Browsing by Author "Ford N"

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Changes in rapid HIV treatment initiation after national "treat all" policy adoption in 6 sub-Saharan African countries: Regression discontinuity analysis.
(2019-Jun) Tymejczyk O; Brazier E; Yiannoutsos CT; Vinikoor M; van Lettow M; Nalugoda F; Urassa M; Sinayobye JD; Rebeiro PF; Wools-Kaloustian K; Davies MA; Zaniewski E; Anderegg N; Liu G; Ford N; Nash D; Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, United States of America.; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.; Global Hepatitis Programme, HIV/AIDS Department, World Health Organization, Geneva, Switzerland.; Department of Medicine, University of Alabama, Birmingham, Alabama, United States of America.; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.; Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America.; Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America.; Rakai Health Sciences Program, Kalisizo and Entebbe, Uganda.; Rwanda Military Hospital, Kigali, Rwanda.; Dignitas International, Zomba, Malawi.; Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, United States of America.; Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Most countries have formally adopted the World Health Organization's 2015 recommendation of universal HIV treatment ("treat all"). However, there are few rigorous assessments of the real-world impact of treat all policies on antiretroviral treatment (ART) uptake across different contexts. METHODS AND FINDINGS: We used longitudinal data for 814,603 patients enrolling in HIV care between 1 January 2004 and 10 July 2018 in 6 countries participating in the global International epidemiology Databases to Evaluate AIDS (IeDEA) consortium: Burundi (N = 11,176), Kenya (N = 179,941), Malawi (N = 84,558), Rwanda (N = 17,396), Uganda (N = 96,286), and Zambia (N = 425,246). Using a quasi-experimental regression discontinuity design, we assessed the change in the proportion initiating ART within 30 days of enrollment in HIV care (rapid ART initiation) after country-level adoption of the treat all policy. A modified Poisson model was used to identify factors associated with failure to initiate ART rapidly under treat all. In each of the 6 countries, over 60% of included patients were female, and median age at enrollment ranged from 32 to 36 years. In all countries studied, national adoption of treat all was associated with large increases in rapid ART initiation. Significant increases in rapid ART initiation immediately after treat all policy adoption were observed in Rwanda, from 44.4% to 78.9% of patients (34.5 percentage points [pp], 95% CI 27.2 to 41.7; p < 0.001), Kenya (25.7 pp, 95% CI 21.8 to 29.5; p < 0.001), Burundi (17.7 pp, 95% CI 6.5 to 28.9; p = 0.002), and Malawi (12.5 pp, 95% CI 7.5 to 17.5; p < 0.001), while no immediate increase was observed in Zambia (0.4 pp, 95% CI -2.9 to 3.8; p = 0.804) and Uganda (-4.2 pp, 95% CI -9.0 to 0.7; p = 0.090). The rate of rapid ART initiation accelerated sharply following treat all policy adoption in Malawi, Uganda, and Zambia; slowed in Kenya; and did not change in Rwanda and Burundi. In post hoc analyses restricted to patients enrolling under treat all, young adults (16-24 years) and men were at increased risk of not rapidly initiating ART (compared to older patients and women, respectively). However, rapid ART initiation following enrollment increased for all groups as more time elapsed since treat all policy adoption. Study limitations include incomplete data on potential ART eligibility criteria, such as clinical status, pregnancy, and enrollment CD4 count, which precluded the assessment of rapid ART initiation specifically among patients known to be eligible for ART before treat all. CONCLUSIONS: Our analysis indicates that adoption of treat all policies had a strong effect on increasing rates of rapid ART initiation, and that these increases followed different trajectories across the 6 countries. Young adults and men still require additional attention to further improve rapid ART initiation.
Emerging priorities for HIV service delivery.
