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Expanding hypertension services in low- and middle-income countries requires efficient and effective service delivery approaches that meet the needs and expectations of people living with hypertension within the resource constraints of existing national health systems. Ideally, a hypertension program will extend treatment coverage while maintaining service quality, maximizing efficient resource utilization and improving clinical outcomes. In this article, we discuss lessons learned from HIV differentiated service delivery initiatives, and make the case that the same approach should be adopted for hypertension programs.

Highlights: - Despite clinical evidence of its effectiveness in secondary prevention of cardiovascular disease, uptake of fixed dose combination therapy (FDCs) for CVD has been poor. - A symposium was held bringing together stakeholders on this issue, including from academia, government and NGOs. - The conclusion made was that what is now needed to improve implementation of FDCs is country-specific health systems analyses to design appropriate implementation strategies. - Implementation strategies must look beyond listing on the WHO Essential Medicines List to consider approaches to improving FDC availability, accessibility, affordability, and adherence. - Strategies might include incorporation of FDCs into the WHO HEARTS technical package, simplified treatment and monitoring algorithms, decentralisation of medicine dispensing and task-sharing for treatment management.

Purpose of review Differentiated service delivery (DSD) for HIV provides an approach to scaling services that are client-centred and aims to address client challenges whilst reducing the burden on health systems. With access to antiretroviral therapy, people living with HIV are living longer and increasingly present with comorbid conditions, such as hypertension and diabetes. This review presents the syndemic burden of HIV, hypertension and diabetes and highlights opportunities and challenges to leveraging DSD across diseases. Recent findings Prevalence of hypertension and diabetes in the eight highest HIV prevalence countries ranges between 20-24% (31.9% in those >50 years old) and 4-10%, respectively. Service delivery models addressing the concurrent syndemics focus primarily on integration of services. Two DSD examples were found where people living with HIV and other comorbidities had their care and treatment supported in healthcare worker-led facility-based adherence clubs. Summary Key enablers that have supported DSD for HIV such as simplified algorithms, optimized formulations, secure drug supply, and strengthened monitoring and evaluation systems are lacking for hypertension and diabetes and thus pose a major challenge to leveraging DSD models for people with syndemic conditions. However, the DSD approach may also catalyse opportunities to provide person-centred care for these syndemics and more implementation research in this area is warranted.

Nathan Ford and co-authors discuss global priorities in the provision of HIV prevention and treatment services.

Differentiated care, or differentiated service delivery (DSD), is increasingly being promoted as one of the possible ways to address and improve access, quality, and efficiency of HIV prevention, care, and treatment. Family-centered care has long been promoted within the provision of HIV services, but the full benefits have not necessarily been realized. In this article, we bring together these two approaches and make the case for how family-centered DSD can offer benefits to both people affected by HIV and the health system. Family-centered DSD approaches are presented for HIV testing and antiretroviral therapy (ART) delivery, referencing policies, best practice examples, and evidence from the field. With differentiated family-centered ART delivery, the potential efficiencies gained by extending ART refills can both benefit clients by reducing the frequency and intensity of contact with the health service and lead to health system gains by not requiring multiple providers to care for one family. A family-centered DSD approach should also be leveraged along the HIV care cascade in the provision of prevention technologies and mobilizing family members to receive regular HIV testing. Furthermore, a family-centered lens should be applied wherever DSD is implemented to ensure that, for example, adolescents who are pregnant receive an adapted package of quality care.

A multicentric, retrospective case-series analysis (facility-based) in five sites across Kenya, Malawi, Mozambique, and Uganda screened HIV-positive adults for hepatitis C virus (HCV) antibodies using Oraquick rapid testing and viral confirmation (in three sites). The results reveal a substantially lower prevalence than previously reported for these countries, suggesting that targeted integration of HCV screening in African HIV programs may be more impactful than routine screening.

We regret that this article is behind a paywall., Patients with advanced HIV disease have a high risk of mortality, mainly from tuberculosis and cryptococcal meningitis. The advanced HIV disease management package recommended by WHO, which includes diagnostics, therapeutics, and patient psychosocial support, is barely implemented in many different countries. Here, we present a framework for the implementation of advanced HIV disease diagnostics. Laboratory and point-of-care-based reflex testing, coupled with provider-initiated requested testing, for cryptococcal antigen and urinary Mycobacterium tuberculosis lipoarabinomannan antigen, should be done for all patients with CD4+ cell counts of 200 cells per μL or less. Implementation of the advanced HIV disease package should be encouraged within primary health-care facilities and task shifting of testing to lay cadres could facilitate access to rapid results. Implementation of differentiated antiretroviral therapy delivery models can allow clinicians enough time to focus on the management of patients with advanced HIV disease. Efficient up-referral and post-discharge systems, including the development of patient-centric advanced HIV disease literacy, are also crucial. Implementation of the advanced HIV disease package is feasible at all health-care levels, and it should be part of the core of the global response towards ending AIDS as a public health threat.

