Browsing by Author "Zaniewski E"

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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.
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.
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.