(2020-Feb) Ford N; Geng E; Ellman T; Orrell C; Ehrenkranz P; Sikazwe I; Jahn A; Rabkin M; Ayisi Addo S; Grimsrud A; Rosen S; Zulu I; Reidy W; Lejone T; Apollo T; Holmes C; Kolling AF; Phate Lesihla R; Nguyen HH; Bakashaba B; Chitembo L; Tiriste G; Doherty M; Bygrave H; National AIDS Control Programme, Ministry of Health, Accra, Ghana.; Department HIV, World Health Organization, Addis Ababa, Ethiopia.; ICAP, Columbia University Mailman School of Public Health, New York, New York, United States of America.; Bill and Melinda Gates Foundation, Seattle, Washington, United States of America.; National AIDS Control Programme, Ministry of Health, Maseru, Lesotho.; Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa.; Department of Surveillance, Prevention and Control of STIs, HIV/AIDS and Viral Hepatitis, Ministry of Health, Brasilia, Brazil.; SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho.; The AIDS Support Organization (TASO), Kampala, Uganda.; International AIDS Society, Cape Town, South Africa.; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.; Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.; Georgetown University, Washington, DC, United States of America.; Treatment and Care Department, Viet Nam Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam.; Ministry of Health and Child Care Zimbabwe, Harare, Zimbabwe.; Ministry of Health, Lilongwe, Malawi.; Department of Medicine, Faculty of Health Sciences, Cape Town, South Africa.; Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America.; Department HIV, World Health Organization Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Department HIV & Global Hepatitis Programme, World Health Organization, Geneva, Switzerland.; Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Nathan Ford and co-authors discuss global priorities in the provision of HIV prevention and treatment services.
Extending Visit Intervals for Clinically Stable Patients on Antiretroviral Therapy: Multicohort Analysis of HIV Programs in Southern Africa.
(2019-Aug-01) Haas AD; Johnson LF; Grimsrud A; Ford N; Mugglin C; Fox MP; Euvrard J; van Lettow M; Prozesky H; Sikazwe I; Chimbetete C; Hobbins M; Kunzekwenyika C; Egger M; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.; Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.; Global Health, Boston University School of Public Health, Boston, MA.; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.; Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia.; Newlands Clinic, Harare, Zimbabwe.; Department of HIV/AIDS World Health Organization, Geneva, Switzerland.; SolidarMed, Masvingo, Zimbabwe.; International AIDS Society, Cape Town, South Africa.; Division of Infectious Diseases, Department of Medicine, Tygerberg Academic Hospital, University of Stellenbosch, Cape Town, South Africa.; Dignitas International, Zomba, Malawi.; SolidarMed, Lucerne, Switzerland.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: The World Health Organization recommends differentiated antiretroviral therapy (ART) delivery with longer visit intervals for clinically stable patients. We examined time trends in visit frequency and associations between criteria for clinical stability and visit frequency in ART programs in Southern Africa. METHODS: We included adults on ART from 4 programs with viral-load monitoring, 2 programs with CD4 monitoring, and 4 programs with clinical monitoring of ART. We classified patients as clinically stable based on virological (viral load <1000 copies/mL), immunological (CD4 >200 cells/µL), or clinical (no current tuberculosis) criteria. We used Poisson regression and survival models to examine associations between criteria for clinical stability and the rate of clinic visits. RESULTS: We included 180,837 patients. There were trends toward fewer visits in more recent years and with longer ART duration. In all ART programs, clinically stable patients were seen less frequently than patients receiving failing ART, but the strength of the association varied. Adjusted incidence rate ratios comparing visit rates for stable patients with patients on failing ART were 0.82 (95% confidence interval: 0.73 to 0.90) for patients classified based on the virological criterion, 0.81 (0.69 to 0.93) for patients classified based on the clinical criterion, and 0.90 (0.85 to 0.96) for patients classified based on the immunological criterion for stability. CONCLUSION: Differences in visit rates between stable patients and patients failing ART were variable and modest overall. Larger differences were seen in programs using virological criteria for clinical stability than in programs using immunological criteria. Greater access to routine viral-load monitoring may increase scale-up of differentiated ART delivery.
Global trends in CD4 count measurement and distribution at first antiretroviral treatment initiation.
