Journal Article > ResearchFull Text
J Int Assoc Provid AIDS Care
JIAPAC. 17 June 2024; Online ahead of print; DOI:10.1177/23259582241260219
Chihana M, Conan N, Ohler L, Huerga H, Wanjala S, et al.
J Int Assoc Provid AIDS Care
JIAPAC. 17 June 2024; Online ahead of print; DOI:10.1177/23259582241260219
BACKGROUND
The burden of advanced HIV disease remains a significant concern in sub-Saharan Africa. In 2015, the World Health Organization released recommendations to treat all people living with HIV (PLHIV) regardless of CD4 (“treat all”) and in 2017 guidelines for managing advanced HIV disease. We assessed changes over time in the proportion of PLHIV with advanced HIV and their care cascade in two community settings in sub-Saharan Africa.
METHODS
Cross-sectional population-based surveys were conducted in Ndhiwa (Kenya) in 2012 and 2018 and in Eshowe (South Africa) in 2013 and 2018. We recruited individuals aged 15-59 years. Consenting participants were interviewed and tested for HIV at home. All participants with HIV had CD4 count measured. Advanced HIV was defined as CD4 < 200 cells/µL.
RESULTS
Overall, 6076 and 6001 individuals were included in 2012 and 2018 (Ndhiwa) and 5646 and 3270 individuals in 2013 and 2018 (Eshowe), respectively. In Ndhiwa, the proportion of PLHIV with advanced HIV decreased from 2012 (159/1376 (11.8%; 95% CI: 9.8-14.2)) to 2018 (53/1000 (5.0%; 3.8-6.6)). The proportion of individuals with advanced HIV on antiretroviral therapy (ART) was 9.1% (6.9-11.8) in 2012 and 4.2% (3.0-5.8) in 2018. In Eshowe, the proportion with advanced HIV was 130/1400 (9.8%; 8.0-11.9) in 2013 and 38/834 (4.5%; 3.3-6.1) in 2018. The proportion with advanced HIV among those on ART was 6.9% (5.5-8.8) in 2013 and 2.8% (1.8-4.3) in 2018. There was a significant increase in coverage for all steps of the care cascade among people with advanced HIV between the two Ndhiwa surveys, with all the changes occurring among men and not women. No significant changes were observed in Eshowe between the surveys overall and by sex.
CONCLUSION
The proportion with advanced HIV disease decreased between the first and second surveys where all guidelines have been implemented between the two HIV surveys.
The burden of advanced HIV disease remains a significant concern in sub-Saharan Africa. In 2015, the World Health Organization released recommendations to treat all people living with HIV (PLHIV) regardless of CD4 (“treat all”) and in 2017 guidelines for managing advanced HIV disease. We assessed changes over time in the proportion of PLHIV with advanced HIV and their care cascade in two community settings in sub-Saharan Africa.
METHODS
Cross-sectional population-based surveys were conducted in Ndhiwa (Kenya) in 2012 and 2018 and in Eshowe (South Africa) in 2013 and 2018. We recruited individuals aged 15-59 years. Consenting participants were interviewed and tested for HIV at home. All participants with HIV had CD4 count measured. Advanced HIV was defined as CD4 < 200 cells/µL.
RESULTS
Overall, 6076 and 6001 individuals were included in 2012 and 2018 (Ndhiwa) and 5646 and 3270 individuals in 2013 and 2018 (Eshowe), respectively. In Ndhiwa, the proportion of PLHIV with advanced HIV decreased from 2012 (159/1376 (11.8%; 95% CI: 9.8-14.2)) to 2018 (53/1000 (5.0%; 3.8-6.6)). The proportion of individuals with advanced HIV on antiretroviral therapy (ART) was 9.1% (6.9-11.8) in 2012 and 4.2% (3.0-5.8) in 2018. In Eshowe, the proportion with advanced HIV was 130/1400 (9.8%; 8.0-11.9) in 2013 and 38/834 (4.5%; 3.3-6.1) in 2018. The proportion with advanced HIV among those on ART was 6.9% (5.5-8.8) in 2013 and 2.8% (1.8-4.3) in 2018. There was a significant increase in coverage for all steps of the care cascade among people with advanced HIV between the two Ndhiwa surveys, with all the changes occurring among men and not women. No significant changes were observed in Eshowe between the surveys overall and by sex.
CONCLUSION
The proportion with advanced HIV disease decreased between the first and second surveys where all guidelines have been implemented between the two HIV surveys.
