Background Initiation criteria and pediatric antiretroviral treatment (ART) regimens have changed over the past few years in South Africa. We reported worse early virological outcomes associated with the use abacavir (ABC)-based regimens at one large site: here we expand this analysis to multiple sites in the IeDEA-Southern Africa collaboration. Methods Data for 9543 ART-naïve children <16 years at treatment initiation started on either stavudine/lamivudine (d4T/3TC) or ABC/3TC with efavirenz (EFV) or ritonavir-boosted lopinavir (LPV/r) treated at six clinics in Johannesburg and Cape Town, South Africa, were analysed with Chi-square tests and logistic regression to evaluate viral suppression at six and twelve months. Results Prevalence of viral suppression at six months in 2174 children started on a d4T-based LPV/r regimen was greater (70%) than among 438 children started on an ABC-based LPV/r regimen (54%, p<0.0001). Among 3189 children started on a d4T-based EFV regimen a higher proportion (86%) achieved suppression at six months compared to 391 children started on ABC-containing EFV regimens (78%, p<0.0001). Relative benefit of d4T vs. ABC on six month suppression remained in multivariate analysis after adjustment for pre-treatment characteristics, cohort and year of program (LPV/r – OR 0.57 [CI: 0.46–0.72]; EFV – OR 0.46 [CI: 0.32–0.65]). Conclusion This expanded analysis is consistent with our previous report of worse virological outcomes after ABC was introduced as part of first-line ART in South Africa. Whether due to the drug itself or coincident with other changes over time, continued monitoring and analyses must clarify causes and prevent suboptimal long term outcomes.
BackgroundKnowledge of tuberculosis incidence and associated factors is required for the development and evaluation of strategies to reduce the burden of HIV-associated tuberculosis.MethodsSystematic literature review and meta-analysis of tuberculosis incidence rates among HIV-infected individuals taking combination antiretroviral therapy.ResultsFrom PubMed, EMBASE and Global Index Medicus databases, 42 papers describing 43 cohorts (32 from high/intermediate and 11 from low tuberculosis burden settings) were included in the qualitative review and 33 in the quantitative review. Cohorts from high/intermediate burden settings were smaller in size, had lower median CD4 cell counts at study entry and fewer person-years of follow up. Tuberculosis incidence rates were higher in studies from Sub-Saharan Africa and from World Bank low/middle income countries. Tuberculosis incidence rates decreased with increasing CD4 count at study entry and duration on combination antiretroviral therapy. Summary estimates of tuberculosis incidence among individuals on combination antiretroviral therapy were higher for cohorts from high/intermediate burden settings compared to those from the low tuberculosis burden settings (4.17 per 100 person-years [95% Confidence Interval (CI) 3.39–5.14 per 100 person-years] vs. 0.4 per 100 person-years [95% CI 0.23–0.69 per 100 person-years]) with significant heterogeneity observed between the studies.ConclusionsTuberculosis incidence rates were high among individuals on combination antiretroviral therapy in high/intermediate burden settings. Interventions to prevent tuberculosis in this population should address geographical, socioeconomic and individual factors such as low CD4 counts and prior history of tuberculosis.
Introduction. South Africa has made remarkable progress in rolling out antiretroviral therapy (ART), with the largest number of people (more than 1.4 million) enrolled on antiretrovirals in the world. Decentralisation of services to primary health centres (PHCs) has strengthened retention of patients on ART and reduced the burden of managing uncomplicated cases at referral hospitals. Methods. This was a ten-step Nurse Initiatied Management of Antiretroviral Treatment (NIMART) rollout intervention in which nurses from 17 primary healthcare facilities of Region F, City of Johannesburg, South Africa, were trained and mentored in NIMART by the Wits Reproductive Health and HIV Research Institute (WRHI) to commence patients on ART in their PHCs. A total of 20 535 patients initiated ART during the 30-month study period. Monthly initiations at both PHCs and referral clinics were monitored. To test the statistical significance of the impact of NIMART rollout on the referral hospital initiations and Region F monthly initiations, interrupted time series analysis was applied. Findings. Ten-step NIMART rollout was applied, with the first step being establishment of NIMART as a priority in order to obtain primary buy-in by the Department of Health (DoH) and City of Johannesburg (CoJ). Forty-five professional nurses were trained in NIMART by WRHI quality improvement mentors. By the end of September 2011, all 17 PHCs in Region F were initiating patients on ART. Total initiations significantly increased by 99 patients immediately after NIMART rollout (p=0.013) and continued to increase by an average of 9 every month (p=0.013), while referral facility initiations decreased by 12 (p=0.791) immediately after NIMART and then decreased by an average of 18 every month (p=0.01). Conclusion. In this study, decentralisation of ART initiation by professional nurses was shown to increase ART uptake and reduce workload at referral facilities, enabling them to concentrate on complicated cases. However, it is important to ensure capacity building, training and mentoring of nurses to integrate HIV services in order to reduce workload and provide a comprehensive package of care to patients. Engaging and having buy-in from DoH/CoJ partners in rolling out NIMART was crucial in increasing outputs as well as for sustainability of the NIMART programme.
A new technology or innovation (see Table 2 below) Other An example of an evaluation of this kind of intervention is Anyango et al. (2010), who evaluated a five-year project in Kenya aimed at improving the income and food security of smallholder farmers through a number of training interventions, including introducing new cultivars to the farmers and training them through farmer field schools, as well as providing training on marketing skills, amongst other things. Ashraf et al. (2008), on the other hand, evaluated agricultural interventions that worked with pre-existing farmer self-help groups and provided farmers with information and short orientation-sessions about switching to export crops and offered in-kind loans and facilitated transactions with exporters.
Gender inequality has been documented as a key driver of negative health outcomes, especially among women. However, studies have not clearly examined the role of gender inequality in maternal health in an African setting. Therefore, the authors of this study examined the role of gender inequality, indicated by lack of female autonomy, in exposing women to maternal health risk. Data were obtained from the 2007 Zambia Demographic and Health Survey on a weighted sample of 3,906 married or partnered women aged 15-49 years. Multivariable analyses revealed that low autonomy in household decision power was associated with maternal health risk (Odds Ratio (OR) = 1.52, p < .001). Autonomy interacted with household wealth showed that respondents who were in the wealthier households and had low autonomy in household decision power (OR = 2.03, p < .05) were more likely to be exposed to maternal health risk than their counterparts who had more autonomy. Efforts to lower women's exposure to maternal mortality and morbidity in Zambia should involve interventions to alter prevailing gender norms that limit women's active participation in decisions about their own health during pregnancy and delivery.
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