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Parry C.D.H.,Alcohol and drug Abuse Research Unit | Parry C.D.H.,Stellenbosch University | Petersen P.,Alcohol and drug Abuse Research Unit | Carney T.,Alcohol and drug Abuse Research Unit | Needle R.,Pangaea Global AIDS Foundation
International Journal of Drug Policy | Year: 2010

Background: Little has been done to improve the integration of drug use and HIV services in sub-Saharan Africa where substance use and HIV epidemics often co-exist. Methods: Data were collected using rapid assessment methods in two phases in Cape Town, Durban and Pretoria, South Africa. Phase I (2005) comprised 140 key informant and focus group drug using interviewees and 19 service providers (SPs), and Phase 2 (2007) comprised 69 drug using focus group interviewees and 11 SPs. Results: Drug users put themselves at risk for HIV transmission through various drug-related sexual practices as well as through needle sharing. Drug users in both phases had limited knowledge of the availability of drug treatment services, and those that had accessed treatment identified a number of barriers, including affordability, stigma and a lack of aftercare and reintegration services. SPs identified similar barriers. Drug users displayed a general awareness of both HIV transmission routes and prevention strategies, but the findings also indicated a number of misperceptions, and problematic access to materials such as condoms and safe injection equipment. Knowledge around HIV treatment was low, and VCT experiences were mixed. SPs recognized the importance of integrating HIV and substance use services, but barriers such as funding issues, networking/referral gaps and additional burden on staff were reported in Phase 2. Conclusion: A comprehensive, accessible, multi-component intervention strategy to prevent HIV risk in drug users needs to be developed including community outreach, risk reduction counselling, VCT and substance use treatment. © 2009 Elsevier B.V.


Lambdin B.H.,Pangaea Global AIDS Foundation | Lambdin B.H.,University of Washington | Micek M.A.,University of Washington | Sherr K.,University of Washington | And 5 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2013

Background: In 2004, the Mozambican Ministry of Health began a national scale-up of antiretroviral therapy (ART) using a vertical model of HIV clinics colocated within large urban hospitals. In 2006, the ministry expanded access by integrating ART into primary health care clinics. Methods: We conducted a retrospective cohort study including adult ART-naive patients initiating ART between January 2006 and June 2008 in public sector clinics in Manica and Sofala provinces. Cox proportional hazards models with robust variances were used to estimate the association between clinic model (vertical/integrated), clinic location (urban/rural), and clinic experience (first 6 months/post first 6 months) and attrition occurring in early patient follow-up (#6 months) and attrition occurring in late patient follow-up (.6 months), while controlling for age, sex, education, pre-ART CD4 count, World Health Organization stage and pharmacy staff burden. Results: A total of 11,775 patients from 17 clinics were studied. The overall attrition rate was 37 per 100 person-years. Patients attending integrated clinics had a higher risk of attrition in late follow-up [hazard ratio (HR) = 1.75; 95% confidence interval (CI): 1.04 to 2.94], and patients attending urban clinics (HR = 0.57; 95% CI: 0.35 to 0.91) had a lower risk of attrition in late follow-up. Though not statistically significant, clinics open for longer than 6 months (HR = 0.71; 95% CI: 0.49 to 1.04) had a lower risk of attrition in early follow-up. Conclusions: Patients attending vertical clinics had a lower risk of attrition. Utilizing primary health clinics to implement ART is necessary to reach higher levels of coverage; however, further implementation strategies should be developed to improve patient retention in these settings. Copyright © 2012 by Lippincott Williams & Wilkins.


Dworkin S.L.,University of California at San Francisco | Dunbar M.S.,Pangaea Global AIDS Foundation | Krishnan S.,Rti International | Krishnan S.,University of California at Berkeley | And 2 more authors.
American Journal of Public Health | Year: 2011

Research frequently points to the need to empower women to effectively combat the twin epidemics of HIV/AIDS and gender-based violence. Simultaneously, there has been increased attention given to working with men in gender equality efforts. The latter approach intervenes on masculinities as part of the fight against HIV/AIDS and violence. No research has considered these 2 lines of work side by side to address several important questions: What are the points of overlap, and the tensions and contradictions between these 2 approaches? What are the limitations and unintended consequences of each? We analyzed these 2 parallel research trends and made suggestions for how to capitalize on the synergies that come from bolstering each position with the strengths of the other.


