Predictors of severe malarial anemia (altered immune responses, poor nutrition, intestinal parasites, and impaired erythropoiesis) differed from those of cerebral malaria (thrombocytopenia, herbal medicine, and intravascular hemolysis). Improved preventive and therapeutic measures may need to consider these differences.
Introduction The World Health Organization (WHO) recommends a CD4 cell count before starting antiretroviral therapy (ART) to detect advanced HIV disease, and routine viral load (VL) testing following ART initiation to detect treatment failure. Donor support for CD4 testing has declined to prioritize access to VL monitoring. We examined trends in CD4 and VL testing among adults (≥15 years of age) starting ART in Southern Africa. Methods We analysed data from 14 HIV treatment programmes in Lesotho, Malawi, Mozambique, South Africa, Zambia and Zimbabwe in 2005 to 2018. We examined the frequency of CD4 and VL testing, the percentage of adults with CD4 or VL tests, and among those having a test, the percentage starting ART with advanced HIV disease (CD4 count <200 cells/mm 3 ) or failing to suppress viral replication (>1000 HIV‐RNA copies/mL) after ART initiation. We used mixed effect logistic regression to assess time trends adjusted for age and sex. Results Among 502,456 adults, the percentage with CD4 testing at ART initiation decreased from a high of 78.1% in 2008 to a low of 38.0% in 2017; the probability declined by 14% each year (odds ratio (OR) 0.86; 95% CI 0.86 to 0.86). Frequency of CD4 testing also declined. The percentage starting ART with advanced HIV disease declined from 83.3% in 2005 to 23.5% in 2018; each year the probability declined by 20% (OR 0.80; 95% CI 0.80 to 0.81). VL testing after starting ART varied; 61.0% of adults in South Africa and 10.7% in Malawi were tested, but fewer than 2% were tested in the other four countries. The probability of VL testing after ART start increased only modestly each year (OR 1.06; 95% CI 1.05 to 1.06). The percentage with unsuppressed VL was 8.6%. There was no evidence of a decrease in unsuppressed VL over time (OR 1.00; 95% CI 0.99 to 1.01). Conclusions CD4 cell counting declined over time, including testing at the start of ART, despite the fact that many patients still initiated ART with advanced HIV disease. Without CD4 testing and expanded VL testing many patients with advanced HIV disease and treatment failure may go undetected, threatening the effectiveness of ART in sub‐Saharan Africa.
Introduction: The traditional “one-size-fits-all” model of HIV care whereby people living with HIV (PLWH) have regular individual clinical visits does not reflect the various preferences and needs of PLWH and stretches the capacity of health facilities (HFs). Little is known about the availability and the experience of differentiated HIV care delivery in the rural areas of Zimbabwe.Methods: We used a mixed-method approach to collect data from clients and providers at 26 HFs in Zimbabwe in 2019. We collected quantitative data about antiretroviral therapy (ART) delivery and time spent at the HF during a visit from one representative healthcare providers (HCP) and a stratified sample of PLWH at each HF. We performed semi-structured interviews among HCPs and focus group discussions (FGDs) among PLWH to collect information about the implementation of differentiated ART delivery (DART) models and their experience. We performed linear regression models to assess factors associated with the time spent in the HFs. We analyzed the interviews using an inductive approach. Transcripts were coded and constricted down to themes significant to the research objectives.Results: The majority (77%) of participating HFs offered at least one of the five DART models recommended in Zimbabwe: 13 (50%) offered community ART refill group (CARG), 1 (4%) club refill, 6 (23%) family refill, and 8 (31%) fast-track refill models. Mobile outreach was not available at any participating HF. In an unadjusted linear model, PLWH enrolled in the fast-track refill model spent 0.40 (95% confidence interval (CI): 0.15-0.56) less time at the HF than PLWH on routine care, whereas PLWH in the family refill model and delegated to go to the HF spent 2.63 (95% CI 1.42-4.88) more time at the HF during visit. Confidentiality and disclosure concerns were highlighted as the major barriers affecting the implementation of DART models, together with travel costs and waiting times. HCPs reported on the challenge of excessive workloads. Fast-track refill was perceived as the most adapted DART model to meet clients’ needs, followed by CARG and family refill.Conclusions: Confidentiality, travel costs and waiting times are key elements to consider in the implementation of differentiated care in rural Zimbabwe. More implementation research is needed to support the roll-out of differentiated HIV services in that region, especially DART models addressing the needs of PLWH. Our study supports the call for personalized care at ART programs in rural Africa.
Background Attrition threatens the success of antiretroviral therapy (ART). In this cohort study, we examined outcomes of people living with HIV (PLHIV) lost to follow-up (LTFU) 2014-2017 at ART programs in Southern Africa. Methods We confirmed LTFU (missed appointment for ≥60 or ≥90 days, according to local guidelines) by checking medical records and used a standardized protocol to trace a weighted random sample of PLHIV who were LTFU in eight ART programs in Lesotho, Malawi, Mozambique, South Africa, Zambia and Zimbabwe, 2017-2019. We ascertained vital status and identified predictors of mortality using logistic regression, adjusted for sex, age, time on ART, time since LTFU, travel time, and urban or rural setting. Results Among 3,256 PLHIV, 385 (12%) were wrongly categorized as LTFU and 577 (17%) had missing contact details. We traced 2,294 PLHIV (71%) by phone calls, home visits or both: 768 (34% of 2,294) were alive and in care, including 385 (17%) silent transfers to another clinic; 528 (23%) were alive without care or unknown care; 252 (11%) had died. Overall, the status of 1,323 (41% of 3,256) PLHIV remained unknown. Mortality was higher in men than women, higher in children than in young people or adults, higher in PLHIV who had been on ART <1 year or lost >1 year, living further from the clinic or in rural areas. Results were heterogeneous across sites. Conclusions Our study highlights the urgent need for better medical record systems at HIV clinics and rapid tracing of PLHIV who are LTFU.
Regression discontinuity analysis demonstrated varied effect of Treat-All on CD4 testing among Southern African countries,
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