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Changes in programmatic outcomes during 7 years of scale-up at a community-based antiretroviral treatment service in South Africa.

Objectives:To assess sustainability of programmatic outcomes in a community-based antiretroviral therapy (ART) service in South Africa during 7 years of scale-up. Methods:Prospective cohort of treatment-naive patients aged ≥15 years enrolled between 2002 and 2008. Data were analyzed by calendar period of ART initiation using time-to-event analysis and logistic regression. Results:ART was initiated by 3162 patients (67% women; median age, 34 years) who were followed-up for a median of 2.4 years (interquartile range, 1.2-3.8). After 6 years, the cumulative probability of death and loss to follow-up (LTFU) was 37.4%. The probabilities of transfer-out to another ART service and of virological failure were 21.6% and 23.1%, respectively. Low mortality risk and excellent virological and immunological responses during the first year of ART were not associated with calendar period of ART initiation. In contrast, risk of LTFU and virological failure both increased between successive calendar periods in unadjusted and adjusted analyses. The number of patients per member of clinic staff increased markedly over time. Conclusions:Successful early outcomes (low mortality and good immunological and virological responses) were sustained between sequential calendar periods during 7 years of scale-up. In contrast, the increasing cumulative probabilities of LTFU or virological failure may reflect decreasing capacity to adequately support patients during long-term therapy as clinic caseload escalated.

Earlier HIV diagnosis: are mobile services the answer?

OBJECTIVES To assess the age and gender differences of clients accessing mobile HIV counselling and testing (HCT) compared with clients accessing facility-based testing, and to determine the difference in HIV prevalence and baseline CD4 counts. METHODS This was a prospective observational cross-sectional study of 3 different HIV testing services in Cape Town. We compared data on age, sex, HIV status and CD4 counts collected between August and December 2008 from a mobile testing service (known as the Tutu Tester), a primary health care clinic, and a district hospital. RESULTS A total of 3 820 individuals were tested: 2 499 at the mobile, 657 at the clinic, and 664 at the hospital. Age and sex distribution differed across services, with the mobile testing more men and older individuals. HIV prevalence was lowest at the mobile (5.9%) compared with the clinic (18.0%) and hospital (23.3%). Of the HIV-infected individuals from the mobile service, 75% had a CD4 count higher than 350 cells/µl compared with 48% and 32% respectively at the clinic and hospital. Age- and sex-adjusted risk for HIV positivity was 3.5 and 4.9 times higher in the clinic-based and hospital-based services compared with the mobile service. CONCLUSION Mobile services are accessed by a different population compared with facility-based services. Mobile service clients were more likely to be male and less likely to be HIV-positive, and those infected presented with earlier disease.

Incentivized recruitment of a population sample to a mobile HIV testing service increases the yield of newly diagnosed cases, including those in need of antiretroviral therapy

The aim of the study was to compare the yields of newly diagnosed cases of HIV infection and advanced immunodeficiency between individuals attending a mobile HIV counselling and testing (HCT) service as participants in a population‐based HIV seroprevalence survey and those accessing the same service as volunteers for routine testing.

Implementation and Operational Research: Community-Based Adherence Clubs for the Management of Stable Antiretroviral Therapy Patients in Cape Town, South Africa: A Cohort Study.

Background:Community-based models of antiretroviral therapy (ART) delivery are widely discussed as a priority in the expansion of HIV treatment services, but data on their effectiveness are limited. We examined outcomes of ART patients decentralized to community-based adherence clubs (CACs) in Cape Town, South Africa and compared these to patients managed in the community health center. Methods:The analysis included 8150 adults initiating ART from 2002 to 2012 in a public sector service followed until the end of 2013. From June 2012, stable patients (on ART >12 months, suppressed viral load) were referred to CACs. Loss to follow-up (LTFU) was compared between services using proportional hazards models with time-varying covariates and inverse probability weights of CAC participation. Findings:Of the 2113 CAC patients (71% female, 7% youth ages ⩽24 years), 94% were retained on ART after 12 months. Among CAC patients, LTFU [adjusted hazard ratio (aHR): 2.17, 95% confidence interval (CI): 1.26 to 3.73] and viral rebound (aHR 2.24, 95% CI: 1.00 to 5.04) were twice as likely in youth (16–24 years old) compared with older patients, but no difference in the risk of LTFU or viral rebound was observed by sex (P-values 0.613 and 0.278, respectively). CAC participation was associated with a 67% reduction in the risk of LTFU (aHR: 0.33, 95% CI: 0.27 to 0.40) compared with community health centre, and this association persisted when stratified by patient demographic and clinic characteristics. Interpretation:CACs are associated with reduced risk of LTFU compared with facility-based care. Community-based models represent an important development to facilitate ART delivery and possibly improve patient outcomes.

