Antiretroviral Therapy Sites Research Articles

Knowledge, Attitude, Practice, and Adherence to Antiretroviral Therapy among People Living with HIV in Nepal.

Patient's knowledge and attitude towards their treatment avert stereotypical misconceptions about the disease and its treatment, as well as aid in attaining optimal adherence. This study investigated the knowledge, attitude, practice, and adherence of antiretroviral therapy (ART) clients in Nepal. A cross-sectional study was conducted among 165 ART clients visiting five ART sites in the far western region and the capital city of Nepal. The convenience sampling method was employed, and the data were collected through interviews with ART clients using a validated questionnaire. Binary logistic regression was used to identify associated factors. Approximately 80.7% had adequate knowledge and 55% had a positive attitude towards ART. Stigmatization was associated with ARV by only 4.2%. Half of the participants (50.3%) revealed that they had surreptitiously stored their ART medication, diverging from the recommended storage guidelines. A significant proportion of respondents (33.3%) chose to repackage the medication as a strategy to prevent unintended disclosure of their HIV status. Many (59.3%) believed that ART does not prolong life. Nevertheless, they advocated the regular use of ART rather than taking it only when the health deteriorates (81.8%). The majority (97.6%) were found to be adherent to their ART. There was a significant association of age with a level of knowledge and attitude (p < 0.05). A significant association was also found between knowledge and attitude towards ART (p < 0.05). None of the variables had a significant association with adherence (p > 0.05). Overall, adequate knowledge was demonstrated, whereas efforts are still needed to improve the attitude of ART clients towards ART. A need for counseling regarding the storage practices of ART is needed. A focus on ensuring the perfect translation of adequate knowledge and a positive attitude to the practice of ART clients is essential. Whether adequate ART knowledge and attitude scores will lead to near-perfect ART adherence needs further investigation.

Retesting of Patients Receiving Antiretroviral Treatment at HIV Care and Treatment and Prevention of Mother-To-Child HIV Transmission Sites in Cameroon

The World Health Organization recommends retesting of newly diagnosed HIV cases for verification of results prior to antiretroviral therapy (ART) initiation. This study aimed at ascertaining the HIV status of clients on lifelong ART. We tested 25% of ART clients in 6 care and treatment (C&amp;T) sites and all HIV-positive women receiving ART in 22 prevention of mother-to-child HIV transmission (PMTCT) sites in Northwest and Southwest regions. Testing was proposed consecutively to clients in group education sessions during ART refill visit until the sample size was achieved. Individual counselling was provided to clients who opted to be retested. Testing was with Determine HIV-1/2 and First Response rapid tests and further testing was with DNA-PCR. Clients with negative test results were counseled to discontinue ART. Results were analyzed comparing misdiagnosis at ART and PMTCT sites. A total of 4526 ART clients were retested for HIV; 3914(86.5%) from ART and 612(13.5%) from PMTCT sites. Female participants dominated (79%) and the median age was 39 years. Higher proportions of clients retested at PMTCT sites were negative with both tests (0.8% vs 0.1%) and had discordant results (1.1% vs 0.4%) than at ART sites. All 32 clients with negative or discordant results were tested with DNA-PCR and 22(0.5%) were negative; 11(0.3%) in ART and 11(1.8%) in PMTCT sites. HIV positive status was confirmed for 99.5% of clients retested, with a lower rate at PMTCT (98.2%) than C&amp;T (99.7%) sites; meaning misdiagnosis and inappropriate ART treatment was more likely at PMTCT. Adherence to recommendation for HIV retesting for verification will reduce inappropriate treatment. Keywords: HIV, Retesting, Misdiagnosis, Care and Treatment Centre, PMTCT, Cameroon

Retention in care among people living with HIV in the national antiretroviral therapy programme in Guinea: A retrospective cohort analysis.

Few studies have investigated retention in HIV care in West Africa. We measured retention in antiretroviral therapy (ART) programmes among people living with HIV and re-engagement in care among those lost to follow up (LTFU) in Guinea and identified associated risk factors using survival analysis. Patient-level data were analysed from 73 ART sites. Treatment interruptions and LTFU were defined as missing a ART refill appointment by over 30 days and by over 90 days respectively. A total of 26,290 patients initiating ART between January 2018 and September 2020 were included in the analysis. The mean age at ART initiation was of 36.2 years, with women accounting for 67% of the cohort. Retention 12 months after ART initiation was 48.7% (95%CI 48.1-49.4%). The LTFU rate was 54.5 per 1000 person-months (95% CI 53.6-55.4), with the peak hazards of LTFU occurring after the first visit and decreasing steadily over time. In an adjusted analysis, the hazards of LTFU were higher among men compared to women (aHR = 1.10; 95%CI 1.08-1.12), being aged 13-25 years old versus older patients (aHR = 1.07; 95%CI = 1.03-1.13), and among those initating ART in smaller health facilities (aHR = 1.52; 95%CI 1.45-1.60). Among 14,683 patients with an LTFU event, 4,896 (33.3%) re-engaged in care, of whom 76% did so within six months from LTFU. The re-engagement rate was 27.1 per 1000 person-months (95%CI 26.3-27.9). Treatment interruptions were correlated with rainfall patterns and end of year mobility patterns. Rates of retention and re-engagement in care are very low in Guinea, undermining the effectiveness and durability of first-line ART regimens. Tracing interventions and differentiated service delivery of ART, including multi-month dispensing may improve care engagement, especially in rural areas. Further research should investigate social and health systems barriers to retention in care.

