Journal Article > CommentaryFull Text
Surgery. 1 July 2015; Volume 158 (Issue 1); 33-36.; DOI:10.1016/j.surg.2015.04.006
Elder G, Murphy RA, Herard P, Dilworth K, Olson D, et al.
Surgery. 1 July 2015; Volume 158 (Issue 1); 33-36.; DOI:10.1016/j.surg.2015.04.006
Journal Article > ResearchFull Text
J Int AIDS Soc. 15 February 2016; Volume 19; DOI:10.7448/IAS.19.1.20673
Maman D, Chilima B, Masiku C, Ayouba A, Masson S, et al.
J Int AIDS Soc. 15 February 2016; Volume 19; DOI:10.7448/IAS.19.1.20673
The antiretroviral therapy (ART) programme supported by Médecins Sans Frontières in the rural Malawian district of Chiradzulu was one of the first in sub-Saharan Africa to scale up ART delivery in 2002. After more than a decade of continuous involvement, we conducted a population survey to evaluate the cascade of care, including population viral load, in the district.
Journal Article > ResearchFull Text
Trop Med Int Health. 1 June 2010; Volume 15; DOI:10.1111/j.1365-3156.2010.02504.x
McGuire M, Munyenyembe T, Szumilin E, Heinzelmann A, Le Paih M, et al.
Trop Med Int Health. 1 June 2010; Volume 15; DOI:10.1111/j.1365-3156.2010.02504.x
OBJECTIVES: To ascertain the outcome of pre-Antiretroviral therapy (ART) and ART patients defaulting from care and investigate reasons for defaulting. METHODS: Patients defaulting from HIV care in Chiradzulu between July 2004 and September 2007 were traced at last known home address. Deaths and moves were recorded, and patients found alive were interviewed. Defaulting was defined as missed last appointment by more than 1 month among patients of unknown vital status. RESULTS: A total of 1637 individuals were traced (54%-88% of eligible), 981 pre-ART and 656 ART patients. Of 694 pre-ART patients found, 49% had died (51% of adults and 38% of children), a median of 47 days after defaulting, and 14% had moved away. Of 451 ART patients found, 54% had died (54% of adults and 50% of children), a median of 52 days after defaulting, and 20% had moved away. Overall, 221 patients were interviewed (90% of those found alive), 42% had worked outside the district in the previous year; 49% of pre-ART and 19% of ART patients had not disclosed their HIV status to other household members. Main reasons for defaulting were stigma (43%), care dissatisfaction (34%), improved health (28%) and for ART discontinuation, poor understanding of disease or treatment (56%) and drug side effects (42%). CONCLUSION: This study in a rural African HIV programme reveals the dynamics related to health service access and use, and it provides information to correct programme mortality estimates for adults and children.
Journal Article > ResearchFull Text
PLOS One. 16 September 2013; Volume 8 (Issue 9); DOI:10.1371/journal.pone.0074090
McGuire M, Farhat JB, Pedrono G, Szumilin E, Heinzelmann A, et al.
