Browsing by Author "van Cutsem, Gilles"

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    Correcting mortality for loss to follow-up: a nomogram applied to antiretroviral treatment programmes in sub-Saharan Africa
    (Public Library of Science, 2011) Egger, Matthias; Spycher, Ben D; Sidle, John; Weigel, Ralf; Geng, Elvin H; Fox, Matthew P; MacPhail, Patrick; van Cutsem, Gilles; Messou, Eugène; Wood, Robin
    Background: The World Health Organization estimates that in sub-Saharan Africa about 4 million HIV-infected patients had started antiretroviral therapy (ART) by the end of 2008. Loss of patients to follow-up and care is an important problem for treatment programmes in this region. As mortality is high in these patients compared to patients remaining in care, ART programmes with high rates of loss to follow-up may substantially underestimate mortality of all patients starting ART. Methods and Findings: We developed a nomogram to correct mortality estimates for loss to follow-up, based on the fact that mortality of all patients starting ART in a treatment programme is a weighted average of mortality among patients lost to follow-up and patients remaining in care. The nomogram gives a correction factor based on the percentage of patients lost to follow-up at a given point in time, and the estimated ratio of mortality between patients lost and not lost to follow-up. The mortality observed among patients retained in care is then multiplied by the correction factor to obtain an estimate of programme-level mortality that takes all deaths into account. A web calculator directly calculates the corrected, programme-level mortality with 95% confidence intervals (CIs). We applied the method to 11 ART programmes in sub-Saharan Africa. Patients retained in care had a mortality at 1 year of 1.4% to 12.0%; loss to follow-up ranged from 2.8% to 28.7%; and the correction factor from 1.2 to 8.0. The absolute difference between uncorrected and corrected mortality at 1 year ranged from 1.6% to 9.8%, and was above 5% in four programmes. The largest difference in mortality was in a programme with 28.7% of patients lost to follow-up at 1 year. Conclusions: The amount of bias in mortality estimates can be large in ART programmes with substantial loss to follow-up. Programmes should routinely report mortality among patients retained in care and the proportion of patients lost. A simple nomogram can then be used to estimate mortality among all patients who started ART, for a range of plausible mortality rates among patients lost to follow-up.
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    Epidemic levels of drug resistant tuberculosis (MDR and XDR-TB) in a high HIV prevalence setting in Khayelitsha, South Africa
    (Public Library of Science, 2010) Cox, Helen S; McDermid, Cheryl; Azevedo, Virginia; Muller, Odelia; Coetzee, David; Simpson, John; Barnard, Marinus; Coetzee, Gerrit; van Cutsem, Gilles; Goemaere, Eric
    BACKGROUND: Although multidrug-resistant tuberculosis (MDR-TB) is emerging as a significant threat to tuberculosis control in high HIV prevalence countries such as South Africa, limited data is available on the burden of drug resistant tuberculosis and any association with HIV in such settings. We conducted a community-based representative survey to assess the MDR-TB burden in Khayelitsha, an urban township in South Africa with high HIV and TB prevalence. METHODOLOGY/PRINCIPAL FINDINGS: A cross-sectional survey was conducted among adult clinic attendees suspected for pulmonary tuberculosis in two large primary care clinics, together constituting 50% of the tuberculosis burden in Khayelitsha. Drug susceptibility testing (DST) for isoniazid and rifampicin was conducted using a line probe assay on positive sputum cultures, and with culture-based DST for first and second-line drugs. Between May and November 2008, culture positive pulmonary tuberculosis was diagnosed in 271 new and 264 previously treated tuberculosis suspects (sample enriched with previously treated cases). Among those with known HIV status, 55% and 71% were HIV infected respectively. MDR-TB was diagnosed in 3.3% and 7.7% of new and previously treated cases. These figures equate to an estimated case notification rate for MDR-TB of 51/100,000/year, with new cases constituting 55% of the estimated MDR-TB burden. HIV infection was not significantly associated with rifampicin resistance in multivariate analyses. Conclusions/Significance There is an extremely high burden of MDR-TB in this setting, most likely representing ongoing transmission. These data highlight the need to diagnose drug resistance among all TB cases, and for innovative models of case detection and treatment for MDR-TB, in order to interrupt transmission and control this emerging epidemic.
