Home-based versus clinic-based care for patients starting antiretroviral therapy with low CD4⁺ cell counts: findings from a cluster-randomized trial.

OBJECTIVES: African health services have shortages of clinical staff. We showed previously, in a cluster-randomized trial, that a home-based strategy using trained lay-workers is as effective as a clinic-based strategy. It is not known whether home-based care is suitable for patients with advanced HIV disease. METHODS: The trial was conducted in Jinja, Uganda. One thousand, four hundred and fifty-three adults initiating ART between February 2005 and January 2009 were randomized to receive either home-based care or routine clinic-based care, and followed up for about 3 years. Trained lay workers, supervised by clinical staff based in a clinic, delivered the home-based care. In this sub-analysis, we compared survival between the two strategies for those who presented with CD4⁺ cell count less than 50 cells/μl and those who presented with higher CD4⁺ cell counts. We used Kaplan-Meier methods and Poisson regression. RESULTS: Four hundred and forty four of 1453 (31%) participants had baseline CD4⁺ cell count less than 50 cells/μl. Overall, 110 (25%) deaths occurred among participants with baseline CD4⁺ cell count less than 50  cells/μl and 87 (9%) in those with higher CD4⁺ cell count. Among participants with CD4 cell count less than 50  cells/μl, mortality rates were similar for the home and facility-based arms; adjusted mortality rate ratio 0.80 [95% confidence interval (CI) 0.53-1.18] compared with 1.22 (95% CI 0.78-1.89) for those who presented with higher CD4⁺ cell count. CONCLUSION: HIV home-based care, with lay workers playing a major role in the delivery of care including providing monthly adherence support, leads to similar survival rates as clinic-based care even among patients who present with very low CD4⁺ cell count. This emphasises the critical role of adherence to antiretroviral therapy

Demographic characteristics and opportunistic diseases associated with attrition during preparation for antiretroviral therapy in primary health centres in Kibera, Kenya.

Using routine data from HIV-positive adult patients eligible for antiretroviral therapy (ART), we report on routinely collected demographic characteristics and opportunistic diseases associated with pre-ART attrition (deaths and loss to follow-up). Among 2471 ART eligible patients, enrolled between January 2005 and November 2008, 446 (18%) were lost to attrition pre-ART. Adjusted risk factors significantly associated with pre-ART attrition included age <35 years (Odds Ratio, OR 1.4, 95% Confidence Interval, CI 1.1-1.8), severe malnutrition (OR 1.5, 95% CI 1.1-2.0), active pulmonary tuberculosis (OR 1.6, 95% CI 1.1-2.4), severe bacterial infections including severe bacterial pneumonia (OR 1.9, 95% CI 1.2-2.8) and prolonged unexplained fever (>1 month), (OR 2.6, 95% CI 1.3-5.2). This study highlights a number of clinical markers associated with pre-ART attrition that could serve as 'pointers' or screening tools to identify patients who merit fast-tracking onto ART and/or closer clinical attention and follow-up

Use of WHO clinical stage for assessing patient eligibility to antiretroviral therapy in a routine health service setting in Jinja, Uganda

In a routine service delivery setting in Uganda, we assessed the ability of the WHO clinical stage to accurately identify HIV-infected patients in whom antiretroviral therapy should be started

A Cluster-Randomised Trial to Compare Home-Based with Health Facility-Based Antiretroviral Treatment in Uganda: Study Design and Baseline Findings

The scale-up of antiretroviral therapy is progressing rapidly in Africa but with a limited evidence-base. We report the baseline results from a large pragmatic cluster-randomised trial comparing different strategies of ART delivery. The trial is integrated in normal health service delivery. 1453 subjects were recruited into the study. Significantly more women (71%) than men (29%) were recruited. The WHO HIV clinical stage at presentation did not differ significantly between men and women: 58% and 53% respectively were at WHO stage III or IV (p=0.9). Median CD4 counts (IQR) x 106cells/l were 98 (28, 160) among men and 111 (36, 166) among women. Sixty-four percent of women and 61% men had plasma viral load ≥100,000 copies. Baseline characteristics did not change over time. Considerably fewer men than women presented for treatment. Both men and women presented at an advanced stage with very low median CD4 count and high plasma viral load