Journal Article > ResearchFull Text
Lancet Global Health. 1 January 2023; Volume 11 (Issue 1); e126-e135.; DOI:10.1016/S2214-109X(22)00463-6
Huerga H, Bastard M, Lubega AV, Akinyi M, Antabak NT, et al.
Lancet Global Health. 1 January 2023; Volume 11 (Issue 1); e126-e135.; DOI:10.1016/S2214-109X(22)00463-6
BACKGROUND
Development of rapid biomarker-based tests that can diagnose tuberculosis using non-sputum samples is a priority for tuberculosis control. We aimed to compare the diagnostic accuracy of the novel Fujifilm SILVAMP TB LAM (FujiLAM) assay with the WHO-recommended Alere Determine TB-LAM Ag test (AlereLAM) using urine samples from HIV-positive patients.
METHODS
We did a diagnostic accuracy study at five outpatient public health facilities in Uganda, Kenya, Mozambique, and South Africa. Eligible patients were ambulatory HIV-positive individuals (aged ≥15 years) with symptoms of tuberculosis irrespective of their CD4 T-cell count (group 1), and asymptomatic patients with advanced HIV disease (CD4 count <200 cells per μL, or HIV clinical stage 3 or 4; group 2). All participants underwent clinical examination, chest x-ray, and blood sampling, and were requested to provide a fresh urine sample, and two sputum samples. FujiLAM and AlereLAM urine assays, Xpert MTB/RIF Ultra assay on sputum or urine, sputum culture for Mycobacterium tuberculosis, and CD4 count were systematically carried out for all patients. Sensitivity and specificity of FujiLAM and AlereLAM were evaluated against microbiological and composite reference standards.
FINDINGS
Between Aug 24, 2020 and Sept 21, 2021, 1575 patients (823 [52·3%] women) were included in the study: 1031 patients in group 1 and 544 patients in group 2. Tuberculosis was microbiologically confirmed in 96 (9·4%) of 1022 patients in group 1 and 18 (3·3%) of 542 patients in group 2. Using the microbiological reference standard, FujiLAM sensitivity was 60% (95% CI 51–69) and AlereLAM sensitivity was 40% (31–49; p<0·001). Among patients with CD4 counts of less than 200 cells per μL, FujiLAM sensitivity was 69% (57–79) and AlereLAM sensitivity was 52% (40–64; p=0·0218). Among patients with CD4 counts of 200 cells per μL or higher, FujiLAM sensitivity was 47% (34–61) and AlereLAM sensitivity was 24% (14–38; p=0·0116). Using the microbiological reference standard, FujiLAM specificity was 87% (95% CI 85–89) and AlereLAM specificity was 86% (95 CI 84–88; p=0·941). FujiLAM sensitivity varied by lot number from 48% (34–62) to 76% (57–89) and specificity from 77% (72–81) to 98% (93–99).
INTERPRETATION
Next-generation, higher sensitivity urine-lipoarabinomannan assays are potentially promising tests that allow rapid tuberculosis diagnosis at the point of care for HIV-positive patients. However, the variability in accuracy between FujiLAM lot numbers needs to be addressed before clinical use.
Development of rapid biomarker-based tests that can diagnose tuberculosis using non-sputum samples is a priority for tuberculosis control. We aimed to compare the diagnostic accuracy of the novel Fujifilm SILVAMP TB LAM (FujiLAM) assay with the WHO-recommended Alere Determine TB-LAM Ag test (AlereLAM) using urine samples from HIV-positive patients.
METHODS
We did a diagnostic accuracy study at five outpatient public health facilities in Uganda, Kenya, Mozambique, and South Africa. Eligible patients were ambulatory HIV-positive individuals (aged ≥15 years) with symptoms of tuberculosis irrespective of their CD4 T-cell count (group 1), and asymptomatic patients with advanced HIV disease (CD4 count <200 cells per μL, or HIV clinical stage 3 or 4; group 2). All participants underwent clinical examination, chest x-ray, and blood sampling, and were requested to provide a fresh urine sample, and two sputum samples. FujiLAM and AlereLAM urine assays, Xpert MTB/RIF Ultra assay on sputum or urine, sputum culture for Mycobacterium tuberculosis, and CD4 count were systematically carried out for all patients. Sensitivity and specificity of FujiLAM and AlereLAM were evaluated against microbiological and composite reference standards.
