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Monitoring prevalence of advanced human immunodeficiency virus (HIV) disease (i.e., CD4+ T-cell count

BackgroundThe last evaluation to assess outcomes for patients receiving antiretroviral therapy (ART) through the Zimbabwe public sector was conducted in 2011, covering the 2007-2010 cohorts. The reported retention at 6, 12, 24 and 36 months were 90.7%, 78.1%, 68.8% and 64.4%, respectively. We report findings of a follow up evaluation for the 2012-2015 cohorts to assess the implementation & impact of recommendations from this prior evaluation.MethodsA nationwide retrospective study was conducted in 2016. Multi-stage proportional sampling was used to select health facilities and study participants records. The data extracted from patient manual records included demographic, baseline clinical characteristics and patient outcomes (active on treatment, died, transferred out, stopped ART and lost to follow-up (LFTU)) at 6, 12, 24 and 36 months. The data were analysed using Stata/IC 14.2. Retention was estimated using survival analysis. The predictors associated with attrition were determined using a multivariate Cox regression model.ResultsA total of 3,810 participants were recruited in the study. The median age in years was 35 (IQR: 28-42). Overall, retention increased to 92.4%, 86.5%, 79.2% and 74.4% at 6, 12, 24 and 36 months respectively. LFTU accounted for 98% of attrition. Being an adolescent or a young adult (aHR 1.41; 95%CI:1.14-1.74), receiving care at primary health care facility (aHR 1.23; 95%CI:1.01-1.49), having initiated ART between 2014-2015 (aHR 1.45; 95%CI:1.24-1.69), having WHO Stage 4 (aHR 2.06; 95%CI:1.51-2.81) and impaired functional status (aHR 1.24; 95%CI:1.04-1.49) predicted attrition.ConclusionThe overall retention was higher in comparison to the previous 2007–-2010 evaluation. Further studies to understand why attrition was found to be higher at primary health care facilities are warranted. Implementation of strategies for managing patients with advanced HIV disease, differentiated care for adolescents and young adults and tracking of LFTU should be prioritised to further improve retention.

Introduction Community ART Refill Groups (CARGs) are an antiretroviral therapy (ART) delivery model where clients voluntarily form into groups, and a group member visits the clinic to collect ART for all group members. In late 2016, Zimbabwe began a nationwide rollout of the CARG model. We conducted a qualitative evaluation to assess the perceived effects of this new national service delivery model. Methods In March‐June 2018, we visited ten clinics implementing the CARG model across five provinces of Zimbabwe and conducted a focus group discussion with healthcare workers and in‐depth interviews with three ART clients per clinic. Clinics had implemented the CARG model for approximately one year. All discussions were audio recorded, transcribed, and translated into English, and thematic coding was performed by two independent analysts. Results In focus groups, healthcare workers described that CARGs made ART distribution faster and facilitated client tracking in the community. They explained that their reduced workload allowed them to provide better care to those clients who did visit the clinic, and they felt that the CARG model should be sustained in the future. CARG members reported that by decreasing the frequency of clinic visits, CARGs saved them time and money, reducing previous barriers to collecting ART and improving adherence. CARG members also valued the emotional and informational support that they received from other members of their CARG, further improving adherence. Multiple healthcare workers did express concern that CARG members with diseases that begin with minor symptoms, such as tuberculosis, may not seek treatment at the clinic until the disease has progressed. Conclusions We found that healthcare workers and clients overwhelmingly perceive CARGs as beneficial. This evaluation demonstrates that the CARG model can be successfully implemented on a national scale. These early results suggest that CARGs may be able to simultaneously improve clinical outcomes and reduce the workload of healthcare workers distributing ART.

Setting: Seven pilot sites in Zimbabwe implementing 6 months of isoniazid preventive therapy (IPT) for people living with the human immunodeficiency virus (PLHIV). Objectives: To determine, among PLHIV started on IPT, the completion rates for a 6-month course of IPT and factors associated with non-adherence. Design: A retrospective cohort study. Results: Of 578 patients, 466 (81%) completed IPT. Of the 112 patients who failed to complete IPT, 69 (60%) were lost to follow-up, 30 (27%) stopped treatment with no documented reasons, 8 (7%) developed toxicity/adverse reactions, 5 (5%) were documented as having drug stock-outs and the remainder transferred out or refused to continue treatment. Currently being on antiretroviral therapy (ART) (aOR 0.09, 95%CI 0.03-0.28) and receiving a ⩾2 month supply of isoniazid at the start of treatment were associated with a lower risk of not completing IPT, while missing clinic visits prior to starting IPT (aOR 5.25, 95%CI 2.10-13.14) was associated with a higher risk of non-completion. Conclusion: IPT completion rates in seven pilot sites of Zimbabwe were comparatively high, showing that IPT roll-out in public health facilities is feasible. Enhanced adherence counselling or active tracing among pre-ART patients and those with a history of loss to follow-up may improve IPT completion rates, along with synchronising IPT and ART resupplies.

