524 results on '"ZACHARIAH, RONY"'
Search Results
502. A global framework for action to improve the primary care response to chronic non-communicable diseases: a solution to a neglected problem.
- Author
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Maher D, Harries AD, Zachariah R, and Enarson D
- Subjects
- Humans, International Cooperation, Problem Solving, Chronic Disease prevention & control, Quality Assurance, Health Care methods
- Abstract
Background: Although in developing countries the burden of morbidity and mortality due to infectious diseases has often overshadowed that due to chronic non-communicable diseases (NCDs), there is evidence now of a shift of attention to NCDs., Discussion: Decreasing the chronic NCD burden requires a two-pronged approach: implementation of the multisectoral policies aimed at decreasing population-level risks for NCDs, and effective and affordable delivery of primary care interventions for patients with chronic NCDs. The primary care response to common NCDs is often unstructured and inadequate. We therefore propose a programmatic, standardized approach to the delivery of primary care interventions for patients with NCDs, with a focus on hypertension, diabetes mellitus, chronic airflow obstruction, and obesity. The benefits of this approach will extend to patients with related conditions, e.g. those with chronic kidney disease caused by hypertension or diabetes. This framework for a "public health approach" is informed by experience of scaling up interventions for chronic infectious diseases (tuberculosis and HIV). The lessons learned from progress in rolling out these interventions include the importance of gaining political commitment, developing a robust strategy, delivering standardised interventions, and ensuring rigorous monitoring and evaluation of progress towards defined targets. The goal of the framework is to reduce the burden of morbidity, disability and premature mortality related to NCDs through a primary care strategy which has three elements: 1) identify and address modifiable risk factors, 2) screen for common NCDs and 3) and diagnose, treat and follow-up patients with common NCDs using standard protocols. The proposed framework for NCDs borrows the same elements as those developed for tuberculosis control, comprising a goal, strategy and targets for NCD control, a package of interventions for quality care, key operations for national implementation of these interventions (political commitment, case-finding among people attending primary care services, standardised diagnostic and treatment protocols, regular drug supply, and systematic monitoring and evaluation), and indicators to measure progress towards increasing the impact of primary care interventions on chronic NCDs. The framework needs evaluation, then adaptation in different settings., Summary: A framework for a programmatic "public health approach" has the potential to improve on the current unstructured approach to primary care of people with chronic NCDs. Research to establish the cost, value and feasibility of implementing the framework will pave the way for international support to extend the benefit of this approach to the millions of people worldwide with chronic NCDs.
- Published
- 2009
- Full Text
- View/download PDF
503. Excellent outcomes among HIV+ children on ART, but unacceptably high pre-ART mortality and losses to follow-up: a cohort study from Cambodia.
- Author
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Raguenaud ME, Isaakidis P, Zachariah R, Te V, Soeung S, Akao K, and Kumar V
- Subjects
- Cambodia epidemiology, Cause of Death trends, Child, Preschool, Female, Follow-Up Studies, Humans, Infant, Male, Retrospective Studies, Survival Rate trends, Time Factors, Treatment Outcome, Anti-Retroviral Agents therapeutic use, HIV immunology, HIV Antibodies analysis, HIV Infections drug therapy, HIV Infections mortality
- Abstract
Background: Although HIV program evaluations focusing on mortality on ART provide important evidence on treatment effectiveness, they do not asses overall HIV program performance because they exclude patients who are eligible but not started on ART for whatever reason. The objective of this study was to measure mortality that occurs both pre-ART and during ART among HIV-positive children enrolled in two HIV-programs in Cambodia., Methods: Retrospective cohort study on 1168 HIV-positive children <15 years old registered in two HIV-programs over a four-year period. Mortality rates were calculated for both children on treatment and children not started on ART., Results: Over half (53%) of children were 5 years or above and only 69(6%) were <18 months. Overall, 9% (105/1168) of children died since the set-up of the programs. By the end of the observation period, 66(14.5%) patients not on ART had died compared to 39(5.5%) of those under treatment, and 100(22%) who did not start ART were lost-to-follow-up compared to 13(2%) on ART. 66/105 (62.8%) of all in-program deaths occurred before starting ART, of which 56% (37/66) and 79% (52/66) occurred within 3 and 6 months of enrollment respectively. Mortality rate ratio between children not on ART and children on ART was 4.1 (95%CI: 2.7-6.2) (P < 0.001). The most common contributing cause of death in first 3 months of treatment and in first 3 months of program enrollment was tuberculosis. 41/52 (79%) children who died within 6 months of enrollment had met the ART eligibility criteria before death., Conclusion: HIV-positive children experienced a high mortality and loss-to-follow-up rates before starting ART. These program outcomes may be improved by a more timely ART initiation. Measuring overall in-program mortality as opposed to only mortality on ART is recommended in order to more accurately evaluate pediatric HIV-programs performance.
