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OBJECTIVE: To describe the electronic medical databases used in antiretroviral therapy (ART) programmes in lower-income countries and assess the measures such programmes employ to maintain and improve data quality and reduce the loss of patients to follow-up. METHODS: In 15 countries of Africa, South America and Asia, a survey was conducted from December 2006 to February 2007 on the use of electronic medical record systems in ART programmes. Patients enrolled in the sites at the time of the survey but not seen during the previous 12 months were considered lost to follow-up. The quality of the data was assessed by computing the percentage of missing key variables (age, sex, clinical stage of HIV infection, CD4+ lymphocyte count and year of ART initiation). Associations between site characteristics (such as number of staff members dedicated to data management), measures to reduce loss to follow-up (such as the presence of staff dedicated to tracing patients) and data quality and loss to follow-up were analysed using multivariate logit models. FINDINGS: Twenty-one sites that together provided ART to 50 060 patients were included (median number of patients per site: 1000; interquartile range, IQR: 72-19 320). Eighteen sites (86%) used an electronic database for medical record-keeping; 15 (83%) such sites relied on software intended for personal or small business use. The median percentage of missing data for key variables per site was 10.9% (IQR: 2.0-18.9%) and declined with training in data management (odds ratio, OR: 0.58; 95% confidence interval, CI: 0.37-0.90) and weekly hours spent by a clerk on the database per 100 patients on ART (OR: 0.95; 95% CI: 0.90-0.99). About 10 weekly hours per 100 patients on ART were required to reduce missing data for key variables to below 10%. The median percentage of patients lost to follow-up 1 year after starting ART was 8.5% (IQR: 4.2-19.7%). Strategies to reduce loss to follow-up included outreach teams, community-based organizations and checking death registry data. Implementation of all three strategies substantially reduced losses to follow-up (OR: 0.17; 95% CI: 0.15-0.20). CONCLUSION: The quality of the data collected and the retention of patients in ART treatment programmes are unsatisfactory for many sites involved in the scale-up of ART in resource-limited settings, mainly because of insufficient staff trained to manage data and trace patients lost to follow-up.

In resource-constrained settings, tuberculosis (TB) is a common opportunistic infection and cause of death in HIV-infected persons. TB may be present at the start of antiretroviral therapy (ART), but it is often under-diagnosed. We describe approaches to TB diagnosis and screening of TB in ART programs in low- and middle-income countries.We surveyed ART programs treating HIV-infected adults in sub-Saharan Africa, Asia and Latin America in 2012 using online questionnaires to collect program-level and patient-level data. Forty-seven sites from 26 countries participated. Patient-level data were collected on 987 adult TB patients from 40 sites (median age 34.7 years; 54% female). Sputum smear microscopy and chest radiograph were available in 47 (100%) sites, TB culture in 44 (94%), and Xpert MTB/RIF in 23 (49%). Xpert MTB/RIF was rarely available in Central Africa and South America. In sites with access to these diagnostics, microscopy was used in 745 (76%) patients diagnosed with TB, culture in 220 (24%), and chest X-ray in 688 (70%) patients. When free of charge culture was done in 27% of patients, compared to 21% when there was a fee (p = 0.033). Corresponding percentages for Xpert MTB/RIF were 26% and 15% of patients (p = 0.001). Screening practices for active disease before starting ART included symptom screening (46 sites, 98%), chest X-ray (38, 81%), sputum microscopy (37, 79%), culture (16, 34%), and Xpert MTB/RIF (5, 11%).Mycobacterial culture was infrequently used despite its availability at most sites, while Xpert MTB/RIF was not generally available. Use of available diagnostics was higher when offered free of charge.

Rockfall is a common hazard along US Interstate Highway 70 in Glenwood Canyon, Colorado. While natural rock slopes source a substantial number of rockfalls, there remains a need to better understand typical rockfall frequencies from these slopes and to relate these frequencies to available rockfall records. In addition, the 2020 Grizzly Creek Fire in the area presents an opportunity to characterize the post-wildfire response of granitic rock slopes. To address these needs, we monitored 4 natural rock slopes of different lithologies and burn severities from 6 to 18 months after the start of the fire using an Unpiloted Aerial Vehicle and Structure from Motion photogrammetry. A total of five rockfalls (0.08–0.68m3) were detected during the monitoring interval at two slopes, while the other two showed no rockfalls. While overall rockfall activity is relatively low, the observed activity is in good agreement with results of previous study in the area, rockfall records for the highway, and analysis of a historical photo of one slope. No increase in rockfall due to the fire was observed during the monitored period, implying that the fire did not significantly affect the studied slopes or that any increase in activity had already returned to background levels by the start of monitoring. Four of the five rockfalls detected were spatially correlated with seeps in the slope, and three were temporally correlated with late winter snowfall and spring thawing, highlighting the importance of water as a consideration in selecting rock slopes for hazard monitoring and mitigation. [ABSTRACT FROM AUTHOR]

