Decentralization of HIV care in Cameroon: Increased access to antiretroviral treatment and associated persistent barriers

ContextThe national antiretroviral treatment (ART) program in Cameroon has reached one of the highest rate of coverage in Western and Central Africa (58% of the estimated eligible HIV-infected population in June 2008).ObjectivesTo assess the extent to which decentralized delivery of HIV care at the district level has contributed to increased access to ART.MethodsComparison of ART-treated and non-ART-treated in the sub-sample of medically eligible HIV-positive patients (n = 2566) in the cross-sectional ANRS-EVAL survey was carried out among patients seeking HIV care in 14 hospitals at central level (Yaoundé, Douala and capitals of 8 provinces) and 13 at district levels. Logistic regressions and multivariate analysis were carried out to identify factors related to non-access to ART at both levels of care.ResultsOnly 7% of eligible patients did not have access to ART. After adjustment for time since initial HIV diagnosis and CD4 counts (at initiation of treatment for those ART-treated and at time of survey for those who were not), younger and male patients, as well as those who only had a primary level education were less likely to be ART-treated at central but not at district level, whereas those who were unemployed were less likely to be treated at both levels. Patients were less likely to be treated in central hospitals with higher workload per medical staff member and absence of task shifting policy, and in district hospitals with non-availability of equipment for CD4 counts and larger size (150 beds or more).ConclusionMain persisting barriers in access to ART in Cameroon are rather due to insufficient access to HIV testing and difficulties in patients’ referral to ART delivery centers after HIV diagnosis, since the overwhelming majority of eligible patients already seeking HIV care had effective access. However, health systems strengthening (HSS) is still needed to overcome some remaining barriers in access to ART and to guarantee its long-term sustainability.     

Measuring adherence to antiretroviral treatment in resource-poor settings: The clinical validity of key indicators

Background  

Access to antiretroviral therapy has dramatically expanded in Africa in recent years, but there are no validated approaches to measure treatment adherence in these settings.     

Measuring adherence to antiretroviral treatment in resource-poor settings: The feasibility of collecting routine data for key indicators

Background  

An East African survey showed that among the few health facilities that measured adherence to antiretroviral therapy, practices and definitions varied widely. We evaluated the feasibility of collecting routine data to standardize adherence measurement using a draft set of indicators.     

早期抗病毒治疗对艾滋病患者生存状况的影响

目的 比较不同时间开始抗病毒治疗对艾滋病患者生存状况的影响,并探讨抗病毒治疗最佳时机.方法 利用国家艾滋病抗病毒治疗信息系统,收集2007-2012年河南省加入抗病毒治疗的艾滋病患者基本和随访信息,并按照基线免疫学水平,将所有研究对象分为早期治疗组(基线CD4+T淋巴细胞计数350～500 cell/μl)和常规治疗组(基线CD4+T淋巴细胞计数≤350 cell/μl),采用生存分析方法进行全死因回顾分析.结果 共纳入16 282例艾滋病患者,常规治疗组病死率明显高于早期治疗组(5.78/100人年vs.1.64/100人年),中位生存期低于早期治疗组中位生存期(2.07年vs.3.15年).常规治疗组6年累积生存率低于早期治疗组(77.39％vs.92.10％,x2=156.00,P＜0.01).多因素分析显示,开始治疗时年龄、性别、婚姻状况、感染途径、初始治疗方案和基线症状数为常规治疗组生存时间的影响因素(P＜0.05),开始治疗时的性别、初始治疗方案和基线症状数为早期治疗组生存时间的影响因素(P＜0.05).结论 早期抗病毒治疗可提高河南省接受抗病毒治疗的艾滋病患者生存率,延长其生存时间.     

Non-adherence to antiretroviral treatment and unplanned treatment interruption among people living with HIV/AIDS in Cameroon: Individual and healthcare supply-related factors

In low-income countries, health system deficiencies may undermine treatment continuity and adherence to antiretroviral therapy (ART) that are crucial for the success of large-scale public ART programs. In addition to examining the effects of individual characteristics, on non-adherence to ART and treatment interruption behaviors – i.e. treatment interruption for more than 2 consecutive days during the previous 4 weeks, this study aims to extend our knowledge on the role played by healthcare supply-related characteristics in shaping these two treatment outcomes. These effects are examined using multilevel logistic models applied to a sub-sample of 2381 ART-treated patients followed-up in 27 treatment centers in Cameroon (ANRS-EVAL survey, 2006–2007).     

