Management
Matthew Fox [Division Head]
Matthew Fox, DSc, MPH, has served as a Co-Director of the Health Economics and Epidemiology Research Office (HE2RO) since 2008 where he oversees a portfolio of research on epidemiologic impacts of the HIV treatment rollout in South Africa. He is also a Professor in the Center for Global Health & Development and in the Department of Epidemiology at Boston University. His research interests include treatment outcomes in HIV-treatment programs, infectious disease epidemiology (with specific interests in HIV and pneumonia), and epidemiologic methods. Dr. Fox is currently funded through a K award from the National Institutes of Allergy and Infectious Diseases, to work on ways to improve retention in HIV-care programs in South Africa from the time of testing HIV-positive through long-term treatment. As part of this work, he is involved in analyses of whether treating patients at higher CD4 counts leads to improved long-term retention and treatment outcomes. Dr. Fox also does research on quantitative sensitivity analysis and recently co-authored a book on these methods, Applying Quantitative Bias Analysis to Epidemiologic Data. He currently teaches a third-level epidemiologic methods class, Advanced Epidemiology. Dr. Fox is a graduate of the Boston University School of Public Health with a master’s degree in epidemiology and biostatistics and a doctorate in epidemiology.
Projects
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Low Prevalence of Depressive Symptoms among Stable Patients on Antiretroviral Therapy in Johannesburg, South Africa
Depression is a leading cause of morbidity worldwide. It affects more than 300 million individuals globally and depressive disorders are currently the 4th leading cause of Years Lived with Disability (YLD) in South Africa. People living with HIV are disproportionately affected by mental health disorders and while the lifetime prevalence of depression in the general population of South Africa is estimated as 9.7%, estimates from HIV-infected populations have ranged from 14-62%, with variability -
Using Routinely Collected Laboratory Data to Characterise Trends in the TB Epidemic
The overall aim of this study is to harness routinely collected laboratory data to characterize the spatial distribution of tuberculosis in South Africa. In collaboration with partners at the University of the Witwatersrand and the National Health Laboratory Service, we are conducting retrospective analyses of de-identified data to highlight areas with greater burden of TB disease and investigate whether burden is changing over time. Results from this work will be informative for planning for -
SLATE: Simplified Algorithm for Treatment Eligibility
In its 2015 revision of the global guidelines for HIV care and treatment, the World Health Organization called for initiating lifelong antiretroviral treatment (ART) for all patients testing positive for HIV, regardless of CD4 cell count. As countries adopt the new recommendation, known as “treat all,” millions of additional patients are becoming eligible for ART worldwide. In sub-Saharan Africa, where most of these patients are located, studies continue to document high losses of -
Retrospective Cost-Effectiveness Analysis for Nurse Initiated and Managed Antiretroviral Treatment for HIV/AIDS in South Africa
In HIV/AIDS treatment programs in resource-constrained settings, one response to a shortage of doctors and other highly trained healthcare providers is “task-shifting” from doctors to less trained clinicians, such as nurses and community healthcare workers. In 2010, South Africa issued new guidelines for its antiretroviral treatment (ART) program to allow senior nurses to initiate and manage adult ART patients at primary health clinics. This policy, known as NIMART (Nurse Initiated and -
Attrition from HIV Care and Treatment Before and After an Increase in the CD4 Count Eligibility Threshold
South Africa has recently announced that as of January 2015, it will be increasing its HIV treatment CD4 eligibility threshold from 350 cells/μl to 500 cells/μl1 making more patients eligible for treatment than ever before. However efforts to increase HIV treatment coverage may be minimized if losses to follow up, which have been shown to be high along the continuum of HIV care, offset gains from getting more people onto treatment. HE2RO will conduct a prospective cohort study of adult -
Modelling the Cost of the National ART Programme under Different Sets of Guidelines: The National ART Cost Model (NACM) and the Treatment as Prevention Cost Model (TasP Cost Model)
On request of the South African Department of Health (NDoH), since 2009 HE2RO has used the detailled cost and outcomes data collected in other projects to develop mathematical models projecting the size of the treatment cohort under different scenarios of antiretroviral treatment (ART eligibility as well as the resulting costs). Our budget models, most notably the National ART Cost Model (NACM) and the Treatment as Prevention Cost Model (TasP Cost Model), have contributed to several sets of -
Impact of Nutritional Supplementation on Physical Development, Retention in Care and Adherence to ART in HIV-Positive Infants and Children
The study aims to determine whether a nutritional supplement, FutureLife HIGH-ENERGY Smart food, given to caregivers/guardians to give to their HIV-positive infants and children for 6 months concurrently with antiretroviral therapy (ART) compared to standard of care results in improved growth and physical development as measured by an increase in height-for-age Z score (HAZ), weight-for-age Z score (WAZ) and mid-upper arm circumference (MUAC) at 6, 12 and 24 months. Secondary outcomes -
Remote Electronic Treatment Adherence Monitoring of Patients on Antiretroviral Therapy in South Africa: A Pilot Study
