Gabriela Patten

Ebola outbreak in rural West Africa: epidemiology, clinical features and outcomes

To describe Ebola cases in the district Ebola management centre of in Kailahun, a remote rural district of Sierra Leone, in terms of geographic origin, patient and hospitalisation characteristics, treatment outcomes and time from symptom onset to admission.

‘I Know that I Do Have HIV but Nobody Saw Me’: Oral HIV Self-Testing in an Informal Settlement in South Africa

Reaching universal HIV-status awareness is crucial to ensure all HIV-infected patients access antiretroviral treatment (ART) and achieve virological suppression. Opportunities for HIV testing could be enhanced by offering self-testing in populations that fear stigma and discrimination when accessing conventional HIV Counselling and Testing (HCT) in health care facilities. This qualitative research aims to examine the feasibility and acceptability of unsupervised oral self-testing for home use in an informal settlement of South Africa. Eleven in-depth interviews, two couple interviews, and two focus group discussions were conducted with seven healthcare workers and thirteen community members. Thematic analysis was done concurrently with data collection. Acceptability to offer home self-testing was demonstrated in this research. Home self-testing might help this population overcome barriers to accepting HCT; this was particularly expressed in the male and youth groups. Nevertheless, pilot interventions must provide evidence of potential harm related to home self-testing, intensify efforts to offer quality counselling, and ensure linkage to HIV/ART-care following a positive self-test result.

Clinical Mentorship of Nurse Initiated Antiretroviral Therapy in Khayelitsha, South Africa: A Quality of Care Assessment

Introduction To combat the AIDS epidemic and increase HIV treatment access, the South African government implemented a nurse-based, doctor-supported model of care that decentralizes administration of antiretroviral treatment (ART) for HIV positive patients through nurse initiated and managed ART. Médecins Sans Frontières (MSF) implemented a mentorship programme to ensure successful task-shifting, subsequently assessing the quality of clinical care provided by nurses. Methods A before-after cross-sectional study was conducted on nurses completing the mentorship programme in Khayelitsha, South Africa, from February 2011-September 2012. Routine clinical data from 229 patient folders and 21 self-assessment questionnaires was collected to determine the number of patients initiated on ART by nurses; quality of ART management before-after mentorship; patient characteristics for doctor and nurse ART initiations; and nurse self-assessments after mentorship. Results Twenty one nurses were authorized by one nurse mentor with one part-time medical officers support, resulting in nurses initiating 77% of ART eligible patients. Improvements in ART management were found for drawing required bloods (91% vs 99%, p = 0.03), assessing adherence (50% vs 78%, p<0.001) and WHO staging (63% vs 91%, p<0.001). Nurse ART initiation indicators were successfully completed at 95–100% for 11 of 16 indicators: clinical presentation; patient weight; baseline blood work (CD4, creatinine, haemoglobin); STI screening; WHO stage, correlating medical history; medications prescribed appropriately; ART start date; and documented return date. Doctors initiated more patients with TB/HIV co-infection and WHO Stage 3 and 4 disease than nurses. Nurse confidence improved for managing HIV-infected children and pregnant women, blood result interpretation and long-term side effects. Conclusions Implementation of a clinical mentorship programme in Khayelitsha led to nurse initiation of a majority of eligible patients, enabling medical officers to manage complex cases. As mentorship can increase clinical confidence and enhance professional development, it should be considered essential for universal ART access in resource limited settings.

Is it safe to drop CD4+ monitoring among virologically suppressed patients: a cohort evaluation from Khayelitsha, South Africa.

For over two decades, the measurement of CD4þ cell count has been the principal means of assessing eligibility for initiation of antiretroviral therapy (ART) and monitoring response to treatment [1]. In high-income settings, treatment response is also supported by routine virologic monitoring as the preferred way to assess adherence and detect virologic failure early and accurately [2,3]. In low-income, high HIV burden settings, access to viral load monitoring remains limited due to the complexity and cost of current technology. However, there has been a progressive evolution favouring increased use of viral load monitoring, and the latest guidelines from the WHO in June 2013 recommend that countries use viral load as the preferred approach to monitoring response to ART [4]. In support of this recommendation, major international agencies are working with countries to support scale-up of viral load capacity in resourcelimited settings [5].

