Suchergebnisse

L'OMS est un des piliers du système des Nations unies. Mais elle n'a pas réussi à coordonner la réponse internationale à la pandémie de Covid-19, ce qui peut s'expliquer de trois manières. D'abord, un rappel historique donne à penser que l'OMS était déjà en situation de fragilité marquée lorsque le Covid-19 a émergé. Ensuite, une chronologie des événements survenus depuis la fin 2019 permet de conclure à des retards dans le mécanisme d'alerte mais surtout dans la séquence des prises de décision par l'OMS puis par les États membres, avec un cadre réglementaire et institutionnel peu adapté et insuffisamment utilisé. Enfin, à l'heure où la réforme profonde de cette organisation est proposée pour adapter la gouvernance internationale en santé aux enjeux actuels et futurs, on peut s'interroger sur la faisabilité et le calendrier de la réforme. Nous discutons des chances de construction d'une OMS 2.0, organisation internationale qui devrait exercer toute sa compétence en santé mondiale.

International audience ; During the past two decades, international efforts to fight against HIV/AIDS have yielded important research successes for child survival in developing countries. Lessons have been learned about which prevention and care approaches are most efficient in responding to the needs of children affected by HIV/AIDS. However the transition from research to action remains largely insufficient. Without the universal access of currently available PMTCT interventions, one out of three infants born to HIV-infected mothers will continue to contract HIV and most of them will die within their first year of life. Yet, economical and cultural barriers limit severely the coverage, acceptability and use of PMTCT services. There is also enough evidence today to roll out paediatric HIV care and treatment, at least at the same speed and extent than adult care and in priority with a family-targeted approach. This however requires improving health care systems as well as long-term political commitment and funding at international, national and more local levels, which is far from guaranteed. Current knowledge indicates that orphans and vulnerable children pay a large tribute to HIV/AIDS and deserve a large-scale response, as their needs remain grossly under-met. Finally, and in line with a growing international consensus, it is more than ever obvious that the fight against HIV/AIDS requires the scaling-up and intensification of primary HIV prevention, as part of a comprehensive response that simultaneously expands access to treatment and care.

International audience ; During the past two decades, international efforts to fight against HIV/AIDS have yielded important research successes for child survival in developing countries. Lessons have been learned about which prevention and care approaches are most efficient in responding to the needs of children affected by HIV/AIDS. However the transition from research to action remains largely insufficient. Without the universal access of currently available PMTCT interventions, one out of three infants born to HIV-infected mothers will continue to contract HIV and most of them will die within their first year of life. Yet, economical and cultural barriers limit severely the coverage, acceptability and use of PMTCT services. There is also enough evidence today to roll out paediatric HIV care and treatment, at least at the same speed and extent than adult care and in priority with a family-targeted approach. This however requires improving health care systems as well as long-term political commitment and funding at international, national and more local levels, which is far from guaranteed. Current knowledge indicates that orphans and vulnerable children pay a large tribute to HIV/AIDS and deserve a large-scale response, as their needs remain grossly under-met. Finally, and in line with a growing international consensus, it is more than ever obvious that the fight against HIV/AIDS requires the scaling-up and intensification of primary HIV prevention, as part of a comprehensive response that simultaneously expands access to treatment and care.

While investigators have a duty to provide research participants with summary findings at the end of a study, providing general information during the course of research is rarely considered. However, this raises an important ethical issue in the context of long-term studies such as cohorts or biobanks. We investigated this issue in the context of two ANRS cohorts of HIV-infected patients, AQUITAINE and COPILOTE. Face-to-face interviews were conducted with HIV patient representatives and research professionals concerning the delivery of information in the course of the research. Respondents stated that participants wish to be informed of research results (both aggregate and individual) but also expect general information about the cohort itself, research progression, and what their participation may provide. It was concluded that information provided during the course of the research may help participants to distinguish between care and research. The essential role of clinicians-investigators in providing information was emphasized.

