Mermin J, Were W, Ekwaru JP, Moore D, Downing R, Behumbiize P, et al. Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: a prospective cohort study

Centers for Disease Control and Prevention-Uganda, Global AIDS Program, National Center for HIV, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention, Centers for Disease Control and Prevention, Entebbe, Uganda.
The Lancet (Impact Factor: 45.22). 03/2008; 371(9614):752-9. DOI: 10.1016/S0140-6736(08)60345-1
Source: PubMed


Antiretroviral therapy (ART) is increasingly available in Africa, but physicians and clinical services are few. We therefore assessed the effect of a home-based ART programme in Uganda on mortality, hospital admissions, and orphanhood in people with HIV-1 and their household members.
In 2001, we enrolled and followed up 466 HIV-infected adults and 1481 HIV-uninfected household members in a prospective cohort study. After 5 months, we provided daily co-trimoxazole (160 mg trimethoprim and 800 mg sulfamethoxazole) prophylaxis to HIV-infected participants. Between May, 2003, and December, 2005, we followed up 138 infected adults who were eligible and 907 new HIV-infected participants and their HIV-negative household members in a study of ART (mainly stavudine, lamivudine, and nevirapine). Households were visited every week by lay providers, and no clinic visits were scheduled after enrolment. We compared rates of death, hospitalisation, and orphanhood during different study periods and calculated the number needed to treat to prevent an outcome.
233 (17%) of 1373 participants with HIV and 40 (1%) of 4601 HIV-uninfected household members died. During the first 16 weeks of ART and co-trimoxazole, mortality in HIV-infected participants was 55% lower than that during co-trimoxazole alone (14 vs 16 deaths per 100 person-years; adjusted hazard ratio 0.45, 95% CI 0.27-0.74, p=0.0018), and after 16 weeks, was reduced by 92% (3 vs 16 deaths per 100 person-years; 0.08, 0.06-0.13, p<0.0001). Compared with no intervention, ART and co-trimoxazole were associated with a 95% reduction in mortality in HIV-infected participants (5 vs 27 deaths per 100 person-years; 0.05, 0.03-0.08, p<0.0001), 81% reduction in mortality in their uninfected children younger than 10 years (0.2 vs 1.2 deaths per 100 person-years; 0.19, 0.06-0.59, p=0.004), and a 93% estimated reduction in orphanhood (0.9 vs 12.8 per 100 person-years of adults treated; 0.07, 0.04-0.13, p<0.0001).
Expansion of access to ART and co-trimoxazole prophylaxis could substantially reduce mortality and orphanhood among adults with HIV and their families living in resource-poor settings.