Electronic patient adherence monitoring is a novel method for improving adherence to HIV treatment. This pilot study aimed to generate preliminary data for a larger trial. We determine the effectiveness and cost-effectiveness of using electronic patient adherence monitoring in patients at high risk of failing second-line antiretroviral therapy (ART) at Themba Lethu HIV clinic in Johannesburg, South Africa compared to the standard of care, which involves optimized adherence counseling. -
Rapid Initiation of Antiretroviral Treatment (RapIT) for Pregnant Women
Alongside the primary RapIT study, we are enrolling pregnant women at a public clinic in Johannesburg in a prospective study of the impact of the guidelines on retention on ART for the duration of pregnancy. We are comparing our main outcome, adherence to ART until delivery, for these women to a retrospective comparison group who received PMTCT under earlier -
RapIT: Rapid Initiation of Antiretroviral Therapy to Promote Early HIV/AIDS Treatment in South Africa
The RapIT study was a randomized strategy evaluation of the feasibility, effectiveness, and cost-effectiveness of rapid ART initiation using accelerated clinic procedures and point-of-care laboratory tests. Outpatient, non-pregnant, HIV-positive adults who came to two South African clinics for an HIV test or CD4 count, consented to study participation, and were eligible for ART under 2010 guidelines were randomized 1:1 to rapid ART initiation or to standard care. Those who were assigned to -
Retention and Attrition from HIV Care
With the rapid expansion of access to antiretroviral therapy (ART) in sub-Saharan Africa, the number of HIV-positive people on treatment has increased dramatically. In South Africa, scale-up of services has put pressure on the ability of treatment programs to maintain care for existing patients while continuing to expand access to new patients. With increased demand and limited capacity, many HIV-positive patients never access care, and many who do discontinue treatment. HE2RO staff, -
Southern African Treatment Programme Evaluation
Understanding HIV epidemic in the wider Southern African region provides context and valuable insight for the National treatment programme. To this end, HE2RO contributes data to the International Epidemiologic Databases to Evaluate AIDS Southern Africa network. This collaboration collects key data and implements methodology to effectively analyse data from large generated datasets to address high priorty HIV/AIDS related questions that are not answerable by a single -
Linkage to National Databases to Enhance Programme Evaluation
HIV care involves a web of local clinics and laboratories throughout South Africa. In the emergency phase of the epidemic, monitoring and evaluation took a backseat to HIV care. Currently HIV care takes place at over 3,000 local clinics throughout South Africa. Laboratory test from the labs and patient records from the clinics provide potentially useful sources of data for monitoring and evaluation of the National treatment programme currently and historically. Linkage of patient records to the -
Pregnant Women
Treatment outcomes among pregnant women remain a critical indicator for monitoring and evaluation of the national treatment program over time. A long-standing collaboration with researchers from the University of North Carolina has enriched the analysis of longitudinal data on pregnant women by the researchers at -
Paediatric and Adolescent Populations
Children and adolescents have been identified as priority populations with the greatest potential impact on the development of the HIV epidemic. HE2RO has used multiple sources of data to evaluate the outcomes of children and adolescents initiating ART at multiple clinics across Gauteng and Mpumalanga. We also utilize prospective cohorts to identify factors associated with treatment adherence and missed clinic visits among adolescents and plan to use national level laboratory data to produce -
Second and Third-Line Antiretroviral Regimens
As South Africa continues its rapid expansion of access to first-line antiretroviral therapy (ART), more patients will need to be switched to second-line therapy as these first-line regimens fail. However, with little experience with second-line treatments in resource-limited settings, it is not clear how well patients will do on these medications if their first regimen fails. As the cost of second-line medications is much higher than first-line, it is critical to evaluate whether these -
First Line Regimen Durability and Adverse Events
Understanding the implications of the side effect profile of individual antiretroviral drugs as well as the durability of drug regimens has considerable significance in settings where resources and drug options for HIV remain limited. HE2RO has explored these questions through longitudinal patient datasets with a particular interest in the effects of tenofovir upon introduction into the national programme. These analyses are ongoing as guidelines continue to evolve and current projects include -
Adult Treatment Outcomes and Opportunistic Infections
As the HIV epidemic matured in South Africa and the national treatment programme reached 10 years since inception, the team at HE2RO has used longitudinal patient databases to evaluate treatment outcomes among adults initiating ART. We consider diverse factors that may influence the effect of ART and also the impact of changing national guidelines in an on-going
Publications
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Frequent Mobility among Postpartum Women: Implications for HIV Treatment and Care
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Regimen durability in HIV-infected children and adolescents initiating first-line antiretroviral therapy in a large public sector HIV cohort in South Africa
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Patient related factors that contribute to poor adherence on second-line HIV treatment
