Nathan Ford

World Health Organization WHO, Genève, Geneva, Switzerland

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Publications (287)3287.38 Total impact

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    ABSTRACT: About 30 million people living with HIV worldwide are eligible for antiretroviral therapy, but less than half of them have access to such treatment. To improve access, some low- and middle-income countries have moved delivery from hospitals to more peripheral health facilities, and have set up training and systems that mean antiretroviral therapy (ART) can be delivered by non-specialist healthcare workers. It is common sense that these approaches are likely to improve access, but some are concerned that they may result in healthcare workers with basic training managing complex and powerful medical treatments in more basic facilities: potentially causing harm. In this Cochrane Column, we highlight two Cochrane reviews that evaluate these policies and were subject to debate and recommendations in the World Health Organization (WHO) consolidated guidelines for antiretroviral treatment in 2013.
    International Journal of Epidemiology 06/2015; DOI:10.1093/ije/dyv111 · 9.20 Impact Factor
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    ABSTRACT: During a World Health Organization-convened Guideline Development Group meeting, recommendations for postexposure prophylaxis (PEP) for human immunodeficiency virus were made and research gaps identified. We used the PEP clinical management pathway and the Grading of Evidence, Assessment, Development and Evaluation (GRADE) system as a framework to formulate future research questions, describe the most feasible study design, and identify potential biases. Three key study design formats were identified to address 12 research questions: (1) survey- and interview-driven research to identify barriers to access to PEP and related clinical care; (2) establishment of a global PEP registry to generate data to inform the choice of an optimal PEP drug regimen, record drug toxicities arising from specific PEP regimens, and track follow-up and linkage to care (including transition from PEP to preexposure prophylaxis); and (3) randomized controlled trials to determine the optimal adherence promotion strategies necessary for successful outcomes following PEP. Positioning key clinical and programmatic research questions within the GRADE framework facilitates the formulation of an evidence-based research agenda and future revisions of guidelines. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail:
    Clinical Infectious Diseases 06/2015; 60 Suppl 3(suppl 3):S205-11. DOI:10.1093/cid/civ139 · 9.42 Impact Factor
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    ABSTRACT: This systematic review aimed to assess the safety and efficacy of antiretroviral options for postexposure prophylaxis (PEP). Recognizing the limited data on the safety and efficacy of antiretroviral drugs for PEP in children, this review was extended to include consideration of data on the use of antiretroviral drugs for treatment of infants and children living with human immunodeficiency virus. The PEP literature was assessed to identify studies reporting safety and completion rates for children given PEP, and this information was complemented by safety and efficacy data for drugs used in antiretroviral therapy. The proportion of patients experiencing each outcome was calculated and data were pooled using random-effects meta-analysis. Three prospective cohort studies reported outcomes of children given zidovudine (ZDV) plus lamivudine (3TC) as a 2-drug PEP regimen. The proportion of children completing the full 28-day course of PEP was 64.0% (95% confidence interval [CI], 41.2%-86.8%), whereas the proportion discontinuing due to adverse events was 4.5% (95% CI, .4%-8.6%). One randomized trial compared abacavir (ABC) plus lamivudine (3TC) and ZDV+3TC as part of a dual or triple first-line antiretroviral therapy regimen; this study showed better efficacy in the ABC-containing combinations and no difference in the time to first serious adverse event. Three randomized trials compared lopinavir/ritonavir (LPV/r) to nevirapine (NVP) for antiretroviral therapy and showed a lower risk of treatment discontinuations associated with LPV/r vs NVP (hazard ratio, 0.56 [95% CI, .41-.75]) but no difference in drug-related adverse events. The overall quality of the evidence was rated as very low. This review supports ZDV+3TC+LPV/r as the preferred 3-drug regimen for PEP in children. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail:
    Clinical Infectious Diseases 06/2015; 60 Suppl 3(suppl 3):S177-81. DOI:10.1093/cid/civ110 · 9.42 Impact Factor
  • Nathan Ford, Kenneth H Mayer