Mimiaga M.J.,Harvard University | Safren S.A.,Harvard University | Safren S.A.,Fenway Institute | Dvoryak S.,Ukrainian Institute on Public Health Policy | And 4 more authors.
AIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV | Year: 2010

Ukraine has one of the most severe HIV/AIDS epidemics in Europe, with an estimated 1.63% of the population living with HIV/AIDS in 2007. Injection drug use (IDU) remains the predominant mode of transmission in Kiev - the capital and largest city. Prior reports suggest that the HIV infection rate among IDUs in Kiev reaches 33%, and many have poor and inequitable access to highly active antiretroviral therapy (HAART). Among those with access to HAART, little is understood about barriers and facilitators to HAART medication adherence. In May 2009, two semi-structured focus groups were conducted with HIV-infected IDUs seeking treatment at the City AIDS Center, Kiev. The goal was to use this information to adapt and tailor, to Ukrainian culture, an evidence-based intervention for improving adherence to HAART. All 16 participants attributed HIV infection to IDU. Their average age was 31.6 (SD=7.0), average time with HIV 5.7 years (SD=4.0), average time on HAART 2.5 years (SD=1.7), average time as IDU 14.6 years (SD=6.8), and 88% were on opioid substitution therapy. The most salient themes related to adherence barriers included: (1) harassment and discrimination by police; (2) opioid dependence; (3) complexity of drug regimen; (4) side effects; (5) forgetting; (6) co-occurring mental health problems; and (7) HIV stigma. Facilitators of adherence included: (1) cues for pill taking; (2) support and reminders from family, significant other, and friends; (3) opioid substitution therapy; and (4) wanting improved health. Additional factors explored included: (1) knowledge about HAART; (2) storage of medications; and (3) IDU and sexual risk behaviors. Findings highlighted structural and individual barriers to adherence. At the structural level, police discrimination and harassment was reported to be a major barrier to adherence to opioid substitution therapy and HAART. Privacy and stigma were barriers at the individual level. Recommendations for adherence interventions included education, training, and identification cards to show police that medication was for treatment of HIV, not for abuse; and involving family members and other systems of support for HIV treatment. © 2009 Taylor & Francis.


Zamudio-Haas S.,University of California at Berkeley | Mudekunye-Mahaka I.,University of Zimbabwe | Lambdin B.H.,Pangaea Global AIDS Foundation | Dunbar M.S.,University of California at Berkeley | Dunbar M.S.,Pangaea Global AIDS Foundation
Reproductive Health Matters | Year: 2012

In the Shona culture of Zimbabwe, a high regard for childbearing contributes to strong pressures on women to have children. For young women living with HIV, consequently, disclosure of HIV status can be a central strategy to garner support for controlling fertility. This paper reports findings from qualitative interviews with 28 young women aged 16-20 living with HIV in urban Zimbabwe and discusses how these findings can contribute to better policies and programs for this population. Regardless of their current relationship status, interview participants described disclosure as a turning point in romantic partnerships, recounting stressful experiences with major ramifications such as abuse and abandonment on the one hand, and support and love on the other. All but one participant had been in a committed relationship, and most had disclosed to a previous or current partner, with about half of disclosure experiences resulting in adverse reactions. Findings suggest that sexual and reproductive health services must do more to help young women living with HIV negotiate the complexities of disclosure in the context of achieving desired fertility. © 2012 Reproductive Health Matters.


Smit P.W.,London School of Hygiene and Tropical Medicine | Sollis K.A.,London School of Hygiene and Tropical Medicine | Fiscus S.,University of North Carolina at Chapel Hill | Ford N.,World Health Organization | And 11 more authors.
PLoS ONE | Year: 2014

Background: Dried blood spots (DBS) have been used as alternative specimens to plasma to increase access to HIV viral load (VL) monitoring and early infant diagnosis (EID) in remote settings. We systematically reviewed evidence on the performance of DBS compared to plasma for VL monitoring and EID. Methods and Findings: Thirteen peer reviewed HIV VL publications and five HIV EID papers were included. Depending on the technology and the viral load distribution in the study population, the percentage of DBS samples that are within 0.5 log of VL in plasma ranged from 52-100%. Because the input sample volume is much smaller in a blood spot, there is a risk of false negatives with DBS. Sensitivity of DBS VL was found to be 78-100% compared to plasma at VL below 1000 copies/ml, but this increased to 100% at a threshold of 5000 copies/ml. Unlike a plasma VL test which measures only cell free HIV RNA, a DBS VL also measures proviral DNA as well as cell-associated RNA, potentially leading to false positive results when using DBS. The systematic review showed that specificity was close to 100% at DBS VL above 5000 copies/ml, and this threshold would be the most reliable for predicting true virologic failure using DBS. For early infant diagnosis, DBS has a sensitivity of 100% compared to fresh whole blood or plasma in all studies. Conclusions: Although limited data are available for EID, DBS offer a highly sensitive and specific sampling strategy to make viral load monitoring and early infant diagnosis more accessible in remote settings. A standardized approach for sampling, storing, and processing DBS samples would be essential to allow successful implementation. Trial Registration: PROSPERO Registration #: CRD42013003621. © 2014 Smit et al.


