Journal Article > CommentaryFull Text
PLOS Med. 2020 February 14; Volume 17 (Issue 2); e1003028.; DOI:10.1371/journal.pmed.1003028.
Ford NP, Geng EH, Ellman T, Orrell C, Ehrenkranz PD, et al.
PLOS Med. 2020 February 14; Volume 17 (Issue 2); e1003028.; DOI:10.1371/journal.pmed.1003028.
Journal Article > CommentaryFull Text
PLOS Med. 2019 May 29; Volume 16 (Issue 5); e1002820.; DOI:10.1371/journal.pmed.1002820
Ehrenkranz PD, Baptiste SL, Bygrave H, Ellman T, Doi N, et al.
PLOS Med. 2019 May 29; Volume 16 (Issue 5); e1002820.; DOI:10.1371/journal.pmed.1002820
Journal Article > ReviewFull Text
Lancet. 2016 July 14; Volume 388 (Issue 10050); DOI:10.1016/S0140-6736(16)30578-5
Telisinghe L, Charalambous S, Topp SM, Herce ME, Hoffmann CJ, et al.
Lancet. 2016 July 14; Volume 388 (Issue 10050); DOI:10.1016/S0140-6736(16)30578-5
Given the dual epidemics of HIV and tuberculosis in sub-Saharan Africa and evidence suggesting a disproportionate burden of these diseases among detainees in the region, we aimed to investigate the epidemiology of HIV and tuberculosis in prison populations, describe services available and challenges to service delivery, and identify priority areas for programmatically relevant research in sub-Saharan African prisons. To this end, we reviewed literature on HIV and tuberculosis in sub-Saharan African prisons published between 2011 and 2015, and identified data from only 24 of the 49 countries in the region. Where data were available, they were frequently of poor quality and rarely nationally representative. Prevalence of HIV infection ranged from 2·3% to 34·9%, and of tuberculosis from 0·4 to 16·3%; detainees nearly always had a higher prevalence of both diseases than did the non-incarcerated population in the same country. We identified barriers to prevention, treatment, and care services in published work and through five case studies of prison health policies and services in Zambia, South Africa, Malawi, Nigeria, and Benin. These barriers included severe financial and human-resource limitations and fragmented referral systems that prevent continuity of care when detainees cycle into and out of prison, or move between prisons. These challenges are set against the backdrop of weak health and criminal-justice systems, high rates of pre-trial detention, and overcrowding. A few examples of promising practices exist, including routine voluntary testing for HIV and screening for tuberculosis upon entry to South African and the largest Zambian prisons, reforms to pre-trial detention in South Africa, integration of mental health services into a health package in selected Malawian prisons, and task sharing to include detainees in care provision through peer-educator programmes in Rwanda, Zimbabwe, Zambia, and South Africa. However, substantial additional investments are required throughout sub-Saharan Africa to develop country-level policy guidance, build human-resource capacity, and strengthen prison health systems to ensure universal access to HIV and tuberculsosis prevention, treatment, and care of a standard that meets international goals and human rights obligations.
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 > Meta-AnalysisFull Text
AIDS. 2009 September 10; Volume 23 (Issue 14); 1867-74.; DOI:10.1097/QAD.0b013e32832e05b2
Keiser O, Tweya H, Boulle AM, Braitstein P, Schechter M, et al.
AIDS. 2009 September 10; Volume 23 (Issue 14); 1867-74.; DOI:10.1097/QAD.0b013e32832e05b2
BACKGROUND
In high-income countries, viral load is routinely measured to detect failure of antiretroviral therapy (ART) and guide switching to second-line ART. Viral load monitoring is not generally available in resource-limited settings. We examined switching from nonnucleoside reverse transcriptase inhibitor (NNRTI)-based first-line regimens to protease inhibitor-based regimens in Africa, South America and Asia.
DESIGN AND METHODS
Multicohort study of 17 ART programmes. All sites monitored CD4 cell count and had access to second-line ART and 10 sites monitored viral load. We compared times to switching, CD4 cell counts at switching and obtained adjusted hazard ratios for switching (aHRs) with 95% confidence intervals (CIs) from random-effects Weibull models.
RESULTS
A total of 20 113 patients, including 6369 (31.7%) patients from 10 programmes with access to viral load monitoring, were analysed; 576 patients (2.9%) switched. Low CD4 cell counts at ART initiation were associated with switching in all programmes. Median time to switching was 16.3 months [interquartile range (IQR) 10.1-26.6] in programmes with viral load monitoring and 21.8 months (IQR 14.0-21.8) in programmes without viral load monitoring (P < 0.001). Median CD4 cell counts at switching were 161 cells/microl (IQR 77-265) in programmes with viral load monitoring and 102 cells/microl (44-181) in programmes without viral load monitoring (P < 0.001). Switching was more common in programmes with viral load monitoring during months 7-18 after starting ART (aHR 1.38; 95% CI 0.97-1.98), similar during months 19-30 (aHR 0.97; 95% CI 0.58-1.60) and less common during months 31-42 (aHR 0.29; 95% CI 0.11-0.79).
CONCLUSION
In resource-limited settings, switching to second-line regimens tends to occur earlier and at higher CD4 cell counts in ART programmes with viral load monitoring compared with programmes without viral load monitoring.
In high-income countries, viral load is routinely measured to detect failure of antiretroviral therapy (ART) and guide switching to second-line ART. Viral load monitoring is not generally available in resource-limited settings. We examined switching from nonnucleoside reverse transcriptase inhibitor (NNRTI)-based first-line regimens to protease inhibitor-based regimens in Africa, South America and Asia.