Protecting the gains: analysis of HIV treatment and service delivery programme data and interventions implemented in 19 African countries during COVID-19.

The potential disruption in antiretroviral therapy (ART) services in Africa at the start of the COVID-19 pandemic raised concern for increased morbidity and mortality among people living with HIV (PLHIV). We describe HIV treatment trends before and during the pandemic and interventions implemented to mitigate COVID-19 impact among countries supported by the US Centers for Disease Control and Prevention (CDC) through the President's Emergency Plan for AIDS Relief (PEPFAR). We analysed quantitative and qualitative data reported by 10,387 PEPFAR-CDC-supported ART sites in 19 African countries between October 2019 and March 2021. Trends in PLHIV on ART, new ART initiations and treatment interruptions were assessed. Viral load coverage (testing of eligible PLHIV) and viral suppression were calculated at select time points. Qualitative data were analysed to summarize facility- and community-based interventions implemented to mitigate COVID-19. The total number of PLHIV on ART increased quarterly from October 2019 (n = 7,540,592) to March 2021 (n = 8,513,572). The adult population (≥15 years) on ART increased by 14.0% (7,005,959-7,983,793), while the paediatric population (<15 years) on ART declined by 2.6% (333,178-324,441). However, the number of new ART initiations dropped between March 2020 and June 2020 by 23.4% for adults and 26.1% for children, with more rapid recovery in adults than children from September 2020 onwards. Viral load coverage increased slightly from April 2020 to March 2021 (75-78%) and viral load suppression increased from October 2019 to March 2021 (91-94%) among adults and children combined. The most reported interventions included multi-month dispensing (MMD) of ART, community service delivery expansion, and technology and virtual platforms use for client engagement and site-level monitoring. MMD of ≥3 months increased from 52% in October 2019 to 78% of PLHIV ≥ age 15 on ART in March 2021. With an overall increase in the number of people on ART, HIV programmes proved to be resilient, mitigating the impact of COVID-19. However, the decline in the number of children on ART warrants urgent investigation and interventions to prevent further losses experienced during the COVID-19 pandemic and future public health emergencies.

Prevalence and associated risk factors for tuberculosis among people living with HIV in Nepal.

BackgroundWorldwide tuberculosis (TB) takes more lives than any other infectious diseases. WHO estimates around 68,000 incident TB cases in Nepal. However, in 2018 only around 27,232 new TB cases were reported in the national system, resulting around 40,768 incident TB cases missing every year in Nepal. National Tuberculosis Control Center carried out this study in anti-retroviral therapy (ART) sites to estimate the prevalence of TB and identify the associated risk factors for TB among the people living with Human Immunodeficiency Virus (PLHIVs) in Nepal.MethodsIt was a cross-sectional institution-based study conducted between March and August 2018. Six ART sites with high caseloads of PLHIVs were selected. PLHIVs who were equal or above 18 years of age and were in ART program at the selected study sites were considered eligible for the study. Diagnosis of tuberculosis among PLHIVs who agreed to participate in the study was carried out as per the National Tuberculosis Management Guideline of National Tuberculosis Program of Nepal.ResultsAmong 403 PLHIVs, tuberculosis was diagnosed in 40 (9.9%) individuals. Median age of the participants was 36 (30–43) years. Prevalence of TB was significantly higher among male PLHIVs than female PLHIVs (13.6% Vs 5.8%; P = 0.02) and Dalit ethnic group compared to Brahmin/Chettri (22.0%Vs5.9%, P = 0.01). The risk of developing TB was found significant among those with HIV stage progressed to WHO stage 3 and 4 (OR = 4.85, P<0.001) and with the family history of TB (OR = 4.50, P = 0.002).ConclusionsPrevalence of TB among PLHIVs in Nepal was found 9.9%. Risk of developing TB was higher among PLHIVs who were male, Dalit, with HIV stage progressed to WHO stage 3 and 4 and with family history of TB. Hence, targeted interventions are needed to prevent the risk of developing TB among PLHIVs. Similarly, integrated, and comprehensive TB and HIV diagnosis and treatment services are needed for the management of TB/HIV co-infection in Nepal.

