Estimating the need for antiretroviral treatment and an assessment of a simplified HIV/AIDS case definition in rural Malawi

McGrath, Nuala; Kranzer, Katharina; Saul, Jacqueline; Crampin, Amelia C.; Malema, Simon; Kachiwanda, Lackson; Żaba, Basia; Jahn, Andreas; Fine, Paul E. M.; Glynn, Judith R.

doi:10.1097/01.aids.0000299417.69432.65

Cited by 24 publications

(41 citation statements)

References 14 publications

(11 reference statements)

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“…The three other studies enrolled participants from a rural community as part of a demographic and health survey (DHS) [29], an antenatal clinic as part of a PMTCT programme [27] and patients admitted in medical wards and assessed in an outpatient medical assessment unit [33]. …”

Section: Resultsmentioning

confidence: 99%

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Diagnostic accuracy of the WHO clinical staging system for defining eligibility for ART in sub‐Saharan Africa: a systematic review and meta‐analysis

Munthali

Taegtmeyer

Garner

et al. 2014

Journal of the International AIDS Society

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IntroductionThe World Health Organization (WHO) recommends that HIV-positive adults with CD4 count ≤500 cells/mm3 initiate antiretroviral therapy (ART). In many countries of sub-Saharan Africa, CD4 count is not widely available or consistently used and instead the WHO clinical staging system is used to determine ART eligibility. However, concerns have been raised regarding its discriminatory ability to identify patients eligible to start ART. We therefore reviewed the accuracy of WHO stage 3 or 4 assessment in identifying ART eligibility according to CD4 count thresholds for ART initiation.MethodsWe systematically searched PubMed and Global Health databases and conference abstracts using a comprehensive strategy for studies that compared the results of WHO clinical staging with CD4 count thresholds. Studies performed in sub-Saharan Africa and published in English between 1998 and 2013 were eligible for inclusion according to our predefined study protocol. Two authors independently extracted data and assessed methodological quality and risk of bias using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) tool. Summary estimates of sensitivity and specificity were derived for each CD4 count threshold and hierarchical summary receiver operator characteristic curves were plotted.ResultsFifteen studies met the inclusion criteria, including 25,032 participants from 14 countries. Most studies assessed individuals attending ART clinics prior to treatment initiation. WHO clinical stage 3 or 4 disease had a sensitivity of 60% (95% CI: 45–73%, Q=914.26, p<0.001) and specificity of 73% (95% CI: 60–83%, Q=1439.43, p<0.001) for a CD4 threshold of ≤200 cells/mm3 (11 studies); sensitivity and specificity for a threshold of CD4 count ≤350 cells/mm3 were 45% (95% CI: 26–66%, Q=1607.31, p<0.001) and 85% (95% CI: 69–93%, Q=896.70, p<0.001), respectively (six studies). For the threshold of CD4 count ≤500 cells/mm3 sensitivity was 14% (95% CI: 13–15%) and specificity was 95% (95% CI: 94–96%) (one study).ConclusionsWhen used for individual treatment decisions, WHO clinical staging misses a high proportion of individuals who are ART eligible by CD4 count, with sensitivity falling as CD4 count criteria rises. Access to accurate, accessible, robust and affordable CD4 count testing methods will be a pressing need for as long as ART initiation decisions are based on criteria other than seropositivity.

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Section: Resultsmentioning

confidence: 99%

“…One study [31] used the Coulter manual method and in three studies [27, 29, 37], the method was not reported. Only two studies [25, 30] reported that external laboratory quality assurance procedures for CD4 counts were followed.…”

Section: Resultsmentioning

confidence: 99%

Diagnostic accuracy of the WHO clinical staging system for defining eligibility for ART in sub‐Saharan Africa: a systematic review and meta‐analysis

Munthali

Taegtmeyer

Garner

et al. 2014

Journal of the International AIDS Society

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“…Median baseline CD4 counts at initiation of HAART have been found to be between 100-150 cells/μl in several low income countries [9-15]. In contrast, a population based study from 2007 indicates that 42% of all HIV patients in Malawi had a CD4 cell count under 350 cells/μl, while 22% had under 200 cells/μl [16]. Shifts to an early treatment start strategy will increase the need for HAART, but few people actually receive HAART.…”

Section: Introductionmentioning

confidence: 99%

Further benefits by early start of HIV treatment in low income countries: Survival estimates of early versus deferred antiretroviral therapy

