluwer Lippincott Williams & Wilkins, 2013-06-01)
      Monitoring of HIV viral load in patients on combination antiretroviral therapy (ART) is not generally available in resource-limited settings. We examined the cost-effectiveness of qualitative point-of-care viral load tests (POC-VL) in sub-Saharan Africa.
    • Cotrimoxazole prophylaxis for HIV-positive TB patients in developing countries.

      Zachariah, R; Massaquoi, M; Medecins sans Frontieres, Operational Research HIV-TB, Medical department, Brussels Operational Center, 68 Rue de Gaspench, L-1617 Luxemburg. zachariah@internet.lu (2006-04)
      Despite provisional recommendations from the World Health Organization and UNAIDS that cotrimoxazole (CTX) prophylaxis be offered to all individuals living with AIDS, including HIV-positive patients with TB, its routine use in developing countries particularly Africa has been minimal. Concerns were expressed regarding its effectiveness in areas of high bacterial resistance, that its widespread use might substantially increase bacterial cross-resistance in the community and that this intervention might promote resistance of malaria parasites to sulphadoxine-pyrimethamine. We review the current evidence on the above concerns and highlight the main operational considerations related to implementing CTX prophylaxis as a basic component of care for HIV-positive TB patients in developing countries.
    • Crunch time for funding of universal access to antiretroviral treatment for people with HIV infection

      Maher, D; von Schoen-Angerer, T; Cohn, J; MRC⁄ UVRI Uganda Research Unit on AIDS, Entebbe, Uganda; London School of Hygiene and Tropical Medicine, London, UK; Medecins sans Frontieres, Geneva, Switzerland; Division of Infectious Diseases, University of Pennsylvania, Philadelphia, PA, USA (Wiley-Blackwell, 2011-07-15)
    • Cryptococcal meningitis in HIV-infected patients: a longitudinal study in Cambodia.

      Espié, Emmanuelle; Pinoges, Loretxu; Balkan, Suna; Chanchhaya, Ngeth; Molfino, Lucas; Narom, Prak; Pujades-Rodríguez, Mar; Epicentre, Médecins Sans Frontières, 8 rue Saint Sabin, Paris, France. (2010-11)
      To describe the frequency of diagnosis of cryptococcosis among HIV-infected patients in Phnom Penh, Cambodia, at programme entry, to investigate associated risk factors, and to determine the incidence of cryptococcal meningitis.
    • Cytomegalovirus retinitis: the neglected disease of the AIDS pandemic.

      Heiden, D; Ford, N; Wilson, D; Rodriguez, W; Margolis, T; Janssens, B; Bedelu, M; Tun, N; Goemaere, E; Saranchuk, P; et al. (PLoS, 2007-12)