PLOS One. 16 September 2013; Volume 8 (Issue 9); DOI:10.1371/journal.pone.0074090
Background: Expanding access to antiretroviral therapy (ART) in sub-Saharan Africa requires implementation of alternative care delivery models to traditional physician-centered approaches. This longitudinal analysis compares outcomes of patients initiated on antiretroviral therapy (ART) by non-physician and physician providers. Methods: Adults (≥15 years) initiating ART between September 2007 and March 2010, and with >1 follow-up visit were included and classified according to the proportion of clinical visits performed by nurses or by clinical officers(≥80% of visits). Multivariable Poisson models were used to compare 2-year program attrition (mortality and lost to follow-up) and mortality by type of provider. In sensitivity analyses only patients with less severe disease were included. Results: A total of 10,112 patients contributed 14,012 person-years to the analysis: 3386 (33.5%) in the clinical officer group, 1901 (18.8%) in the nurse care group and 4825 (47.7%) in the mixed care group. Overall 2-year program retention was 81.8%. Attrition was lower in the mixed care and higher in the clinical officer group, compared to the nurse group (adjusted incidence rate ratio [aIRR]=0.54, 95%CI 0.45-0.65; and aIRR=3.03, 95%CI 2.56-3.59,respectively). While patients initiated on ART by clinical officers in the mixed care group had lower attrition(aIRR=0.36, 95%CI 0.29-0.44) than those in the overall nurse care group; no differences in attrition were found between patients initiated on ART by nurses in the mixed care group and those included in the nurse group (aIRR=1.18, 95%CI 0.95-1.47). Two-year mortality estimates were aIRR=0.72, 95%CI 0.49-1.09 and aIRR=5.04,95%CI 3.56-7.15, respectively. Slightly higher estimates were observed when analyses were restricted to patients with less severe disease. Conclusion: The findings of this study support the use of a mixed care model with well trained and regularly supervised nurses and medical assistants to provide HIV care in countries with high HIV prevalence.
Journal Article > ResearchFull Text
Trop Med Int Health. 1 September 2011; Volume 16 (Issue 12); DOI:10.1111/j.1365-3156.2011.02874.x
Kanapathipillai R, McGuire M, Mogha R, Szumilin E, Heinzelmann A, et al.
Trop Med Int Health. 1 September 2011; Volume 16 (Issue 12); DOI:10.1111/j.1365-3156.2011.02874.x
Objective Viral load testing is used in the HIV programme of Chiradzulu, Malawi, to confirm the diagnosis of immunological failure to prevent unnecessary switching to second-line therapy. Our objective was to quantify the benefit of this strategy for management of treatment failure in a large decentralized HIV programme in Africa. Methods Retrospective analysis of monitoring data from adults treated with first-line antiretroviral regimens for >1 year and meeting the WHO immunological failure criteria in an HIV programme in rural Malawi. The positive predictive value of using immunological failure criteria to diagnose virological failure (viral load >5000 copies/ml) was estimated. Results Of the 227 patients with immunological failure (185 confirmed with a repeat CD4 measurement), 155 (68.2%) had confirmatory viral load testing. Forty-four (28.4%) had viral load >5000 copies/ml and 57 (36.8%) >1000 copies/ml. Positive predictive value was 28.4% (95% CI 21.4-36.2%). Repeat CD4 count testing showed that 41% of patients initially diagnosed with immunological failure did no longer meet failure criteria. Conclusions Our results support the need for confirming all cases of immunological failure with viral load testing before switching to second-line ART to optimize the use of resources in developing countries.
Journal Article > ResearchFull Text
Int J Infect Dis. 11 December 2014; Volume 31; 61-67.; DOI:10.1016/j.ijid.2014.12.010
Polonsky JA, Singh B, Masiku C, Langendorf C, Kagoli M, et al.
Int J Infect Dis. 11 December 2014; Volume 31; 61-67.; DOI:10.1016/j.ijid.2014.12.010
BACKGROUND
HIV infection increases measles susceptibility in infants, but little is known about this relationship among older children and adults. We conducted a facility-based study to explore whether HIV status and/or CD4 count were associated with either measles seroprotection and/or measles antibody concentration.
METHODS
We conveniently sampled HIV-infected patients presenting for follow-up care, and HIV-uninfected individuals presenting for HIV testing at Chiradzulu District Hospital, Malawi, from January to September 2012. We recorded age, sex and reported measles vaccination and infection history. Blood samples were taken to determine CD4 count and measles antibody concentration.
RESULTS
1935 (1434 HIV-infected; 501 HIV-uninfected) participants were recruited. The majority of adults, and approximately half the children, were measles seroprotected, with lower odds among HIV-infected children (adjusted OR=0.27, 95% CI: 0.10-0.69, p=0.006), but not adults. Among HIV-infected participants, neither CD4 count (p=0.16) nor time on antiretroviral therapy (p=0.25) were associated with measles antibody concentration, while older age (p<0.001) and female sex (p<0.001) were independently associated with this measure.