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    ABSTRACT: The 2014 World Health Organization (WHO) guidelines for postexposure prophylaxis (PEP) developed recommendations for PEP irrespective of exposure source in recognition of the need to simplify eligibility assessment and prescribing practices. Traditionally, separate PEP guidelines have been developed according to exposure type, with difference guidelines for occupational exposure, nonoccupational exposure, and sexual assault. Recognizing the need to improve uptake and completion rates for PEP, the WHO 2014 guideline does not differentiate between exposure sources, but rather provides recommendations across all exposures. Recommendations for simplifying prescribing approaches and supporting adherence are also provided. In translating this guidance into national PEP guidelines, countries are encouraged to consider the need to provide PEP in a way that maximizes uptake and completion rates. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail:
    Clinical Infectious Diseases 06/2015; 60 Suppl 3:S161-4. DOI:10.1093/cid/civ068 · 9.42 Impact Factor
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    ABSTRACT: The provision of starter packs for human immunodeficiency virus postexposure prophylaxis (PEP) is practiced in many settings to facilitate rapid initiation by nonexperts and encourage adherence. However, the impact of starter packs on PEP completion rates has not been systematically assessed. We systematically reviewed the evidence on outcomes associated with starter packs for PEP compared to full prescriptions. Four databases and 2 conference abstract sites were searched up to December 2013; this search was updated in 1 database in June 2014. PEP completion rates, stratified by prescribing practice, were pooled using random-effects meta-analysis. Fifty-four studies provided data on 11 714 PEP initiations. Thirty-seven studies, including 3 randomized controlled trials (RCTs) and 34 observational cohorts, provided information on starter packs (although none of the RCTs specifically assessed starter packs), and 17 studies, including 2 RCTs and 15 observational cohorts, provided information on full prescriptions. Overall, outcomes were better when participants were offered a full 28-day course of PEP at initial presentation to healthcare, with fewer refusals (11.4% [95% confidence interval {CI}, 5.3%-17.5%] vs 22% [95% CI, 16.7%-28.1%]) and higher completion rates (70% [95% CI, 56.7%-77.3%] vs 53.2% [95% CI, 44.4%-62.2%]). More than a quarter (28% [95% CI, 21.4%-34.5%]) of individuals provided with a PEP starter pack failed to return for their subsequent appointment and therefore defaulted prior to receiving a full course of PEP. The quality of the evidence overall was rated as very low. The findings of this review suggest that starter packs do not improve adherence to PEP and may result in lower adherence and completion rates. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail:
    Clinical Infectious Diseases 06/2015; 60 Suppl 3(suppl 3):S182-6. DOI:10.1093/cid/civ093 · 9.42 Impact Factor
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    ABSTRACT: The choice of preferred regimens for human immunodeficiency virus postexposure prophylaxis (PEP) has evolved over the last 2 decades as more data have become available regarding the safety and tolerability of newer antiretroviral drugs. We undertook a systematic review to assess the safety and efficacy of antiretroviral options for PEP to inform the World Health Organization guideline revision process. Four databases were searched up to 1 June 2014 for studies reporting outcomes associated with specific PEP regimens. Data on PEP completion and discontinuation due to adverse events was extracted and pooled estimates were obtained using random-effects meta-analyses. Fifteen studies (1830 PEP initiations) provided evaluable information on 2-drug regimens (zidovudine [ZDV]- or tenofovir [TDF]-based regimens), and 10 studies (1755 initiations) provided evaluable information on the third drug, which was usually a protease inhibitor. The overall quality of the evidence was rated as very low. For the 2-drug regimen, PEP completion rates were 78.4% (95% confidence interval [CI], 66.1%-90.7%) for people receiving a TDF-based regimen and 58.8% (95% CI, 47.2%-70.4%) for a ZDV-based regimen; the rate of PEP discontinuation due to an adverse event was lower among people taking TDF-based PEP (0.3%; 95% CI, 0%-1.1%) vs a ZDV-based regimen (3.2%; 95% CI, 1.5%-4.9%). For the 3-drug comparison, PEP completion rates were highest for the TDF-based regimens (TDF+emtricitabine [FTC]+lopinavir/ritonavir [LPV/r], 71.1%; 95% CI, 43.6%-98.6%; TDF+FTC+raltegravir [RAL], 74.7%; 95% CI, 41.4%-100%; TDF+FTC+ boosted darunavir [DRV/r], 93.9%; 95% CI, 90.2%-97.7%) and lowest for ZDV+ lamivudine [3TC]+LPV/r (59.1%; 95% CI, 36.2%-82.0%). Discontinuations due to adverse drug reactions were lowest for TDF+FTC+RAL (1.9%; 95% CI, 0%-3.8%) and highest for ZDV+3TC+boosted atazanavir (21.2%; 95% CI, 13.5%-30.0%). The findings of this review provide evidence supporting the use of coformulated TDF and 3TC/FTC as preferred backbone drugs for PEP. Choice of third drug will depend on setting; for resource-limited settings, LPV/r is a reasonable choice, pending the improved availability of better-tolerated drugs with less potential for drug-drug interactions. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail:
