Global efforts to control tuberculosis (TB) faced significant challenges during the COVID-19 pandemic, particularly in Haiti, where it coincided with a severe humanitarian crisis. To minimize facility visits for patients, a differentiated service delivery (DSD) model with multi-month dispensing of TB drugs was implemented at two high-volume health facilities in Port-au-Prince, Haiti. All patients aged 18 years and older who initiated drug-susceptible TB treatment from January 1 to August 31, 2022 were included in the prospective cohort. Clinicians first identified clinically stable patients who met criteria for DSD eligibility and offered them enrollment in the DSD model. Those deemed unsuitable for DSD or declined DSD were treated under the standard of care (SOC) model. DSD patients received an initial 2-month supply of medication followed by either a 4-month supply or two additional 2-month supplies. They also received remote follow-up via mobile communication within 24-48 hours of treatment initiation, biweekly during the first two months, and monthly during the last four months. Under SOC, patients came to the facility for clinical review and drug dispensation every 2-4 weeks during the first two months, and monthly during the last four months. Robust Poisson regression was used to analyze the relationship between treatment success and cohort type. During the project period, a total of 551 patients initiated TB treatment: 151 in the DSD model and 400 under SOC. Thirty-nine percent were female; median age was 33 years; and 25% were HIV-positive. Treatment success (defined as those who were cured or completed treatment) was significantly higher in the DSD group at (140/151; 93%), compared to 312/400 (78%) in the SOC group (adjusted risk ratio [aRR]: 1.10, p = 0.02): however, there was no significant difference after excluding patients who were lost-to-follow-up (aRR: 1.00; p = 0.85). This project demonstrates that a DSD model can achieve high TB treatment success rates, even amid challenging circumstances like the COVID-19 pandemic and socio-political unrest. Adapting healthcare systems through innovative service delivery methods is essential to effectively meet patient needs during global health crises.

Background Few studies have evaluated baseline predictors of clinical outcomes among people with human immunodeficiency virus (HIV) starting antiretroviral therapy (ART) in the modern era of rapid ART initiation.Methods We conducted a secondary analysis of a previously reported open-label randomized controlled trial of 2 rapid treatment initiation strategies for people with treatment-naive HIV and tuberculosis symptoms at a large urban clinic in Haiti. We used logistic regression models to assess associations between baseline characteristics and (1) retention in care at 48 weeks, (2) HIV viral load suppression at 48 weeks (among participants who underwent viral load testing), and (3) all-cause mortality. For the viral load suppression outcome, we used inverse probability weighting to account for potential selection bias resulting from exclusion of participants who did not undergo viral load testing.Results A total of 500 participants were enrolled in the study from November 2017 to January 2020. Tuberculosis was diagnosed in 88 participants (18%), and ART was started in 494 (99%). After multivariable adjustment, less than secondary school education (adjusted odds ratio [AOR] 0.21 [95% confidence interval (CI), .10-.46]) was significantly associated with a reduced odds of retention in care. Dolutegravir initiation (AOR, 2.57 [95% CI, 1.22-5.43]), age (1.42 per 10-year increase [1.01-1.99]), and tuberculosis diagnosis (3.92 [1.36-11.28]) were significantly associated with increased odds of retention. Age (AOR, 1.36 [95% CI, 1.05-1.75]) and dolutegravir initiation (1.75 [1.07-2.85]) were positively associated with viral suppression, and tuberculosis diagnosis (0.50 [.28-.89) was negatively associated with viral suppression, with similar findings after incorporation of inverse probability weights. Higher CD4 cell count at enrollment was significantly associated with a lower odds of mortality (unadjusted odds ratio, 0.69 [95% CI, .55-.87]), and anemia was associated with a significantly greater odds of mortality (4.86 [1.71-13.81]).Conclusions We identified sociodemographic, treatment-related, clinical, and laboratory-based predictors of clinical outcomes. These characteristics may serve as markers of subpopulations that could benefit from additional interventions to support treatment success after rapid treatment initiation. This secondary analysis of a randomized controlled trial of rapid treatment initiation strategies for people with treatment-na & iuml;ve HIV and tuberculosis in Haiti identified sociodemographic, treatment-related, clinical, and laboratory-based predictors of clinical outcomes after rapid antiretroviral therapy initiation.

