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Application opportunities of geographic information systems analysis to support achievement of the UNAIDS 90-90-90 targets in South Africa.
South African Medical Journal. 2017 Nov 27; 107(12):1065-1071.In an effort to achieve control of the HIV epidemic, 90-90-90 targets have been proposed whereby 90% of the HIV-infected population should know their status, 90% of those diagnosed should be receiving antiretroviral therapy, and 90% of those on treatment should be virologically suppressed. In this article we present approaches for using relatively simple geographic information systems (GIS) analyses of routinely available data to support HIV programme management towards achieving the 90-90-90 targets, with a focus on South Africa (SA) and other high-prevalence settings in low- and middle-income countries. We present programme-level GIS applications to map aggregated health data and individual-level applications to track distinct patients. We illustrate these applications using data from City of Johannesburg Region D, demonstrating that GIS has great potential to guide HIV programme operations and assist in achieving the 90-90-90 targets in SA.
AIDS. 2016 Nov 28; 30(18):2865-2873.OBJECTIVE: In 2015, the WHO recommended initiation of antiretroviral therapy (ART) in all HIV-positive patients regardless of CD4 cell count. We evaluated the cost-effectiveness of immediate versus deferred ART initiation among patients with CD4 cell counts exceeding 500cells/mul in four resource-limited countries (South Africa, Nigeria, Uganda, and India). DESIGN: A 5-year Markov model with annual cycles, including patients at CD4 cell counts more than 500 cells/mul initiating ART or deferring therapy until historic ART initiation criteria of CD4 cell counts more than 350 cells/mul were met. METHODS: The incidence of opportunistic infections, malignancies, cardiovascular disease, unscheduled hospitalizations, and death, were informed by the START trial results. Risk of HIV transmission was obtained from a systematic review. Disability weights were based on published literature. Cost inputs were inflated to 2014 US dollars and based on local sources. Results were expressed in cost per disability-adjusted life years averted and measured against WHO cost-effectiveness thresholds. RESULTS: Immediate initiation of ART is associated with a cost per disability-adjusted life years averted of -$317 [95% confidence interval (CI): -$796-$817] in South Africa; -$507 (95% CI: -$765-$837) in Nigeria; -$136 (-$382-$459) in Uganda; and -$78 (-$256-$374) in India. The results are largely driven by the impact of ART on reducing the risk of new HIV transmissions. CONCLUSIONS: In HIV-positive patients with CD4 counts above 500 cells/mul in the four studied countries, immediate initiation of ART versus deferred therapy until historic eligibility criteria are met is cost-effective and likely even cost-saving over time.
Short Communication: Population-Based Surveillance of HIV-1 Drug Resistance in Cameroonian Adults Initiating Antiretroviral Therapy According to the World Health Organization Guidelines.
AIDS Research and Human Retroviruses. 2016 Apr; 32(4):329-33.With ongoing earlier enrollment on and rapid scale-up of antiretroviral therapy (ART) in Cameroon, there are increasing risks of transmitted HIV drug resistance (HIVDR) at population levels. We, therefore, evaluated the threshold of HIVDR in a population initiating ART, to inform on the effectiveness of first-line regimens, considering HIV-1 diversity, plasma viral load (PVL), and CD4-based disease progression. A total of 53 adults [median (interquartile range, IQR) CD4: 162 cell/mm(3) (48-284); median (IQR) PVL: 5.34 log10 RNA (4.17-6.42) copies/ml] initiating ART in 2014 at the Yaounde Central Hospital were enrolled for HIV-1 protease-reverse transcriptase sequencing. Drug resistance mutations (DRMs) were interpreted using the 2009 World Health Organization (WHO) list versus the Stanford HIVdb algorithm version 7.0. Level of DRMs was low (3.77%) versus moderate (7.55%), respectively, following the WHO list (T69D, K103N) versus Stanford HIVdb (T69D, A98G, K103N, K238T), respectively. Prevailing clade was CRF02_AG (71.70%). Based on Stanford HIVdb, a slightly higher proportion of patients with DRMs were found among ones infected with CRF02_AG than in those non-CRF02_AG infected (7.89% vs. 6.67%, p = 1.000), with lower PVL (7.69% <5.5 vs. 0% >/=5.5 log10 RNA copies/ml, p = .488) and with higher CD4 counts (9.52% CD4 >/=200 vs. 3.33% CD4 <200 cells/mm(3), p = .749). Thresholds of DRMs suggest that standard first-line regimens currently used in Cameroon may remain effective at population levels, despite scale-up of ART in the country, pending adherence, and closed virological monitoring. With an intent-to-diagnose approach, the discrepant levels of DRMs support using Stanford HIVdb to evaluate initial ART, while revising the WHO list for surveillance.
