Browsing by Author "Holmes C"

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Accurate dried blood spots collection in the community using non-medically trained personnel could support scaling up routine viral load testing in resource limited settings.
(2019) Sikombe K; Hantuba C; Musukuma K; Sharma A; Padian N; Holmes C; Czaicki N; Simbeza S; Somwe P; Bolton-Moore C; Sikazwe I; Geng E; Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia.; Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America.; Division of Epidemiology, University of California, Berkeley, Berkeley, California, United States of America.; Center for Global Health and Quality, Georgetown University, Washington, District of Columbia, United States of America.; Division of Infectious Diseases, University of Alabama, Birmingham, Alabama, United States of America.; Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Regular plasma HIV-RNA testing for persons living with HIV on antiretroviral therapy (ART) is now the global standard, but as many as 60% of persons in Africa today on ART do not have access to standard laboratory HIV-RNA assays. As a result, patients in Zambia often receive treatment without any means of determining true virologic failure, which poses a risk of premature switch of ART regimens and widespread HIV drug resistance. Dry blood spots (DBS) on the other hand require unskilled personnel and less complex storage supply chain so are ideal to capture viral-load results from HIV patients outside clinic settings. We assess collection of DBS in the community using non-medically trained personnel (NMP) and documented challenges. We trained 23 NMP to collect DBS from lost to follow-up (LTFU) patients in 4 rural and urban Zambian districts. We developed a phlebotomy box to transport DBS without contamination at ambient temperature and concomitant training and standard operating procedures. We evaluated this through field observations, bi-weekly meetings, reports, and staff meetings. The laboratory assessed DBS quality for testing validity. We attempted to collect DBS from 357 participants in the community. Though individual reasons for refusal from the remaining 37% were not collected, NMPs reported privacy concerns, awkward box-size which drew attention in the community and fears of undisclosed uses of samples related to witchcraft and circulating narratives about past research. Successful DBS collection was not associated with patient gender, age, time on ART, enrolment CD4, facility. DBS viral-load collection by NMP is feasible in Zambia. Our training approach and assessments of NMP not part of the health system can be extended to patients by giving them more responsibility to manage their own differentiated care groups. Concerted efforts that compare collection of DBS by NMP to those collected by skilled-medical personnel are needed.
Application of a Multistate Model to Evaluate Visit Burden and Patient Stability to Improve Sustainability of Human Immunodeficiency Virus Treatment in Zambia.
(2018-Sep-28) Roy M; Holmes C; Sikazwe I; Savory T; Mwanza MW; Bolton Moore C; Mulenga K; Czaicki N; Glidden DV; Padian N; Geng E; Division of Epidemiology, University of California Berkeley.; Division of HIV/AIDS, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco General Hospital.; Centre for Infectious Diseases Research in Zambia, Lusaka.; Department of Epidemiology and Biostatistics, University of California, San Francisco.; University of Alabama, Birmingham.; Johns Hopkins University School of Medicine, Baltimore, Maryland.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Differentiated service delivery (DSD) for human immunodeficiency virus (HIV)-infected persons who are clinically stable on antiretroviral therapy (ART) has been embraced as a solution to decrease access barriers and improve quality of care. However, successful DSD implementation is dependent on understanding the prevalence, incidence, and durability of clinical stability. METHODS: We evaluated visit data in a cohort of HIV-infected adults who made at least 1 visit between 1 March 2013 and 28 February 2015 at 56 clinics in Zambia. We described visit frequency and appointment intervals using conventional stability criteria and used a mixed-effects linear regression model to identify predictors of appointment interval. We developed a multistate model to characterize patient stability over time and calculated incidence rates for transition between states. RESULTS: Overall, 167819 patients made 3418018 post-ART initiation visits between 2004 and 2015. Fifty-four percent of visits were pharmacy refill-only visits, and 24% occurred among patients on ART for >6 months and whose current CD4 was >500 cells/mm3. Median appointment interval at clinician visits was 59 days, and time on ART and current CD4 were not strong predictors of appointment interval. Cumulative incidence of clinical stability was 66.2% at 2 years after enrollment, but transition to instability (31 events per 100 person-years) and lapses in care (41 events per100 person-years) were common. CONCLUSIONS: Current facility-based care was characterized by high visit burden due to pharmacy refills and among treatment-experienced patients. Differentiated service delivery models targeted toward stable patients need to be adaptive given that clinical stability was highly transient and lapses in care were common.