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Tenofovir stock shortages have limited impact on clinic-and patient-level HIV treatment outcomes in public sector clinics in South Africa
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Changes in elevated cholesterol in the era of Tenofovir: risk factors, clinical management and outcomes
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Timing of pregnancy, postpartum risk of virology failure and loss to follow up among HIV-positive women
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The right combination – treatment outcomes among HIV-positive patients initiating first-line fixed-dose antiretroviral therapy in a public sector HIV clinic in Johannesburg, South Africa
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Cohort profile: the Right to Care Clinical HIV Cohort, South Africa
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Predicting the need for third-line antiretroviral therapy by identifying patients at high risk for failing second-line antiretroviral therapy in South Africa
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Initiating Antiretroviral Therapy at a Patient’s First Clinic Visit: The RapIT Study
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The High Cost of HIV-Positive Inpatient Care at an Urban Hospital in Johannesburg, South Africa
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Retention of adult patients on antiretroviral therapy in low- and middle-income countries: systematic review and meta-analysis 2008-2013
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The effect of initiating tenofovir on HIV treatment outcomes in adults in southern Africa: a regression discontinuity analysis
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A descriptive analysis of South Africa’s national third line antiretroviral therapy cohort
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A predictive risk model for first line treatment failure in South Africa
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Delaying second line antiretroviral therapy after first line failiure in South Africa: Moderating effect of CD4 count
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Predictors and Outcomes of Incident High Cholesterol in Adults on ART in South Africa
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Systematic review of retention of pediatric patients on HIV treatment in low and middle-income countries 2008–2013
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CD41 T cell recovery during suppression of HIV replication: an international comparison of the immunological efficacy of antiretroviral therapy in North America, Asia and Africa
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Rapid antiretroviral therapy initiation reduces attrition between HIV testing and treatment in Africa
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The relation between efavirenz versus nevirapine and virologic failure in Johannesburg, South Africa
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Attrition through Multiple Stages of HIV Care in South Africa
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CD4 monitoring improves the sensitivity of a clinical algorithm developed to identify virological failure in HIV-positive patients on first-line antiretroviral therapy
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Does most early mortality in patients on ART occur in care or lost to follow-up? Evidence from the Themba Lethu Clinic, South Africa
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Impacts of disaggregating programmatic outcomes by documentation of citizenship in South Africa
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Disaggregating programmatic outcomes by documentation of citizenship in South Africa
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Predictors and impact of suboptimal immune response in HIV-infected patients in South Africa
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Cotrimoxazole use and immune system recovery among newly initiating HIV-infected patients in an urban outpatient HIV clinic in Johannesburg, South Africa
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Decrease in Single-drug Substitutions in the First 24-months on First-line Treatment amongst HIV-positive Children and Adolescents in South Africa
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24-month Treatment Outcomes Amongst HIV-Positive Children and Adolescent Patients Prescribed Stavudine vs. Abacavir
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Long-term outcomes of over one thousand patients on second-line antiretroviral therapy in South Africa
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Eight years experience with attrition and mortality on antiretroviral therapy in South Africa
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Second line failure and protease inhibitor resistance in a clinic in Johannesburg, South Africa
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Long-term Virologic Response in a Cohort of HIV-infected Patients in South Africa
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Predictors of Time to Switch to Second Line ART after First Line Failure in Johannesburg, South Africa
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Risk Factors Associated with TB in Children Receiving ART in a South African Multicenter HIV Cohort
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Obesity or hypertension at ART initiation and outcomes amongst HIV patients in South Africa
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Predictors of incident hypertension in HIV-positive adults over 24 months on ART in South Africa
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Immunodeficiency at the start of combination antiretroviral therapy in low-, middle-, and high-income countries.
