Programmatic Impact of the Evolution of WHO Pediatric Antiretroviral Treatment Guidelines for Resource-Limited Countries (Tukula Fenna Project, Uganda) (original) (raw)
Estimating the Impact and Cost of the WHO 2010 Recommendations for Antiretroviral Therapy
AIDS Research and Treatment, 2011
In July 2010, WHO published new recommendations on providing antiretroviral therapy to adults and adolescents, including starting ART earlier, usually at a CD4 count of 350 or lower, specific regimens for first-and second-line therapies, and other recommendations. This paper estimates the potential impact and cost of the revised guidelines by first, calculating the number of people that would be in need of antiretroviral therapy (ART) with different eligibility criteria, and second, calculating the costs associated with the potential impact. Results indicate that switching the eligibility criterion from CD4 count < 200 to < 350 increases the need for ART in low-and middle-income countries (country-level) by 50% (range 34% to 70%). The costs of ART programs only to increase coverage to 80% by 2015 would be 44% more (range 29% to 63%) when switching the eligibility criterion to CD4 count < 350. When testing and outreach costs are included, total costs increase by 62%, from US$26.3 billion under the previous eligibility criterion of treating those with CD4 < 200 to US$42.5 billion using the revised eligibility criterion of treating those with CD4 < 350. of Hindawi Publishing Corporation
Journal of the International AIDS Society, 2018
Introduction: The CD4 cell count and percent at initiation of combination antiretroviral therapy (cART) are measures of advanced HIV disease and thus are important indicators of programme performance for children living with HIV. In particular, World Health Organization (WHO) 2017 guidelines on advanced HIV disease noted that >80% of children aged <5 years started cART with WHO Stage 3 or 4 disease or severe immune suppression. We compared temporal trends in CD4 measures at cART start in children from low-, middle-and high-income countries, and examined the effect of WHO treatment initiation guidelines on reducing the proportion of children initiating cART with advanced disease. Methods: We included children aged <16 years from the International Epidemiology Databases to Evaluate acquired immunodeficiency syndrome (AIDS) (IeDEA) Collaboration (Caribbean, Central and South America, Asia-Pacific, and West, Central, East and Southern Africa), the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE), the North American Pediatric HIV/AIDS Cohort Study (PHACS) and International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) 219C study. Severe immunodeficiency was defined using WHO guidelines. We used generalized weighted additive mixed effect models to analyse temporal trends in CD4 measurements and piecewise regression to examine the impact of 2006 and 2010 WHO cART initiation guidelines. Results: We included 52,153 children from fourteen low-, eight lower middle-, five upper middle-and five high-income countries. From 2004 to 2013, the estimated percentage of children starting cART with severe immunodeficiency declined from 70% to 42% (low-income), 67% to 64% (lower middle-income) and 61% to 43% (upper middle-income countries). In highincome countries, severe immunodeficiency at cART initiation declined from 45% (1996) to 14% (2012). There were annual decreases in the percentage of children with severe immunodeficiency at cART initiation after the WHO guidelines revisions in 2006 (low-, lower middle-and upper middle-income countries) and 2010 (all countries). Conclusions: By 2013, less than half of children initiating cART had severe immunodeficiency worldwide. WHO treatment initiation guidelines have contributed to reducing the proportion of children and adolescents starting cART with advanced disease. However, considerable global inequity remains, in 2013, >40% of children in low-and middle-income countries started cART with severe immunodeficiency compared to <20% in high-income countries.
The impact and cost of the 2013 WHO recommendations on eligibility for antiretroviral therapy
AIDS, 2014
Objectives: The present study presents estimates of the number of people who would become newly eligible for antiretroviral therapy if all countries adopted the 2013 WHO treatment guidelines. It also shows the cost and impact that would result if coverage expanded to 80% of those eligible. Methods: The AIDS Impact Model (AIM) and the Goals model within the Spectrum modelling system were used for these estimates. Projections of costs and AIDS deaths are based on estimates for 116 low-income and middle-income countries. Projections of impact on HIV incidence are based on simulation modelling for 24 high burden countries, with the results scaled up to represent all low-income and middle-income countries. Results: If the 2013 guidelines were adopted universally, the number eligible for treatment would rise to 28.6 million in 2013. Achieving 80% coverage would mean 28 million on antiretroviral therapy by 2025, and would avert 2.9 million deaths and 3.9 million new infections from 2013 to 2025 compared with the 2010 guidelines. Conclusion: The 2013 guidelines significantly expand the number eligible for treatment. Reaching those newly eligible will require additional resources, but is likely to produce significant benefits.