GPs from the UK have historically spent time abroad during their medical careers, working as clinicians in both high and low-to-middle income countries.1,2 With progressive globalisation and advances in communication and transport, there is an increasing interest in global health training3–5 and a variety of opportunities for GPs from the UK to engage in international work and global health issues.6–8 As the NHS seeks to address the challenges of an ageing population and cost effectiveness while striving for high quality health care, UK primary care is in constant evolution. The past decade has seen an emergent policy emphasis on clinical leadership, identifying competencies needed for doctors to contribute meaningfully to planning and delivering health services.9–11 These have been recently expressed in the NHS Leadership Framework, informed by analysis of NHS leadership data and literature.12 The recent acceptance of the Royal College of General Practitioners’ (RCGP) bid to extend GP training to 4 years13 reflects major changes to healthcare delivery including a progressive transition from hospital to community settings and integration of clinical services. It also highlights the shift in NHS structure whereby GPs are becoming increasingly responsible for design as well as delivery of services.14 Figure 1 Domains of the NHS Leadership Framework (reproduced with permission from the NHS Leadership Framework) . Given these developments and the dynamic role of the GP within the context of recent health reform, it may now appear reasonable to question whether international work experience is an appropriate use of time and whether it is of value to UK GPs, to the NHS, or towards improving global health. The 2007 Crisp …

BackgroundMobile Health or mHealth interventions, including Short Message Service (SMS), can help increase access to care, enhance the efficiency of health service delivery and improve diagnosis and treatment for HIV. Text messaging, or SMS, allows for the low cost transmission of information, and has been used to send appointment reminders, information about HIV counselling and treatment, messages to encourage adherence and information on nutrition and side-effects. HIV Viral Load (VL) monitoring is recommended by the WHO and has been progressively adopted in many settings. In Zimbabwe, implementation of VL is routine and has been rolled out with support of Médecins Sans Frontières (MSF) since 2012. An SMS intervention to assist with the management of VL results was introduced in two rural districts of Zimbabwe. After completion of the HIV VL testing at the National Microbiology Reference Laboratory in Harare, results were sent to health facilities via SMS. Consenting patients were also sent an SMS informing them that their viral load results were ready for collection at their nearest health facilities. No actual VL results were sent to patients.MethodsA qualitative study was conducted in seven health-care facilities using in-depth interviews (n = 32) and focus group discussions (n = 5) to explore patient and health-care worker experiences of the SMS intervention. Purposive sampling was used to select participants to ensure that male and female patients, as well as those with differing VL results and who lived differing distances from the clinics were included. Data were transcribed, translated from Shona into English, coded and thematically analysed using NVivo software.ResultsThe VL SMS intervention was considered acceptable to patients and health-care workers despite some challenges in implementation. The intervention was perceived by health-care workers as improving adherence and well-being of patients as well as improving the management of VL results at health facilities. However, there were some concerns from participants about the intervention, including challenges in understanding the purpose and language of the messages and patients coming to their health facility unnecessarily. Health-care workers were more concerned than patients about unintentional HIV disclosure relating to the content of the messages or phone-sharing.ConclusionThis was an innovative intervention in Zimbabwe, in which SMS was used to send VL results to health-care facilities, and notifications of the availability of VL results to patients. Interventions such as this have the potential to reduce unnecessary clinic visits and ensure patients with high VL results receive timely support, but they need to be properly explained, alongside routine counselling, for patients to fully benefit. The findings of this study also have potential policy implications, as if implemented well, such an SMS intervention has the potential to help patients adopt a more active role in the self-management of their HIV disease, become more aware of the importance of adherence and VL monitoring and seek follow-up at clinics when results are high.

For more than two decades, CD4 cell count measurements have been central to understanding HIV disease progression, making important clinical decisions, and monitoring the response to antiretroviral therapy (ART). In well resourced settings, the monitoring of patients on ART has been supported by routine virological monitoring. Viral load monitoring was recommended by WHO in 2013 guidelines as the preferred way to monitor people on ART, and efforts are underway to scale up access in resource-limited settings. Recent studies suggest that in situations where viral load is available and patients are virologically suppressed, long-term CD4 monitoring adds little value and stopping CD4 monitoring will have major cost savings. CD4 cell counts will continue to play an important part in initial decisions around ART initiation and clinical management, particularly for patients presenting late to care, and for treatment monitoring where viral load monitoring is restricted. However, in settings where both CD4 cell counts and viral load testing are routinely available, countries should consider reducing the frequency of CD4 cell counts or not doing routine CD4 monitoring for patients who are stable on ART.

