Guy Harling

Determinants of Mortality and Nondeath Losses from an Antiretroviral Treatment Service in South Africa: Implications for Program Evaluation

BACKGROUND The scale-up of antiretroviral treatment (ART) services in resource-limited settings requires a programmatic model to deliver care to large numbers of people. Understanding the determinants of key outcome measures--including death and nondeath losses--would assist in program evaluation and development. METHODS Between September 2002 and August 2005, all in-program (pretreatment and on-treatment) deaths and nondeath losses were prospectively ascertained among treatment-naive adults (n=1235) who were enrolled in a community-based ART program in South Africa. RESULTS At study censorship, 927 patients had initiated ART after a median of 34 days after enrollment in the program. One hundred twenty-one (9.8%) patients died. Mortality rates were 33.3 (95% CI, 25.5-43.0), 19.1 (95% CI, 14.4-25.2), and 2.9 (95% CI, 1.8-4.8) deaths/100 person-years in the pretreatment interval, during the first 4 months of ART (early deaths), and after 4 months of ART (late deaths), respectively. Pretreatment and early treatment deaths together accounted for 87% of deaths, and were independently associated with advanced immunodeficiency at enrollment. Late deaths were comparatively few and were only associated with the response to ART at 4 months. Nondeath program losses (loss to follow-up, 2.3%; transfer-out, 1.9%; relocation, 0.7%) were not associated with immune status and were evenly distributed during the study period. CONCLUSIONS Loss to follow-up and late mortality rates were low, reflecting good cohort retention and treatment response. However, the extremely high pretreatment and early mortality rates indicate that patients are enrolling in ART programs with far too advanced immunodeficiency. Causes of late access to the ART program, such as delays in health care access, health system delays, or inappropriate treatment criteria, need to be addressed.

Do age-disparate relationships drive HIV incidence in young women? Evidence from a population cohort in rural KwaZulu-Natal, South Africa.

Background:Based on ethnographic investigations and mathematical models, older sexual partners are often considered a major risk factor for HIV for young women in sub-Saharan Africa. Numerous public health campaigns have been conducted to discourage young women from relationships with older men. However, longitudinal evidence relating sex partner age disparity to HIV acquisition in women is limited. Methods:Using data from a population-based open cohort in rural KwaZulu-Natal, South Africa, we studied 15- to 29-year-old women who were HIV seronegative at first interview between January 2003 and June 2012 (n = 2444). We conducted proportional hazards analysis to establish whether the age disparity of womens most recent sexual partner, updated at each surveillance round, was associated with subsequent HIV acquisition. Results:A total of 458 HIV seroconversions occurred over 5913 person-years of follow-up (incidence rate: 7.75 per 100 person-years). Age disparate relationships were common in this cohort; 37.7% of women reported a partner 5 or more years older than themselves. The age disparity of womens partners was not associated with HIV acquisition when measured either continuously [hazard ratio (HR) for 1-year increase in partners age: 1.00, 95% confidence interval (CI): 0.97 to 1.03] or categorically (man ≥5 years older: HR, 0.98; 95% CI: 0.81 to 1.20; man ≥10 years older: HR, 0.98; 95% CI: 0.67 to 1.43). These results were robust to adjustment for known sociodemographic and behavioral HIV risk factors and did not vary significantly by womens age, marital status, education attainment, or household wealth. Conclusions:HIV incidence in young women was very high in this rural community in KwaZulu-Natal. Partner age disparity did not predict HIV acquistion. Campaigns to reduce age-disparate sexual relationships may not be a cost-effective use of HIV prevention resources in this setting.

No Association between HIV and Intimate Partner Violence among Women in 10 Developing Countries

Background Intimate Partner Violence (IPV) has been reported to be a determinant of womens risk for HIV. We examined the relationship between womens self-reported experiences of IPV in their most recent relationship and their laboratory-confirmed HIV serostatus in ten low- to middle-income countries. Methodology/Principal Findings Data for the study came from the most recent Demographic and Health Surveys conducted in Dominican Republic, Haiti, India, Kenya, Liberia, Malawi, Mali, Rwanda, Zambia and Zimbabwe. Each survey population was a cross-sectional sample of women aged 15–49 years. Information on IPV was obtained by a face-to-face interview with the mother with an 81.1% response rate; information on HIV serostatus was obtained from blood samples with an 85.3% response rate. Demographic and socioeconomic variables were considered as potentially confounding covariates. Logistic regression models accounting for multi-stage survey design were estimated individually for each country and as a pooled total with country fixed effects (n = 60,114). Country-specific adjusted odds ratios (OR) for physical or sexual IPV compared to neither ranged from 0.45 [95% confidence interval (CI): 0.23–0.90] in Haiti to 1.35 [95% CI: 0.95–1.90] in India; the pooled association was 1.03 [95% CI: 0.94–1.13]. Country-specific adjusted ORs for physical and sexual IPV compared to no sexual IPV ranged from 0.41 [95% CI: 0.12–1.36] in Haiti to 1.41 [95% CI: 0.26–7.77] in Mali; the pooled association was 1.05 [95% CI: 0.90–1.22]. Conclusions IPV and HIV were not found to be consistently associated amongst ever-married women in national population samples in these lower income countries, suggesting that IPV is not consistently associated with HIV prevalence worldwide. More research is needed to understand the circumstances in which IPV and HIV are and are not associated with one another.

