Search

Introduction: Despite the central role of caregivers in managing HIV treatment for children living with HIV, viral suppression within caregiver-child dyads in which both members are living with HIV is not well described. Methods: We conducted a retrospective analysis of children living with HIV Results: Of 7667 children who received care at AMPATH during the study period, 1698 were linked to a caregiver living with HIV and included as caregiver-child dyads. For caregivers, 94% were mothers, median age at ART initiation 32.8 years, median CD4 count at ART initiation 164 cells/[mm.sup.3] and 23% were not virally suppressed. For children, 52% were female, median age at ART initiation 4.2 years, median CD4 values at ART initiation were 15% (age < 5 years) and 396 cells/[mm.sup.3] (age [greater than or equal to] 5 years), and 38% were not virally suppressed. In the multivariable model, children were found more likely to not be virally suppressed if their caregivers were not suppressed compared to children with suppressed caregivers (aOR = 2.40, 95% CI: 1.86 to 3.10). Other characteristics associated with child viral non-suppression included caregiver ART regimen change prior to the VL, caregiver receipt of a non-NNRTI-based regimen at the time of the VL, younger child age at ART initiation and child tuberculosis treatment at the time of the VL. Conclusions: Children were at higher risk of viral non-suppression if their caregivers were not virally suppressed compared to children with suppressed caregivers. A child's viral suppression status should be closely monitored if his or her caregiver is not suppressed. Keywords: HIV; child; caregiver; viraemia; adherence; sub-Saharan Africa, 1 | INTRODUCTION The scale-up of antiretroviral therapy (ART) in sub-Saharan Africa has improved survival of both children living with HIV and their parents and caregivers living with HIV [1]. [...]

Introduction: Weaknesses in care programmes providing anti-retroviral therapy (ART) persist and are often instigated by late HIV diagnosis and poor linkage to care. We investigated the potential for a home-based counselling and testing (HBCT) campaign to be improved through the optimal timing and enhancement of testing rounds to generate greater health outcomes at minimum cost. Methods: Using a mathematical model of HIV care calibrated to longitudinal data from The Academic Model Providing Access To Healthcare (AMPATH) in Kenya, we simulated HBCT campaigns between 2016 and 2036, assessing the impact and total cost of care for each, for a further 20 years. Results: We find that simulating five equally spaced rounds averts 1.53 million disability-adjusted life-years (DALYs) at a cost of $1617 million. By altering the timing of HBCT rounds, a four-round campaign can produce greater impact for lower cost. With 'front-loaded' rounds, the cost per DALY averted is reduced by 12% as fewer rounds are required ($937 vs. $1060). Furthermore, improvements to HBCT coverage and linkage to care avert over two million DALYs at a cost per DALY averted of $621 (41% less than the reference scenario). Conclusions: Countries implementing HBCT can reduce costs by optimally timing rounds and generate greater health outcomes through improving linkage, coverage, and retention. Tailoring HBCT campaigns to individual settings can enhance patient outcomes for minimal cost. Keywords: HIV; care cascade; mathematical model; home-based counselling & testing; treatment cascade; antiretroviral therapy; HIV testing, 1 | INTRODUCTION Remarkable progress has been made during the past decade towards reducing HIV-related mortality, reducing transmission and prolonging the life-expectancy of HIV-positive individuals [1-3]. With a 42% decline [...]

Background: In resource‐poor settings, mortality is at its highest during the first 3 months after combination antiretroviral treatment (cART) initiation. A clear predictor of mortality during this period is having a low CD4 count at the time of treatment initiation. The objective of this study was to evaluate the effect on survival and clinic retention of a nurse‐based rapid assessment clinic for high‐risk individuals initiating cART in a resource‐constrained setting. Methods: The USAID‐AMPATH Partnership has enrolled more than 140,000 patients at 25 clinics throughout western Kenya. High Risk Express Care (HREC) provides weekly or bi‐weekly rapid contacts with nurses for individuals initiating cART with CD4 counts of ≤100 cells/mm[sup.3]. All HIV‐infected individuals aged 14 years or older initiating cART with CD4 counts of ≤100 cells/mm[sup.3] were eligible for enrolment into HREC and for analysis. Adjusted hazard ratios (AHRs) control for potential confounding using propensity score methods. Results: Between March 2007 and March 2009, 4,958 patients initiated cART with CD4 counts of ≤100 cells/mm[sup.3]. After adjusting for age, sex, CD4 count, use of cotrimoxazole, treatment for tuberculosis, travel time to clinic and type of clinic, individuals in HREC had reduced mortality (AHR: 0.59; 95% confidence interval: 0.45‐0.77), and reduced loss to follow up (AHR: 0.62; 95% CI: 0.55‐0.70) compared with individuals in routine care. Overall, patients in HREC were much more likely to be alive and in care after a median of nearly 11 months of follow up (AHR: 0.62; 95% CI: 0.57‐0.67). Conclusions: Frequent monitoring by dedicated nurses in the early months of cART can significantly reduce mortality and loss to follow up among high‐risk patients initiating treatment in resource‐constrained settings., Background Combination antiretroviral treatment (cART) has proven itself to be an effective therapeutic mechanism for suppressing viral replication and enabling reconstitution of the immune system, thus allowing patients to recover [...]

