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Lilongwe, Malawi

May M.,University of Bristol | Boulle A.,University of Cape Town | Phiri S.,Lighthouse Trust | Messou E.,CePReF Clinic | And 7 more authors.
The Lancet | Year: 2010

Prognostic models have been developed for patients infected with HIV-1 who start combination antiretroviral therapy (ART) in high-income countries, but not for patients in sub-Saharan Africa. We developed two prognostic models to estimate the probability of death in patients starting ART in sub-Saharan Africa. We analysed data for adult patients who started ART in four scale-up programmes in Côte d'Ivoire, South Africa, and Malawi from 2004 to 2007. Patients lost to follow-up in the first year were excluded. We used Weibull survival models to construct two prognostic models: one with CD4 cell count, clinical stage, bodyweight, age, and sex (CD4 count model); and one that replaced CD4 cell count with total lymphocyte count and severity of anaemia (total lymphocyte and haemoglobin model), because CD4 cell count is not routinely measured in many African ART programmes. Death from all causes in the first year of ART was the primary outcome. 912 (8·2) of 11 153 patients died in the first year of ART. 822 patients were lost to follow-up and not included in the main analysis; 10 331 patients were analysed. Mortality was strongly associated with high baseline CD4 cell count (≥200 cells per μL vs <25; adjusted hazard ratio 0·21, 95 CI 0·17-0·27), WHO clinical stage (stages III-IV vs I-II; 3·45, 2·43-4·90) , bodyweight (≥60 kg vs <45 kg; 0·23, 0·18-0·30), and anaemia status (none vs severe: 0·27, 0·20-0·36). Other independent risk factors for mortality were low total lymphocyte count, advanced age, and male sex. Probability of death at 1 year ranged from 0·9 (95 CI 0·6-1·4) to 52·5 (43·8-61·7) with the CD4 model, and from 0·9 (0·5-1·4) to 59·6 (48·2-71·4) with the total lymphocyte and haemoglobin model. Both models accurately predict early mortality in patients starting ART in sub-Saharan Africa compared with observed data. Prognostic models should be used to counsel patients, plan health services, and predict outcomes for patients with HIV-1 infection in sub-Saharan Africa. US National Institute of Allergy And Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and National Cancer Institute. © 2010 Elsevier Ltd.

Rosenberg N.E.,UNC Project | Rosenberg N.E.,University of North Carolina at Chapel Hill | Mtande T.K.,UNC Project | Saidi F.,UNC Project | And 11 more authors.
The Lancet HIV | Year: 2015

Background: Couples HIV testing and counselling (CHTC) is encouraged but is not widely done in sub-Saharan Africa. We aimed to compare two strategies for recruiting male partners for CHTC in Malawi's option B+ prevention of mother-to-child transmission programme: invitation only versus invitation plus tracing and postulated that invitation plus tracing would be more effective. Methods: We did an unblinded, randomised, controlled trial assessing uptake of CHTC in the antenatal unit at Bwaila District Hospital, a maternity hospital in Lilongwe, Malawi. Women were eligible if they were pregnant, had just tested HIV-positive and therefore could initiate antiretroviral therapy, had not yet had CHTC, were older than 18 years or 16-17 years and married, reported a male sex partner in Lilongwe, and intended to remain in Lilongwe for at least 1 month. Women were randomly assigned (1:1) to either the invitation only group or the invitation plus tracing group with block randomisation (block size=4). In the invitation only group, women were provided with an invitation for male partners to present to the antenatal clinic. In the invitation plus tracing group, women were provided with the same invitation, and partners were traced if they did not present. When couples presented they were offered pregnancy information and CHTC. Women were asked to attend a follow-up visit 1 month after enrolment to assess social harms and sexual behaviour. The primary outcome was the proportion of couples who presented to the clinic together and received CHTC during the study period and was assessed in all randomly assigned participants. This study is registered with ClinicalTrials.gov, number NCT02139176. Findings: Between March 4, 2014, and Oct 3, 2014, 200 HIV-positive pregnant women were enrolled and randomly assigned to either the invitation only group (n=100) or the invitation plus tracing group (n=100). 74 couples in the invitation plus tracing group and 52 in the invitation only group presented to the clinic and had CHTC (risk difference 22%, 95% CI 9-35; p=0·001) during the 10 month study period. Of 181 women with follow-up data, two reported union dissolution, one reported emotional distress, and none reported intimate partner violence. One male partner, when traced, was confused about which of his sex partners was enrolled in the study. No other adverse events were reported. Interpretation: An invitation plus tracing strategy was highly effective at increasing CHTC uptake. Invitation plus tracing with CHTC could have many substantial benefits if brought to scale. Funding: National Institutes of Health. © 2015 Elsevier Ltd.