HIV viraemia and mother-to-child transmission risk after antiretroviral therapy initiation in pregnancy in Cape Town, South Africa.

Maternal HIV viral load (VL) drives mother‐to‐child HIV transmission (MTCT) risk but there are few data from sub‐Saharan Africa, where most MTCT occurs. We investigated VL changes during pregnancy and MTCT following antiretroviral therapy (ART) initiation in Cape Town, South Africa.

Community health care workers in South Africa are at increased risk for tuberculosis.

2have indicated that HCWs have an increased risk of TB disease compared with the general population. The risk for TB disease is even higher among HCWs co-infected with HIV. Studies from South Africa found an HIV prevalence among HCWs of 15.7% in 4 provinces in 2002 3 and of 11.5% in 2 hospitals in Gauteng in 2005. 4 Many sub-Saharan African countries face a severe shortage of qualified HCWs as a result of the dual HIV/TB epidemic, which has triggered task shifting to a range of lay community health care workers (CHWs) – for example, home-based care workers, lay counsellors and adherence supporters, for both TB and highly active antiretroviral therapy (HAART). CHWs may experience a considerable occupational TB risk; however, their risk of TB disease and HIV prevalence has never been documented. The TB/HIV Care Association is a non-governmental organisation that employs CHWs to provide adherence support to both TB patients and patients taking HAART. The Desmond Tutu HIV Foundation partnered with the TB/HIV Care Association to provide HIV and TB testing to their CHWs, and subsequently determined the prevalence of diagnosed and undiagnosed TB and HIV among them. Methods

Integration of TB and ART services fails to improve TB treatment outcomes: Comparison of ART/TB primary healthcare services in Cape Town, South Africa

BACKGROUND The combined tuberculosis (TB) and HIV epidemics in South Africa (SA) have created enormous operational challenges for a health service that has traditionally run vertical programmes for TB treatment and antiretroviral therapy (ART) in separate facilities. This is particularly problematic for TB/HIV co-infected patients who need to access both services. OBJECTIVE To determine whether integrated TB facilities had better TB treatment outcomes than single-service facilities in Cape Town, SA. METHODS TB treatment outcomes were determined for newly registered, adult TB patients (aged > or = 18 years) at 13 integrated ART/TB primary healthcare (PHC) facilities and four single-service PHC facilities from 1 January 2009 to 30 June 2010. A chi2 test adjusted for a cluster sample design was used to compare outcomes by type of facility. RESULTS Of 13,542 newly registered patients, 10,030 received TB treatment in integrated facilities and 3,512 in single-service facilities. There was no difference in baseline characteristics between the two groups with HIV status determined for 9,351 (93.2%) and 3,227 (91.9%) patients, of whom 6 649 (66.3%) and 2,213 (63%) were HIV-positive in integrated facilities and single-service facilities, respectively. The median CD4+ count of HIV-positive patients was 152 cells/microl (interquartile range (IQR) 71-277) for integrated facilities and 148 cells/microl (IQR 67-260) for single-service facilities. There was no statistical difference in the TB treatment outcome profile between integrated and single-service facilities for all TB patients (p = 0.56) or for the sub-set of HIV-positive TB patients (p = 0.58) CONCLUSION: This study did not demonstrate improved TB treatment outcomes in integrated PHC facilities and showed that the provision of ART in the same facility as TB services was not associated with lower TB death and default rates.