FINDINGS
Between Aug 24, 2020 and Sept 21, 2021, 1575 patients (823 [52·3%] women) were included in the study: 1031 patients in group 1 and 544 patients in group 2. Tuberculosis was microbiologically confirmed in 96 (9·4%) of 1022 patients in group 1 and 18 (3·3%) of 542 patients in group 2. Using the microbiological reference standard, FujiLAM sensitivity was 60% (95% CI 51–69) and AlereLAM sensitivity was 40% (31–49; p<0·001). Among patients with CD4 counts of less than 200 cells per μL, FujiLAM sensitivity was 69% (57–79) and AlereLAM sensitivity was 52% (40–64; p=0·0218). Among patients with CD4 counts of 200 cells per μL or higher, FujiLAM sensitivity was 47% (34–61) and AlereLAM sensitivity was 24% (14–38; p=0·0116). Using the microbiological reference standard, FujiLAM specificity was 87% (95% CI 85–89) and AlereLAM specificity was 86% (95 CI 84–88; p=0·941). FujiLAM sensitivity varied by lot number from 48% (34–62) to 76% (57–89) and specificity from 77% (72–81) to 98% (93–99).
INTERPRETATION
Next-generation, higher sensitivity urine-lipoarabinomannan assays are potentially promising tests that allow rapid tuberculosis diagnosis at the point of care for HIV-positive patients. However, the variability in accuracy between FujiLAM lot numbers needs to be addressed before clinical use.
Journal Article > ResearchFull Text
Int J Tuberc Lung Dis. 1 March 2017; Volume 21 (Issue 3); 314-319.; DOI:10.5588/ijtld.16.0661
Huerga H, Bastard M, Kamene M, Wanjala S, Arnold A, et al.
Int J Tuberc Lung Dis. 1 March 2017; Volume 21 (Issue 3); 314-319.; DOI:10.5588/ijtld.16.0661
SETTING
In March 2006, the first multidrug-resistant tuberculosis (MDR-TB) treatment programme was implemented in Kenya.
OBJECTIVE
To describe patients' treatment outcomes and adverse events.
DESIGN
A retrospective case note review of patients started on MDR-TB treatment at two Médecins Sans Frontières-supported sites and the national referral hospital of Kenya was undertaken. Sites operated an ambulatory model of care. Patients were treated for a minimum of 24 months with at least 4-5 drugs for the intensive phase of treatment, including an injectable agent.
RESULTS
Of 169 patients, 25.6% were human immunodeficiency virus (HIV) positive and 89.3% were culture-positive at baseline. Adverse events occurred in 67.4% of patients: 45.9% had nausea/vomiting, 43.9% electrolyte disturbance, 41.8% dyspepsia and 31.6% hypothyroidism. The median time to culture conversion was 2 months. Treatment outcomes were as follows: 76.6% success, 14.5% deaths, 8.3% lost to follow-up and 0.7% treatment failure. HIV-positive individuals (adjusted odds ratio [aOR] 3.51, 95% confidence interval [CI] 1.12-11.03) and women (aOR 2.73, 95%CI 1.01-7.39) had a higher risk of unfavourable outcomes, while the risk was lower in those with culture conversion at 6 months (aOR 0.11, 95%CI 0.04-0.32).
CONCLUSION
In Kenya, where an ambulatory model of care is used for MDR-TB treatment, treatment success was high, despite high rates of HIV. Almost half of the patients experienced electrolyte disturbance and one third had hypothyroidism; this supports the view that systematic regular biochemical monitoring is needed in Kenya.
In March 2006, the first multidrug-resistant tuberculosis (MDR-TB) treatment programme was implemented in Kenya.
OBJECTIVE
To describe patients' treatment outcomes and adverse events.
DESIGN
A retrospective case note review of patients started on MDR-TB treatment at two Médecins Sans Frontières-supported sites and the national referral hospital of Kenya was undertaken. Sites operated an ambulatory model of care. Patients were treated for a minimum of 24 months with at least 4-5 drugs for the intensive phase of treatment, including an injectable agent.
RESULTS
Of 169 patients, 25.6% were human immunodeficiency virus (HIV) positive and 89.3% were culture-positive at baseline. Adverse events occurred in 67.4% of patients: 45.9% had nausea/vomiting, 43.9% electrolyte disturbance, 41.8% dyspepsia and 31.6% hypothyroidism. The median time to culture conversion was 2 months. Treatment outcomes were as follows: 76.6% success, 14.5% deaths, 8.3% lost to follow-up and 0.7% treatment failure. HIV-positive individuals (adjusted odds ratio [aOR] 3.51, 95% confidence interval [CI] 1.12-11.03) and women (aOR 2.73, 95%CI 1.01-7.39) had a higher risk of unfavourable outcomes, while the risk was lower in those with culture conversion at 6 months (aOR 0.11, 95%CI 0.04-0.32).