Background The global burden of childhood tuberculosis (TB) is estimated to be 0.5 million new cases per year. Human immunodeficiency virus (HIV)–infected children are at high risk for TB. Diagnosis of TB in HIV-infected children remains a major challenge. Methods We describe TB diagnosis and screening practices of pediatric antiretroviral treatment (ART) programs in Africa, Asia, the Caribbean, and Central and South America. We used web-based questionnaires to collect data on ART programs and patients seen from March to July 2012. Forty-three ART programs treating children in 23 countries participated in the study. Results Sputum microscopy and chest Radiograph were available at all programs, mycobacterial culture in 40 (93%) sites, gastric aspiration in 27 (63%), induced sputum in 23 (54%), and Xpert MTB/RIF in 16 (37%) sites. Screening practices to exclude active TB before starting ART included contact history in 41 sites (84%), symptom screening in 38 (88%), and chest Radiograph in 34 sites (79%). The use of diagnostic tools was examined among 146 children diagnosed with TB during the study period. Chest Radiograph was used in 125 (86%) children, sputum microscopy in 76 (52%), induced sputum microscopy in 38 (26%), gastric aspirate microscopy in 35 (24%), culture in 25 (17%), and Xpert MTB/RIF in 11 (8%) children. Conclusions Induced sputum and Xpert MTB/RIF were infrequently available to diagnose childhood TB, and screening was largely based on symptom identification. There is an urgent need to improve the capacity of ART programs in low- and middle-income countries to exclude and diagnose TB in HIV-infected children. [ABSTRACT FROM PUBLISHER]

Introduction: Late presentation to HIV care leads to increased morbidity and mortality. We explored risk factors and reasons for late HIV testing and presentation to care in the nationally representative Swiss HIV Cohort Study (SHCS). Methods: Adult patients enrolled in the SHCS between July 2009 and June 2012 were included. An initial CD4 count <350 cells/µl or an AIDS-defining illness defined late presentation. Demographic and behavioural characteristics of late presenters (LPs) were compared with those of non-late presenters (NLPs). Information on self-reported, individual barriers to HIV testing and care were obtained during face-to-face interviews. Results: Of 1366 patients included, 680 (49.8%) were LPs. Seventy-two percent of eligible patients took part in the survey. LPs were more likely to be female (p<0.001) or from sub-Saharan Africa (p<0.001) and less likely to be highly educated (p=0.002) or men who have sex with men (p<0.001). LPs were more likely to have their first HIV test following a doctor's suggestion (p=0.01), and NLPs in the context of a regular check-up (p=0.02) or after a specific risk situation (p<0.001). The main reasons for late HIV testing were “did not feel at risk” (72%), “did not feel ill” (65%) and “did not know the symptoms of HIV” (51%). Seventy-one percent of the participants were symptomatic during the year preceding HIV diagnosis and the majority consulted a physician for these symptoms. Conclusions: In Switzerland, late presentation to care is driven by late HIV testing due to low risk perception and lack of awareness about HIV. Tailored HIV testing strategies and enhanced provider-initiated testing are urgently needed. [ABSTRACT FROM AUTHOR]

Background: Since 2005, increasing numbers of children have started antiretroviral therapy (ART) in sub-Saharan Africa and, in recent years, WHO and country treatment guidelines have recommended ART initiation for all infants and very young children, and at higher CD4 thresholds for older children. We examined temporal changes in patient and regimen characteristics at ART start using data from 12 cohorts in 4 countries participating in the IeDEA-SA collaboration. Methodology/Principal Findings: Data from 30,300 ART-naïve children aged <16 years at ART initiation who started therapy between 2005 and 2010 were analysed. We examined changes in median values for continuous variables using the Cuzick's test for trend over time. We also examined changes in the proportions of patients with particular disease severity characteristics (expressed as a binary variable e.g. WHO Stage III/IV vs I/II) using logistic regression. Between 2005 and 2010 the number of children starting ART each year increased and median age declined from 63 months (2006) to 56 months (2010). Both the proportion of children <1 year and ≥10 years of age increased from 12 to 19% and 18 to 22% respectively. Children had less severe disease at ART initiation in later years with significant declines in the percentage with severe immunosuppression (81 to 63%), WHO Stage III/IV disease (75 to 62%), severe anemia (12 to 7%) and weight-for-age z-score<−3 (31 to 28%). Similar results were seen when restricting to infants with significant declines in the proportion with severe immunodeficiency (98 to 82%) and Stage III/IV disease (81 to 63%). First-line regimen use followed country guidelines. Conclusions/Significance: Between 2005 and 2010 increasing numbers of children have initiated ART with a decline in disease severity at start of therapy. However, even in 2010, a substantial number of infants and children started ART with advanced disease. These results highlight the importance of efforts to improve access to HIV diagnostic testing and ART in children. [ABSTRACT FROM AUTHOR]

Objectives: In resource-constrained settings, tuberculosis (TB) is a common opportunistic infection and cause of death in HIV-infected persons. TB may be present at the start of antiretroviral therapy (ART), but it is often under-diagnosed. We describe approaches to TB diagnosis and screening of TB in ART programs in low- and middle-income countries. Methods and findings: We surveyed ART programs treating HIV-infected adults in sub-Saharan Africa, Asia and Latin America in 2012 using online questionnaires to collect program-level and patient-level data. Forty-seven sites from 26 countries participated. Patient-level data were collected on 987 adult TB patients from 40 sites (median age 34.7 years; 54% female). Sputum smear microscopy and chest radiograph were available in 47 (100%) sites, TB culture in 44 (94%), and Xpert MTB/RIF in 23 (49%). Xpert MTB/RIF was rarely available in Central Africa and South America. In sites with access to these diagnostics, microscopy was used in 745 (76%) patients diagnosed with TB, culture in 220 (24%), and chest X-ray in 688 (70%) patients. When free of charge culture was done in 27% of patients, compared to 21% when there was a fee (p = 0.033). Corresponding percentages for Xpert MTB/RIF were 26% and 15% of patients (p = 0.001). Screening practices for active disease before starting ART included symptom screening (46 sites, 98%), chest X-ray (38, 81%), sputum microscopy (37, 79%), culture (16, 34%), and Xpert MTB/RIF (5, 11%). Conclusions: Mycobacterial culture was infrequently used despite its availability at most sites, while Xpert MTB/RIF was not generally available. Use of available diagnostics was higher when offered free of charge. [ABSTRACT FROM AUTHOR]

