Niklaus Daniel Labhardt

Outcomes of antiretroviral treatment programs in rural Southern Africa

Background:Data on outcomes of antiretroviral treatment (ART) programs in rural sub-Saharan African are scarce. We describe early losses and long-term outcomes in 6 rural programs in Southern Africa with limited access to viral load monitoring and second-line ART. Methods:Patients aged ≥16 years starting ART in 2 programs each in Zimbabwe, Mozambique, and Lesotho were included. We evaluated risk factors for no follow-up after starting ART and mortality and loss to follow-up (LTFU) over 3 years of ART, using logistic regression and competing risk models. Odds ratios and subdistribution hazard ratios, adjusted for gender, age category, CD4 category, and World Health Organization stage at start of ART are reported. Results:Among 7725 patients, 449 (5.8%) did not return after initiation of ART. During 9575 person-years, 698 (9.6%) of those with at least 1 follow-up visit died, and 1319 (18.1%) were LTFU. At 3 years, the cumulative incidence of death and LTFU were 12.5% (11.5%–13.5%) and 25.4% (24.0%–26.9%), respectively, with important differences between countries as follows: in Zimbabwe 75.1% (72.8%–77.3%) were alive and on ART at 3 years compared with 55.4% (52.8%–58.0%) in Lesotho and 51.6% (48.0%–55.2%) in Mozambique. In all settings, young age and male gender predicted LTFU, whereas advanced clinical stage and low baseline CD4 counts predicted death. Conclusions:In African ART programs with limited access to second-line treatment, mortality, and LTFU are high in the first 3 years of ART. Low retention in care is a major threat to the sustainability of ART delivery in Southern Africa, particularly in rural sites.

Bridging the gap: how traditional healers interact with their patients : a comparative study in Cameroon

Objective  To compare traditional healers (TH) and Cameroonian representatives of Western medicine (Western providers (WP)) in terms of patient characteristics and communication patterns during the consultation in rural Cameroon.

Early assessment of the implementation of a national programme for the prevention of mother‐to‐child transmission of HIV in Cameroon and the effects of staff training: a survey in 70 rural health care facilities

Objectives  To assess the availability of equipment and the staff’s knowledge to prevent Mother‐To‐Child Transmission (PMTCT) in rural healthcare facilities recently covered by the national PMTCT programme in Cameroon.

Outcomes of antiretroviral treatment programmes in rural Lesotho: health centres and hospitals compared

Lesotho was among the first countries to adopt decentralization of care from hospitals to nurse‐led health centres (HCs) to scale up the provision of antiretroviral therapy (ART). We compared outcomes between patients who started ART at HCs and hospitals in two rural catchment areas in Lesotho.

Adoption of new HIV treatment guidelines and drug substitutions within first-line as a measure of quality of care in rural Lesotho: health centers and hospitals compared

Objective  In 2007, Lesotho launched new national antiretroviral treatment (ART) guidelines, prioritising tenofovir and zidovudine over stavudine as a backbone together with lamivudine. We compared the rate of adoption of these new guidelines and substitution of first‐line drugs by health centers (HC) and hospitals in two catchment areas in rural Lesotho.

Clinical and socio-demographic predictors for virologic failure in rural Southern Africa: preliminary findings from CART-1

In 2013, the World Health Organization (WHO) recommended scaling up of routine viral load (VL) monitoring for patients on antiretroviral therapy (ART) in resource‐limited settings [ 1 ]. During the transition phase from no VL‐testing at all to routine VL‐monitoring, targeted VL for groups at particular risk of virologic failure (VF) may be an option [ 2 ]. We present socio‐demographic and clinical risk factors for VF in a cohort in rural Lesotho with no access to VL prior to the study.

Higher rates of metabolic syndrome among women taking zidovudine as compared to tenofovir in rural Africa: preliminary data from the CART-1 study

Due to its side effects stavudine (D4T) has been replaced by zidovudine (AZT) and tenofovir (TDF) in most low‐ and middle‐income countries (LMICs). In 2014 about 38% of adult first‐line regimens contain AZT and 62% TDF [ 1 ]. Whereas the unfavourable metabolic outcomes of D4T in comparison to TDF have been described extensively, studies from LMICs comparing metabolic profiles between patients on AZT and TDF are scarce. Given the high number of patients in LMICs still taking AZT, data on their metabolic profile are needed. We present rates of metabolic syndrome (MS) in adult patients taking either AZT‐ or TDF‐containing first‐line, non‐nucleoside reverse transcriptase (NNRTI)‐based regimens.

Should viral load thresholds be lowered?: Revisiting the WHO definition for virologic failure in patients on antiretroviral therapy in resource-limited settings.

Abstract The World Health Organization (WHO) guidelines on antiretroviral therapy (ART) define treatment failure as 2 consecutive viral loads (VLs) ≥1000 copies/mL. There is, however, little evidence supporting 1000 copies as an optimal threshold to define treatment failure. Objective of this study was to assess the correlation of the WHO definition with the presence of drug-resistance mutations in patients who present with 2 consecutive unsuppressed VL in a resource-limited setting. In 10 nurse-led clinics in rural Lesotho children and adults on first-line ART for ≥6 months received a first routine VL. Those with plasma VL ≥80 copies/mL were enrolled in a prospective study, receiving enhanced adherence counseling (EAC) and a follow-up VL after 3 months. After a second unsuppressed VL genotypic resistance testing was performed. Viruses with major mutations against ≥2 drugs of the current regimen were classified as “resistant”. A total of 1563 adults and 191 children received a first routine VL. Of the 138 adults and 53 children with unsuppressed VL (≥80 copies/mL), 165 (116 adults; 49 children) had a follow-up VL after EAC; 108 (74 adults; 34 children) remained unsuppressed and resistance testing was successful. Ninety of them fulfilled the WHO definition of treatment failure (both VL ≥1000 copies/mL); for another 18 both VL were unsuppressed but with <1000 copies/mL. The positive predictive value (PPV) for the WHO failure definition was 81.1% (73/90) for the presence of resistant virus. Among the 18 with VL levels between 80 and 1000 copies/mL, thereby classified as “non-failures”, 17 (94.4%) harbored resistant viruses. Lowering the VL threshold from 1000 copies/mL to 80 copies/mL at both determinations had no negative influence on the PPV (83.3%; 90/108). The current WHO-definition misclassifies patients who harbor resistant virus at VL below 1000 c/mL as “nonfailing.” Lowering the threshold to VL ≥80 copies/mL identifies a significantly higher number of patients with treatment-resistant virus and should be considered.

Fieber bei Reiserückkehrern

Kenntnisse des regionalen Vorkommens bzw. der geographischen Verteilung infrage kommender Infektionskrankheiten sind fur die Abklarung besonders wichtig. Dabei gilt auch hier: «Haufiges ist haufig, Seltenes ist selten».

Fièvre au retour d’un voyage

La connaissance de l’epidemiologie regionale et de la distribution geographique des maladies infectieuses possibles est particulierement essentielle pour l’evaluation.