Introduction: Tenofovir-based first-line antiretroviral therapy (ART) is recommended globally. To evaluate the impact of its incorporation into the World Health Organization (WHO) guidelines, we examined treatment failure and drug resistance among a cohort of patients on tenofovir-based first-line ART at the Academic Model Providing Access to Healthcare, a large HIV treatment programme in western Kenya. Methods: We determined viral load (VL), drug resistance and their correlates in patients on [greater than or equal to] six months of tenofovir-based firstline ART. Based on enrolled patients' characteristics, we described these measures in those with (prior ART group) and without (tenofovir-only group) prior non-tenofovir-based first-line ART using Wilcoxon rank sum and Fisher's exact tests. Results: Among 333 participants (55% female; median age 41 years; median CD4 336 cells/[micro]L), detectable (>40 copies/mL) VL was found in 18%, and VL > 1000 copies/mL (WHO threshold) in 10%. Virologic failure at both thresholds was significantly higher in 217 participants in the tenofovir-only group compared with 116 in the prior ART group using both cut-offs (24% vs. 7% with VL >40 copies/mL; 15% vs. 1% with VL >1000 copies/mL). Failure in the tenofovir-only group was associated with lower CD4 values and advanced WHO stage. In 35 available genotypes from 51 participants in the tenofovir-only group with VL >40 copies/mL (69% subtype A), any resistance was found in 89% and dual-class resistance in 83%. Tenofovir signature mutation K65R occurred in 71% (17/24) of the patients infected with subtype A. Patients with K65R had significantly lower CD4 values, higher WHO stage and more resistance mutations. Conclusions: In this Kenyan cohort, tenofovir-based first-line ART resulted in good (90%) virologic suppression including high suppression (99%) after switch from non-tenofovir-based ART. Lower virologic suppression (85%) and high observed resistance levels (89%) in the tenofovir-only group impact future treatment options, support recommendations for widespread VL monitoring in such resource limited settings to identify early treatment failure and suggest consideration of individualized resistance testing to design effective subsequent regimens. Keywords: HIV; drug resistance; tenofovir; Kenya; subtype., Introduction In 2014, 10.7 million people in sub-Saharan Africa received antiretroviral therapy (ART), an effort that reduced the number of AIDS-related deaths in the region by 48% [1]. As new [...]

Introduction: Antiretroviral resistance leads to treatment failure and resistance transmission. Resistance data in western Kenya are limited. Collection of non‐plasma analytes may provide additional resistance information. Methods: We assessed HIV diversity using the REGA tool, transmitted resistance by the WHO mutation list and acquired resistance upon first‐line failure by the IAS–USA mutation list, at the Academic Model Providing Access to Healthcare (AMPATH), a major treatment programme in western Kenya. Plasma and four non‐plasma analytes, dried blood‐spots (DBS), dried plasma‐spots (DPS), ViveST[sup.TM]‐plasma (STP) and ViveST‐blood (STB), were compared to identify diversity and evaluate sequence concordance. Results: Among 122 patients, 62 were treatment‐naïve and 60 treatment‐experienced; 61% were female, median age 35 years, median CD4 182 cells/µL, median viral‐load 4.6 log[sub.10] copies/mL. One hundred and ninety‐six sequences were available for 107/122 (88%) patients, 58/62 (94%) treatment‐naïve and 49/60 (82%) treated; 100/122 (82%) plasma, 37/78 (47%) attempted DBS, 16/45 (36%) attempted DPS, 14/44 (32%) attempted STP from fresh plasma and 23/34 (68%) from frozen plasma, and 5/42 (12%) attempted STB. Plasma and DBS genotyping success increased at higher VL and shorter shipment‐to‐genotyping time. Main subtypes were A (62%), D (15%) and C (6%). Transmitted resistance was found in 1.8% of plasma sequences, and 7% combining analytes. Plasma resistance mutations were identified in 91% of treated patients, 76% NRTI, 91% NNRTI; 76% dual‐class; 60% with intermediate‐high predicted resistance to future treatment options; with novel mutation co‐occurrence patterns. Nearly 88% of plasma mutations were identified in DBS, 89% in DPS and 94% in STP. Of 23 discordant mutations, 92% in plasma and 60% in non‐plasma analytes were mixtures. Mean whole‐sequence discordance from frozen plasma reference was 1.1% for plasma‐DBS, 1.2% plasma‐DPS, 2.0% plasma‐STP and 2.3% plasma‐STB. Of 23 plasma‐STP discordances, one mutation was identified in plasma and 22 in STP (p Conclusions: In a large treatment programme in western Kenya, we report high HIV‐1 subtype diversity; low plasma transmitted resistance, increasing when multiple analytes were combined; and high‐acquired resistance with unique mutation patterns. Resistance surveillance may be augmented by using non‐plasma analytes for lower‐cost genotyping in resource‐limited settings., Introduction Antiretroviral therapy (ART) resistance is a cause and a consequence of treatment failure [1, 2]. Optimizing treatment in resource‐limited settings (RLS) is problematic due to limited availability and high [...]