Feldacker C.,Lighthouse Trust | Feldacker C.,University of Washington | Johnson D.,University of Malawi | Hosseinipour M.,University of Malawi | And 3 more authors.
PLoS ONE | Year: 2012

Background: Lighthouse Trust operates two, public, integrated HIV clinics, Lighthouse (LH) and Martin Preuss Center (MPC), in Lilongwe, Malawi. Approximately 20% of patients eligible for antiretroviral therapy (ART) do not start ART. We explore individual and geographic factors that influence whether ART-eligible patients initiate ART. Methods: Adult patients eligible for ART between 2008-2011 were included. Analysis was stratified by clinic. Using logistic regression, we evaluated factors associated with initiating ART including gender, age, body mass index (BMI), employment, tuberculosis (TB), eligible at initial registration, WHO stage, CD4, months in pre-ART care (from initial registration to eligibility date), and patient neighborhood distance to clinic. Results: Of 14,216 study patients, 4841 were from LH; 9285 were from MPC. At LH and MPC, respectively, median age was 34.2 and 33.8 years; median BMI was 22.0 and 20.6; and median distance was 5.6 and 4.9 Km. In multivariate models, odds of starting ART was highest among those older than 35 years and those eligible for ART based on WHO stages 3-4 vs. those in WHO stages 1-2 with CD4<250. Patients with 1-12 months in pre-ART were at least 11 times more likely to start ART than peers with less pre-ART time. At LH, living 2.5-5 Km from the clinic increased the likelihood of starting ART over patients living closer. Conclusions: Length of the pre-ART period is the most significant predictor of starting ART among eligible patients. Better understanding of motivation for retention in pre-ART care may reduce attrition along the treatment cascade. © 2012 Feldacker et al.

Estill J.,University of Bern | Tweya H.,University of Bern | Egger M.,University of Bern | Egger M.,University of Cape Town | And 9 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2014

Objective: Treatment as prevention depends on retaining HIVinfected patients in care. We investigated the effect on HIV transmission of bringing patients lost to follow-up (LTFU) back into care. Design: Mathematical model. Methods: Stochastic mathematical model of cohorts of 1000 HIVinfected patients on antiretroviral therapy, based on the data from 2 clinics in Lilongwe, Malawi. We calculated cohort viral load (sum of individual mean viral loads each year) and used a mathematical relationship between viral load and transmission probability to estimate the number of new HIV infections. We simulated 4 scenarios: "no LTFU" (all patients stay in care), "no tracing" (patients LTFU are not traced), "immediate tracing" (after missed clinic appointment), and "delayed tracing" (after 6 months). Results: About 440 of 1000 patients were LTFU over 5 years. Cohort viral loads (million copies/mL per 1000 patients) were 3.7 [95% prediction interval (PrI), 2.9-4.9] for no LTFU, 8.6 (95% PrI, 7.3-10.0) for no tracing, 7.7 (95% PrI, 6.2-9.1) for immediate, and 8.0 (95% PrI, 6.7-9.5) for delayed tracing. Comparing no LTFU with no tracing, the number of new infections increased from 33 (95% PrI, 29-38) to 54 (95% PrI, 47-60) per 1000 patients. Immediate tracing prevented 3.6 (95% PrI, 23.3 to 12.8) and delayed tracing 2.5 (95% PrI, 25.8 to 11.1) new infections per 1000. Immediate tracing was more efficient than delayed tracing: to 116 and 142 tracing efforts, respectively, were needed prevent 1 new infection. Conclusions: Tracing of patients LTFU enhances the preventive effect of antiretroviral therapy, but the number of transmissions prevented is small. © 2013 by Lippincott Williams & Wilkins.

Tweya H.,The International Union Against Tuberculosis and Lung Disease | Tweya H.,University of Bern | Gugsa S.,Lighthouse Trust | Gugsa S.,University of Washington | And 10 more authors.
Tropical Medicine and International Health | Year: 2014

Objective: To assess factors, outcomes and reasons for loss to follow-up (LTFU) among pregnant and breastfeeding women initiated on a lifelong antiretroviral therapy (ART) for PMTCT in a large antenatal clinic in Malawi. Methods: We identified all pregnant and breastfeeding women who were initiated on ART between September 2011 and September 2013 and had missed their clinic appointment by at least 3 weeks at Bwaila Hospital, the largest antenatal clinic in Malawi. These women were traced by phone or home visits. Their true status and reasons for ART discontinuation were documented during tracing. Results: A total of 2930 women started ART for PMTCT; 2458 (84%) pregnant and 472 (16%) breastfeeding, of which, 577 (20%) missed a scheduled clinic appointment. LTFU was associated with younger age, being pregnant, and earlier year of ART initiation. We successfully traced 229 (40%), of whom, 10 (4%) had died. Of the 219 women found alive, 118 (54%) had stopped taking ARV drugs, 67 (30%) had self-transferred to another ART clinic, 13 (6%) had collected drugs from other sources, 9 (4%) had treatment interruptions and 12 (5%) had other outcomes. Reasons cited for stopping ART were travel (38%), lack of transport money (16%), not understanding the initial ARV education session (10%), being too weak/sick (10%), ARV side effects (10%) and other reasons. Conclusion: Approximately half of the women who were traced were taking ARVs. The study emphasises the need for enhanced post-test counselling strategies, ongoing psychosocial support, provision of incentives and further decentralisation efforts of PMTCT services. © 2014 John Wiley & Sons Ltd.

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