Browsing by Author "Technau KG"

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Cervical cancer prevention and care in HIV clinics across sub-Saharan Africa: results of a facility-based survey.
(2024-Jul) Asangbeh-Kerman SL; Davidović M; Taghavi K; Dhokotera T; Manasyan A; Sharma A; Jaquet A; Musick B; Twizere C; Chimbetete C; Murenzi G; Tweya H; Muhairwe J; Wools-Kaloustian K; Technau KG; Anastos K; Yotebieng M; Jousse M; Ezechi O; Orang'o O; Bosomprah S; Pierre Boni S; Basu P; Bohlius J
INTRODUCTION: To eliminate cervical cancer (CC), access to and quality of prevention and care services must be monitored, particularly for women living with HIV (WLHIV). We assessed implementation practices in HIV clinics across sub-Saharan Africa (SSA) to identify gaps in the care cascade and used aggregated patient data to populate cascades for WLHIV attending HIV clinics. METHODS: Our facility-based survey was administered between November 2020 and July 2021 in 30 HIV clinics across SSA that participate in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. We performed a qualitative site-level assessment of CC prevention and care services and analysed data from routine care of WLHIV in SSA. RESULTS: Human papillomavirus (HPV) vaccination was offered in 33% of sites. Referral for CC diagnosis (42%) and treatment (70%) was common, but not free at about 50% of sites. Most sites had electronic health information systems (90%), but data to inform indicators to monitor global targets for CC elimination in WLHIV were not routinely collected in these sites. Data were collected routinely in only 36% of sites that offered HPV vaccination, 33% of sites that offered cervical screening and 20% of sites that offered pre-cancer and CC treatment. CONCLUSIONS: Though CC prevention and care services have long been available in some HIV clinics across SSA, patient and programme monitoring need to be improved. Countries should consider leveraging their existing health information systems and use monitoring tools provided by the World Health Organization to improve CC prevention programmes and access, and to track their progress towards the goal of eliminating CC.
Characterizing the double-sided cascade of care for adolescents living with HIV transitioning to adulthood across Southern Africa.
(2020-Jan) Tsondai PR; Sohn AH; Phiri S; Sikombe K; Sawry S; Chimbetete C; Fatti G; Hobbins MA; Technau KG; Rabie H; Bernheimer J; Fox MP; Judd A; Collins IJ; Davies MA
INTRODUCTION: As adolescents and young people living with HIV (AYLH) age, they face a "transition cascade," a series of steps associated with transitions in their care as they become responsible for their own healthcare. In high-income countries, this usually includes transfer from predominantly paediatric/adolescent to adult clinics. In sub-Saharan Africa, paediatric HIV care is mostly provided in decentralized, non-specialist primary care clinics, where "transition" may not necessarily include transfer of care but entails becoming more autonomous for one's HIV care. Using different age thresholds as proxies for when "transition" to autonomy might occur, we evaluated pre- and post-transition outcomes among AYLH. METHODS: We included AYLH aged <16 years at enrolment, receiving antiretroviral therapy (ART) within International epidemiology Databases to Evaluate AIDS Southern Africa (IeDEA-SA) sites (2004 to 2017) with no history of transferring care. Using the ages of 16, 18, 20 and 22 years as proxies for "transition to autonomy," we compared the outcomes: no gap in care (≥2 clinic visits) and viral suppression (HIV-RNA <400 copies/mL) in the 12 months before and after each age threshold. Using log-binomial regression, we examined factors associated with no gap in care (retention) in the 12 months post-transition. RESULTS: A total of 5516 AYLH from 16 sites were included at "transition" age 16 (transition-16y), 3864 at 18 (transition-18y), 1463 at 20 (transition-20y) and 440 at 22 years (transition-22y). At transition-18y, in the 12 months pre- and post-transition, 83% versus 74% of AYLH had no gap in care (difference 9.3 (95% confidence interval (CI) 7.8 to 10.9)); while 65% versus 62% were virally suppressed (difference 2.7 (-1.0 to 6.5%)). The strongest predictor of being retained post-transition was having no gap in the preceding year, across all transition age thresholds (transition-16y: adjusted risk ratio (aRR) 1.72; 95% CI (1.60 to 1.86); transition-18y: aRR 1.76 (1.61 to 1.92); transition-20y: aRR 1.75 (1.53 to 2.01); transition-22y: aRR 1.47; (1.21 to 1.78)). CONCLUSIONS: AYLH with gaps in care need targeted support to prevent non-retention as they take on greater responsibility for their healthcare. Interventions to increase virologic suppression rates are necessary for all AYLH ageing to adulthood.