Background: Few estimates exist of the life expectancy of HIV-positive adults receiving antiretroviral treatment (ART) in low-and middle-income countries. We aimed to estimate the life expectancy of patients starting ART in South Africa and compare it with that of HIV-negative adults. Methods and Findings: Data were collected from six South African ART cohorts. Analysis was restricted to 37,740 HIV-positive adults starting ART for the first time. Estimates of mortality were obtained by linking patient records to the national population register. Relative survival models were used to estimate the excess mortality attributable to HIV by age, for different baseline CD4 categories and different durations. Non-HIV mortality was estimated using a South African demographic model. The average life expectancy of men starting ART varied between 27.6 y (95% CI: 25.2-30.2) at age 20 y and 10.1 y (95% CI: 9.3-10.8) at age 60 y, while estimates for women at the same ages were substantially higher, at 36.8 y (95% CI: 34.0-39.7) and 14.4 y (95% CI: 13.3-15.3), respectively. The life expectancy of a 20-y-old woman was 43.1 y (95% CI: 40.1-46.0) if her baseline CD4 count was $200 cells/ml, compared to 29.5 y (95% CI: 26.2-33.0) if her baseline CD4 count was ,50 cells/ml. Life expectancies of patients with baseline CD4 counts $200 cells/ml were between 70% and 86% of those in HIV-negative adults of the same age and sex, and life expectancies were increased by 15%-20% in patients who had survived 2 y after starting ART. However, the analysis was limited by a lack of mortality data at longer durations. Conclusions: South African HIV-positive adults can have a near-normal life expectancy, provided that they start ART before their CD4 count drops below 200 cells/ml. These findings demonstrate that the near-normal life expectancies of HIV-positive individuals receiving ART in high-income countries can apply to low- and middle-income countries as well. [ABSTRACT FROM AUTHOR]

Introduction: There are limited data on paediatric HIV care and treatment programmes in low-resource settings. Methods: A standardized survey was completed by International epidemiologic Databases to Evaluate AIDS paediatric cohort sites in the regions of Asia-Pacific (AP), Central Africa (CA), East Africa (EA), Southern Africa (SA) and West Africa (WA) to understand operational resource availability and paediatric management practices. Data were collected through January 2010 using a secure, web-based software program (REDCap). Results: A total of 64,552 children were under care at 63 clinics (AP, N=10; CA, N=4; EA, N=29; SA, N=10; WA, N=10). Most were in urban settings (N=41, 65%) and received funding from governments (N=51, 81%), PEPFAR (N=34, 54%), and/or the Global Fund (N=15, 24%). The majority were combined adult-paediatric clinics (N=36, 57%). Prevention of motherto- child transmission was integrated at 35 (56%) sites; 89% (N=56) had access to DNA PCR for infant diagnosis. African (N=40/ 53) but not Asian sites recommended exclusive breastfeeding up until 4-6 months. Regular laboratory monitoring included CD4 (N=60, 95%), and viral load (N=24, 38%). Although 42 (67%) sites had the ability to conduct acid-fast bacilli (AFB) smears, 23 (37%) sites could conduct AFB cultures and 18 (29%) sites could conduct tuberculosis drug susceptibility testing. Loss to follow-up was defined as >3 months of lost contact for 25 (40%) sites, >6 months for 27 sites (43%) and >12 months for 6 sites (10%). Telephone calls (N=52, 83%) and outreach worker home visits to trace children lost to follow-up (N=45, 71%) were common. Conclusions: In general, there was a high level of patient and laboratory monitoring within this multiregional paediatric cohort consortium that will facilitate detailed observational research studies. Practices will continue to be monitored as the WHO/ UNAIDS Treatment 2.0 framework is implemented [ABSTRACT FROM AUTHOR]

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Background: Increased mortality among men on antiretroviral therapy (ART) has been documented but remains poorly understood. We examined the magnitude of and risk factors for gender differences in mortality on ART. Methods and Findings: Analyses included 46,201 ART-naï ve adults starting ART between January 2002 and December 2009 in eight ART programmes across South Africa (SA). Patients were followed from initiation of ART to outcome or analysis closure. The primary outcome was mortality; secondary outcomes were loss to follow-up (LTF), virologic suppression, and CD4+ cell count responses. Survival analyses were used to examine the hazard of death on ART by gender. Sensitivity analyses were limited to patients who were virologically suppressed and patients whose CD4+ cell count reached .200 cells/ml. We compared gender differences in mortality among HIV+ patients on ART with mortality in an age-standardised HIV-negative population. Among 46,201 adults (65% female, median age 35 years), during 77,578 person-years of follow-up, men had lower median CD4+ cell counts than women (85 versus 110 cells/μl, p<0.001), were more likely to be classified WHO stage III/IV (86 versus 77%, p<0.001), and had higher mortality in crude (8.5 versus 5.7 deaths/100 person-years, p<0.001) and adjusted analyses (adjusted hazard ratio [AHR] 1.31, 95% CI 1.22-1.41). After 36 months on ART, men were more likely than women to be truly LTF (AHR 1.20, 95% CI 1.12-1.28) but not to die after LTF (AHR 1.04, 95% CI 0.86-1.25). Findings were consistent across all eight programmes. Virologic suppression was similar by gender; women had slightly better immunologic responses than men. Notably, the observed gender differences in mortality on ART were smaller than gender differences in age-standardised death rates in the HIV-negative South African population. Over time, non-HIV mortality appeared to account for an increasing proportion of observed mortality. The analysis was limited by missing data on baseline HIV disease characteristics, and we did not observe directly mortality in HIV-negative populations where the participating cohorts were located. Conclusions: HIV-infected men have higher mortality on ART than women in South African programmes, but these differences are only partly explained by more advanced HIV disease at the time of ART initiation, differential LTF and subsequent mortality, and differences in responses to treatment. The observed differences in mortality on ART may be best explained by background differences in mortality between men and women in the South African population unrelated to the HIV/AIDS epidemic. [ABSTRACT FROM AUTHOR]