Rollout of routine HIV-1 viral load monitoring is hampered by high costs and logistical difficulties associated with sample collection and transport. New strategies are needed to overcome these constraints. Dried blood spots from finger pricks have been shown to be more practical than the use of plasma specimens, and pooling strategies using plasma specimens have been demonstrated to be an efficient method to reduce costs. This study found that combination of finger-prick dried blood spots and a pooling strategy is a feasible and efficient option to reduce costs, while maintaining accuracy in the context of a district hospital in Malawi.

Introduction : Counselling services are recommended by the World Health Organization and have been partially adopted by national HIV guidelines. In settings with a high HIV burden, patient education and counselling is often performed by lay workers, mainly supported with international funding. There are few examples where ministries of health have been able to absorb lay counsellors into their health systems or otherwise sustain their work. We document the role of lay cadres involved in HIV testing and counselling and adherence support and discuss approaches to sustainability. Methods : We focused on a purposive sample of eight sub-Saharan African countries where Medecins Sans Frontieres supports HIV programmes: Guinea, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Zambia and Zimbabwe. We reviewed both published and grey literature, including national policies and donor proposals, and interviewed key informants, including relevant government staff, donors and non-governmental organizations. Results and discussion : Lay counsellors play a critical role in scaling up HIV services and addressing gaps in the HIV testing and treatment cascade by providing HIV testing and counselling and adherence support at both the facility and community levels. Countries have taken various steps in recognizing lay counsellors, including harmonizing training, job descriptions and support structures. However, formal integration of this cadre into national health systems is limited, as lay counsellors are usually not included in national strategies or budgeting. Conclusions : The current trend of reduced donor support for lay counsellors, combined with lack of national prioritization, threatens the sustainability of this cadre and thereby quality HIV service delivery. Keywords: adherence support; antiretroviral therapy; community health workers; HIV/AIDS; HIV testing and counselling; human resources for health; lay counsellors; lay workers; patient education and counselling; retention in care; sub-Saharan Africa; task shifting. (Published: 13 May 2016) Citation: Bemelmans M et al. Journal of the International AIDS Society 2016, 19 :20751 http://www.jiasociety.org/index.php/jias/article/view/20751 | http://dx.doi.org/10.7448/IAS.19.1.20751

The latest WHO guidelines (2010) for antiretroviral therapy (ART) in adults and adolescents recommend that countries should progressively reduce the use of stavudine in favour of tenofovir or zidovudine and that ART initiation commence at an earlier CD4 threshold of350 cell/mm(3). In Lesotho, a high-burden, resource-limited setting, these two changes had been recommended since late 2007. A number of practical steps were taken to support implementation of Lesotho's national ART guidelines at the program level including: development of guidelines tailored to nurses working in primary care settings; training and clinical mentorship of different levels of health care workers; laboratory support; pharmacy support; and monitoring and evaluation. Clinical and programmatic benefits included decreased mortality, toxicity, and simplified patient management that was supportive of the decentralized, nurse-led model of care. This experience demonstrates that, despite limited resources, it was feasible to provide a standard of care similar to that of western guidelines and that these changes were supportive of simplified patient management.

Introduction: The latest WHO guidelines recommend initiating antiretroviral therapy (ART) at CD4 cell counts less than 350cells/ml. However, donors and national governments are reluctant to support implementation owing to uncertainty regarding feasibility and relative benefit. Lesotho has supported earlier initiation since 2008. We assessed outcomes comparing early (CD4 cell counts >200cells/ml) and late (CD4 cell counts � 200cells/ml) initiation. Methods: We describe survival probability among patients initiating ART at CD4 cell counts 200 or less and more than 200cells/ml and assess associations between baseline CD4 cell counts and mortality, morbidity, loss to follow-up and hospitalization using Cox regression adjusting for confounders identified a priori. Results: Our analysis included 1177 patients; median age was 38 years and the majority (67%) were women. Median time on ART for the overall cohort was 506 days (interquartile range 396‐608). Five hundred and thirty eight patients initiated ART at a CD4 cell count 200cells/ml or less (interquartile range 54‐160) and 639 patients initiated at CD4 cell count more than 200cells/ml (interquartile range 238‐321). In multivariate analysis, we found that patients initiating at CD4 cell count more than 200cells/ml were 68% less likely to die (adjusted hazard ratio 0.32, 95% confidence interval 0.20‐0.50), and 39% less likely to be lost to follow-up (adjusted hazard ratio 0.61, 95% confidence interval 0.43‐0.87). Initiating ART at CD4 cell count more than 200cells/ml was also associated with a 27% reduction in the rate of incident morbidity (adjusted hazard ratio 0.73, 95% confidence interval 0.65‐0.82) and a 63% decreased rate of hospitalization (adjusted hazard ratio 0.37, 95% confidence interval 0.19‐0.73). Conclusion: Earlier initiation is feasible in a low resource, high HIV prevalence setting, and provides important benefits in terms of reduced mortality, morbidity, retention and hospitalization. Donors should fully support the implementation of the latest WHO recommendations. 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins AIDS 2010, 24:2645‐2650