Effect of antiretroviral therapy care interruptions on mortality in children living with HIV.
(2022-Apr-01) Davies C; Johnson L; Sawry S; Chimbetete C; Eley B; Vinikoor M; Technau KG; Ehmer J; Rabie H; Phiri S; Tanser F; Malisita K; Fatti G; Osler M; Wood R; Newton S; Haas A; Davies MA
OBJECTIVE: To evaluate the characteristics and outcomes of HIV-infected children that have care interruptions, during which the child's health status and use of medication is unknown. DESIGN: We included data on children initiating ART between 2004 and 2016 at less than 16 years old at 16 International Epidemiologic Databases to Evaluate AIDS Southern Africa cohorts. Children were classified as loss to follow up (LTFU) if they had not attended clinic for more than 180 days. Children had a care interruption if they were classified as LTFU, and subsequently returned to care. Children who died within 180 days of ART start were excluded. METHODS: The main outcome was all cause mortality. Two exposed groups were considered: those with a first care interruption within the first 6 months on ART, and those with a first care interruption after 6 months on ART. Adjusted hazard ratios were determined using a Cox regression model. RESULTS: Among 53 674 children included, 23 437 (44%) had a care interruption, of which 10 629 (20%) had a first care interruption within 6 months on ART and 12 808 (24%) had a first care interruption after 6 months on ART. Increased mortality was associated with a care interruption within 6 months on ART [adjusted hazard ratio (AHR) = 1.52, 95% CI 1.12-2.04] but not with a care interruption after 6 months on ART (AHR = 1.05, 95% CI 0.77-1.44). CONCLUSION: The findings suggest that strengthening retention of children in care in the early period after ART initiation is critical to improving paediatric ART outcomes.
Outcomes of Infants Starting Antiretroviral Therapy in Southern Africa, 2004-2012.
(2015-Aug-15) Porter M; Davies MA; Mapani MK; Rabie H; Phiri S; Nuttall J; Fairlie L; Technau KG; Stinson K; Wood R; Wellington M; Haas AD; Giddy J; Tanser F; Eley B
BACKGROUND: There are limited published data on the outcomes of infants starting antiretroviral therapy (ART) in routine care in Southern Africa. This study aimed to examine the baseline characteristics and outcomes of infants initiating ART. METHODS: We analyzed prospectively collected cohort data from routine ART initiation in infants from 11 cohorts contributing to the International Epidemiologic Database to Evaluate AIDS in Southern Africa. We included ART-naive HIV-infected infants aged <12 months initiating ≥3 antiretroviral drugs between 2004 and 2012. Kaplan-Meier estimates were calculated for mortality, loss to follow-up (LTFU), transfer out, and virological suppression. We used Cox proportional hazard models stratified by cohort to determine baseline characteristics associated with outcomes mortality and virological suppression. RESULTS: The median (interquartile range) age at ART initiation of 4945 infants was 5.9 months (3.7-8.7) with follow-up of 11.2 months (2.8-20.0). At ART initiation, 77% had WHO clinical stage 3 or 4 disease and 87% were severely immunosuppressed. Three-year mortality probability was 16% and LTFU 29%. Severe immunosuppression, WHO stage 3 or 4, anemia, being severely underweight, and initiation of treatment before 2010 were associated with higher mortality. At 12 months after ART initiation, 17% of infants were severely immunosuppressed and the probability of attaining virological suppression was 56%. CONCLUSIONS: Most infants initiating ART in Southern Africa had severe disease with high probability of LTFU and mortality on ART. Although the majority of infants remaining in care showed immune recovery and virological suppression, these responses were suboptimal.
