RESUMEN
The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) supports country programs in identifying persons living with HIV infection (PLHIV), providing life-saving treatment, and reducing the spread of HIV in countries around the world (1,2). CDC used Monitoring, Evaluation, and Reporting (MER) data* to assess the extent to which COVID-19 mitigation strategies affected HIV service delivery across the HIV care continuum globally during the first year of the COVID-19 pandemic. Indicators included the number of reported HIV-positive test results, the number of PLHIV who were receiving antiretroviral therapy (ART), and the rates of HIV viral load suppression. Percent change in performance was assessed between countries during the first 3 months of 2020, before COVID-19 mitigation efforts began (January-March 2020), and the last 3 months of the calendar year (October-December 2020). Data were reviewed for all 41 countries to assess total and country-level percent change for each indicator. Then, qualitative data were reviewed among countries in the upper quartile to assess specific strategies that contributed to programmatic gains. Overall, positive percent change was observed in PEPFAR-supported countries in HIV treatment (5%) and viral load suppression (2%) during 2020. Countries reporting the highest gains across the HIV care continuum during 2020 attributed successes to reducing or streamlining facility attendance through strategies such as enhancing index testing (offering of testing to the biologic children and partners of PLHIV)§ and community- and home-based testing; treatment delivery approaches; and improvements in data use through monitoring activities, systems, and data quality checks. Countries that reported program improvements during the first year of the COVID-19 pandemic offer important information about how lifesaving HIV treatment might be provided during a global public health crisis.
Asunto(s)
COVID-19 , Infecciones por VIH/tratamiento farmacológico , Cooperación Internacional , Antirretrovirales/uso terapéutico , Salud Global , Programas de Gobierno , Infecciones por VIH/diagnóstico , Humanos , Estados UnidosRESUMEN
BACKGROUND: In 2014, the Joint United Nations Program on HIV/AIDS (UNAIDS) issued treatment goals for human immunodeficiency virus (HIV). The 90-90-90 target specifies that by 2020, 90% of individuals living with HIV will know their HIV status, 90% of people with diagnosed HIV infection will receive antiretroviral treatment (ART), and 90% of those taking ART will be virally suppressed. Consistent methods and routine reporting in the public domain will be necessary for tracking progress towards the 90-90-90 target. METHODS AND FINDINGS: For the period 2010-2016, we searched PubMed, UNAIDS country progress reports, World Health Organization (WHO), UNAIDS reports, national surveillance and program reports, United States President's Emergency Plan for AIDS Relief (PEPFAR) Country Operational Plans, and conference presentations and/or abstracts for the latest available national HIV care continuum in the public domain. Continua of care included the number and proportion of people living with HIV (PLHIV) who are diagnosed, on ART, and virally suppressed out of the estimated number of PLHIV. We ranked the described methods for indicators to derive high-, medium-, and low-quality continuum. For 2010-2016, we identified 53 national care continua with viral suppression estimates representing 19.7 million (54%) of the 2015 global estimate of PLHIV. Of the 53, 6 (with 2% of global burden) were high quality, using standard surveillance methods to derive an overall denominator and program data from national cohorts for estimating steps in the continuum. Only nine countries in sub-Saharan Africa had care continua with viral suppression estimates. Of the 53 countries, the average proportion of the aggregate of PLHIV from all countries on ART was 48%, and the proportion of PLHIV who were virally suppressed was 40%. Seven countries (Sweden, Cambodia, United Kingdom, Switzerland, Denmark, Rwanda, and Namibia) were within 12% and 10% of achieving the 90-90-90 target for "on ART" and for "viral suppression," respectively. The limitations to consider when interpreting the results include significant variation in methods used to determine national continua and the possibility that complete continua were not available through our comprehensive search of the public domain. CONCLUSIONS: Relatively few complete national continua of care are available in the public domain, and there is considerable variation in the methods for determining progress towards the 90-90-90 target. Despite bearing the highest HIV burden, national care continua from sub-Saharan Africa were less likely to be in the public domain. A standardized monitoring and evaluation approach could improve the use of scarce resources to achieve 90-90-90 through improved transparency, accountability, and efficiency.
