38 research outputs found
Providing better care to HIV-infected pregnant women, children and their families in a rural sub-Saharan African clinic
Novel strategies to increase the uptake of prevention of mother-to-child HIV transmission (PMTCT) services are needed in sub-Saharan Africa to reach the goal of elimination of paediatric HIV. In this same region, HIV diagnosis, linkage into care, antiretroviral treatment coverage and treatment outcomes of children need to be improved. Family-centered approaches may facilitate access to HIV care and improve the clinical management.
This thesis was developed mainly as an operational and implementation science research. The main objective of this PhD was to improve maternal and paediatric HIV services in Ifakara, Tanzania, to move towards the UNAIDS goals: 1) elimination of paediatric HIV and 2) “90-90-90” target (i) 90% of children living with HIV know their HIV status, ii) 90% of children with diagnosed HIV receive ART, iii) 90% of children receiving ART are virologically suppressed).
First, we conducted a cross-sectional study to assess the PMTCT services uptake in Ifakara. Second, we designed and implemented a package of measures as a strategy to improve the paediatric and maternal HIV care. Third, we evaluated the impact of the strategy. Forth, we did a prospective study evaluating the PMTCT cascade after the implementation of the package of measures and we compared the results with the initial cross-sectional assessment. Last, we investigated the prevalence and determinants of virological failure and acquired antiretroviral drug resistances in HIV-infected children.
The studies included in this thesis show that with an operational approach, real changes can be implemented in a rural Tanzanian setting. The work in Ifakara documents a feasible and scalable model for maternal and paediatric HIV care that if extended to other sub-Saharan African settings can contribute to the goals of zero new HIV infections among children, keep mothers in good health and close the paediatric treatment gap
A Bundle of Services Increased Ascertainment of Tuberculosis among HIV-Infected Individuals Enrolled in a HIV Cohort in Rural Sub-Saharan Africa
OBJECTIVES: To report on trends of tuberculosis ascertainment
among HIV patients in a rural HIV cohort in Tanzania, and
assessing the impact of a bundle of services implemented in
December 2012, consisting of three components:(i)integration of
HIV and tuberculosis services; (ii)GeneXpert for tuberculosis
diagnosis; and (iii)electronic data collection. DESIGN:
Retrospective cohort study of patients enrolled in the Kilombero
Ulanga Antiretroviral Cohort (KIULARCO), Tanzania.). METHODS:
HIV patients without prior history of tuberculosis enrolled in
the KIULARCO cohort between 2005 and 2013 were included.Cox
proportional hazard models were used to estimate rates and
predictors of tuberculosis ascertainment. RESULTS: Of 7114 HIV
positive patients enrolled, 5123(72%) had no history of
tuberculosis. Of these, 66% were female, median age was 38
years, median baseline CD4+ cell count was 243 cells/microl, and
43% had WHO clinical stage 3 or 4. During follow-up, 421
incident tuberculosis cases were notified with an estimated
incidence of 3.6 per 100 person-years(p-y)[95% confidence
interval(CI)3.26-3.97]. The incidence rate varied over time and
increased significantly from 2.96 to 43.98 cases per 100 p-y
after the introduction of the bundle of services in December
2012. Four independent predictors of tuberculosis ascertainment
were identified:poor clinical condition at baseline (Hazard
Ratio (HR) 3.89, 95% CI 2.87-5.28), WHO clinical stage 3 or 4
(HR 2.48, 95% CI 1.88-3.26), being antiretroviralnaive (HR 2.97,
95% CI 2.25-3.94), and registration in 2013(HR 6.07, 95% CI
4.39-8.38). CONCLUSION: The integration of tuberculosis and HIV
services together with comprehensive electronic data collection
and use of GeneXpert increased dramatically the ascertainment of
tuberculosis in this rural African HIV cohort
Prevention of mother-to-child transmission of HIV Option B+ cascade in rural Tanzania: The One Stop Clinic model
BACKGROUND: Strategies to improve the uptake of Prevention of
Mother-To-Child Transmission of HIV (PMTCT) are needed. We
integrated HIV and maternal, newborn and child health services
in a One Stop Clinic to improve the PMTCT cascade in a rural
Tanzanian setting. METHODS: The One Stop Clinic of Ifakara
offers integral care to HIV-infected pregnant women and their
families at one single place and time. All pregnant women and
HIV-exposed infants attended during the first year of Option B+
implementation (04/2014-03/2015) were included. PMTCT was
assessed at the antenatal clinic (ANC), HIV care and labour
ward, and compared with the pre-B+ period. We also characterised
HIV-infected pregnant women and evaluated the MTCT rate.
RESULTS: 1,579 women attended the ANC. Seven (0.4%) were known
to be HIV-infected. Of the remainder, 98.5% (1,548/1,572) were
offered an HIV test, 94% (1,456/1,548) accepted and 38 (2.6%)
tested HIV-positive. 51 were re-screened for HIV during late
pregnancy and one had seroconverted. The HIV prevalence at the
ANC was 3.1% (46/1,463). Of the 39 newly diagnosed women, 35
(90%) were linked to care. HIV test was offered to >98% of
ANC clients during both the pre- and post-B+ periods. During the
post-B+ period, test acceptance (94% versus 90.5%, p<0.0001)
and linkage to care (90% versus 26%, p<0.0001) increased. Ten
additional women diagnosed outside the ANC were linked to care.