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- 2009
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504. Ethics of conducting research in conflict settings.
- Author
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Ford N, Mills EJ, Zachariah R, and Upshur R
- Abstract
Humanitarian agencies are increasingly engaged in research in conflict and post-conflict settings. This is justified by the need to improve the quality of assistance provided in these settings and to collect evidence of the highest standard to inform advocacy and policy change. The instability of conflict-affected areas, and the heightened vulnerability of populations caught in conflict, calls for careful consideration of the research methods employed, the levels of evidence sought, and ethical requirements. Special attention needs to be placed on the feasibility and necessity of doing research in conflict-settings, and the harm-benefit ratio for potential research participants.
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- 2009
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505. Very early mortality in patients starting antiretroviral treatment at primary health centres in rural Malawi.
- Author
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Zachariah R, Harries K, Moses M, Manzi M, Line A, Mwagomba B, and Harries AD
- Subjects
- Adult, Anti-Retroviral Agents therapeutic use, CD4 Lymphocyte Count, Candidiasis, Oral etiology, Epidemiologic Methods, Female, Humans, Malawi epidemiology, Male, Malnutrition complications, Practice Guidelines as Topic, Rural Health, Tuberculosis, Pulmonary complications, AIDS-Related Opportunistic Infections mortality, Candidiasis, Oral mortality, HIV-1, Malnutrition mortality, Tuberculosis, Pulmonary mortality, Weight Loss
- Abstract
Objectives: To report on the cumulative proportion of deaths occurring within 3 months of starting antiretroviral treatment (ART) and to identify factors associated with such deaths, among adults at primary health centres in a rural district of Malawi., Methods: Retrospective cohort study: from June 2006 to April 2008, deaths occurring over a 3-month period were determined and risk factors examined., Results: A total of 2316 adults (706 men and 1610 women; median age 35 years) were included in the analysis and followed up for a total of 1588 person-years (PY); 277 (12%) people died, of whom 206 (74%) people died within 3 months of initiating ART (cumulative incidence: 13.0; 95% confidence interval: 11.3-14.8 per 100 PY of follow-up). Significant risk factors associated with early deaths included male sex, WHO stage 4 disease, oesophageal or persistent oral candidiasis and unexplained presumed or measured weight loss >10%. One in every 3 patients who either died or was lost to follow up had unexplained weight loss >10%, and survival in this group was significantly different from patients without this condition., Conclusions: Seven in 10 individuals initiating ART at primary health centres die early. Specific groups of patients are at higher risk of such mortality and should receive priority attention, care and support.
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- 2009
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506. The vital signs of chronic disease management.
- Author
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Harries AD, Zachariah R, Kapur A, Jahn A, and Enarson DA
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- Anti-Retroviral Agents therapeutic use, Antitubercular Agents therapeutic use, Blood Pressure Determination, Body Temperature, Developing Countries, Female, HIV Infections drug therapy, HIV Infections physiopathology, Heart Rate, Humans, Male, Monitoring, Physiologic, Registries, Respiration, Tuberculosis drug therapy, Tuberculosis physiopathology, Chronic Disease drug therapy
- Abstract
The vital signs of pulse rate, blood pressure, temperature and respiratory rate are the 'nub' of individual patient management. At the programmatic level, vital signs could also be used to monitor the burden and treatment outcome of chronic disease. Case detection and treatment outcome constitute the vital signs of tuberculosis control within the WHO's 'DOTS' framework, and similar vital signs could be adapted and used for management of chronic diseases. The numbers of new patients started on therapy in each month or quarter (new incident cases) are sensitive indicators for programme performance and access to services. Using similar reporting cycles, treatment outcomes for all patients can be assessed, the vital signs being: alive and retained on therapy at the respective facility; died; stopped therapy; lost to follow-up; and transferred out to another facility. Retention on treatment constitutes the prevalent number of cases, the burden of disease, and this provides important strategic information for rational drug forecasting and logistic planning. If case numbers and outcomes of chronic diseases were measured reliably and consistently as part of an integrated programmatic approach, this would strengthen the ability of resource-poor countries to monitor and assess their response to these growing epidemics.
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- 2009
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507. Weight evolution in HIV-1 infected women in Rwanda after stavudine substitution due to lipoatrophy: comparison of zidovudine with tenofovir/abacavir.