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Fármacos Anti-VIH/uso terapéutico , Infecciones por VIH/epidemiología , Infecciones por VIH/terapia , Planificación de Atención al Paciente , Vigilancia en Salud Pública/métodos , Bases de Datos Factuales/estadística & datos numéricos , Erradicación de la Enfermedad/métodos , Erradicación de la Enfermedad/estadística & datos numéricos , VIH-1 , Humanos , Planificación de Atención al Paciente/estadística & datos numéricos , Sector Público , Naciones Unidas/estadística & datos numéricos , Organización Mundial de la SaludRESUMEN
Population size estimation of key populations at risk of HIV is essential to every national response. We implemented population size estimation of men who have sex with men (MSM) in Ghana using a three-stage approach within the 2011 Ghana Men's Study: during the study's formative assessment, the larger integrated bio-behavioral surveillance (IBBS) survey; and during the stakeholder meeting. We used six methods in combination within the three-stage approach (literature review, mapping with census, unique object multiplier, service multiplier, wisdom of the crowd, and modified Delphi) to generate size estimates from 16 locations (4 IBBS survey sites and 12 other locations) and used the estimates from the 16 sites to extrapolate the total MSM population size of Ghana. We estimated the number of MSM in Ghana to be 30,579 with a plausible range of 21,645-34,470. The overall estimate suggests that the prevalence of MSM in Ghana is 0.48 % of the adult male population. Lessons learned are shared to inform and improve applications of the methods in future studies.
Asunto(s)
Infecciones por VIH/prevención & control , Homosexualidad Masculina/estadística & datos numéricos , Vigilancia de la Población/métodos , Conducta Sexual/estadística & datos numéricos , Adulto , Recolección de Datos , Ghana/epidemiología , Infecciones por VIH/epidemiología , Humanos , Masculino , Densidad de Población , Prevalencia , Factores de Riesgo , Poblaciones VulnerablesRESUMEN
The epidemic of Ebola virus disease (Ebola) in West Africa that began in March 2014 has caused approximately 13,200 suspected, probable, and confirmed cases, including approximately 6,500 in Liberia. About 50% of Liberia's reported cases have been in Montserrado County (population 1.5 million), the most populous county, which contains the capital city, Monrovia. To examine the course of the Ebola epidemic in Montserrado County, data on Ebola treatment unit (ETU) admissions, laboratory testing of patient blood samples, and collection of dead bodies were analyzed. Each of the three data sources indicated consistent declines of 53%-73% following a peak incidence in mid-September. The declines in ETU admissions, percentage of patients with reverse transcription-polymerase chain reaction (RT-PCR) test results positive for Ebola, and dead bodies are the first evidence of reduction in disease after implementation of multiple prevention and response measures. The possible contributions of these interventions to the decline is not yet fully understood or corroborated. A reduction in cases suggests some progress; however, eliminating Ebola transmission is the critical goal and will require greatly intensified efforts for complete, high-quality surveillance to direct and drive the rapid intervention, tracking, and response efforts that remain essential.
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Ebolavirus/aislamiento & purificación , Epidemias/prevención & control , Fiebre Hemorrágica Ebola/prevención & control , Admisión del Paciente/estadística & datos numéricos , Fiebre Hemorrágica Ebola/epidemiología , Humanos , Liberia/epidemiologíaRESUMEN
BACKGROUND: Antiretroviral therapy (ART) is being administered in developing nations at unprecedented numbers following the World Health Organization's (WHO) development of standardized first-line drug regimens. To ensure continued efficacy of these drug regimens, WHO recommends monitoring virological responses and development of human immunodeficiency virus (HIV) drug resistance (HIVDR) in HIV-infected patients in a prospective cohort. The current study compared dried fluid spot specimens with the reference standard plasma specimens as a practical tool for viral load (VL) and HIVDR genotyping in resource-limited settings. METHODS: Dried blood spot (DBS), dried plasma spot (DPS), and plasma specimens were collected from 173 -patients receiving ART at 2 hospital sites in Abuja, Nigeria. HIV-1 VL analysis was performed using NucliSENS EasyQ HIV-1 v1.1 RUO test kits. Genotyping of the HIV-1 pol gene was performed using a broadly sensitive in-house assay. RESULTS: Direct comparison of VL levels showed that DBS specimens, and not DPS specimens, gave results comparable to those of plasma specimens (P = .0619 and .0007, respectively); however, both DBS and DPS specimens had excellent correlation with plasma specimens in predicting virological failure (VL, ≥1000 copies/mL) in patients (κ = 0.78 and 0.83, respectively). Of the 18 specimens with a plasma VL ≥1000 copies/mL, HIVDR genotyping rates were 100% in DBS and 38.9% in DPS specimens, and DBS specimens identified 61 of 65 HIVDR mutations (93.8%) identified in plasma specimens. CONCLUSIONS: Our results indicate that DBS specimens could be used for surveys to monitor HIVDR prevention failure in resource-limited settings.