82% (37/45) of these newly-enrolled women started antiretroviral
treatment (ART). After a median time of 17 months, 27% (12/45)
were lost to follow-up. 79 women under HIV care became pregnant
and all received ART. After a median follow-up time of 19
months, 6% (5/79) had been lost. 5,727 women delivered at the
hospital, 20% (1,155/5,727) had unknown HIV serostatus. Of
these, 30% (345/1,155) were tested for HIV, and 18/345 (5.2%)
were HIV-positive. Compared to the pre-B+ period more women were
tested during labour (30% versus 2.4%, p<0.0001). During the
study, the MTCT rate was 2.2%. CONCLUSIONS: The implementation
of Option B+ through an integrated service delivery model
resulted in universal HIV testing in the ANC, high rates of
linkage to care, and MTCT below the elimination threshold.
However, HIV testing in late pregnancy and labour, and retention
during early ART need to be improved
A decade of HIV care in rural Tanzania: Trends in clinical outcomes and impact of clinic optimisation in an open, prospective cohort
OBJECTIVES: Our objectives were to describe trends in enrolment
and clinical outcomes in the open, prospective Kilombero and
Ulanga Antiretroviral Cohort (KIULARCO) in the Morogoro region
of southern Tanzania, and identify strengths and areas for
improvement in the care of HIV-positive individuals in rural
Tanzania. METHODS: We included adults (>/=15 years) and
children (<15 years) enrolled in the cohort in 2005-2014. The
cohort underwent significant changes from autumn 2012 to
optimise care. We evaluated mortality and loss to follow-up
(LTFU) using competing risks methods, ART usage, opportunistic
infections (OI), co-infections and laboratory abnormalities.
RESULTS: Overall, 7010 adults and 680 children were enrolled;
enrolment peaked in 2008 but has increased steadily since 2011.
Among adults (65% female; median age 37 [interquartile range
31-45] years), the proportion referred from hospital wards
quadrupled in 2013-14 versus earlier years. 653 (9%) adults died
and 2648 (38%) were LTFU; the five-year cumulative probabilities
of death and LTFU were 10.3% and 44.0%, respectively. Among
children, 69 (10%) died and 225 (33%) were LTFU. The
corresponding five-year probabilities were 12.1% and 39.6%.
Adult ART use (regardless of eligibility) increased from 5% in
2005 to 89% in 2014 (similarly among children), with 9% on
second-line therapy in 2014 (17% of children). OI diagnoses
increased over time; tuberculosis prevalence at enrolment
quadrupled from 6% in 2011 to 26% in 2014. The proportion of
newly-enrolled participants assessed for laboratory
abnormalities peaked at nearly 100% in 2014 (from a minimum of
24%), yet abnormality prevalences remained fairly constant.
CONCLUSIONS: In this cohort, ART usage improved dramatically and
is approaching targets of 90%. Improved screening led to
increases in detection of OIs and laboratory abnormalities,
suggesting that a large number of these co-morbidities
previously went undetected and untreated. Further work will
address the high LTFU rates and implications for mortality
estimates, and the management and outcomes of co-morbidities
Cohort profile: the Kilombero and Ulanga Antiretroviral Cohort (KIULARCO): a prospective HIV cohort in rural Tanzania
The Kilombero and Ulanga Antiretroviral Cohort (KIULARCO) is a single-site, open and ongoing prospective cohort of people living with human immunodeficiency virus (PLWHIV) established in 2005 at the Chronic Diseases Clinic of Ifakara (CDCI), within the Saint Francis Referral Hospital (SFRH) in Ifakara, Tanzania. The objectives of KIULARCO are to (i) provide patient and cohort-level information on the outcomes of HIV treatment; (ii) provide cohort-level information on opportunistic infections and comorbidities; (iii) evaluate aspects of human immunodeficiency virus (HIV) care and treatment that have national or international policy relevance; (iv) provide a platform for studies on improving HIV care and treatment in sub-Saharan Africa; and (v) contribute to generating local capacity to deal with the challenges posed by the HIV/AIDS pandemic in this region. Moreover, KIULARCO may serve as a model for other healthcare settings in rural sub-Saharan Africa. Since 2005, all patients diagnosed with HIV at the Saint Francis Referral Hospital are invited to participate in the cohort, including non-pregnant adults, pregnant women, adolescents, children and infants. The information collected includes demographics, baseline and follow-up clinical data, laboratory data, medication history, drug toxicities, diagnoses and outcomes. Real-time data are captured during the patient encounter through an electronic medical record system that allowed transition to a paperless clinic in 2013. In addition, KIULARCO is associated with a biobank of cryopreserved plasma samples and cell pellets collected from all participants before and at different time-points during antiretroviral treatment. Up to the end of 2016, 12 185 PLWHIV have been seen at the CDCI; 9218 (76%) of whom have been enrolled into KIULARCO and 6965 (76%) of these have received ART from the clinic. Patients on ART attend at least every 3 months, with laboratory monitoring every 6 months. KIULARCO data have been used to generate relevant information regarding ART outcomes, opportunistic infections, non-AIDS comorbidities, prevention of mother-to-child transmission of HIV, paediatric HIV, and mortality and retention in care. Requests for collaborations on analyses can be submitted to the KIULARCO scientific committee. KIULARCO provides a framework for improving the quality of care of people living with HIV in sub-Saharan Africa, to generate relevant information to evaluate ART programmes and to build local capacity to deal with HIV/AIDS. The comprehensiveness of the data collected, together with the biobank spanning over ten years has created a unique research platform in rural sub-Saharan Africa
Women's Preferences Regarding Infant or Maternal Antiretroviral Prophylaxis for Prevention of Mother-To-Child Transmission of HIV during Breastfeeding and Their Views on Option B+ in Dar es Salaam, Tanzania.