Implications of adopting new WHO guidelines for antiretroviral therapy initiation in Ethiopia

Objective

To assess the implications of implementing the World Health Organization (WHO) 2010 guidelines for antiretroviral therapy (ART) initiation in adults and adolescents with human immunodeficiency virus (HIV) infection, which recommend initiating ART at a CD4+ T lymphocyte (CD4+) threshold of ≤ 350 cells/mm³ instead of ≤ 200 cells/mm³, which was the earlier threshold.

Methods

Between April and May 2010, CD4+ test results were collected for all HIV-infected patients recorded in the pre-ART and ART registers of 19 high-patient-load health centres in Addis Ababa, Ethiopia, and the regions of Amhara, Oromia, SNNPR (Southern Nations, Nationalities and People''s Region) and Tigray. At 12 centres patient records were independently reviewed to assess data accuracy. To estimate the total number of patients who would need ART at health centres if Ethiopia adopted the new WHO guidelines, the number of patients needing ART based on current guidelines were added to the number of asymptomatic patients enrolled in pre-ART with a CD4+ count > 200 but ≤ 350 cells/mm³

Findings

Adoption of the new WHO guidelines would increase the total number of patients on ART in the 19 health centres in Ethiopia by about 30%: from 3583 to 4640.

Conclusion

The shift in the CD4+ threshold for ART initiation will substantially increase the demand for ART in Ethiopia. Since under the current systems only 60% of Ethiopia’s patients in need of ART are receiving the medications, scaling up ART programmes to accommodate the increased demand for drugs will not be possible unless government funding and support increase concurrently.     

Incidence of morphological and lipid abnormalities: gender and treatment differentials after initiation of first antiretroviral therapy

OBJECTIVE: To provide population-based incidence estimates for constituent symptoms of human immundeficiency virus (HIV)-related lipodystrophy syndrome and to identify possible independent predictors of accrued cases. DESIGN: Prospective population-based cohort. Methods Study subjects were antiretroviral-na?ve individuals who initiated treatment between October 1998 and May 2001 and provided completed self-reported data regarding the occurrence of lipoatrophy, lipohypertrophy and increased triglyceride and cholesterol levels. Possible predictors of incident lipoatrophy, lipohypertrophy, dyslipidaemia and mixed lipodystrophy (symptoms of both lipoatrophy and lipohypertrophy) were identified using logistic regression modelling. A sub-analysis restricted to subjects retaining original treatment at study completion was conducted using similar methods. RESULTS: Among the 366 study subjects, cumulative incidence was 29% for lipoatrophy, 23% for lipohypertrophy, 9% for dyslipidaemia, and 13% for mixed lipodystrophy after a median duration of 12 months of antiretroviral therapy. In an intentto-treat analysis incident lipoatrophy and lipohypertrophy were independently associated with initiation of protease inhibitor (PI)-containing regimens, (adjusted odds ratio [AOR] = 1.94; 95% CI: 1.25-3.03 and AOR = 1.76; 95% CI: 1.09-2.85, respectively) and female gender (AOR = 2.06; 95% CI: 1.03-4.12 and AOR = 2.36; 95% CI: 1.17-4.74, respectively). Both mixed lipodystrophy and reported dyslipidaemia were associated only with PI inclusion in the initial regimen (AOR = 2.27; 95% CI: 1.14-4.53 and AOR = 2.14; 95% CI: 1.26-3.65, respectively). Similar results were obtained in analysis of individuals retained in initial treatment groups throughout follow-up. CONCLUSION: Incident morphological and lipid abnormalities are common among individuals initiating first-time antiretroviral therapy. Use of PI was consistently associated with all lipodystrophy-related abnormalities after adjustment for a broad range of patient personal, clinical and treatment characteristics.     

