Journal Article > ResearchFull Text
Public Health Action. 2014 June 21; Volume 4 (Issue 2); 113-115.; DOI: 10.5588/pha.14.0018
Kanyerere H, Mganga A, Harries AD, Tayler-Smith K, Jahn A, et al.
Public Health Action. 2014 June 21; Volume 4 (Issue 2); 113-115.; DOI: 10.5588/pha.14.0018
From 2000 to 2012, Malawi scaled up antiretroviral therapy (ART) from <3000 to 404 905 persons living with HIV/AIDS (human immunodeficiency virus/acquired immune-deficiency syndrome), representing an ART coverage of 40.6% among those living with HIV. During this time, annual tuberculosis (TB) notifications declined by 28%, from 28 234 to 20 463. Percentage declines in annual TB case notifications were as follows: new TB (26%), recurrent TB (40%), new smear-positive pulmonary TB (19%), new smear-negative pulmonary TB (42%), extra-pulmonary TB (19%), HIV-positive TB (30%) and HIV-negative TB (10%). The decline in TB notifications is associated with ART scale-up, supporting its value in controlling TB in high HIV prevalence areas in sub-Saharan Africa.
Journal Article > CommentaryFull Text
Public Health Action. 2014 June 21; Volume 3 (Issue 3); DOI:10.5588/pha.13.0018
Kanyerere H, Mganga A, Harries AD, Tayler-Smith K, Jahn A, et al.
Public Health Action. 2014 June 21; Volume 3 (Issue 3); DOI:10.5588/pha.13.0018
Journal Article > CommentaryFull Text
Lancet. 2011 July 16; Volume 378 (Issue 9787); 282-4.; DOI:10.1016/S0140-6736(10)62303-3
Schouten EJ, Jahn A, Midiani D, Makombe SD, Mnthambala A, et al.
Lancet. 2011 July 16; Volume 378 (Issue 9787); 282-4.; DOI:10.1016/S0140-6736(10)62303-3
Journal Article > ResearchFull Text
Public Health Action. 2016 December 21; Volume 6 (Issue 4); 247-251.; DOI:10.5588/pha.16.0053
Kanyerere H, Girma B, Mpunga J, Tayler-Smith K, Harries AD, et al.
Public Health Action. 2016 December 21; Volume 6 (Issue 4); 247-251.; DOI:10.5588/pha.16.0053
SETTING
For 30 years, Malawi has experienced a dual epidemic of human immunodeficiency virus (HIV) infection and tuberculosis (TB) that has recently begun to be attenuated by the scale-up of antiretroviral therapy (ART).
OBJECTIVE
To report on the correlation between ART scale-up and annual national TB case notification rates (CNR) in Malawi, stratified by HIV-positive and HIV-negative status, from 2005 to 2015.
DESIGN
A retrospective descriptive ecological study using aggregate data from national reports. Results: From 2005 to 2015, ART was scaled up in Malawi from 28 470 to 618 488 total patients, with population coverage increasing from 2.4% to 52.2%. During this time, annual TB notifications declined by 35%, from 26 344 to 17 104, and the TB CNR per 100 000 population declined by 49%, from 206 to 105. HIV testing uptake increased from 51% to 92%. In known HIV-positive TB patients, the CNR decreased from a high of 1247/100 000 to 710/100 000, a 43% decrease. In known HIV-negative TB patients, the CNR also decreased, from a high of 66/100 000 to 49/100 000, a 26% decrease.
CONCLUSION
TB case notifications have continued to decline in association with ART scale-up, with the decline seen more in HIV-positive than HIV-negative TB. These findings have programmatic implications for national TB control efforts.
For 30 years, Malawi has experienced a dual epidemic of human immunodeficiency virus (HIV) infection and tuberculosis (TB) that has recently begun to be attenuated by the scale-up of antiretroviral therapy (ART).
OBJECTIVE
To report on the correlation between ART scale-up and annual national TB case notification rates (CNR) in Malawi, stratified by HIV-positive and HIV-negative status, from 2005 to 2015.
DESIGN
A retrospective descriptive ecological study using aggregate data from national reports. Results: From 2005 to 2015, ART was scaled up in Malawi from 28 470 to 618 488 total patients, with population coverage increasing from 2.4% to 52.2%. During this time, annual TB notifications declined by 35%, from 26 344 to 17 104, and the TB CNR per 100 000 population declined by 49%, from 206 to 105. HIV testing uptake increased from 51% to 92%. In known HIV-positive TB patients, the CNR decreased from a high of 1247/100 000 to 710/100 000, a 43% decrease. In known HIV-negative TB patients, the CNR also decreased, from a high of 66/100 000 to 49/100 000, a 26% decrease.
CONCLUSION
TB case notifications have continued to decline in association with ART scale-up, with the decline seen more in HIV-positive than HIV-negative TB. These findings have programmatic implications for national TB control efforts.
Journal Article > ResearchFull Text
Public Health Action. 2015 June 21; Volume 5 (Issue 2); 116-118.; DOI:10.5588/pha.14.0109
Kanyerere H, Mganga A, Harries AD, Tayler-Smith K, Zachariah R, et al.