    Clinical Infectious Diseases 06/2015; 60 Suppl 3(suppl 3):S170-6. DOI:10.1093/cid/civ092 · 9.42 Impact Factor
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    ABSTRACT: The efficacy of antiretrovirals as postexposure prophylaxis (PEP) to prevent viral acquisition was demonstrated in nonhuman primate models of human immunodeficiency virus (HIV) in the early 1990s. To complement the evidence base for efficacy of HIV PEP in humans, we systematically reviewed the published data on PEP efficacy across animal studies. PubMed, Web of Science, and Embase were searched from inception to 31 May 2014 for randomized and nonrandomized studies reporting seroconversions among uninfected animals exposed to HIV or simian immunodeficiency virus, irrespective of route of exposure. Seroconversion risk data were pooled using random-effects models, and associations explored through meta-regression. Twenty-five studies (408 primates) were included for review. The risk of serconversion was 89% lower among animals exposed to PEP compared with those that did not receive PEP (odds ratio, 0.11 [95% confidence interval, .05-.23]). Heterogeneity was low (I(2) = 0.0%). In meta-regression, a significant association was found between timing of PEP and seroconversion and the use of tenofovir compared with other drugs. This review provides further evidence of the protective benefit of PEP in preventing HIV acquisition, and the importance of initiating PEP as early as possible following virus exposure. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail:
    Clinical Infectious Diseases 06/2015; 60 Suppl 3(suppl 3):S165-9. DOI:10.1093/cid/civ069 · 9.42 Impact Factor
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    ABSTRACT: There is a clear convergence toward an overarching strategic use of antiretroviral drugs to prevent human immunodeficiency virus (HIV) infection. Four interventions-immediate antiretroviral therapy (ART) for the infected partner in a serodiscordant couple, preexposure prophylaxis (PrEP), prevention of mother-to-child transmission (PMTCT), and postexposure prophylaxis (PEP)-are all strongly recommended by the World Health Organization as effective ways to prevent HIV infection. For HIV-infected individuals, ART to protect an HIV-uninfected partner and PMTCT are both part of an expanding list of recommendations for starting ART immediately to both treat and prevent HIV infection. For HIV-uninfected individuals, PrEP and PEP are increasingly being seen as related interventions, and there are compelling reasons to consider the provision of PEP as a potential gateway to PrEP. The effectiveness of each of these interventions depends on overcoming barriers to seeking services, adequate community understanding and engagement, high levels of access and uptake of services including HIV testing and counselling, and high levels of adherence. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail:
    Clinical Infectious Diseases 06/2015; 60 Suppl 3(suppl 3):S159-60. DOI:10.1093/cid/civ091 · 9.42 Impact Factor
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    ABSTRACT: Of the estimated 130-150 million people who are chronically infected with hepatitis C virus, around 90% reside in low- and middle-income countries. People who inject drugs are disproportionately affected by HCV, with a global estimated prevalence (based on serological reports of HCV antibodies) of 67%; world-wide over 10 million people who inject drugs are infected with HCV. Treatment for HCV has improved dramatically in recent years with the arrival of new direct acting antivirals (DAAs) and this is stimulating considerable efforts to scale up access to treatment. However, treatment coverage among the general population is less than 10% in most countries, and coverage for people who inject drugs is generally much lower. It is estimated that globally around 2 million people who inject drugs need treatment for HCV. The DAAs offer significant potential to rapidly expand access to treatment for HCV. While the ideal combination therapy remains to be established, key characteristics include high efficacy, tolerability, pan-genotypic activity, short treatment duration, oral therapy, affordability, limited drug-drug interactions, and availability as fixed-dose combinations and once daily treatments. This paper outlines 10 key priorities for improving access to HCV treatment for people who inject drugs: (1) affordable access to direct acting antivirals; (2) increased awareness and testing; (3) standardization of treatment; (4) simplification of service delivery; (5) integration of services; (6) peer support; (7) treatment within a framework of comprehensive prevention; (8) tracking progress; (9) dedicated funding; and (10) enabling policies. Copyright © 2015. Published by Elsevier B.V.