Setting: Zimbabwe has a human immunodeficiency virus (HIV) driven tuberculosis (TB) epidemic, with antiretroviral therapy (ART) scaled up in the public sector since 2004. Objective: To determine whether national ART scale-up was associated with annual national TB case notification rates (CNR), stratified by disease type and category, between 2000 and 2013. Design: This was a retrospective study using aggregate data from global reports. Results: The number of people living with HIV and retained on ART from 2004 to 2013 increased from 8400 to 665 299, with ART coverage increasing from

Setting: A non-governmental organisation-supported clinic offering health services including antiretroviral therapy (ART). Objective: To compare ART retention between younger (age 10–14 years) vs. older (age 15–19 years) adolescents and younger (age 20–29 years) vs. older (age ⩾30 years) adults and determine adolescent- and adult-specific attrition-associated factors among those initiated on ART between 2010 and 2011. Design: Retrospective cohort study. Results: Of 110 (7%) adolescents and 1484 (93%) adults included in the study, no differences in retention were observed between younger vs. older adolescents at 6, 12 and 24 months. More younger adolescents were initiated with body mass index

Setting: Following the operational research study conducted during the isoniazid preventive therapy (IPT) pilot phase in Zimbabwe, recommendations for improvement were adopted by the national antiretroviral therapy (ART) programme. Objectives: To compare before (January 2013–June 2014) and after the recommendations (July 2014–December 2015), the extent of IPT scale-up and IPT completion rates, and after the recommendations the risk factors for IPT non-completion, in 530 ART clinics. Design: Retrospective cohort study. Results: People living with the human immunodeficiency virus newly initiating IPT increased every quarter (Q), from 585 in Q 1, 2013 to 4246 in Q 4, 2015, with 5648 new IPT initiations in the 18 months before the recommendations compared to 20 513 in the 18 months after the recommendations were made. The number of ART clinics initiating IPT increased from 10 (2%) in Q 1, 2013 to 198 (37%) in Q 4, 2015. Overall IPT completion rates were 89% in the post-recommendation period compared with 81% in the pilot phase (P < 0.001). After adjusting for confounders, being lost to follow-up from clinic review visits 1 year prior to IPT initiation was associated with a higher risk of not completing IPT, while having synchronised IPT and ART resupplies was associated with a lower risk. Conclusions: Implementation of recommendations from the initial operational research study have improved IPT scale-up in Zimbabwe.

While the advent of antiretroviral therapy (ART) has increased survival and reduced the number of acquired immune-deficiency syndrome (AIDS) related deaths among people living with the human immunodeficiency virus (HIV) virus (PLHIV), HIV/AIDS remains a global health problem and sub-Saharan Africa continues to bear the greatest burden of disease. There are also major challenges in the HIV response: as of December 2013, only 36% of PLHIV globally were on ART, and for every individual started on ART there were two new PLHIV diagnosed. This has led to considerable debate around adopting an HIV 'treat all' approach aimed at greatly escalating the number of PLHIV initiated and retained on ART, regardless of CD4 cell count or World Health Organization (WHO) clinical stage, with the intended goal of achieving viral suppression which should in turn reduce HIV transmission, morbidity and mortality in affected individuals. This paper examines the issues being discussed in Zimbabwe, a low-income country with a high burden of HIV/AIDS, about the implications and opportunities of adopting an HIV 'treat all' approach, along with pertinent operational research questions that need to be answered to move the agenda forward. These discussions are timely, given the recent WHO recommendations advising ART for all PLHIV, regardless of CD4 cell count.Si l'arrivée de la thérapie antirétrovirale (TAR) a accru la survie et réduit le nombre de décès liés au syndrome d'immunodéficience acquise (SIDA) parmi les personnes infectées par le virus de l'immunodéficience humaine (VIH), le VIH/SIDA reste un problème de santé publique mondial et l'Afrique sub-saharienne continue à supporter la plus lourde part de la maladie. La riposte au VIH/SIDA est également confrontée à de grands défis : en décembre 2013, seulement 36% des personnes infectées par le VIH dans le monde étaient sous TAR, et pour chaque patient mis sous TAR, il y avait deux nouvelles infections à VIH. Ceci a entrainé un débat considérable à propos de l'adoption de l'approche VIH « traitement pour tous » visant à augmenter considérablement le nombre de personnes infectées par le VIH mises et maintenues sous TAR, sans tenir compte du nombre de CD4 ni du stade clinique de l'Organisation mondiale de la santé (OMS), dans le but d'aboutir à une suppression du virus qui, à son tour, réduirait la transmission, la morbidité et la mortalité parmi les personnes affectées. Cet article discute des questions qui sont en cours de débat au Zimbabwe, un pays à faible revenu durement frappé par le VIH/SIDA, à propos des implications et des opportunités de l'adoption d'une approche du VIH de type « traitement pour tous » en parallèle avec des problèmes pertinents de recherche opérationnelle qui nécessitent une réponse pour que les choses avancent. Ces discussions arrivent à point nommé en raison des récentes recommandations de l'OMS relatives au TAR pour toutes les personnes infectées par le VIH, quel que soit le nombre de CD4.La disponibilidad del tratamiento antirretrovírico (TAR) ha mejorado la supervivencia de los pacientes aquejados de síndrome de inmunodeficiencia adquirida (sida) y disminuido la mortalidad asociada con el sida en las personas infectadas por el virus de la inmunodeficiencia humana (VIH); sin embargo, la infección por el VIH y el sida siguen siendo un problema mundial de salud y África subsahariana soporta aun la más alta carga de morbilidad. Existen además obstáculos mayores en la respuesta al VIH. Hasta diciembre del 2013, solo el 36% de las personas infectadas por el VIH en el mundo recibía TAR, y por cada persona que lo iniciaba, se presentaban dos casos nuevos de infección. Esta situación ha dado lugar a discusiones frecuentes sobre la adopción de la estrategia de ‘tratar a todas las personas’ infectadas, con el fin de aumentar en gran medida la escala de administración del TAR y la fidelización al mismo, independientemente del recuento de linfocitos CD4 y del estadio clínico de la enfermedad según la escala de la Organización Mundial de la Salud (OMS); la meta prevista es alcanzar la supresión del VIH, reducir la transmisión y disminuir la morbilidad y la mortalidad de las personas afectadas. El presente artículo examina los aspectos que se analizan actualmente en Zimbabwe, un país de bajos ingresos con una alta carga de morbilidad por el VIH/sida, en materia de repercusiones y oportunidades de adopción de la estrategia de ‘tratar a todas las personas’ afectadas por el VIH, y considera además las problemáticas de investigación operativa que se deben resolver a fin de avanzar con el programa. Estas deliberaciones son muy oportunas, dadas las recientes recomendaciones de l'OMS sobre la administración del TAR a todas las personas infectadas por el VIH, con independencia del recuento de linfocitos CD4.