Comparison of patient exit interviews with unannounced standardised patients for assessing HIV service delivery in Zambia: a study nested within a cluster randomised trial.
(2023-Jul-05) Sikombe K; Pry JM; Mody A; Rice B; Bukankala C; Eshun-Wilson I; Mutale J; Simbeza S; Beres LK; Mukamba N; Mukumbwa-Mwenechanya M; Mwamba D; Sharma A; Wringe A; Hargreaves J; Bolton-Moore C; Holmes C; Sikazwe IT; Geng E; Center for Innovation in Global Health, Georgetown University Medical Center, Washington, District of Columbia, USA.; Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA.; Implementation Science Unit, Center for Infectious Disease Research in Zambia, Lusaka, Zambia kombatende.sikombe@cidrz.org.; Implementation Science Unit, Center for Infectious Disease Research in Zambia, Lusaka, Zambia.; Social and Behavioural Science Research Group, Center for Infectious Disease Research in Zambia, Lusaka, Zambia.; Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.; Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.; Internal Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA.; Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVES: To compare unannounced standardised patient approach (eg, mystery clients) with typical exit interviews for assessing patient experiences in HIV care (eg, unfriendly providers, long waiting times). We hypothesise standardised patients would report more negative experiences than typical exit interviews affected by social desirability bias. SETTING: Cross-sectional surveys in 16 government-operated HIV primary care clinics in Lusaka, Zambia providing antiretroviral therapy (ART). PARTICIPANTS: 3526 participants aged ≥18 years receiving ART participated in the exit surveys between August 2019 and November 2021. INTERVENTION: Systematic sample (every n OUTCOME MEASURES: We compared patient experience among patients who received brief training prior to their care visit (explaining each patient experience construct in the exit survey, being anonymous, without manipulating behaviour) with those who did not undergo training on the survey prior to their visit. RESULTS: Among 3526 participants who participated in exit surveys, 2415 were untrained (56% female, median age 40 (IQR: 32-47)) and 1111 were trained (50% female, median age 37 (IQR: 31-45)). Compared with untrained, trained patients were more likely to report a negative care experience overall (adjusted prevalence ratio (aPR) for aggregate sum score: 1.64 (95% CI: 1.39 to 1.94)), with a greater proportion reporting feeling unwelcome by providers (aPR: 1.71 (95% CI: 1.20 to 2.44)) and witnessing providers behaving rude (aPR: 2.28 (95% CI: 1.63 to 3.19)). CONCLUSION: Trained patients were more likely to identify suboptimal care. They may have understood the items solicited better or felt empowered to be more critical. We trained existing patients, unlike studies that use 'standardised patients' drawn from outside the patient population. This low-cost strategy could improve patient-centred service delivery elsewhere. TRIAL REGISTRATION NUMBER: Assessment was nested within a parent study; www.pactr.org registered the parent study (PACTR202101847907585).
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.
Improved Retention With 6-Month Clinic Return Intervals for Stable Human Immunodeficiency Virus-Infected Patients in Zambia.
(2018-Jan-06) Mody A; Roy M; Sikombe K; Savory T; Holmes C; Bolton-Moore C; Padian N; Sikazwe I; Geng E; Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia.; Division of HIV, ID, and Global Medicine, University of California, San Francisco and Zuckerberg San Francisco General Hospital.; Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland.; Division of Infectious Diseases, University of Alabama, Birmingham.; Division of Epidemiology, University of California, Berkeley.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Extending appointment intervals for stable HIV-infected patients in sub-Saharan Africa can reduce patient opportunity costs and decongest overcrowded facilities. METHODS: We analyzed a cohort of stable HIV-infected adults (on treatment with CD4 >200 cells/μL for more than 6 months) who presented for clinic visits in Lusaka, Zambia. We used multilevel, mixed-effects logistic regression adjusting for patient characteristics, including prior retention, to assess the association between scheduled appointment intervals and subsequent missed visits (>14 days late to next visit), gaps in medication (>14 days late to next pharmacy refill), and loss to follow-up (LTFU; >90 days late to next visit). RESULTS: A total of 62084 patients (66.6% female, median age 38, median CD4 438 cells/μL) made 501281 visits while stable on antiretroviral therapy. Most visits were scheduled around 1-month (25.0% clinical, 44.4% pharmacy) or 3-month intervals (49.8% clinical, 35.2% pharmacy), with fewer patients scheduled at 6-month intervals (10.3% clinical, 0.4% pharmacy). After adjustment and compared to patients scheduled to return in 1 month, patients with six-month clinic return intervals were the least likely to miss visits (adjusted odds ratio [aOR], 0.20; 95% confidence interval [CI], 0.17-0.24); miss medication pickups (aOR, 0.47; 95% CI 0.39-0.57), and become LTFU prior to the next visit (aOR, 0.41; 95% CI, 0.31-0.54). CONCLUSIONS: Six-month clinic return intervals were associated with decreased lateness, gaps in medication, and LTFU in stable HIV-infected patients and may represent a promising strategy to reduce patient burdens and decongest clinics.