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Sangre/virología , Desecación , Infecciones por VIH/virología , VIH-1/aislamiento & purificación , Pruebas de Sensibilidad Microbiana/métodos , Manejo de Especímenes/métodos , Carga Viral/métodos , Fármacos Anti-VIH/administración & dosificación , Terapia Antirretroviral Altamente Activa , Monitoreo de Drogas/métodos , Infecciones por VIH/tratamiento farmacológico , Humanos , NigeriaRESUMEN
This report describes a pilot study, conducted in Nigeria, of the World Health Organization protocol for monitoring human immunodeficiency virus (HIV) drug resistance (HIVDR) and associated program factors among patients receiving first-line antiretroviral therapy (ART). In 2008, 283 HIV-infected patients starting ART were consecutively enrolled at 2 ART clinics in Abuja. Twelve months after ART initiation, 62% were alive and on first-line ART, 3% had died, 1% had transferred out of the program, and 34% were lost to follow-up. Among patients on first-line ART at 12 months, 90% had viral suppression. However, in view of the high loss to follow-up rate (34%), strategies for patient retention and tracking are critical to minimize possible HIVDR and optimize treatment outcomes.
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Fármacos Anti-VIH/farmacología , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/virología , Adulto , Instituciones de Atención Ambulatoria , Fármacos Anti-VIH/uso terapéutico , Farmacorresistencia Viral , Femenino , Estudios de Seguimiento , VIH/efectos de los fármacos , VIH/genética , Infecciones por VIH/epidemiología , Humanos , Masculino , Nigeria/epidemiología , Resultado del Tratamiento , Carga Viral/estadística & datos numéricos , Organización Mundial de la SaludRESUMEN
In 2004, Malawi began scaling up its national antiretroviral therapy (ART) program. Because of limited treatment options, population-level surveillance of acquired human immunodeficiency virus drug resistance (HIVDR) is critical to ensuring long-term treatment success. The World Health Organization target for clinic-level HIVDR prevention at 12 months after ART initiation is ≥ 70%. In 2007, viral load and HIVDR genotyping was performed in a retrospective cohort of 596 patients at 4 ART clinics. Overall, HIVDR prevention (using viral load ≤ 400 copies/mL) was 72% (95% confidence interval [CI], 67%-77%; range by site, 60%-83%) and detected HIVDR was 3.4% (95% CI, 1.8%-5.8%; range by site, 2.5%-4.7%). Results demonstrate virological suppression and HIVDR consistent with previous reports from sub-Saharan Africa. High rates of attrition because of loss to follow-up were noted and merit attention.
Asunto(s)
Antirretrovirales/farmacología , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/epidemiología , Adulto , Antirretrovirales/uso terapéutico , Farmacorresistencia Viral , Femenino , VIH/efectos de los fármacos , VIH/genética , Infecciones por VIH/virología , Humanos , Malaui/epidemiología , Masculino , Persona de Mediana Edad , Vigilancia de la Población , Estudios Retrospectivos , Resultado del Tratamiento , Carga Viral , Organización Mundial de la SaludRESUMEN
Since 2004, the Malawi antiretroviral treatment (ART) program has provided a public health-focused system based on World Health Organization clinical staging, standardized first-line ART regimens, limited laboratory monitoring, and no patient-level monitoring of human immunodeficiency virus drug resistance (HIVDR). The Malawi Ministry of Health conducts periodic evaluations of HIVDR development in prospective cohorts at sentinel clinics. We evaluated viral load suppression, HIVDR, and factors associated with HIVDR in 4 ART sites at 12-15 months after ART initiation. More than 70% of patients initiating ART had viral suppression at 12 months. HIVDR prevalence (6.1%) after 12 months of ART was low and largely associated with baseline HIVDR. Better follow-up, removal of barriers to on-time drug pickups, and adherence education for patients 16-24 years of age may further prevent HIVDR.