Cost-effectiveness of earlier initiation of antiretroviral therapy for uninsured HIV-infected adults

OBJECTIVES: This study was designed to examine the societal cost-effectiveness and the impact on government payers of earlier initiation of antiretroviral therapy for uninsured HIV-infected adults. METHODS: A state-transition simulation model of HIV disease was used. Data were derived from the Multicenter AIDS Cohort Study, published randomized trials, and medical care cost estimates for all government payers and for Massachusetts, NewYork, and Florida. RESULTS: Quality-adjusted life expectancy increased from 7.64 years with therapy initiated at 200 CD4 cells/microL to 8.21 years with therapy initiated at 500 CD4 cells/microL. Initiating therapy at 500 CD4/microL was a more efficient use of resources than initiating therapy at 200 CD4/microL and had an incremental cost-effectiveness ratio of $17,300 per quality-adjusted life-year gained, compared with no therapy. Costs to state payers in the first 5 years ranged from $5,500 to $24,900 because of differences among the states in the availability of federal funds forAIDS drug assistance programs. CONCLUSIONS: Antiretroviral therapy initiated at 500 CD4 cells/microL is cost-effective from a societal: perspective compared with therapy initiated later. States should consider Medicaid waivers to expand access to early therapy.     

Within-person variance in biochemical indicators of iron status: effects on prevalence estimates

The effect of within-person variance on prevalence estimates from population distributions based on a single measurement was examined for hematologic and iron-status indicators collected in the Hispanic Health and Nutrition Examination Survey (HHANES). Within-person to between-person variance ratios (W:Bs) were estimated for 11 indicators by using data from 80 persons who provided blood twice in HHANES. Distributions of selected iron-status indicators from 20-44-y-old Mexican American females from HHANES were adjusted for within-person variance by using the W:B estimates, and prevalences of low values based on the original and adjusted distributions were compared. W:B were less than 1 for the majority of the indicators. Nonetheless, prevalences of low values from the original distributions were inflated when commonly used cutoff values were applied. Within-person variance in serum analytes needs to be controlled when the prevalence of a condition in populations is assessed.     

云南省2005年-2009年上半年艾滋病抗病毒治疗指标分析

[目的] 通过回顾分析云南省开展艾滋病抗病毒治疗的相关指标,为深入规范开展工作提供依据.[方法] 依据各州市2005年～2009年6月上报的艾滋病抗病毒治疗数据报表和卫生部<艾滋病抗病毒药物治疗信息系统>,对几年来艾滋病抗病毒治疗相关指标进行回顾性分析.[结果]云南省艾滋病抗病毒治疗的人数逐年有较大的增加;抗病毒治疗入纽治疗1年的病人1年后的存活在治比例达到国家要求、1年中7次随访率有起伏,1年中4次CD4检测率在不断上升,所有治疗半年以上的病人当年病毒载量检测率起伏很大.[结论]云南省艾滋病抗病毒治疗的人教和规模及规范性方面有了长是进步,但抗病毒治疗工作仍任重道远.     

Cost-effectiveness of early initiation of first-line combination antiretroviral therapy in Uganda

ABSTRACT: BACKGROUND: Ugandan national guidelines recommend initiation of combination antiretroviral therapy (cART) at CD4+ T cell (CD4) count below 350cell/mul, but the implementation of this is limited due to availability of medication. However, cART initiation at higher CD4 count increases survival, albeit at higher lifetime treatment cost. This analysis evaluates the cost-effectiveness of initiating cART at a CD4 count between 250--350cell/mul (early) versus <250cell/mul (delayed). METHODS: Life expectancy of cART-treated patients, conditional on baseline CD4 count, was modeled based on published literature. First-line cART costs $192 annually, with an additional $113 for patient monitoring. Delaying initiation of cART until the CD4 count falls below 250cells/mul would incur the cost of the bi-annual CD4 count tests and routine maintenance care at $85 annually. We compared lifetime treatment costs and disability adjusted life-expectancy between early vs. delayed cART for ten baseline CD4 count ranges from 250-350cell/mul. All costs and benefits were discounted at 3 % annually. RESULTS: Treatment delay varied from 6--18 months. Early cART initiation increased life expectancy from 1.5-3.5 years and averted 1.33--3.10 disability adjusted life years (DALY's) per patient. Lifetime treatment costs were $4,300--$5,248 for early initiation and $3,940--$4,435 for delayed initiation. The cost/DALY averted of the early versus delayed start ranged from $260--$270. CONCLUSIONS: In HIV-positive patients presenting with CD4 count between 250-350cells/mul, immediate initiation of cART is a highly cost-effective strategy using the recommended one-time per capita GDP threshold of $490 reported for Uganda. This would constitute an efficient use of scarce health care funds.     