    International Journal of Drug Policy 05/2015; DOI:10.1016/j.drugpo.2015.05.004 · 2.40 Impact Factor
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    ABSTRACT: An estimated 150 million people worldwide are infected with hepatitis C virus (HCV). HIV co-infection accelerates the progression of HCV and represents a major public health challenge. We aimed to determine the epidemiology of HCV and the prevalence of HIV co-infection in sub-Saharan Africa. We searched Medline and Embase (Ovid) from Jan 1, 2002, to Dec 31, 2014, for studies containing data for HCV seroprevalence in different population groups in WHO-defined regions of sub-Saharan Africa. We estimated pooled regional prevalence estimates with a DerSimonian-Laird random-effects model. Data were further stratified by risk factor and HIV status. We included 213 studies from 33 countries in sub-Saharan Africa, comprising 287 separate cohorts with 1 198 167 individuals. The pooled HCV seroprevalence from all cohorts was 2·98% (95% CI 2·86-3·10). The pooled HCV seroprevalence was 2·65% (95% CI 2·53-2·78) across all 185 low-risk cohorts, 3·04% (2·23-3·84) in antenatal clinic groups, 1·99% (1·86-2·12) in blood donors, but 6·9% (6·1-7·5) in other general population cohorts. The pooled seroprevalence of HCV was 11·87% (95% CI 7·05-16·70) across all high-risk groups and 9·95% (6·79-13·11) in patients with liver disease. 101 cohorts included HIV-positive samples tested for HCV (42 648 individuals), with a pooled seroprevalence of 5·73% (95% CI 4·90-6·56). We recorded a high seroprevalence of HCV across populations of sub-Saharan Africa, including in HIV-positive adults, with evidence of regional variation in the general population. Monitoring of antenatal HCV prevalence might be a helpful indicator of population trends in HCV infection; however, larger population surveys are needed to monitor these trends. Access to prevention and treatment needs to be improved for both monoinfected and co-infected individuals. None. Copyright © 2015 Elsevier Ltd. All rights reserved.