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Antirretrovirales/uso terapéutico , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/epidemiología , Adolescente , Adulto , Antirretrovirales/farmacología , Farmacorresistencia Viral , Femenino , VIH/efectos de los fármacos , VIH/genética , Infecciones por VIH/virología , Humanos , Malaui/epidemiología , Masculino , Cumplimiento de la Medicación , Programas Nacionales de Salud , Prevalencia , Estudios Prospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: The potential disruption in antiretroviral therapy (ART) services in Africa at the start of the COVID-19 pandemic raised concern for increased morbidity and mortality among people living with HIV (PLHIV). We describe HIV treatment trends before and during the pandemic and interventions implemented to mitigate COVID-19 impact among countries supported by the US Centers for Disease Control and Prevention (CDC) through the President's Emergency Plan for AIDS Relief (PEPFAR). METHODS: We analysed quantitative and qualitative data reported by 10,387 PEPFAR-CDC-supported ART sites in 19 African countries between October 2019 and March 2021. Trends in PLHIV on ART, new ART initiations and treatment interruptions were assessed. Viral load coverage (testing of eligible PLHIV) and viral suppression were calculated at select time points. Qualitative data were analysed to summarize facility- and community-based interventions implemented to mitigate COVID-19. RESULTS: The total number of PLHIV on ART increased quarterly from October 2019 (n = 7,540,592) to March 2021 (n = 8,513,572). The adult population (≥15 years) on ART increased by 14.0% (7,005,959-7,983,793), while the paediatric population (<15 years) on ART declined by 2.6% (333,178-324,441). However, the number of new ART initiations dropped between March 2020 and June 2020 by 23.4% for adults and 26.1% for children, with more rapid recovery in adults than children from September 2020 onwards. Viral load coverage increased slightly from April 2020 to March 2021 (75-78%) and viral load suppression increased from October 2019 to March 2021 (91-94%) among adults and children combined. The most reported interventions included multi-month dispensing (MMD) of ART, community service delivery expansion, and technology and virtual platforms use for client engagement and site-level monitoring. MMD of ≥3 months increased from 52% in October 2019 to 78% of PLHIV ≥ age 15 on ART in March 2021. CONCLUSIONS: With an overall increase in the number of people on ART, HIV programmes proved to be resilient, mitigating the impact of COVID-19. However, the decline in the number of children on ART warrants urgent investigation and interventions to prevent further losses experienced during the COVID-19 pandemic and future public health emergencies.
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COVID-19 , Infecciones por VIH , Adulto , Niño , Humanos , Adolescente , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/epidemiología , Infecciones por VIH/prevención & control , COVID-19/prevención & control , Pandemias/prevención & control , Antirretrovirales/uso terapéutico , África/epidemiologíaRESUMEN
As antiretroviral therapy (ART) is scaled up in resource-limited countries, surveillance for HIV drug resistance (DR) is vital to ensure sustained effectiveness of first-line ART. We have developed and applied a broadly sensitive dried-blood-spot (DBS)-based genotyping assay for surveillance of HIV-1 DR in international settings. In 2005 and 2006, 171 DBS samples were collected under field conditions from newly diagnosed HIV-1-infected individuals from Malawi (n = 58), Tanzania (n = 60), and China (n =53). In addition, 30 DBS and 40 plasma specimens collected from ART patients in China and Cameroon, respectively, were also tested. Of the 171 DBS analyzed at the protease and RT regions, 149 (87.1%) could be genotyped, including 49 (81.7%) from Tanzania, 47 (88.7%) from China, and 53 (91.4%) from Malawi. Among the 70 ART patient samples analyzed, 100% (30/30) of the Chinese DBS and 90% (36/40) of the Cameroonian plasma specimens were genotyped, including 8 samples with a viral load of <400 copies/ml. The results of phylogenetic analyses indicated that the subtype, circulating recombinant form (CRF), and unique recombinant form (URF) distribution was as follows: 73 strains were subtype C (34%), 37 were subtype B (17.2%), 24 each were CRF01_AE or CRF02_AG (11.2% each), 22 were subtype A1 (10.2%), and 9 were unclassifiable (UC) (4.2%). The remaining samples were minor strains comprised of 6 that were CRF07_BC (2.8%), 5 that were CRF10_CD (2.3%), 3 each that were URF_A1C and CRF08_BC (1.4%), 2 each that were G, URF_BC, and URF_D/UC (0.9%), and 1 each that were subtype F1, subtype F2, and URF_A1D (0.5%). Our results indicate that this broadly sensitive genotyping assay can be used to genotype DBS collected from areas with diverse HIV-1 group M subtypes and CRFs. Thus, the assay is likely to become a useful screening tool in the global resistance surveillance and monitoring of HIV-1 where multiple subtypes and CRFs are found.