(2024-Nov-06) de Waal R; Wools-Kaloustian K; Brazier E; Althoff KN; Jaquet A; Duda SN; Kumarasamy N; Savory T; Byakwaga H; Murenzi G; Justice A; Ekouevi DK; Cesar C; Pasayan MKU; Thawani A; Kasozi C; Babakazo P; Karris M; Messou E; Cortes CP; Kunzekwenyika C; Choi JY; Owarwo NC; Niyongabo A; Marconi VC; Ezechi O; Castilho JL; Petoumenos K; Johnson L; Ford N; Kassanjee R; Department of Medicine, University of California San Diego, USA.; Institute for Implementation Science in Population Health, City University of New York, USA.; National Institute for Health and Medical Research UMR 1219, Research Institute for Sustainable Development EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, France.; Centre for Infectious Disease Epidemiology and Research, School of Public Health, University of Cape Town, South Africa. CIDER, Level 3 Falmouth Building, Anzio Road, Observatory, 7925, South Africa.; Association Nationale de Soutien aux Séropositifs et malades du SIDA-Santé PLUS (ANSS-Santé PLUS), Burundi.; Kinshasa School of Public Health, University of Kinshasa, Democratic Republic of Congo.; Centre for Reproduction and Population Health Studies, Nigerian Institute for Medical Research, Lagos, Nigeria.; Infectious Diseases Medical Centre, CART CRS, Voluntary Health Services, Chennai, India.; Fundacion Huesped, Argentina.; Emory University School of Medicine and Rollins School of Public Health, Atlanta, USA.; Research for Development (RD Rwanda), and Rwanda Military Referral and Teaching Hospital, Kigali, Rwanda.; Research Institute for Tropical Medicine, Muntinlupa City, Philippines.; Université de Lomé, Centre de Formation et de Recherche en Santé Publique, Lomé, Togo.; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, USA.; Department of Internal Medicine, Faculty of Medicine, University of Chile, and Hospital Clínico San Borja Arriarán & Fundación Arriarán, Santiago, Chile.; Department of Biomedical Informatics, Vanderbilt University Medical Center, USA.; VA Connecticut Healthcare System, Yale Schools of Medicine and Public Health, Yale University, USA.; Department of Community Health, Mbarara University of Science and Technology, Uganda.; Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea.; The Kirby Institute, University of New South Wales, Sydney, Australia.; Lighthouse Trust, Lilongwe, Malawi.; Centre de Prise en charge, de Recherche et de Formation (CePReF) Yopougon-Attié, Abidjan, Côte d'Ivoire.; Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland.; SolidarMed Zimbabwe.; Infectious Diseases Institute, Makerere University, Uganda.; Division of Infectious Diseases, Vanderbilt University Medical Center, TN, USA.; Masaka Regional Referral Hospital, Masaka City, Uganda.; Department of Medicine, Indiana University School of Medicine, USA.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: While people with HIV (PWH) start antiretroviral treatment (ART) regardless of CD4 count, CD4 measurement remains crucial for detecting advanced HIV disease and evaluating ART programmes. We explored CD4 measurement (proportion of PWH with a CD4 result available) and prevalence of CD4 <200 cells/µL at ART initiation within the International epidemiology Databases to Evaluate AIDS (IeDEA) global collaboration. METHODS: We included PWH at participating ART programmes who first initiated ART at age 15-80 years during 2005-2019. We described proportions of PWH (i) with CD4 (measured within 6 months before to 2 weeks after ART initiation); and (ii) among those with a CD4, with CD4 <200; by year of ART initiation and region. RESULTS: We included 1,355,104 PWH from 42 countries in 7 regions; 63% were female. Median (interquartile range) age at ART initiation was 37 (31-44) in men and 32 (26-39) in women. CD4 measurement initially increased, or remained stable over time until around 2013, but then declined to low levels in some regions (Southern Africa, except South Africa: from 54 to 13%; East Africa 85 to 31%; Central Africa 72 to 20%; West Africa: 91 to 53%; and Latin America: 87 to 56%). Prevalence of CD4<200 declined over time in all regions, but plateaued after 2015 at ≥30%. CONCLUSIONS: CD4 measurement has declined sharply in recent years, especially in sub-Saharan Africa. Among those with a CD4, the prevalence of CD4 <200 remains concerningly high. Scaling up CD4 testing and securing adequate funding are urgent priorities.