There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy in sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for clinical assessment. The clinic costs are comparable with the costs of the drugs themselves and CD4 counts are measured every 6 months, but patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes, a transition to more cost-effective delivery of antiretroviral therapy is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (the viral load) provides a direct measure of the current treatment effect. Viral-load-informed differentiated care is a means of tailoring care so that those with suppressed viral load visit the clinic less frequently and attention is focussed on those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach to measuring viral load in many countries is to collect dried blood spot samples for testing in regional laboratories; however, there have been concerns over the sensitivity and specificity of this approach to define treatment failure and the delay in returning results to the clinic. We use modelling to synthesize evidence and evaluate the cost-effectiveness of viral-load-informed differentiated care, accounting for limitations of dried blood sample testing. We find that viral-load-informed differentiated care using dried blood sample testing is cost-effective and is a recommended strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of point-of-care viral load tests that may become available in the future.

Introduction: Expanding and sustaining antiretroviral therapy (ART) coverage may require simplified HIV service delivery strategies that concomitantly reduce the burden of care on the health system and patients while ensuring optimal outcomes. We conducted a systematic review to assess the impact of reduced frequency of clinic visits and drug dispensing on patient outcomes. Methods: As part of the development process of the World Health Organization antiretroviral (ARV) guidelines, we systematically searched medical literature databases for publications up to 30 August 2016. Information was extracted on trial characteristics, patient characteristics and the following outcomes: mortality, morbidity, treatment adherence, retention, patient and provider acceptability, cost and patients exiting the programme. When feasible, conventional pairwise meta-analyses were conducted. Results and discussion: Of 6443 identified citations, 21 papers, pertaining to 16 studies, were included in this review, with 11 studies contributing to analyses. Although analyses were feasible, they were limited by the sparse evidence base, despite the importance of the research area, and relatively low quality. Comparative analyses of eight studies reporting on frequency of clinic visits showed that less frequent clinic visits led to higher odds of being retained in care (odds ratio [OR]: 1.90; 95% CI: 1.21–2.99). No differences were found with respect to viral failure, morbidity or mortality; however, most estimates were favourable to reduced clinic visits. Reduced frequency of ARVs pick-ups showed a trend towards better retention (OR: 1.93; 95% CI: 0.62–6.04). Strategies using community support tended to have better outcomes; however, their implementation varied, particularly by location. External validity may be questionable. Conclusions: Our systematic review suggests that reduction of clinical visits (and likely ARVs pick-ups) may improve clinical outcomes, and that they are a viable option to relieve health systems and reduce burden of care for PLHIV. Strategies aimed at reducing clinic visits or drug refill services should focus on stable patients who are virally suppressed, tolerant to their drug regimen and fully adherent. These strategies may be critical to the current changes taking place in HIV treatment policy; thus, due to the data limitations, further high quality research is needed to inform policy and programmatic interventions.