Retention in Care, Loss to Follow-up and Associated Patient Characteristics: A Retrospective Cohort Study among Adults Receiving Antiretroviral Therapy from Urban Health Facilities in Ghana

Abstract Introduction: Assessing treatment outcomes among persons receiving antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection is important for clinical and public health decisions. Although Komfo Anokye Teaching Hospital and Suntreso Government Hospital have offered ART to several patients for more than a decade, their treatment outcomes have not been well reported. We aimed at investigating retention in care, loss to follow-up, and patient characteristics associated with these outcomes among HIV-infected adults receiving ART from two urban treatment sites in the Ashanti Region of Ghana in order to design interventions to improve therapy outcomes. Materials and method: We conducted medical records review (MRR) from September to December 2020 among HIV-infected patients receiving ART from two urban ART sites in Kumasi, Ghana. Patients were eligible if they were adults aged ≥ 20-years and had taken ART for ≥ 3-years as of December 2019. Retention in care, loss to follow-up (LTFU) and mortality among our study patients were investigated from ART initiation up to 3-years. In this study, retention of patients in care was defined as actively attending clinic and picking ARVs within the follow-up period. Loss to follow-up was defined as having discontinued clinic attendance and ARVs pick-up for more than 90 days after the last scheduled visit. Logistic regression analyses were performed to study the treatment outcomes and their associated patient characteristics. Results: Of the 370 patients whose medical records were reviewed, 258 (69.7%) were female, 260 (70.3%) were retained in ART up to 3-years, 29.7% were lost to follow-up of whom 9.1% were confirmed dead. Overall mortality was therefore 2.7%. Being employed (AOR 2.55, p = 0.015, 95% CI 1.201-5.4.414), female (AOR 1.319, CI 95% 0.754-2.310), divorced (AOR 1.266, CI 95% 0.506-3.166) and having primary level of education (AOR 1.539, CI 95% 0.915-2.590) were associated with greater odds of being retained in care. Conclusion: Although mortality among our study cohort was low and bout 70% were retained in ART up to 3-years, loss to follow-up was high, especially within the first 6 months. Effective follow-up interventions are required to reduce LTFU during the first 6 months of treatment and among younger adults, patients with secondary and tertiary education as well as single and married patients who were less likely to be retained in care.

Same-day antiretroviral therapy initiation hub model at the Thai Red Cross Anonymous Clinic in Bangkok, Thailand: an observational cohort study.

IntroductionWHO has recommended rapid antiretroviral therapy (ART) initiation, including same‐day ART (SDART). However, data on the feasibility in real‐world settings are limited. We implemented a cohort study at a stand‐alone HIV testing centre to examine its applicability and effectiveness.MethodsData were collected from the Thai Red Cross Anonymous Clinic in Bangkok, Thailand, between July 2017 and July 2018 from clients who were ART‐naïve and could return for follow‐up visits. Baseline laboratory tests and chest X‐ray were performed according to national guidelines, and clinical eligibility was determined based on physical examination and chest X‐ray findings. Primary outcomes were retention in care and viral load suppression at 3, 6 and 12 months.ResultsDuring the study period, 2427 people tested HIV positive. Of these, 2107 (2207/2427, 86.8%) met logistical criteria, and 1904 (1904/2427, 78.5%) agreed to SDART. One thousand seven hundred and twenty‐nine (1729/2427, 71.2%) were placed on ART, with 1257 received same‐day initiation and 1576 initiated ART within 7 days; 1198 clients were successfully referred to free, sustained ART sites. Retention among eligible clients who accepted SDART service at months 3, 6 and 12 was 79.8%, 75.2% and 75.3%, respectively.ConclusionsSame‐day ART initiation hub model at a stand‐alone HIV testing centre in an urban setting in Bangkok, Thailand, is highly feasible and has a potential for scaling up.Clinical Trial NumberNCT04032028

Prevalence, healthcare costs and management of non-communicable diseases in people living with human immunodeficiency virus: A scoping review.