Data inform patient care and public health programming, and increase understanding of an epidemic's evolution and successful interventions. The US President's Emergency Plan for AIDS Relief investments in digital data systems facilitates data availability to those making decisions about treating human immunodeficiency virus (HIV) infections, interrupting HIV transmission, and allocating resources for HIV services. This article presents a case study from Haiti showing how digital investments support clinical care, community services, and disease surveillance. An algorithm of biometric identification and person characteristics links records across these systems to provide a more complete picture than would be possible from any of the individual digital solutions.

Background Few studies have evaluated baseline predictors of clinical outcomes among people with human immunodeficiency virus (HIV) starting antiretroviral therapy (ART) in the modern era of rapid ART initiation. Methods We conducted a secondary analysis of a previously reported open-label randomized controlled trial of 2 rapid treatment initiation strategies for people with treatment-naive HIV and tuberculosis symptoms at a large urban clinic in Haiti. We used logistic regression models to assess associations between baseline characteristics and (1) retention in care at 48 weeks, (2) HIV viral load suppression at 48 weeks (among participants who underwent viral load testing), and (3) all-cause mortality. For the viral load suppression outcome, we used inverse probability weighting to account for potential selection bias resulting from exclusion of participants who did not undergo viral load testing. Results A total of 500 participants were enrolled in the study from November 2017 to January 2020. Tuberculosis was diagnosed in 88 participants (18%), and ART was started in 494 (99%). After multivariable adjustment, less than secondary school education (adjusted odds ratio [AOR] 0.21 [95% confidence interval (CI), .10–.46]) was significantly associated with a reduced odds of retention in care. Dolutegravir initiation (AOR, 2.57 [95% CI, 1.22–5.43]), age (1.42 per 10-year increase [1.01–1.99]), and tuberculosis diagnosis (3.92 [1.36–11.28]) were significantly associated with increased odds of retention. Age (AOR, 1.36 [95% CI, 1.05–1.75]) and dolutegravir initiation (1.75 [1.07–2.85]) were positively associated with viral suppression, and tuberculosis diagnosis (0.50 [.28–.89) was negatively associated with viral suppression, with similar findings after incorporation of inverse probability weights. Higher CD4 cell count at enrollment was significantly associated with a lower odds of mortality (unadjusted odds ratio, 0.69 [95% CI, .55–.87]), and anemia was associated with a significantly greater odds of mortality (4.86 [1.71–13.81]). Conclusions We identified sociodemographic, treatment-related, clinical, and laboratory-based predictors of clinical outcomes. These characteristics may serve as markers of subpopulations that could benefit from additional interventions to support treatment success after rapid treatment initiation.

Background:Tenofovir disoproxil fumarate/lamivudine/dolutegravir (TLD) is widely prescribed in low and middle-income countries. Data on long-term outcomes are limited. Methods:We included all persons with HIV (PWH) ≥15 years of age who initiated or switched to TLD in Port-au-Prince, Haiti. We described treatment outcomes by pre-switch viral load and assessed predictors of virologic failure using multivariable logistic regression. Results:A total of 10 354 PWH initiated or switched to TLD from November 2018 to March 2021, and were included in the analyses. Of these, 2217 (21.4%) were ART-naïve and 8137 (78.6%) switched from an non-nucleoside reverse transcriptase inhibitor (NNTRI)-based regimen. Median follow-up time on TLD was 2.8 years (IQR: 2.3, 3.1). HIV-1 RNA <1000 copies/mL was achieved at the latest measurement in 92.7% of recipients of care (RoC) with pre-switch suppression, 88.5% without pre-switch viral load, 58.3% with pre-switch failure, and 81.8% of RoC ART-naïve at TLD initiation. Among treatment-experienced RoC, predictors of ≥1000 copies/mL at latest test included younger age (adjusted odds ratio [aOR]: 0.44; 95% CI: 0.34, 0.57 for age ≥50 vs <30 years), shorter time on ART (aOR: 0.91; 95% CI: 0.89, 0.93/year), lower education (aOR: 1.31; 95% CI: 1.13, 1.52), and higher pre-switch viral load: (aOR: 7.23; 95% CI: 6.06, 8.63 for ≥10 000 vs < 1000 copies/mL). Conclusions:Virologic outcomes on TLD are outstanding for PWH with pre-switch suppression. However, rates of virologic suppression are suboptimal among PWH who were ART-naïve at TLD initiation, and among those with a history of pre-switch failure, additional interventions are necessary, including access to long-acting treatment regimens.