BACKGROUND: Limited engagement in clinic-based care is affecting the HIV response. We explored the field experiences and perceptions of local health care workers regarding home-based strategies as opportunities to improve the cascade of care of people living with HIV in rural South Africa as part of a Universal Test-and-Treat approach. METHODS: In Hlabisa sub-district, home-based HIV services, including rapid HIV testing and counselling, and support for linkage to and retention in clinic-based HIV care, were implemented by health care workers within the ANRS 12249 Treatment-as-Prevention (TasP) trial. From April to July 2016, we conducted a mixed-methods study among health care workers from the TasP trial and from local government clinics, using self-administrated questionnaires (n = 90 in the TasP trial, n = 56 in government clinics), semi-structured interviews (n = 13 in the TasP trial, n = 5 in government clinics) and three focus group discussions (n = 6-10 health care workers of the TasP trial per group). Descriptive statistics were used for quantitative data and qualitative data were analysed thematically. RESULTS: More than 90% of health care workers assessed home-based testing and support for linkage to care as feasible and acceptable by the population they serve. Many health care workers underlined how home visits could facilitate reaching people who had slipped through the cracks of the clinic-based health care system and encourage them to successfully access care. Health care workers however expressed concerns about the ability of home-based services to answer the HIV care needs of all community members, including people working outside their home during the day or those who fear HIV-related stigmatization. Overall, health care workers encouraged policy-makers to more formally integrate home-based services in the local health system. They promoted reshaping the disease-specific and care-oriented services towards more comprehensive goals. CONCLUSION: Because home-based services allow identification of ...

BACKGROUND: Limited engagement in clinic-based care is affecting the HIV response. We explored the field experiences and perceptions of local health care workers regarding home-based strategies as opportunities to improve the cascade of care of people living with HIV in rural South Africa as part of a Universal Test-and-Treat approach. METHODS: In Hlabisa sub-district, home-based HIV services, including rapid HIV testing and counselling, and support for linkage to and retention in clinic-based HIV care, were implemented by health care workers within the ANRS 12249 Treatment-as-Prevention (TasP) trial. From April to July 2016, we conducted a mixed-methods study among health care workers from the TasP trial and from local government clinics, using self-administrated questionnaires (n = 90 in the TasP trial, n = 56 in government clinics), semi-structured interviews (n = 13 in the TasP trial, n = 5 in government clinics) and three focus group discussions (n = 6-10 health care workers of the TasP trial per group). Descriptive statistics were used for quantitative data and qualitative data were analysed thematically. RESULTS: More than 90% of health care workers assessed home-based testing and support for linkage to care as feasible and acceptable by the population they serve. Many health care workers underlined how home visits could facilitate reaching people who had slipped through the cracks of the clinic-based health care system and encourage them to successfully access care. Health care workers however expressed concerns about the ability of home-based services to answer the HIV care needs of all community members, including people working outside their home during the day or those who fear HIV-related stigmatization. Overall, health care workers encouraged policy-makers to more formally integrate home-based services in the local health system. They promoted reshaping the disease-specific and care-oriented services towards more comprehensive goals. CONCLUSION: Because home-based services allow identification of ...

BackgroundInformation is currently limited on the long‐term follow up of HIV‐1 infected women who are on highly active antiretroviral therapy (HAART) that contains nevirapine and lamivudine and who were previously exposed to antiretroviral drugs for the prevention of mother to child transmission (PMTCT) of HIV.MethodsWe studied the 36‐month immunological response to HAART in HIV‐1 infected women in Côte d'Ivoire. The women were previously exposed to antiretroviral drug regimens for PMTCT, including single‐dose nevirapine and/or short‐course zidovudine with or without lamivudine. All HAART regimens included a non‐nucleoside reverse transcriptase inhibitor.ResultsAt 36 months: the median absolute increase in CD4+ T cell count was +359 cells/mm3 (IQR: 210‐466) in 200 women who had undergone 36‐month follow‐up visits; +359 cells/mm3 (IQR: 222‐491) in 88 women not exposed to PMTCT antiretrovirals; and +363 cells/mm3 (IQR: 200‐464) in 112 women exposed to at least one antiretroviral PMTCT regimen. Overall, 49 (19.8%) of the 247 women who initiated HAART met the immunological failure criteria at least once during follow up. The overall probability of immunological failure was 0.08 (95% CI: 0.12‐0.15) at 12 months, and 0.21 (95% CI: 0.16‐0.27) at 36 months. No difference was observed according to the presence or absence of resistance mutations to nevirapine or lamivudine in women tested at four weeks postpartum. In addition, at 36 months, 23% of women were lost to follow up, dead or had stopped their treatment.ConclusionsA non‐nucleoside reverse transcriptase inhibitor‐based antiretroviral regimen, initiated a year or more after PMTCT exposure and that includes nevirapine, remains a good option for at least the first 36 months of treatment.