Background HIV Viral Load and Early Infant Diagnosis technologies in many high burden settings are restricted to centralized laboratory testing, leading to long result turnaround times and patient attrition. GeneXpert (Cepheid, CA, USA) is a polyvalent near point-of-care platform and is widely implemented for Xpert MTB/RIF diagnosis. This study sought to evaluate the operational feasibility of integrated HIV VL, EID and MTB/RIF testing in new GeneXpert platforms. Methods Whole blood samples were collected from consenting patients due for routine HIV VL testing and DBS samples from infants due for EID testing, at three rural health facilities in Zimbabwe. Sputum samples were collected from all individuals suspected of TB. GeneXpert testing was reserved for all EID, all TB suspects and priority HIV VL at each site. Blood samples were further sent to centralized laboratories for confirmatory testing. GeneXpert polyvalent testing results and patient outcomes, including infrastructural and logistical requirements are reported. The study was conducted over a 10-month period. Results The fully automated GeneXpert testing device, required minimal training and biosafety considerations. A total of 1,302 HIV VL, 277 EID and 1,581 MTB/RIF samples were tested on a four module GeneXpert platform in each study site. Xpert HIV-1 VL testing was prioritized for patients who presented with advanced HIV disease, pregnant women, adolescents and suspected ART failures patients. On average, the study sites had a GeneXpert utilization rate of 50.4% (Gutu Mission Hospital), 63.5% (Murambinda Mission Hospital) and 17.5% (Chimombe Rural Health Centre) per month. GeneXpert polyvalent testing error rates remained lower than 4% in all sites. Decentralized EID and VL testing on Xpert had shorter overall median TAT (1 day [IQR: 0-4] and 1 day [IQR: 0-1] respectively) compared to centralized testing (17 days [IQR: 13-21] and 26 days [IQR: 23-32] respectively). Among patients with VL >1000 copies/ml (73/640; 11.4%) at GMH health facility, median time to enhanced adherence counselling was 8 days and majority of those with documented outcomes had re-suppressed VL (20/32; 62.5%). Median time to ART initiation among Xpert EID positive infants at GMH was 1 day [IQR: 0-1]. Conclusion Implementation of near point-of-care GeneXpert platform for integrated multi-disease testing within district and sub-district healthcare settings is feasible and will increase access to VL, and EID testing to priority populations. Quality management systems including monitoring of performance indicators, together with regular on-site supervision are crucial, and near-POC test results must be promptly actioned-on by clinicians for patient management.