BackgroundCoexistence of human immunodeficiency virus (HIV) and non-communicable diseases (NCDs) is an important public health issue of increasing concern. However, the prevalence, healthcare costs and management protocols for NCDs in people living with HIV (PLHIV) remain unclear in most settings.AimTo scope evidence on prevalence, healthcare costs and disease management protocols associated with NCDs in PLHIV from studies published before July 2019.MethodsElectronic databases were searched for published articles, and reference lists were checked for relevant studies. Key terms included were HIV/AIDS, co-morbidity or multi-morbidity, NCDs, healthcare costs, treatment protocols, diabetes mellitus, hypertension in various combinations.ResultsA total of 152 records were assessed, and thereafter 25 studies were included in the final review after all the elimination. Twelve of the 25 studies mostly reported prevalence of NCDs in PLHIV, 4 reported impact of HIV–NCD co-morbidity on healthcare costs and 1 reported management protocols and capacity of antiretroviral therapy (ART) sites to manage HIV–NCD co-morbidity.ConclusionsResults showed higher prevalence rates of diabetes mellitus and hypertension in PLHIV compared with HIV-negative people. However, there was inconsistency in NCD prevalence data from studies conducted in sub-Saharan African (SSA) countries, and limited research evidence on capacity of ART sites to manage NCDs in PLHIV. Low prevalence rates of NCDs reported in SSA countries could be an indication of limited capacity to screen for NCDs because of the influence of health system and/or patient-level factors. Most studies were generally limited to cross-sectional studies, with very few interventional, longitudinal studies.

Prevalence of diabetes mellitus and hypertension in people living with human immunodeficiency virus on antiretroviral therapy in Gweru district, Zimbabwe.

BackgroundWhile antiretroviral therapy (ART) has markedly increased survival in people living with human immunodeficiency virus (PLHIV), emerging trends of co-existence of non-communicable diseases (NCDs) and HIV could negate the gains already achieved in controlling HIV.AimThe study aimed to determine the prevalence of hypertension and diabetes mellitus in PLHIV on ART in Gweru district.SettingSix high-volume ART sites in Gweru district under Midlands province in Zimbabwe.MethodsThis was a cross-sectional study. Screening and data collection occurred over a 3-month cycle when all patients were expected to have visited the ART sites for their monthly ART drug supply. The process also allowed the identification of health system challenges regarding data management for HIV-NCD comorbidity. Poisson regression analysis was used to calculate NCD prevalence ratio (PR) in PLHIV.ResultsNearly 18 000 PLHIV registered for ART were identified. Hypertension (19.5%) and diabetes mellitus (8.4%) were the most common NCDs identified with a high proportion of those who did not know their diagnosis (over 50%). The prevalence of hypertension and/or diabetes mellitus among women was 74.9% compared to 25.1% in men (PR 3.22; 95% CI: 3.07–5.51, p = 0.0000). Other factors associated with increased prevalence of hypertension and/or diabetes mellitus were age group of ≥ 60 years (PR 2.5; 95% CI: 1.42–3.22, p = 0.00023), and duration of ≥ 5 years on ART (PR 6.4; 95% CI: 4.70–8.01, p = 0.0011). Separate data collection for NCDs and HIV was a key challenge affecting quantification of magnitude of HIV-NCDs comorbidity and subsequently management of NCDs in PLHIV.ConclusionsIndications of increasing prevalence of NCDs in PLHIV call for integrated electronic data management for HIV, TB and NCDs. This will allow active NCD case finding, and eventually improve prevalence data and treatment for HIV-NCD comorbidity. Future studies should focus on the health experiences and access to treatment in PLHIV diagnosed with NCDs; and to establish the accurate manner in which HIV status, ART and NCDs might be associated, through conducting a case control or cohort study.

Implementing an Integrated Pharmaceutical Management Information System for Antiretrovirals and Other Medicines: Lessons From Namibia.

The success of the Namibian government's "treatment for all" approach to control and stop the country's HIV epidemic is dependent on an uninterrupted supply of antiretrovirals (ARVs) for people living with HIV. The public health system in Namibia, however, was constrained by an inefficient paper-based pharmaceutical information system resulting in unreliable and inaccessible data, contributing to persistent stock-outs of ARVs and other essential pharmaceuticals. This article describes the incremental implementation of an integrated pharmaceutical management information system to provide timely and reliable commodity and patient data for decision making in Namibia's national antiretroviral therapy (ART) program and the Ministry of Health and Social Services (MoHSS). The system has 4 interlinked information tools: (1) the Electronic Dispensing Tool (EDT) that manages the dispensing and inventory of antiretrovirals at service delivery points; (2) the EDT national database, which facilitates the flow, storage, and collation of ART data at the central level; (3) the Facility Electronic Stock Card used to manage pharmaceutical stocks and report inventory movement data to the national level; and (4) the Pharmaceutical Management Information Dashboard that integrates all 3 tools plus the warehouse management tool used by the central and regional medical stores into 1 dashboard that serves as a platform for the analysis and dissemination of pharmaceutical information throughout the health system. Implementing the pharmaceutical management information system was a prolonged and complicated process, with key challenges related to user acceptance and human resource constraints. The integrated pharmaceutical management information system enables Namibia to collect more than 90% of transactional commodity and patient dispensing data from more than 85% of all ART sites. Health managers use information from the system for medicine quantification decisions and to improve pharmaceutical service delivery. The MoHSS and its partners in the national ART program use the information for monitoring the World Health Organization early warning indicators for HIV drug resistance; ART defaulter tracing; and for planning, reporting, and research purposes. Namibia's pharmaceutical management information system demonstrates the feasibility and benefits of integrating related tools while maintaining their specialized functionality to address country-specific information and inventory management needs.