2010

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BackgroundInternational HIV guidelines have recently shifted from a medium-late to an early-start treatment strategy. As a consequence, more people will be eligible to Highly Active Antiretroviral Therapy (HAART). We estimate mean life years gained using different treatment indications in low income countries.MethodsWe carried out a systematic search to identify relevant studies on the treatment effect of HAART. Outcome from identified observational studies were combined in a pooled-analyses and we apply these data in a Markov life cycle model based on a hypothetical Tanzanian HIV population. Survival for three different HIV populations with and without any treatment is estimated. The number of patients included in our pooled-analysis is 35 047.ResultsProviding HAART early when CD4 is 200-350 cells/μl is likely to be the best outcome strategy with an expected net benefit of 14.5 life years per patient. The model predicts diminishing treatment benefits for patients starting treatment when CD4 counts are lower. Patients starting treatment at CD4 50-199 and <50 cells/μl have expected net health benefits of 7.6 and 7.3 life years. Without treatment, HIV patients with CD4 counts 200-350; 50-199 and < 50 cells/μl can expect to live 4.8; 2.0 and 0.7 life years respectively.ConclusionsThis study demonstrates that HIV patients live longer with early start strategies in low income countries. Since low income countries have many constraints to full coverage of HAART, this study provides input to a more transparent debate regarding where to draw explicit eligibility criteria during further scale up of HAART.

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“…These can be used to extrapolate for planning purposes to larger urban populations [14]. Careful follow up allowed an estimation of survival [15-17].…”

Section: Introductionmentioning

confidence: 99%

Changing clinical needs of people living with AIDS and receiving home based care in Malawi - the Bangwe Home Based Care Project 2003-2008 - a descriptive study

Gondwe

Bowie

2010

BMC Public Health

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BackgroundHome based care (HBC) has been an important component of the response to the AIDS epidemic in Africa, and particularly so before antiretroviral therapy (ART) became available. Has HBC become unnecessary now that ART is available in many African countries? One way to investigate this is to assess the changing need for comprehensive HBC as an ART programme becomes available. The Bangwe HBC programme in Malawi has been collecting data since 2003 before ART became available in 2005/6. Has the introduction of ART changed the clinical needs for HBC?MethodsInformation obtained at initial assessment and follow up visits of patients receiving HBC were combined to assess case severity, survival and the response to treatment. This information was used to assess trends in mortality and the incidence, duration and severity of common symptoms over a six year period in a defined urban population in Malawi.Results1266 patients, of whom 1190 were followed up and of whom 652 (55%) died, were studied. 282 (25%) patients died within two months of being first seen with an improvement between 2003-2005 and 2006-2008 of reduced mortality from 28% to 20%. 341 (27%) patients were unable to care for themselves on first assessment and 675 (53%) had stage 4 AIDS disease. Most patients had a mix of symptoms at presentation. Self care increased somewhat over the six years although case severity as measured by WHO staging and nutritional status did not.350 patients were on ART either started before or after initial assessment. There were significant barriers to accessing ART with 156 (51%) of 304 stage 3 or 4 patients first assessed in 2007 or 2008 not receiving ART.Over the six year period new HBC cases reduced by 8% and follow up visits increased by 9% a year. Between 4 and 5 people sought HBC for the first time each week from an urban health centre catchment of 100,000, which required 37.3 follow up visits each week.ConclusionsSince the availability of ART in the local health facilities and despite strenuous efforts to persuade people to seek HIV testing and ART, in practice barriers existed and half the eligible HBC patients did not have access to ART. This is one reason why the clinical need for HBC services had not changed much. In terms of quantity of care the number of new patients seeking HBC reduced by 8% a year. In terms of content of care, while there had been a marginal increase in self care the severity of illness had not changed and the survival of a significant proportion of patients generated the need for repeat visits, which increased by 9% a year. In conclusion, although the content has changed the need for HBC has not diminished despite the availability of ART.

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Estimating the need for antiretroviral treatment and an assessment of a simplified HIV/AIDS case definition in rural Malawi

Abstract: The field checklist was not a suitable tool for individual staging. Criteria for ART eligibility based on clinical staging alone missed two-thirds of those eligible by clinical staging and CD4 cell count.

Cited by 24 publications

References 14 publications

Diagnostic accuracy of the WHO clinical staging system for defining eligibility for ART in sub‐Saharan Africa: a systematic review and meta‐analysis

Diagnostic accuracy of the WHO clinical staging system for defining eligibility for ART in sub‐Saharan Africa: a systematic review and meta‐analysis

Further benefits by early start of HIV treatment in low income countries: Survival estimates of early versus deferred antiretroviral therapy

Changing clinical needs of people living with AIDS and receiving home based care in Malawi - the Bangwe Home Based Care Project 2003-2008 - a descriptive study

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