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Rosen JG, Ndyanabo A, Nakawooya H, Galiwango RM, Ssekubugu R, Ssekasanvu J, Kim S, Rucinski KB, Nakigozi G, Nalugoda F, Kigozi G, Quinn TC, Chang LW, Kennedy CE, Reynolds SJ, Kagaayi J, Grabowski MK. Incidence of Health Facility Switching and Associations With HIV Viral Rebound Among Persons on Antiretroviral Therapy in Uganda: A Population-based Study. Clin Infect Dis 2024; 78:1591-1600. [PMID: 38114162 PMCID: PMC11175689 DOI: 10.1093/cid/ciad773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/02/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND A substantial proportion of persons on antiretroviral therapy (ART) considered lost to follow-up have actually transferred their human immunodeficiency virus (HIV) care to other facilities. However, the relationship between facility switching and virologic outcomes, including viral rebound, is poorly understood. METHODS We used data from 40 communities (2015-2020) in the Rakai Community Cohort Study to estimate incidence of facility switching and viral rebound. Persons aged 15-49 years with serologically confirmed HIV who self-reported ART use and contributed ≥1 follow-up visit were included. Facility switching and virologic outcomes were assessed between 2 consecutive study visits (ie, index and follow-up visits, interval of approximately 18 months). Those who reported different HIV treatment facilities between index and follow-up study visits were classified as having switched facilities. Virologic outcomes included viral rebound among individuals initially suppressed (<200 copies/mL). Multivariable Poisson regression was used to estimate associations between facility switching and viral rebound. RESULTS Overall, 2257 persons who self-reported ART use (median age, 35 years; 65% female, 92% initially suppressed) contributed 3335 visit-pairs and 5959 person-years to the analysis. Facility switching was common (4.8 per 100 person-years; 95% confidence interval [CI], 4.2-5.5) and most pronounced in persons aged <30 years and fishing community residents. Among persons suppressed at their index visit (n = 2076), incidence of viral rebound was more than twice as high in persons who switched facilities (adjusted incidence rate ratio = 2.27; 95% CI, 1.16-4.45). CONCLUSIONS Facility switching was common and associated with viral rebound among persons initially suppressed. Investments in more agile, person-centered models for mobile clients are needed to address system inefficiencies and bottlenecks that can disrupt HIV care continuity.
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Affiliation(s)
- Joseph G Rosen
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | | | | | - Seungwon Kim
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Katherine B Rucinski
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | - Thomas C Quinn
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Larry W Chang
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Caitlin E Kennedy
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Steven J Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - M Kate Grabowski
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Rosen JG, Ssekubugu R, Chang LW, Ssempijja V, Galiwango RM, Ssekasanvu J, Ndyanabo A, Kisakye A, Nakigozi G, Rucinski KB, Patel EU, Kennedy CE, Nalugoda F, Kigozi G, Ratmann O, Nelson LJ, Mills LA, Kabatesi D, Tobian AAR, Quinn TC, Kagaayi J, Reynolds SJ, Grabowski MK. Temporal dynamics and drivers of durable HIV viral load suppression and persistent high- and low-level viraemia during Universal Test and Treat scale-up in Uganda: a population-based study. J Int AIDS Soc 2024; 27:e26200. [PMID: 38332519 PMCID: PMC10853573 DOI: 10.1002/jia2.26200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 12/04/2023] [Indexed: 02/10/2024] Open
Abstract
INTRODUCTION Population-level data on durable HIV viral load suppression (VLS) following the implementation of Universal Test and Treat (UTT) in Africa are limited. We assessed trends in durable VLS and viraemia among persons living with HIV in 40 Ugandan communities during the UTT scale-up. METHODS In 2015-2020, we measured VLS (<200 RNA copies/ml) among participants in the Rakai Community Cohort Study, a longitudinal population-based HIV surveillance cohort in southern Uganda. Persons with unsuppressed viral loads were characterized as having low-level (200-999 copies/ml) or high-level (≥1000 copies/ml) viraemia. Individual virologic outcomes were assessed over two consecutive RCCS survey visits (i.e. visit-pairs; ∼18-month visit intervals) and classified as durable VLS (<200 copies/ml at both visits), new/renewed VLS (<200 copies/ml at follow-up only), viral rebound (<200 copies/ml at initial visit only) or persistent viraemia (≥200 copies/ml at both visits). Population prevalence of each outcome was assessed over calendar time. Community-level prevalence and individual-level predictors of persistent high-level viraemia were also assessed using multivariable Poisson regression with generalized estimating equations. RESULTS Overall, 3080 participants