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High Rates of Retention and Viral Suppression with a Model of Community-Based HIV Care in a Setting of Severe Civil Unrest 19 Pages Posted: 27 Feb 2024 See all articles by Patrice JosephPatrice JosephLes Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO)Rochelle SunHarvard UniversityColette GuiteauLes Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO)Marc Antoine Jean JusteLes Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO)Nancy DorvilLes Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO)Stalz Charles VilbrunLes Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO)Rode SecoursLes Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO)Karine SevereLes Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO)Parnel RaymondLes Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO)Fernande CetouteLes Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO)Wilnide Jean BaptisteLes Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO)Guyrlaine Pierre-Louis ForestalLes Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO)Stanley CadetLes Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO)Adias MarcelinLes Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO)Marie Marcelle DeschampsLes Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO)Akanksha DuaUniversity of California, San Francisco (UCSF)Hoi Ching CheungAnalysis Group, Inc.Jean William PapeLes Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO)Serena P. KoenigHarvard University More... Abstract Background: There are limited data on the effectiveness of differentiated service delivery (DSD) for HIV care during sociopolitical turmoil. We assessed outcomes with a DSD model of care that includes patient choice between community-based antiretroviral therapy (ART) centers, home-based ART dispensing, or facility-based care at GHESKIO clinic during a period of severe civil unrest in in Port-au-Prince, Haiti. Methods: This retrospective analysis included data on patients with at least one HIV visit at GHESKIO between May 1, 2019, and December 31, 2021. Multivariable logistic regression models were used to assess predictors of attending ≥1 community visit during the study period, and failure to attend timely visits. HIV-1 RNA test results were reported among patients who had been ART for ≥3 months at last visit. Findings: Of the 18,625 patients included in the analysis, 9,659 (51.9%) attended at least one community visit. The proportion of community visits ranged from 0.3% (2019) to 44.1% (2021). Predictors of ≥1 community visit included male sex (aOR: 1.13; 95% CI: 1.06, 1.20), secondary education (aOR: 1.07; 95% CI: 1.01, 1.14), income >$US 1.00/day (aOR: 1.24; 95% CI: 1.14, 1.35), longer duration on ART (aOR: 1.08 per additional year; 95% CI: 1.07, 1.09), and residence in Carrefour (p< 0.001 in comparisons with all other zones). Younger age and shorter time on ART were associated with late visits, loss to follow-up, and death (p<0.001, all comparisons). Among 12,586 patients with an on-time final visit, 11,131 (88.4%) received a viral load test and 9,639 (86.6%) had HIV-1 RNA <1000 copies/mL. Interpretation: The socio-political situation in Haiti has presented extraordinary challenges to the health care system, but retention and viral suppression rates remain high with a model of community-based HIV care. Additional interventions are needed to improve outcomes for younger patients, and those with shorter time on ART.Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for- profit sectors. PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria provide funding for HIV service delivery at GHESKIO.Declaration of Interest: We declare no competing interests.Ethical Approval: Due to the retrospective study design, it was not feasible to obtain informed consent. This study was reviewed and approved by the institutional review boards of GHESKIO, Weill Cornell Medical College, and Brigham and Women’s Hospital. Keywords: community-based HIV care, HIV service delivery in civil unrest, differentiated service delivery models, health service provision during conflict, health systems resilience Suggested Citation: Suggested Citation Joseph, Patrice and Sun, Rochelle and Guiteau, Colette and Jean Juste, Marc Antoine and Dorvil, Nancy and Vilbrun, Stalz Charles and Secours, Rode and Severe, Karine and Raymond, Parnel and Cetoute, Fernande and Jean Baptiste, Wilnide and Forestal, Guyrlaine Pierre-Louis and Cadet, Stanley and Marcelin, Adias and Deschamps, Marie Marcelle and Dua, Akanksha and Cheung, Hoi Ching and Pape, Jean William and Koenig, Serena P., High Rates of Retention and Viral Suppression with a Model of Community-Based HIV Care in a Setting of Severe Civil Unrest. Available at SSRN: https://ssrn.com/abstract=4738698 Patrice Joseph (Contact Author) Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) ( email ) Rochelle Sun Harvard University ( email ) 1875 Cambridge StreetCambridge, MA 02138United States Colette Guiteau Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) ( email ) Marc Antoine Jean Juste Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) ( email ) Nancy Dorvil Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) ( email ) Stalz Charles Vilbrun Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) ( email ) Rode Secours Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) ( email ) Karine Severe Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) ( email ) Parnel Raymond Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) ( email ) Fernande Cetoute Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) ( email ) Wilnide Jean Baptiste Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) ( email ) Guyrlaine Pierre-Louis Forestal Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) ( email ) Stanley Cadet Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) ( email ) Adias Marcelin Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) ( email ) Marie Marcelle Deschamps Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) ( email ) Akanksha Dua University of California, San Francisco (UCSF) ( email ) Hoi Ching Cheung Analysis Group, Inc. ( email ) Jean William Pape Les Centres Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) ( email ) Serena P. Koenig Harvard University ( email ) Download This Paper Open PDF in Browser Please enable JavaScript to view the comments powered by Disqus. 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Introduction:Few studies have evaluated baseline predictors of clinical outcomes among people with HIV starting antiretroviral therapy (ART) in the modern era of rapid ART initiation. Methods:We conducted a secondary analysis of a randomized controlled trial of two rapid treatment initiation strategies for people with treatment-naïve HIV and tuberculosis symptoms at an urban clinic in Haiti. We used logistic regression models to assess associations between baseline characteristics and (1) retention in care at 48 weeks, (2) HIV viral load suppression at 48 weeks (among participants who underwent viral load testing), and (3) all-cause mortality. Results:500 participants were enrolled in the study 11/2017-1/2020. Eighty-eight (18%) participants were diagnosed with tuberculosis, and ART was started in 494 (99%). After adjustment, less than secondary education (adjusted odds ratio [AOR] 0.21, 95% CI 0.10-0.46), dolutegravir initiation (AOR 2.57, 95% CI 1.22-5.43), age (AOR 1.42 per 10-year increase, 95% CI 1.01-1.99), and tuberculosis diagnosis (AOR 3.92, 95% CI 1.36-11.28) were significantly associated with retention. Age (AOR 1.36, 95% CI 1.05-1.75), dolutegravir initiation (AOR 1.75, 95% CI 1.07-2.85), and tuberculosis diagnosis (AOR 0.50, 95% CI 0.28-0.89) were associated with viral suppression. Higher CD4 cell count at enrollment (unadjusted odds ratio [OR] 0.69, 95% CI 0.55-0.87) and anemia (OR 4.86, 95% CI 1.71-13.81) were associated with mortality. Conclusions:We identified sociodemographic, treatment-related, clinical, and laboratory-based predictors of clinical outcomes. These characteristics may serve as markers of sub-populations that could benefit from additional interventions to support treatment success after rapid treatment initiation.