Effect of changing antiretroviral treatment eligibility criteria on patient load in Kampala, Uganda
Aids Care-psychological and Socio-medical Aspects of Aids/hiv, 2011
In many resource-poor countries, CD4 count thresholds of eligibility for antiretroviral treatment (ART) were initially low (B200 cells/mm 3 ) but are now being increased to improve patient survival and to reduce HIV transmission. There are few quantitative data on the effect of such increases on the demand for ART. The objective of this study was to measure HIV prevalence and the proportion of HIV-positives eligible for antiretroviral therapy at different CD4 cut-off levels among users of public health care services in Kampala, Uganda. We recruited 1200 adults from three primary care clinics in Kampala, including equal numbers of family planning (FP) clients, pregnant women, adult patients with any complaint, and persons seeking HIV counseling and testing. All participants were screened for HIV and those positive had a CD4 count done. HIV prevalence in all patients was 16.9% (203/1200). ART eligibility based on CD4 counts significantly increased from 36% at a 200 cells/mm 3 cut-off to 44% at 250 cells and to 57% at 350 cells cut-off (p for x 2 trendB0.001). We concluded that changing cut-off levels to higher CD4 counts will significantly increase patient load in Kampala's primary care clinics, but a phased implementation should minimize negative effects on quality of care.
BMC infectious diseases, 2017
Viral suppression is a critical indicator of HIV treatment success. In the era of test-and-start, little is known about treatment outcomes and time to undetectable viral loads. This study compares treatment outcomes, median times to achieve undetectable viral loads and its predictors under different antiretroviral (ART) treatment initiation schedules (i.e. within seven days of enrolment or later). A retrospective cohort of 367 patients <18 years who enrolled in care between January 2010 and December 2015 with a baseline viral load of >5000 copies/ml were followed up for 60 months. Undetectable viral load measurements were based on both Roche (<20copies/ml) and Abbot (<75copies/ml). Clinical treatment outcomes were compared using chi-squared test. Survival experiences between the two cohorts were assessed through incidence rates and Kaplan Meier curves. A cox model with competing risks was used to assess predictors for time to undetectable viral load. Of the 367 patients,...
Feasibility and Challenges in Providing Antiretroviral Treatment to Children in Sub-Saharan Africa
The scale-up of pediatric antiretroviral therapy (ART) in sub-Saharan Africa over the past decade involved unprecedented political and donor commitment. These pediatric ART programs have demonstrated they can provide ART to human immunodeficiency virus (HIV)-infected children and that these children achieve treatment outcomes comparable to children in high-resource settings. Several obstacles, however, have hindered program implementation and impacted treatment outcomes. Challenges particularly affecting children include shortages of properly trained healthcare providers, lack of laboratory capacity for infant diagnosis and pediatric treatment monitoring, poor adherence, disclosure of HIV infection status and attrition. Innovative solutions to these challenges have been developed and programs are demonstrating they can successfully expand services to increase ART coverage in affected communities. As programs optimize the care and treatment of children, and more efficiently provide HIV services within the health care system, new challenges arise, including integration of child and family health services, use of electronic health records and the potential need for rationing antiretroviral drugs. Further evaluation of innovative solutions to these challenges and barriers to care, as well as continued commitment on the part of governments and donors, will be required if all HIV-infected children are to receive proper care.