- Author
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van Griensven J, Zachariah R, Rasschaert F, Atté EF, and Reid T
- Subjects
- Adenine analogs & derivatives, Adenine therapeutic use, Adult, Anti-HIV Agents adverse effects, Dideoxynucleosides therapeutic use, Drug Therapy, Combination, Female, HIV-Associated Lipodystrophy Syndrome chemically induced, Humans, Organophosphonates therapeutic use, Rwanda, Stavudine adverse effects, Stavudine therapeutic use, Tenofovir, Treatment Outcome, Weight Loss drug effects, Zidovudine therapeutic use, Anti-HIV Agents therapeutic use, Body Weight drug effects, HIV-1, HIV-Associated Lipodystrophy Syndrome drug therapy
- Abstract
This cohort study was conducted amongst female patients manifesting lipoatrophy while receiving stavudine-containing first-line antiretroviral treatment regimens at two urban health centres in Rwanda. The objectives were to assess weight evolution after stavudine substitution and to describe any significant difference in weight evolution when zidovudine or tenofovir/abacavir was used for substitution. All adult patients on stavudine-containing first-line regimens who developed lipoatrophy (diagnosed using a lipodystrophy case definition study-based questionnaire) and whose treatment regimen was changed were included (n=114). In the most severe cases stavudine was replaced with tenofovir or abacavir (n=39), and in the remainder with zidovudine (n=75). For patients changed to zidovudine a progressive weight loss was seen, while those on tenofovir/abacavir showed a progressive weight increase from six months. The between-group difference in weight evolution was significant from nine months (difference at 12 months: 2.3 kg, P=0.02). These differences were confirmed by follow-up lipoatrophy scores. In multivariate analysis, substitution with tenofovir/abacavir remained significantly associated with weight gain. This is the first study in Africa assessing weight gain as a proxy for recovery after stavudine substitution due to lipoatrophy, providing supporting evidence that tenofovir/abacavir is superior to zidovudine. The weight loss with zidovudine might justify earlier substitution and access to better alternatives like tenofovir/abacavir.
- Published
- 2009
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508. Discordant immunologic and virologic responses to antiretroviral therapy and associated mortality in a large treatment program in Rwanda.
- Author
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van Griensven J, Zachariah R, Rasschaert F, and Reid T
- Subjects
- Adult, Female, HIV Infections immunology, HIV Infections virology, Humans, Male, Rwanda epidemiology, Anti-HIV Agents therapeutic use, HIV Infections drug therapy, HIV Infections mortality
- Published
- 2009
- Full Text
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509. Increased baseline body weight is a risk factor associated with virological failure while on antiretroviral treatment.
- Author
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van Griensven J and Zachariah R
- Subjects
- Adult, CD4 Lymphocyte Count, Female, HIV drug effects, HIV physiology, HIV Infections virology, Humans, Logistic Models, Male, Risk Factors, Treatment Failure, Viral Load, Anti-HIV Agents therapeutic use, Body Weight, HIV Infections drug therapy
- Published
- 2008
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510. Adapting the DOTS framework for tuberculosis control to the management of non-communicable diseases in sub-Saharan Africa.
- Author
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Harries AD, Jahn A, Zachariah R, and Enarson D
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- Africa South of the Sahara epidemiology, Female, Humans, Infection Control, Male, Population Dynamics, Program Evaluation, Tuberculosis drug therapy, World Health Organization, Tuberculosis prevention & control
- Published
- 2008
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511. Task shifting for antiretroviral treatment delivery in sub-Saharan Africa: not a panacea.
- Author
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Philips M, Zachariah R, and Venis S
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- Africa South of the Sahara, Humans, Quality of Health Care, World Health Organization, Antiretroviral Therapy, Highly Active, Clinical Competence, Delivery of Health Care, HIV Infections drug therapy, Health Workforce
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- 2008
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512. Scaling-up co-trimoxazole prophylaxis in HIV-exposed and HIV-infected children in high HIV-prevalence countries.
- Author
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Zachariah R, Harries AD, Luo C, Bachman G, and Graham SM
- Subjects
- AIDS-Related Opportunistic Infections mortality, Adolescent, Anti-Infective Agents administration & dosage, Chemoprevention, Child, Child, Preschool, Developing Countries, HIV Infections complications, HIV Infections mortality, Health Policy, Humans, Infant, Infant, Newborn, Prevalence, Trimethoprim, Sulfamethoxazole Drug Combination administration & dosage, AIDS-Related Opportunistic Infections prevention & control, Anti-Infective Agents therapeutic use, HIV Infections epidemiology, Trimethoprim, Sulfamethoxazole Drug Combination therapeutic use
- Abstract
Co-trimoxazole (trimethoprim-sulfamethoxazole) is a widely available antibiotic that substantially reduces HIV-related morbidity and mortality in both adults and children. Prophylaxis with co-trimoxazole is a recommended intervention of proven benefit that could serve not only as an initial step towards improving paediatric care in young children with limited access to antiretroviral treatment, but also as an important complement to antiretroviral therapy in resource-limited settings. Despite co-trimoxazole's known clinical benefits, the potential operational benefits, and favourable recommendations by WHO, UNAIDS, and UNICEF, its routine use in developing countries--particularly sub-Saharan Africa--has remained limited. Out of an estimated 4 million children in need of co-trimoxazole prophylaxis (HIV-exposed and HIV-infected), only 4% are currently receiving this intervention. We discuss some of the major barriers preventing the scale-up of co-trimoxazole prophylaxis for children in countries with a high prevalence of HIV and propose specific actions required to tackle these challenges.