Flexner C.,Johns Hopkins University | Plumley B.,Pangaea Global AIDS Foundation | Brown Ripin D.H.,Clinton Health Access Initiative
Current Opinion in HIV and AIDS | Year: 2013

PURPOSE OF REVIEW: In this issue of Current Opinion, the Guest Editors and their colleagues provide a comprehensive overview of current activities aimed at optimizing global HIV treatment. In this introduction, we outline current goals and approaches that will be described in more detail elsewhere in this issue. RECENT FINDINGS: Two recent conferences, the first and second Conference on Antiretroviral Drug Optimization (CADO), brought together experts from academia, governments, foundations, the pharmaceutical industry, and community activists to develop a global HIV-treatment research agenda for the coming decade focused on better therapies and how to make them accessible to a broader population of people living with HIV. Important recommendations included a focus on more efficient process chemistry for antiretroviral drugs, investigation of antiretroviral dose reduction as a possible optimization strategy, recognition of the increasing importance of concurrent infections and comorbidities especially tuberculosis and aging-related diseases, and identifying a highly effective and affordable nontoxic, once-daily fixed-dose combination regimen for first-line treatment. SUMMARY: HIV treatment optimization is a process intended to enhance the long-term efficacy, adherence, tolerability, safety, convenience, and affordability of combination ART. The ultimate goal of this process is to expand access to well tolerated and effective lifetime treatment to all those in need. © 2013 Wolters Kluwer Health.


Lambdin B.H.,Pangaea Global AIDS Foundation | Micek M.A.,University of Washington | Koepsell T.D.,University of Washington | Hughes J.P.,University of Washington | And 7 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2011

Introduction: Human resource shortages are viewed as one of the primary obstacles to provide effective services to growing patient populations receiving antiretroviral therapy (ART) and to expand ART access further. We examined the relationship of patient volume, human resource levels, and patient characteristics with attrition from HIV treatment programs in central Mozambique. Methods: We conducted a retrospective cohort study of adult, ART-naive, nonpregnant patients who initiated ART between January 2006 and June 2008 in the national HIV care program. Cox proportional hazards models were used to assess the association of patient volume, clinical staff burden, and pharmacy staff burden with attrition, adjusting for patient characteristics. Results: A total of 11,793 patients from 18 clinics were studied. After adjusting for patient characteristics, patients attending clinics with medium pharmacy staff burden [hazard ratio (HR) = 1.39 (95% CI: 1.07 to 1.80)] and high pharmacy staff burden [HR = 2.09 (95% CI: 1.50 to 2.91)] tended to have a higher risk of attrition (P value for trend: <0.001). Patients attending clinics with higher clinical staff burden did not have a statistically higher risk of attrition. Patients attending clinics with medium patient volume levels [HR = 1.45 (95% CI: 1.04 to 2.04)] and high patient volume levels [HR = 1.41 (95% CI: 1.04 to 1.92)] had a higher risk of attrition, but the trend test was not significant (P = 0.198). DISCUSSION:: Patients attending clinics with higher pharmacy staff burden had a higher risk of attrition. These results highlight a potential area within the health system where interventions could be applied to improve the retention of these patient populations. © 2011 Lippincott Williams & Wilkins.


Gupta A.,Yale University | Mbwambo J.,Muhimbili University of Health and Allied Sciences | Mteza I.,Muhimbili National Hospital | Shenoi S.,Yale University | And 5 more authors.
International Journal of Tuberculosis and Lung Disease | Year: 2014

SETTING: Active case finding is a World Health Organization (WHO) endorsed strategy for improving tuberculosis (TB) case detection. Despite WHO recommendations for active case finding among people who inject drugs (PWID), few studies have been published. The historical focus of case finding has been in populations that are human immunodeficiency virus-positive, incarcerated or at higher occupational risk. OBJECTIVE: We sought to examine the yield of active case finding among PWID newly started on methadone in Tanzania. DESIGN: Of 222 methadone clients, 156 (70%) met with study administrators; 150 consented to participate, 139 (93%) of whom were male. The median age was 34 years. A symptom-based questionnaire was developed by the investigators and administered to every consenting patient by a native Swahili speaker. RESULTS: Of the 150 patients surveyed, 16 (11%) had one or more TB symptoms and were referred for laboratory testing. Six new TB cases were identified in this active case finding program, with a prevalence of 4%. CONCLUSION: This study presents the first data on TB prevalence in a population of PWID in Tanzania. This prevalence is 23 times that of the general Tanzanian TB prevalence of 0.2%. These results have significant implications for TB control. © 2014 The Union.


Thairu L.,Stanford University | Katzenstein D.,Stanford University | Israelski D.,Pangaea Global AIDS Foundation
AIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV | Year: 2011

Access to reliable and low cost CD4 T-cell enumeration to stage illness and monitor anti-retroviral therapy remains elusive in resource-limited settings. We report challenges in delivering CD4 testing using the microcapillary Fluorescence-Activated Cell Sorter (FACS) methodology (Guava EasyCD4 instrument Guava Technologies, Hayward) in Burkina Faso and Zimbabwe. Resources, instruments, reagents, and training were provided to local laboratories within the existing infrastructure and data on CD4 were collected from routine laboratory testing. Challenges encountered included frequent instrument breakdown; poor manufacturer maintenance; difficulties in managing reagent stocks; high technician turnover; reliance on antiquated data management systems; redundant service provision; and lack of repeat testing in male HIV+ patients and in patients with higher CD4 counts after initial staging. While adopting newer, less expensive technologies such as fluorescent platforms and point of care tests can facilitate access to lower cost CD4 testing, our experience suggests that supply chain, corporate commitment to implementation, and community factors also require consideration. © 2011 Taylor & Francis.

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