Increasing transfers-out from an antiretroviral treatment service in South Africa: patient characteristics and rates of virological non-suppression.

Objectives To determine the proportion, characteristics and outcomes of patients who transfer-out from an antiretroviral therapy (ART) service in a South African township. Methods This retrospective cohort study included all patients aged ≥15 years who enrolled between September 2002 and December 2009. Follow-up data were censored in December 2010. Kaplan-Meier survival analysis was used to describe time to transfer-out and cox proportional hazard analysis was used to determine associated risk factors. Results 4511 patients (4003 ART-naïve and 508 non-naïve at baseline) received ART during the study period. Overall, 597 (13.2%) transferred out. The probability of transferring out by one year of ART steadily increased from 1.4% in 2002/2004 cohort to 8.9% for the 2009 cohort. Independent risk factors for transfer-out were more recent calendar year of enrolment, younger age (≤25 years) and being ART non-naïve at baseline (i.e., having previously transferred into this clinic from another facility). The proportions of patients transferred out who had a CD4 cell count <200 cells/µL and/or a viral load ≥1000 copies/mL were 19% and 20%, respectively. Conclusions With scale-up of ART over time, an increasing proportion of patients are transferring between ART services and information systems are needed to track patients. Approximately one-fifth of these have viral loads >1000 copies/mL around the time of transfer, suggesting the need for careful adherence counseling and assessment of medication supplies among those planning transfer.

Antiretroviral treatment uptake in patients with HIV-associated TB attending co-located TB and ART services

BACKGROUND Delivery of integrated care for patients with HIV-associated TB is challenging. We assessed the uptake and timing of antiretroviral treatment (ART) among eligible patients attending a primary care service with co-located ART and TB clinics. METHODS In a retrospective cohort study, all HIV-associated TB patients (≥18 years old) who commenced TB treatment in 2010 were included. Data were analysed using basic descriptive statistics and log-binomial regression analysis. RESULTS Of a total of 497 patients diagnosed with HIV-associated TB, 274 were eligible to start ART for the first time (median CD4 count, 159 cells/µl). ART was started during TB treatment by 220 (80.3%) patients. Among the 54 (19.7%) who did not start ART, 23 (42.6%) were either lost to follow-up (LTFU) or died before enrolling for ART; 12 (22.2%) were either LTFU or died after enrolling but before starting ART; 5 (9.3%) were transferred out; and 14 (25.9%) only started ART after completion of TB treatment. The median delay between starting TB treatment and starting ART was 51 days (IQR 29 - 77). Overall, only 58.6% of patients started ART within 8 weeks of TB treatment, and 12.7% of those with CD4 counts <50 cells/µl started ART within 2 weeks. CONCLUSIONS In a setting with co-located TB and ART clinics, delays to starting ART were substantial, and one-fifth of eligible patients did not start ART during TB treatment. Co-location of services alone is insufficient to permit timely initiation of ART; further measures need to be implemented to facilitate integrated treatment.

Quality of induced sputum using a human-powered nebuliser in a mobile human immunodeficiency virus testing service in South Africa.

OBJECTIVES To investigate the quality of induced sputum samples using a human-powered (HPN) and an electric-powered nebuliser (EPN). METHODS For each participant two sputum samples were induced using the HPN and the EPN. The sequence of the two nebulisers was allocated at random. The proportion of good quality sputum according to different assessment criteria was compared using an exact McNemar test. The difference in time to expectoration was compared using the Wilcoxon matched-pairs signed-rank test. RESULTS A total of 123 individuals were eligible for the study. Nine individuals refused to participate and five were unable to produce a sputum sample. The proportion of good quality sputum was higher among sputum samples induced by the HPN compared to those obtained using the EPN. The median time to produce a sputum sample was 2.2 min (IQR 1.13-4.1) for the HPN and 2.5 min (IQR 1.4-4.1) for the EPN. CONCLUSION The HPN induced good quality sputum within 3 min. The device operates without electricity and is suitable not only for remote clinics with unreliable electricity, but also for mobile services and community-based intensified tuberculosis (TB) case finding. Further research needs to investigate the yield of TB in sputum samples induced by the HPN.