The delivery of HIV care in the initial rapid scale-up of HIV care and treatment was based on existing clinic-based models, which are common in highly resourced settings and largely undifferentiated for individual needs. A new framework for treatment based on variable intensities of care tailored to the specific needs of different groups of individuals across the cascade of care is proposed here. Service intensity is characterised by four delivery components: (i) types of services delivered, (ii) location of service delivery, (iii) provider of health services and (iv) frequency of health services. How these components are developed into a service delivery framework will vary across countries and populations, with the intention being to improve acceptability and care outcomes. The goal of getting more people on treatment before they become ill will necessitate innovative models of delivering both testing and care. As HIV programmes expand treatment eligibility, many people entering care will not be ‘patients’ but healthy, active and productive members of society 1. To take the framework to scale, it will be important to: (i) define which individuals can be served by an alternative delivery framework; (ii) strengthen health systems that support decentralisation, integration and task shifting; (iii) make the supply chain more robust; and (iv) invest in data systems for patient tracking and for programme monitoring and evaluation. La delivrance des soins du VIH dans le deploiement initial rapide des soins et du traitement du VIH a ete basee sur des modeles existants dans les cliniques, qui sont courants dans les regions beneficiant d’importantes ressources et largement indifferenciees pour les besoins individuels. Un nouveau cadre est propose ici pour le traitement base selon les intensites variables de soins, adaptes aux besoins specifiques des differents groupes de personnes a travers la cascade de soins. L’intensite des services est caracterisee par quatre elements de delivrance: (1) les types de services delivres, (2) l’emplacement de la delivrance des services, (3) Les prestataires des services de sante et (4) la frequence des services de sante. La facon dont ces elements sont developpes dans un cadre de prestation de services peut varier selon les pays et les populations, l’intention etant d’ameliorer les resultats d’acceptabilite et des soins. Le but d’obtenir plus de personnes sous traitement avant qu’ils ne tombent malades necessitera des modeles innovateurs de prestation a la fois pour depistage et pour les soins. Comme les programmes VIH etendent l’eligibilite au traitement, beaucoup de gens qui entrent dans les soins ne seront pas des “malades- mais des elements sains de la societe, actifs et productifs. Afin de tenir le cadre a l’echelle, il sera important de: (1) definir les individus qui peuvent etre traites par un cadre alternatif de prestation, (2) renforcer les systemes de sante qui soutiennent la decentralisation, l’integration et le transfert des tâches; (3) rendre la chaine d’approvisionnement plus robuste et (4) investir dans des systemes de donnees pour le suivi des patients et pour le suivi et l’evaluation du programme. Los servicios de atencion del VIH durante el inicio de la primera etapa de rapida expansion del tratamiento y cuidados del VIH estaban basados en modelos clinicos existentes, comunes en lugares con abundancia de recursos y poco diferenciados en cuanto a necesidades individuales. Aqui se propone un nuevo marco para el tratamiento basado en intensidades variables de cuidados, hecho a medida segun las necesidades especificas de los diferentes grupos de individuos a lo largo del tratamiento. La intensidad del servicio se caracteriza por cuatro componentes de entrega: (1) tipologia de los servicios ofrecidos, (2) lugar de entrega de los servicios, (3) proveedor de los servicios sanitarios, y (4) frecuencia de los servicios sanitarios. El como estos componentes conforman un marco de entrega de servicios variara segun el pais y la poblacion, con la intencion de mejorar la aceptabilidad y los resultados de los cuidados. El objetivo de conseguir que mas personas reciban tratamiento antes de que enfermen requerira de modelos innovadores en la oferta tanto de pruebas para deteccion como de los cuidados. A medida que los programas para el VIH expandan los criterios de elegibilidad para el tratamiento, muchas de las personas que comiencen a recibir cuidados no seran “pacientes- sino miembros sanos, activos y productivos de la sociedad. Con el fin de expandir la escala de esta estructura, seria importante: (1) definir cuales individuos pueden ser atendidos dentro de un marco de entrega de servicios alternativo; (2) fortalecer los sistemas sanitarios que apoyan la descentralizacion, integracion y delegacion de funciones; (3) robustecer la cadena de proveedores; e (4) invertir en sistemas de datos para el seguimiento de pacientes y para la monitorizacion y evaluacion de programas.

Text messages (SMS) are being increasingly integrated into HIV programs across Southern Africa to improve patient adherence, linkage to care and provide psycho-social support. Careful attention needs to be paid to the design of SMS-based interventions for clients of HIV-care services to ensure that any potential harm, such as unwanted disclosure of HIV status, is minimized. In this article we propose a set of best practice recommendations to ensure that any SMS-based intervention considers ethical principles to safeguard safety, autonomy and confidentiality of its targeted HIV-positive beneficiaries. This analysis draws from our operational experience in Southern Africa in the design and conduct of mHealth interventions in the frame of HIV projects. The recommendations, framed in the context of the Belmont Report's three ethical pillars, may contribute to more safely operationalize any SMS service integrated into an HIV program if adopted by mHealth planners and implementers. We encourage actors to report on the ethical and methodological pathways followed when conducting SMS-based innovations to improve the wellbeing and quality provision of HIV-care for their targeted clients.