Mortality by baseline CD4 cell count among HIV patients initiating antiretroviral therapy: evidence from a large cohort in Uganda

Evaluations of CD4 cell count and other prognostic factors on the survival of HIV patients in sub-Saharan Africa are extremely limited. Funders have been reticent to recommend earlier initiation of treatment. We aimed to examine the effect of baseline CD4 cell count on mortality using data from HIV patients receiving combination antiretroviral therapy (cART) in Uganda

The experience of “medicine companions” to support adherence to antiretroviral therapy: quantitative and qualitative data from a trial population in Uganda

Good adherence is critical for antiretroviral therapy (ART) in sub-Saharan Africa. We report on the characteristics of medicine companions (MCs) chosen by Ugandan patients enrolling on ART, and on how MCs were chosen, and what roles they played. Baseline data on MCs of 1453 participants in a randomized controlled trial comparing facility and home-based delivery of ART in Jinja, Uganda were analyzed. Textual data on experience with MCs were collected through in-depth interviews among a subsample of 40 trial participants equally divided by sex and trial arm. Significantly more women (71%) than men (29%) were recruited. The majority (75%) of women participants were either widowed (51%) or separated or divorced (24%), whereas most of the men (66%) were married. Women were most likely to choose a child as their MC while men were most likely to choose their spouse; 41% of women chose an MC under 21 compared with only 14% of men. Only 31% of married women chose their husband, compared with 66% of married men who chose their wife. Qualitative interviews suggested MCs proved useful for reminding and other supportive tasks in the first three months but were generally less essential by six months and beyond. Convenience, reliability, and trust were key considerations in choosing an MC. Children provided the only alternative for many unmarried women, but even some married women felt children made more reliable MCs than husbands. Participants who had disclosed their serostatus usually received drug-taking reminders from multiple household members. One participant in the qualitative sample with poor family relations delayed starting treatment due to unwillingness to identify an MC. MCs were generally welcome and useful in supporting early adherence. However, disclosure to an MC should not be a condition of obtaining treatment

Mental disorder and the outcome of HIV/AIDS in low-income and middle-income countries: a systematic review.

OBJECTIVES: To conduct a systematic review of the literature to examine the interrelationship between mental health and treatment outcomes in low-income and middle-income settings; to update the work of Collins et al. (2006). DESIGN: Systematic review of peer-reviewed articles that examined one of the following: the effects of mental disorders (including cognitive impairment) upon engagement with treatment and/or adherence; their influence upon HIV-related clinical outcomes; and the impact of interventions for mental disorder. METHODS: Articles about mental health and HIV/AIDS were included if they were published after 2005 and addressed one of the areas of interest described above. Systematic methods were used for searching, screening, and data extraction. Studies employing quantitative measures of exposures and outcomes wherein all participants had a diagnosis of HIV/AIDS were included. RESULTS: This review found ample and moderately consistent evidence that adverse mental health and alcohol consumption are associated with reduced adherence. Variation in measurement and the relative paucity of work meant that interpretation of studies examining engagement with care and other clinical outcomes was difficult. Evidence on the efficacy and effectiveness of mental health interventions in low-income and middle-income settings was very limited. CONCLUSION: This review suggests that psychosocial factors, namely, depression and alcohol may have adverse effects upon HIV-related outcomes. However, further large, high-quality studies examining outcomes other than adherence are needed. There is also an urgent need for randomized controlled trials of interventions for mental disorder and a need to investigate their impact upon HIV-related outcomes

Gaining user insights into the research-to-operational elements of Impact-based Forecasting (IbF) from within the SHEAR programme : summary of findings