Background: Changes in CD4 cell counts are poorly documented in individuals with low or moderate-level viremia while on antiretroviral treatment (ART) in resource-limited settings. We assessed the impact of on-going HIV-RNA replication on CD4 cell count slopes in patients treated with a first-line combination ART. Method: Naïve patients on a first-line ART regimen with at least two measures of HIV-RNA available after ART initiation were included in the study. The relationships between mean CD4 cell count change and HIV-RNA at 6 and 12 months after ART initiation (M6 and M12) were assessed by linear mixed models adjusted for gender, age, clinical stage and year of starting ART. Results: 3,338 patients were included (14 cohorts, 64% female) and the group had the following characteristics: a median follow-up time of 1.6 years, a median age of 34 years, and a median CD4 cell count at ART initiation of 107 cells/µL. All patients with suppressed HIV-RNA at M12 had a continuous increase in CD4 cell count up to 18 months after treatment initiation. By contrast, any degree of HIV-RNA replication both at M6 and M12 was associated with a flat or a decreasing CD4 cell count slope. Multivariable analysis using HIV-RNA thresholds of 10,000 and 5,000 copies confirmed the significant effect of HIV-RNA on CD4 cell counts both at M6 and M12. Conclusion: In routinely monitored patients on an NNRTI-based first-line ART, on-going low-level HIV-RNA replication was associated with a poor immune outcome in patients who had detectable levels of the virus after one year of ART. [ABSTRACT FROM AUTHOR]

Background: The objective was to examine the short-term risk and predictors of anaemia following initiation of combination antiretroviral therapy (cART) in HIV-infected patients from the Western Africa, Eastern Africa, Southern Africa, Central Africa, Asian-Pacific, and Caribbean and Central and South America regions of the International Epidemiologic Databases to Evaluate AIDS (IeDEA) collaboration. Methods: Anaemia was defined as haemoglobin of < 10 g/dL. Patients were included if they started cART with three or more drugs, had prior haemoglobin of > = 10 g/dL, and had one or more follow-up haemoglobin tests. Factors associated with anaemia up to 12 months were examined using Cox proportional hazards models and stratified by IeDEA region. Results: Between 1998 and 2008, 19,947 patients initiated cART with baseline and follow-up haemoglobin tests (7358, 7289, 2853, 471, 1550 and 426 in the Western Africa, Eastern Africa, Southern Africa, Central Africa, Asian- Pacific, and Caribbean and Central and South America regions, respectively). At initiation, anaemia was found in 45% of Western Africa patients, 29% of Eastern Africa patients, 21% of Southern Africa patients, 36% of Central Africa patients, 15% of patients in Asian-Pacific and 14% of patients in Caribbean and Central and South America. Among patients with haemoglobin of > = 10 g/dL at baseline (13,445), the risks of anaemia were 18.2, 6.6, 9.7, 22.9, 11.8 and 19.5 per 100 person-years in the Western Africa, Eastern Africa, Southern Africa, Central Africa, Asian, and Caribbean and Central and South America regions, respectively. Factors associated with anaemia were female sex, low baseline haemoglobin level, low baseline CD4 count, more advanced disease stage, and initial cART containing zidovudine. Conclusions: In data from 34 cohorts of HIV-infected patients from sub-Saharan Africa, Central and South America, and Asia, the risk of anaemia within 12 months of initiating cART was moderate. Routine haemoglobin monitoring was recommended in patients at risk of developing anaemia following cART initiation. [ABSTRACT FROM AUTHOR]

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Background: To better understand the need for paediatric second-line antiretroviral therapy (ART), an ART management survey and a cross-sectional analysis of second-line ART use were conducted in the TREAT Asia Paediatric HIV Observational Database and the IeDEA Southern Africa (International Epidemiologic Databases to Evaluate AIDS) regional cohorts. Methods: Surveys were conducted in April 2009. Analysis data from the Asia cohort were collected in March 2009 from 12 centres in Cambodia, India, Indonesia, Malaysia, and Thailand. Data from the IeDEA Southern Africa cohort were finalized in February 2008 from 10 centres in Malawi, Mozambique, South Africa and Zimbabwe. Results: Survey responses reflected inter-regional variations in drug access and national guidelines. A total of 1301 children in the TREAT Asia and 4561 children in the IeDEA Southern Africa cohorts met inclusion criteria for the cross-sectional analysis. Ten percent of Asian and 3.3% of African children were on second-line ART at the time of data transfer. Median age (interquartile range) in months at second-line initiation was 120 (78-145) months in the Asian cohort and 66 (29-112) months in the southern African cohort. Regimens varied, and the then current World Health Organizationrecommended nucleoside reverse transcriptase combination of abacavir and didanosine was used in less than 5% of children in each region. Conclusions: In order to provide life-long ART for children, better use of current first-line regimens and broader access to heat-stable, paediatric second-line and salvage formulations are needed. There will be limited benefit to earlier diagnosis of treatment failure unless providers and patients have access to appropriate drugs for children to switch to. [ABSTRACT FROM AUTHOR]