Applying the ICMJE authorship criteria to operational research in low-income countries: the need to engage programme managers and policy makers

1 Medical Department (Operational Research Unit), Medecins sans Frontieres, Operational Centre Brussels, MSF-Luxembourg, Luxembourg, Luxembourg 2 Department of Molecular and Cellular Interactions, Flemish Institute of Biotechnology, Brussels, Belgium 3 Department of Microbiology, Institute of Tropical Medicine, Antwerp, Belgium 4 Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya 5 Centre for International Health, University of Bergen, Bergen, Norway 6 Center for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France 7 International Union Against TB and Lung Disease, Kampala, Uganda 8 Medecins Sans Frontieres, Addis Ababa, Ethiopia 9 International Union Against Tuberculosis and Lung Disease, South East Asia office, New Delhi, India 10 Medecins Sans Frontieres, Somali Mission, Somalia 11 Medecins Sans Frontieres, Bujumbura, Burundi 12 National Institute for Medical Research, Dar Es Salaam, Tanzania 13 National Tuberculosis Control Programme, Harare, Zimbabwe 14 Medecins Sans Frontieres, Capetown, South Africa 15 Medecins Sans Frontieres, Nairobi, Kenya 16 Joint Center for Bioethics, University of Toronto, Toronto, Canada 17 London School of Hygiene and Tropical Medicine, London, UK

Outcomes from the Implementation of a Counselling Model Supporting Rapid Antiretroviral Treatment Initiation in a Primary Healthcare Clinic in Khayelitsha, South Africa

Background Lengthy antiretroviral treatment (ART) preparation contributes to high losses to care between communicating ART eligibility and initiating ART. To address this shortfall, Médecins Sans Frontières implemented a revised approach to ART initiation counselling preparation (integrated for TB co-infected patients), shifting the emphasis from pre-initiation sessions to addressing common barriers to adherence and strengthening post-initiation support in a primary healthcare facility in Khayelitsha, South Africa. Methods An observational cohort study was conducted using routinely collected data for all ART-eligible patients attending their first counselling session between 23 July 2012 and 30 April 2013 to assess losses to care prior to and post ART initiation. Viral load completion and suppression rates of those retained on ART were also calculated. Results Overall, 449 patients enrolled in the study, of whom 3.6% did not return to the facility to initiate ART. Of those who were initiated, 96.7% were retained at their first ART refill visit and 85.9% were retained 6 months post ART initiation. Of those retained, 80.2% had a viral load taken within 6 months of initiating ART, with 95.4% achieving viral load suppression. Conclusions Adapting counselling to enable rapid ART initiation is feasible and has the potential to reduce losses to care prior to ART initiation without increasing short-term losses thereafter or compromising patient adherence.

Extending dispensing intervals for stable patients on ART.

To the Editors: Over the past decade, antiretroviral therapy (ART) programs have been rapidly expanded in resource-limited settings. South Africa has the largest ART program in the world with nearly 2 million people accessing treatment. ART Adherence Clubs (ACs) have been implemented in the Western Cape of South Africa to improve long-term retention in care for stable ART patients by providing quick and patient-friendly access to treatment and care while decreasing the burden on overstretched health care facilities. ACs are facilitated by a lay club facilitator and consist of approximately 30 stable patients who meet every 2 months either at the health facility or in a community venue. Patients are eligible to join an AC if they have been on the same ART regimen for 12 months or more, have had 2 consecutive undetectable viral loads, and do not have any other medical condition requiring more frequent follow-up. Each visit consists of a quick clinical assessment and on-site dispensation of prepacked ART with a nurse available for referral as necessary. Early evidence suggests ACs are effective in retaining stable patients in care with high levels of virologic suppression. Migration is common in subSaharan Africa where patients move away from home for economic reasons. This movement results in circular migration patterns that impact adherence and retention in antiretroviral care. In the Western Cape, many patients return to their province of origin over the holiday period of December/January and do not seek care while away. This migration puts patients at risk of ART interruptions and defaulting care, especially when time away from the Western Cape is extended beyond the period initially intended due to unforeseen circumstances. The extent of this seasonal migration has not been quantified, but experience at the clinics suggests that most patients are affected. Current ART pharmacy guidelines in South Africa require ART scripts to be written every 6 months despite national adult ART guidelines that only require an annual clinical assessment for stable ART patients. Although national policy allows 3-month dispensing, there is great variation between provinces and individual facilities. Accordingly, stable patients in the Western Cape receive a maximum of 2 months of ART per visit. To support ART patients who most commonly migrate over the holiday period, ACs that were scheduled to meet between mid-December 2012 and midJanuary 2013 were given 4 months of ART in their October/November 2012 AC visit. Four months of ART were dispensed as two 2 monthly supplies to align with national policy. Data are limited on how long ART dispensing intervals should be to optimize retention in care. The objective was to compare outcomes among AC members who received 2-month ART (normal standard of care) to 4-month ART. The Hannan Crusaid Treatment Center in Gugulethu and Ubuntu Site B Clinic in Khayelitsha are large treatment facilities in periurban, high-prevalence areas of Cape Town, South Africa. Both services have been described, in detail, previously and are or have previously been supported by the nongovernmental organizations Desmond Tutu HIV Foundation and Médecins Sans Frontières, South Africa, respectively. All adult ACs at the Hannan Crusaid Treatment Center and Ubuntu Site B Clinic who were enrolled in an AC before the end of 2012 were included in the analysis. Adult ACs include stable patients of 18 years or older. AC procedures at the 2 sites are similar. Data presented includes the number and proportion of patients receiving each interval of ARVs overall and by site. ACs were assigned to receive either 4 or 2 months of treatment based on when their December/ January visit was scheduled. ACs with a scheduled visit between 17 December and 18 January were assigned to the 4-month group. Outcomes of patients who received two 2-month prescriptions simultaneously (ie, 4 months) of ART (group A) are compared with those who received the standard 2 months of ART (group B). Outcomes include the proportion of patients defaulting from ACs 4 months after their final visit in 2012 and for those with blood results in 2013 the proportion of patients who were not virally suppressed (viral load above 400 copies/mL). Associations by group were assessed with x2 tests. A total of 1860 patients in 1 of 76 ACs were eligible for the analysis (Table 1). Over the holiday period, 42 ACs were given 4 months of ART and 34 ACs were given 2 months of ART. Four months after the final AC visit in 2012, 4.0% had defaulted care overall [group A, 41 of 1054 (3.9%); group B, 33 of 806 (4.1%)]. There was no difference in the risk of defaulting from an AC in group A who received 4 months of ART compared with group B who received 2 months of ART (risk ratio, 0.95; 95% confidence interval: 0.61 to 1.49; P = 0.82). Of the 1507 of patients with a blood draw at their first or second 2013 visit, 3.6% were not virally suppressed [group A, 31 of 842 (3.7%); group B, 23 of 665 (3.5%)]. No significant associations were observed between viral suppression and group (risk ratio, 1.06; 95% confidence interval: 0.63 to 1.81; P = 0.82). Between the last visit of 2012 and the first schedule visit of 2013, none of the club patients died. This analysis was limited to 2 sites where 4 months of ART was provided to those clubs whose 2-month return date would have fallen in December or the first part of January. These findings were presented at the International Conference on AIDS & STIs in Africa, December 2013, Cape Town, South Africa. The authors have no conflicts of interest to disclose. A. G. is supported by funding from the Canadian Institutes of Health Research and the South African Centre for Epidemiological Modeling and Analysis. L. M. is supported by an International Leadership Award from the Elizabeth Glaser Pediatric AIDS Foundation. Letters to the Editor J Acquir Immune Defic Syndr Volume 66, Number 2, June 1, 2014