Impact based Forecasting (IbF) is an expanding and evolving area of research within National Meteorological and Hydrological Services (NMHSs) and the humanitarian sector, with a broad aim to enhance communication and timely action to reduce losses associated with natural hazards. Although the principles of IbF may seem new to some disciplines, they leverage knowledge built over several years within the risk and emergency management communities (Smith, 2013) and therefore although its application may be newer to some disciplines, many of the principles and practices are based on existing risk theory concepts. However, a key advance of IbF is the pull-through of these concepts into implementable prototypes, tools and services and in order to do this, a growth in interdisciplinary working. The World Meteorological Organisation (WMO), as well as global Non-Governmental Organisations (e.g. Red Cross Red Crescent) strongly advocate for a shift towards IbF and have developed supporting guidelines (WMO, 2015a; Red Cross Climate Centre, 2020; WMO, 2021) to enhance implementation of such techniques across the globe. In doing this the WMO have distinguished two main types of IbF, subjective and objective. A subjective IbF relies on expert interpretation to provide the impact-based elements to a forecast or warning, whilst an objective IbF utilises vulnerability and exposure datasets, together with hazard information to calculate the risk and/or impacts. It is noted however, that risk assessments almost always utilise a combination of both subjective and objective methods. There are a wide range of dependencies on how an IbF system might evolve, and it is these dependencies which have introduced variety into the approaches and methods used to generate impact-based forecasts and warnings. This variability is also driven by different interpretations of what IbF should provide. Some stakeholders desire to have information on the number of assets or people that might be affected; however, most IbF warnings systems currently provide categorical risk forecasts (i.e. very low, low, medium and high) with supporting generalised impact information. Although the difference between these styles of output may appear subtle it can have significant implications for the development of forecasting and warning applications and the upstream modelling requirements. IbF has rapidly become an umbrella term under which a plethora of methods are being tried and different disciplines engaged. This broad scope is beneficial for research as it enables blue-sky thinking, transdisciplinary research opportunities and ideally, sustained cooperation and collaboration between a wide range of groups (e.g. stakeholders, researchers, technologists, practitioners, decision-makers). However, these same benefits can pose challenges when moving towards operational implementation, particularly for NMHSs with reduced institutional capacities. It should also be noted that the term IbF is linked to a range of other activities and terminologies, including forecast-based action and forecast-based financing (FbF). The lens through which IbF is viewed therefore influences its role and the value it might provide in meeting the objective ‘to enhance usability by making forecasts and warnings more actionable’. Given the growing scope of IbF and the potential challenges this may have for implementation, this research aims to answer the following questions: (1) Is there a shared understanding of what IbF is across individuals involved in its development? (2) Is there a shared perception of the challenges, barriers and opportunities associated with implementing IbF operationally? To accomplish this aim, practitioners, forecasters and researchers, working within the NERC Science for Humanitarian Emergencies and Resilience (SHEAR) Programme, were invited to provide their perspectives on a range of IbF related topics through a set of semi-structured interviews. This report provides a synthesis of the interviewee transcripts from key informant interviews. In section 2 the methodology is described, while section 3 provides a review of the key findings from the complete set of interviews. The final section (section 4) provides recommendations and concluding remarks

Action-based flood forecasting for triggering humanitarian action

Too often, credible scientific early warning information of increased disaster risk does not result in humanitarian action. With financial resources tilted heavily towards response after a disaster, disaster managers have limited incentive and ability to process complex scientific data, including uncertainties. These incentives are beginning to change, with the advent of several new Forecast-based Financing systems that provide funding based on a forecast of an extreme event. Given the changing landscape, here we demonstrate a method to select and use appropriate forecasts for specific humanitarian disaster prevention actions, even in a data-scarce location. This action-based forecasting methodology takes into account the parameters of each action, such as action lifetime, when verifying a forecast. Forecasts are linked with action based on an understanding of (1) the magnitude of previous flooding events and (2) the willingness to act "in vain" for specific actions. This is applied in the context of the Uganda Red Cross Society Forecast-based Financing pilot project, with forecasts from the Global Flood Awareness System (GloFAS). Using this method, we define the "danger level" of flooding, and we select the probabilistic forecast triggers that are appropriate for specific actions. Results from this methodology can be applied globally across hazards, and fed into a financing system that ensures that automatic, pre-funded early action will be triggered by forecasts