- Published
- 2007
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513. High prevalence of lipoatrophy among patients on stavudine-containing first-line antiretroviral therapy regimens in Rwanda.
- Author
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van Griensven J, De Naeyer L, Mushi T, Ubarijoro S, Gashumba D, Gazille C, and Zachariah R
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- Adult, Antiretroviral Therapy, Highly Active, Cross-Sectional Studies, Female, HIV Infections epidemiology, HIV Infections metabolism, HIV-Associated Lipodystrophy Syndrome chemically induced, HIV-Associated Lipodystrophy Syndrome epidemiology, Humans, Male, Prevalence, Rwanda epidemiology, Sex Factors, Anti-HIV Agents adverse effects, Anti-Retroviral Agents adverse effects, HIV Infections drug therapy, HIV-1, Lipodystrophy chemically induced, Stavudine adverse effects
- Abstract
This study was conducted among individuals placed on WHO-recommended first-line antiretroviral therapy (ART) at two urban health centres in Kigali, Rwanda, in order to determine (a) the overall prevalence of lipodystrophy and (b) the risk factors for lipoatropy. Consecutive individuals on ART for >1 year were systematically subjected to a standardised case definition-based questionnaire and clinical assessment. Of a total of 409 individuals, 370 (90%) were on an ART regimen containing stavudine (d4T), whilst the rest were receiving a zidovudine (AZT)-containing regimen. Lipodystrophy was apparent in 140 individuals (34%), of whom 40 (9.8%) had isolated lipoatrophy, 20 (4.9%) had isolated lipohypertrophy and 80 (19.6%) had mixed patterns. Fifty-six percent of patients reported the effects as disturbing. The prevalence of lipoatrophy was more than three times higher when taking d4T compared with AZT-containing regimens (31.4% vs. 10.3%). Being female, d4T-based ART, baseline body mass index >or=25 kg/m(2) or baseline CD4 count >or=150 cells/microl and increasing duration of ART were all significantly associated with lipoatrophy. Lipoatrophy appears to be an important long-term complication of WHO-recommended first-line ART regimens. These data highlight the urgent need for access to more affordable and less toxic ART regimens in resource-limited settings.
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- 2007
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514. Treatment outcomes stratified by baseline immunological status among young children receiving nonnucleoside reverse-transcriptase inhibitor-based antiretroviral therapy in resource-limited settings.
- Author
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O'Brien DP, Sauvageot D, Olson D, Schaeffer M, Humblet P, Pudjades M, Ellman T, Zachariah R, Szumilin E, Arnould L, and Read T
- Subjects
- Acquired Immunodeficiency Syndrome mortality, CD4 Lymphocyte Count, Child, Preschool, Drug Therapy, Combination, Female, Humans, Male, Probability, Survival Analysis, Treatment Outcome, Acquired Immunodeficiency Syndrome drug therapy, Acquired Immunodeficiency Syndrome immunology, Developing Countries, Health Resources supply & distribution, Immune Tolerance, Reverse Transcriptase Inhibitors therapeutic use
- Abstract
A study of 568 children aged <5 years who commenced nonnucleoside reverse-transcriptase inhibitor-based antiretroviral therapy in resource-limited settings revealed good early outcomes. After 12 months of antiretroviral therapy, survival probability was 0.89 (95% confidence interval, 0.86-0.92), with no significant difference among children stratified on the basis of baseline immunological levels; 62% attained a CD4 cell percentage >25%, and 7% continued to have a CD4 cell percentage <15%.
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- 2007
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515. Acceptance of anti-retroviral therapy among patients infected with HIV and tuberculosis in rural Malawi is low and associated with cost of transport.