Public Health Action. 2015 June 21; Volume 5 (Issue 2); 116-118.; DOI:10.5588/pha.14.0109
Between 2000 and 2012, the annual numbers of patients treated for tuberculosis (TB) in Malawi declined by 28%, from 28 234 to 20 463. During this time, the proportion of TB patients tested for the human immunodeficiency virus (HIV) increased from 6% to 87%. Most HIV-infected patients received cotrimoxazole preventive therapy, and the proportion receiving antiretroviral therapy increased to 88%. Between 2000 and 2008 there was a significant decline in all adverse outcomes (from 31% to 14%), and particularly in deaths (from 23% to 10%) and loss to follow-up (from 5.2% to 1.9%, P < 0.001). After 2008, there was no decrease in any adverse outcome. Ways to further reduce TB-associated mortality are discussed.
Journal Article > CommentaryFull Text
PLOS Med. 2010 August 10; Volume 7 (Issue 8); DOI:10.1371/journal.pmed.1000319
Douglas GP, Gadabu OJ, Joukes S, Mumba S, McKay MV, et al.
PLOS Med. 2010 August 10; Volume 7 (Issue 8); DOI:10.1371/journal.pmed.1000319
Journal Article > CommentaryAbstract
Trans R Soc Trop Med Hyg. 2011 August 1; Volume 105 (Issue 8); DOI:10.1016/j.trstmh.2011.04.014
Zachariah R, Tayler-Smith K, Manzi M, Massaquoi M, Mwagomba B, et al.
Trans R Soc Trop Med Hyg. 2011 August 1; Volume 105 (Issue 8); DOI:10.1016/j.trstmh.2011.04.014
Among adults eligible for antiretroviral therapy (ART) in Thyolo (rural Malawi) and Kibera (Nairobi, Kenya), this study (a) reports on retention and attrition during the preparation phase and after starting ART and (b) identifies risk factors associated with attrition. 'Retention' implies being alive and on follow-up, whilst 'attrition' implies loss to follow-up, death or stopping treatment (if on ART). There were 11,309 ART-eligible patients from Malawi and 3633 from Kenya, of whom 8421 (74%) and 2792 (77%), respectively, went through the preparation phase and started ART. In Malawi, 2649 patients (23%) were lost to attrition in the preparation phase and 2189 (26%) after starting ART. Similarly, in Kenya 546 patients (15%) were lost to attrition in the ART preparation phase and 647 (23%) while on ART. Overall programme attrition was 43% (4838/11,309) for Malawi and 33% (1193/3633) for Kenya. Restricting cohort evaluation to 'on ART' (as is usually done) underestimates overall programme attrition by 38% in Malawi and 36% in Kenya. Risk factors associated with attrition in the preparation phase included male sex, age <35 years, advanced HIV/AIDS disease and increasing malnutrition. Considerable attrition occurs during the preparation phase of ART, and programme evaluations confined to on-treatment analysis significantly underestimate attrition. This has important operational implications, which are discussed here.
Journal Article > CommentaryFull Text
Trop Med Int Health. 2010 December 1; Volume 15; DOI:10.1111/j.1365-3156.2010.02662.x
Harries AD, Zachariah R, Tayler-Smith K, Schouten EJ, Chimbwandira F, et al.
Trop Med Int Health. 2010 December 1; Volume 15; DOI:10.1111/j.1365-3156.2010.02662.x
The debate on the interaction between disease-specific programmes and health system strengthening in the last few years has intensified as experts seek to tease out common ground and find solutions and synergies to bridge the divide. Unfortunately, the debate continues to be largely academic and devoid of specificity, resulting in the issues being irrelevant to health care workers on the ground. Taking the theme 'What would entice HIV- and tuberculosis (TB)-programme managers to sit around the table on a Monday morning with health system experts', this viewpoint focuses on infection control and health facility safety as an important and highly relevant practical topic for both disease-specific programmes and health system strengthening. Our attentions, and the examples and lessons we draw on, are largely aimed at sub-Saharan Africa where the great burden of TB and HIV ⁄ AIDS resides, although the principles we outline would apply to other parts of the world as well. Health care infections, caused for example by poor hand hygiene, inadequate testing of donated blood, unsafe disposal of needles and syringes, poorly sterilized medical and surgical equipment and lack of adequate airborne infection control procedures, are responsible for a considerable burden of illness amongst patients and health care personnel, especially in resource-poor countries. Effective infection control in a district hospital requires that all the components of a health system function well: governance and stewardship, financing,infrastructure, procurement and supply chain management, human resources, health information systems, service delivery and finally supervision. We argue in this article that proper attention to infection control and an emphasis on safe health facilities is a concrete first step towards strengthening the interaction between disease-specific programmes and health systems where it really matters – for patients who are sick and for the health care workforce who provide the care and treatment.
Journal Article > ResearchFull Text
Trop Med Int Health. 2015 October 28; Volume 21 (Issue 1); 101-107.; DOI:10.1111/tmi.12630
Kanyerere H, Harries AD, Tayler-Smith K, Jahn A, Zachariah R, et al.