Background There are limited data on the effectiveness of differentiated service delivery (DSD) for HIV care during sociopolitical turmoil. We assessed outcomes with a DSD model of care that includes patient choice between community-based antiretroviral therapy (ART) centres, home-based ART dispensing, or facility-based care at GHESKIO clinic during a period of severe civil unrest in Port-au-Prince, Haiti. Methods This retrospective analysis included data on patients with at least one HIV visit at GHESKIO between May 1, 2019, and December 31, 2021. Multivariable logistic regression models were used to assess predictors of attending ≥1 community visit during the study period, and failure to attend timely visits. HIV-1 RNA test results were reported among patients who had been ART for ≥3 months at last visit. Findings Of the 18,625 patients included in the analysis, 9659 (51.9%) attended at least one community visit. The proportion of community visits ranged from 0.3% (2019) to 44.1% (2021). Predictors of ≥1 community visit included male sex (aOR: 1.13; 95% CI: 1.06, 1.20), secondary education (aOR: 1.07; 95% CI: 1.01, 1.14), income > $USD 1.00/day (aOR: 1.24; 95% CI: 1.14, 1.35), longer duration on ART (aOR: 1.08 per additional year; 95% CI: 1.07, 1.09), and residence in Carrefour/Gressier (p < 0.0001 in comparisons with all other zones). Younger age and shorter time on ART were associated with late visits and loss to follow-up. Among 12,586 patients with an on-time final visit who had been on ART for ≥3 months, 11,131 (88.4%) received a viral load test and 9639 (86.6%) had HIV-1 RNA < 1000 copies/mL. Interpretation The socio-political situation in Haiti has presented extraordinary challenges to the health care system, but retention and viral suppression rates remain high with a model of community-based HIV care. Additional interventions are needed to improve outcomes for younger patients, and those with shorter time on ART. Funding No funding.