Background: Retention of patients on antiretroviral therapy (ART) over time is a proxy for quality of care and an outcome indicator to monitor ART programs. Using existing databases (Antiretroviral in Lower Income Countries of the International Databases to Evaluate AIDS and Médecins Sans Frontie` res), we evaluated three sampling approaches to simplify the generation of outcome indicators. Methods and Findings: We used individual patient data from 27 ART sites and included 27,201 ART-naive adults (≥15 years) who initiated ART in 2005. For each site, we generated two outcome indicators at 12 months, retention on ART and proportion of patients lost to follow-up (LFU), first using all patient data and then within a smaller group of patients selected using three sampling methods (random, systematic and consecutive sampling). For each method and each site, 500 samples were generated, and the average result was compared with the unsampled value. The 95% sampling distribution (SD) was expressed as the 2.5th and 97.5th percentile values from the 500 samples. Overall, retention on ART was 76.5% (range 58.9-88.6) and the proportion of patients LFU, 13.5% (range 0.8-31.9). Estimates of retention from sampling (n = 5696) were 76.5% (SD 75.4-77.7) for random, 76.5% (75.3-77.5) for systematic and 76.0% (74.1-78.2) for the consecutive method. Estimates for the proportion of patients LFU were 13.5% (12.6-14.5), 13.5% (12.6-14.3) and 14.0% (12.5-15.5), respectively. With consecutive sampling, 50% of sites had SD within ±5% of the unsampled site value. Conclusions: Our results suggest that random, systematic or consecutive sampling methods are feasible for monitoring ART indicators at national level. However, sampling may not produce precise estimates in some sites. [ABSTRACT FROM AUTHOR]

Background: Data from HIV treatment programs in resource-limited settings show extensive rates of loss to follow-up (LTFU) ranging from 5% to 40% within 6 mo of antiretroviral therapy (ART) initiation. Our objective was to project the clinical impact and cost-effectiveness of interventions to prevent LTFU from HIV care in West Africa. Methods and Findings: We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) International model to project the clinical benefits and cost-effectiveness of LTFU-prevention programs from a payer perspective. These programs include components such as eliminating ART co-payments, eliminating charges to patients for opportunistic infectionrelated drugs, improving personnel training, and providing meals and reimbursing for transportation for participants. The efficacies and costs of these interventions were extensively varied in sensitivity analyses. We used World Health Organization criteria of <3× gross domestic product per capita (3× GDP per capita = US$2,823 for Côte d'Ivoire) as a plausible threshold for ''cost-effectiveness.'' The main results are based on a reported 18% 1-y LTFU rate. With full retention in care, projected per-person discounted life expectancy starting from age 37 y was 144.7 mo (12.1 y). Survival losses from LTFU within 1 y of ART initiation ranged from 73.9 to 80.7 mo. The intervention costing US$22/person/year (e.g., eliminating ART co-payment) would be cost-effective with an efficacy of at least 12%. An intervention costing US$77/person/year (inclusive of all the components described above) would be cost-effective with an efficacy of at least 41%. Conclusions: Interventions that prevent LTFU in resource-limited settings would substantially improve survival and would be cost-effective by international criteria with efficacy of at least 12%-41%, depending on the cost of intervention, based on a reported 18% cumulative incidence of LTFU at 1 y after ART initiation. The commitment to start ART and treat HIV in these settings should include interventions to prevent LTFU. [ABSTRACT FROM AUTHOR]

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Comparing HIV treatment in Switzerland, where drug selection is individualized, and South Africa, where a programmatic approach is used, Matthias Egger and colleagues find similar virologic outcomes over two years. [ABSTRACT FROM AUTHOR]

Copyright of Tropical Medicine & International Health is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Aims: To compare the gender distribution of HIV-infected adults receiving highly active antiretroviral treatment (HAART) in resource-constrained settings with estimates of the gender distribution of HIV infection; to describe the clinical characteristics of women and men receiving HAART. Methods: The Antiretroviral Therapy in Lower-Income Countries, ART-LINC Collaboration is a network of clinics providing HAART in Africa, Latin America, and Asia. We compared UNAIDS data on the gender distribution of HIV infection with the proportions of women and men receiving HAART in the ART-LINC Collaboration. Results: Twenty-nine centers in 13 countries participated. Among 33,164 individuals, 19,989 (60.3%) were women. Proportions of women receiving HAART in ART-LINC centers were similar to, or higher than, UNAIDS estimates of the proportions of HIV-infected women in all but two centers. There were fewer women receiving HAART than expected from UNAIDS data in one center in Uganda and one center in India. Taking into account heterogeneity across cohorts, women were younger than men, less likely to have advanced HIV infection, and more likely to be anemic at HAART initiation. Conclusions: Women in resource-constrained settings are not necessarily disadvantaged in their access to HAART. More attention needs to be paid to ensuring that HIV-infected men are seeking care and starting HAART. [ABSTRACT FROM AUTHOR]

