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Background The effect of antiretroviral treatment (ART) eligibility expansions on patient outcomes, including rates of timely ART initiation among those enrolling in care, has not been assessed on a large scale. In addition, it is not known whether ART eligibility expansions may lead to 'crowding out' of sicker patients. Methods and findings We examined changes in timely ART initiation (within 6 months) at the original site of HIV care enrollment after ART eligibility expansions among 284,740 adult ART-naïve patients at 171 International Epidemiology Databases to Evaluate AIDS (IeDEA) network sites in 22 countries where national policies expanding ART eligibility were introduced between 2007 and 2015. Half of the sites included in this analysis were from Southern Africa, one-third were from East Africa, and the remainder were from the Asia-Pacific, Central Africa, North America, and South and Central America regions. The median age of patients enrolling in care at contributing sites was 33.5 years, and the median percentage of female patients at these clinics was 62.5%. We assessed the 6-month cumulative incidence of timely ART initiation (CI-ART) before and after major expansions of ART eligibility (i.e., expansion to treat persons with CD4 [less than or equal to] 350 cells/[mu]L [145 sites in 22 countries] and CD4 [less than or equal to] 500 cells/[mu]L [152 sites in 15 countries]). Random effects metaregression models were used to estimate absolute changes in CI-ART at each site before and after guideline expansion. The crude pooled estimate of change in CI-ART was 4.3 percentage points (95% confidence interval [CI] 2.6 to 6.1) after ART eligibility expansion to CD4 [less than or equal to] 350, from a baseline median CI-ART of 53%; and 15.9 percentage points (pp) (95% CI 14.3 to 17.4) after ART eligibility expansion to CD4 [less than or equal to] 500, from a baseline median CI-ART of 57%. The largest increases in CI-ART were observed among those newly eligible for treatment (18.2 pp after expansion to CD4 [less than or equal to] 350 and 47.4 pp after expansion to CD4 [less than or equal to] 500), with no change or small increases among those eligible under prior guidelines (CD4 [less than or equal to] 350: -0.6 pp, 95% CI -2.0 to 0.7 pp; CD4 [less than or equal to] 500: 4.9 pp, 95% CI 3.3 to 6.5 pp). For ART eligibility expansion to CD4 [less than or equal to] 500, changes in CI-ART were largest among younger patients (16-24 years: 21.5 pp, 95% CI 18.9 to 24.2 pp). Key limitations include the lack of a counterfactual and difficulty accounting for secular outcome trends, due to universal exposure to guideline changes in each country. Conclusions These findings underscore the potential of ART eligibility expansion to improve the timeliness of ART initiation globally, particularly for young adults., Author(s): Olga Tymejczyk 1,2,*, Ellen Brazier 1,2, Constantin Yiannoutsos 3, Kara Wools-Kaloustian 4, Keri Althoff 5, Brenda Crabtree-Ramírez 6, Kinh Van Nguyen 7, Elizabeth Zaniewski 8, Francois Dabis 9, Jean [...]

The World Health Organization (WHO) has conducted two major updates to global guidance for the management of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections in 2016. (1,2) [...]