Background:The World Health Organization recommends initiating same-day antiretroviral therapy (ART) while tuberculosis (TB) testing is under way for patients with non-meningitic symptoms at HIV diagnosis, though safety data are limited. C-reactive protein (CRP) testing may improve TB risk stratification in this population. Methods:In this baseline analysis of 498 adults (>18 years) with TB symptoms at HIV diagnosis who were enrolled in a trial of rapid ART initiation in Haiti, we describe test characteristics of varying CRP thresholds in the diagnosis of TB. We also assessed predictors of high CRP as a continuous variable using generalized linear models. Results:Eighty-seven (17.5%) participants were diagnosed with baseline TB. The median CRP was 33.0 mg/L (interquartile range: 5.1, 85.5) in those with TB, and 2.6 mg/L (interquartile range: 0.8, 11.7) in those without TB. As the CRP threshold increased from ≥1 mg/L to ≥10 mg/L, the positive predictive value for TB increased from 22.4% to 35.4% and negative predictive value decreased from 96.9% to 92.3%. With CRP thresholds varying from <1 to <10 mg/L, a range from 25.5% to 64.9% of the cohort would have been eligible for same-day ART and 0.8% to 5.0% would have untreated TB at ART initiation. Conclusions:CRP concentrations can be used to improve TB risk stratification, facilitating same-day decisions about ART initiation. Depending on the CRP threshold, one-quarter to two-thirds of patients could be eligible for same-day ART, with a reduction of 3- to 20-fold in the proportion with untreated TB, compared with a strategy of same-day ART while awaiting TB test results.

During a 2-year period, eight cases of a distinct illness were seen among 1,424 neonates admitted to a newly established neonatal care unit in southern Haiti. The newborns presented with a picture of sepsis with shock, vomiting, hypotonia, lethargy, and abdominal distention. Five cases proved fatal and another case left the hospital against advice in extremis with little chance of survival. In each case, the illness was associated with a history of ingestion of teas that included castor oil, known as lok in Haitian Creole. The presumptive cause of the illness was established by the presence of a dark, oily substance in drainage from the nares and nasogastric tubes and by subsequent admission on direct questioning of the caregivers, who said that the infants had been given large amounts of lok. The castor oil tea had been given to three infants in the immediate neonatal period where its use is attributed to encouraging the passage of meconium. The five remaining infants were between 15 and 30 days of life when they were given lok shortly before admission to the neonatal unit for treatment of an undefined illness. All of them were term infants with no identified risks at birth. As nasogastric tubes are not routinely placed in sick neonates, and the parents did not volunteer information about lok administration, the practice may be more widespread than that recorded here. Although our data are confined to observations in Haiti, the use of traditional medicines is a globally widespread phenomenon. Attention must be drawn to the potential toxicity of such preparations and means found to ban their use in neonates.