BACKGROUND: Limited engagement in clinic-based care is affecting the HIV response. We explored the field experiences and perceptions of local health care workers regarding home-based strategies as opportunities to improve the cascade of care of people living with HIV in rural South Africa as part of a Universal Test-and-Treat approach. METHODS: In Hlabisa sub-district, home-based HIV services, including rapid HIV testing and counselling, and support for linkage to and retention in clinic-based HIV care, were implemented by health care workers within the ANRS 12249 Treatment-as-Prevention (TasP) trial. From April to July 2016, we conducted a mixed-methods study among health care workers from the TasP trial and from local government clinics, using self-administrated questionnaires (n = 90 in the TasP trial, n = 56 in government clinics), semi-structured interviews (n = 13 in the TasP trial, n = 5 in government clinics) and three focus group discussions (n = 6-10 health care workers of the TasP trial per group). Descriptive statistics were used for quantitative data and qualitative data were analysed thematically. RESULTS: More than 90% of health care workers assessed home-based testing and support for linkage to care as feasible and acceptable by the population they serve. Many health care workers underlined how home visits could facilitate reaching people who had slipped through the cracks of the clinic-based health care system and encourage them to successfully access care. Health care workers however expressed concerns about the ability of home-based services to answer the HIV care needs of all community members, including people working outside their home during the day or those who fear HIV-related stigmatization. Overall, health care workers encouraged policy-makers to more formally integrate home-based services in the local health system. They promoted reshaping the disease-specific and care-oriented services towards more comprehensive goals. CONCLUSION: Because home-based services allow identification of people early during their infection and encourage them to take actions leading to viral suppression, HCWs assessed them as valuable components within the panel of UTT interventions, aiming to reach the 90-90-90 UNAIDS targets, especially in the rural Southern African region. TRIAL REGISTRATION: The registration number of the ANRS 12249 TasP trial on ClinicalTrials.gov is NCT01509508.

AbstractIntroduction: Liver fibrosis is often the first stage of liver disease in people living with HIV (PLWHIV) in industrialized countries. However, little is known about liver fibrosis and its correlates among PLWHIV in sub‐Saharan Africa.Methods: The study was undertaken in three HIV referral clinics in Côte d'Ivoire, Senegal and Togo. Enrolled PLWHIV underwent a non‐invasive assessment of liver fibrosis combining liver stiffness measure (LSM) with transient elastography and the aspartate aminotransferase‐to‐platelet ratio index (APRI). Significant liver fibrosis was defined as LSM ≥7.1 kPa. Patients were screened for alcohol use (alcohol use disorder identification test (AUDIT)‐C questionnaire), hepatitis B virus (HBV) antigen, hepatitis Delta virus (HDV) antibody and anti‐hepatitis C (HCV) antibody. A logistic regression model was used to identify the factors associated with significant liver fibrosis.Results: A total of 807 PLWHIV were screened at a median age of 43 years (interquartile range (IQR): 36–50). Their median CD4 count was 393 cells/mm3 (IQR: 234–563) and 682 (84.5%) were on antiretroviral therapy (ART). The prevalence of significant fibrosis was 5.3% (3.8–6.7). Infections with HBV and HCV were identified in 74 (9.2%) and nine (1.1%) participants. Main factors associated with liver fibrosis were alcohol use (AUDIT‐C >6): (odds ratio (OR) = 4.0, confidence interval (CI): 1.2–14.0), (Ref. AUDIT‐C <4) and HBV infection (OR = 2.9, CI: 1.2–7.2). Of the 74 patients positively screened for HBV, 50.0% were on a tenofovir‐based ART regimen. Overall, 10% of HIV/HBV coinfected patients were detected with a positive HDV antibody with a higher prevalence in patients with a significant liver fibrosis (43.0%) compared to others (6.3%) (p = 0.01).Conclusions: Considering the WHO recommendations to screen for HBV infection and treat co‐infected patients with tenofovir‐based ART, screening of alcohol use and brief interventions to prevent alcohol abuse should be implemented in West Africa, especially in HBV/HIV co‐infected patients.

AbstractIntroductionExcessive alcohol consumption leads to unfavourable outcomes in people living with HIV (PLHIV), including reduced adherence to antiretroviral therapy (ART) and engagement into care. However, there is limited information on alcohol consumption patterns among PLHIV in sub‐Saharan Africa.MethodsUsing a cross‐sectional approach, the Alcohol Use Disorders Identification Test (AUDIT‐C) was administered to PLHIV attending HIV clinics in Côte d'Ivoire, Togo, Senegal and Zambia (2013 to 2015). Hazardous drinking was defined as an AUDIT‐C score ≥4 for men or ≥3 for women, and binge drinking as ≥6 drinks at least once per month. The prevalence of binge drinking was compared to estimates from the general population using data from the World Health Organization. Factors associated with binge drinking among persons declaring any alcohol use in the past year were assessed using a logistic regression model to estimate odds ratio (OR) and their corresponding 95% confidence intervals (CI).ResultsAmong 1824 PLHIV (median age 39 years, 62.8% female), the prevalence of hazardous alcohol use ranged from 0.9% in Senegal to 38.4% in Zambia. The prevalence of binge drinking ranged from 14.3% among drinkers in Senegal to 81.8% in Zambia, with higher estimates among PLHIV than in the general population. Male sex (OR 2.4, 95% CI 1.6 to 3.7), tobacco use (OR 1.7, 95% CI 1.0 to 2.9) and living in Zambia were associated with binge drinking.ConclusionsAlcohol consumption patterns varied widely across settings and binge drinking was more frequent in HIV‐positive individuals compared to the general population. Interventions to reduce excessive alcohol use are urgently needed to optimize adherence in the era of universal ART.