- Author
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Zachariah R, Harries AD, Manzi M, Gomani P, Teck R, Phillips M, and Firmenich P
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- Adolescent, Adult, Aged, Antitubercular Agents therapeutic use, Child, Child, Preschool, Cross-Sectional Studies, Female, HIV Infections economics, Health Care Costs, Humans, Malawi, Male, Middle Aged, Retrospective Studies, Rural Health, Rural Population, Tuberculosis drug therapy, Tuberculosis, Pulmonary complications, Tuberculosis, Pulmonary drug therapy, Young Adult, Anti-HIV Agents therapeutic use, HIV Infections complications, HIV Infections drug therapy, Patient Acceptance of Health Care, Transportation of Patients economics, Tuberculosis complications
- Abstract
Background: A study was conducted among newly registered HIV-positive tuberculosis (TB) patients systematically offered anti-retroviral treatment (ART) in a district hospital in rural Malawi in order to a) determine the acceptance of ART b) conduct a geographic mapping of those placed on ART and c) examine the association between "cost of transport" and ART acceptance., Methodology/principal Findings: A retrospective cross-sectional analysis was performed on routine program data for the period of February 2003 to July 2004. Standardized registers and patient cards were used to gather data. The place of residence was used to determine road distances to the Thyolo district hospital. Cost of transport from different parts of the district was based on the known cost for public transport to the road-stop closest to the patient's residence. Of 1,290 newly registered TB patients, 1,003(78%) underwent HIV-testing of whom 770 (77%) were HIV-positive. 742 of these individuals (pulmonary TB = 607; extra-pulmonary TB = 135) were considered eligible for ART of whom only 101(13.6%) accepted ART. Cost of transport to the hospital ART site was significantly associated with ART acceptance and there was a linear trend in association between cost and ART acceptance (chi(2) for trend = 25.4, P<0.001). Individuals who had to pay 50 Malawi Kwacha (1 United States Dollar = 100 Malawi Kwacha, MW) or less for a one-way trip to the Thyolo hospital were four times more likely to accept ART than those who had to pay over 100 MW (Adjusted Odds ratio = 4.0, 95% confidence interval: 2.0-8.1, P<0.001)., Conclusions/significance: ART acceptance among TB patients in a rural district in Malawi is low and associated with cost of transport to the centralized hospital based ART site. Decentralizing the ART offer from the hospital to health centers that are closer to home communities would be an essential step towards reducing the overall cost and burden of travel.
- Published
- 2006
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516. Risk factors for high early mortality in patients on antiretroviral treatment in a rural district of Malawi.
- Author
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Zachariah R, Fitzgerald M, Massaquoi M, Pasulani O, Arnould L, Makombe S, and Harries AD
- Subjects
- AIDS-Related Opportunistic Infections mortality, Adult, CD4 Lymphocyte Count, Cross-Sectional Studies, Female, HIV Infections complications, HIV Infections drug therapy, Humans, Malawi epidemiology, Male, Nutrition Disorders complications, Nutrition Disorders epidemiology, Risk Factors, Rural Health, Sex Distribution, Survival Analysis, Treatment Outcome, Anti-Retroviral Agents therapeutic use, HIV Infections mortality
- Abstract
Objectives: Among adults started on antiretroviral treatment (ART) in a rural district hospital (a) to determine the cumulative proportion of deaths that occur within 3 and 6 months of starting ART, and (b) to identify risk factors that may be associated with such mortality., Design and Setting: A cross-sectional analytical study set in Thyolo district, Malawi., Methods: Over a 2-year period (April 2003 to April 2005) mortality within the first 3 and 6 months of starting ART was determined and risk factors were examined., Results: A total of 1507 individuals (517 men and 990 women), whose median age was 35 years were included in the study. There were a total of 190 (12.6%) deaths on ART of which 116 (61%) occurred within the first 3 months (very early mortality) and 150 (79%) during the first 6 months of initiating ART. Significant risk factors associated with such mortality included WHO stage IV disease, a baseline CD4 cell count under 50 cells/mul and increasing grades of malnutrition. A linear trend in mortality was observed with increasing grades of malnutrition (chi for trend = 96.1, P = 0.001) and decreasing CD4 cell counts (chi for trend = 72.4, P = 0.001). Individuals who were severely malnourished [body mass index (BMI) < 16.0 kg/m] had a six times higher risk of dying in the first 3 months than those with a normal nutritional status., Conclusions: Among individuals starting ART, the BMI and clinical staging could be important screening tools for use to identify and target individuals who, despite ART, are still at a high risk of early death.
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- 2006
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517. In resource-limited settings good early outcomes can be achieved in children using adult fixed-dose combination antiretroviral therapy.