Background: Antiretroviral therapy (ART) has increased the life expectancy of people living with HIV (PLHIV); HIV is now considered a chronic disease. Non-communicable diseases (NCDs) and HIV care were integrated into primary care clinics operated within the informal settlement of Kibera, Nairobi, Kenya. We describe early cohort outcomes among PLHIV and HIV-negative patients, both of whom had NCDs. Methods: A retrospective analysis was performed of routinely collected clinic data from January 2010 to June 2013. All patients .14 years with hypertension and/or diabetes were included. Results: Of 2206 patients included in the analysis, 210 (9.5%) were PLHIV. Median age at enrollment in the NCD program was 43 years for PLHIV and 49 years for HIV-negative patients (p,0.0001). The median duration of follow up was 1.4 (IQR 0.7–2.1) and 1.0 (IQR 0.4–1.8) years for PLHIV and HIV-negative patients, respectively (p¼0.003). Among patients with hypertension, blood pressure outcomes were similar, and for those with diabetes, outcomes for HbA1c, fasting glucose and cholesterol were not significantly different between the two groups. The frequency of chronic kidney disease (CKD) was 12% overall. Median age for PLHIV and CKD was 50 vs 55 years for those without HIV (p¼0.005). Conclusions: In this early comparison of PLHIV and HIV-negative patients with NCDs, there were significant differences in age at diagnosis but both groups responded similarly to treatment. This study suggests that integrating NCD care for PLHIV along with HIV-negative patients is feasible and achieves similar results.

Background CD4+ T-cell testing of blood specimens collected in standard EDTA Vacutainer tubes and transported at ambient temperature, must be completed within 48 hours with the BD FACSCount™ flow cytometer, restricting specimen collection in remote clinics with no on-site testing and limited specimen transport services. We conducted a study in Buhera District, Zimbabwe, to assess the stability and accuracy of CD4+ T-cell results of samples collected in Stabilization Tubes (ST) and stored at ambient temperature for varying time periods. Methods Paired EDTA and ST samples were collected from 51 HIV-positive patients aged 18 years and older. CD4+ T-cell testing was done on arrival in the laboratory (Day 0). ST samples were retested on Days 3, 5, and 7. Nineteen ST samples were stored for an additional week and retested on Day 14. Results There was a strong correlation between absolute CD4+ T-cell counts measured in the EDTA Day 0 reference sample and Day 7 ST sample (Spearman's rho: 0.9778; mean difference: -4.9 cells/μL and limits of agreement (LOA): 98.5 and 88.7 cells/μL); and the reference sample and Day 14 ST sample (Spearman's rho: 0.9632; mean difference 5.1 cells/μL and LOA: -99.6 and 109.8 cells/μL. Using a 350 cells/μL threshold, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were all 100% on Day 7, and 83.3%, 100%, 100% and 92.9% on Day 14. Using a 500 cells/μL threshold, the sensitivity, specificity, PPV and NVP were 100%, 88.5%, 88.5% and 100% on Day 7 and 88.9%, 80.0%, 80.0% and 88.9% on Day 14. Conclusions CD4 ST can be used and stored up to 7 days as a reliable alternative to standard EDTA tubes in settings where CD4+ T-cell testing within 48 hours is not feasible. Despite the small sample size, results suggest that ST may be stored up to 14 days at room temperature for CD4 testing, without compromising accuracy. However, further studies with larger sample sizes are needed to confirm this preliminary finding. Electronic supplementary material The online version of this article (doi:10.1186/s12879-014-0553-9) contains supplementary material, which is available to authorized users.

Introduction : In 2012 Community ART Groups (CAGs), a community-based model of antiretroviral therapy (ART) delivery were piloted in Thyolo District, Malawi as a way to overcome patient barriers to accessing treatment, and to decrease healthcare workers’ workload. CAGs are self-formed groups of patients on ART taking turns to collect ART refills for all group members from the health facility. We conducted a qualitative study to assess the benefits and challenges of CAGs from patients’ and healthcare workers’ (HCWs) perspectives. Methods : Data were collected by means of 15 focus group discussions, 15 individual in-depth interviews, and participant observation in 2 health centres. The 94 study participants included CAG members, ART patients eligible for CAGs who remained in conventional care, former CAG members who returned to conventional care and HCWs responsible for providing HIV care. Patient participants were purposively selected from ART registers, taking into account age and gender. Narratives were audio-recorded, transcribed, and translated from Chichewa to English. Data were analyzed through a thematic analysis. Results : Patients and HCWs spoke favourably about the practical benefits of CAGs. Patient benefits included a reduced frequency of clinic visits, resulting in reduced transportation costs and time savings. HCW benefits included a reduced workload. Additionally peer support was perceived as an added value of the groups allowing not only sharing of the logistical constraints of drugs refills, but also enhanced emotional support. Identified barriers to joining a CAG included a lack of information on CAGs, unwillingness to disclose one’s HIV status, change of residence and conflicts among CAG members. Participants reported that HIV-related stigma persists and CAGs were seen as an effective strategy to reduce exposure to discriminatory labelling by community members. Conclusions : In this setting, patients and HCWs perceived CAGs to be an acceptable model of ART delivery. Despite addressing important practical barriers to accessing ART, and providing peer support, CAGs were not well known by patients and had a limited impact on reducing HIV-related stigma. The CAG model of ART delivery should be considered in similar settings. Further measures need to be devised and implemented to address HIV-related stigma. Keywords HIV; ART delivery; differentiated care; task-shifting; service delivery; Malawi (Published: 28 March 2017) Pellecchia U et al. Journal of the International AIDS Society 2017, 20 :21374 http://www.jiasociety.org/index.php/jias/article/view/21374 | http://dx.doi.org/10.7448/IAS.20.1.21374