Patients' Satisfaction with HIV Care Providers in Public Health Facilities in Lusaka: A Study of Patients who were Lost-to-Follow-Up from HIV Care and Treatment.
(2020-Apr) Mukamba N; Chilyabanyama ON; Beres LK; Simbeza S; Sikombe K; Padian N; Holmes C; Sikazwe I; Geng E; Schwartz SR; Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA. sschwartz@jhu.edu.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. njekwa.mukamba@gmail.com.; Centre for Global Health and Quality, Georgetown University Medical Center, Washington, DC, USA.; Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA.; Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA.; Division of Epidemiology, University of California, Berkeley, Berkeley, CA, USA.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Prognosis among those who are HIV infected has improved but long-term retention is challenging. Health systems may benefit from routinely measuring patient satisfaction which is a potential driver of engagement in HIV care, but it is not often measured in Africa, and Zambia in particular. This study aims to internally validate a patient satisfaction tool, assess satisfaction among patients previously lost-to-follow up (LTFU) from HIV care in Lusaka province and to measure association between patient satisfaction with their original clinic and re-engagement in HIV care. A cross-sectional assessment of satisfaction was conducted by tracing sampled patients drawn from public health facilities. Our findings suggest that satisfaction tool, previously validated in USA, exhibits high internal consistency for measuring patient satisfaction in the Zambian health system. Patient satisfaction with healthcare providers is associated with re-engagement in HIV care. Future interventions on patient-centred care are likely to optimize and support retention in care.
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.
Understanding Engagement in HIV Programmes: How Health Services Can Adapt to Ensure No One Is Left Behind.
(2020-Oct) Grimsrud A; Wilkinson L; Eshun-Wilson I; Holmes C; Sikazwe I; Katz IT; Harvard Global Health Institute, Cambridge, MA, USA.; Massachusetts General Hospital Center for Global Health, Boston, MA, USA.; Harvard Medical School, Boston, MA, USA.; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.; School of Medicine, Washington University, St Louis, MO, USA.; International AIDS Society, 3 Doris Road, Claremont, Cape Town, 7708, South Africa.; Desmond Tutu HIV Centre, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa. anna.grimsrud@iasociety.org.; Center for Innovation in Global Health, Georgetown University, Washington, DC, USA.; Department of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; International AIDS Society, 3 Doris Road, Claremont, Cape Town, 7708, South Africa. anna.grimsrud@iasociety.org.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
PURPOSE OF REVIEW: Despite the significant progress in the HIV response, gaps remain in ensuring engagement in care to support life-long medication adherence and viral suppression. This review sought to describe the different points in the HIV care cascade where people living with HIV were not engaging and highlight promising interventions. RECENT FINDINGS: There are opportunities to improve engagement both between testing and treatment and to support re-engagement in care for those in a treatment interruption. The gap between testing and treatment includes people who know their HIV status and people who do not know their status. People in a treatment interruption include those who interrupt immediately following initiation, early on in their treatment (first 6 months) and late (after 6 months or more on ART). For each of these groups, specific interventions are required to support improved engagement. There are diverse needs and specific populations of people living with HIV who are not engaged in care, and differentiated service delivery interventions are required to meet their needs and expectations. For the HIV response to realise the 2030 targets, engagement will need to be supported by quality care and patient choice combined with empowered patients who are treatment literate and have been supported to improve self-management.