Same-Day Antiretroviral Therapy Initiation Hub Model at the Thai Red Cross Anonymous Clinic in Bangkok, Thailand: High Levels of Acceptability, Long-Term Retention, and Viral Load Suppression

Background: WHO has recommended rapid antiretroviral therapy (ART) initiation, including same-day ART (SDART). However, data on the feasibility in real-world settings are limited. We implemented a cohort study at a stand-alone HIV testing center using initiation hub model to examine its applicability and effectiveness. Methods: We collected data from the Thai Red Cross Anonymous Clinic in Bangkok, Thailand, from clients who were ART-naive and could return for follow-up visits (logistical criteria). Baseline laboratory tests and chest x-ray were performed according to national guidelines, and clinical eligibility was determined based only on physical examination and chest x-ray finding. Acceptability and care linkage were assessed, as well as viral load (VL) suppression and retention in care three, six, and 12 months after ART initiation. Historical data from clients at the same venue between February 2015 to June 2017 were used to compare ART initiation after HIV diagnosis and VL suppression with SDART clients by using Cox proportional-hazards model. Findings: Between July 2017 and July 2018, 2,427 people tested HIV-positive at the clinic, and 2,107 met logistical criteria. Of these, 1,904 (90·4%) agreed to SDART. 1,624 (85·3%) were placed on ART, and 77·4% (1,251/1,624) received same-day initiation. 92·8% (1,198/1,291) were successfully referred to sustained ART sites. Retention at month three, six, and 12 was 93·3% (1,211/1,289), 89·0% (757/851), and 92·1% (70/76), respectively. When compared to historical data, the hazard ratios to ART initiation after HIV diagnosis and viral load suppression among SDART clients were 3·6 (95%CI:3·4-3·8;p<0·001), and 2·1 (95%CI:1·8- 2·3;p<0·001), respectively. Interpretation: Same-Day ART at a stand-alone HIV testing center in an urban setting in Bangkok, Thailand, is highly feasible, and improves ART uptake and viral load suppression. Funding Statement: The United States Agency for International Development (USAID), the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), and the Thai Red Cross AIDS Research Centre. Declaration of Interests: All authors declare no competing interests related to this work. Ethics Approval Statement: This study was approved by the Institutional Review Board of Chulalongkorn University.

Knowledge and utilization of family planning methods among people living with HIV in Kathmandu, Nepal

BackgroundAddressing family planning (FP) needs of people living with HIV is an effective response to HIV prevention. Healthy timing and spacing of births help ensure the health and well-being of all women and infants, regardless of their HIV-infection. In addition, preventing unintended pregnancies is an important strategy for prevention of mother to child transmission of HIV. The main purpose of this study was to explore the knowledge of family planning methods and identify factors affecting the utilization of such methods among HIV infected men and women attending two Anti-Retroviral Therapy (ART) sites of Kathmandu, Nepal.MethodsThis was a descriptive cross-sectional study. Two ART sites of Kathmandu were purposively chosen and a sample of 265 respondents (both men and women) was selected based on proportionate probability random sampling. A structured questionnaire was administered face to face to all of the eligible participants.ResultsThe mean ± SD age of the participants was 36.62 ± 7.58 years. Sixty five percent of the respondents’ spouses were HIV positive. A majority of the respondents (72%) had heard of seven modern family planning methods. Considerably high number (72%) of the respondents or their spouses were using at least one of the method of family planning. The most common method was condom (83%) and the least common was IUCD (0.50%). The use of short acting (pills, depo-provera) and long acting (implant, IUCD) family planning methods other than condom dropped from 56.6 to 2% after diagnosis. Utilization of family planning methods was significantly associated with gender, education and HIV status of spouse. Males (Adjusted Odds Ratio (AOR) = 2.48, 95% CI = 1.20–5.07, p = 0.01) educated respondents (AOR = 3.27, 95% CI = 1.41–7.54, p = < 0.01) and individuals whose spouse were not infected with HIV (AOR = 4.70, 95% CI = 1.41–15.67, p = 0.01) were more likely to use FP methods.ConclusionThe tendency for HIV infected men and women to avoid additional child bearing in Nepal is higher compared to sub-Saharan Africa. However, the use of effective methods of family planning is low. Therefore, more effective counselling sessions by service providers regarding the availability and use of alternative family planning methods besides condom is necessary.

