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; Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America.; Department of Medicine, University of Alabama, Birmingham, Alabama, United States of America.; Rakai Health Sciences Program, Kalisizo and Entebbe, Uganda.; Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, United States of America.; Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania.; Global Hepatitis Programme, HIV/AIDS Department, World Health Organization, Geneva, Switzerland.; Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America.; Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, United States of America.; Dignitas International, Zomba, Malawi.; Rwanda Military Hospital, Kigali, Rwanda.; Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America.; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.; 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; Centre National de Reference en Matiere de VIH/SIDA (CNR), Bujumbura, Burundi.; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, 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.; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.; ISPED, Centre Inserm U1219-Bordeaux Population Health, Université de Bordeaux, Bordeaux, France.; Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.; School of Medicine, University of Zambia, Lusaka, Zambia.; World Health Organisation, Geneva, Switzerland.; Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland.; Rwanda Military Hospital, Kigali, Rwanda.; Department of Epidemiology and Population Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.; Department of Epidemiology and Biostatistics, City University of New York, School of Public Health, New York, NY, USA.; Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.; Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA.; Service de Maladies Infectieuses et Tropicales (SMIT), CHU de Treichville, Abidjan, Cote d'Ivoire.; Department of Global Health, Boston University School of Public Health, Boston, MA, USA.; Institut Supérieur des Sciences de la santé, Université Polytechnique de Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso.; 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.
Scale of differentiated service delivery implementation in HIV care facilities in low- and middle-income countries: a global facility survey.
(2025-Jul) Fernández Villalobos NV; Helfenstein F; Khol V; Twizere C; Secco M; Castelnuovo B; Huwa J; Tiendredbeogo T; Wester CW; Fong SM; Murenzi G; Caro-Vega Y; Lyamuya RE; Rafael I; Zannou DM; Petoumenos K; Nsonde DM; Pinto J; Wools-Kaloustian K; Moore CB; Takassi OE; Kiertiburanakul S; Awoh RA; Ali SM; Fatti G; Malateste K; Zaniewski E; Ballif M; Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.; National Center for HIV/AIDS, Dermatology & STDs, Phnom Penh, Cambodia.; Department of Clinical Research, University of Bern, Bern, Switzerland.; School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya.; Kheth'Impilo AIDS Free Living, Cape Town, South Africa.; Lighthouse Trust, Lilongwe, Malawi.; Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil.; University of Buea, Buea, Cameroon.; SolidarMed, Pemba, Mozambique.; Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.; Department of Pediatrics, Hospital Likas, Kota Kinabalu, Malaysia.; Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, USA.; Lome University, Lome, Togo.; Department of Infectious Diseases, Bern University Hospital and University of Bern, Bern, Switzerland.; Centre National de Référence en matière de VIH/SIDA (CNR), Bujumbura, Burundi.; Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; 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.; Einstein-Rwanda Research and Capacity Building Program, Research for Development and Rwanda Military Referral and Teaching Hospital, Kigali, Rwanda.; Morogoro Regional Hospital - CTC, Indiana University, Morogoro, Tanzania.; The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia.; Departamento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.; Centre national de référence pour la recherche et la prise en charge des PVVIH au Centre National Hospitalier Universitaire HK MAGA (CNHU-HKM), Cotonou, Bénin.; Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.; Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.; University of Alabama at Birmingham, Birmingham, Alabama, USA.; Centre de Traitement Ambulatoire of Brazzaville, Brazzaville, Congo.
INTRODUCTION: In 2016, the World Health Organization recommended differentiated service delivery (DSD) as a client-centred approach to simplify HIV care in frequency and intensity, thus reducing the clinic visit burden on individuals and HIV programmes. We describe the scale of DSD implementation among HIV facilities in low- and middle-income countries (LMICs) in Latin America, Africa and the Asia-Pacific before the COVID-19 pandemic. METHODS: We analysed facility-level survey data from HIV care facilities participating in the International epidemiology Databases to Evaluate AIDS consortium in 2019. We used descriptive statistics to summarise the availability of DSD, multi-month dispensing (MMD) and DSD for HIV treatment models. We explored factors associated with DSD implementation using multivariable models. RESULTS: We included 175 facilities in the Asia-Pacific (n = 30), Latin America (n = 8), Central Africa (n = 21), East Africa (n = 74), Southern Africa (n = 28) and West Africa (n = 14). Overall, 133 facilities (76%) reported implementing DSD. Of these, 91% offered DSD for HIV treatment, 61% for HIV testing and 59% for antiretroviral therapy (ART) initiation. The most common duration of ART refills for clinically stable clients was 3MMD, (70%), followed by monthly (14%) and 6MMD (10%). Facility-based individual models were the most frequently available DSD for the HIV treatment model (82%), followed by client-managed group models (60%). Out-of-facility individual models were available at 48% of facilities. Facility-based individual models were particularly common among facilities in East (92%) and Southern Africa (96%). Facilities in medium and high HIV prevalence countries, and those with 3MMD, were more likely to implement DSD. CONCLUSIONS: In 2019, DSD was available in most HIV care facilities globally but was not evenly implemented across regions and HIV services. Most offered facility-based DSD for HIV treatment models and 3MMD for clinically stable clients. Efforts to expand DSD for HIV testing and ART initiation and to offer longer MMD can improve long-term retention in care of people living with HIV in LMICs, while further alleviating the operational burden on healthcare services. These findings from the pre-COVID-19 era underline the need for strengthening DSD in HIV care, which remains at the centre of current efforts towards client-centred care.
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 Global Health, Boston University, Boston, MA, USA.; Department of Epidemiology, Boston University, Boston, MA, USA.; Department of Biostatistics, School of Public Health, University of Ghana, Accra, Ghana.; Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, United Kingdom.; Kheth'Impilo AIDS Free Living, Cape Town, South Africa.; Gugulethu ART Programme (Desmond Tutu HIV Centre), Cape Town, South Africa.; SolidarMed, Masvingo, Zimbabwe.; 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.; Department of HIV/AIDS and Global Hepatitis Programme, World Health Organization, Geneva, Switzerland.; Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.; SolidarMed, Maseru, Lesotho.; Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.; School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.; Lighthouse, Lilongwe, Malawi.; Africa Health Research Institute, KwaZulu-Natal, South Africa.; Division of Infectious Diseases, Department of Medicine, Stellenbosch University, Cape Town, South Africa.; Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, 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.; 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.