BACKGROUND:Attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is high worldwide. We assessed whether same-day HIV testing and ART initiation improves retention and virologic suppression.METHODS AND FINDINGS:We conducted an unblinded, randomized trial of standard ART initiation versus same-day HIV testing and ART initiation among eligible adults ≥18 years old with World Health Organization Stage 1 or 2 disease and CD4 count ≤500 cells/mm3. The study was conducted among outpatients at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic infections (GHESKIO) Clinic in Port-au-Prince, Haiti. Participants were randomly assigned (1:1) to standard ART initiation or same-day HIV testing and ART initiation. The standard group initiated ART 3 weeks after HIV testing, and the same-day group initiated ART on the day of testing. The primary study endpoint was retention in care 12 months after HIV testing with HIV-1 RNA <50 copies/ml. We assessed the impact of treatment arm with a modified intention-to-treat analysis, using multivariable logistic regression controlling for potential confounders. Between August 2013 and October 2015, 762 participants were enrolled; 59 participants transferred to other clinics during the study period, and were excluded as per protocol, leaving 356 in the standard and 347 in the same-day ART groups. In the standard ART group, 156 (44%) participants were retained in care with 12-month HIV-1 RNA <50 copies, and 184 (52%) had <1,000 copies/ml; 20 participants (6%) died. In the same-day ART group, 184 (53%) participants were retained with HIV-1 RNA <50 copies/ml, and 212 (61%) had <1,000 copies/ml; 10 (3%) participants died. The unadjusted risk ratio (RR) of being retained at 12 months with HIV-1 RNA <50 copies/ml was 1.21 (95% CI: 1.04, 1.38; p = 0.015) for the same-day ART group compared to the standard ART group, and the unadjusted RR for being retained with HIV-1 RNA <1,000 copies was 1.18 (95% CI: 1.04, 1.31; p = 0.012). The main limitation of this study is that it was conducted at a single urban clinic, and the generalizability to other settings is uncertain.CONCLUSIONS:Same-day HIV testing and ART initiation is feasible and beneficial in this setting, as it improves retention in care with virologic suppression among patients with early clinical HIV disease.TRIAL REGISTRATION:This study is registered with ClinicalTrials.gov number NCT01900080.

Globally, treatment outcomes for people with multi-drug/rifampin-resistant tuberculosis (MDR/RR-TB) are sub-optimal, with MDR/RR-TB programs further weakened due to the COVID-19 pandemic, and in Haiti, by severe civil unrest. We assessed the impact of these disruptions on treatment outcomes at GHESKIO, in Port-au-Prince, Haiti. We conducted a retrospective analysis including all adults (age ≥18 years) who initiated MDR/RR-TB treatment at GHESKIO from 2010 to 2020. We assessed predictors of poor treatment outcome using multivariable logistic regression, adjusting for baseline characteristics and year of treatment. 453 patients initiated treatment for MDR/RR-TB at GHESKIO. Median age was 31 (IQR: 25, 40), 233 (51.4%) were male, and 100 (22.1%) were living with HIV. Three hundred sixty-nine patients (81.5%) achieved cure, 42 (9.3%) died, 40 (8.8%) were lost to follow-up and 2 (<1%) failed treatment. HIV status was associated with poor treatment outcome (aRR: 1.65 (95% CI: 1.09, 2.48)) but there was no difference by year of treatment initiation. Outcomes for patients with MDR/RR-TB remained outstanding, even during the COVID-19 pandemic and severe civil unrest in Haiti. We attribute this resilience in care to the adaptability of program staff and provision of economic and psychosocial support.

Patients with multidrug-resistant tuberculosis who received regimens containing high-dose isoniazid (INHHD) had similar time to culture conversion and treatment outcomes as patients who received regimens with bedaquiline. INHHD is an inexpensive and safe medication that may contribute additive efficacy in combination regimens.