A Clinical Prediction Score in Addition to WHO Criteria for Anti-Retroviral Treatment Failure in Resource-Limited Settings - Experience from Lesotho.
PLoS ONE. 2012 Oct 31; 7(10):e47937.Objective: To assess the positive predictive value (PPV) of a clinical score for viral failure among patients fulfilling the WHO-criteria for anti-retroviral treatment (ART) failure in rural Lesotho. Methods: Patients fulfilling clinical and/or immunological WHO failure-criteria were enrolled. The score includes the following predictors: Prior ART exposure (1 point), CD4-count below baseline (1), 25% and 50% drop from peak CD4-count (1 and 2), hemoglobin drop=1 g/dL (1), CD4 count<100/µl after 12 months (1), new onset papular pruritic eruption (1), and adherence<95% (3). A nurse assessed the score the day blood was drawn for viral load (VL). Reported confidence intervals (CI) were calculated using Wilsons method. Results: Among 1'131 patients on ART=6 months, 134 (11.8%) had immunological and/or clinical failure, 104 (78%) had blood drawn (13 died, 10 lost to follow-up, 7 did not show up). From 92 (88%) a result could be obtained (2 samples hemolysed, 10 lost). Out of these 92 patients 47 (51%) had viral failure (=5000 copies), 27 (29%) viral suppression (<40) and 18 (20%) intermediate viremia (40-4999). Overall, 20 (22%) had a score=5. A score=5 had a PPV of 100% to detect a VL>40 copies (95%CI: 84-100), and of 90% to detect a VL=5000 copies (70-97). Within the score, adherence<95%, CD4-count<100/Âµl and papular pruritic eruption were the strongest single predictors. Among 47 patients failing, 8 (17%) died before or within 4 weeks after being switched. Overall mortality was 4 (20%) among those with score=5 and 4 (5%) if score<5 (OR 4.3; 95%CI: 0.96-18.84, p = 0.057). Conclusion: A score=5 among patients fulfilling WHO-criteria had a PPV of 100% for a detectable VL and 90% for viral failure. In settings without regular access to VL-testing, this PPV may be considered high enough to switch this patient-group to second-line treatment without confirmatory VL-test.
The evolving cost of HIV in South Africa: Changes in health care cost with duration on antiretroviral therapy for public sector patients.
Journal of Acquired Immune Deficiency Syndromes. 2007 Jul; 45(3):348-354.A retrospective costing study of 212 patients enrolled in a nongovernmental organization-supported public sector antiretroviral treatment (ART) program near Cape Town, South Africa was performed from a health care system perspective. t-Regression was used to analyze total costs in 3 periods: Pre-ART (median length = 30 days), first 48 weeks on ART (Year One), and 49 to 112 weeks on ART (Year Two). Average cost per patient Pre-ART was $404. Average cost per patient-year of observation was $2502 in Year One and $1372 in Year Two. The proportion of costs attributable to hospital care fell from 70% Pre-ART to 24% by Year Two; the proportion attributable to ART rose from 31% in Year One to 55% in Year Two. In multivariate analysis, Pre-ART and Year One costs were significantly lower for asymptomatic patients compared with those with AIDS. Costs were significantly higher for those who died Pre-ART or in Year One. In Year Two, only week 48 CD4 cell count and being male were significantly associated with lower costs. This analysis suggests that the total cost of treatment for patients on ART falls by almost half after 1 year, largely attributable to a reduction in hospital costs. (author's)
WHO clinical staging of HIV infection and disease, tuberculosis and eligibility for antiretroviral treatment: relationship to CD4 lymphocyte counts.