- Author
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O'Brien DP, Sauvageot D, Zachariah R, and Humblet P
- Subjects
- Africa, Anti-Retroviral Agents economics, Anti-Retroviral Agents therapeutic use, Asia, Southeastern, CD4 Lymphocyte Count, Child, Child, Preschool, Drug Administration Schedule, Drug Costs, Female, HIV Infections immunology, HIV Infections mortality, Humans, Male, Safety, Survival Rate, Treatment Outcome, Anti-Retroviral Agents administration & dosage, Developing Countries, HIV Infections drug therapy
- Abstract
Objectives: To (a) determine early treatment outcomes and (b) assess safety in children treated with adult fixed-dose combination (FDC) antiretroviral tablets., Setting: Sixteen Medecins Sans Frontieres (MSF) HIV programs in eight countries in resource-limited settings (RLS)., Methods: Analysis of routine program data gathered June 2001 to March 2005., Results: A total of 1184 children [median age, 7 years; inter-quartile range (IQR), 4.6-9.3] were treated with antiretroviral therapy (ART) of whom 616(52%) were male. At ART initiation, Centres for Disease Control stages N, A, B and C were 9, 14, 38 and 39%, respectively. Children were followed up for a median period of 6 months (IQR, 2-12 months). At 12 months the median CD4 percentage gain in children aged 18-59 months was 15% (IQR, 6-18%), and the percentage with CD4 gain < 15% was reduced from 85% at baseline to 11%. In those aged 60-156 months, median CD4 cell count gain was 275 cells/microl (IQR, 84-518 cells/microl), and the percentage with CD4 < 200 cells/mul reduced from 51% at baseline to 11%. Treatment outcomes included; 1012 (85%) alive and on ART, 36 (3%) deaths, 15 (1%) stopped ART, 89 (8%) lost to follow-up, and 31 (3%) with unknown outcomes. Overall probability of survival at 12 months was 0.87 (0.84-0.89). Side effects caused a change to alternative antiretroviral drugs in 26 (2%) but no deaths., Conclusions: Very satisfactory early outcomes can be achieved in children in RLS using generic adult FDC antiretroviral tablets. These findings strongly favour their use as an "interim solution" for scaling-up ART in children; however, more appropriate pediatric antiretroviral drugs remain urgently needed.
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- 2006
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518. Tuberculosis after HAART initiation in HIV-positive patients from five countries with a high tuberculosis burden.
- Author
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Bonnet MM, Pinoges LL, Varaine FF, Oberhauser BB, O'Brien DD, Kebede YY, Hewison CC, Zachariah RR, and Ferradini LL
- Subjects
- Adult, Antiretroviral Therapy, Highly Active, Cambodia, Cameroon, Confidence Intervals, Endemic Diseases, Female, Follow-Up Studies, Humans, Incidence, Kenya, Malawi, Male, Thailand, Time Factors, Antiviral Agents therapeutic use, Developing Countries, HIV Infections drug therapy, HIV Infections microbiology, HIV-1, Tuberculosis complications
- Abstract
Background: HAART reduces tuberculosis (TB) incidence in people living with HIV/AIDS but those starting HAART may develop active TB or subclinical TB may become apparent in the immune reconstitution inflammatory syndrome., Objective: To measure the incidence rate of notified TB in people receiving HAART in five HIV programmes occurring in low-resource countries with a high TB/HIV burden., Methods: A retrospective review in five Médecins Sans Frontières programmes (Cambodia, Thailand, Kenya, Malawi and Cameroon) allowed incidence rates of notified TB to be calculated based on follow-up time after HAART initiation., Result: Among 3151 patients analysed, 90% had a CD4 cell count of < 200 cells/mul. Median follow-up time ranged from 3.7 months in Thailand or Kenya to 11.1 months in Cambodia. Incidence rates were 7.6, 10.4, 17.6, 14.3 and 4.8/100 person-years for pulmonary TB and 12.7, 4.3, 6.9, 2.1 and 0/100 person-years for extra-pulmonary TB in the programmes in Cambodia, Thailand, Kenya, Malawi and Cameroon, respectively. Overall, 62.3% of pulmonary TB and 54.9% of extra-pulmonary TB were diagnosed within 3 months after HAART initiation., Conclusion: High incidence rates of notified TB under HAART in programmes held in poor-resource countries were observed; these were likely to include both undiagnosed prevalent TB at HAART initiation and subclinical TB developing during the immune reconstitution inflammatory syndrome. This raises operational issues concerning TB diagnosis and treatment of TB/HIV-coinfected patients and prompts for urgent TB and HIV care integration.
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- 2006
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519. Generic fixed-dose combination antiretroviral treatment in resource-poor settings: multicentric observational cohort.