Global Trends in CD4 Measurement and Immunosuppression at ART Initiation Among Children With HIV.
(2025-Apr-04) Patten G; Malateste K; Bolton Moore C; Sipambo N; Mokone L; Anderegg N; Wools-Kaloustian K; Michael D; Odhiambo F; Kasozi C; Desmonde S; Amorissani-Folquet M; Leroy V; Kumara Wati D; Nallusamy R; Kinikar A; Quy DT; Yotebieng M; Ebasone PV; Lelo P; Pinto J; Rouzier V; Machado DM; Haw NJ; Ford N; Department of Pediatrics, Prof. Dr. I.G.N.G. Ngoerah General Hospital, Udayana University, Bali, Indonesia.; School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil.; Pediatric Department, Cocody University Hospital, Abidjan, Cote d'Ivoire.; Department of Medicine, Indiana University School of Medicine; Indianapolis, Indiana.; Department of Pediatrics, BJ Government Medical College and Sassoon General Hospital, Pune, India.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; Kalembe Lembe Pediatric Hospital, Kinshasa, Democratic Republic of the Congo.; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.; Clinical Research Education, Networking and Consultancy (CRENC), Yaoundé, Cameroon.; Department of Pediatrics, Escola Paulista de Medicina, Federal University of Sao Paulo (UNIFESP), São Paulo, Brazil.; Centres GHESKIO, Port-au-Prince, Haiti.; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.; SolidarMed, Maseru, Lesotho.; World Health Organization, Geneva, Switzerland.; Children's Hospital 1, Ho Chi Minh City, Vietnam.; University of Bordeaux, National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, Bordeaux, France.; Department of Paediatrics and Child Health, Harriet Shezi Children's Clinic, Chris Hani Baragwanath Academic Hospital, University of Witwatersrand, Johannesburg, South Africa.; From the Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa.; Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.; Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York.; Centre d'Epidémiologie et de Recherche en santé des POPulations (CERPOP), French National Institute for Health and Medical Research (Inserm), University of Toulouse 3, UMR 1295, Toulouse, France.; Department of Pediatrics, Penang Hospital, Penang, Malaysia.; Masaka Regional Referral Hospital, Masaka City, Uganda.; Tanzanian National Institute of Medical Research, Mwanza, Tanzania.
Eligibility for antiretroviral therapy is no longer based on immune criteria. In a global cohort of 97,453 children, between 2005 and 2021, we observed large declines in CD4 measurement, from 51% to 12% among <5 seconds, and from 74% to 20% among those 5-14 years of age. Lack of CD4 testing may negatively affect clinical care and surveillance of severe immune suppression.
Retention and mortality on antiretroviral therapy in sub-Saharan Africa: collaborative analyses of HIV treatment programmes.