The Evolving Cost of HIV in South Africa Changes in Health Care Cost With Duration on Antiretroviral Therapy for Public Sector Patients

A retrospective costing study of 212 patients enrolled in a nongovernmental organization-supported public sector antiretroviral treatment (ART) program near Cape Town, South Africa was performed from a health care system perspective. γ-Regression was used to analyze total costs in 3 periods: Pre-ART (median length = 30 days), first 48 weeks on ART (Year One), and 49 to 112 weeks on ART (Year Two). Average cost per patient Pre-ART was

The cost of treatment and care for people living with HIV infection: implications of published studies, 1999-2008

404. Average cost per patient-year of observation was

Socioeconomic disparities in Sexually Transmitted Infections among young adults in the United States: examining the interaction between income and race/ethnicity

2502 in Year One and

Standard measures are inadequate to monitor pediatric adherence in a resource-limited setting.

1372 in Year Two. The proportion of costs attributable to hospital care fell from 70% Pre-ART to 24% by Year Two; the proportion attributable to ART rose from 31% in Year One to 55% in Year Two. In multivariate analysis, Pre-ART and Year One costs were significantly lower for asymptomatic patients compared with those with AIDS. Costs were significantly higher for those who died Pre-ART or in Year One. In Year Two, only week 48 CD4 cell count and being male were significantly associated with lower costs. This analysis suggests that the total cost of treatment for patients on ART falls by almost half after 1 year, largely attributable to a reduction in hospital costs.

Healthcare utilization of patients accessing an African national treatment program.

Purpose of reviewIncreasing number of people living with HIV (PLHIV) will require expanded access to health services. Countries need robust and contemporary strategic information on the cost of care to monitor and evaluate the effectiveness, efficiency, equity, and acceptability of services. Published HIV cost literature from July 1999 to December 2008 was reviewed. Articles were identified using specific databases and scored, based on explicit criteria relating to the services covered, utilization data, cost data used and quality of the study. Recent findingsOne hundred and fifteen articles were identified, 47% came from North America, 29% from Europe, 17% from Africa and 8% from Asia; no studies from Latin America could be identified. The mean score across all studies was 33.7 out of a maximum of 64, with a median of 34 and a range of 11–51. Mean score did not change significantly over time (Pearsons R8 = 0.3; P > 0.05). SummaryGreat variation was observed in the methods used to estimate cost data across the studies identified, including range of services, patients covered and outcomes costed. Progress in the quantity and quality of studies published since 1999 has been limited. More consistent costing methods and more comprehensive coverage – both by country and level of care – are needed in order for policymakers and other stakeholders to be able to optimally monitor and evaluate the cost and cost–effectiveness of country services for HIV treatment and care, especially as population costs are likely to increase with more PLHIV on antiretroviral therapy.

A spatial analysis of social and economic determinants of tuberculosis in Brazil

Background There is considerable evidence of racial/ethnic patterning of sexually transmitted infection (STI) risk in the United States. There is also evidence that poorer persons are at increased STI risk. Evidence regarding the interaction of race/ethnicity and income is limited, particularly nationally at the individual level. Methods We examined the pattern of socioeconomic gradients in STI infection among young people in a nationwide US study and determined how these gradients varied by race/ethnicity. We estimated the cumulative diagnosis prevalence of chlamydia, gonorrhea, or trichomoniasis (via self-report or laboratory confirmation) for young adults (ages, 18–26 years old) Hispanics and non-Hispanic whites, blacks, and others across income quintiles in the Add Health data set. We ran regression models to evaluate these relationships adjusting for individual- and school-level covariates. Results Sexually transmitted infection diagnosis was independently associated with both racial/ethnic identity and with low income, although the racial/ethnic disparities were much larger than income-based ones. A negative gradient of STI risk with increasing income was present within all racial/ethnic categories, but was stronger for nonwhites. Conclusions Both economic and racial/ethnic factors should be considered in deciding how to target STI prevention efforts in the United States. Particular focus may be warranted for poor, racial/ethnic minority women.

HIV self-testing among female sex workers in Zambia: A cluster randomized controlled trial

This study aims to compare the use and cost of objective and subjective measures of adherence to pediatric antiretroviral treatment in a primary care facility in South Africa. In a 1-month longitudinal study of 53 caregiver-child dyads, pharmacy refill (PR), measurement of returned syrups (RS), caregiver self-report (3DR) and Visual Analogue Scale (VAS) were compared to Medication Event Monitoring System (MEMS). Adherence was 100% for both VAS and 3DR; by PR and RS 100% and 103%, respectively. MEMS showed that 92% of prescribed doses were administered, but only 66% of these within the correct 12-hourly interval. None of the four measures correlated significantly with MEMS. MEMS data suggest that timing of doses is often more deviant from prescribed than expected and should be better addressed when monitoring adherence. Of all, MEMS was by far the most expensive measure. Alternative, cheaper electronic devices need to be more accessible in resource-limited settings.