Acceptability and use of a virtual support group for HIV-positive youth in Khayelitsha, Cape Town using the MXit social networking platform

ABSTRACT Introduction: Médecins Sans Frontières supports human immunodeficiency virus (HIV)-infected youth, aged 12–25 years, at a clinic in Khayelitsha, South Africa. Patients are enrolled in youth clubs, and provided with a virtual chat room, using the cell-phone-based social networking platform, MXit, to support members between monthly/bimonthly club meetings. The acceptability and uptake of MXit was assessed. Methods: MXit was facilitated by lay counsellors, was password protected, and participants could enter and leave at will. Club members were asked to complete self-administered questionnaires and participate in two focus-group discussions. Results and discussion: In total, 60 club members completed the questionnaire, and 12 participated in the focus groups. Fifty-eight percentage were aged 23–25 years, 63% were female and 83% had a cell phone. Sixty percentage had used MXit before, with 38% having used it in the past month. Sixty-five percentage were aware of the chat-room and 39% knew how to access it. Thirty-four percentage used the chat-room at least once, 20% had visited the chat-room in the past month, and 29% had used MXit to have private conversations with other club members. Fifty-seven percentage used the chat-room to get advice, and 84% of all respondents felt that offering a service outside the youth club meetings was important and would like to see one to continue. The cost of using social media platforms was an issue with some, as well as the need for anonymity. Preference for other platforms, logistical obstacles, or loss of interest contributed to non-use. Conclusions: Reported usage of the MXit chat-room was low, but participants indicated acceptance of the programme and their desire to interact with their peers through social media. Suggestions to improve the platform included accessible chat histories, using more popular platforms such as Facebook or WhatsApp, and to have topical discussions where pertinent information for youth is provided.