Prognosis of children with HIV-1 infection starting antiretroviral therapy in Southern Africa: a collaborative analysis of treatment programs.
(2014-Jun) Davies MA; May M; Bolton-Moore C; Chimbetete C; Eley B; Garone D; Giddy J; Moultrie H; Ndirangu J; Phiri S; Rabie H; Technau KG; Wood R; Boulle A; Egger M; Keiser O
BACKGROUND: Prognostic models for children starting antiretroviral therapy (ART) in Africa are lacking. We developed models to estimate the probability of death during the first year receiving ART in Southern Africa. METHODS: We analyzed data from children ≤10 years of age who started ART in Malawi, South Africa, Zambia or Zimbabwe from 2004 to 2010. Children lost to follow up or transferred were excluded. The primary outcome was all-cause mortality in the first year of ART. We used Weibull survival models to construct 2 prognostic models: 1 with CD4%, age, World Health Organization clinical stage, weight-for-age z-score (WAZ) and anemia and the other without CD4%, because it is not routinely measured in many programs. We used multiple imputation to account for missing data. RESULTS: Among 12,655 children, 877 (6.9%) died in the first year of ART. We excluded 1780 children who were lost to follow up/transferred from main analyses; 10,875 children were therefore included. With the CD4% model probability of death at 1 year ranged from 1.8% [95% confidence interval (CI): 1.5-2.3] in children 5-10 years with CD4% ≥10%, World Health Organization stage I/II, WAZ ≥ -2 and without severe anemia to 46.3% (95% CI: 38.2-55.2) in children <1 year with CD4% < 5%, stage III/IV, WAZ< -3 and severe anemia. The corresponding range for the model without CD4% was 2.2% (95% CI: 1.8-2.7) to 33.4% (95% CI: 28.2-39.3). Agreement between predicted and observed mortality was good (C-statistics = 0.753 and 0.745 for models with and without CD4%, respectively). CONCLUSIONS: These models may be useful to counsel children/caregivers, for program planning and to assess program outcomes after allowing for differences in patient disease severity characteristics.
Tuberculosis Diagnosis, Treatment, and Prevention Services for Children Living with HIV in Low- and Middle-Income Countries: A Multiregional Site Survey.
(2025-Jun-16) Laycock K; Technau KG; Lelo P; Jantarabenjakul W; Yonaba C; Pinto J; Menser M; Maruri F; Odhiambo F; Rambiki E; Babakazo P; Nguyen VL; Folquet M; Machado DM; Kalema N; Muula G; Brazier E; Nguyen DQ; Dame J; Luque MT; Semeere A; Eley B; Yotebieng M; Kariminia A; Rouzier V; Byakwaga H; Marcy O; Enane LA
BACKGROUND: Tuberculosis (TB) remains a leading cause of morbidity and mortality for children living with HIV (CLHIV), with gaps in TB screening, diagnostics, management, and TB preventive therapy (TPT). We investigated reported practices in these domains at sites caring for CLHIV in low- and middle-income countries (LMICs) within the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium. METHODS: We implemented a site survey from September 2020 to February 2021, querying pre-pandemic practices. This analysis included sites in LMICs providing care for CLHIV that diagnosed TB in 2019. We analyzed responses using descriptive statistics and assessed regional differences using Fisher's exact or chi-square tests. RESULTS: Of 238 IeDEA sites, 227 (95%) responded and 135 met the inclusion criteria. Most (90%) reported screening for TB at HIV care enrollment. Access to diagnostics varied significantly by region, including nucleic acid amplification testing (NAAT, range 67-100%), mycobacterial culture (range 43%-83%), and drug susceptibility testing (range 30%-82%) (P < .001). On-site TB treatment was high (90%). Reported stock-outs occurred for isoniazid (23/116, 20%) and other TB medications (11/114, 9.6%, range 0%-33%, P = .008). TPT provision ranged 50%-100% (P < .001). Six months of isoniazid was the most common TPT regimen for children (88%). Shorter TPT regimens were uncommon (0.9%-2.8%), as were regimens for multidrug-resistant TB exposure (4.6%). CONCLUSIONS: Overall reported availability of NAAT and integrated TB/HIV treatment for CLHIV cared for at these IeDEA sites in LMICs is encouraging but varies by context. Heterogeneous implementation gaps remain-particularly for drug susceptibility testing, TPT delivery, and TPT regimens-which may impede TB prevention, management, and successful outcomes for CLHIV, warranting continued close attention over time and as global TB care guidelines and services evolve.
