HIV among children in Ethiopia

Westerlund E, Jerene D, Mulissa Z, Hallström I and Lindtjørn B. Pre-ART retention in care and prevalence of tuberculosis among HIV-infected children at a district hospital in southern Ethiopia. BMC Pediatrics 2014, 14:250


Background  The Ethiopian epidemic is currently on the wane. However, the situation for infected children is in some ways lagging behind due to low treatment coverage and deficient prevention of mother-to-child transmission. Too few studies have examined HIV infected children presenting to care in low-income countries in general. Considering the presence of local variations in the nature of the epidemic a study in Ethiopia could be of special value for the continuing fight against HIV. The aim of this study is to describe the main characteristics of children with HIV presenting to care at a district hospital in a resource-limited area in southern Ethiopia. The aim was also to analyse factors affecting pre-ART loss to follow-up, time to ART-initiation and disease stage upon presentation.

Methods  This was a prospective cohort study. The data analysed were collected in 2009 for the period January 2003 through December 2008 at Arba Minch Hospital and additional data on the ART-need in the region were obtained from official reports.

Results   The pre-ART loss to follow-up rate was 29.7%. Older children (10-14 years) presented in a later stage of their disease than younger children (76.9% vs. 45.0% in 0-4 year olds, chi-square test, chi2 = 8.8, P = 0.01). Older girls presented later than boys (100.0% vs. 57.1%, Fisher’s exact test, P = 0.02). Children aged 0-4 years were more likely to be lost to follow-up (40.0 vs. 21.8%, chi-square test, chi2 = 5.4, P = 0.02) and had a longer time to initiate ART (Cox regression analysis, HR: 0.50, 95% CI: 0.25-0.97, P = 0.04, controlling for sex, place of residence, enrolment phase and WHO clinical stage upon presentation). Neither sex was overrepresented in the sample. Tuberculosis prevalence upon presentation and previous history of tubercolosis were 14.5% and 8% respectively.

Conclusions  The loss to follow-up is alarmingly high and children present too late. Further research is needed to explore specific causes and possible solutions.

Excellent for Centre for International Health

Recently, The Research Council of  Norway evaluated health research in Norway.

The core research groups at Centre for International Health both received the grade “Excellent” by an international expert panel which evaluated medicine and health research in Norway.

The evaluation panel concludes that “the Centre for International Health is the leading research centre within international and global health in the Nordic countries, and one of the leading centres in Europe”.

CIH combines biomedical and public-health research. Both the Child Health and Nutrition, and the HIV and TB Research group received “excellent” grades. Both research groups address important research questions, and base their research on long-term collaboration with universities in Asia and Africa. The research also addresses  the needs of the population, and translates research findings into improved treatment and better control of diseases.

Read the full evaluation report here.


Missing AIDS Patients

ResearchBlogging.orgIt is important for HIV infected patients to take their drugs regularly. Interruptions in treatment lead to viral strains that are resistant to the cheapest medications, and to higher rates of illness and death. Unfortunately, many AIDS patients do not come for their antiretroviral medications. Such patients are labelled as “lost to follow-up.”

During the early years of antiretroviral treatment (ART) drug distribution in Africa, researchers reported high rates of adherence to treatment, often as high as in Europe or the United States. At the same time, studies showed higher early mortality rates among patients treated with antiretroviral drugs in settings with limited resources. A reason for the high death rates was late presentation of patients to care.

In a recent review of 2191 adult HIV patients in south Ethiopia, we show that patients now start to present at earlier stages of their illness, and death has decreased among adult HIV patients. Early treatment start contributed to improved survival (Mulissa, Jerene and Lindtjørn, 2010).

Unfortunately, 25 per cent were lost before that started treatment. This means they were diagnosed, but did not return for treatment, and this have increased during the recent years. We also found that 15% per cent of those who start treatment were lost to follow up. 40% of the latter group had died, and 20% had started treatment in another institution.

Some ART programmes in Africa are experimenting with different programmes to reduce loss to follow-up. Some organizations offer a two- or three-month supply of medication for each clinic visit, others deliver drugs to patients’ homes, and some have tried to refund patients for transport costs. None of these efforts have been evaluated.