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    • "However, little is known about the personal social networks among older people living with HIV/AIDS (OPLWHA) in Africa in general, and in Togo in particular, and whether or not these networks correlate with self-reported health. It is important to study the social networks and health among OPLWHA in Africa because the expanding distribution of antiretroviral therapy (ART) has improved survival among OPLWHA, causing this population to grow (Negin and Cumming 2010; Mermin et al. 2008). In fact, Negin and Cumming (2010) estimated that nearly 3 million people living with HIV/AIDS in sub-Saharan Africa are over 50 years old. "
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    ABSTRACT: Personal social networks and their association with the health of older people have been explored, but there are few studies that examined the relationship between the general health of older people living with HIV/AIDS (OPLWHA) and their personal social networks. This exploratory study investigates the characteristics of personal networks among OPLWHA and the relationship between the self-rated health and personal social networks of OPLWHA in Lomé, Togo. Forty-nine OPLWHA were interviewed via an egocentric survey. We examined the composition and size of the networks of OPLWHA. Also, the correlation between networks and self-reported health was examined. Findings show that the OPLWHA had personal social networks that included three types of people: immediate kin, extended kin, and non-kin. Additionally, these networks varied by size. While the mean number of people in the smaller network (people from whom the OPLWHA can borrow an important sum of money) was less than one person (0.55), the mean number of people in the larger network was three (people with whom the OPLWHA enjoy socializing). Furthermore, only the network of people with whom OPLWHA enjoy socializing had a significant positive correlation on the self-rated health of OPLWHA. Consistent with prior research, we found that the mere existence of a network does not imply that the network has a positive correlation with the subject or that the network provides the social support needed to positively influence health. A study of the correlation between social network characteristics and health in the population of older people with HIV/AIDS is important as the number of OPLWHA continues to grow.
    Journal of Cross-Cultural Gerontology 07/2014; 29(3). DOI:10.1007/s10823-014-9238-5
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    • "Treatment with ART was estimated to avert 7.3 discounted DALYs among HIV-infected individuals who survived >16 weeks. This value was drawn from the same Zambian analysis used to estimate treatment costs, and it was obtained by comparing deaths in the Zambian ART program with deaths observed in a prior, well-characterized home-based AIDS care (HBAC) cohort of 466 HIV-infected patients not receiving ART in Tororo District, Uganda, adjusted for differences in CD4+ T-cell counts and sex distribution between groups [16,19,24,25]. "
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    ABSTRACT: Background Low body mass index (BMI) individuals starting antiretroviral therapy (ART) for HIV infection in sub-Saharan Africa have high rates of death and loss to follow-up in the first 6 months of treatment. Nutritional supplementation may improve health outcomes in this population, but the anticipated benefit of any intervention should be commensurate with the cost given resource limitations and the need to expand access to ART in the region. Methods We used Markov models incorporating historical data and program-wide estimates of treatment costs and health benefits from the Zambian national ART program to estimate the improvements in 6-month survival and program retention among malnourished adults necessary for a combined nutrition support and ART treatment program to maintain cost-effectiveness parity with ART treatment alone. Patients were stratified according to World Health Organization criteria for severe (BMI <16.0 kg/m2), moderate (16.00-16.99 kg/m2), and mild (17.00-18.49 kg/m2) malnutrition categories. Results 19,247 patients contributed data between May 2004 and October 2010. Quarterly survival and retention were lowest in the BMI <16.0 kg/m2 category compared to higher BMI levels, and there was less variation in both measures across BMI strata after 180 days. ART treatment was estimated to cost $556 per year and averted 7.3 disability-adjusted life years. To maintain cost-effectiveness parity with ART alone, a supplement needed to cost $10.99 per quarter and confer a 20% reduction in both 6-month mortality and loss to follow-up among BMI <16.0 kg/m2 patients. Among BMI 17.00-18.49 kg/m2 patients, supplement costs accompanying a 20% reduction in mortality and loss to follow-up could not exceed $5.18 per quarter. In sensitivity analyses, the maximum permitted supplement cost increased if the ART program cost rose, and fell if patients classified as lost to follow-up at 6 months subsequently returned to care. Conclusions Low BMI adults starting ART in sub-Saharan Africa are at high risk of early mortality and loss to follow-up. The expense of providing nutrition supplementation would require only modest improvements in survival and program retention to be cost-effective for the most severely malnourished individuals starting ART, but interventions are unlikely to be cost-effective among those in higher BMI strata.
    Cost Effectiveness and Resource Allocation 04/2014; 12(1):10. DOI:10.1186/1478-7547-12-10 · 0.87 Impact Factor
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    • "Such strategies include malaria management for effective treatment in Africa (Hopkins, Talisuna, Whitty, & Staedke, 2007; Kidane & Morrow, 2000), neonatal care (Bang et al., 2005), reduction of maternal mortality (Goldie, Sweet, Carvalho, Natchu, & Hu, 2010), sexual and reproductive health services for men and women (Bell, Mthembu, O'Sullivan, & Moody, 2007), and concurrent therapy for HIV and tuberculosis (Gandhi et al., 2009). Home-based antiretroviral treatment (ART) has been shown to be effective in reducing mortality and hospital admissions (Mermin et al., 2008), but has relatively low cost-effectiveness (Marseille et al., 2009). Similarly, home-based HIV counselling and testing for household members of HIV-infected individuals has been reported to be feasible and have a higher uptake than clinic-based counselling and testing (Lugada et al., 2010). "
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    ABSTRACT: Home-based voluntary HIV counselling and testing (HB-VCT) has been reported to have a high uptake, but it has not been rigorously evaluated. We designed a model for HB-VCT appropriate for wider scale-up, and investigated the acceptance of home-based counselling and testing, equity in uptake and negative life events with a cluster-randomized trial. Thirty six rural clusters in southern Zambia were pair-matched based on baseline data and randomly assigned to the intervention or the control arm. Both arms had access to standard HIV testing services. Adults in the intervention clusters were offered HB-VCT by local lay counsellors. Effects were first analysed among those participating in the baseline and post-intervention surveys and then as intention-to-treat analysis. The study was registered with, number ISRCTN53353725. A total of 836 and 858 adults were assigned to the intervention and control clusters, respectively. In the intervention arm, counselling was accepted by 85% and 66% were tested (n = 686). Among counselled respondents who were cohabiting with the partner, 62% were counselled together with the partner. At follow-up eight months later, the proportion of adults reporting to have been tested the year prior to follow-up was 82% in the intervention arm and 52% in the control arm (Relative Risk (RR) 1.6, 95% CI 1.4-1.8), whereas the RR was 1.7 (1.4-2.0) according to the intention-to-treat analysis. At baseline the likelihood of being tested was higher for women vs. men and for more educated people. At follow-up these differences were found only in the control communities. Measured negative life events following HIV testing were similar in both groups. In conclusion, this HB-VCT model was found to be feasible, with a very high acceptance and to have important equity effects. The high couple counselling acceptance suggests that the home-based approach has a particularly high HIV prevention potential.
    Social Science [?] Medicine 06/2013; 86:9-16. DOI:10.1016/j.socscimed.2013.02.036 · 2.89 Impact Factor
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