(2018-Feb) Haas AD; Zaniewski E; Anderegg N; Ford N; Fox MP; Vinikoor M; Dabis F; Nash D; Sinayobye JD; Niyongabo T; Tanon A; Poda A; Adedimeji AA; Edmonds A; Davies MA; Egger M; Institut Supérieur des Sciences de la santé, Université Polytechnique de Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso.; Department of Epidemiology and Biostatistics, City University of New York, School of Public Health, New York, NY, USA.; Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA.; Department of Epidemiology and Population Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa.; ISPED, Centre Inserm U1219-Bordeaux Population Health, Université de Bordeaux, Bordeaux, France.; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.; Department of Global Health, Boston University School of Public Health, Boston, MA, USA.; Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.; World Health Organisation, Geneva, Switzerland.; Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.; Rwanda Military Hospital, Kigali, Rwanda.; Service de Maladies Infectieuses et Tropicales (SMIT), CHU de Treichville, Abidjan, Cote d'Ivoire.; Centre National de Reference en Matiere de VIH/SIDA (CNR), Bujumbura, Burundi.; School of Medicine, University of Zambia, Lusaka, Zambia.; Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland.; Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
INTRODUCTION: By 2020, 90% of all people diagnosed with HIV should receive long-term combination antiretroviral therapy (ART). In sub-Saharan Africa, this target is threatened by loss to follow-up in ART programmes. The proportion of people retained on ART long-term cannot be easily determined, because individuals classified as lost to follow-up, may have self-transferred to another HIV treatment programme, or may have died. We describe retention on ART in sub-Saharan Africa, first based on observed data as recorded in the clinic databases, and second adjusted for undocumented deaths and self-transfers. METHODS: We analysed data from HIV-infected adults and children initiating ART between 2009 and 2014 at a sub-Saharan African HIV treatment programme participating in the International epidemiology Databases to Evaluate AIDS (IeDEA). We used the Kaplan-Meier method to calculate the cumulative incidence of retention on ART and the Aalen-Johansen method to calculate the cumulative incidences of death, loss to follow-up, and stopping ART. We used inverse probability weighting to adjust clinic data for undocumented mortality and self-transfer, based on estimates from a recent systematic review and meta-analysis. RESULTS: We included 505,634 patients: 12,848 (2.5%) from Central Africa, 109,233 (21.6%) from East Africa, 347,343 (68.7%) from Southern Africa and 36,210 (7.2%) from West Africa. In crude analyses of observed clinic data, 52.1% of patients were retained on ART, 41.8% were lost to follow-up and 6.0% had died 5 years after ART initiation. After accounting for undocumented deaths and self-transfers, we estimated that 66.6% of patients were retained on ART, 18.8% had stopped ART and 14.7% had died at 5 years. CONCLUSIONS: Improving long-term retention on ART will be crucial to attaining the 90% on ART target. Naïve analyses of HIV cohort studies, which do not account for undocumented mortality and self-transfer of patients, may severely underestimate both mortality and retention on ART.
Sustainable HIV treatment in Africa through viral-load-informed differentiated care.
(2015-Dec-03) Phillips A; Shroufi A; Vojnov L; Cohn J; Roberts T; Ellman T; Bonner K; Rousseau C; Garnett G; Cambiano V; Nakagawa F; Ford D; Bansi-Matharu L; Miners A; Lundgren JD; Eaton JW; Parkes-Ratanshi R; Katz Z; Maman D; Ford N; Vitoria M; Doherty M; Dowdy D; Nichols B; Murtagh M; Wareham M; Palamountain KM; Chakanyuka Musanhu C; Stevens W; Katzenstein D; Ciaranello A; Barnabas R; Braithwaite RS; Bendavid E; Nathoo KJ; van de Vijver D; Wilson DP; Holmes C; Bershteyn A; Walker S; Raizes E; Jani I; Nelson LJ; Peeling R; Terris-Prestholt F; Murungu J; Mutasa-Apollo T; Hallett TB; Revill P; Instituto Nacional de Saúde (INS), Ministry of Health, PO Box 264, Maputo, Mozambique.; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street E6531, Baltimore, Maryland 21205, USA.; Department of Population Health, New York University School of Medicine, 227 East 30th Street Office 615, New York, New York 10016, USA.; Infectious Diseases Institute (IDI), College of Health Sciences, Makerere University, PO Box 22418, Kampala, Uganda.; Kellogg School of Management, Northwestern University, 2001 Sheridan Road Evanston, Illinois 60208, USA.; Medicine, Global Health and Epidemiology, University of Washington (UW), 325 9th Avenue, Seattle, Washington 