Genital ulcers in Kenya : clinical and laboratory study

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Outcomes of community-based differentiated models of multi-month dispensing of antiretroviral medication among stable HIV-infected patients in Lesotho : a cluster randomised non-inferiority trial protocol

CITATION: Faturiyele, I. O., et al. 2018. Outcomes of community-based differentiated models of multi-month dispensing of antiretroviral medication among stable HIV-infected patients in Lesotho : a cluster randomised non-inferiority trial protocol. BMC Public Health, 18:1069, doi:10.1186/s12889-018-5961-0.The original publication is available at https://bmcpublichealth.biomedcentral.comBackground: Current World Health Organization (WHO) guidelines recommend early initiation of HIV positive patients on antiretroviral therapy (ART) irrespective of their clinical or immunological status known as the test and start approach. Lesotho, like many other countries introduced this approach in 2016 as a strategy to reach epidemic control. There will be rapidly growing number of HIV-infected individuals initiating treatment leading to practical challenges on health systems such as congestion, long waiting time for patients and limited time to provide quality services to patients. Differentiated models of ART delivery is an innovative solution that helps to increase access to care, while reducing the burden on existing health systems. Ultimately this model will help to achieve retention and viral suppression. We describe a demonstration study designed to evaluate a community-based differentiated model of multi-month dispensing (MMD) approaches of ART among stable HIV patients in Lesotho. Methods: This study will be a three-arm cluster randomised trial, which will enrol approximately 5760 HIV-infected individuals who are stable on ART in 30 selected clusters. The clusters, which are health facilities, will be randomly assigned into the following differentiated model of care arms: (i) 3 monthly ART supply at facilities (Control), (ii) 3 monthly ART supply through community ART groups (CAGs) and (iii) 6 monthly ART supply through community ART distribution points (CAD). Primary outcomes are retention in care and virologic suppression, and secondary outcomes include feasibility and cost effectiveness. Discussion: Important lessons will be learnt to allow for improved implementation of such demonstration projects, including various needs for reliable supply of medication, access to quality clinical data including access to viral loads (VLs) results, frameworks to support lay worker cadre, involvement of community stakeholders, and reliable data systems including records of key indicators. MMD will have positive implications including improved retention, virologic suppression, convenience and access to medication.https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-5961-0Publisher's versio

Estimating the cost of diagnosing HIV at birth in Lesotho.

BACKGROUND:Infants with HIV infection, particularly those infected in utero, who do not receive antiretroviral therapy (ART) have high mortality in the first year of life. Virologic diagnostic testing is recommended by the World Health Organization between ages 4 and 6 weeks after birth. However, adding very early infant diagnosis (VEID) testing at birth has been suggested to enable earlier diagnosis and rapid treatment of in utero infection. We assessed the costs of adding VEID to the standard 6-week testing in Lesotho where coverage of PMTCT services is nearly universal. METHODS:Retrospective cost data were collected at eight health-care facilities in three districts participating in an observational prospective study that included birth testing as well as at the National Reference Laboratory in Lesotho, to investigate the cost-per-infection identified. Extrapolating to the national level, it was possible to estimate the impact of VEID on the identification of HIV-infected infants. RESULTS:The unit cost-per-VEID test in Lesotho in 2015 was $40.50. Major cost drivers were supplies/commodities (46$8,060 per HIV-positive infant identified. Sensitivity analysis showed costs based on Lesotho costing data ranged from $810 to$16,194 per-infected child with varying in utero infection rates from 5% and 0.25%, respectively. With 11,157 HIV-exposed births nationally from pregnant women on PMTCT, 66.3% VEID coverage, and 0.5% in utero infection, 37 infants infected with HIV could have been identified at birth in 2015 and 8 early infant deaths potentially averted with immediate ART compared with waiting for 6-week testing. CONCLUSION:If Lesotho costing data from this pilot study were applied to different epidemic circumstances, the cost-per-infected child identified by adding VEID birth testing to standard 6-week testing was lowest when in utero infection rates were high (when HIV prevalence is high and PMTCT coverage is low)