    The Lancet Infectious Diseases 05/2015; DOI:10.1016/S1473-3099(15)00006-7 · 19.45 Impact Factor
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    ABSTRACT: Efavirenz (EFV) is widely used for the treatment of antiretroviral-naïve HIV-positive individuals, but there are concerns about the risk of adverse neuropsychiatric events. We systematically reviewed the safety of efavirenz in first-line therapy. 4 databases were searched up to October 2014 for randomized trials comparing efavirenz against non-efavirenz based-regimens for the treatment of antiretroviral-naïve HIV-positive adults and children. The primary outcome was drug discontinuation as a result of any adverse event. Relative risks and proportions were pooled using random effects meta-analysis. 42 trials were included for review. A lower relative and absolute risk of discontinuations due to adverse drug reactions was seen with efavirenz compared to nevirapine. The relative and absolute risk of discontinuation was greater for efavirenz compared to low dose efavirenz, rilpivirine, tenofovir, atazanavir, and maraviroc. The relative risk of discontinuation was greater for efavirenz compared to dolutegravir and raltegravir but absolute risks were not significantly different. There was no difference in the risk of any severe clinical adverse events for any comparison. With the exception of dizziness, fewer than 10% of patients exposed to efavirenz experienced any other specific type of neuropsychniatric event. No suicides were reported. This review found that over 90% of patients remained on an EFV-based first-line regimen after an average follow up time of 78 weeks. The relative risk of discontinuations due to adverse events was higher for efavirenz compared to most other first-line options but absolute differences were less than 5% for all comparisons.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 04/2015; DOI:10.1097/QAI.0000000000000606 · 4.39 Impact Factor
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    ABSTRACT: Rwanda has achieved substantial progress in scaling up of antiretroviral therapy. We aimed to assess the effect of increased access to antiretroviral therapy on life expectancy among HIV-positive patients in two distinct periods of lower and higher antiretroviral therapy coverage (1997-2007 and 2008-11). In a retrospective observational cohort study, we collected clinical and demographic data for all HIV-positive patients enrolled in care at 110 health facilities across all five provinces of Rwanda. We included patients aged 15 years or older with a known enrolment date between 1997 and 2014. We constructed abridged life tables from age-specific mortality rates and life expectancy stratified by sex, CD4 cell count, and WHO disease stage at enrolment in care and initiation of antiretroviral therapy. We included 72 061 patients in this study, contributing 213 983 person-years of follow-up. The crude mortality rate was 33·4 deaths per 1000 person-years (95% CI 32·7-34·2). Life expectancy for the overall cohort was 25·6 additional years (95% CI 25·1-26·1) at 20 years of age and 23·3 additional years (95% CI 22·9-23·7) at 35 years of age. Life expectancy at 20 years of age in the period of 1997-2007 was 20·4 additional years (95% CI 19·5-21·3); for the period of 2008-11, life expectancy had increased to 25·6 additional years (95% CI 24·8-26·4). Individuals enrolling in care with CD4 cell counts of 500 cells per μL or more, and with WHO disease stage I, had the highest life expectancies. This study adds to the growing body of evidence showing the benefit to HIV-positive patients of early enrolment in care and initiation of antiretroviral therapy. Bill & Melinda Gates Foundation. Copyright © 2015 Nsanzimana et al. Open Access article distributed under the terms of CC BY-NC-SA. Published by .. All rights reserved.
    The Lancet Global Health 03/2015; 6(3). DOI:10.1016/S2214-109X(14)70364-X · 10.04 Impact Factor
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    ABSTRACT: Measurement of CD4+ T-lymphocytes (CD4) is a crucial parameter in the management of HIV patients, particularly in determining eligibility to initiate antiretroviral treatment (ART). A number of technologies exist for CD4 enumeration, with considerable variation in cost, complexity, and operational requirements. We conducted a systematic review of the performance of technologies for CD4 enumeration. Studies were identified by searching electronic databases MEDLINE and EMBASE using a pre-defined search strategy. Data on test accuracy and precision included bias and limits of agreement with a reference standard, and misclassification probabilities around CD4 thresholds of 200 and 350 cells/μl over a clinically relevant range. The secondary outcome measure was test imprecision, expressed as % coefficient of variation. Thirty-two studies evaluating 15 CD4 technologies were included, of which less than half presented data on bias and misclassification compared to the same reference technology. At CD4 counts <350 cells/μl, bias ranged from -35.2 to +13.1 cells/μl while at counts >350 cells/μl, bias ranged from -70.7 to +47 cells/μl, compared to the BD FACSCount as a reference technology. Misclassification around the threshold of 350 cells/μl ranged from 1-29% for upward classification, resulting in under-treatment, and 7-68% for downward classification resulting in overtreatment. Less than half of these studies reported within laboratory precision or reproducibility of the CD4 values obtained. A wide range of bias and percent misclassification around treatment thresholds were reported on the CD4 enumeration technologies included in this review, with few studies reporting assay precision. The lack of standardised methodology on test evaluation, including the use of different reference standards, is a barrier to assessing relative assay performance and could hinder the introduction of new point-of-care assays in countries where they are most needed.