Robust resilience measurement can improve our understanding of how people and societies respond to climate risk. It also allows for the effectiveness of resilience‐building interventions to be tracked over time. To date, the majority of measurement tools use objective methods of evaluation. Broadly speaking, these relate to approaches that solicit little, if any, judgment on behalf of the subject in question. More recently, subjective methods of evaluation have been proposed. These take a contrasting epistemological view, relying on people's self‐assessments of their own capacity to deal with climate risk. Subjective methods offer some promise in complementing objective methods, including: factoring in people's own knowledge of resilience and what contributes to it; more nuanced contextualization; and the potential to reduce survey length and fatigue. Yet, considerable confusion exists in understanding subjectivity and objectivity. Little is also known about the merits and limitations of different approaches to measurement. Here, I clarify the conceptual and practical relationships between objective and subjective forms of measuring resilience, aiming to provide practical guidance in distinguishing between them. In reviewing existing toolkits, I propose a subjectivity–objectivity continuum that groups measurement approaches according to two core tenets: (a) how resilience is defined and (b) how resilience is evaluated. I then use the continuum to explore the strengths and weaknesses of different types of toolkits, allowing comparison across each. I also emphasize that there is no one‐size fits all approach to resilience measurement. As such, evaluators should carefully consider: their epistemology of resilience; core objectives for measurement; as well as resource and data constraints, before choosing which methods to adopt. This article is categorized under: Vulnerability and Adaptation to Climate Change > Values‐Based Approach to Vulnerability and Adaptation Mapping key strengths and limitations of approaches to resilience measurement on the subjectivity–objectivity continuum. [ABSTRACT FROM AUTHOR]

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Background: The objective was to examine the short‐term risk and predictors of anaemia following initiation of combination antiretroviral therapy (cART) in HIV‐infected patients from the Western Africa, Eastern Africa, Southern Africa, Central Africa, Asian‐Pacific, and Caribbean and Central and South America regions of the International Epidemiologic Databases to Evaluate AIDS (IeDEA) collaboration. Methods: Anaemia was defined as haemoglobin of < 10 g/dL. Patients were included if they started cART with three or more drugs, had prior haemoglobin of > = 10 g/dL, and had one or more follow‐up haemoglobin tests. Factors associated with anaemia up to 12 months were examined using Cox proportional hazards models and stratified by IeDEA region. Results: Between 1998 and 2008, 19,947 patients initiated cART with baseline and follow‐up haemoglobin tests (7358, 7289, 2853, 471, 1550 and 426 in the Western Africa, Eastern Africa, Southern Africa, Central Africa, Asian‐Pacific, and Caribbean and Central and South America regions, respectively). At initiation, anaemia was found in 45% of Western Africa patients, 29% of Eastern Africa patients, 21% of Southern Africa patients, 36% of Central Africa patients, 15% of patients in Asian‐Pacific and 14% of patients in Caribbean and Central and South America. Among patients with haemoglobin of > = 10 g/dL at baseline (13,445), the risks of anaemia were 18.2, 6.6, 9.7, 22.9, 11.8 and 19.5 per 100 person‐years in the Western Africa, Eastern Africa, Southern Africa, Central Africa, Asian, and Caribbean and Central and South America regions, respectively. Factors associated with anaemia were female sex, low baseline haemoglobin level, low baseline CD4 count, more advanced disease stage, and initial cART containing zidovudine. Conclusions: In data from 34 cohorts of HIV‐infected patients from sub‐Saharan Africa, Central and South America, and Asia, the risk of anaemia within 12 months of initiating cART was moderate. Routine haemoglobin monitoring was recommended in patients at risk of developing anaemia following cART initiation., Background According to World Health Organization (WHO) estimations [1], access to combination antiretroviral treatment (cART) has improved dramatically in low‐ and middle‐income countries with limited resources. At the end of [...]

Background: To better understand the need for paediatric second‐line antiretroviral therapy (ART), an ART management survey and a cross‐sectional analysis of second‐line ART use were conducted in the TREAT Asia Paediatric HIV Observational Database and the IeDEA Southern Africa (International Epidemiologic Databases to Evaluate AIDS) regional cohorts. Methods: Surveys were conducted in April 2009. Analysis data from the Asia cohort were collected in March 2009 from 12 centres in Cambodia, India, Indonesia, Malaysia, and Thailand. Data from the IeDEA Southern Africa cohort were finalized in February 2008 from 10 centres in Malawi, Mozambique, South Africa and Zimbabwe. Results: Survey responses reflected inter‐regional variations in drug access and national guidelines. A total of 1301 children in the TREAT Asia and 4561 children in the IeDEA Southern Africa cohorts met inclusion criteria for the cross‐sectional analysis. Ten percent of Asian and 3.3% of African children were on second‐line ART at the time of data transfer. Median age (interquartile range) in months at second‐line initiation was 120 (78‐145) months in the Asian cohort and 66 (29‐112) months in the southern African cohort. Regimens varied, and the then current World Health Organization‐recommended nucleoside reverse transcriptase combination of abacavir and didanosine was used in less than 5% of children in each region. Conclusions: In order to provide life‐long ART for children, better use of current first‐line regimens and broader access to heat‐stable, paediatric second‐line and salvage formulations are needed. There will be limited benefit to earlier diagnosis of treatment failure unless providers and patients have access to appropriate drugs for children to switch to., Background An estimated 2.5 million children worldwide are living with HIV [1], and more than 354,000 of them were on antiretroviral treatment (ART) at the end of 2009. Global paediatric [...]