International Journal of Tuberculosis and Lung Disease. 2005 Mar; 9(3):258-262.Setting: Thyolo district, Malawi. Objectives: To determine in HIV- positive individuals aged over 13 years CD4 lymphocyte counts in patients classified as WHO Clinical Stage III and IV and patients with active and previous tuberculosis (TB). Design: Cross-sectional study. Methods: CD4 lymphocyte counts were determined in all consecutive HIV-positive individuals presenting to the antiretroviral clinic in WHO Stage III and IV. Results: A CD4 lymphocyte count of =350 cells/µl was found in 413 (90%) of 457 individuals in WHO Stage III and IV, 96% of 77 individuals with active TB, 92% of 65 individuals with a history of pulmonary TB (PTB) in the last year, 91% of 89 individuals with a previous history of PTB beyond 1 year, 81% of 32 individuals with a previous history of extra-pulmonary TB, 93% of 107 individuals with active or past TB with another HIV-related disease and 89% of 158 individuals with active or past TB without another HIV-related disease. Conclusions: In our setting, nine of 10 HIV-positive individuals presenting in WHO Stage III and IV and with active or previous TB have CD4 counts of =350 cells/µl. It would thus be reasonable, in this or similar settings where CD4 counts are unavailable for clinical management, for all such patients to be considered eligible for antiretroviral therapy. (author's)
Geneva, Switzerland, WHO, . 47 p.The Caregiver Booklet is designed to help patients, family members, and community caregivers in the home-based care of serious long term illness. Home care is best for many people with long term illnesses, including those who are close to the end of life. All patients being cared for at home should be first assessed and treated by a health worker, who will help caregivers provide high quality home care and ensure that medicines are taken correctly. This booklet explains how to: 1. Deal with specific symptoms. 2. Provide care for terminal and bedridden patients at home. 3. Decide when to seek help from a health facility. The booklet should be given to the patient or caregiver and its contents explained by a nurse or community worker. The first section of the booklet covers ways to prevent problems from occuring and should be followed in all patients. The second section explains how to treat specific symptoms that may occur. (excerpt)
Geneva, Switzerland, UNAIDS, 2003. Prepared for the 2nd Meeting of the UNAIDS Global Reference Group on HIV / AIDS and Human Rights, August 25-27, 2003. 3 p.Over 20 years ago, policy and programmatic approaches to HIV testing emerged in a context of great fear about HIV/AIDS and about how to prevent HIV infected individuals from transmitting the virus. As testing methods were developed, HIV testing assumed an important role in epidemiological surveillance, and as treatment became available, on individual testing for clinical purposes. Yet, as national responses to the emerging epidemics unfolded, numerous States argued that the protection of public health warranted compulsory testing requirements of certain populations considered to be “high risk”, mandatory testing for access to certain goods and services, named reporting of those found to be infected and sometimes contact tracing and mandatory notification of partners, family, employers or community members. The realities of stigma, discrimination and the neglect of human rights protections were recognized to keep people away from prevention and care, and creating fertile ground for people not to get tested and, unaware of their HIV status, to further spread the virus. This recognition lead to a bridge between those concerned with human rights protections and those concerned with public health imperatives. Over time, the components of supportive testing became clearer, the concept of voluntary counseling and testing (VCT) was promulgated and policy direction from GPA/WHO centered on making voluntary counseling and testing an important focus of all national responses to the HIV/AIDS epidemics. This policy, further elaborated by WHO and UNAIDS remains in place today. (excerpt)