Challenges to and opportunities for the adoption and routine use of early warning indicators to monitor pediatric HIV drug resistance in Kenya

BackgroundPediatric non-adherence to antiretroviral therapy (ART), loss to follow-up, and HIV drug resistance (HIVDR) are challenges to achieving UNAIDS’ targets of 90% of those diagnosed HIV-positive receiving treatment, and 90% of those receiving treatment achieving viral suppression. In Kenya, the pediatric population represents 8% of total HIV infections and pediatric virological failure is estimated at 33%. The monitoring of early warning indicators (EWIs) for HIVDR can help to identify and correct gaps in ART program functioning to improve HIV care and treatment outcomes. However, EWIs have not been integrated into health systems. We assessed challenges to the use of EWIs and solutions to challenges identified by frontline health administrators.MethodsWe conducted key informant interviews with health administrators who were fully knowledgeable of the ART program at 23 pediatric ART sites in 18 counties across Kenya from May to June 2015. Thematic content analysis identified themes for three EWIs: on-time pill pick-up, retention in care, and virological suppression.ResultsNine themes—six at the facility level and three at the patient level—emerged as major challenges to EWI monitoring. At the facility level, themes centered on system issues (e.g., slow return of viral load results), staff shortages and inadequate adherence counseling skills, lack of effective patient tracking and linkage systems, and lack of support for health personnel. At the patient level, themes focused on stigma, non-disclosure of HIV status to children who are age eligible, and little engagement of guardians in the children’s care.Practical solutions identified included the use of lay health workers (e.g., peer educators, community health workers) to implement a variety of care and treatment tasks, whole facility approaches to adherence counseling, adolescent peer support groups, and working with children directly as soon as they are age eligible.DiscussionThe monitoring of EWIs has not been routine in health facilities in Kenya due to several challenges. However, facilities have implemented novel strategies to address some of these barriers. Future work is needed to assess whether scale-up of some of these approaches can aid in the effective use of EWIs and improving HIV care outcomes among the pediatric population.

Validity of reported retention in antiretroviral therapy after roll-out to peripheral facilities in Mozambique: Results of a retrospective national cohort analysis.

BackgroundRetention in anti-retroviral therapy (ART) presents a challenge in sub-Saharan Africa. In Mozambique, after roll-out to peripheral facilities, the 12-month retention rate was reported mostly from sites with an electronic patient tracking system (EPTS), representing only 65% of patients. We conducted a nationally representative study, compared 12-month retention at EPTS and non-EPTS sites, and its predictors.MethodsApplying a proportionate to population size sampling strategy, we obtained a nationally representative sample of patients who initiated ART between January 2013 and June 2014. We calculated weighted proportions of the patients’ status at 12 months after ART initiation, and 12-month incidence of lost to follow-up (LTFU) and death. We assessed determinants of LTFU and death by calculating adjusted hazard ratios (AHR) through multivariate cox-proportional hazard models.ResultsAmong 19,297 patients sampled, 54.3% were still active, 33.1% LTFU, 2.0% dead, 2.6% transferred-out and 8.0% had unknown status, 12 months after ART initiation. Total attrition rate (LTFU or dead) was 45.5/100PY, higher at facilities without EPTS (51.8/100PY) than with EPTS (37.7/100PY). Clinical stage IV (AHR = 1.7), CD4 count ≤150 (AHR = 1.3) and being pregnant (AHR = 1.6) were significantly associated with LTFU. Clinical stage III or IV (AHR = 2.1 and 3.8), CD4 count ≤150 (AHR = 3.0), not being pregnant (AHR = 3.0), and ART regimens with stavudine (AHR = 4.28) were significantly associated with deaths. Patients enrolled in adherence support groups were 4.6 times less likely to be LTFU, but the number (n = 174) was too small to be significant (p = 0.273).ConclusionRetention in ART was substantially lower at non-EPTS sites. EPTS should be expanded to all ART sites to facilitate comprehensive routine monitoring of retention in care. Retention in Mozambique is low and needs to be improved, especially among pregnant women and patients with advanced disease at ART initiation. The effect of ART adherence support groups needs to be further monitored.

Lessons Learned From Option B+ in the Evolution Toward "Test and Start" From Malawi, Cameroon, and the United Republic of Tanzania.

The acceleration of prevention of mother-to-child transmission (PMTCT) activities, coupled with the rollout of 2010 World Health Organization (WHO) guidelines, led to important discussions and innovations at global and country levels. One paradigm-shifting innovation was Option B+ in Malawi. It was later included in WHO guidelines and eventually adopted by all 22 Global Plan priority countries. This article presents Malawi's experience with designing and implementing Option B+ and provides complementary narratives from Cameroon and Tanzania. Malawi's HIV program started in 2002, but by 2009, the PMTCT program was lagging far behind the antiretroviral therapy (ART) program because of numerous health system challenges. When WHO recommended Option A and Option B for PMTCT in 2010, it was clear that Malawi's HIV program would not be able to successfully implement either option without increasing existing barriers to PMTCT services and potentially decreasing women's access to care. Subsequent stakeholder discussions led to the development of Option B+. Operationalizing Option B+ required several critical considerations, including the complete integration of ART and PMTCT programs, systematic reduction of barriers to facilitate doubling the number of ART sites in less than a year, building consensus with stakeholders, and securing additional resources for the new program. During the planning and implementation process, several lessons were learned which are considerations for countries transitioning to "treat-all": Comprehensive change requires effective government leadership and coordination; national clinical guidelines must accommodate health system limitations; ART services and commodities should be decentralized within facilities; the general public should be well informed about major changes in the national HIV program; and patients should be educated on clinic processes to improve program monitoring.