Introduction Access to antiretroviral therapy (ART) has improved in lower-income countries over the past 4 years as a result of an exceptional commitment by the international community and donor agencies. [...], Objective To describe the electronic medical databases used in antiretroviral therapy (ART) programmes in lower-income countries and assess the measures such programmes employ to maintain and improve data quality and reduce the loss of patients to follow-up. Methods In 15 countries of Africa, South America and Asia, a survey was conducted from December 2006 to February 2007 on the use of electronic medical record systems in ART programmes. Patients enrolled in the sites at the time of the survey but not seen during the previous 12 months were considered lost to follow-up. The quality of the data was assessed by computing the percentage of missing key variables (age, sex, clinical stage of HIV infection, CD4+ lymphocyte count and year of ART initiation). Associations between site characteristics (such as number of staff members dedicated to data management), measures to reduce loss to follow-up (such as the presence of staff dedicated to tracing patients) and data quality and loss to follow-up were analysed using multivariate logit models. Findings Twenty-one sites that together provided ART to 50 060 patients were included (median number of patients per site: 1000; interquartile range, IQR: 72-19 320). Eighteen sites (86%) used an electronic database for medical record-keeping; 15 (83%) such sites relied on software intended for personal or small business use. The median percentage of missing data for key variables per site was 10.9% (IQR: 2.0-18.9%) and declined with training in data management (odds ratio, OR: 0.58; 95% confidence interval, CI: 0.37-0.90) and weekly hours spent by a clerk on the database per 100 patients on ART (OR: 0.95; 95% CI: 0.90-0.99). About 10 weekly hours per 100 patients on ART were required to reduce missing data for key variables to below 10%. The median percentage of patients lost to follow-up 1 year after starting ART was 8.5% (IQR: 4.2-19.7%). Strategies to reduce loss to follow-up included outreach teams, community-based organizations and checking death registry data. Implementation of all three strategies substantially reduced losses to follow-up (OR: 0.17; 95% CI: 0.15-0.20). Conclusion The quality of the data collected and the retention of patients in ART treatment programmes are unsatisfactory for many sites involved in the scale-up of ART in resource-limited settings, mainly because of insufficient staff trained to manage data and trace patients lost to follow-up. Objectif Decrire les bases de donnees medicales electroniques utilisees par les programmes de traitement antirotroviral (ART) dans les pays a faible revenu et evaluer les mesures que ces programmes appliquent pour preserver et ameliorer la qualite des donnees et reduire le nombre de patients perdus de vue. Methodes Une etude a ete menee de decembre 2006 a fevrier 2007 dans 15 pays d'Afrique, d'Amerique du Sud et d'Asie sur l'utilisation des systemes d'enregistrement electronique des donnees medicales dans le cadre des programmes ART. Les patients recrutes sur les sites au moment de l'enquete qui n'avaient pas ete vus pendant les 12 derniers mois ont ete consideres comme perdus de vue. On a evalue la qualite des donnees en calculant le pourcentage de variables cles manquantes (age, sexe, stade clinique de l'infection a VlH, numeration des lymphocytes CD4+ et annee de mise en route du traitement ART). On a analyse les associations entre les caracteristiques des sites (relies que le nombre de membres du personnel affectes a la gestion des donnees) et les mesures pour reduire le nombre de perdus de vue (relies que la presence de personnel charge de retrouver les patients) d'une part et la qualite des donnees et le nombre de perdus de vue, d'autre part, a l'aide de modeles logit multivaries. Resultats Vingt-une sites, fournissant globalement un traitement ART a 50 060 patients, ont participe a l'etude (nombre median de patients par site : 1000; intervalle interquartile, IIQ : 72-19320). Dix-huit de ces sites (86%) ont utilise une base de donnees electronique pour l'enregistrement des donnees medicales et 15 (83%) d'entre eux ont fait appel a des Iogiciels destines aux petites entreprises ou a un usage individuel. Le pourcentage median de donnees manquantes pour les variables cles etait de 10,9% (IIQ : 2,0-18,9%) et diminuait avec le degre de formation a la gestion des donnees (odds ratio, OR : 0,58; intervalle de confiance a 95%, IC : 0,37-0,90) et avec le nombre d'heures par semaine consacrees par des employes a la base de donnees pour 100 patients sous traitement ART (OR : 0,95;IC a 95% : 0,90-0,99). II fallait environ 10 heures par semaine pour 100 patients sous traitement ART pour amener le pourcentage de donnees manquantes concernant les variables cles a moins de 10%. Le pourcentage median de patients perdus de vue 1 an apres la mise en route du traitement ART etait de 8,5% (IIQ :4,2-19,7%). Parmi les strategies employees pour reduire le nombre de perdus de vue, figuraient le recours a des equipes de proximite et a des organisations communautaires, ainsi que le controle des donnees d'enregistrement des deces. La mise en oeuvre de ces trois strategies a permis de diminuer substantiellement les nombres de perdus de vue (OR :0,17;IC a 95% :0,15-0,20). Conclusion La qualite des donnees recueillies et la retention des patients dans les programmes de traitement ART etaient insatisfaisantes pour de nombreux sites participant a l'extension du traitement ART dans les pays a ressources limitees, en raison principalement de la formation insuffisante du personnel a la gestion des donnees et au tracage des patients perdus de vue. Objetivo Describir las bases de datos clinicos electronicas utilizadas en los programas de tratamiento antirretroviral (TAR) en los paises de ingresos bajos y evaluar las medidas empleadas en esos programas para mantener y mejorar la calidad de los datos y reducir la perdida de pacientes durante el seguimiento. Metodos Entre diciembre de 2006 y febrero de 2007 se Ilevo a cabo en 15 paises de Africa, America del Sur y Asia una encuesta sobre la utilizacion de sistemas electronicos de historias clinicas en los programas de TAR. Se consideraron perdidos para el seguimiento los pacientes participantes en los centros estudiados a los que no se habia vuelto a ver en los doce meses anteriores. La calidad de los datos se evaluo calculando el porcentaje de variables clave omitidas (edad, sexo, fase clinica de la infeccion por VIH, recuento de linfocitos CD4+ y ano de inicio del TAR). Las relaciones entre las caracteristicas del centro estudiado (como el numero de trabajadores dedicados a la gestion de datos), las medidas tendentes a reducir las perdidas de seguimiento (por ejemplo la existencia de personal dedicado a localizar a los pacientes) y la calidad de los datos y las perdidas de seguimiento fueron analizadas mediante modelos Iogit de varias variables. Resultados El estudio abarco 21 centros que suministraron TARa 50 060 pacientes en total (mediana de pacientes por centro: 1000; intervalo intercuartilico, IIC: 72-19 320). Dieciocho centros (86%) usaban bases de datos electronicas para sus historias clinicas; 15 (83%) de esos centros utilizaban para ello software concebido para uso personal o de pequenas empresas. La mediana del porcentaje de datos omitidos sobre variables fundamentales por centro fue de 10,9% (IIC: 2,0-18,9%) y disminuia con la capacitacion para la gestion de datos (razon de posibilidades, OR: 0,58; intervalo de confianza del 95%, IC95%: 0,37-0,90) y las horas semanales dedicadas por un auxiliar administrativo a la base de datos por 100 pacientes sometidos a TAR (OR: 0,95; IC95%: 0,90-0,99). Se requerian unas 10 horas semanales por 100 pacientes sometidos a TAR para reducir los datos faltantes para variables clave a niveles inferiores ai 10%. La mediana del porcentaje de pacientes perdidos para el seguimiento ai cabo de un ano de iniciado el TAR fue de 8,5% (IIC: 4,2-19,7%). Entre las estrategias aplicadas para reducir las perdidas de seguimiento cabe citar los equipos de extension, las organizaciones comunitarias y la verificacion de los datos de los registros de defuncion. La aplicacion de esas tres estrategias permitio reducir sustancialmente las perdidas durante el seguimiento (OR: 0,17; IC95%: 0,15-0,20). Conclusion La calidad de los datos reunidos y la retencion de pacientes en los programas de TAR son insatisfactorias en muchos de los centros que participan en la expansion del TAR en entornos con recursos limitados, principalmente como consecuencia de la falta de personal suficiente con la preparacion necesaria para gestionar los datos y localizar a los pacientes perdidos para el seguimiento.

