Scaling up isoniazid preventive therapy in Zimbabwe: has operational research influenced policy and practice?

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

Trends in Prevalence of Advanced HIV Disease at Antiretroviral Therapy Enrollment - 10 Countries, 2004-2015.

Monitoring prevalence of advanced human immunodeficiency virus (HIV) disease (i.e., CD4+ T-cell count <200 cells/μL) among persons starting antiretroviral therapy (ART) is important to understand ART program outcomes, inform HIV prevention strategy, and forecast need for adjunctive therapies.*,†,§ To assess trends in prevalence of advanced disease at ART initiation in 10 high-burden countries during 2004-2015, records of 694,138 ART enrollees aged ≥15 years from 797 ART facilities were analyzed. Availability of national electronic medical record systems allowed up-to-date evaluation of trends in Haiti (2004-2015), Mozambique (2004-2014), and Namibia (2004-2012), where prevalence of advanced disease at ART initiation declined from 75% to 34% (p<0.001), 73% to 37% (p<0.001), and 80% to 41% (p<0.001), respectively. Significant declines in prevalence of advanced disease during 2004-2011 were observed in Nigeria, Swaziland, Uganda, Vietnam, and Zimbabwe. The encouraging declines in prevalence of advanced disease at ART enrollment are likely due to scale-up of testing and treatment services and ART-eligibility guidelines encouraging earlier ART initiation. However, in 2015, approximately a third of new ART patients still initiated ART with advanced HIV disease. To reduce prevalence of advanced disease at ART initiation, adoption of World Health Organization (WHO)-recommended "treat-all" guidelines and strategies to facilitate earlier HIV testing and treatment are needed to reduce HIV-related mortality and HIV incidence

Critical considerations for adopting the HIV 'treat all' approach in Zimbabwe: is the nation poised?

While the advent of antiretroviral therapy (ART) has increased survival and reduced the number of acquired immune-deficiency syndrome (AIDS) related deaths among people living with the human immunodeficiency virus (HIV) virus (PLHIV), HIV/AIDS remains a global health problem and sub-Saharan Africa continues to bear the greatest burden of disease. There are also major challenges in the HIV response: as of December 2013, only 36% of PLHIV globally were on ART, and for every individual started on ART there were two new PLHIV diagnosed. This has led to considerable debate around adopting an HIV 'treat all' approach aimed at greatly escalating the number of PLHIV initiated and retained on ART, regardless of CD4 cell count or World Health Organization (WHO) clinical stage, with the intended goal of achieving viral suppression which should in turn reduce HIV transmission, morbidity and mortality in affected individuals. This paper examines the issues being discussed in Zimbabwe, a low-income country with a high burden of HIV/AIDS, about the implications and opportunities of adopting an HIV 'treat all' approach, along with pertinent operational research questions that need to be answered to move the agenda forward. These discussions are timely, given the recent WHO recommendations advising ART for all PLHIV, regardless of CD4 cell count

Declining tuberculosis case notification rates with the scale-up of antiretroviral therapy in Zimbabwe.

Setting: Zimbabwe has a human immunodeficiency virus (HIV) driven tuberculosis (TB) epidemic, with antiretroviral therapy (ART) scaled up in the public sector since 2004. Objective: To determine whether national ART scale-up was associated with annual national TB case notification rates (CNR), stratified by disease type and category, between 2000 and 2013. Design: This was a retrospective study using aggregate data from global reports. Results: The number of people living with HIV and retained on ART from 2004 to 2013 increased from 8400 to 665 299, with ART coverage increasing from <0.5% to 48%. TB CNRs, all types and categories, increased from 2000 to 2003, and declined thereafter from 2004 to 2013. The decreases in annual TB notifications between the highest rates (before 2004) and lowest rates (2013) were all forms of TB (56%), new TB (60%), previously treated TB (53%), new smear-positive pulmonary TB (PTB) (40%), new smear-negative/smear-unknown PTB (58%) and extra-pulmonary TB (58%). Conclusion: Significant declines in TB CNRs were observed during ART scale-up, especially for smear-negative PTB and extra-pulmonary TB. These encouraging national trends support the continued scale-up of ART for people living with HIV as a way of tackling the twin epidemics of HIV/acquired immune-deficiency syndrome and TB in Zimbabwe

Routine implementation of isoniazid preventive therapy in HIV-infected patients in seven pilot sites in Zimbabwe.

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