contributed 4604 visit-pairs over three survey rounds. Most visit-pairs (72.4%) exhibited durable VLS, with few (2.5%) experiencing viral rebound. Among those with any viraemia at the initial visit (23.5%, n = 1083), 46.9% remained viraemic through follow-up, 91.3% of which was high-level viraemia. One-fifth (20.8%) of visit-pairs exhibiting persistent high-level viraemia self-reported antiretroviral therapy (ART) use for ≥12 months. Prevalence of persistent high-level viraemia varied substantially across communities and was significantly elevated among young persons aged 15-29 years (vs. 40- to 49-year-olds; adjusted risk ratio [adjRR] = 2.96; 95% confidence interval [95% CI]: 2.21-3.96), males (vs. females; adjRR = 2.40, 95% CI: 1.87-3.07), persons reporting inconsistent condom use with non-marital/casual partners (vs. persons with marital/permanent partners only; adjRR = 1.38, 95% CI: 1.10-1.74) and persons reporting hazardous alcohol use (adjRR = 1.09, 95% CI: 1.03-1.16). The prevalence of persistent high-level viraemia was highest among males <30 years (32.0%). CONCLUSIONS Following universal ART provision, most persons living with HIV in south-central Uganda are durably suppressed. Among persons exhibiting any viraemia, nearly half exhibited high-level viraemia for ≥12 months and reported higher-risk behaviours associated with onward HIV transmission. Intensified efforts linking individuals to HIV treatment services could accelerate momentum towards HIV epidemic control.
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Affiliation(s)
- Joseph Gregory Rosen
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | | | - Larry W. Chang
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Rakai Health Sciences ProgramEntebbeUganda
- Division of Infectious DiseasesJohns Hopkins School of MedicineBaltimoreMarylandUSA
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Victor Ssempijja
- Rakai Health Sciences ProgramEntebbeUganda
- Clinical Monitoring Research Program DirectorateFrederick National Laboratory for Cancer ResearchFrederickMarylandUSA
| | | | - Joseph Ssekasanvu
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Rakai Health Sciences ProgramEntebbeUganda
| | | | | | | | - Katherine B. Rucinski
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Eshan U. Patel
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Caitlin E. Kennedy
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Rakai Health Sciences ProgramEntebbeUganda
| | | | | | | | - Lisa J. Nelson
- Division of Global HIV and TBCenters for Disease Control and PreventionKampalaUganda
| | - Lisa A. Mills
- Division of Global HIV and TBCenters for Disease Control and PreventionKampalaUganda
| | - Donna Kabatesi
- Division of Global HIV and TBCenters for Disease Control and PreventionKampalaUganda
| | - Aaron A. R. Tobian
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of PathologyJohns Hopkins School of MedicineBaltimoreMarylandUSA
| | - Thomas C. Quinn
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Rakai Health Sciences ProgramEntebbeUganda
- Division of Infectious DiseasesJohns Hopkins School of MedicineBaltimoreMarylandUSA
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Division of Intramural ResearchNational Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
| | | | - Steven J. Reynolds
- Rakai Health Sciences ProgramEntebbeUganda
- Division of Infectious DiseasesJohns Hopkins School of MedicineBaltimoreMarylandUSA
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Division of Intramural ResearchNational Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
| | - Mary Kathryn Grabowski
- Rakai Health Sciences ProgramEntebbeUganda
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of PathologyJohns Hopkins School of MedicineBaltimoreMarylandUSA
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Rosen JG, Ssekubugu R, Chang LW, Ssempijja V, Galiwango RM, Ssekasanvu J, Ndyanabo A, Kisakye A, Nakigozi G, Rucinski KB, Patel EU, Kennedy CE, Nalugoda F, Kigozi G, Ratmann O, Nelson LJ, Mills LA, Kabatesi D, Tobian AAR, Quinn TC, Kagaayi J, Reynolds SJ, Grabowski MK. Temporal dynamics and drivers of durable HIV viral load suppression and persistent high- and low-level viremia during Universal Test and Treat scale-up in Uganda: a population-based study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.06.15.23291445. [PMID: 37398460 PMCID: PMC10312875 DOI: 10.1101/2023.06.15.23291445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Introduction Population-level data on durable HIV viral load suppression (VLS) following implementation of Universal Test and Treat (UTT) in Africa are limited. We assessed trends in durable VLS and viremia among persons living with HIV in 40 Ugandan communities during UTT scale-up. Methods In 2015-2020, we measured VLS (defined as <200 RNA copies/mL) among participants in the Rakai Community Cohort Study, a longitudinal population-based HIV surveillance cohort in southern Uganda. Persons with unsuppressed viral loads were characterized as having low-level (200-999 copies/mL) or high-level (≥1,000 copies/mL) viremia. Individual