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Sangre/virología , Desecación , Infecciones por VIH/virología , VIH-1/efectos de los fármacos , Manejo de Especímenes/métodos , Camerún , China , Genotipo , VIH-1/clasificación , VIH-1/genética , VIH-1/aislamiento & purificación , Humanos , Malaui , Pruebas de Sensibilidad Microbiana/métodos , Datos de Secuencia Molecular , Filogenia , Análisis de Secuencia de ADN , TanzaníaRESUMEN
BACKGROUND: Public health triangulation is a process for reviewing, synthesising and interpreting secondary data from multiple sources that bear on the same question to make public health decisions. It can be used to understand the dynamics of HIV transmission and to measure the impact of public health programs. While traditional intervention research and meta-analysis would be ideal sources of information for public health decision making, they are infrequently available, and often decisions can be based only on surveillance and survey data. METHODS: The process involves examination of a wide variety of data sources and both biological, behavioral and program data and seeks input from stakeholders to formulate meaningful public health questions. Finally and most importantly, it uses the results to inform public health decision-making. There are 12 discrete steps in the triangulation process, which included identification and assessment of key questions, identification of data sources, refining questions, gathering data and reports, assessing the quality of those data and reports, formulating hypotheses to explain trends in the data, corroborating or refining working hypotheses, drawing conclusions, communicating results and recommendations and taking public health action. RESULTS: Triangulation can be limited by the quality of the original data, the potentials for ecological fallacy and "data dredging" and reproducibility of results. CONCLUSIONS: Nonetheless, we believe that public health triangulation allows for the interpretation of data sets that cannot be analyzed using meta-analysis and can be a helpful adjunct to surveillance, to formal public health intervention research and to monitoring and evaluation, which in turn lead to improved national strategic planning and resource allocation.
Asunto(s)
Brotes de Enfermedades , Infecciones por VIH/epidemiología , Vigilancia de la Población/métodos , Salud Pública , Estadística como Asunto/métodos , HumanosRESUMEN
BACKGROUND: Malawi started rapid scale-up of antiretroviral therapy (ART) in 2004 and by December 2006 had initiated 81,821 patients on treatment in the public sector. Owing to capacity constraints, standard patient care, treatment initiation and follow up are based on World Health Organization (WHO) clinical staging and do not provide laboratory monitoring to assess treatment failure. METHODS: To monitor possible transmission of HIV drug resistance (HIVDR) an HIVDR threshold surveillance based on the WHO guidelines was implemented in Malawi. Anonymous dried blood specimens were collected from routine blood samples of HIV-positive women attending primagravida antenatal care and aged <25 years. RESULTS: Of 59 samples tested, 54 were successfully amplified indicating good specimen quality and processing. The WHO protocol algorithm to classify the prevalence of transmitted drug resistance in the site sample only required the genotyping of 34 of the samples. None of the major drug resistance mutations on the WHO surveillance list were found in these 34 specimens. CONCLUSIONS: Malawi HIVDR transmission can be classified as <5% for all relevant drugs and drug classes in this population. On the basis of the very positive experience of this survey, an expanded HIVDR surveillance system will be implemented to inform the ART program as it continues to scale-up.
Asunto(s)
Antirretrovirales/uso terapéutico , Farmacorresistencia Viral/genética , Infecciones por VIH/transmisión , VIH-1/genética , VIH-2/genética , Programas Nacionales de Salud , Atención Prenatal , Organización Mundial de la Salud , Adulto , Femenino , Genotipo , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/epidemiología , Infecciones por VIH/virología , Humanos , Malaui/epidemiología , Programas Nacionales de Salud/estadística & datos numéricos , Vigilancia de la Población , Atención Prenatal/estadística & datos numéricos , Evaluación de Programas y Proyectos de Salud , Resultado del TratamientoRESUMEN
PROBLEM: As national antiretroviral treatment (ART) programmes scale-up, it is essential that information is complete, timely and accurate for site monitoring and national planning. The accuracy and completeness of reports independently compiled by ART facilities, however, is often not known. APPROACH: This study assessed the quality of quarterly aggregate summary data for April to June 2006 compiled and reported by ART facilities ("site report") as compared to the "gold standard" facility summary data compiled independently by the Ministry of Health supervision team ("supervision report"). Completeness and accuracy of key case registration and outcome variables were compared. Data were considered inaccurate if variables from the site reports were missing or differed by more than 5% from the supervision reports. Additionally, we compared the national summaries obtained from the two data sources. LOCAL SETTING: Monitoring and evaluation of Malawi's national ART programme is based on WHO's recommended tools for ART monitoring. It includes one master card for each ART patient and one patient register at each ART facility. Each quarter, sites complete cumulative cohort analyses and teams from the Ministry of Health conduct supervisory visits to all public sector ART sites to ensure the quality of reported data. RELEVANT CHANGES: Most sites had complete case registration and outcome data; however many sites did not report accurate data for several critical data fields, including reason for starting, outcome and regimen. The national summary using the site reports resulted in a 12% undercount in the national total number of persons on first-line treatment. Several facility-level characteristics were associated with data quality. LESSONS LEARNED: While many sites are able to generate complete data summaries, the accuracy of facility reports is not yet adequate for national monitoring. The Ministry of Health and its partners should continue to identify and support interventions such as supportive supervision to build sites' capacity to maintain and compile quality data to ensure that accurate information is available for site monitoring and national planning.