Prevention of mother-to-child transmission (PMTCT) programme, Mpilo Hospital antenatal clinic, Zimbabwe.Before and after the introduction of a one-stop shop approach and task-shifting of antiretroviral treatment (ART) to midwives in the PMTCT programme, 1) to compare ART uptake and 2) to determine socio-demographic and other characteristics associated with non-initiation of ART post integration.Before and after cohort study.A total of 285 women were eligible for ART before the introduction of the one-stop approach and 280 after. Of the 285, 163 (57%) initiated ART before integration; this increased to 244/280 (87%) after integration (RR 1.5, 95% CI 1.4-1.7, P0.001). A total of 36 (13%) women did not initiate ART after integration; this was significantly associated with cotrimoxazole uptake (P = 0.03).Integrating ART into antenatal care along with task-shifting to midwives considerably increased the uptake of ART. This provides further evidence for scaling up integration rapidly to other facilities in Zimbabwe, and is in line with the vision of a world where no child will be born with the human immunodeficiency virus by 2015.Le Programme de Prévention de la Transmission de la Mère à l’Enfant (PMTCT), clinique prénatale de l’Hôpital Mpilo, Zimbabwe.Etude avant-après de l’introduction d’une approche en une étape et du déplacement des tâches du traitement antirétroviral (ART) vers les accoucheuses du PMTCT, afin 1) de comparer la mise en route de l’ART et 2) de déterminer les caractéristiques socio-démographiques et autres en association avec la non-mise en route de l’ART dans la période post-introduction.Etude de cohorte avant et après.Avant l’introduction de la visite unique, 285 femmes ont été éligibles pour l’ART vs. 280 après cette introduction. Avant l’intégration, l’ART a été mis en route chez 163 (57%) des 285 femmes ; après l’intégration, cette valeur a augmenté jusqu’à 244/280, soit 87% (RR 1,5 ; IC95% 1,4–1,7 ;La mise en route de l’ART augmente considérablement après l’intégration de l’ART dans les soins prénatals en même temps que le déplacement des tâches vers les accoucheuses. Ceci ajoute une évidence de plus en faveur d’une extension rapide d’une telle intégration dans d’autres services du Zimbabwe, et est en accord avec le but recherché d’un monde sans enfants nés avec le virus de l’immunodéficience humaine d’ici 2015.El Programa de Prevención de la Transmisión Maternoinfantil (PMTCT) en la consulta prenatal del hospital Mpilo, en Zimbabwe.1) Comparar la aceptación del tratamiento antirretrovírico (ART) y 2) determinar las características sociodemográficas y otras características que se asocian con la falta de iniciación del ART, antes y después de la introducción de un mecanismo de ‘ventanilla única’ que integra el ART a los servicios de atención prenatal y la delegación de las funciones de suministro del tratamiento a las parteras, en el marco del Programa de PMTCT.Fue este un estudio de cohortes anteriores y posteriores a la introducción del mecanismo de ventanilla única.Antes de la introducción del nuevo mecanismo de centralización se presentaron 285 mujeres aptas para recibir el ART y 280 mujeres después del comienzo de su aplicación. De las 285 mujeres, 163 (57%) iniciaron el ART antes de la integración y después de la misma esta proporción aumentó a 244/280 (87%; RR 1,5; IC95% 1,4–1,7;La integración de la administración del ART a los servicios de atención prenatal, acompañada de la delegación de funciones a las parteras, aumenta de manera considerable la aceptación del ART. Esta observación respalda una rápida ampliación de escala de esta integración a otros centros en Zimbabwe y corresponde al objetivo mundial de eliminar en el 2015 los nacimientos de niños contaminados por el virus de la inmunodeficiencia humana.

Background. In 2013, the tuberculosis (TB) mortality rate was highest in southern Zimbabwe at 16%. We therefore sought to determine factors associated with mortality among registered TB patients in this region.Methodology. This was a retrospective record review of registered patients receiving anti-TB treatment in 2013.Results. Of 1,971 registered TB patients, 1,653 (84%) were new cases compared with 314 (16%) retreatment cases. There were 1,538 (78%) TB/human immunodeficiency virus (HIV) coinfected patients, of whom 1,399 (91%) were on antiretroviral therapy (ART) with median pre-ART CD4 count of 133 cells/uL (IQR, 46–282). Overall, 428 (22%) TB patients died. Factors associated with increased mortality included being ≥65 years old [adjusted relative risk (ARR) = 2.48 (95% CI 1.35–4.55)], a retreatment TB case [ARR = 1.34 (95% CI, 1.10–1.63)], and being HIV-positive [ARR = 1.87 (95% CI, 1.44–2.42)] whilst ART initiation was protective [ARR = 0.25 (95% CI, 0.22–0.29)]. Cumulative mortality rates were 10%, 14%, and 21% at one, two, and six months, respectively, after starting TB treatment.Conclusion. There was high mortality especially in the first two months of anti-TB treatment, with risk factors being recurrent TB and being HIV-infected, despite a high uptake of ART.