- Author
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Calmy A, Pinoges L, Szumilin E, Zachariah R, Ford N, and Ferradini L
- Subjects
- Adult, Anti-HIV Agents adverse effects, Anti-HIV Agents therapeutic use, Antiretroviral Therapy, Highly Active adverse effects, CD4 Lymphocyte Count, Drug Administration Schedule, Drugs, Generic adverse effects, Drugs, Generic therapeutic use, Epidemiologic Methods, Female, Humans, Lamivudine administration & dosage, Lamivudine adverse effects, Lamivudine therapeutic use, Male, Medically Underserved Area, Nevirapine administration & dosage, Nevirapine adverse effects, Nevirapine therapeutic use, Reverse Transcriptase Inhibitors adverse effects, Reverse Transcriptase Inhibitors therapeutic use, Stavudine administration & dosage, Stavudine adverse effects, Stavudine therapeutic use, Treatment Outcome, Anti-HIV Agents administration & dosage, Antiretroviral Therapy, Highly Active methods, Developing Countries, Drugs, Generic administration & dosage, HIV Infections drug therapy, Reverse Transcriptase Inhibitors administration & dosage
- Abstract
Background: The use fixed-dose combination (FDC) is a critical tool in improving HAART. Studies on the effectiveness of combined lamivudine, stavudine and nevirapine (3TC/d4T/NVP) are scarce., Objective: To analyse 6861 patients in a large observational cohort from 21 Médecins Sans Frontieres (MSF) HIV/AIDS programmes taking 3TC/d4T/NVP, with subcohort analyses of patients at 12 and 18 months of treatment., Methods: Survival was analysed using Kaplan-Meier method and factors associated with progression to death with Cox proportional hazard ratio., Results: Median baseline CD4 cell count at initiating of FDC was 89 cells/microl [interquartile range (IQR), 33-158]. The median follow-up time was 4.1 months (IQR, 1.9-7.3). The incidence rate of death during follow-up was 14.2/100 person-years [95% confidence interval (CI), 13.8-14.5]. Estimates of survival (excluding those lost to follow-up) were 0.93 (95% CI, 92-94) at 6 months (n = 2,231) and 0.90 (95% CI, 89-91) at 12 months (n = 472). Using a Cox model, the following factors were associated with death: male gender, symptomatic infection, body mass index < 18 kg/m and CD4 cell count 15-50 cells/microl or < 15 cells/microl. Subcohort analysis of 655 patients after 1 year of follow-up (M12 FDC cohort) revealed that 77% remained on HAART, 91% of these still on the FDC regimen; 5% discontinued the FDC because of drug intolerance. At 18 months, 77% of the patients remained on HAART., Conclusions: Positive outcomes for d4T/3TC/NVP are reported for up to 18 months in terms of efficacy and safety.
- Published
- 2006
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520. Do aid agencies have an ethical duty to comply with researchers? A response to Rennie.
- Author
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Zachariah R, Janssens V, and Ford N
- Subjects
- Democratic Republic of the Congo, Global Health, Humans, Physicians, Policy Making, Cooperative Behavior, Developing Countries, Health Services Research ethics, Organizations ethics, Refusal to Participate ethics, Relief Work ethics, Resource Allocation ethics, Social Responsibility
- Abstract
Medical AID organisations such as Médecins Sans Frontières receive several requests from individuals and international academic institutions to conduct research at their implementation sites in Africa. Do AID agencies have an ethical duty to comply with research requests? In this paper we respond to the views and constructed theories (albeit unfounded) of one such researcher, whose request to conduct research at one of our sites in the Democratic Republic of Congo was turned down.
- Published
- 2006
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521. Safety, effectiveness, and outcomes of concomitant use of highly active antiretroviral therapy with drugs for tuberculosis in resource-poor settings.
- Author
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Harries AD, Chimzizi R, and Zachariah R
- Subjects
- Antitubercular Agents administration & dosage, Developing Countries, Drug Administration Schedule, Drug Interactions, Humans, Poverty, Tuberculosis classification, AIDS-Related Opportunistic Infections drug therapy, Antiretroviral Therapy, Highly Active, Antitubercular Agents therapeutic use, HIV Infections drug therapy, Tuberculosis drug therapy
- Published
- 2006
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522. Monitoring the response to antiretroviral therapy in resource-poor settings: the Malawi model.
- Author
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Harries AD, Gomani P, Teck R, de Teck OA, Bakali E, Zachariah R, Libamba E, Mwansambo A, Salaniponi F, and Mpazanje R
- Subjects
- Anti-Retroviral Agents therapeutic use, Antiretroviral Therapy, Highly Active standards, Cohort Studies, Delivery of Health Care organization & administration, Delivery of Health Care standards, Developing Countries, Disease Outbreaks, HIV Seropositivity epidemiology, HIV Seropositivity mortality, Health Resources supply & distribution, Humans, Malawi epidemiology, Practice Guidelines as Topic, Program Evaluation methods, Treatment Outcome, Antiretroviral Therapy, Highly Active methods, HIV Seropositivity drug therapy
- Abstract
With assistance from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), Malawi is scaling-up the delivery of antiretroviral (ARV) therapy to HIV-positive eligible patients. The country has developed National ARV Treatment Guidelines, which emphasize a structured and standardized approach for all aspects of ARV delivery, including monitoring and evaluation. Using the successful DOTS model adapted by National TB Control Programmes throughout the world, Malawi has developed a system of quarterly ARV cohort and cumulative ARV quarterly analyses. Thyolo district, in the southern region of Malawi, has been using this system since April 2003. This paper describes the standardized ARV treatment regimens and the treatment outcomes used in Thyolo to assess the impact of treatment, the registration and monitoring systems and how the cohort analyses are carried out. Data are presented for case registration and treatment outcome for the first quarterly cohort (April to June) and the combined cohorts (April to June and July to September). Such quarterly analyses may be useful for districts and Ministries of Health in assessing ARV delivery, although the burden of work involved in calculating the numbers may become large once ARV delivery systems have been established for several years.