Mulissa, Z., Jerene, D., & Lindtjørn, B. (2010). Patients Present Earlier and Survival Has Improved, but Pre-ART Attrition Is High in a Six-Year HIV Cohort Data from Ethiopia PLoS ONE, 5 (10) DOI: 10.1371/journal.pone.0013268

Operational research

ResearchBlogging.orgIn global health, operational research is an idea increasingly used by donors and policy makers. It involves analytical methods to help improve public health interventions and treatment of diseases in real-life situations. It is thus different from randomized clinical trials that determines efficacy of an intervention in a strictly controlled environment with inclusion and exclusion criteria, whereas operational research assess effectiveness within routine, and real-life settings.

Recently Zachariah and colleagues (2009) defined operational research as: “The search for knowledge on interventions, strategies, or tools that can improve the quality, effectiveness, or coverage of programmes in which the research is being done”.

Operational research involves descriptive, case–control, and cohort analysis. Some say that basic science research and randomised controlled trials is not operational research. However, effectiveness trials refer to whether an intervention works in people to whom it has been offered, and should in my view form an integral part of operational research. Results from such randomized trials can be are translated to benefit in the diverse setting of routine care.

For a health programme, the relevance of such research is whether it contributes to an improved performance or influences policy change at district, national, or even international levels.

Some examples of operational research from south Ethiopia include:

  • Antiretroviral treatment in resource limited settings (Jerene et al 2006): This cohort study assessed feasibility and effectiveness of antiretroviral therapy by use of historical controls.
  • An effectiveness trial in south Ethiopia aimed to evaluate if community health workers could improved smear-positive case detection and treatment success rates (Datiko and Lindtjørn, 2009). The study showed that involving of health extension workers (HEWs) in sputum collection and treatment improved smear-positive case detection and treatment success rate, possibly because of an improved service access. This finding has policy implications and could be applied in settings with low health service coverage and a shortage of health workers.


Zachariah R, Harries AD, Ishikawa N, Rieder HL, Bissell K, Laserson K, Massaquoi M, Van Herp M, & Reid T (2009). Operational research in low-income countries: what, why, and how? The Lancet infectious diseases, 9 (11), 711-7 PMID: 19850229

Jerene D, Naess A, & Lindtjørn B (2006). Antiretroviral therapy at a district hospital in Ethiopia prevents death and tuberculosis in a cohort of HIV patients. AIDS research and therapy, 3 PMID: 16600050

Datiko, D., & Lindtjørn, B. (2010). Cost and Cost-Effectiveness of Treating Smear-Positive Tuberculosis by Health Extension Workers in Ethiopia: An Ancillary Cost-Effectiveness Analysis of Community Randomized Trial PLoS ONE, 5 (2) DOI: 10.1371/journal.pone.0009158

2010 AAAS

During the last week I have attended the Annual Meeting of AAAS in San Diego. This is the largest gathering of interdisciplinary research. For me it was an interesting meeting.

I learned that much of the current research in biology and health is interdisciplinary, and mathematical modelling plays an important role in the research.

It was also interesting to learn about efforts to stop the spread in southern Africa:

  • Antiretroviral treatments (ARVs) and universal testing could stop the spread of Aids in South Africa within five years, a top scientist says.
  • In Botswana, a research group from Los Angeles is evaluating if one antiretroviral drug (monotherapy) can be given to disease free individuals and thus reduce disease incidence.

One of the main themes in many of the sessions were the increasing worry about public distrust in science. Several Leading scientists admitted the recent controversies surrounding climate research have damaged the image of science as a whole.

The President of the US National Academy of Sciences, Ralph Cicerone, said the controversial e-mail exchanges about climate change data had caused people to suspect that scientists “oppressed free speech” and that some feel that scientists are suppressing dissent.

Several speakers agreed that scientists needed to be more open about their findings. Recent polls, including one carried out by the BBC, have suggested that climate scepticism is on the rise.

Some highlights at the meeting is found here.

