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Background: Access to antiretroviral therapy (ART) has rapidly expanded; as of the end of 2010, an estimated 6.6 million people are receiving ART in low-income and middle-income countries. Few reports have focused on the experiences of rural health centers or the use of community health workers. We report clinical and programatic outcomes at 24 months for a cohort of patients enrolled in a community-based ART program in southeastern Rwanda under collaboration between Partners In Health and the Rwandan Ministry of Health., Methods and Findings: A retrospective medical record review was performed for a cohort of 1041 HIV+ adult patients initiating community-based ART between June 1, 2005, and April 30, 2006. Key programatic elements included free ART with direct observation by community health worker, tuberculosis screening and treatment, nutritional support, a transportation allowance, and social support. Among 1041 patients who initiated community-based ART, 961 (92.3%) were retained in care, 52 (5%) died and 28 (2.7%) were lost to follow-up. Median CD4 T-cell count increase was 336 cells per microliter [interquartile range: (IQR): 212-493] from median 190 cells per microliter (IQR: 116-270) at initiation., Conclusions: A program of intensive community-based treatment support for ART in rural Rwanda had excellent outcomes in 24-month retention in care. Having committed to improving access to HIV treatment in sub-Saharan Africa, the international community, including country HIV programs, should set high programmatic outcome benchmarks.

We found that comprehensive, integrated, community-based intervention (characterized by daily home visits from a community health worker, directly observed treatment, nutritional support, and transportation stipends) was associated with higher antiretroviral therapy retention at 1 year among adults in rural Rwanda.Background. Minimizing death and ensuring high retention and good adherence remain ongoing challenges for human immunodeficiency virus (HIV) treatment programs. We examined whether the addition of community-based accompaniment (characterized by daily home visits from a community health worker, directly observed treatment, nutritional support, transportation stipends, and other support as needed) to the Rwanda national model for antiretroviral therapy (ART) delivery would improve retention in care, viral load suppression, and change in CD4 count, relative to the national model alone.Methods. We conducted a prospective observational cohort study among 610 HIV-infected adults initiating ART in 1 of 2 programs in rural Rwanda. Psychosocial and clinical characteristics were recorded at ART initiation. Death, treatment retention, and plasma viral load were assessed at 1 year. CD4 count was evaluated at 6-month intervals. Multivariable regression models were used to adjust for baseline differences between the 2 populations.Results. Eighty-five percent and 79% of participants in the community-based and clinic-based programs, respectively, were retained with viral load suppression at 1 year. After adjusting for CD4 count, depression, physical health quality of life, and food insecurity, community-based accompaniment was protective against death or loss to follow-up during the first year of ART (hazard ratio, 0.17; 95% confidence interval [CI], .09–.35; P < .0001). In a second multivariable analysis, individuals receiving accompaniment were more likely to be retained with a suppressed viral load at 1 year (risk ratio: 1.15; 95% CI, 1.03–1.27; P = .01).Conclusions. These findings indicate that community-based accompaniment is effective in improving retention, when added to a clinic-based program with fewer patient support mechanisms. [ABSTRACT FROM AUTHOR]

Summary: We evaluated peripheral blood tests to diagnose iron deficiency on medical wards in Blantyre, Malawi, where infection and HIV are prevalent. We compared full blood count, ferritin and serum transferrin receptor (TfR) levels with an estimation of iron in bone marrow aspirates. Of consecutive adults admitted with severe anaemia (haemoglobin <7g/dl), 81 had satisfactory bone marrow aspirates. The main outcome measures were the validity of each test (sensitivity, specificity, and positive and negative predictive values) and likelihood ratios (LR) for iron deficiency. Twenty patients (25%) were iron deficient and 64 (79%) were HIV-positive. Iron deficiency was more common in HIV-negative compared with HIV-positive patients (59% vs. 16%; P <0.001). In HIV-positive patients, the optimal ferritin cut-off was 150μg/l (sensitivity 20%, specificity 93%, LR 2.7), but no test was accurate enough to be clinically useful. In HIV-negative patients, ferritin was the single most accurate test (cut-off <70μg/l, 100% specificity, 90% sensitive, LR if positive ∞, LR if negative 10). TfR measurement did not improve the accuracy. Mean cell volume was not a good predictor of iron status except in HIV-negative patients (cut-off <85 fl, specificity 71%, sensitivity 90%). In populations with high levels of infection and HIV, an HIV test is necessary to interpret any tests of iron deficiency. In HIV-negative patients, ferritin is the best blood test for iron deficiency, using a higher cut-off than usual. For HIV-positive patients, it is difficult to diagnose iron deficiency without bone marrow aspirates. [Copyright &y& Elsevier]

Summary: Severe anaemia is a common presentation in non-pregnant adults admitted to hospital in southern Africa. Standard syndromic treatment based on data from the pre-HIV era is for iron deficiency, worms and malaria. We prospectively investigated 105 adults admitted consecutively to medical wards with haemoglobin &#60;7g/dl. Those with acute blood loss were excluded. Patients were investigated for possible parasitic, bacterial, mycobacterial and nutritional causes of anaemia, including bone marrow aspiration, to identify potentially treatable causes. Seventy-nine per cent of patients were HIV-positive. One-third of patients had tuberculosis, which was diagnosed only by bone marrow culture in 8% of HIV-positive patients. In 21% of individuals bacteria were cultured, with non-typhi salmonella predominating and Streptococcus pneumoniae rare. Iron deficiency, hookworm infection and malaria were not common in HIV-positive anaemic adults, although heavy hookworm infections were found in 6 (27%) of the 22 HIV-negative anaemic adults. In conclusion, conventional treatment for severe anaemia in adults is not appropriate in an area of high HIV prevalence. Occult mycobacterial disease and bacteraemia are common, but iron deficiency is not common in HIV-positive patients. In addition to iron supplements, management of severe anaemia should include investigation for tuberculosis, and consideration of antibiotics active against enterobacteria. [Copyright &y& Elsevier]