Variations in the characteristics and outcomes of children living with HIV following universal ART in sub-Saharan Africa (2006-17): a retrospective cohort study.
(2021-Jun) Iyun V; Technau KG; Vinikoor M; Yotebieng M; Vreeman R; Abuogi L; Desmonde S; Edmonds A; Amorissani-Folquet M; Davies MA
BACKGROUND: The proportion of children living with HIV and receiving antiretroviral therapy (ART) in sub-Saharan Africa has increased greatly since 2006, yet the changes in their demographic characteristics and treatment outcomes have not been well described. We examine the trends in characteristics and outcomes of children living with HIV who were younger than 5 years at ART initiation, and compare outcomes over time and across country income groups. METHODS: We conducted a retrospective cohort analysis of data from children living with HIV who were younger than 5 years at ART initiation from 45 paediatric sites in 16 low-income, lower-middle-income, and upper-middle-income countries in sub-Saharan Africa (Benin, Burundi, Côte d'Ivoire, Democratic Republic of the Congo, Ghana, Kenya, Lesotho, Malawi, Mali, Mozambique, Rwanda, South Africa, Togo, Uganda, Zambia, and Zimbabwe). Outcomes were trends in patient characteristics at ART initiation (age, weight, height, and CD4%), and comparisons of mortality and loss to follow-up during ART over time and in various economic settings. We identified risk factors for mortality using Cox proportional hazards models. Each participating region had relevant institutional ethics review board approvals to contribute data to the analysis. FINDINGS: We included 32 221 children living with HIV and initiating ART younger than 5 years between Jan 1, 2006, and Dec 31, 2017. Median age at ART initiation was 20·4 months (IQR 9·4-36·0) in 2006-10, 19·2 months (8·3-33·6) in 2011-13, and 19·2 months (8·8-33·7) in 2014-17. Median age at ART initiation was 13·2 months (IQR 4·7-26·8) in upper-middle-income countries, 22·6 months (13·2-37·5) in lower-middle-income countries and 24·2 months (13·5-39·1) in low-income countries. The proportion of children initiating ART younger than 3 months increased from 770 (5·1%) of 14 943 children in 2006-10 to 728 (10·0%) of 7290 children in 2014-17. The proportion of children initiating ART with severe immunosuppression decreased from 5469 (74·7%) of 7314 children for whom CD4% data were available in 2006-10 to 2353 (55·2%) of 4269 children in 2014-17. Mortality at 24 months on ART decreased from 970 (6·5%) of 14 943 children in 2006-10 to 214 (2·9%) of 7290 children in 2014-17. Loss to follow-up was 20·5% (95% CI 20·1-21·0) overall, and was similar across time periods. In multivariable analysis, lower mortality was observed for more recent ART initiation cohorts (adjusted hazard ratio 0·70, 95% CI 0·63-0·79 for 2011-13; 0·53, 0·45-0·72 for 2014-17 vs 2006-10) and for those residing in an upper-middle-income country (0·42, 0·35-0·49 vs low-income countries). INTERPRETATION: Mortality declined significantly after universal ART recommendations for children younger than 2 years in 2010 and children younger than 5 years in 2013. However, substantial variations persisted across country income groups, and one in five children continue to be lost to follow-up. Targeted interventions are required to improve outcomes of children living with HIV, especially in the poorest countries. FUNDING: National Institute of Allergy and Infectious Disease.