Since 2003, the US President's Emergency Plan for AIDS Relief (PEPFAR) has supported implementation and maintenance of health information systems for HIV/AIDS and related diseases, such as tuberculosis, in numerous countries. As the COVID-19 pandemic emerged, several countries conducted rapid assessments and enhanced existing PEPFAR-funded HIV and national health information systems to support COVID-19 surveillance data collection, analysis, visualization, and reporting needs. We describe efforts at the US Centers for Disease Control and Prevention (CDC) headquarters in Atlanta, Georgia, USA, and CDC country offices that enhanced existing health information systems in support COVID-19 pandemic response. We describe CDC activities in Haiti as an illustration of efforts in PEPFAR countries. We also describe how investments used to establish and maintain standards-based health information systems in resource-constrained settings can have positive effects on health systems beyond their original scope.

BACKGROUND:Haiti has the highest rate of neonatal mortality in the Latin America and Caribbean region. While the rate of facility births in Haiti has doubled over the past two decades, there have been no comparable reductions in maternal or neonatal mortality. Little data is available on the clinical characteristics of complications and morbidities among newborns requiring hospitalization after birth and their contribution to neonatal mortality. There is a need to better understand the status of newborn clinical care capacity in Haiti to prioritize training and resources.METHODS:We performed a retrospective observational cohort study of neonates admitted to a large public referral hospital in southern Haiti in the first 2 years of operation of a new neonatal unit that we established. All neonate cases hospitalized in the unit in these 2 years were reviewed and analyzed to identify their clinical characteristics and outcomes. Multivariable logistic regression was used to identify independent risk factors of hospital mortality. We present the outcomes for 1399 neonates admitted to the unit during August 2017 and August 2019.RESULTS:The leading cause of death was prematurity, followed by hypoxia and infection. Inborn neonates had better rates of hospital survival than those born elsewhere; they were also more likely to be born via cesarean section and to be admitted immediately following birth. There were no differences between the proportion of premature or low-birth-weight babies born at the hospital or elsewhere. Mortality in the second year of the unit's operation was 12%, almost half that of the first year (21%). Multivariable regression analysis showed that mortality was consistently higher among premature and very low birthweight babies.CONCLUSIONS:With modest investments, we were able to halve the mortality on a neonatal unit in Haiti. Resources are needed to address prematurity as an important outcome since hospital mortality was significant in this group. To this end, investment in uninterrupted supplies of oxygen and antibiotics, as well as ensuring adequate newborn resuscitation, infection control, laboratory testing, and timely morbidity and mortality reviews would go a long way toward lowering hospital mortality in Haiti.

Objectives Tuberculosis (TB) is the leading infectious cause of death in the world. Multi-drug resistant TB (MDR-TB) is a major public health problem as treatment is long, costly, and associated to poor outcomes. Here, we report epidemiological data on the prevalence of drug-resistant TB in Haiti. Methods This cross-sectional prevalence study was conducted in five health centers across Haiti. Adult, microbiologically confirmed pulmonary TB patients were included. Molecular genotyping (rpoB gene sequencing and spoligotyping) and phenotypic drug susceptibility testing were used to characterize rifampin-resistant MTB isolates detected by Xpert MTB/RIF. Results Between April 2016 and February 2018, 2,777 patients were diagnosed with pulmonary TB by Xpert MTB/RIF screening and positive MTB cultures. A total of 74 (2.7%) patients were infected by a drug-resistant (DR-TB) M. tuberculosis strain. Overall HIV prevalence was 14.1%. Patients with HIV infection were at a significantly higher risk for infection with DR-TB strains compared to pan-susceptible strains (28.4% vs. 13.7%, adjusted odds ratio 2.6, 95% confidence interval 1.5–4.4, P = 0.001). Among the detected DR-TB strains, T1 (29.3%), LAM9 (13.3%), and H3 (10.7%) were the most frequent clades. In comparison with previous spoligotypes studies with data collected in 2000–2002 and in 2008–2009 on both sensitive and resistant strains of TB in Haiti, we observed a significant increase in the prevalence of the drug-resistant MTB Spoligo-International-Types (SIT) 137 (X2 clade: 8.1% vs. 0.3% in 2000–02 and 0.9% in 2008–09, p<0.001), 5 (T1 clade: 6.8% vs 1.9 in 2000–02 and 1.7% in 2008–09, P = 0.034) and 455 (T1 clade: 5.4% vs 1.6% and 1.1%, P = 0.029). Newly detected spoligotypes (SIT 6, 7, 373, 909 and 1624) were also recorded. Conclusion This study describes the genotypic and phenotypic characteristics of DR-TB strains circulating in Haiti from April 2016 to February 2018. Newly detected MTB clades harboring multi-drug resistance patterns among the Haitian population as well as the higher risk of MDR-TB infection in HIV-positive people highlights the epidemiological relevance of these surveillance data. The importance of detecting RIF-resistant patients, as proxy for MDR-TB in peripheral sites via molecular techniques, is particularly important to provide adequate patient case management, prevent the transmission of resistant strains in the community and to contribute to the surveillance of resistant strains.