You can treat my HIV - But can you treat my blood pressure? Availability of integrated HIV and non-communicable disease care in northern Malawi.

BackgroundMany patients on antiretroviral therapy (ART) in Malawi have or will develop non-communicable diseases (NCDs). The current capacity of ART sites to provide care for NCDs is not known.AimThis study aimed to assess the capacity of ART sites to provide care for hypertension and diabetes in rural Malawi.SettingTwenty-five health centres and five hospitals in two rural districts in northern Malawi.MethodsA cross-sectional survey was performed between March and May 2014 at all facilities. Qualitative interviews were held with three NCD coordinators.ResultsTreatment of hypertension and diabetes was predominantly hospital-based. Sixty percent of hospitals had at least one clinician and one nurse trained in NCD care, whereas 5% of health centres had a clinician and 8% had a nurse trained in NCD care. Hundred percent of hospitals and 92% of health centres had uninterrupted supply of hydrochlorothiazide in the previous 6 months, but only 40% of hospitals and no health centres had uninterrupted supply of metformin. Hundred percent of hospitals and 80% of health centres had at least one blood pressure machine, and 80% of hospitals and 32% of health centres had one glucometer. Screening for hypertension amongst ART patients was only conducted at one hospital and no health centres. At health centres, integrated NCD and ART care was more common, with 48% (12/25) providing ART and NCD treatment in the same consultation.ConclusionsThe results reflect the status of the initial stages of the Malawi NCD programme at sites currently providing ART care.

Frequency and impact of suboptimal immune recovery on first-line antiretroviral therapy within the International Epidemiologic Databases to Evaluate AIDS in East Africa.

To describe patterns of suboptimal immune recovery (SO-IR) and associated HIV-related-illnesses during the first 5 years following first-line antiretroviral therapy (ART) initiation across seven ART sites in East Africa. Retrospective analysis of data from seven ART clinical sites (three Uganda, two Kenya and two Tanzania). SO-IR was described by proportions of ART-treated adults with CD4 cell counts less than 200, less than 350 and less than 500 cells/μl. Kaplan-Meier survival analysis techniques were used to assess predictors of SO-IR, and incident rates of HIV-related illnesses at CD4 cell counts less than 200, 200-350, 351-499, and >500 cells/μl, respectively. Overall 80 843 adults initiated non-nucleoside reverse transcriptase inhibitor-based first-line ART; 65% were women and median CD4 cell count was 126 [interquartile range (IQR), 52-202] cells/μl. Cumulative probability of SO-IR <200 cells/μl, <350 cells/μl and <500 cells/μl, after 5 years, was 11, 38 and 63%, respectively. Incidence of HIV-related illnesses was higher among those with CD4 cell counts less than 200 and 200-350 cells/μl, than those who achieved CD4 counts above these thresholds. The most common events, at CD4 < 200 cells/μl, were pulmonary tuberculosis [incident rate 15.98 (15.47-16.51)/100 person-years at risk (PYAR), oral candidiasis [incident rate 12.5 (12.03-12.94)] and herpes zoster [incident rate 6.30 (5.99-6.64)] events/100 PYAR. With attainment of a CD4 cell count level 200-350 cells/μl, there was a substantial reduction in events/100 PYAR - by 91% to 1.45 (1.29-1.63) for TB, by 94% to 0.75 (0.64-0.89) for oral candidiasis, by 84% to 0.99 (0.86-1.14) for Herpes Zoster, and by 78% to 1.22 (1.07-1.39) for chronic diarrhea. The incidence of all events decreased further with CD4 counts above these thresholds. Around 40% of adults initiated on ART have suboptimal immune recovery with CD4 counts <350 cells/μl after five years. Such patients will require closer monitoring for both HIV-related and non-HIV-related clinical events.

Growth in HIV-infected children on long-term antiretroviral therapy.