IntroductionThe scale‐up of highly active antiretroviral therapy (HAART) has led to a significant improvement in survival of the HIV‐positive patient but its effects on health‐related quality of life (HRQOL) are less known and context‐dependent. Our aim was to assess the temporal changes and factors associated with HRQOL among HIV‐positive adults initiating HAART in Burkina Faso.MethodsHIV‐positive people initiating HAART were prospectively included and followed over a one‐year period in three HIV clinics of Ouagadougou. HRQOL was assessed at baseline and at each follow‐up visit using physical (PHS) and mental (MHS) summary scores derived from the Medical Outcome Study 36‐Item short‐form health survey (MOS SF‐36) questionnaire. Toxicity related to HAART modification and self‐reported symptoms were recorded during follow‐up visits. Determinants associated with baseline and changes in both scores over a one‐year period were assessed using a mixed linear model.ResultsA total of 344 patients were included. Their median age at baseline was 37 years [interquartile range (IQR) 30–44] and their median CD4 count was 181 cells/mm3 (IQR 97–269). The mean [standard deviation (SD)] PHS score increased from 45.4 (11.1) at baseline to 60.0 (3.1) at 12 months (p<10−4) and the mean (SD) MHS score from 42.2 (8.7) to 43.9 (3.4) (p<10−2). After one year of treatment, patients that experienced on average two symptoms during follow‐up presented with significantly lower PHS (63.9) and MHS (43.8) scores compared to patients that presented no symptoms with PHS and MHS of 68.2 (p<10−4) and 45.3 (p<10−3), respectively.DiscussionThe use of HAART was associated with a significant increase in both physical and mental aspects of the HRQOL over a 12‐month period in this urban African population. Perceived symptoms experienced during follow‐up visits were associated with a significant impairment in HRQOL. The appropriate and timely management of reported symptoms during the follow‐up of HAART‐treated patients is a key component to restore HRQOL.

AbstractIntroductionThe universal test‐and‐treat (UTT) strategy aims to maximize population viral suppression (PVS), that is, the proportion of all people living with HIV (PLHIV) on antiretroviral treatment (ART) and virally suppressed, with the goal of reducing HIV transmission at the population level. This article explores the extent to which temporal changes in PVS explain the observed lack of association between universal treatment and cumulative HIV incidence seen in the ANRS 12249 TasP trial conducted in rural South Africa.MethodsThe TasP cluster‐randomized trial (2012 to 2016) implemented six‐monthly repeat home‐based HIV counselling and testing (RHBCT) and referral of PLHIV to local HIV clinics in 2 × 11 clusters opened sequentially. ART was initiated according to national guidelines in control clusters and regardless of CD4 count in intervention clusters. We measured residency status, HIV status, and HIV care status for each participant on a daily basis. PVS was computed per cluster among all resident PLHIV (≥16, including those not in care) at cluster opening and daily thereafter. We used a mixed linear model to explore time patterns in PVS, adjusting for sociodemographic changes at the cluster level.Results8563 PLHIV were followed. During the course of the trial, PVS increased significantly in both arms (23.5% to 46.2% in intervention, +22.8, p < 0.001; 26.0% to 44.6% in control, +18.6, p < 0.001). That increase was similar in both arms (p = 0.514). In the final adjusted model, PVS increase was most associated with increased RHBCT and the implementation of local trial clinics (measured by time since cluster opening). Contextual changes (measured by calendar time) also contributed slightly. The effect of universal ART (trial arm) was positive but limited.ConclusionsPVS was improved significantly but similarly in both trial arms, explaining partly the null effect observed in terms of cumulative HIV incidence between arms. The PVS gains due to changes in ART‐initiation guidelines alone are relatively small compared to gains obtained by strategies to maximize testing and linkage to care. The achievement of the 90‐90‐90 targets will not be met if the operational and implementational challenges limiting access to care and treatment, often context‐specific, are not properly addressed. Clinical trial number: NCT01509508 (clinicalTrials.gov)/DOH‐27‐0512‐3974 (South African National Clinical Trials Register).