All public health facilities in Chitungwiza District, Zimbabwe.To determine, in new tuberculosis (TB) patients registered in 2009, 1) the proportion of persons human immunodeficiency virus (HIV) tested, stratified by age, sex and type of TB, and 2) treatment outcomes in relation to type of TB and HIV status.Retrospective cohort study.Of 1800 TB patients, 1100 (61%) were tested, of whom 877 (80%) were HIV-positive and 75 (9%) were documented as receiving antiretroviral treatment (ART). HIV testing and HIV positivity were similar between patients with different types of TB. Overall, the treatment success rate was 70%, and 17% had transferred out. Being HIV-positive on ART was associated with better treatment success and lower transfer out; age ≥55 years was associated with poor treatment success and higher death rates. Defaulting was more common in those who did not undergo smear testing or in extra-pulmonary TB patients, while deaths were higher in males.In a Zimbabwe district, less than two thirds of TB patients were tested. Better treatment success was observed in patients documented as HIV-positive and on ART. Important lessons for improved TB control include increasing HIV testing uptake for better access to ART, more comprehensive recording practices on ART and better reporting on true outcomes of transfer-out patients.Tous les services de santé publique dans le District de Chitungwiza au Zimbabwe.Déterminer chez les nouveaux patients atteints de tuberculose (TB) en 2009 : 1) la proportion testée pour le virus de l’immunodéficiencehumaine (VIH), avec stratification par âge, sexe et type de TB ; et 2) les résultats du traitement en relation avec le type de TB et le statut VIH.Etude rétrospective de cohorte.Sur 1800 patients TB, 1100 (61%) ont été testés, parmi lesquels 877 (80%) étaient séropositifs pour le VIH ; chez 75 (9%) un traitement antirétroviral (ART) était signalé. Les tests VIH et la séropositivité VIH ont été similaires chez les patients atteints de différents types de TB. Dans l’ensemble, les taux de succès du traitement ont été de 70% et les transferts vers d’autres services s’élèvent à 17%. Le fait d’être séropositif pour le VIH et sous ART est associé avec un meilleur résultat du traitement et un plus faible taux de transfert. Un âge ⩾55 ans est en association avec de médiocres résultats du traitement et des taux plus élevés de décès. L’abandon est plus courant chez ceux dont les frottis n’avaient pas été exécutés ou qui étaient atteints de TB extra-pulmonaire, alors que les décès ont été plus fréquents chez ceux de sexe masculin.Todos los establecimientos de atención de salud del Distrito de Chitungwiza en Zimbabwe.Determinar en los pacientes registrados como casos nuevos de tuberculosis (TB) en el 2009, la proporción que recibió la prueba diagnóstica de infección por el virus de la inmunodeficiencia humana (VIH), con estratificación en función de la edad, el sexo y el tipo de TB; se estudiaron además los desenlaces terapéuticos según la presentación clínica de la enfermedad y la situación frente al VIH.Fue este un estudio retrospectivo de cohortes.De los 1800 pacientes registrados con TB, 1100 (61%) recibieron la prueba diagnóstica del VIH, cuyo resultado fue positivo en 877 casos (80%) y se confirmó que 75 pacientes (9%) estaban recibiendo tratamiento antirretrovírico (ART). La proporción de pacientes en quienes se practicó la prueba del VIH y la positividad del resultado fue equivalente en los grupos con las diferentes presentaciones clínicas de la TB. En general, la tasa de éxito terapéutico fue 70% y se transfirieron a otros centros 17% de casos. Se observó que un resultado positivo frente al VIH y la administración del ART se asociaban con un mejor desenlace terapéutico y que la baja tasa de transferencias y la edad ≥55 años eran factores que se asociaban con desenlaces desfavorables y tasas más altas de mortalidad; el abandono del tratamiento fue más frecuente en los pacientes que no contaban con baciloscopia del esputo y en los casos de TB extra-pulmonar. La mortalidad fue mayor en los hombres. Conclusión: En este distrito de Zimbabwe, se efectuó la prueba diagnóstica del VIH en menos de dos tercios de los casos de TB y los pacientes con infección por el VIH que recibían ART presentaron desenlaces terapéuticos más favorables. Estos resultados aportan enseñanzas importantes en el perfeccionamiento del control de la TB, como son la utilidad de aumentar la aceptabilidad de la prueba diagnóstica de la infección por el VIH a fin de ampliar el acceso al ART, fomentar la exhaustividad de las prácticas de registro de estos pacientes y lograr una mayor precisión en la notificación del desenlace terapéutico real de los pacientes transferidos a otros centros durante el tratamiento.Dans un district du Zimbabwe, moins de deux tiers des patients TB ont été testés pour le VIH et les résultats du traitement ont été meilleurs chez les patients documentés comme séropositifs pour le VIH et sous ART. Comme mesures importantes en vue d’une meilleure maîtrise de la TB, il faut citer une meilleure utilisation du test VIH en vue d’un meilleur accès à l’ART, des pratiques d’enregistrement plus complètes sur l’ART et une amélioration des rapports concernant les vrais résultats chez les patients transférés vers d’autres services.

Introduction Zimbabwe has a high human immunodeficiency virus (HIV) burden. It is therefore important to scale up HIV-testing and counseling (HTC) as a gateway to HIV prevention, treatment and care. Objective To determine factors associated with being HIV-tested among adult men and women in Zimbabwe. Methods Secondary analysis was done using data from 7,313 women and 6,584 men who completed interviewer-administered questionnaires and provided blood specimens for HIV testing during the Zimbabwe Demographic and Health Survey (ZDHS) 2010–11. Factors associated with ever being HIV-tested were determined using multivariate logistic regression. Results HIV-testing was higher among women compared to men (61% versus 39%). HIV-infected respondents were more likely to be tested compared to those who were HIV-negative for both men [adjusted odds ratio (AOR) = 1.53; 95% confidence interval (CI) (1.27–1.84)] and women [AOR = 1.42; 95% CI (1.20–1.69)]. However, only 55% and 74% of these HIV-infected men and women respectively had ever been tested. Among women, visiting antenatal care (ANC) [AOR = 5.48, 95% CI (4.08–7.36)] was the most significant predictor of being tested whilst a novel finding for men was higher odds of testing among those reporting a sexually transmitted infection (STI) in the past 12 months [AOR = 1.86, 95%CI (1.26–2.74)]. Among men, the odds of ever being tested increased with age ≥20 years, particularly those 45–49 years [AOR = 4.21; 95% CI (2.74–6.48)] whilst for women testing was highest among those aged 25–29 years [AOR = 2.01; 95% CI (1.63–2.48)]. Other significant factors for both sexes were increasing education level, higher wealth status and currently/formerly being in union. Conclusions There remains a high proportion of undiagnosed HIV-infected persons and hence there is a need for innovative strategies aimed at increasing HIV-testing, particularly for men and in lower-income and lower-educated populations. Promotion of STI services can be an important gateway for testing more men whilst ANC still remains an important option for HIV-testing among pregnant women.