98104, USA.; Clinical Research Department, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK.; International Diagnostics Centre, London School of Hygiene &Tropical, Medicine, Keppel Street, London WC1E 7HT, UK.; HIV/AIDS and Global Hepatitis Programme, World Health Organization, 20 Ave Appia 1211, Geneva, Switzerland.; Division of Infectious Disease, Laboratory Grant Building S-146, Office Lane 154, Stanford University Medical Center, 300 Pasteur Drive, Stanford, California 94305-5107, USA.; CHIP, Department of infectious diseases, Rigshospitalet, University of Copenhagen, Blegdamsvej 92100 Copenhagen, Denmark.; Centre for Infectious Disease Research in Zambia, 5032 Great North Road, Lusaka, Zambia.; Health Services Research &Policy, London School of Hygiene and Tropical Medicine, Room 134, 15-17 Tavistock Place, London WC1H 9SY, UK.; The Office of the US Global AIDS Coordinator and Health Diplomacy (S/GAC), U.S. Department of State, SA-22, Suite 10300, 2201 C Street, Washington DC 20520, USA.; Department of Infectious Disease Epidemiology, Imperial College London, St Mary's Campus, Norfolk Place, London W2 1PG, UK.; Massachusetts General Hospital Division of Infectious Diseases, 50 Staniford Street, 936 Boston, Massachusetts 02114, USA.; Institute for Disease Modeling, 3150 139th Avenue SE, Bellevue, Washington 98005, USA.; Department of Infection and Population Health, University College London, Rowland Hill Street, London NW3 2PF, UK.; WHO Country Office 86 Enterprise Road Cnr, Glenara PO Box CY 348, Causeway Harare, Zimbabwe.; University of Zimbabwe, College of Health Sciences, Department of Paediatrics and Child Health, PO Box A178, Avondale, Harare, Zimbabwe.; University of New South Wales, Level 6, Wallace Wurth Building, UNSW Campus, Sydney, New South Wales 2052, Australia.; Care and Treatment Branch Center for Global Health, Division of Global HIV/AIDS (GAP), CDC, MS-E04, 1600 Clifton Road NE, Atlanta, Georgia 30333, USA.; Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.; Southern Africa Medical Unit (SAMU), Medecins sans Frontieres (MSF) SA, Waverley Business Park, Wyecroft Rd, Mowbray 7700, Cape Town, South Africa.; Médecins Sans Frontières, Access Campaign, rue du Lausanne 82, 1202 Geneva Switzerland.; Médecins Sans Frontières, 78 rue de Lausanne, Case Postale 116, 1211 Geneva 21, Switzerland.; Centre for Health Economics, University of York, Heslington, York YO10 5DD, UK.; Clinton Health Access Initiative, 383 Dorchester Avenue, Boston, Massachusetts 02127, USA.; Department of Viroscience, Erasmus Medical Center, PO Box 20403000CA Rotterdam, the Netherlands.; Division of General Medical Disciplines, Department of Medicine Stanford University, MSOB 1265 Welch Road x332 Stanford, California 94305, USA.; Ministry of Health and Child Care, P. O CY 1122, Causeway, Harare, Zimbabwe.; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials &Methodology, Aviation House, 125 Kingsway, London WC2B 6NH, UK.; Department of Molecular Medicine and Haematology, University of the Witwatersrand, South Africa.; Bill and Melinda Gates Foundation, PO Box 23350, Seattle, Washington 98199, USA.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy in sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for clinical assessment. The clinic costs are comparable with the costs of the drugs themselves and CD4 counts are measured every 6 months, but patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes, a transition to more cost-effective delivery of antiretroviral therapy is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (the viral load) provides a direct measure of the current treatment effect. Viral-load-informed differentiated care is a means of tailoring care so that those with suppressed viral load visit the clinic less frequently and attention is focussed on those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach to measuring viral load in many countries is to collect dried blood spot samples for testing in regional laboratories; however, there have been concerns over the sensitivity and specificity of this approach to define treatment failure and the delay in returning results to the clinic. We use modelling to synthesize evidence and evaluate the cost-effectiveness of viral-load-informed differentiated care, accounting for limitations of dried blood sample testing. We find that viral-load-informed differentiated care using dried blood sample testing is cost-effective and is a recommended strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of point-of-care viral load tests that may become available in the future.
The revolving door of HIV care: Revising the service delivery cascade to achieve the UNAIDS 95-95-95 goals.