Background: Since 2003 pediatric antiretroviral treatment (ART) programs have scaled-up in sub-Saharan Africa and should be evaluated to assess progress and identify areas for improvement. We evaluated secular trends in the characteristics and treatment outcomes of children in three pediatric ART clinics in urban and rural areas in Zambia. Methods: Routinely collected data were analyzed from three ART programs in rural (Macha and Mukinge) and urban (Lusaka) Zambia between program implementation and July 2008. Data were obtained from electronic medical record systems and medical record abstraction, and were categorized by year of program implementation. Characteristics of all HIV-infected and exposed children enrolled in the programs and all children initiating treatment were compared by year of implementation. Results: Age decreased and immunologic characteristics improved in all groups over time in both urban and rural clinics, with greater improvement observed in the rural clinics. Among children both eligible and ineligible for ART at clinic enrollment, the majority started treatment within a year. A high proportion of children, particularly those ineligible for ART at clinic enrollment, were lost to follow-up prior to initiating ART. Among children initiating ART, clinical and immunologic outcomes after six months of treatment improved in both urban and rural clinics. In the urban clinics, mortality after six months of treatment declined with program duration, and in the rural clinics, the proportion of children defaulting by six months increased with program duration. Conclusions: Treatment programs are showing signs of progress in the care of HIV-infected children, particularly in the rural clinics where scale-up increased rapidly over the first three years of program implementation. However, continued efforts to optimize care are needed as many children continue to enroll in ART programs at a late stage of disease and thus are not receiving the full benefits of treatment.
AIDS Research and Human Retroviruses, 2012
From 2006 to 2011, a cohort study was conducted among 1000 children resident in urban and rural settings of Uganda to ascertain and compare the response to antiretroviral therapy (ART) among urban versus rural children and the factors associated with this response. Clinical, immunological, and virological parameters were ascertained at baseline and weeks 24, 48, 96, and 144 after ART initiation. Adherence to ART was assessed at enrollment by self-report (SR) and pill counts (PC). Overall, 499/948 (52.6%) children were resident in rural areas, 504/948 (53.1%) were male, and their mean age was 11.9 -4.4 years (urban children) and 11.4 -4.1 years (rural children). The urban children were more likely to switch to second-line ART at a rate of 39.9 per 1000 person-years (95% CI: 28.2-56.4) versus 14.9 per 1000 person-years (95% CI: 8.7-25.7), p = 0.0038, develop any new WHO 3/4 events at 127/414 (30.7%) versus 108/466 (23.2%), p = 0.012, and have a higher cumulative incidence of hospitalization of 54/449 (12.0%) versus 32/499 (6.4%), p = 0.003, when compared to rural children. No differences were observed in mean changes in weight, height, CD4 count and percentage, and hemoglobin and viral load between urban and rural children. Adherence of ‡ 95% was observed in 88.2% of urban versus 91.3% of rural children by SR ( p = 0.130), and in 78.8% of urban versus 88.8% of rural children by PC ( p < 0.0001). In this study rural children had more favorable clinical outcomes and were more likely to adhere optimally to ART than urban children.
AIDS, 2008
Objective: We aimed to evaluate clinical and immunological outcomes of paediatric patients receiving combination antiretroviral therapy (cART) enrolled in The AIDS Support Organization (TASO) Uganda national HIV/AIDS programme. Design: Observational study of patients (age <14 years) enrolled in 10 clinics across Uganda for which TASO has data. Methods: We extracted patient demographic, immunological and clinical outcomes from the TASO databases regarding age, sex, cART regimen, CD4 cell count and WHO stage at initiation, tuberculosis, mortality and adherence. Outcomes were analysed using Pearson's rank-order correlations, Wilcoxon's rank sum tests, Cox proportional hazard model and survivor functions. Results: Of the total 770 HIV children on cART, median age was 9 years (interquartile range, 5-13 years), and median follow-up time was 377 days (interquartile range, 173-624 days). Seven hundred and fifty-one children (97.5%) initiated nonnucleoside reverse transcriptase inhibitor-based regimens. Three hundred and sixty-five children (47.5%) initiated cART with severe immune suppression (CD4 cell percentage <15). Of the 18 (2.3%) children that died, mortality was associated with lower CD4 cell percentage at initiation (B coefficient À0.144, standard error 0.06, P ¼ 0.02). Of the total, 229 (30%) were single or double orphans and more likely to initiate cART at an older age (mean age, 9.25 vs. 8.35 years, P ¼ 0.02) and have a lower CD4 cell count (median, 268 vs. 422 cells/ml, P 0.0001) and CD4 cell percentage (median 12.8 vs. 15.5%, P ¼ 0.02) at initiation. Pulmonary tuberculosis was present in 43 (5.6%) patients at initiation and 21 (2.3%) after cART. Almost all patients (94.9%) demonstrated more than 95% adherence. Conclusion: Children on cART in Uganda demonstrate positive clinical outcomes. However, additional support is required to ensure timely cART access among orphans and young children.