Objective To assess the effectiveness of treatment for hepatitis C virus (HCV) infection in low- and middle-income countries and identify factors associated with successful outcomes. Methods We performed a systematic review and meta-analysis of studies of HCV treatment programmes in low- and middle- income countries. The primary outcome was a sustained virological response (SVR). Factors associated with treatment outcomes were identified by random-effects meta-regression analysis. Findings The analysis involved data on 12 213 patients included in 93 studies from 17 countries. The overall SVR rate was 52% (95% confidence interval, CI: 48-56). For studies in which patients were predominantly infected with genotype] or 4 HCV, the pooled SVR rate was 49% (95% CI: 43-55). This was significantly lower than the rate of 59% (9.5% CI: 54-64) found in studies in which patients were predominantly infected with other genotypes (P= 0.012). Factors associated with successful outcomes included treatment with pegylated interferon and ribavirin, infection with an HCV genotype other than genotype 1 or 4 and the absence of liver damage or human immunodeficiency virus infection at baseline. No significant difference in the SVR rate was observed between weight-adjusted and fixed-dose ribavirin treatment. Overall, 17% (%% CI: 13-23) of adverse events resulted in treatment interruption or close modification, but only 4% (95% CI: 3-5) resulted in treatment discontinuation. Conclusion The outcomes of treatment for HCV infection in low- and middle-income countries were similar to those reported in highincome countries. Objectif Evaluer l'efficacite du traitement de l'infection par le virus de l'hepatite C (VHC) dans les pays a revenu faible et moyen et identifier les facteurs associes aux resultats positifs. Methodes Nous avons effectue une evaluation systematique et une meta-analyse des etudes sur les programmes de traitement du VHC dans les pays a revenu faible et moyen. Le resultat principal consistait en une reponse virologique soutenue (RVS). Les facteurs lies aux resultats du traitement ont ete identifies a l'aide d'une analyse de meta-regression des effets aleatoires. Resultats L'analyse portait sur les donnees de 12 213 patients inclus dans 93 etudes provenant de 17 pays differents. Le taux de RVS general etait de 52% (intervalle de confiance de 95%, IC: 48-56). Pour les etudes dans lesquelles les patients etaient principalement atteints par le VHC de genotype 1 ou 4, le taux de RVS groupe etait de 49% (IC de 95%: 43-55). Ce taux etait largement inferieur a celui de 59% (IC de 95%: 54-64) presente dans les etudes dans lesquelles les patients etaient principalement atteints par d'autres genotypes (P= 0,012). Les facteurs lies aux resultats positifs incluaient le traitement a I'interferon pegyle et a la ribavirine, I'infection a un VHC de genotype autre que 1 ou 4 et I'absence de Iesions au fole ou d'infection par le virus de I'immunodeficience humaine initialement. Aucune difference significative dans le taux de RVS fia ete observee entre les traitements de ribavirine adaptes au poids et ceux a dose fixe. Dans I'ensemble, 17% (IC de 95%: 13-23) des effets indesirables ont entraine une interruption du traitement ou une modification des doses, tandis que 4% (IC de 95%: 3-5) d'entre eux ont entraine un abandon du traitement. Conclusion Les resultats du traitement de I'infection du VHC dans les pays a revenu faible et moyen etaient similaires a ceux qui etaient indiques dans les pays a revenu eleve. Objetivo Determinar la efectividad del tratamiento para la infeccion por el virus de la hepatitis C (VHC) en paises de ingresos medios y bajos e identificar los factores asociados con unos resultados satisfactorios. Metodos Realizamos un examen sistematico y un meta-analisis de estudios de programas de tratamiento del VHC en paises de ingresos medios y bajos. EI resultado fundamental fue una respuesta viral sostenida (RVS). Los factores asociados con los resultados del tratamiento se identificaron mediante un analisis de metarregresion de efectos aleatorios.. Resultados El analisis incluyo datos sobre 12 213 pacientes en 93 estudios de 17 paises. La tasa global de RVS fue del 52% (intervalo de confianza, IC del 95%: 48-56). Para estudios en los que los pacientes estaban predominantemente infectados con VHC del genotipo 1 o 4, la rasa de RVS combinada fue del 49% (IC del 95%: 43-55). Esta fue significativamente menor que la rasa del 59% (IC del 95%: 54-64) encontrada en estudios en los que los pacientes estaban predominantemente infectados con otros genotipos (P = 0,012). Los factores asociados con los resultados satisfactorios incluyeron el tratamiento con interferon pegilado y ribavirina, la infeccion del VHC de un genotipo distinto al 1 o al 4 y la ausencia de lesion hepatica o de infeccion por el virus de la inmunodeficiencia humana en el inicio. No se observaron diferencias significativas en la rasa de RVS entre el tratamiento de ribavirina adaptado al peso del paciente y el de dosis fijas. En conjunto, el 17% (IC del 95%: 13-23) de los eventos adversos provoco la interrupcion del tratamiento o la modificacion de la dosis, mientras que el 4% (IC del 95%: 3-5) causo el abandono del tratamiento. Conclusion Los resultados del tratamiento de la infeccion del VHC en paises de ingresos bajos y medios fueron similares a los de paises de ingresos elevados., Introduction Hepatitis C virus (HCV) infection is a growing public health concern. Globally an estimated 180 million people, or roughly 3% of the world's population, are currently infected. (1) The [...]