(2021-May) Ehrenkranz P; Rosen S; Boulle A; Eaton JW; Ford N; Fox MP; Grimsrud A; Rice BD; Sikazwe I; Holmes CB; Center for Innovation in Global Health, Georgetown University, Washington, DC, United States of America.; MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom.; Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America.; Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.; HIV & Global Hepatitis Programme, World Health Organization, Geneva, Switzerland.; Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom.; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.; HIV Programmes & Advocacy Department, International AIDS Society, Cape Town, South Africa.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.; Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America.; Global Health, Bill & Melinda Gates Foundation, Seattle, WA, United States of America.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Peter Ehrenkranz and co-authors present a cyclical cascade of care for people with HIV infection, aiming to facilitate assessment of outcomes.
Trends in CD4 and viral load testing 2005 to 2018: multi-cohort study of people living with HIV in Southern Africa.
(2020-Jul) Zaniewski E; Dao Ostinelli CH; Chammartin F; Maxwell N; Davies MA; Euvrard J; van Dijk J; Bosomprah S; Phiri S; Tanser F; Sipambo N; Muhairwe J; Fatti G; Prozesky H; Wood R; Ford N; Fox MP; Egger M; Department of Biostatistics, School of Public Health, University of Ghana, Accra, Ghana.; Department of Global Health, Boston University, Boston, MA, USA.; Kheth'Impilo AIDS Free Living, Cape Town, South Africa.; Lighthouse, Lilongwe, Malawi.; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.; Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.; SolidarMed, Masvingo, Zimbabwe.; Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.; SolidarMed, Maseru, Lesotho.; Department of Epidemiology, Boston University, Boston, MA, USA.; Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.; Gugulethu ART Programme (Desmond Tutu HIV Centre), Cape Town, South Africa.; Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, United Kingdom.; Division of Infectious Diseases, Department of Medicine, Stellenbosch University, Cape Town, South Africa.; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.; Department of HIV/AIDS and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland.; Africa Health Research Institute, KwaZulu-Natal, South Africa.; Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.; School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
INTRODUCTION: The World Health Organization (WHO) recommends a CD4 cell count before starting antiretroviral therapy (ART) to detect advanced HIV disease, and routine viral load (VL) testing following ART initiation to detect treatment failure. Donor support for CD4 testing has declined to prioritize access to VL monitoring. We examined trends in CD4 and VL testing among adults (≥15 years of age) starting ART in Southern Africa. METHODS: We analysed data from 14 HIV treatment programmes in Lesotho, Malawi, Mozambique, South Africa, Zambia and Zimbabwe in 2005 to 2018. We examined the frequency of CD4 and VL testing, the percentage of adults with CD4 or VL tests, and among those having a test, the percentage starting ART with advanced HIV disease (CD4 count <200 cells/mm RESULTS: Among 502,456 adults, the percentage with CD4 testing at ART initiation decreased from a high of 78.1% in 2008 to a low of 38.0% in 2017; the probability declined by 14% each year (odds ratio (OR) 0.86; 95% CI 0.86 to 0.86). Frequency of CD4 testing also declined. The percentage starting ART with advanced HIV disease declined from 83.3% in 2005 to 23.5% in 2018; each year the probability declined by 20% (OR 0.80; 95% CI 0.80 to 0.81). VL testing after starting ART varied; 61.0% of adults in South Africa and 10.7% in Malawi were tested, but fewer than 2% were tested in the other four countries. The probability of VL testing after ART start increased only modestly each year (OR 1.06; 95% CI 1.05 to 1.06). The percentage with unsuppressed VL was 8.6%. There was no evidence of a decrease in unsuppressed VL over time (OR 1.00; 95% CI 0.99 to 1.01). CONCLUSIONS: CD4 cell counting declined over time, including testing at the start of ART, despite the fact that many patients still initiated ART with advanced HIV disease. Without CD4 testing and expanded VL testing many patients with advanced HIV disease and treatment failure may go undetected, threatening the effectiveness of ART in sub-Saharan Africa.