    PLoS ONE 03/2015; 10(3):e0115019. DOI:10.1371/journal.pone.0115019 · 3.53 Impact Factor
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    ABSTRACT: Background & Aims: Combinations of direct-acting antivirals can cure hepatitis C virus in the majority of treatment-naïve patients. Mass treatment programmes to cure hepatitis C virus in developing countries are only feasible if the costs of treatment and laboratory diagnostics are very low. This analysis aimed to estimate minimum costs of direct acting antiviral treatment and associated diagnostic monitoring. Methods: Clinical trials of hepatitis C virus direct-acting antivirals were reviewed to identify combinations with consistently high rates of sustained virological response across hepatitis C genotypes. For each direct-acting antiviral, molecular structures, doses, treatment duration and components of retro-synthesis were used to estimate costs of large-scale, generic production. Manufacturing costs per gram of direct-acting antiviral were based upon treating at least 5 million patients/year and a 40% margin for formulation. Costs of diagnostic support were estimated based on published minimum prices of genotyping, hepatitis C virus antigen tests plus full blood count/clinical chemistry. Results: Predicted minimum costs for 12-week courses of combination direct-acting antivirals with the most consistent efficacy results were: US$122 per person for sofosbuvir+daclatasvir, US$152 for sofosbuvir+ribavirin, US$192 for sofosbuvir+ledipasvir and US$115 for MK-8742+MK-5172. Diagnostic testing costs were estimated at US$90 for genotyping US$34 for two hepatitis C virus antigen tests and US$22 for two full blood count/clinical chemistry. Conclusions: Minimum costs of treatment and diagnostics to cure hepatitis C virus infection were estimated at US$171-360 per-person without genotyping or US$261-450 per-person with genotyping. These cost estimates assume that existing large-scale treatment programmes can be established. This article is protected by copyright. All rights reserved. © 2014 by the American Association for the Study of Liver Diseases.
    Hepatology 02/2015; 61(4). DOI:10.1002/hep.27641 · 11.19 Impact Factor
  • The Lancet HIV 01/2015; DOI:10.1016/S2352-3018(14)00039-3
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    Clinical Infectious Diseases 12/2014; DOI:10.1093/cid/ciu1138 · 9.42 Impact Factor
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    ABSTRACT: This study assesses the extent to which the strength of a recommendation in a World Health Organization (WHO) guideline affects uptake of the recommendation in national guidelines.
    Journal of Clinical Epidemiology 12/2014; 68(6). DOI:10.1016/j.jclinepi.2014.11.006 · 5.48 Impact Factor
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    The Lancet HIV 12/2014; 1(3):e104-e111.
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    ABSTRACT: We evaluated variations in completion rates for HIV postexposure prophylaxis (PEP) according to the exposure type (occupational, nonoccupational, and sexual assault), patient, and programme characteristics. Four major databases were searched together with conference abstract databases from inception to 1 December 2013, updated in PubMed on 1 June 2014. Randomized and nonrandomized studies reporting completion rates for PEP were included regardless of exposure type, age, or geographical location and data pooled using random-effects meta-analysis. Ninety-seven studies, reporting outcomes on 21 462 PEP initiations, were reviewed. Nonoccupational exposure to HIV was the main reason for PEP in 34 studies (n = 11 840), occupational exposure in 22 studies (n = 3058), sexual assault in 26 studies (n = 3093), and the remainder of studies (15 studies, n = 3471) reported outcomes for mixed exposures. Overall, 56.6% [95% confidence (CI) 50.9-62.2%; τ 0.25] of people considered eligible for PEP completed the full standard 28-day course. Compared with the overall estimate of PEP completion, rates were highest for studies reporting PEP for nonoccupational exposures (65.6%, 95% CI 55.6-75.6%) and lowest for sexual assault (40.2%, 95% CI 31.2-49.2%); higher rates of PEP completion were also reported for MSM (67.2%, 95% CI 59.5-74.9%). Completion rates appeared to be lower for adolescents (36.6%, 95% CI 4.0-69.2%) compared with adults (59.1%, 95% CI 53.9-64.2%) or children (64.0%, 95% CI 41.2-86.8%). Adherence to a full 28-day course of antiretroviral drugs prescribed for PEP is poor. Efforts should be made to simplify guidelines for prescribers and support adherence for people taking PEP, with particular attention needed for adolescents and victims of sexual assault.