What Should we do When HIV-Positive Children Fail First-Line Combination Antiretroviral Therapy? A Comparison of 4 ART Management Strategies

Background: Managing virologic failure (VF) in HIV-infected children is especially difficult in resource-limited settings, given limited availability of alternative drugs, concerns around adherence, and the development of HIV resistance mutations. We aimed to evaluate 4 management strategies for children following their first episode of VF by comparing their immunologic and virologic outcomes. Methods: We included children (< 16 years of age) with VF from 8 International Epidemiologic Database to Evaluate AIDS Southern Africa cohorts, initiating combination antiretroviral therapy (cART) between 2004 and 2010, who followed one of the 4 management strategies: continuing on their failing regimen; switching to a second-line regimen; switching to a holding regimen (either lamivudine monotherapy or other non-cART regimen); discontinuing all ART. We compared the effect of management strategy on the 52-week change in CD4% and log10VL from VF, using inverse probability weighting of marginal structural linear models. Results: Nine hundred eighty-two patients were followed over 54,168 weeks. Relative to remaining on a failing regimen, switching to second-line showed improved immunologic and virologic responses 52 weeks after VF with gains in CD4% of 1.5% (95% confidence interval [CI], 0.2–2.8) and declines in log10VL of -1.4 copies/mL (95% CI, -2.0, -0.8), while switching to holding regimens or discontinuing treatment had worse immunologic (-5.4% (95% CI, -12.1, 1.3) and -5.6% (95% CI, -15.4, 4.1) and virologic outcomes (0.2 (95% CI, -3.6, 4.1) and 0.8 (95% CI, -0.6, 2.1), respectively. Conclusions: The results provide useful guidance for managing children with VF. Consideration should be given to switching children failing first-line cART to second-line, given the improved virologic and immune responses when compared with other strategies.BACKGROUND Managing virologic failure (VF) in HIV-infected children is especially difficult in resource-limited settings, given limited availability of alternative drugs, concerns around adherence, and the development of HIV resistance mutations. We aimed to evaluate 4 management strategies for children following their first episode of VF by comparing their immunologic and virologic outcomes. METHODS We included children (< 16 years of age) with VF from 8 International Epidemiologic Database to Evaluate AIDS Southern Africa cohorts, initiating combination antiretroviral therapy (cART) between 2004 and 2010, who followed one of the 4 management strategies: continuing on their failing regimen; switching to a second-line regimen; switching to a holding regimen (either lamivudine monotherapy or other non-cART regimen); discontinuing all ART. We compared the effect of management strategy on the 52-week change in CD4% and log10VL from VF, using inverse probability weighting of marginal structural linear models. RESULTS Nine hundred eighty-two patients were followed over 54,168 weeks. Relative to remaining on a failing regimen, switching to second-line showed improved immunologic and virologic responses 52 weeks after VF with gains in CD4% of 1.5% (95% confidence interval [CI], 0.2-2.8) and declines in log10VL of -1.4 copies/mL (95% CI, -2.0, -0.8), while switching to holding regimens or discontinuing treatment had worse immunologic (-5.4% (95% CI, -12.1, 1.3) and -5.6% (95% CI, -15.4, 4.1) and virologic outcomes (0.2 (95% CI, -3.6, 4.1) and 0.8 (95% CI, -0.6, 2.1), respectively. CONCLUSIONS The results provide useful guidance for managing children with VF. Consideration should be given to switching children failing first-line cART to second-line, given the improved virologic and immune responses when compared with other strategies.

Lamivudine Monotherapy as a holding regimen for HIV-positive children

Background In resource-limited settings holding regimens, such as lamivudine monotherapy (LM), are used to manage HIV-positive children failing combination antiretroviral therapy (cART) to mitigate the risk of drug resistance developing, whilst adherence barriers are addressed or when access to second- or third-line regimens is restricted. We aimed to investigate characteristics of children placed on LM and their outcomes. Methods We describe the characteristics of children (age <16 years at cART start) from 5 IeDEA-SA cohorts with a record of LM during their treatment history. Among those on LM for >90 days we describe their immunologic outcomes on LM and their immunologic and virologic outcomes after resuming cART. Findings We included 228 children in our study. At LM start their median age was 12.0 years (IQR 7.3–14.6), duration on cART was 3.6 years (IQR 2.0–5.9) and median CD4 count was 605.5 cells/μL (IQR 427–901). Whilst 110 (48%) had no prior protease inhibitor (PI)-exposure, of the 69 with recorded PI-exposure, 9 (13%) patients had documented resistance to all PIs. After 6 months on LM, 70% (94/135) experienced a drop in CD4, with a predicted average CD4 decline of 46.5 cells/μL (95% CI 37.7–55.4). Whilst on LM, 46% experienced a drop in CD4 to <500 cells/μL, 18 (8%) experienced WHO stage 3 or 4 events, and 3 children died. On resumption of cART the average gain in CD4 was 15.65 cells/uL per month and 66.6% (95% CI 59.3–73.7) achieved viral suppression (viral load <1000) at 6 months after resuming cART. Interpretation Most patients experienced immune decline on LM. Its use should be avoided in those with low CD4 counts, but restricted use may be necessary when treatment options are limited. Managing children with virologic failure will continue to be challenging until more treatment options and better adherence strategies are available.