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Antirretrovirales/administración & dosificación , Recolección de Datos/normas , Registros Médicos/normas , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/epidemiología , Humanos , Malaui/epidemiología , Proyectos de InvestigaciónRESUMEN
Malawi is scaling-up provision of free antiretroviral therapy (ART) in the public sector. In the fourth quarter of 2004 and the first quarter of 2005, 3261 and 4530 new patients, respectively, were started on ART. Of these patients, approximately 40% were male and 95% were adults aged > or =13 years. The age group data show that women who accessed ART were in general 10 years younger than men. Between 84% and 90% of patients were started on ART because of being clinically assessed as being in WHO stages III or IV, with the remainder started on ART owing to a low CD4 lymphocyte count. The number of tuberculosis (TB) patients started on ART was 351 (11% of ART patients) in the fourth quarter of 2004 and 702 (15% of ART patients, and 16% of registered TB patients) in the first quarter of 2005. Twenty-nine pregnant women were referred to ART from prevention of mother-to-child transmission programmes in the first quarter of 2005. Between 56% and 62% of patients were subsistence farmers, housewives or in business. Steady progress is being made with national scale-up, although more attention needs to be directed to children, pregnant women and patients with TB to improve their access to ART.
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Terapia Antirretroviral Altamente Activa/estadística & datos numéricos , Infecciones por VIH/tratamiento farmacológico , Aceptación de la Atención de Salud/estadística & datos numéricos , Adolescente , Adulto , Anciano , Niño , Preescolar , Atención a la Salud/estadística & datos numéricos , Femenino , Humanos , Lactante , Recién Nacido , Malaui , Masculino , Persona de Mediana Edad , Ocupaciones/estadística & datos numéricosRESUMEN
OBJECTIVE: To determine factors associated with HIV status unawareness and assess HIV prevention knowledge and condom use among people living with HIV/AIDS (PLHIV) in Mozambique. DESIGN: Cross-sectional household-based nationally representative AIDS Indicator Survey. METHODS: Analyses focused on HIV-infected adults and were weighted for the complex sampling design. We identified PLHIV who had never been tested for HIV or received their test results prior to this survey. Logistic regression was used to assess factors associated with HIV status unawareness. RESULTS: Of persons with positive HIV test results (Nâ=â1182), 61% (95% confidence interval [CI] 57-65%) were unaware of their serostatus. Men had twice the odds of being unaware of their serostatus compared with women [adjusted odds ratio (aOR) 2.05, CI 1.40-2.98]. PLHIV in the poorest wealth quintile were most likely to be unaware of their serostatus (aOR 3.15, CI 1.09-9.12) compared to those in the middle wealth quintile. Most PLHIV (83%, CI 79-87%) reported not using a condom during their last sexual intercourse, and PLHIV who reported not using a condom during their last sexual intercourse were more likely to be unaware of their serostatus (aOR 2.32, CI 1.57-3.43) than those who used a condom. CONCLUSIONS: Knowledge of HIV-positive status is associated with more frequent condom use in Mozambique. However, most HIV-infected persons are unaware of their serostatus, with men and persons in the poorest wealth quintile being more likely to be unaware. These findings support calls for expanded HIV testing, especially among groups less likely to be aware of their HIV status and key populations at higher risk for infection.