The WHO 2010 guidelines for prevention of mother-to-child transmission (PMTCT) of HIV recommended prophylactic antiretroviral treatment (ART) either for infants (Option A) or mothers (Option B) during breastfeeding for pregnant women with a CD4 count of >350 cell/µL in low-income countries. In 2012, WHO proposed that all HIV-infected pregnant women should receive triple ART for life (B+) irrespective of CD4 count. Tanzania has recently switched from Option A to B+, with a few centers practicing B. However, more information on the real-life feasibility of these options is needed. This qualitative study explored women's preferences for Option A vs B and their views on Option B+ in Dar es Salaam, Tanzania. We conducted four focus group discussions with a total of 27 pregnant women with unknown HIV status, attending reproductive and child health clinics, and 31 in-depth interviews among HIV-infected pregnant and post-delivery women, 17 of whom were also asked about B+. Most participants were in favor of Option B compared to A. The main reasons for choosing Option B were: HIV-associated stigma, fear of drug side-effects on infants and difficult logistics for postnatal drug adherence. Some of the women asked about B+ favored it as they agreed that they would eventually need ART for their own survival. Some were against B+ anticipating loss of motivation after protecting the child, fearing drug side-effects and not feeling ready to embark on lifelong medication. Some were undecided. Option B was preferred. Since Tanzania has recently adopted Option B+, women with CD4 counts of >350 cell/µL should be counseled about the possibility to "opt-out" from ART after cessation of breastfeeding. Drug safety and benefits, economic concerns and available resources for laboratory monitoring and evaluation should be addressed during B+ implementation to enhance long-term feasibility and effectiveness
Uptake of guidelines on prevention of mother-to-child transmission of HIV in rural Tanzania: time for change
Guidelines on prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) are inconsistently implemented in low-income countries. Strategies are needed to improve the uptake of these guidelines to prevent avoidable new HIV infections of infants. In 2010 the World Health Organisation presented its new PMTCT guidelines, offering two options for short courses of antiretroviral prophylaxis: Option A and Option B. Option A consists of antenatal prophylaxis with zidovudine followed by intrapartum and postpartum prophylaxis with single-dose nevirapine and zidovudine plus lamivudine. Option B recommends triple antiretroviral prophylaxis until after finishing breastfeeding. Tanzania has adopted Option A, and it is currently implementing it. A new option termed Option B+ has emerged recently, which recommends providing lifelong antiretroviral treatment to all HIV-positive pregnant women. In this article, we discuss the likely impact of this last PMTCT strategy in rural Africa with an example of an observational cross-sectional analysis in a rural referral hospital in Tanzania aiming to assess the uptake of PMTCT recommendations. Gaps were identified at all steps of the PMTCT pathway. Effective uptake of PMTCT guidelines has been shown to be extremely challenging in this setting. The continuously changing recommendations on PMTCT stress the need for a much simpler and effective approach. We argue in favour of implementing Option B+ in Tanzania. Financial challenges need to be faced, but Option B+ would help to overcome many barriers that prevent guidelines to be implemented in order to increase coverage and ultimately achieve the goal of 'virtual elimination' of mother-to-child transmission in sub-Saharan Africa
Disseminated tuberculosis in an HIV-infected child: rifampicin resistance detected by GeneXpert in a lymph node aspirate but not in cerebrospinal fluid
A 9-year-old HIV-infected child previously treated with inadequate doses of antitubercular drugs based on weight was admitted 5 months after initial tuberculosis (TB) diagnosis with acute hemiplegia and inguinal lymphadenopathies in a rural hospital in Tanzania. He was diagnosed with TB meningitis and lymphadenitis using Xpert Mycobacterium tuberculosis/rifampicin (MTB/RIF) assay. Rifampicin resistance was detected in the lymph node aspirate but not in the cerebrospinal fluid. His TB therapy was optimised based on available medications and antiretroviral treatment was initiated 6 weeks later. Despite these efforts, the clinical evolution was poor and the child died 12 weeks after admission