The introduction of efficacious new hepatitis C virus (HCV) treatments galvanized the World Health Organization to define ambitious targets for eliminating HCV as a public health threat by 2030. ...Formidable obstacles to reaching this goal can best be overcome through a micro-elimination approach, which entails pursuing elimination goals in discrete populations through multi-stakeholder initiatives that tailor interventions to the needs of these populations. Micro-elimination is less daunting, less complex, and less costly than full-scale, country-level initiatives to eliminate HCV, and it can build momentum by producing small victories that inspire more ambitious efforts. The micro-elimination approach encourages stakeholders who are most knowledgeable about specific populations to engage with each other and also promotes the uptake of new models of care. Examples of micro-elimination target populations include medical patients, people who inject drugs, migrants, and prisoners, although candidate populations can be expected to vary greatly in different countries and subnational areas.
A recurring question about viral hepatitis is why it receives so little funding and attention from global health policy makers and donors. One reason for this is the difficulty in accurately ...quantifying and explaining the morbidity and mortality related to viral hepatitis.
The introduction of direct-acting antiviral (DAA) medicines in 2013 revolutionised the treatment of chronic hepatitis C virus (HCV) infection. The efficacy of DAA therapy is impressive-in many ...clinical trials HCV cannot be detected by sensitive laboratory assays in more than 90% of people who complete DAA therapy, and observational studies have documented similar results.1,2
Assumptions about survival of HIV-infected children in Africa without antiretroviral therapy need to be updated to inform ongoing UNAIDS modelling of paediatric HIV epidemics among children. Improved ...estimates of infant survival by timing of HIV-infection (perinatally or postnatally) are thus needed.
A pooled analysis was conducted of individual data of all available intervention cohorts and randomized trials on prevention of HIV mother-to-child transmission in Africa. Studies were right-censored at the time of infant antiretroviral initiation. Overall mortality rate per 1000 child-years of follow-up was calculated by selected maternal and infant characteristics. The Kaplan-Meier method was used to estimate survival curves by child's HIV infection status and timing of HIV infection. Individual data from 12 studies were pooled, with 12,112 children of HIV-infected women. Mortality rates per 1,000 child-years follow-up were 39.3 and 381.6 for HIV-uninfected and infected children respectively. One year after acquisition of HIV infection, an estimated 26% postnatally and 52% perinatally infected children would have died; and 4% uninfected children by age 1 year. Mortality was independently associated with maternal death (adjusted hazard ratio 2.2, 95%CI 1.6-3.0), maternal CD4<350 cells/ml (1.4, 1.1-1.7), postnatal (3.1, 2.1-4.1) or peri-partum HIV-infection (12.4, 10.1-15.3).
These results update previous work and inform future UNAIDS modelling by providing survival estimates for HIV-infected untreated African children by timing of infection. We highlight the urgent need for the prevention of peri-partum and postnatal transmission and timely assessment of HIV infection in infants to initiate antiretroviral care and support for HIV-infected children.
Highlights • Most countries lack current age–seroprevalence data on hepatitis A virus (HAV). • Universal vaccination is recommended for countries with intermediate HAV endemicity. • We propose a ...three-stage method for estimating country-specific HAV endemicity levels. • We applied this method to the 23 countries of the Middle East and North Africa. • Several countries in the region should consider HAV vaccination programs.
Expansion of provider-initiated testing and counselling (PITC) is one strategy to increase accessibility of HIV testing services. Insufficient human resources was identified as a primary barrier to ...increasing PITC coverage in Zimbabwe. We evaluated if deployment of supplemental PITC providers at public facilities in Zimbabwe was associated with increased numbers of individuals tested and diagnosed with HIV.
From July 2016 to May 2017, International Training and Education Center for Health (I-TECH) deployed 138 PITC providers to supplement existing ministry healthcare workers offering PITC at 249 facilities. These supplemental providers were assigned to facilities on a weekly basis. Each week, I-TECH providers reported the number of HIV tests and positive diagnoses they performed. Using routine reporting systems, we obtained from each facility the number of clients tested and diagnosed with HIV per month. Including data both before and during the intervention period, and utilizing the weekly variability in placement locations of the supplemental PITC providers, we employed generalized estimating equations to assess if the placement of supplemental PITC providers at a facility was associated with a change in facility outputs.