Background: Because men in Africa are less likely to access HIV/AIDS care than women, we aimed to determine if men have differing outcomes from women across a nationally representative sample of adult patients receiving combination antiretroviral therapy in Uganda. Methods: We estimated survival distributions for adult male and female patients using Kaplan‐Meier, and constructed multivariable regressions to model associations of baseline variables with mortality. We assessed person‐years of life lost up to age 55 by sex. To minimize the impact of patient attrition, we assumed a weighted 30% mortality rate among those lost to follow up. Results: We included data from 22,315 adults receiving antiretroviral therapy. At baseline, men tended to be older, had lower CD4 baseline values, more advanced disease, had pulmonary tuberculosis and had received less treatment follow up (all at p < 0.001). Loss to follow up differed between men and women (7.5 versus 5.9%, p < 0.001). Over the period of study, men had a significantly increased risk of death compared with female patients (adjusted hazard ratio 1.43, 95% CI 1.31‐1.57, p < 0.001). The crude mortality rate for males differed importantly from females (43.9, 95% CI 40.7‐47.0/1000 person‐years versus 26.9, 95% CI 25.4‐28.5/1000 person years, p < 0.001). The probability of survival was 91.2% among males and 94.1% among females at 12 months. Person‐years of life lost was lower for females than males (689.7 versus 995.9 per 1000 person‐years, respectively). Conclusions: In order to maximize the benefits of antiretroviral therapy, treatment programmes need to be gender sensitive to the specific needs of both women and men. Particular efforts are needed to enroll men earlier into care., Background Although the global prevalence of HIV among women has remained stable at 50%, in sub‐Saharan Africa, it is markedly higher in females than in males [1]. Similarly in Africa, [...]

Background: In Malawi, the dramatic shortage of human resources for health is negatively impacted by HIV‐related morbidity and mortality among health workers and their relatives. Many staff find it difficult to access HIV care through regular channels due to fear of stigma and discrimination. In 2006, two workplace initiatives were implemented in Thyolo District: a clinic at the district hospital dedicated to all district health staff and their first‐degree relatives, providing medical services, including HIV care; and a support group for HIV‐positive staff. Methods: Using routine programme data, we evaluated the following outcomes up to the end of 2009: uptake and outcome of HIV testing and counselling among health staff and their dependents; uptake and outcomes of antiretroviral therapy (ART) among health staff; and membership and activities of the support group. In addition, we included information from staff interviews and a job satisfaction survey to describe health workers' opinions of the initiatives. Results: Almost two‐thirds (91 of 144, 63%) of health workers and their dependents undergoing HIV testing and counselling at the staff clinic tested HIV positive. Sixty‐four health workers had accessed ART through the staff clinic, approximately the number of health workers estimated to be in need of ART. Of these, 60 had joined the support group. Cumulative ART outcomes were satisfactory, with more than 90% alive on treatment as of June 2009 (the end of the study observation period). The availability, confidentiality and quality of care in the staff clinic were considered adequate by beneficiaries. Conclusions: Staff clinic and support group services successfully provided care and support to HIV‐positive health workers. Similar initiatives should be considered in other settings with a high HIV prevalence., Background Malawi's severe health worker shortage is attributable to both an inadequate supply of trained health workers and poor retention of staff within the health system due to low remuneration, [...]

Background: AIDS‐associated Kaposi's sarcoma is an important, life‐threatening opportunistic infection among people living with HIV/AIDS in resource‐limited settings. In western countries, the introduction of combination antiretroviral therapy (cART) and new chemotherapeutic agents has resulted in decreased incidence and improved prognosis of AIDS‐associated Kaposi's sarcoma. In African cohorts, however, mortality remains high. In this study, we describe disease characteristics and risk factors for mortality in a public sector HIV programme in South Africa. Methods: We analysed data from an observational cohort study of HIV‐infected adults with AIDS‐associated Kaposi's sarcoma, enrolled between May 2001 and January 2007 in three primary care clinics. Paper records from primary care and tertiary hospital oncology clinics were reviewed to determine the site of Kaposi's sarcoma lesions, immune reconstitution inflammatory syndrome stage, and treatment. Baseline characteristics, cART use and survival outcomes were extracted from an electronic database maintained for routine monitoring and evaluation. Cox regression was used to model associations with mortality. Results: Of 6292 patients, 215 (3.4%) had AIDS‐associated Kaposi's sarcoma. Lesions were most commonly oral (65%) and on the lower extremities (56%). One quarter of patients did not receive cART. The mortality and lost‐to‐follow‐up rates were, respectively, 25 (95% CI 19‐32) and eight (95% CI 5‐13) per 100 person years for patients who received cART, and 70 (95% CI 42‐117) and 119 (80‐176) per 100 person years for patients who did not receive cART. Advanced T stage (adjusted HR, AHR = 5.3, p < 0.001), advanced S stage (AHR = 5.1, p = 0.008), and absence of chemotherapy (AHR = 2.4, p = 0.012) were associated with mortality. Patients with AIDS‐associated Kaposi's sarcoma presented with advanced disease and high rates of mortality and loss to follow up. Risk factors for mortality included advanced Kaposi's sarcoma disease and lack of chemotherapy use. Contributing factors to the high mortality for patients with AIDS‐associated Kaposi's sarcoma likely included late diagnosis of HIV disease, late accessibility to cART, and sub‐optimal treatment of advanced Kaposi's sarcoma. Conclusions: These findings confirm the importance of early access to both cART and chemotherapy for patients with AIDS‐associated Kaposi's sarcoma. Early diagnosis and improved treatment protocols in resource‐poor settings are essential., Background AIDS‐associated Kaposi's sarcoma (AIDS‐KS) is an important, life‐threatening opportunistic infection among people living with HIV/AIDS in resource‐limited settings. Treatment with combination antiretroviral treatment (cART) has led to a sharp [...]

