Diagnostic accuracy of the Xpert CT/NG and OSOM Trichomonas Rapid assays for point-of-care STI testing among young women in South Africa: a cross-sectional study.

CAPRISA, 2019.Abstract available in PDF

Managing invasions at the cost of native habitat? An experimental test of the impact of fire on the invasion of Chromolaena odorata in a South African savanna

AgriwetenskappeBewaringsekologie en EntomologiePlease help us populate SUNScholar with the post print version of this article. It can be e-mailed to: [email protected]

Acceptability of point-of-care viral load testing to facilitate differentiated care: a qualitative assessment of people living with HIV and nurses in South Africa

Background: Providing viral load (VL) results to people living with HIV (PLHIV) on antiretroviral therapy (ART) remains a challenge in low and middle-income countries. Point-of-care (POC) VL testing could improve ART monitoring and the quality and efficiency of differentiated models of HIV care. We assessed the acceptability of POC VL testing within a differentiated care model that involved task-shifting from professional nurses to less highly-trained enrolled nurses, and an option of collecting treatment from a community-based ART delivery programme. Methods: We undertook a qualitative sub-study amongst clients on ART and nurses within the STREAM study, a randomized controlled trial of POC VL testing and task-shifting in Durban, South Africa. Between March and August 2018, we conducted 33 semi-structured interviews with clients, professional and enrolled nurses and 4 focus group discussions with clients. Interviews and focus groups were audio recorded, transcribed, translated and thematically analysed. Results: Amongst 55 clients on ART (median age 31, 56% women) and 8 nurses (median age 39, 75% women), POC VL testing and task-shifting to enrolled nurses was acceptable. Both clients and providers reported that POC VL testing yielded practical benefits for PLHIV by reducing the number of clinic visits, saving time, travel costs and days off work. Receiving same-day POC VL results encouraged adherence amongst clients, by enabling them to see immediately if they were ‘good’ or ‘bad’ adherers and enabled quick referrals to a community-based ART delivery programme for those with viral suppression. However, there was some concern regarding the impact of POC VL testing on clinic flows when implemented in busy public-sector clinics. Regarding task-shifting, nurses felt that, with extra training, enrolled nurses could help decongest healthcare facilities by quickly issuing ART to stable clients. Clients could not easily distinguish enrolled nurses from professional nurses, instead they highlighted the importance of friendliness, respect and good communication between clients and nurses. Conclusions: POC VL testing combined with task-shifting was acceptable to clients and healthcare providers. Implementation of POC VL testing and task shifting within differentiated care models may help achieve international treatment targets.</p

HIV treatment outcomes among people with initiation CD4 counts >500 cells/µL after implementation of Treat All in South African public clinics: a retrospective cohort study

Introduction:&nbsp;The World Health Organisation recommends to&nbsp;Treat All&nbsp;people with HIV, irrespective of CD4 count. However, people with CD4 counts &gt;500&nbsp;cells/&micro;L may be asymptomatic and therefore less motivated to adhere to antiretroviral therapy (ART). We aimed to assess whether people initiated with CD4 counts &gt;500&nbsp;cells/&micro;L had worse treatment outcomes compared to those initiated at lower CD4 counts. Methods:&nbsp;We performed a retrospective cohort study among non‐pregnant adults initiating ART at eight public clinics in South Africa between September 2016, when&nbsp;Treat All&nbsp;was implemented, and August 2017. We assessed whether initiation CD4 count &gt;500&nbsp;cells/&micro;L was associated with the outcomes of attrition (death, lost to follow‐up or treatment interruption &gt;180&nbsp;days), and viraemia &gt;1000&nbsp;copies/mL, by twelve months using Cox proportional hazards and Poisson regression models. Results and discussion:&nbsp;Among 4952 patients initiating ART, the median age was 32.4&nbsp;years (interquartile range (IQR) 27.2 to 39.7), 58.9% were women and 30.3% had an initiation CD4 count &gt;500&nbsp;cells/&micro;L. After twelve months, 3382 (68.3%) were retained in care, 303 (6.1%) had transferred to another clinic, 1010 (20.4%) were lost to follow‐up, 232 (4.7%) had a treatment interruption &gt;180&nbsp;days and 25 (0.5%) were known to have died. Overall, 1267 experienced attrition at a median time of 91&nbsp;days (IQR 23 to 213), with 302 of these (23.8%) experiencing attrition immediately after their ART initiation visit. Among those in care at twelve months with viral load results, 4.6% had viraemia. In multivariable analysis, the hazard of attrition was similar between patients newly eligible for ART with CD4 counts &gt;500&nbsp;cells/&micro;L compared to those with CD4 &le;500&nbsp;cells/&micro;L (adjusted hazard ratio 1.03, 95% confidence interval (CI) 0.90 to 1.17). The risk of viraemia was lower among patients with CD4 counts &gt;500&nbsp;cells/&micro;L compared to those with CD4 &le;500&nbsp;cells/&micro;L (adjusted risk ratio 0.58, 95% CI 0.37 to 0.92). Conclusions:&nbsp;After implementation of&nbsp;Treat All&nbsp;in South African public clinics, we found that patients newly eligible for ART with initiation CD4 counts &gt;500&nbsp;cells/&micro;L had comparable or better outcomes compared to those with lower CD4 counts. These finding support ongoing implementation of&nbsp;Treat All&nbsp;in our setting.</p

Differentiated service delivery for people using second-line antiretroviral therapy: clinical outcomes from a retrospective cohort study in KwaZulu-Natal, South Africa