Asunto(s)
Condones , Infecciones por VIH/psicología , Sexo Seguro/psicología , Adolescente , Adulto , Estudios Transversales , Femenino , Infecciones por VIH/prevención & control , Humanos , Masculino , Persona de Mediana Edad , Mozambique , Análisis Multivariante , Oportunidad Relativa , Factores Sexuales , Factores SocioeconómicosRESUMEN
BACKGROUND: Several studies support the need for effective interventions to reduce HIV transmission risk behaviors among people living with HIV/AIDS (PLWHAs). DESIGN: Cross-sectional nationally representative demographic health survey of Kenya (2003) and Malawi (2004-2005) that included HIV testing for consenting adults. METHODS: We analyzed demographic health survey data for awareness of HIV status and sexual behaviors of PLWHAs (Kenya: 412; Malawi: 664). The analysis was adjusted (weighted) for the design of the survey and the results are nationally representative. FINDINGS: Eighty-four percent of PLWHAs in Kenya and 86% in Malawi had sex in the past 12 months and in each country, 10% reported using condoms at last intercourse. Among sexually active PLWHAs, 86% in Kenya and 96% in Malawi reported their spouse or cohabiting partner as their most recent partner. In multivariate logistic regression models, married or cohabiting PLWHAs were significantly more likely to be sexually active and less likely to use condoms. Over 80% of PLWHAs were unaware of their HIV status. Of HIV-infected women, nearly three-quarters did not want more children either within the next 2 years or ever, but 32% in Kenya and 20% in Malawi were using contraception. INTERPRETATION: In 2003-2005, majority of PLWHAs in Kenya and Malawi were unaware of their HIV status and were sexually active, especially married or cohabiting PLWHAs. Of HIV-infected women not wanting more children, few used contraception. HIV testing should be expanded, prevention programs should target married or cohabiting couples and family planning services should be integrated with HIV services.
Asunto(s)
Infecciones por VIH/prevención & control , Conocimientos, Actitudes y Práctica en Salud , Asunción de Riesgos , Conducta Sexual , Adolescente , Adulto , Condones/estadística & datos numéricos , Conducta Anticonceptiva/estadística & datos numéricos , Anticonceptivos/administración & dosificación , Dispositivos Anticonceptivos/estadística & datos numéricos , Estudios Transversales , Femenino , Infecciones por VIH/diagnóstico , Infecciones por VIH/psicología , Infecciones por VIH/transmisión , Encuestas Epidemiológicas , Humanos , Kenia , Malaui , Masculino , Evaluación de Necesidades , Embarazo , Complicaciones Infecciosas del Embarazo/psicología , Factores Socioeconómicos , Adulto JovenRESUMEN
BACKGROUND: Approximately 1 million people are infected with HIV in Malawi, where AIDS is the leading cause of death in adults. By December 31, 2007, more than 141,000 patients were initiated on antiretroviral treatment (ART) by use of a public health approach to scale up HIV services. METHODS: We analyzed national quarterly and longitudinal cohort data from October 2004 to December 2006 to examine trends in characteristics of patients initiating ART, end-of-quarter clinical outcomes, and 6- and 12-month survival probability. FINDINGS: During a 27-month period, 72,666 patients were initiated on ART, of whom about two-thirds were women. The percentage of patients initiated on ART who were children and farmers increased from 5.5% to 9.0% and 23% to 32%, respectively (P < 0.001 for trends). Estimated survival probability ranged from 85% to 88% at 6 months and 81% to 84% at 12 months on ART. INTERPRETATION: In Malawi, a public health approach to ART increased treatment access and maintained high 6- and 12-month survival. Resource-limited countries scaling up ART programs may benefit from this approach of simplified clinical decision making, standardized ART regimens, nonphysician care, limited laboratory support, and centralized monitoring and evaluation.
Asunto(s)
Síndrome de Inmunodeficiencia Adquirida/tratamiento farmacológico , Fármacos Anti-VIH/uso terapéutico , Salud Pública , Síndrome de Inmunodeficiencia Adquirida/mortalidad , Adolescente , Adulto , Anciano , Femenino , Humanos , Malaui , Masculino , Persona de Mediana Edad , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: Monitoring and evaluation of national antiretroviral therapy (ART) programs is vital, but routine, standardized assessment of national ART patient monitoring systems has not been established. Malawi has undertaken an ambitious ART scale-up effort, with over 57,000 patients initiated on ART by June 2006. We assessed the national ART monitoring and evaluation system in Malawi to ensure that the response to the epidemic was being monitored efficiently and effectively, and that data collected were useful. METHODS: The evaluation, performed in August 2005, generally followed the Updated Guidelines for Evaluating Public Health Surveillance Systems (CDC) and Interim Patient Monitoring Guidelines for HIV Care and ART (WHO). Assessment was conducted with qualitative methods, including twelve ART site visits, with standardized key informant interviews with ART clinic coordinators, clinical staff, and data managers, at each site. Meetings were also held with key governmental stakeholders, including Ministry of Health and National AIDS Commission. RESULTS: The national monitoring and evaluation system devised by the Ministry of Health HIV/AIDS Unit is successful in achieving its objectives, and facilitates important aspects of the national response to HIV. Several basic changes in the data collection tools and system would facilitate more effective long-term assessment of the ART program and support improved patient care. As the number of ART sites and patients continues to expand, the current manual paper-based system may be overwhelmed. Identification and implementation of a feasible electronic data system that would maintain and improve data quality and the efficiency of data recording and reporting and enhance patient care is a priority. CONCLUSIONS: The assessment of ART monitoring and evaluation systems can optimize the effectiveness of national ART programs, and should be considered in other resource-constrained countries rapidly scaling up ART.