Early initiation of highly active antiretroviral therapies for AIDS: dynamic choice with endogenous and exogenous learning

Criteria for initiation of highly active antiretroviral treatments (HAART) in HIV-infected patients remain a matter of debate world-wide because short-term benefits have to be balanced with costs of these therapies, and restrictions placed on future treatment options if resistant viral strains develop. On the other hand, postponing the introduction of HAART may involve a therapeutic opportunity cost if a patient's health is allowed to deteriorate to such an extent of becoming unable to benefit from new treatments currently under development when they become available. We introduce a two period model where period one treatment adoption is an irreversible act with future, but uncertain, consequences. New information, both endogenous and exogenous, arises over time and shapes the conditions surrounding the second period therapeutic decision. A surprising result is that, under conditions that appear close to those surrounding the HAART debate, the magnitude of the feared resistance effect has no effect on leaves the optimal treatment decision as far as it is high enough.     

Determinants of delay from cancer diagnosis to treatment initiation in a cohort of brazilian women with breast cancer

This objective this study was to identify the time interval between breast cancer (BC) diagnosis and treatment initiation and delay-associated factors. This is a prospective cohort study that followed breast cancer patients, enrolled and treated at the cancer center in Rio de Janeiro (RJ) – Brazil, from October 02, 2014 to April 30, 2015. Participants were interviewed at the first consultation. Treatment-related information was collected six months after recruitment. The median and interquartile range (IQR) were calculated. The interval between breast cancer diagnosis and treatment initiation of more than 60 days was considered the delay, according to the maximum term determined by Brazilian law. The association between independent variables and the outcome was performed using the crude odds ratios (OR). Variables presenting p < .20 in the univariate analysis were included in the multiple logistic regression model by the stepwise forward method, and those with p < .05 were retained in the final model. A total of 470 patients were included in the study. The median time was of 127 days (IQR: 85– 174). Delay was observed in 89.1% of the cases. After adjustment, the variables associated with delay were age ≥ 60 years (OR: 2.48; 95% CI 1.22–5.06), initial clinical staging (<2B) (OR: 2.01; 95% CI 1.05–3.86) and residence outside the city of Rio de Janeiro (OR: 2.75; 95% CI 1.38–5.51). Delays in starting treatment were associated with sociodemographic and clinical factors. Improving patient quality of care and restructuring the health service can minimise delays.     

Stroke surveillance: population-based estimates and projections for New Zealand

OBJECTIVE: To estimate the incidence, prevalence and mortality of stroke in New Zealand (NZ) in 2001, projected to 2011. METHODS: Multistate lifetable models were constructed using smoothed rates of first-ever stroke incidence and relative risks of mortality estimated from the most recent Auckland Regional Community Stroke (ARCOS) Study. Estimates of the burden of stroke in NZ were calculated by applying rates output by the model to the 2001 population. Stroke incidence, prevalence and mortality were then projected to 2011, assuming similar trends in stroke incidence and case fatality to those estimated between the 1991/92 and 2002/03 studies. RESULTS: A total of 5,200 first-ever strokes were estimated to have occurred in NZ in 2001. Rates of stroke rose exponentially with increasing age and were 20% higher among males than females at most ages. Nevertheless, the lifetable risk of stroke was lower for males (16%) than females (18%). On average, males survived a year longer than females after a first-ever stroke (9.0 vs. 8.2 years). The incidence rates of first-ever stroke declined by approximately 1% per year between 1991 and 2003. The lifetable risk of stroke remained stable for females but increased for males (from 14% to 16%) over this period. Stroke prevalence also increased by approximately 1% per year, whereas stroke-related mortality fell by 4% per year. If these trends continue, approximately 6,000 first-ever strokes (2% annual increase), 45,000 stroke survivors (2% annual increase) and 2,000 stroke-related deaths (1% annual decline) are expected in 2011. CONCLUSION: Stroke mortality is falling faster than stroke incidence. This, together with population growth and ageing, will lead to a rising burden of stroke-related disability over the next decade.