DESIGN AND METHODS
Multicohort study of 17 ART programmes. All sites monitored CD4 cell count and had access to second-line ART and 10 sites monitored viral load. We compared times to switching, CD4 cell counts at switching and obtained adjusted hazard ratios for switching (aHRs) with 95% confidence intervals (CIs) from random-effects Weibull models.
RESULTS
A total of 20 113 patients, including 6369 (31.7%) patients from 10 programmes with access to viral load monitoring, were analysed; 576 patients (2.9%) switched. Low CD4 cell counts at ART initiation were associated with switching in all programmes. Median time to switching was 16.3 months [interquartile range (IQR) 10.1-26.6] in programmes with viral load monitoring and 21.8 months (IQR 14.0-21.8) in programmes without viral load monitoring (P < 0.001). Median CD4 cell counts at switching were 161 cells/microl (IQR 77-265) in programmes with viral load monitoring and 102 cells/microl (44-181) in programmes without viral load monitoring (P < 0.001). Switching was more common in programmes with viral load monitoring during months 7-18 after starting ART (aHR 1.38; 95% CI 0.97-1.98), similar during months 19-30 (aHR 0.97; 95% CI 0.58-1.60) and less common during months 31-42 (aHR 0.29; 95% CI 0.11-0.79).
CONCLUSION
In resource-limited settings, switching to second-line regimens tends to occur earlier and at higher CD4 cell counts in ART programmes with viral load monitoring compared with programmes without viral load monitoring.
Journal Article > ResearchFull Text
Bull World Health Organ. 2007 November 1; Volume 85 (Issue 11); 851-857.; DOI:10.2471/blt.07.041434
Makombe SD, Jahn A, Tweya H, Chuka S, Yu JKL, et al.
Bull World Health Organ. 2007 November 1; Volume 85 (Issue 11); 851-857.; DOI:10.2471/blt.07.041434
OBJECTIVE
To assess the human resources impact of Malawis rapidly growing antiretroviral therapy (ART) programme and balance this against the survival benefit of health-care workers who have accessed ART themselves.
METHODS
We conducted a national cross-sectional survey of the human resource allocation in all public-sector health facilities providing ART in mid-2006. We also undertook a survival analysis of health-care workers who had accessed ART in public and private facilities by 30 June 2006, using data from the national ART monitoring and evaluation system.
FINDINGS
By 30 June 2006, 59 581 patients had accessed ART from 95 public and 28 private facilities. The public sites provided ART services on 2.4 days per week on average, requiring 7% of the clinician workforce, 3% of the nursing workforce and 24% of the ward clerk workforce available at the facilities. We identified 1024 health-care workers in the national ART-patient cohort (2% of all ART patients). The probabilities for survival on ART at 6 months, 12 months and 18 months were 85%, 81% and 78%, respectively. An estimated 250 health-care workers lives were saved 12 months after ART initiation. Their combined work-time of more than 1000 staff-days per week was equivalent to the human resources required to provide ART at the national level.
CONCLUSION
A large number of ART patients in Malawi are managed by a small proportion of the health-care workforce. Many health-care workers have accessed ART with good treatment outcomes. Currently, staffing required for ART balances against health-care workers lives saved through treatment, although this may change in the future.
To assess the human resources impact of Malawis rapidly growing antiretroviral therapy (ART) programme and balance this against the survival benefit of health-care workers who have accessed ART themselves.
METHODS
We conducted a national cross-sectional survey of the human resource allocation in all public-sector health facilities providing ART in mid-2006. We also undertook a survival analysis of health-care workers who had accessed ART in public and private facilities by 30 June 2006, using data from the national ART monitoring and evaluation system.
FINDINGS
By 30 June 2006, 59 581 patients had accessed ART from 95 public and 28 private facilities. The public sites provided ART services on 2.4 days per week on average, requiring 7% of the clinician workforce, 3% of the nursing workforce and 24% of the ward clerk workforce available at the facilities. We identified 1024 health-care workers in the national ART-patient cohort (2% of all ART patients). The probabilities for survival on ART at 6 months, 12 months and 18 months were 85%, 81% and 78%, respectively. An estimated 250 health-care workers lives were saved 12 months after ART initiation. Their combined work-time of more than 1000 staff-days per week was equivalent to the human resources required to provide ART at the national level.
CONCLUSION
A large number of ART patients in Malawi are managed by a small proportion of the health-care workforce. Many health-care workers have accessed ART with good treatment outcomes. Currently, staffing required for ART balances against health-care workers lives saved through treatment, although this may change in the future.
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 > ReviewAbstract
Trans R Soc Trop Med Hyg. 2011 March 2; Volume 105 (Issue 6); DOI:10.1016/j.trstmh.2011.03.002
Zachariah R, Mwagomba B, Misinde D, Mandere BC, Bemeyani A, et al.
Trans R Soc Trop Med Hyg. 2011 March 2; Volume 105 (Issue 6); DOI:10.1016/j.trstmh.2011.03.002
Vital registration - the systematic recording of births and deaths - has both legal and health significance. In particular, accurate recording and reporting of vital statistics are public goods to enable the monitoring of progress towards achieving health related targets of the 2015 United Nations Millennium Development Goals (MDG). The reality in Africa is that most births and deaths cannot be traced in legal records or official statistics and as such, there is currently no way of assessing progress towards achieving MDG targets and this applies particularly to rural settings in Africa. From the context of a rural district in Malawi, we describe an informal traditional system for the reporting of deaths at village level, and discuss the potential opportunities, challenges and ways forward in the wider implementation and interpretation of vital data generated by such a system. Such a system might provide an interim solution for accelerating the production and use of district level vital statistics for legal, administrative, statistical purposes and to report on the MDG in rural Africa while waiting for more comprehensive national systems to become a reality.
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.