Introduction Evidence is needed to guide the inclusion of broader groups of people living with HIV (PLHIV) in differentiated service delivery (DSD) programmes. We assessed treatment outcomes among PLHIV on second-line regimens in a community antiretroviral therapy (ART) delivery programme, compared to those who remained at clinics. Methods Using data from 61 public clinics, we did a retrospective cohort study among PLHIV receiving second-line ART following rollout of the Centralized Chronic Medicines Dispensing and Distribution (CCMDD) programme in KwaZulu-Natal, South Africa. We included PLHIV from the timepoint when they were first eligible, though not necessarily referred, for community ART within CCMDD and followed them for 18 months. We used multivariable logistic regression to compare 12-month attrition and viraemia between clients referred for community ART and those remaining in clinic care. Results Among 209,744 PLHIV aged ≥ 18 years who collected ART between October 2016 and December 2018, 7511 (3.6%) received second-line ART. Of these, 2575 (34.3%) were eligible for community ART. The median age was 39.0 years (interquartile range 34.0–45.0) and 1670 (64.9%) were women. Five hundred and eighty-four (22.7%) were referred for community ART within 6 months of meeting eligibility criteria. Overall, 4.5% [95% confidence interval (CI) 3.0–6.6%] in community ART and 4.4% (95% CI 3.5–5.4%) in clinic care experienced attrition at 12 months post eligibility for community ART. Two thousand one hundred and thirty-eight (83.0%) had a viral load recorded 6–18 months after becoming eligible, and of these, 10.3% (95% CI 7.7–13.3%) in community ART and 11.3% (95% CI 9.8–12.9%) in clinic care had viraemia > 200 copies/ml. In separate regressions adjusted for age, gender, district, time on second-line ART, nucleoside reverse transcriptase inhibitor backbone and year of eligibility, no differences in the odds of attrition [adjusted odds ratio (aOR) 1.02, 95% CI 0.71–1.47] or viraemia (aOR 0.91, 95% CI 0.64–1.29) were observed between those in community ART and those remaining in clinic care. Conclusions We found good outcomes among PLHIV who were stable on second-line regimens and referred for community ART. Efforts to expand DSD access among this group should be prioritized

Protocol for a randomised feasibility study of Point-Of-care HIV viral load testing to Enhance Re-suppression in South Africa: the POwER study

Introduction Access to HIV viral load testing remains difficult for many people on antiretroviral therapy (ART) in low-income and middle-income countries. Weak laboratory and clinic systems often delay the detection and management of viraemia, which can lead to morbidity, drug resistance and HIV transmission. Point-of-care testing could overcome these challenges. We aim to assess whether it is feasible to conduct a randomised trial of point-of-care viral load testing to manage viraemia. Methods and analysis We will conduct an open-label, single-site, individually randomised, feasibility study of Point-Of-care HIV viral load testing to Enhance Re-suppression, in Durban, South Africa. We will enrol approximately 100 people living with HIV who are aged ≥18 years, receiving first-line ART but with recent viraemia ≥1000 copies/mL, and randomise them 1:1 to receive point-of-care viral load or standard laboratory viral load monitoring, after 12 weeks. All participants will continue to receive care from public sector healthcare workers following South African HIV management guidelines. Participants with persistent viraemia ≥1000 copies/mL will be considered for switching to second-line ART. We will compare the proportion in each study arm who achieve the primary outcome of viral suppression <50 copies/mL at 24 weeks after enrolment. Additional outcomes include proportions retained in the study, proportions with HIV drug resistance, time to viral load results and time to switching to second-line ART. We will assess implementation of point-of-care viral load testing using process evaluation data, and through interviews and focus groups with healthcare workers. Ethics and dissemination University of Oxford Tropical Research Ethics Committee and the Biomedical Research Ethics Committee of the University of KwaZulu-Natal have approved the study. We will present results to stakeholders, and through conferences and open-access, peer-reviewed journals. Trial registration number PACTR202001785886049

Protocol for a randomised controlled implementation trial of point-of-care viral load testing and task shifting: the Simplifying HIV TREAtment and Monitoring (STREAM) study

Introduction Achieving the Joint United Nations Programme on HIV and AIDS 90-90-90 targets requires models of HIV care that expand antiretroviral therapy (ART) coverage without overburdening health systems. Point-of-care (POC) viral load (VL) testing has the potential to efficiently monitor ART treatment, while enrolled nurses may be able to provide safe and cost-effective chronic care for stable patients with HIV. This study aims to demonstrate whether POC VL testing combined with task shifting to enrolled nurses is non-inferior and costeffective compared with laboratory-based VL monitoring and standard HIV care. Methods and analysis The STREAM (Simplifying HIV TREAtment and Monitoring) study is an open-label, noninferiority, randomised controlled implementation trial. HIV-positive adults, clinically stable at 6 months after ART initiation, will be recruited in a large urban clinic in South Africa. Approximately 396 participants will be randomised 1:1 to receive POC HIV VL monitoring and potential task shifting to enrolled nurses, versus laboratory VL monitoring and standard South African HIV care. Initial clinic follow-up will be 2-monthly in both arms, with VL testing at enrolment, 6 months and 12 months. At 6 months (1 year after ART initiation), stable participants in both arms will qualify for a differentiated care model involving decentralised ART pickup at community-based pharmacies. The primary outcome is retention in care and virological suppression at 12 months from enrolment. Secondary outcomes include time to appropriate entry into the decentralised ART delivery programme, costs per virologically suppressed patient and cost-effectiveness of the intervention compared with standard care. Findings will inform the scale up of VL testing and differentiated care in HIV-endemic resource-limited settings. Ethics and dissemination Ethical approval has been granted by the University of KwaZulu-Natal Biomedical Research Ethics Committee (BFC296/16) and University of Washington Institutional Review Board (STUDY00001466). Results will be presented at international conferences and published in academic peer-reviewed journals.</p