Introduction : The number of people on antiretroviral therapy (ART) for the long-term management of HIV in low-and middle-income countries (LMICs) is continuing to increase, along with the prevalence of Non-Communicable Diseases (NCDs). The need to provide large volumes of HIV patients with ART has led to significant adaptations in how medication is delivered, but access to NCD care remains limited in many contexts. Medication Adherence Clubs (MACs) were established in Kibera, Kenya to address the large numbers of patients requiring chronic HIV and/or NCD care. Stable NCD and HIV patients can now collect their chronic medication every three months through a club, rather than through individual clinic appointments. Methodology : We conducted a qualitative research study to assess patient and health-care worker perceptions and experiences of MACs in the urban informal settlement of Kibera, Kenya. A total of 106 patients (with HIV and/or other NCDs) and health-care workers were purposively sampled and included in the study. Ten focus groups and 19 in-depth interviews were conducted and 15 sessions of participant observation were carried out at the clinic where the MACs took place. Thematic data analysis was conducted using NVivo software, and coding focussed on people's experiences of MACs, the challenges they faced and their perceptions about models of care for chronic conditions. Results : MACs were considered acceptable to patients and health-care workers because they saved time, prevented unnecessary queues in the clinic and provided people with health education and group support whilst they collected their medication. Some patients and health-care workers felt that MACs reduced stigma for HIV positive patients by treating HIV as any other chronic condition. Staff and patients reported challenges recruiting patients into MACs, including patients not fully understanding the eligibility criteria for the clubs. There were also some practical challenges during the implementation of the clubs, but MACs have shown that it is possible to learn from ART provision and enable stable HIV and NCD patients to collect chronic medication together in a group. Conclusions : Extending models of care previously only offered to HIV-positive cohorts to NCD patients can help to de-stigmatise HIV, allow for the efficient clinical management of co-morbidities and enable patients to benefit from peer support. Through MACs, we have demonstrated that an integrated approach to providing medication for chronic diseases including HIV can be implemented in resource-poor settings and could thus be rolled out in other similar contexts.

Though the advantages of routine virological monitoring for patients on anti-retroviral therapy have been established, cost and complexity limit its full implementation. Monitoring is important for diagnosing virological failure early on, before the development of drug resistance mutations, and to trigger early adherence interventions. Simple and cost-effective viral load tests that facilitate simplification and decentralization of testing and strategies, such as the use of dried blood spots and pooled sample testing, which further aid simplification, are becoming available. In addition, replacing immunological monitoring with virological monitoring in non-viremic patients in a phased manner will reduce the costs associated with dual immuno-virological monitoring. Going forward, the simplification of testing paired with price reducing strategies that will allow for healthy competition between multiple manufacturers will enable the implementation of viral load testing in resource-poor settings. It is important that future HIV and AIDS treatment guidelines provide clear recommendations for routine virological monitoring and that governments and donors fund the implementation of accurate and operationally proven testing platforms in a comprehensive manner.

Around 2 million adolescents and 3 million youth are estimated to be living with HIV worldwide. Antiretroviral outcomes for this group appear to be worse compared to adults. We report antiretroviral therapy outcomes from a rural setting in Zimbabwe among patients aged 10–30 years who were initiated on ART between 2005 and 2008. The cohort was stratified into four age groups: 10–15 (young adolescents) 15.1–19 years (adolescents), 19.1–24 years (young adults) and 24.1–29.9 years (older adults). Survival analysis was used to estimate rates of deaths and loss to follow-up stratified by age group. Endpoints were time from ART initiation to death or loss to follow-up. Follow-up of patients on continuous therapy was censored at date of transfer, or study end (31 December 2008). Sex-adjusted Cox proportional hazards models were used to estimate hazard ratios for different age groups. 898 patients were included in the analysis; median duration on ART was 468 days. The risk of death were highest in adults compared to young adolescents (aHR 2.25, 95%CI 1.17–4.35). Young adults and adolescents had a 2–3 times higher risk of loss to follow-up compared to young adolescents. When estimating the risk of attrition combining loss to follow-up and death, young adults had the highest risk (aHR 2.70, 95%CI 1.62–4.52). This study highlights the need for adapted adherence support and service delivery models for both adolescents and young adults.