Background The rate of facility births in Haiti has doubled over the past two decades, but without comparable reductions in maternal or neonatal mortality. To care for newborns requiring hospitalization in Haiti, we worked with the public health leadership in the Haitian department of the South ( Sud ) to establish a ward for compromised neonates in a large public hospital with over 3000 annual deliveries but no neonatal care capacity. Methods Significant investments were made in establishing basic neonatal services, training nurses, installing and managing a supply chain, and strengthening infrastructure. We present outcomes for 1399 neonates admitted to the ward during the first two years of operation. Results Two-thirds of admissions were made from the hospital’s maternity ward after birth, while the remaining babies were born at home or at referring facilities. Inborn neonates had better rates of hospital survival than those born elsewhere; they were also more likely to be born via cesarean section and to be admitted immediately following birth. Babies born elsewhere were more likely to die during their hospital stay. There were no differences between the proportion of premature or low-birth-weight babies born at the hospital or elsewhere. Nursing care proved to be a critical part of the care delivery system. Conclusions To support maternal and newborn care, we conclude that integrated, high-frequency nursing training is necessary for both maternity and neonatal nurses. Resources are needed to address prematurity as an important outcome, especially as it is indicative of poor prenatal care, regardless of place of birth.

This case describes the development and application of a national electronic medical record system, iSanté, to drive improvement as part of Haiti's national HIV quality management program. The Haiti Ministry of Health, with support from donor agencies and local implementing partners, developed iSanté in 2008 to support public health, specifically to facilitate and prioritize use of data for quality improvement and real-time monitoring of HIV care and treatment nationwide. This case describes the development and implementation of the HIV quality management program at the facility level and the development of the iSanté electronic medical record system to record and tabulate data to facilitate evidence-based decision-making about patient care in order to improve patient outcomes.

Background: Tuberculosis (TB) is the leading infectious cause of death worldwide. A major barrier to control of the pandemic is a lack of clinical biomarkers with the ability to distinguish active TB from healthy and sick controls and potential for development into point-of-care diagnostics. Methods: We conducted a prospective case control study to identify candidate urine-based diagnostic biomarkers of active pulmonary TB (discovery cohori) and obiained a separate blinded "validation" cohort of confirmed cases of active pulmonary TB and controls with non-Luberculous pulmonary disease for validation. Clean-caLch urine samples were collected and analyzed using high performance liquid chromaLography-coupled Lime-of-flight mass spectrometry. Results: We discovered ten molecules from the discovery cohort with receiver-operator characteristic (ROC) area-under-the-curve (AUC) values >85%. These 10 molecules also significantly decreased after 60 days of treatment in a subset of 20 participants followed over time. Of these, a specific combination of diacetylspermine, neopterin, sialic acid, and N-acetylhexosamine exhibited ROC AUCs >80% in a blinded validation cohort of participants with active TB and non-tuberculous pulmonary disease. Conclusion: Urinary levels of diacetylspermine, neoptelin, sialic acid, and N-acetylhexosa mine distinguished patients with tuberculosis from healthy controls and patients with non-tuberculous pulmonary diseases, providing a potential noninvasive biosignature of active TB. (C) 2018 The Author(s). Published by Elsevier B.V.