CONCLUSION
In Kenya, where an ambulatory model of care is used for MDR-TB treatment, treatment success was high, despite high rates of HIV. Almost half of the patients experienced electrolyte disturbance and one third had hypothyroidism; this supports the view that systematic regular biochemical monitoring is needed in Kenya.
Journal Article > Short ReportFull Text
Clin Infect Dis. 2 November 2019; Volume 71 (Issue 2); 415-418.; DOI:10.1093/cid/ciz1084
Seung KJ, Khan PY, Franke MF, Ahmed SM, Aiylchiev S, et al.
Clin Infect Dis. 2 November 2019; Volume 71 (Issue 2); 415-418.; DOI:10.1093/cid/ciz1084
Delamanid should be effective against highly resistant strains of Mycobacterium tuberculosis, but uptake has been slow globally. In the endTB (expand new drug markets for TB) Observational Study, which enrolled a large, heterogeneous cohorts of patients receiving delamanid as part of a multidrug regimen, 80% of participants experienced sputum culture conversion within 6 months.
Journal Article > ResearchFull Text
Clin Infect Dis. 11 July 2020; Volume 71 (Issue 2); 415-418.; DOI:10.1093/cid/ciz1084
Seung KJ, Khan P, Franke MF, Ahmed S, Aiylchiev S, et al.
Clin Infect Dis. 11 July 2020; Volume 71 (Issue 2); 415-418.; DOI:10.1093/cid/ciz1084
Delamanid should be effective against highly resistant strains of Mycobacteriumtuberculosis, but uptake has been slow globally. In the endTB (expand new drug markets for TB) Observational Study, which enrolled a large, heterogeneous cohorts of patients receiving delamanid as part of a multidrug regimen, 80% of participants experienced sputum culture conversion within 6 months.
Journal Article > ResearchFull Text
PLOS One. 27 December 2018; Volume 13 (Issue 12); DOI:10.1371/journal.pone.0209778
Opollo VS, Nikuze A, Ben Farhat J, Anyango E, Humwa F, et al.
PLOS One. 27 December 2018; Volume 13 (Issue 12); DOI:10.1371/journal.pone.0209778
Access to point-of-care HIV testing shortens turn-around times, time to diagnosis and reduces loss to follow-up hence minimizing barriers to early linkage to care and treatment among HIV infected infants. Currently samples for early infant HIV diagnosis are sent to centralized testing facilities which are few and located only at specific regions in Kenya. However, there are Point of Care (POC) early infant diagnosis [EID] technologies elsewhere such as SAMBA and ALERE-Q that are yet to be evaluated in Kenya despite the urgent need for data to inform policy formulation regarding EID. The Cepheid GeneXpert HIV-1 Qual (GeneXpert) technology for POC EID offers a great opportunity to minimize HIV associated morbidity, mortality and loss to follow-up through decentralization of early infant HIV testing to the clinics. This technology also allows for same-day results thus facilitating prompt linkage to care.
Journal Article > ResearchFull Text
Clin Infect Dis. 8 May 2018; Volume 67 (Issue 5); DOI:10.1093/cid/ciy173
Luong Nguyen LB, Yazdanpanah Y, Maman D, Wanjala S, Vandenbulcke A, et al.
Clin Infect Dis. 8 May 2018; Volume 67 (Issue 5); DOI:10.1093/cid/ciy173
In southwest Kenya, the prevalence of human immunodeficiency virus (HIV) infection is about 25%. Médecins Sans Frontières has implemented a voluntary community testing (VCT) program, with linkage to care and retention interventions, to achieve the Joint United Nations Program on HIV and AIDS (UNAIDS) 90-90-90 targets by 2017. We assessed the effectiveness and cost-effectiveness of these interventions.
Journal Article > CommentaryFull Text
Int J Tuberc Lung Dis. 1 October 2020; Volume 24 (Issue 10); 1081-1086.; DOI:10.5588/ijtld.20.0141
Seung KJ, Khan UT, Varaine FFV, Ahmed SM, Bastard M, et al.