AbstractIntroductionThe universal test and treat strategy (UTT) was developed to maximize the proportion of all HIV‐positive individuals on antiretroviral treatment (ART) and virally suppressed, assuming that it will lead to a reduction in HIV incidence at the population level. The evolution over time of the cross‐sectional HIV care cascade is determined by individual longitudinal trajectories through the HIV care continuum and underlying population dynamics. The purpose of this paper is to quantify the contribution of each component of population change (in‐ and out‐migration, HIV seroconversion, ageing into the cohort and definitive exit such as death) on the HIV care cascade in the context of the ANRS 12249 Treatment as Prevention (TasP) cluster‐randomized trial, investigating UTT in rural KwaZulu‐Natal, South Africa, between 2012 and 2016.MethodsHIV test results and information on clinic visits, ART prescriptions, viral load and CD4 count, migration and deaths were used to calculate residency status, HIV status and HIV care status for each individual on a daily basis. Position within the HIV care continuum was considered as a score ranging from 0 (undiagnosed) to 4 (virally suppressed). We compared the cascade score of each individual joining or leaving the population of resident adults living with HIV with the average score of their cluster at the time of entry or exit. Then, we computed the contribution of each entry or exit on the average cascade score and their annualized total contribution, by component of change.ResultsWhile the average cascade score increased over time in all clusters, that increase was constrained by population dynamics. Permanent exits and ageing into the people living with HIV cohort had a marginal effect. Both in‐migrants and out‐migrants were less likely to be retained at each step of the HIV care continuum. However, their overall impact on the cross‐sectional cascade was limited as the effect of in‐ and out‐migration balanced each other. The contribution of HIV seroconversions was negative in all clusters.ConclusionsIn a context of high HIV incidence, the continuous flow of newly infected individuals slows down the efforts to increase ART coverage and population viral suppression, ultimately attenuating any population‐level impact on HIV incidence.Clinical Trial NumberNCT01509508 (clinicalTrials.gov)/DOH‐27‐0512‐3974 (South African National Clinical Trials Register).

IntroductionWe aimed to quantify and identify associated factors of linkage to HIV care following home‐based HIV counselling and testing (HBHCT) in the ongoing ANRS 12249 treatment‐as‐prevention (TasP) cluster‐randomized trial in rural KwaZulu‐Natal, South Africa.MethodsIndividuals ≥16 years were offered HBHCT; those who were identified HIV positive were referred to cluster‐based TasP clinics and offered antiretroviral treatment (ART) immediately (five clusters) or according to national guidelines (five clusters). HIV care was also available in the local Department of Health (DoH) clinics. Linkage to HIV care was defined as TasP or DoH clinic attendance within three months of referral among adults not in HIV care at referral. Associated factors were identified using multivariable logistic regression adjusted for trial arm.ResultsOverall, 1323 HIV‐positive adults (72.9% women) not in HIV care at referral were included, of whom 36.9% (n=488) linked to care <3 months of referral (similar by sex). In adjusted analyses (n=1222), individuals who had never been in HIV care before referral were significantly less likely to link to care than those who had previously been in care (<33% vs. >42%, p<0.001). Linkage to care was lower in students (adjusted odds‐ratio [aOR]=0.47; 95% confidence interval [CI] 0.24–0.92) than in employed adults, in adults who completed secondary school (aOR=0.68; CI 0.49–0.96) or at least some secondary school (aOR=0.59; CI 0.41–0.84) versus ≤ primary school, in those who lived at 1 to 2 km (aOR=0.58; CI 0.44–0.78) or 2–5 km from the nearest TasP clinic (aOR=0.57; CI 0.41–0.77) versus <1 km, and in those who were referred to clinic after ≥2 contacts (aOR=0.75; CI 0.58–0.97) versus those referred at the first contact. Linkage to care was higher in adults who reported knowing an HIV‐positive family member (aOR=1.45; CI 1.12–1.86) versus not, and in those who said that they would take ART as soon as possible if they were diagnosed HIV positive (aOR=2.16; CI 1.13–4.10) versus not.ConclusionsFewer than 40% of HIV‐positive adults not in care at referral were linked to HIV care within three months of HBHCT in the TasP trial. Achieving universal test and treat coverage will require innovative interventions to support linkage to HIV care.