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    “It’s a secret between us”: a qualitative study on children and care-giver experiences of HIV disclosure in Kinshasa, Democratic Republic of Congo
    (2021-02-06) Sumbi, Elysée M; Venables, Emilie; Harrison, Rebecca; Garcia, Mariana; Iakovidi, Kleio; van Cutsem, Gilles; Chalachala, Jean L
    Background It is estimated that 64,000 children under 15 years of age are living with HIV in the Democratic Republic of Congo (DRC). Non-disclosure – in which the child is not informed about their HIV status - is likely to be associated with poor outcomes during adolescence including increased risk of poor adherence and retention, and treatment failure. Disclosing a child’s HIV status to them can be a difficult process for care-givers and children, and in this qualitative study we explored child and care-giver experiences of the process of disclosing, including reasons for delay. Methods A total of 22 in-depth interviews with care-givers and 11 in-depth interviews with HIV positive children whom they were caring for were conducted in one health-care facility in the capital city of Kinshasa. Care-givers were purposively sampled to include those who had disclosed to their children and those who had not. Care-givers included biological parents, grandmothers, siblings and community members and 86% of them were female. Interviews were conducted in French and Lingala. All interviews were translated and/or transcribed into French before being manually coded. Thematic analysis was conducted. Verbal informed consent/assent was taken from all interviewees. Results At the time of interview, the mean age of children and care-givers was 17 (15–19) and 47 (21–70) years old, respectively. Many care-givers had lost family members due to HIV and several were HIV positive themselves. Reasons for non-disclosure included fear of stigmatisation; wanting to protect the child and not having enough knowledge about HIV or the status of the child to disclose. Several children had multiple care-givers, which also delayed disclosure, as responsibility for the child was shared. In addition, some care-givers were struggling to accept their own HIV status and did not want their child to blame them for their own positive status by disclosing to them. Conclusions Child disclosure is a complex process for care-givers, health-care workers and the children themselves. Care-givers may require additional psycho-social support to manage disclosure. Involving multiple care-givers in the care of HIV positive children could offer additional support for disclosure.
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    Outcomes of patients failing first-line antiretroviral treatment in a decentralised programme led by nurses in the Democratic Republic of Congo
    (2019) Gils, Tinne; Davies, Mary-Ann; van Cutsem, Gilles
    Background: Task-shifting of care and first-line treatment for people living with HIV (PLHIV) from doctors to nurses is feasible, effective and acceptable in sub-Saharan Africa. Since first-line resistance to antiretroviral therapy (ART) is increasing, comprehensive HIV care should be informed by viral load (VL) monitoring to ensure timely detection of treatment failure and switch to second-line ART if appropriate. Patients identified with a first elevated VL (FEVL) enter a cycle with extra counselling sessions, VL re-testing, and potential regimen switch, putting additional strain on scarce human resources. However, identification of treatment failure and its management remains largely doctor-led and there are limited results from programmes with nurse-led management of treatment failure. Health service-delivery in the Democratic Republic of Congo (DRC) is challenging in a weak health system, pressured by epidemics and political unrest. Despite low HIV prevalence in the capital Kinshasa (1.6%), many PLHIV present with advanced disease and early mortality is high. HIV care and treatment, VL testing and second-line switch in decentralised facilities in Kinshasa is exclusively managed by nurses, but results have so far not been documented. Methods Patient outcome data in three primary care facilities in Kinshasa, were routinely collected since ART introduction in 2002 and entered in the national Tier.net database. A protocol (Section A: Study protocol) was developed with detailed methods and procedures for a retrospective analysis of patient outcomes after having had a FEVL (≥1000 copies/ml). The protocol includes analysis of predictors for favourable outcomes (i.e. retained and with VL