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Cohort Profile: The international epidemiological databases to evaluate AIDS (IeDEA) in sub-Saharan Africa

Open access
Egger, M., Ekouevi, D. K., Williams, C., Lyamuya, R. E., Mukumbi, H., Braitstein, P., Hartwell, T., Graber, C., Chi, B. H., Boulle, A., Dabis, F., Wools-Kaloustian, K.·2012·International Journal of Epidemiology
DOI 10.1093/ije/dyr080
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Abstract

The HIV/AIDS pandemic is a public health emergency in many low and middle-income countries. Out of the estimated 33.3 million people with HIV at the end of 2009, 22.5 million were in sub-Saharan Africa and the majority of these were women.1 The introduction in 1996 of combination anti-retroviral therapy (ART) led to a substantial reduction in morbidity and mortality in high-income countries.2,3 In more recent years, efforts by governmental programmes such as the President’s Emergency Program for AIDS Relief (PEPFAR) and The Global Fund as well as non-governmental programmes have resulted in the scale-up of ART in resource-limited settings: at the end of 2009, 5.25 million people were reported to be receiving ART therapy in low- and middle-income countries.1 Although still far from achieving universal coverage,1 the massive concerted scale-up of ART is unprecedented in global health. The long-term outcomes of ART in Africa and other regions are, however, not well defined. Poor retention in care, limited access to second-line ART regimens, co-infections and comorbidities of HIV infection, for example tuberculosis and cancer, and the emergence of drug resistance and toxicities are important challenges to long-term programme effectiveness in resource-limited settings.7 The World Health Organization (WHO) advocates a public health approach to ART in resource-limited settings, to maximize benefit in a setting of low levels of training for health-care workers, high patient burden and limited availability of drugs. Key characteristics include the standardization of first-line and second-line ART regimens, simplified clinical decision-making and standardized clinical and laboratory monitoring.4–6 In 2005, the National Institute of Allergy and Infectious Diseases (NIAID) sought applications for a global consortium structured through regional centres to pool existing clinical and epidemiological data on HIV-infected people, and particularly patients on ART: the International epidemiological Databases to Evaluate AIDS (IeDEA, see Figure 1 for logo).8 Funding of IeDEA has recently been extended to 2011–2016. The seven regions included in IeDEA are North America, Caribbean/Central and South America, Asia/Pacific and four regions in sub-Saharan Africa. A Coordinating Centre (currently at RTI International, NC, USA) provides logistical and data management and harmonization support to the regional networks. Two of the IeDEA cohorts have previously been described in the journal.9,10 The objective of the present report is to describe the four African IeDEA regions: West Africa, Central Africa, East Africa and Southern Africa. Logo of the IeDEA The African networks of IeDEA aim to inform the scale-up of ART in sub-Saharan Africa through clinical and epidemiological research. The specific research questions differ by region, but the objectives are similar and cover all populations, including pregnant women, infants, children, adolescents and adult patients. They can be summarized as follows: To provide robust evaluation of the delivery of ART in children, adolescents and adults in sub-Saharan Africa, with a focus on long-term programme effectiveness and outcomes. To describe the long-term and temporal trends in regimen durability and tolerability and to examine monitoring strategies. To describe important comorbidities and co-infections of HIV infection, including malaria, tuberculosis and cancer. To examine the pregnancy- and HIV-related outcomes of women initiating ART during pregnancy and of infants exposed to HIV or ART in utero. To develop and apply novel statistical methods to deal with missing data, loss to follow-up, competing risks and time-dependent confounding. To establish procedures to link the HIV cohort data with other databases, at local or national level, for example routine mortality data or tuberculosis and cancer registries. A total of 183 clinics providing ART in 17 countries in sub-Saharan Africa participate in IeDEA’s four African regions (Figure 2). Most sites are located in urban areas, operate at the primary care level, are led by nurses or clinical officers rather than physicians and are part of the public health care system of the country (Table 1). About two-thirds of sites have the capacity to measure CD4 cell counts, and a third can do HIV-1 RNA tests. Virtually all sites provide adherence support to patients, screen and provide treatment for tuberculosis. ART provision at most sites started during or after 2004 with the exception of several clinics in West Africa, which introduced ART earlier. Figure 3 shows the cumulative number of treatment sites and adult patients starting ART. There has been a rapid increase in facilities and patients contributing data to IeDEA which is for the most part due to rapid scale-up by a few countries in each region. For example, South Africa and Zambia in Southern Africa and Nigeria in West Africa had the most rapid scale-up in their region. All three contributing

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Metadata

Authors
Egger, M., Ekouevi, D. K., Williams, C., Lyamuya, R. E., Mukumbi, H., Braitstein, P., Hartwell, T., Graber, C., Chi, B. H., Boulle, A., Dabis, F., & Wools-Kaloustian, K.
Venue
International Journal of Epidemiology
Publisher
Oxford University Press (OUP)
Published
2011-05-18
Volume
41
Issue
5
Pages
1256-1264
ISSN
  • 0300-5771 (ISSN-L)
  • 1464-3685
DOI
10.1093/ije/dyr080
OpenAlex
W2144304933
Cited by
257
References
29
FWCI
11.01
Type
journal article
Language
en
Open access
bronze

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