Treating children with AIDS

We are reviewing the treatment results among patients receiving antiretroviral therapy at Arba Minch Hospital.

From Ethiopia there are few results published on treatment outcome in children with HIV infection. We have therefore reviewed the survival of children 14 years or younger.

The preliminary results (se Figure) show the five-year survival rate is about 90 %.

Most of the deaths occur during the first twelve months, and usually occurs among patients with advanced disease when we started treatment.

Long-term outcome of HIV treatment

We are reviewing the outcome of antiretroviral treatment at Arba Minch Hospital. We started treating patients in 2003, and since then about 1550 patients have received the antiviral drugs.

Our early papers showed the death rates among patients were high during the first months of treatment. We thought the reasons for these high death rates were the patients came late for treatment; that is, they presented themselves with late stage disease.

Our objective for the study is to see if the treatment results improve over time, and if patients present with earlier stage disease. Dr Zewdie Mulissa and Dr Degu Dare take part in this study.

Our preliminary findings confirm improved survival, and that patients come earlier for treatment. We are now also trying to find out what happens to patients after they are diagnosed with HIV until they start treatment.

Antiretroviral therapy is cost-effective

As the resource implications of expanding anti-retroviral therapy (ART) are likely to be large, there is a need to explore its cost-effectiveness. We therefore assessed the cost-effectiveness of ART for routine clinical practice in a district hospital setting in Ethiopia.

We estimated the unit cost of HIV-related care from the 2004/5 fiscal year expenses of Arba Minch Hospital in southern Ethiopia. We estimated outpatient and in-patient service use from HIV-infected patients who received care and treatment at the hospital between January 2003 and March 2006. We measured the health effect as life years gained (LYG) for patients receiving ART compared with those not receiving such treatment. The study adopted a health care provider perspective and included both direct and overhead costs. We used Markov model to estimate the lifetime costs, health benefits and cost-effectiveness of ART.

ART yielded an undiscounted 9.4 years expected survival, and resulted in 7.1 extra LYG compared to patients not receiving ART. The lifetime incremental cost is US$2,215 and the undiscounted incremental cost per LYG is US$314. When discounted at 3%, the additional LYG decreases to 5.5 years and the incremental cost per LYG increases to US$325.

The undiscounted and discounted incremental costs per LYG from introducing ART were less than the per capita GDP threshold at the base year. Thus, ART could be regarded as cost-effective in a district hospital setting in Ethiopia.


Bikilla AD, Jerene DS, Robberstad B and Lindtjørn B. Cost-effectiveness of anti-retroviral therapy at a district hospital in southern Ethiopia. Cost Effectiveness and Resource Allocation 2009, 7:13doi:10.1186/1478-7547-7-13

Also see [intlink id=”146″ type=”post”]previous post on cost of HIV treatment[/intlink]:

Bikilla AD , Jerene D, Robberstad B and Lindtjorn B. Cost estimates of HIV care and treatment with and without anti-retroviral therapy at Arba Minch Hospital in southern Ethiopia. Cost Effectiveness and Resource Allocation 2009, 7:6doi:10.1186/1478-7547-7-6

ART programme and task shifting

The use of antiretroviral drugs, and HIV counselling and testing in Ethiopia has increased in Ethiopia. Dr Degu Dare, who was among the first to start ART at rural hospitals in Ethiopia, is the co-author of a recent paper in PLoS Medicine (1).

Has this expansion of ART affected the performance of other health programmes such as tuberculosis and maternal and child health services is the question they asked.

Very interestingly, the authors document task shifting to the health officers, nurses, and health extension workers, and that this might be responsible for the successes of the ART programme in Ethiopia. However, HIV prevention interventions and management of chronic care patients are lagging behind. This may be because doctors leave the public sector to work for NGOs.

1. Assefa Y, Jerene D, Lulseged S, Ooms G, Van Damme W (2009) Rapid Scale-Up of Antiretroviral Treatment in Ethiopia: Successes and System-Wide Effects. PLoS Med 6(4): e1000056. doi:10.1371/ journal.pmed.1000056