re-suppressed at 12 months after first high VL or administratively censored or transferred with suppressed VL), and analysis of compliance to existing protocols. The protocol received approval by ethics boards of the Ministry of Health of the DRC and the University of Cape Town. A structured literature review was conducted (Section B: Literature review), critically appraising peer-reviewed publications describing outcomes of PLHIV on ART after first-line failure in sub-Saharan Africa under programmatic conditions. The review included studies where treatment failure and switch were managed by medical doctors, due to paucity of data of nurse-led management of treatment failure. Predictors for outcomes after failure and switch to secondline were also extracted from available literature. A journal-ready manuscript (Section C: Manuscript) presents the findings of the analysis conducted on patients with a FEVL in three decentralised nurse-led facilities in Kinshasa, and predictors for favourable outcomes. Results Of 294 adults with FEVL who did not switch to second-line before confirmatory VL, 82% had a second VL (VL2) done within 24 months of FEVL at a median (interquartile range [IQR]) of 4.0 (3.1-5.6) months) after FEVL. Among patients with VL2 done, 69% had VL2 ≥1000copies/ml, of whom 75% switched to second-line a median of 1.1 (IQR, 0.7-2.0) months after VL2. Among the 85% of patients who were not deceased, LTFU or transferred out by 6 months after second-line switch, 82% had VL6 versus ≤3 months after FEVL and switching 1-3 versus ≤1 month after VL2 ≥ 1000copies/ml were independently associated with lower odds of a favourable outcome. Conclusion Exclusively nurse-managed detection of virologic failure and switch to second-line ART in decentralised health facilities yielded acceptable outcomes in our cohort in urban Kinshasa. Early detection and fast switch can help improve retention and viral suppression following virologic failure. Task-shifting along the viral load cascade is a feasible and safe strategy in settings with limited human resources and growing viral resistance.
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    Time to ART initiation among patients treated for rifampicin-resistant tuberculosis in Khayelitsha, South Africa: impact on mortality and treatment success
    (Public Library of Science, 2015) Daniels, Johnny Flippie; Khogali, Mohammed; Mohr, Erika; Cox, Vivian; Moyo, Sizulu; Edginton, Mary; Hinderaker, Sven Gudmund; Meintjes, Graeme; Hughes, Jennifer; De Azevedo, Virginia; van Cutsem, Gilles; Cox, Helen Suzanne
    Setting Khayelitsha, South Africa, with high burdens of rifampicin-resistant tuberculosis (RR-TB) and HIV co-infection. Objective To describe time to antiretroviral treatment (ART) initiation among HIV-infected RR-TB patients initiating RR-TB treatment and to assess the association between time to ART initiation and treatment outcomes. Design A retrospective cohort study of patients with RR-TB and HIV co-infection not on ART at RR-TB treatment initiation. RESULTS: Of the 696 RR-TB and HIV-infected patients initiated on RR-TB treatment between 2009 and 2013, 303 (44%) were not on ART when RR-TB treatment was initiated. The median CD4 cell count was 126 cells/mm 3 . Overall 257 (85%) patients started ART during RR-TB treatment, 33 (11%) within 2 weeks, 152 (50%) between 2-8 weeks and 72 (24%) after 8 weeks. Of the 46 (15%) who never started ART, 10 (21%) died or stopped RR-TB treatment within 4 weeks and 16 (37%) had at least 4 months of RR-TB treatment. Treatment success and mortality during treatment did not vary by time to ART initiation: treatment success was 41%, 43%, and 50% among patients who started ART within 2 weeks, between 2-8 weeks, and after 8 weeks (p = 0.62), while mortality was 21%, 13% and 15% respectively (p = 0.57). Mortality was associated with never receiving ART (adjusted hazard ratio (aHR) 6.0, CI 2.1-18.1), CD4 count ≤100 (aHR 2.1, CI 1.0-4.5), and multidrug-resistant tuberculosis (MDR-TB) with second-line resistance (aHR 2.5, CI 1.1-5.4). CONCLUSIONS: Despite wide variation in time to ART initiation among RR-TB patients, no differences in mortality or treatment success were observed. However, a significant proportion of patients did not initiate ART despite receiving >4 months of RR-TB treatment. Programmatic priorities should focus on ensuring all patients with RR-TB/HIV co-infection initiate ART regardless of CD4 count, with special attention for patients with CD4 counts ≤ 100 to initiate ART as soon as possible after RR-TB treatment initiation.