CONCLUSIONS
We found no evidence that HIV infection contributes to the risk for measles infection among adults, but HIV-infected children (including at ages older than previously reported), were less likely to be seroprotected in this sample.
HIV infection increases measles susceptibility in infants, but little is known about this relationship among older children and adults. We conducted a facility-based study to explore whether HIV status and/or CD4 count were associated with either measles seroprotection and/or measles antibody concentration.
METHODS
We conveniently sampled HIV-infected patients presenting for follow-up care, and HIV-uninfected individuals presenting for HIV testing at Chiradzulu District Hospital, Malawi, from January to September 2012. We recorded age, sex and reported measles vaccination and infection history. Blood samples were taken to determine CD4 count and measles antibody concentration.
RESULTS
1935 (1434 HIV-infected; 501 HIV-uninfected) participants were recruited. The majority of adults, and approximately half the children, were measles seroprotected, with lower odds among HIV-infected children (adjusted OR=0.27, 95% CI: 0.10-0.69, p=0.006), but not adults. Among HIV-infected participants, neither CD4 count (p=0.16) nor time on antiretroviral therapy (p=0.25) were associated with measles antibody concentration, while older age (p<0.001) and female sex (p<0.001) were independently associated with this measure.
CONCLUSIONS
We found no evidence that HIV infection contributes to the risk for measles infection among adults, but HIV-infected children (including at ages older than previously reported), were less likely to be seroprotected in this sample.
Journal Article > ResearchFull Text
Trop Med Int Health. 1 February 2005; Volume 10 (Issue 2); DOI:10.1111/j.1365-3156.2004.01367.x
Checchi F, Roddy P, Kamara S, Williams A, Morineau G, et al.
Trop Med Int Health. 1 February 2005; Volume 10 (Issue 2); DOI:10.1111/j.1365-3156.2004.01367.x
OBJECTIVES: To provide nationally relevant information on the antimalarial efficacy of chloroquine (CQ), sulphadoxine-pyrimethamine (SP) and amodiaquine (AQ) in Sierra Leone, with a view to updating antimalarial policy in the country. METHODS: Between October 2002 and May 2003, standard WHO methodology for in vivo efficacy assessment was used in five sites to study the therapeutic response of 6-59 months old uncomplicated Plasmodium falciparum malaria cases treated with CQ (n = 247), SP (n = 353) or AQ (n = 434). Follow-up was of 28 days, with polymerase chain reaction genotyping to distinguish late recrudescences from re-infections. RESULTS: Overall 85.3% of patients reached an analysable endpoint. CQ failure proportions were very high, ranging from 39.5% (95% CI: 25.0-55.6) in Kabala to 78.8% (65.3-88.9) in Kailahun. Early failures under CQ were frequent. SP efficacy was also disappointing, with failure from 23.2% (13.9-34.9) in Kabala to 46.1% (35.4-57.0) in Kailahun. AQ resistance was more moderate, ranging from 5.4% (1.8-12.1) in Makeni to 29.8% (20.3-40.8) in Kailahun, with almost no early failures. AQ also provided more rapid fever and parasite clearance. CONCLUSION: In a consensus meeting organized by the Ministry of Health and Sanitation, and based on these findings, artesunate (AS) + AQ and artemether-lumefantrine (Coartemtrade mark) were identified as the only options to rapidly replace CQ. The choice fell on AS + AQ because of expected high efficacy, lower cost in a blister presentation, and the absence of safety data on artemether-lumefantrine in pregnancy. Donor support is required to support this policy change. Throughout Africa, as SP resistance increases, these two regimens are probably the only options available while newer combinations are developed. Efficacy studies should focus on testing AQ and AS + AQ.