Asunto(s)
Antirretrovirales/uso terapéutico , Programas de Gobierno/métodos , Infecciones por VIH/tratamiento farmacológico , Actitud del Personal de Salud , Recolección de Datos/métodos , Infecciones por VIH/epidemiología , Humanos , Malaui/epidemiología , Registros Médicos , Vigilancia de la Población/métodos , Evaluación de Programas y Proyectos de Salud/métodos , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: To assess the human resources impact of Malawis rapidly growing antiretroviral therapy (ART) programme and balance this against the survival benefit of health-care workers who have accessed ART themselves. METHODS: We conducted a national cross-sectional survey of the human resource allocation in all public-sector health facilities providing ART in mid-2006. We also undertook a survival analysis of health-care workers who had accessed ART in public and private facilities by 30 June 2006, using data from the national ART monitoring and evaluation system. FINDINGS: By 30 June 2006, 59 581 patients had accessed ART from 95 public and 28 private facilities. The public sites provided ART services on 2.4 days per week on average, requiring 7% of the clinician workforce, 3% of the nursing workforce and 24% of the ward clerk workforce available at the facilities. We identified 1024 health-care workers in the national ART-patient cohort (2% of all ART patients). The probabilities for survival on ART at 6 months, 12 months and 18 months were 85%, 81% and 78%, respectively. An estimated 250 health-care workers lives were saved 12 months after ART initiation. Their combined work-time of more than 1000 staff-days per week was equivalent to the human resources required to provide ART at the national level. CONCLUSION: A large number of ART patients in Malawi are managed by a small proportion of the health-care workforce. Many health-care workers have accessed ART with good treatment outcomes. Currently, staffing required for ART balances against health-care workers lives saved through treatment, although this may change in the future.
Asunto(s)
Fármacos Anti-VIH/uso terapéutico , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/mortalidad , Personal de Salud/estadística & datos numéricos , Adolescente , Adulto , Anciano , Fármacos Anti-VIH/administración & dosificación , Recuento de Linfocito CD4 , Estudios Transversales , Femenino , Asignación de Recursos para la Atención de Salud/organización & administración , Humanos , Malaui/epidemiología , Masculino , Persona de Mediana Edad , Análisis de SupervivenciaRESUMEN
PROBLEM: Many resource-poor countries have started scaling up antiretroviral therapy (ART). While reports from individual clinics point to successful implementation, there is limited information about progress in government institutions at a national level. APPROACH: Malawi started national ART scale-up in 2004 using a structured approach. There is a focus on one generic, fixed-dose combination treatment with stavudine, lamivudine and nevirapine. Treatment is delivered free of charge to eligible patients with HIV and there is a standardized system for recruiting patients, monthly follow-up, registration, monitoring and reporting of cases and outcomes. All treatment sites receive quarterly supervision and evaluation. LOCAL SETTING: In January 2004, there were nine public sector facilities delivering ART to an estimated 4 000 patients. By December 2005, there were 60 public sector facilities providing free ART to 37,840 patients using national standardized systems. Analysis of quarterly cohort treatment outcomes at 12 months showed 80% of patients were alive, 10% dead, 9% lost to follow-up and 1% had stopped treatment. LESSONS LEARNED: Achievements were the result of clear national ART guidelines, implementing partners working together, an intensive training schedule focused on clinical officers and nurses, a structured system of accrediting facilities for ART delivery, quarterly supervision and monitoring, and no stock-outs of antiretroviral drugs. The main challenges are to increase the numbers of children, pregnant women and patients with tuberculosis being started on ART, and to avert high early mortality and losses to follow-up. The capacity of the health sector to cope with escalating case loads and to scale up prevention alongside treatment will determine the future success of ART delivery in Malawi.