Article approval pending, Latest World Health Organization guidelines recommend shifting away from Stavudine (d4T)-based regimens due to severe side effects. However, widespread replacement of d4T by Tenofovir (TDF) or Zidovudine (AZT) is hampered by cost concerns.

INTRODUCTION: Current guidelines contraindicate TDF use when creatinine clearance (CrCl) falls below 50 ml/min. We report prevalence of abnormal renal function at baseline and factors associated with abnormal renal function from a community cohort in Lesotho. METHODS: We calculated changes in CrCl from baseline for patients initiated on TDF at 6 and 12 months and the proportion of patients initiated on TDF who developed renal impairment. Screening algorithms were developed using risk factors determined by multivariate analysis. RESULTS: Among 933 adults for whom baseline creatinine was available, 176 (18.9%) presented with a baseline CrCl

Background The latest World Health Organization guidelines recommend replacing stavudine with tenofovir or zidovudine in first-line antiretroviral therapy in resource-limited settings. We report on outcomes and toxicities among patients on these different regimens in a routine treatment cohort in Lesotho. Methods All adult patients initiating antiretroviral therapy from January 1, 2008, to December 31, 2008, were included in the analysis and followed until December 31, 2009. Choice of regimen was determined by clinical criteria. Results Of 1124 patient records analyzed, median age was 39 years, and the majority (67.7%) were women. Five hundred eighty-seven patients were started on tenofovir, 255 on zidovudine, and 282 on stavudine. Patients on zidovudine were more than twice as likely to experience a toxicity-driven regimen substitution compared with tenofovir (adjusted hazard ratio: 2.32, 95% confidence interval: 1.23 to 4.40); for patients on stavudine, the risk of a toxicity-driven regimen switch was almost 6 times higher than tenofovir (adjusted hazard ratio: 5.43, 95% confidence interval: 3.31 to 8.91). Conclusions Our findings support the latest World Health Organization Guidelines, in particular the adoption of tenofovir in first line, given the advantages in terms of tolerability and availability as a once-daily formulation.

BACKGROUND: The provision of antiretroviral therapy (ART) to migrant populations raises particular challenges with respect to ensuring adequate treatment support, adherence, and retention in care. We assessed rates of loss to follow-up for migrant workers compared with non-migrant workers in a routine treatment programme in Morjia, Lesotho. DESIGN: All adult patients (≥18 years) initiating ART between January 1, 2008, and December 31, 2008, and followed up until the end of 2009, were included in the study. We described rates of loss to follow-up according to migrant status by Kaplan-Meier estimates, and used Poisson regression to model associations between migrant status and loss to follow-up controlling for potential confounders identified a priori. RESULTS: Our cohort comprised 1185 people, among whom 12% (148) were migrant workers. Among the migrant workers, median age was 36.1 (29.6-45.9) and the majority (55%) were male. We found no statistically significant differences between baseline characteristics and migrant status. Rates of lost to follow up were similar between migrants and non-migrants in the first 3 months but differences increased thereafter. Between 3 and 6 months after initiating antiretroviral therapy, migrants had a 2.78-fold increased rate of defaulting (95%CI 1.15-6.73); between 6 and 12 months the rate was 2.36 times greater (95%CI 1.18-4.73), whereas after 1 year the rate was 6.69 times greater (95%CI 3.18-14.09). CONCLUSIONS: Our study highlights the need for programme implementers to take into account the specific challenges that may influence continuity of antiretroviral treatment and care for migrant populations.

INTRODUCTION: Lesotho has the third highest HIV prevalence in the world (an adult prevalence of 23.2%). Despite a lack of resources for health, the country has implemented state-of-the-art antiretroviral treatment guidelines, including early initiation of treatment (

No abstract available. (Published: 1 December 2016) Citation: Grimsrud A et al. Journal of the International AIDS Society 2016, 19 :21484 http://www.jiasociety.org/index.php/jias/article/view/21484 | http://dx.doi.org/10.7448/IAS.19.1.21484

EDITOR—Two important issues emerge from the article by Forrest and Barrett on humanitarian medicine.1 Firstly, the use of the terms “moderate physical pressure” or “torture lite” risks euphemising torture into acceptability. In 1976 the European Commission on Human Rights held that certain techniques used by the British security forces in …