Introduction : Expanding and sustaining antiretroviral therapy (ART) coverage may require simplified HIV service delivery strategies that concomitantly reduce the burden of care on the health system and patients while ensuring optimal outcomes. We conducted a systematic review to assess the impact of reduced frequency of clinic visits and drug dispensing on patient outcomes. Methods : As part of the development process of the World Health Organization antiretroviral (ARV) guidelines, we systematically searched medical literature databases for publications up to 30 August 2016. Information was extracted on trial characteristics, patient characteristics and the following outcomes: mortality, morbidity, treatment adherence, retention, patient and provider acceptability, cost and patients exiting the programme. When feasible, conventional pairwise meta-analyses were conducted. Results and discussion : Of 6443 identified citations, 21 papers, pertaining to 16 studies, were included in this review, with 11 studies contributing to analyses. Although analyses were feasible, they were limited by the sparse evidence base, despite the importance of the research area, and relatively low quality. Comparative analyses of eight studies reporting on frequency of clinic visits showed that less frequent clinic visits led to higher odds of being retained in care (odds ratio [OR]: 1.90; 95% CI: 1.21–2.99). No differences were found with respect to viral failure, morbidity or mortality; however, most estimates were favourable to reduced clinic visits. Reduced frequency of ARVs pick-ups showed a trend towards better retention (OR: 1.93; 95% CI: 0.62–6.04). Strategies using community support tended to have better outcomes; however, their implementation varied, particularly by location. External validity may be questionable. Conclusions : Our systematic review suggests that reduction of clinical visits (and likely ARVs pick-ups) may improve clinical outcomes, and that they are a viable option to relieve health systems and reduce burden of care for PLHIV. Strategies aimed at reducing clinic visits or drug refill services should focus on stable patients who are virally suppressed, tolerant to their drug regimen and fully adherent. These strategies may be critical to the current changes taking place in HIV treatment policy; thus, due to the data limitations, further high quality research is needed to inform policy and programmatic interventions. Keywords HIV Services; clinical visit frequency; antiretroviral therapy HIV/AIDS; systematic literature review; meta-analysis To access the supplementary material to this article please see Supplementary Files under Article Tools online. (Published: 21 July 2017) Mutasa-Apollo T et al. Journal of the International AIDS Society 2017, 20 :21647 http://www.jiasociety.org/index.php/jias/article/view/21647 | http://dx.doi.org/10.7448/IAS.20.5.21647

Background Since establishment of Zimbabwe's National Antiretroviral Therapy (ART) Programme in 2004, ART provision has expanded from