    AIDS (London, England) 11/2014; 28(18):2721-2727. DOI:10.1097/QAD.0000000000000505 · 6.56 Impact Factor
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    ABSTRACT: For more than two decades, CD4 cell count measurements have been central to understanding HIV disease progression, making important clinical decisions, and monitoring the response to antiretroviral therapy (ART). In well resourced settings, the monitoring of patients on ART has been supported by routine virological monitoring. Viral load monitoring was recommended by WHO in 2013 guidelines as the preferred way to monitor people on ART, and efforts are underway to scale up access in resource-limited settings. Recent studies suggest that in situations where viral load is available and patients are virologically suppressed, long-term CD4 monitoring adds little value and stopping CD4 monitoring will have major cost savings. CD4 cell counts will continue to play an important part in initial decisions around ART initiation and clinical management, particularly for patients presenting late to care, and for treatment monitoring where viral load monitoring is restricted. However, in settings where both CD4 cell counts and viral load testing are routinely available, countries should consider reducing the frequency of CD4 cell counts or not doing routine CD4 monitoring for patients who are stable on ART. Copyright © 2014 Elsevier Ltd. All rights reserved.
    The Lancet Infectious Diseases 11/2014; DOI:10.1016/S1473-3099(14)70896-5 · 19.45 Impact Factor

Publication Stats

5k Citations
3,287.38 Total Impact Points


  • 2013–2015
    • World Health Organization WHO
      • Department of HIV/AIDS (HIV)
      Genève, Geneva, Switzerland
    • Johns Hopkins University
      Baltimore, Maryland, United States
    • Stellenbosch University
      Stellenbosch, Western Cape, South Africa
  • 2012–2015
    • Imperial College London
      • Division of Infectious Diseases
      Londinium, England, United Kingdom
    • University of Ottawa
      • Faculty of Health Sciences
      Ottawa, Ontario, Canada
    • Stanford University
      • Division of General Medical Disciplines
      Palo Alto, CA, United States
  • 2002–2015
    • University of Cape Town
      • • Centre of Infectious Disease Epidemiology & Research
      • • School of Public Health and Family Medicine
      Kaapstad, Western Cape, South Africa
    • London School of Hygiene and Tropical Medicine
      Londinium, England, United Kingdom
  • 2014
    • University of Liverpool
      Liverpool, England, United Kingdom
  • 2002–2014
    • Médecins Sans Frontières
      Bruxelles, Brussels Capital Region, Belgium
  • 1999–2013
    • Doctors Without Borders
      Lutetia Parisorum, Île-de-France, France
  • 2011
    • University of Washington Seattle
      • School of Public Health
      Seattle, Washington, United States
  • 2008–2011
    • Simon Fraser University
      • Faculty of Health Sciences
      Burnaby, British Columbia, Canada
    • Groote Schuur Hospital
      Kaapstad, Western Cape, South Africa
    • College of Medicine of South Africa
      Kaapstad, Western Cape, South Africa
  • 2010
    • Johns Hopkins Medicine
      • Department of Surgery
      Baltimore, MD, United States
  • 2004
    • Veterinarians Without Borders Switzerland
      Geneva, Switzerland
  • 2001
    • University of Toronto
      Toronto, Ontario, Canada
  • 2000
    • Utrecht University
      Utrecht, Utrecht, Netherlands