Trop Med Int Health. 2015 October 28; Volume 21 (Issue 1); 101-107.; DOI:10.1111/tmi.12630
OBJECTIVES
Since 1985, Malawi has experienced a dual epidemic of HIV and tuberculosis (TB) which has been moderated recently by the advent of antiretroviral therapy (ART). The aim of this study was to describe the association over several decades between HIV/AIDS, the scale-up of ART and TB case notifications.
METHODS
Aggregate data were extracted from annual reports of the National TB Control Programme, the Ministry of Health HIV Department and the National Statistics Office. ART coverage was calculated using the total HIV population as denominator (derived from UNAIDS Spectrum software).
RESULTS
In 1970, there were no HIV-infected persons but numbers had increased to a maximum of 1.18 million by 2014. HIV prevalence reached a maximum of 10.8% in 2000, thereafter decreasing to 7.5% by 2014. Numbers alive on ART increased from 2586 in 2003 to 536 527 (coverage 45.3%) by 2014. In 1985, there were 5286 TB cases which reached a maximum of 28 234 in 2003 and then decreased to 17 723 by 2014 (37% decline from 2003). There were increases in all types of new TB between 1998-2003 which then declined by 30% for extrapulmonary TB, by 37% for new smear-positive PTB and by 50% for smear-negative PTB. Previously treated TB cases reached a maximum of 3443 in 2003 and then declined by 42% by 2014.
CONCLUSION
The rise and fall of TB in Malawi between 1985 and 2014 was strongly associated with HIV infection and ART scale-up; this has implications for ending the TB epidemic in high HIV-TB burden countries.
Since 1985, Malawi has experienced a dual epidemic of HIV and tuberculosis (TB) which has been moderated recently by the advent of antiretroviral therapy (ART). The aim of this study was to describe the association over several decades between HIV/AIDS, the scale-up of ART and TB case notifications.
METHODS
Aggregate data were extracted from annual reports of the National TB Control Programme, the Ministry of Health HIV Department and the National Statistics Office. ART coverage was calculated using the total HIV population as denominator (derived from UNAIDS Spectrum software).
RESULTS
In 1970, there were no HIV-infected persons but numbers had increased to a maximum of 1.18 million by 2014. HIV prevalence reached a maximum of 10.8% in 2000, thereafter decreasing to 7.5% by 2014. Numbers alive on ART increased from 2586 in 2003 to 536 527 (coverage 45.3%) by 2014. In 1985, there were 5286 TB cases which reached a maximum of 28 234 in 2003 and then decreased to 17 723 by 2014 (37% decline from 2003). There were increases in all types of new TB between 1998-2003 which then declined by 30% for extrapulmonary TB, by 37% for new smear-positive PTB and by 50% for smear-negative PTB. Previously treated TB cases reached a maximum of 3443 in 2003 and then declined by 42% by 2014.
CONCLUSION
The rise and fall of TB in Malawi between 1985 and 2014 was strongly associated with HIV infection and ART scale-up; this has implications for ending the TB epidemic in high HIV-TB burden countries.
Journal Article > ReviewFull Text
J Int AIDS Soc. 2011 July 6; Volume 14; DOI:10.1186/1758-2652-14-S1-S4
Schouten EJ, Jahn A, Ben-Smith A, Makombe SD, Harries AD, et al.
J Int AIDS Soc. 2011 July 6; Volume 14; DOI:10.1186/1758-2652-14-S1-S4
The number of people receiving antiretroviral treatment (ART) has increased considerably in recent years and is expected to continue to grow in the coming years. A major challenge is to maintain uninterrupted supplies of antiretroviral (ARV) drugs and prevent stock outs. This article discusses issues around the management of ARVs and prevention of stock outs in Malawi, a low-income country with a high HIV/AIDS burden, and a weak procurement and supply chain management system. This system for ARVs, paid for by the Global Fund to Fight AIDS, Tuberculosis and Malaria, and bypassing the government Central Medical Stores, is in place, using the United Nations Children’s Fund’s (UNICEF’s) procurement services. The system, managed by a handful of people who spend limited time on supply management, is characterized by a centrally coordinated quantification based on verified data from all national ART clinics, parallel procurement through UNICEF, and direct distribution to ART clinics. The model worked well in the first years of the ART programme with a single first-line ARV regimen, but with more regimens becoming available (e.g., alternative first-line, second-line and paediatric regimens), it has become more difficult to administer. Managing supplies through a parallel system has the advantage that weaknesses in the national system have limited influence on the ARV procurement and supply chain management system. However, as the current system operates without a central warehouse and national buffer stock capacity, it diminishes the ability to prevent ARV stock outs. The process of ordering ARVs, from the time that estimates are made to the arrival of supplies in health facilities, takes approximately one year. Addressing the challenges involved in maintaining ARVs through an efficient procurement and supply chain management system that prevents ARV stock outs through the establishment of a dedicated procurement team, a central warehouse and/or national buffer stock is a priority.