Introduction: Lesotho has the third highest HIV prevalence in the world (an adult prevalence of 23.2%). Despite a lack of resources for health, the country has implemented state‐of‐the‐art antiretroviral treatment guidelines, including early initiation of treatment ( Programme approach: We describe two‐year outcomes of a decentralized HIV/AIDS care programme run by Doctors Without Borders/Médecins Sans Frontières, the Ministry of Health and Social Welfare, and the Christian Health Association of Lesotho in Scott catchment area, a rural health zone covering 14 clinics and one district hospital. Outcome data are described through a retrospective cohort analysis of adults and children initiated on ART between 2006 and 2008. Discussion and Evaluation: Overall, 13,243 people have been enrolled in HIV care (5% children), and 5376 initiated on ART (6.5% children), 80% at primary care level. Between 2006 and 2008, annual enrolment more than doubled for adults and children, with no major external increase in human resources. The proportion of adults arriving sick (CD4 Conclusion: Despite major resource constraints, Lesotho is comparing favourably with its better resourced neighbour, using the latest international ART recommendations. The successful two‐year outcomes are further evidence that HIV/AIDS care and treatment can be provided effectively at the primary care level. The programme highlights how improving HIV care strengthened the primary health care system, and validates several critical areas for task shifting that are being considered by other countries in the region, including nurse‐driven ART for adults and children, and lay counsellor‐supported testing and counselling, adherence and case management., Introduction Lesotho has the third highest HIV prevalence in the world (after Swaziland and Botswana), at 23.2% among adults aged 15 to 49 [1], and is the poorest of the [...]

As sub‐Saharan African countries continue to scale up antiretroviral treatment, there has been an increasing emphasis on moving provision of services from hospital level to the primary health care clinic level. Delivery of antiretroviral treatment at the clinic level increases the number of entry points to care, while the greater proximity of services encourages retention in care. In Tete City, Mozambique, patients on antiretrovirals were rapidly down referred from a provincial hospital to four urban clinics in large numbers without careful planning, resulting in a number of patients being lost to follow‐up. We outline some key lessons learned to support down referral, including the need to improve process management, clinic infrastructure, monitoring systems, and patient preparation. Down referral can be avoided by initiating patients' antiretroviral treatment at clinic level from the outset., Introduction As sub‐Saharan African countries continue to scale up antiretroviral treatment (ART), there has been an increasing emphasis on moving provision of services from hospitals to primary heath care (PHC) [...]

Cryptococcal meningitis accounts for 1 in 5 AIDS-related deaths globally. World Health Organization guidelines strongly recommend a single high dose of liposomal amphotericin B as part of preferred treatment, but this drug remains unaffordable in most low- and middle-income countries. A proactive approach is needed from manufacturers and other stakeholders to improve access. [ABSTRACT FROM AUTHOR]

Introduction: Successful population-level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale-up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource-limited settings. Methods: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource-limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta-analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low- and middle-income countries. Interventions are categorized broadly as education and counselling; information and communication technology-enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described. Results and discussion: The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource-limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi-media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement. Conclusions: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS. Keywords: HIV; antiretroviral therapy adherence; interventions; resource-limited settings, Introduction Antiretroviral therapy (ART) has transformed HIV infection from a terminal disease into a manageable chronic illness [1]. ART can also reduce viral load (i.e. HIV RNA levels) and the [...]

Cytomegalovirus (CMV), a member of the herpesvirus family, was a familiar cause of blindness and death in patients with advanced AIDS in Western countries prior to the introduction of highly [...]

As scale-up of antiretroviral therapy (ART) progresses in less-developed countries, the challenges of providing treatment to marginalised populations become of increasing concern. One such marginalised group is prisoners. While there [...]

Introduction Armed conflict and HIV infection have had a profound impact on the societies of sub-Saharan Africa. The number of countries engaged in armed conflict has fluctuated, totalling 24 African [...]