- Published
- 2004
- Full Text
- View/download PDF
523. Voluntary counselling, HIV testing and adjunctive cotrimoxazole reduces mortality in tuberculosis patients in Thyolo, Malawi.
- Author
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Zachariah R, Spielmann MP, Chinji C, Gomani P, Arendt V, Hargreaves NJ, Salaniponi FM, and Harries AD
- Subjects
- AIDS-Related Opportunistic Infections complications, Adolescent, Adult, Aged, Chemotherapy, Adjuvant, Child, Child, Preschool, Cohort Studies, Feasibility Studies, Female, Follow-Up Studies, HIV Seropositivity, Humans, Infant, Malawi, Male, Middle Aged, Patient Compliance, Proportional Hazards Models, Rural Health, Self Administration, Survival Analysis, Treatment Outcome, Tuberculosis complications, Tuberculosis mortality, Voluntary Programs, AIDS-Related Opportunistic Infections drug therapy, Anti-Infective Agents therapeutic use, Counseling, HIV Infections diagnosis, Trimethoprim, Sulfamethoxazole Drug Combination therapeutic use, Tuberculosis drug therapy
- Abstract
Objectives: To assess the feasibility and effectiveness of voluntary counselling, HIV testing and adjunctive cotrimoxazole in reducing mortality in a cohort of tuberculosis (TB) patients registered under routine programme conditions in a rural district of Malawi., Design: 'Before' and 'after' cohort study using historical controls., Methods: Between 1 July 1999 and 30 June 2000 all TB patients were started on standardized anti-TB treatment, and offered voluntary counselling and HIV testing (VCT). Those found to be HIV-positive were offered cotrimoxazole at a dose of 480 mg twice daily, provided there were no contraindications. Side-effects were monitored clinically. End-of-treatment outcomes in this cohort (intervention group) were compared with a cohort registered between 1 July 1998 and 30 June 1999 in whom VCT and cotrimoxazole was not offered (control group)., Findings: A total of 1986 patients was registered in the study: 1061 in the intervention group and 925 in the control cohort. In the intervention group, 1019 (96%) patients were counselled pre-test, 964 (91%) underwent HIV testing and 938 (88%) were counselled post-test. The overall HIV-seroprevalence rate was 77%. A total of 693 patients were given cotrimoxazole of whom 14 (2%) manifested minor dermatological reactions. The adjusted relative risk of death in the intervention group compared with the control group was 0.81 (P < 0.001). The number needed to treat with VCT and adjunctive cotrimoxazole to prevent one death during anti-TB treatment was 12.5., Interpretation: This study shows that VCT and adjunctive cotrimoxazole is feasible, safe and reduces mortality rates in TB patients under routine programme conditions.
- Published
- 2003
- Full Text
- View/download PDF
524. Sexually transmitted infections among prison inmates in a rural district of Malawi.
- Author
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Zachariah R, Harries AD, Chantulo AS, Yadidi AE, Nkhoma W, and Maganga O
- Subjects
- Adult, Condoms statistics & numerical data, Humans, Incidence, Malawi epidemiology, Male, Rural Health, Sexually Transmitted Diseases prevention & control, Prisoners statistics & numerical data, Sexually Transmitted Diseases epidemiology
- Abstract
As part of a comprehensive human immunodeficiency virus (HIV) prevention strategy targeting high-risk groups, sexually transmitted infection (STI) clinics are offered to all prisoners in Thyolo district, southern Malawi. Prison inmates are not, however, allowed access to condoms as it is felt that such an intervention might encourage homosexuality which is illegal in Malawi. A study was conducted between January 2000 and December 2001 in order to determine the prevalence, incidence, and patterns of STIs among male inmates of 2 prisons in this rural district. A total of 4229 inmates were entered into the study during a 2-year period. Of these, 178 (4.2%) were diagnosed with an STI. This included 83 (46%) inmates with urethral discharge, 60 (34%) with genital ulcer disease (GUD), and 35 (20%) inmates with epididymo-orchitis. Fifty (28%) STIs were considered incident cases acquired within the prisons (incidence risk 12 cases/1000 inmates/year). GUD was the most common STI in this group comprising 52% of all STI. This study shows that a considerable proportion of STIs among inmates are acquired within prison. In a setting of same-sex inmates, this suggests inter-prisoner same-sex sexual activity. The findings have implications for HIV transmission and might help in developing more rational policies on STI control and condom access within Malawi prisons.
- Published
- 2002
- Full Text
- View/download PDF
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