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Changing the South African HIV and TB guidelines: The role of cost modelling
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Loss to Initiation and Linkage to Care
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Epidemiological Outcomes of the HIV Treatment Rollout
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Kaposi Sarcoma-Associated Herpes Virus and Response to Antiretroviral Therapy: A Prospective Study of HIV-Infected Adults
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A Novel Approach to Accounting for Loss to Follow-Up when Estimating the Relationship between CD4 Count at ART Initiation and Mortality
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Anemia among HIV-Infected Patients Initiating Antiretroviral Therapy in South Africa: Improvement in Hemoglobin regardless of Degree of Immunosuppression and the Initiating ART Regimen
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The Relation Between Efavirenz. vs. Nevirapine and Virologic Failure in Johannesburg, South Africa
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Current CD4 Count, More than Baseline, Predicts Loss to Follow-up from HIV Care
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Effect of home based HIV counselling and testing intervention in rural South Africa: cluster randomised trial
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Same-Day CD4 Testing to Improve Uptake of HIV Care and Treatment in South Africa: Point-of-Care Is Not Enough
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Treatment Response and Mortality among Patients Starting Antiretroviral Therapy with and without Kaposi Sarcoma: A Cohort Study
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Antiretroviral treatment outcomes after the introduction of tenofovir in the public-sector in South Africa
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The need for quantitative bias analysis in HIV/AIDS research: The case of nevirapine vs. efavirenz on virologic failure in Johannesburg, South Africa
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Risk of Mortality and Loss to Follow-up amongst HIV-Positive Patients Prescribed Stavudine vs. Tenofovir: A matched cohort analysis
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Incidence and Risk Factors Associated with Tuberculosis in HIV-positive Children Receiving Antiretroviral Therapy in a Large South African Multicenter Cohort
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Decrease in Single Drug Substitutions in the First 12-months on First-line Treatment amongst HIV-positive Patients in Johannesburg, South Africa
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Incidence of Herpes Zoster among HIV-infected Patients on Antiretroviral Therapy in Johannesburg, South Africa – Who Should We Vaccinate?
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Viremia Copy-years as a Measure of Viral Load Burden and Associated Mortality Risk among Antiretroviral Therapy Patients in Johannesburg, South Africa
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Attrition through Multiple Stages of HIV Care in South Africa: A Challenge for Test-and-Treat
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The Effect of 30 vs. 40mg of Stavudine vs. Tenofovir on Treatment Outcomes amongst HIV-positive Patients in Johannesburg, South Africa
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An Introduction to the Cascade of Care
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Incident pulmonary tuberculosis on antiretroviral therapy: seven years of experience at the Themba Lethu Clinic in Johannesburg, South Africa
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CD4 criteria improves the sensitivity of a clinical algorithm developed to identify viral failure in HIV-positive patients on first-line antiretroviral therapy
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Patient retention from HIV diagnosis through one year on antiretroviral therapy at a primary health clinic in Johannesburg, South Africa
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Reduced loss to ART initiation among patients initiating cotrimoxazole prophylaxis therapy in Johannesburg, South Africa
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Initiation of ART at higher CD4 counts under South Africa’s revised antiretroviral therapy guidelines results in improved patient outcomes
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HIV treatment outcomes after seven years in a large public-sector HIV treatment program in Johannesburg, South Africa
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The Feasibility of Using Criteria to Identify Stable Patients on HAART at Themba Lethu Clinic
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Short-term impacts of a change in ART initiation threshold for patients co-infected with TB in Johannesburg, South Africa
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Low rates of nucleoside reverse transcriptase inhibitor resistance in a well monitored cohort in South Africa on antiretroviral therapy
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Investing in the Epidemic: The Cost of AIDS to Businesses in Africa