Supplemental PITC providers performed an average of 62 (SD = 52) HIV tests per week and diagnosed 4.4 (SD = 4.9) individuals with HIV per week. However, using facility reports from the same period, we found that each person-week of PITC provider deployment at a facility was associated with an additional 16.7 (95% CI, 12.2-21.1) individuals tested and an additional 0.9 (95% CI, 0.5-1.2) individuals diagnosed with HIV. We also found that staff placement at clinics was associated with a larger increase in HIV testing than staff placement at polyclinics or hospitals (24.0 vs. 9.8; p < 0.001).
This program resulted in increased numbers of individuals tested and diagnosed with HIV. The discrepancy between the average weekly HIV tests conducted by supplemental PITC providers (62) and the increase in facility-level HIV tests associated with one week of PITC provider deployment (16.7) suggests that supplemental PITC providers displaced existing staff who may have been reassigned to fulfil other duties at the facility.
Introduction
Community ART Refill Groups (CARGs) are an antiretroviral therapy (ART) delivery model where clients voluntarily form into groups, and a group member visits the clinic to collect ART for ...all group members. In late 2016, Zimbabwe began a nationwide rollout of the CARG model. We conducted a qualitative evaluation to assess the perceived effects of this new national service delivery model.
Methods
In March‐June 2018, we visited ten clinics implementing the CARG model across five provinces of Zimbabwe and conducted a focus group discussion with healthcare workers and in‐depth interviews with three ART clients per clinic. Clinics had implemented the CARG model for approximately one year. All discussions were audio recorded, transcribed, and translated into English, and thematic coding was performed by two independent analysts.
Results
In focus groups, healthcare workers described that CARGs made ART distribution faster and facilitated client tracking in the community. They explained that their reduced workload allowed them to provide better care to those clients who did visit the clinic, and they felt that the CARG model should be sustained in the future. CARG members reported that by decreasing the frequency of clinic visits, CARGs saved them time and money, reducing previous barriers to collecting ART and improving adherence. CARG members also valued the emotional and informational support that they received from other members of their CARG, further improving adherence. Multiple healthcare workers did express concern that CARG members with diseases that begin with minor symptoms, such as tuberculosis, may not seek treatment at the clinic until the disease has progressed.
Conclusions
We found that healthcare workers and clients overwhelmingly perceive CARGs as beneficial. This evaluation demonstrates that the CARG model can be successfully implemented on a national scale. These early results suggest that CARGs may be able to simultaneously improve clinical outcomes and reduce the workload of healthcare workers distributing ART.
In Africa, the risk of mother-to-child transmission of HIV-1 infection is high. Short-course perinatal oral zidovudine might decrease the rate of transmission. We assessed the safety and efficacy of ...such a regimen among HIV-1-seropositive breastfeeding women in Abidjan, Côte d'Ivoire.
From April, 1996, to February, 1998, all consenting, eligible HIV-1-seropositive pregnant women attending a public antenatal clinic in Abidjan were enrolled at 36 weeks' gestation and randomly assigned placebo or zidovudine (300 mg tablets), one tablet twice daily until the onset of labour, one tablet at onset of labour, and one tablet every 3 h until delivery. We used HIV-1-DNA PCR to test the infection status of babies at birth, 4 weeks, and 3 months. We stopped the study on Feb 18, 1998, when efficacy results were available from a study in Bangkok, Thailand, in which the same regimen was used in a non-breastfeeding population.
280 women were enrolled (140 in each group). The median duration of the prenatal drug regimen was 27 days (range 1–80) and the median duration of labour was 7·5 h. Treatment was well tolerated with no withdrawals because of adverse events. All babies were breastfed. Among babies with known infection status at age 3 months, 30 (26·1%) of 115 babies in the placebo group and 19 (16·5%) of 115 in the zidovudine group were identified as HIV-1 infected. The estimated risk of HIV-1 transmission in the placebo and zidovudine groups were 21·7% and 12·2% (p=0·05) at 4 weeks, and 24·9% and 15·7% (p=0·07) at 3 months. Efficacy was 44% (95% CI -1 to 69) at age 4 weeks and 37% (-5 to 63) at 3 months.
Short-course oral zidovudine was safe, well tolerated, and decreased mother-to-child transmission of HIV-1 at age 3 months. Substantial efforts will be needed to ensure successful widespread implementation of such a regimen.
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