All public health facilities in two provinces of Zimbabwe.To determine, among tuberculosis (TB) patients with human immunodeficiency virus (HIV) registered in 2010, 1) the proportion started on antiretroviral treatment (ART), 2) the timing of ART in relation to the start of anti-tuberculosis treatment, and 3) whether timing of ART influenced anti-tuberculosis treatment outcomes.Retrospective cohort study.Of the 2655 HIV-positive TB patients, 1115 (42%) were documented as receiving ART. Of these, 178 (16%) started ART prior to anti-tuberculosis treatment. Of those who started after anti-tuberculosis treatment, 17% started within 2 weeks, 43% between 2 and 8 weeks and 40% after 8 weeks. Treatment success in the cohort was 82%, with 14% deaths before completion of anti-tuberculosis treatment. Not receiving ART during anti-tuberculosis treatment was associated with lower anti-tuberculosis treatment success (adjusted RR 0.70, 95%CI 0.53-0.91) and more deaths (adjusted RR 3.43, 95%CI 2.2-5.36). There were no differences in TB treatment outcomes by timing of ART initiation.ART uptake is low given the improved treatment outcomes in those put on ART during anti-tuberculosis treatment. Better integration of HIV and TB services is needed to ensure increased coverage and earlier ART uptake.L’ensemble des services de santé publique dans deux provinces du Zimbabwe.Déterminer parmi les patients atteints de tuberculose (TB), infectés par le virus de l’immunodéficience humaine (VIH) et enregistrés en 2010, 1) la proportion de patients chez qui le traitement antirétroviral (ART) a été commencé, 2) le moment de la mise en route de l’ART en rapport avec le début du traitement antituberculeux, et 3) dans quelle mesure le moment de la mise en route de l’ART a eu une influence sur les résultats du traitement de la TB.Etude rétrospective de cohorte.Sur les 2655 patients TB infectés par le VIH, 1115 (42%) ont été répertoriés comme traités par l’ART. Parmi ces derniers, 178 (16%) ont commencé l’ART avant le traitement TB. Parmi les patients qui ont commencé l’ART après le traitement TB, 17% l’ont commencé dans les 2 semaines, 43% entre 2 et 8 semaines et 40% après 8 semaines. Dans la cohorte, le taux de succès du traitement a été de 82%, avec 14% de décès avant l’achèvement du traitement antituberculeux. Le fait de ne pas bénéficier de l’ART au cours du traitement TB a été en association avec une diminution du succès du traitement TB (RR ajusté 0,70 ; IC95% 0,53–0,91) et une augmentation du nombre de décès (RR ajusté 3,43 ; IC95% 2,2–5,36). On n’a pas noté de différence dans les résultats du traitement TB en fonction du moment de la mise en route de l’ART.L’utilisation de l’ART est faible vu la prévalence importante de la co-infection VIH et l’amélioration des résultats du traitement antituberculeux chez les patients qui ont bénéficié de l’ART durant le traitement de la TB. Une meilleure intégration des services VIH et TB est nécessaire afin d’assurer une couverture plus importante et une utilisation plus précoce de l’ART.Todos los centros públicos de atención de salud en dos provincias de Zimbabue.Determinar en los pacientes con tuberculosis (TB) e infección por el virus de la inmunodeficiencia humana (VIH) registrados en el 2010 los siguientes aspectos: 1) la proporción de pacientes que comenzaron el tratamiento antirretrovírico (ART); 2) el momento del comienzo del ART con respecto a la pauta antituberculosa; y 3) la influencia del ART en el desenlace terapéutico de la TB.Estudio retrospectivo de cohortes.Se documentó la administración del ART en 1115 de los 2655 (42%) pacientes seropositivos frente al VIH con TB y 178 de ellos (16%) lo habían comenzado antes del tratamiento antituberculoso. De los pacientes que comenzaron a recibir medicamentos ART después del inicio de la pauta antituberculosa, el 17% comenzó en las 2 primeras semanas, el 43% entre la segunda y la octava semana y 40% después de 8 semanas de tratamiento contra la TB. El éxito terapéutico en la cohorte estudiada fue 82% y 14% de pacientes fallecieron antes de completar el tratamiento antituberculoso. El hecho de no recibir medicamentos ART durante el tratamiento contra la TB se asoció con un menor éxito terapéutico (aRR 0,70; IC95% 0,53–0,91) y una mayor mortalidad (aRR 3,43; IC95% 2,2–5,36). No se observaron diferencias en el desenlace del tratamiento antituberculoso en función del momento de iniciación de los medicamentos ART.La utilización del ART es baja, si se considera la alta prevalencia de coinfección por TB e infección por el VIH y la mejoría del desenlace terapéutico en los pacientes que reciben medicamentos ART durante la pauta antituberculosa. Se precisa una mayor integración de los servicios de atención de estas dos enfermedades, con el fin de ampliar la cobertura del ART y comenzar más temprano su administración.

Purpose of review We reviewed recent literature on the cascade of HIV care from HIV testing to suppression of viral load, which has emerged as a critical focus as HIV treatment programs have scaled up. Recent findings In low- and middle-income countries, HIV testing and diagnosis of people living with HIV (PLHIV), although rapidly expanding, are generally relatively low. Linkage and retention in care are global challenges, with substantial attrition between diagnosis, laboratory or clinical staging, and antiretroviral therapy (ART) initiation, and additional substantial attrition on ART due to loss to follow-up and death. ART coverage is rapidly expanding but is still relatively low, especially when considered as a percentage of all PLHIV. Adherence is also suboptimal and virological suppression is incomplete. Summary Taken together, the attrition at each step of the cascade of care results in overall low levels of viral load suppression in the total population of PLHIV. More robust monitoring from the facility to global levels and implementation of established and emerging interventions are needed at each step of the cascade to enhance HIV diagnosis, linkage to and retention in care, ART use, and adherence, and ultimately reduce viral load, improve clinical outcomes, and reduce HIV transmission.

Background Zimbabwe is a Southern African country with a high HIV-TB burden and is ranked 19th among the 22 Tuberculosis high burden countries worldwide. Recurrent TB is an important problem for TB control, yet there is limited information about treatment outcomes in relation to HIV status. This study was therefore conducted in Chitungwiza, a high density dormitory town outside the capital city, to determine in adults registered with recurrent TB how treatment outcomes were affected by type of recurrence and HIV status. Methods Data were abstracted from the Chitungwiza district TB register for all 225 adult TB patients who had previously been on anti-TB treatment and who were registered as recurrent TB from January to December 2009. The Chi-square and Fischer's exact tests were used to establish associations between categorical variables. Multivariate relative risks for associations between the various TB treatment outcomes and HIV status, type of recurrent TB, sex and age were calculated using Poisson regression with robust error variance. Results Of 225 registered TB patients with recurrent TB, 159 (71%) were HIV tested, 135 (85%) were HIV-positive and 20 (15%) were known to be on antiretroviral treatment (ART). More females were HIV-tested (75/90, 83%) compared with males (84/135, 62%). There were 103 (46%) with relapse TB, 32 (14%) with treatment after default, and 90 (40%) with "retreatment other" TB. There was one failure patient. HIV-testing and HIV-positivity were similar between patients with different types of TB. Overall, treatment success was 73% with transfer-outs at 14% being the most common adverse outcome. TB treatment outcomes did not differ by HIV status. However those with relapse TB had better treatment success compared to "retreatment other" TB patients, (adjusted RR 0.81; 95% CI 0.68 - 0.97, p = 0.02). Conclusions No differences in treatment outcomes by HIV status were established in patients with recurrent TB. Important lessons from this study include increasing HIV testing uptake, a better understanding of what constitutes "retreatment other" TB, improved follow-up of true outcomes in patients who transfer-out and better recording practices related to HIV care and treatment especially for ART.