Introduction UNAIDS estimates that 3.4 million children under the age of 15 years are currently living with HIV infection; 91% of these children reside in sub-Saharan Africa [1]. HIV infection [...], Introduction: There are limited data on paediatric HIV care and treatment programmes in low-resource settings. Methods: A standardized survey was completed by International epidemiologic Databases to Evaluate AIDS paediatric cohort sites in the regions of Asia-Pacific (AP), Central Africa (CA), East Africa (EA), Southern Africa (SA) and West Africa (WA) to understand operational resource availability and paediatric management practices. Data were collected through January 2010 using a secure, web-based software program (REDCap). Results: A total of 64,552 children were under care at 63 clinics (AP, N = 10; CA, N = 4; EA, N = 29; SA, N = 10; WA, N = 10). Most were in urban settings (N = 41, 65%) and received funding from governments (N = 51, 81%), PEPFAR (N = 34, 54%), and/or the Global Fund (N = 15, 24%). The majority were combined adult-paediatric clinics (N = 36, 57%). Prevention of mother-to-child transmission was integrated at 35 (56%) sites; 89% (N = 56) had access to DNA PCR for infant diagnosis. African (N = 40/53) but not Asian sites recommended exclusive breastfeeding up until 4-6 months. Regular laboratory monitoring included CD4 (N = 60, 95%), and viral load (N = 24, 38%). Although 42 (67%) sites had the ability to conduct acid-fast bacilli (AFB) smears, 23 (37%) sites could conduct AFB cultures and 18 (29%) sites could conduct tuberculosis drug susceptibility testing. Loss to follow-up was defined as >3 months of lost contact for 25 (40%) sites, >6 months for 27 sites (43%) and >12 months for 6 sites (10%). Telephone calls (N = 52, 83%) and outreach worker home visits to trace children lost to follow-up (N = 45, 71%) were common. Conclusions: In general, there was a high level of patient and laboratory monitoring within this multiregional paediatric cohort consortium that will facilitate detailed observational research studies. Practices will continue to be monitored as the WHO/UNAIDS Treatment 2.0 framework is implemented. Keywords: paediatric HIV; cohort; observational; Africa; Asia.