Int J Tuberc Lung Dis. 1 October 2020; Volume 24 (Issue 10); 1081-1086.; DOI:10.5588/ijtld.20.0141
In 2015, the initiative Expand New Drug Markets for TB (endTB) began, with the objective of reducing barriers to access to the new and repurposed TB drugs. Here we describe the major implementation challenges encountered in 17 endTB countries. We provide insights on how national TB programmes and other stakeholders can scale-up the programmatic use of new and repurposed TB drugs, while building scientific evidence about their safety and efficacy. For any new drug or diagnostic, multiple market barriers can slow the pace of scale-up. During 2015–2019, endTB was successful in increasing the number of patients receiving new and repurposed TB drugs in 17 countries. The endTB experience has many lessons, which are relevant to country level introduction of new TB drugs, as well as non-TB drugs and diagnostics. For example: the importation of TB drugs is possible even in the absence of registration; emphasis on good clinical monitoring is more important than pharmacovigilance reporting; national guidelines and expert committees can both facilitate and hinder innovative practice; clinicians use new and repurposed TB drugs when they are available; data collection to generate scientific evidence requires financial and human resources; pilot projects can drive national scale-up.
Journal Article > ResearchFull Text
Trop Med Int Health. 12 October 2021; Volume 26 (Issue 12); 1609-1615.; DOI:10.1111/tmi.13688
Conan N, Badawi M, Chihana ML, Wanjala S, Kingwara L, et al.
Trop Med Int Health. 12 October 2021; Volume 26 (Issue 12); 1609-1615.; DOI:10.1111/tmi.13688
Français
BACKGROUND
HIV-positive individuals who maintain an undetectable viral load cannot transmit the virus to others. In 2012, an HIV population-based survey was conducted in Ndhiwa sub-county (Kenya) to provide information on the HIV local epidemic. We carried out a second survey 6 years after the first one, to assess progress in HIV diagnosis and care and differences in the HIV prevalence and incidence between the two surveys.
METHODS
A cross-sectional, population-based survey using cluster sampling and geospatial random selection was implemented in 2018, using the same design as 2012. Consenting participants aged 15-59 years were interviewed and tested for HIV at home. HIV-positive individuals received viral load testing (viral suppression defined as <1000 copies/ml) and Lag-Avidity EIA assay (to measure recent infection). The 90-90-90 UNAIDS indicators were also assessed.
RESULTS
Overall, 6029 individuals were included in 2018. HIV prevalence was 16.9%. Viral suppression among all HIV-positive was 88.3% in 2018 (vs. 39.9% in 2012, p < 0.001). HIV incidence was 0.75% in 2018 vs. 1.90% in 2012 (p = 0.07). In 2018, the 90-90-90 indicators were 93%-97%-95% (vs. 60%-68%-83% in 2012).
CONCLUSIONS
A two-fold increase in the HIV viral load suppression rate along with a decreasing trend in incidence was observed over 6 years in Ndhiwa sub-county. Achieving high rates of viral suppression in HIV populations that can lead to reducing HIV transmission in sub-Saharan contexts is feasible. Nevertheless, we will need further efforts to sustain this progress.
HIV-positive individuals who maintain an undetectable viral load cannot transmit the virus to others. In 2012, an HIV population-based survey was conducted in Ndhiwa sub-county (Kenya) to provide information on the HIV local epidemic. We carried out a second survey 6 years after the first one, to assess progress in HIV diagnosis and care and differences in the HIV prevalence and incidence between the two surveys.
METHODS
A cross-sectional, population-based survey using cluster sampling and geospatial random selection was implemented in 2018, using the same design as 2012. Consenting participants aged 15-59 years were interviewed and tested for HIV at home. HIV-positive individuals received viral load testing (viral suppression defined as <1000 copies/ml) and Lag-Avidity EIA assay (to measure recent infection). The 90-90-90 UNAIDS indicators were also assessed.
RESULTS
Overall, 6029 individuals were included in 2018. HIV prevalence was 16.9%. Viral suppression among all HIV-positive was 88.3% in 2018 (vs. 39.9% in 2012, p < 0.001). HIV incidence was 0.75% in 2018 vs. 1.90% in 2012 (p = 0.07). In 2018, the 90-90-90 indicators were 93%-97%-95% (vs. 60%-68%-83% in 2012).
CONCLUSIONS
A two-fold increase in the HIV viral load suppression rate along with a decreasing trend in incidence was observed over 6 years in Ndhiwa sub-county. Achieving high rates of viral suppression in HIV populations that can lead to reducing HIV transmission in sub-Saharan contexts is feasible. Nevertheless, we will need further efforts to sustain this progress.
Journal Article > Short ReportFull Text
J Acquir Immune Defic Syndr. 1 April 2021; Volume Publish Ahead of Print; DOI:10.1097/QAI.0000000000002689
Bossard C, Schramm B, Wanjala S, Jain L, Mucinya G, et al.
J Acquir Immune Defic Syndr. 1 April 2021; Volume Publish Ahead of Print; DOI:10.1097/QAI.0000000000002689