BACKGROUND: Sub-Saharan Africa suffers from a high burden of undernutrition, affecting 23.2% of its population, and in 2015 constituted 69% of the estimated people living with Human Immunodeficiency Virus (HIV) globally. Zimbabwe, in Southern African has a HIV prevalence of 14.7%, but malnutrition (under- and over-nutrition) in this population has not been characterized. A nationally representative survey was therefore conducted to determine malnutrition prevalence and associated factors among HIV-positive adults (≥15 years) enrolled at antiretroviral therapy (ART) clinics in Zimbabwe. METHODS: Height and weight measurements were taken for all enrolled participants who had attended their scheduled clinic review visits. Malnutrition was determined using body mass index (BMI) calculations and classified as undernutrition ( 350 cells/mL[aOR = 4.85 (95% CI, 1.03–22.77)]. CONCLUSION: Zimbabwe faces two types of nutritional disorders; undernutrition and overweight / obesity, in its HIV-infected population, both of which are associated with increased morbidity and mortality. This may reflect a shift in the pattern of HIV/AIDS from being a highly fatal infectious disease to a chronic manageable condition.

Background Zimbabwe is among the 22 Tuberculosis (TB) high burden countries worldwide and runs a well-established, standardized recording and reporting system on case finding and treatment outcomes. During TB treatment, patients transfer-out and transfer-in to different health facilities, but there are few data from any national TB programmes about whether this process happens and if so to what extent. The aim of this study therefore was to describe the characteristics and outcomes of TB patients that transferred into Harare City health department clinics under the national TB programme. Specific objectives were to determine i) the proportion of a cohort of TB patients registered as transfer-in, ii) the characteristics and treatment outcomes of these transfer-in patients and iii) whether their treatment outcomes had been communicated back to their respective referral districts after completion of TB treatment. Methods Data were abstracted from patient files and district TB registers for all transfer-in TB patients registered from January to December 2010 within Harare City. Descriptive statistics were calculated. Results Of the 7,742 registered TB patients in 2010, 263 (3.5%) had transferred-in: 148 (56%) were males and overall median age was 33 years (IQR, 26–40). Most transfer-in patients (74%) came during the intensive phase of TB treatment, and 58% were from rural health-facilities. Of 176 patients with complete data on the time period between transfer-in and transfer-out, only 85 (48%) arrived for registration in Harare from referral districts within 1 week of being transferred-out. Transfer-in patients had 69% treatment success, but in 21% treatment outcome status was not evaluated. Overall, 3/212 (1.4%) transfer-in TB patients had their TB treatment outcomes reported back to their referral districts. Conclusion There is need to devise better strategies of following up TB patients to their referral Directly Observed Treatment (DOT) centres from TB diagnosing centres to ensure that they arrive promptly and on time. Recording and reporting of information must improve and this can be done through training and supervision. Use of mobile phones and other technology to communicate TB treatment outcomes back to the referral districts would seem the obvious way to move forward on these issues.

BACKGROUND: Delayed presentation of pulmonary TB (PTB) patients for treatment from onset of symptoms remains a threat to controlling individual disease progression and TB transmission in the community. Currently, there is insufficient information about treatment delays in Zimbabwe, and we therefore determined the extent of patient and health systems delays and their associated factors in patients with microbiologically confirmed PTB. METHODS: A structured questionnaire was administered at 47 randomly selected health facilities in Zimbabwe by trained health workers to all patients aged ≥18 years with microbiologically confirmed PTB who were started on TB treatment and entered in the health facility TB registers between 01 January and 31 March 2013. Multivariate logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CIs) for associations between patient/health system characteristics and patient delay >30 days or health system delay >4 days. RESULTS: Of the 383 recruited patients, 211(55%) were male with an overall median age of 34 years (IQR, 28-43). There was a median of 28 days (IQR, 21-63) for patient delays and 2 days (IQR, 1-5) for health system delays with 184 (48%) and 118 (31%) TB patients experiencing health system delays >30 days and health system delays >4 days respectively. Starting TB treatment at rural primary healthcare vs district/mission facilities [aOR 2.70, 95% CI 1.27-5.75, p = 0.01] and taking self-medication [aOR 2.33, 95% CI 1.23-4.43, p = 0.01] were associated with encountering patient delays. Associated with health system delays were accessing treatment from lower level facilities [aOR 2.67, 95% CI 1.18-6.07, p = 0.019], having a Gene Xpert TB diagnosis [aOR 0.21, 95% CI 0.07-0.66, p = 0.008] and >4 health facility visits prior to TB diagnosis [(aOR) 3.34, 95% CI 1.11-10.03, p = 0.045]. CONCLUSION: Patient delays were longer and more prevalent, suggesting the need for strategies aimed at promoting timely seeking of appropriate medical consultation among presumptive TB patients. Health system delays were uncommon, suggesting a fairly efficient response to microbiologically confirmed PTB cases. Identified risk factors should be explored further and specific strategies aimed at addressing these factors should be identified in order to lessen patient and health system delays.