To describe growth in HIV-infected children on long-term antiretroviral therapy (ART) and to assess social, clinical, immunological and virological factors associated with suboptimal growth. This observational cohort study included all HIV-infected children at an urban ART site in South Africa who were younger than 5 years at ART initiation and with more than 5 years of follow-up. Growth was assessed using weight-for-age Z-scores (WAZ), height-for-age Z-scores (HAZ) and body mass index (BMI)-for-age Z-scores (BAZ). Children were stratified according to pre-treatment anthropometry and age. Univariate and mixed linear analysis were used to determine associations between independent variables and weight and height outcomes. The majority of the 159 children presented with advanced clinical disease (90%) and immunosuppression (89%). Before treatment underweight, stunting and wasting were common (WAZ<-2 = 50%, HAZ<-2 = 73%, BAZ<-2 = 19%). Weight and BMI improved during the initial 12 months, while height improved over the entire 5-year period. Height at study exit was significantly worse for children with growth impairment at ART initiation (P < 0.001), and infants (<1 year) demonstrated superior improvement in terms of BMI (P = 0.04). Tuberculosis was an independent risk factor for suboptimal weight (P = 0.01) and height (P = 0.02) improvement. Weight gain was also hindered by lack of electricity (P = 0.04). Immune reconstitution and virological suppression were not associated with being underweight or stunted at study endpoint. Malnutrition was a major clinical concern for this cohort of HIV-infected children. Early ART initiation, tuberculosis co-infection management and nutritional interventions are crucial to ensure optimal growth in HIV-infected children.

Addressing the Unmet Need for ART among HIV+ Women and Newborns in Cameroon through Strengthening the Supply Chain of PMTCT Commodities

Background: The Government of Cameroon and its partners have made major investments in the last decade in prevention, treatment, and care of HIV-infected patients. However, unmet need for antiretroviral therapy (ART) among HIV-positive pregnant women remains high at 66%. Critical to satisfying this need is ensuring adequate availability of prevention of mother-to-child transmission (PMTCT) commodities for rollout of new Option B+ guidelines. The Cameroon supply system consists of a cost recovery system for essential medicines and other health commodities and a free-of-charge system for priority commodities including those for PMTCT and ART. This study examines options for improving the supply and availability of these commodities. Method: Supply chain (SC) operational data was collected in July 2014 from central (CENAME) and 4 regional warehouses (CAPRs); 10 district stores; and 30 service delivery points (SDPs), including ART and PMTCT sites. The study also included seven central private-sector logistics firms. In addition, SC cost data was obtained from CENAME and CAPRs financial statements audited in 2013. Data collected served for analysis of three options to improve effectiveness of delivering PMTCT commodities, based on the four variables detailed in Figure 2.4.1. Results: Asset utilization within the cost recovery system ranged between 73% and 89% while inventory turnover was at 1.5. Therefore, a reliable supply of medicines to SDPs is ensured. However, for PMTCT and ART commodities, distribution to the SDPs was unreliable (in 2013, 40% of prescriptions remained unfilled). Meanwhile, results of the options analysis indicated that the model of CAPRs delivering PMTCT commodities to SDPs was the most desirable. Although the distance traveled was higher, the need for network storage space was minimal. Moreover, its total cost and human resource requirements were more favorable. Conclusion: As a result of disseminating the findings, the Ministry of Health adopted Option 2. PMTCT free-of-charge commodities are also amenable to being managed within the existing effective cost recovery system.

English

Though cases of AIDS are visible in Nigeria and high awareness of human immunodeficiency virus (HIV), correct knowledge on human immunodeficiency virus (HIV) transmission and prevention has remained low with significant numbers of people living with HIV/AIDS having low attitudes towards life and the disease itself. This study determined the baseline knowledge on human immunodeficiency virus (HIV) transmission and prevention and attitudes towards HIV/AIDS of adult HIV positive patient enrolled into care at all 4 comprehensive antiretroviral therapy (ART) sites in Yola, Nigeria. Baseline reports on the knowledge and attitudes of adult HIV positive patients were obtained from a 3 arm randomized single blind clinical trial involving 386 randomly selected and allocated adult HIV patients who were enrolled into ART care at all 4 comprehensive ART sites in Yola. The intervention was 10 to 15 min clinic based Clinician Client Centred counselling and the 3 groups were; intervention group1, intervention group 2 and the control group. An interviewer administered validated and reliable structured questionnaire was used for data collection. Outcome measures were sound knowledge on HIV transmission and prevention and attitudes towards HIV/AIDS. Data was analyzed using SPSS version 22. Test of significance was at α level 0.05. Overall 237 (61.4%) had sound knowledge on HIV transmission and prevention, while 346 (89.6%) of respondents had high attitudes towards HIV/AIDS. Though majority of respondents had sound knowledge on HIV transmission and prevention as well as high attitudes towards HIV/AIDS, interventions to improve knowledge and attitudes among this group of individuals would improve positive preventive strategies. Key words: Adult HIV patients, knowledge, attitudes, HIV/AIDS.