virologic outcomes were assessed over two consecutive RCCS survey visits (i.e., visit-pairs; ∼18 month visit intervals) and classified as durable VLS (<200 copies/mL at both visits), new/renewed VLS (<200 copies/mL at follow-up only), viral rebound (<200 copies/mL at initial visit only), or persistent viremia (<200 copies/mL at neither visit). Population prevalence of each outcome was assessed over calendar time. Community-level prevalence and individual-level predictors of persistent high-level viremia were also assessed using multivariable Poisson regression with generalized estimating equations. Results Overall, 3,080 participants contributed 4,604 visit-pairs over three survey rounds. Most visit-pairs (72.4%) exhibited durable VLS, with few (2.5%) experiencing viral rebound. Among those with viremia at the initial visit ( n =1,083), 46.9% maintained viremia through follow-up, 91.3% of which was high-level viremia. One-fifth (20.8%) of visit-pairs exhibiting persistent high-level viremia self-reported antiretroviral therapy (ART) use for ≥12 months. Prevalence of persistent high-level viremia varied substantially across communities and was significantly elevated among young persons aged 15-29 years (versus 40-49-year-olds; adjusted risk ratio [adjRR]=2.96; 95% confidence interval [95%CI]:2.21-3.96), men (versus women; adjRR=2.40, 95%CI:1.87-3.07), persons reporting inconsistent condom use with non-marital/casual partners (versus persons with marital/permanent partners only; adjRR=1.38, 95%CI:1.10-1.74), and persons exhibiting hazardous alcohol use (adjRR=1.09, 95%CI:1.03-1.16). The prevalence of persistent high-level viremia was highest among men <30 years (32.0%). Conclusions Following universal ART provision, most persons living with HIV in south-central Uganda are durably suppressed. Among persons exhibiting viremia, nearly half maintain high-level viremia for ≥12 months and report higher-risk behaviors associated with onward HIV transmission. Enhanced linkage to HIV care and optimized treatment retention could accelerate momentum towards HIV epidemic control.
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Leslie HH, Mooney AC, Gilmore HJ, Agnew E, Grignon JS, deKadt J, Shade SB, Ratlhagana MJ, Sumitani J, Barnhart S, Steward WT, Lippman SA. Prevalence, motivation, and outcomes of clinic transfer in a clinical cohort of people living with HIV in North West Province, South Africa. BMC Health Serv Res 2022; 22:1584. [PMID: 36572869 PMCID: PMC9791728 DOI: 10.1186/s12913-022-08962-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/13/2022] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Continuity of care is an attribute of high-quality health systems and a necessary component of chronic disease management. Assessment of health information systems for HIV care in South Africa has identified substantial rates of clinic transfer, much of it undocumented. Understanding the reasons for changing sources of care and the implications for patient outcomes is important in informing policy responses. METHODS In this secondary analysis of the 2014 - 2016 I-Care trial, we examined self-reported changes in source of HIV care among a cohort of individuals living with HIV and in care in North West Province, South Africa. Individuals were enrolled in the study within 1 year of diagnosis; participants completed surveys at 6 and 12 months including items on sources of care. Clinical data were extracted from records at participants' original clinic for 12 months following enrollment. We assessed frequency and reason for changing clinics and compared the demographics and care outcomes of those changing and not changing source of care. RESULTS Six hundred seventy-five (89.8%) of 752 study participants completed follow-up surveys with information on sources of HIV care; 101 (15%) reported receiving care at a different facility by month 12 of follow-up. The primary reason for changing was mobility (N=78, 77%). Those who changed clinics were more likely to be young adults, non-citizens, and pregnant at time of diagnosis. Self-reported clinic attendance and ART adherence did not differ based on changing clinics. Those on ART not changing clinics reported 0.66 visits more on average than were documented in clinic records. CONCLUSION At least 1 in 6 participants in HIV care changed clinics within 2 years of diagnosis, mainly driven by mobility; while most appeared lost to follow-up based on records from the original clinic, self-reported visits and adherence were equivalent to those not changing clinics. Routine clinic visits could incorporate questions about care at other locations as well as potential relocation, particularly for younger, pregnant, and non-citizen patients, to support existing efforts to make HIV care records portable and facilitate continuity of care across clinics. TRIAL REGISTRATION The original trial was registered with ClinicalTrials.gov , NCT02417233, on 12 December 2014.
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Affiliation(s)
- Hannah H. Leslie
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Alyssa C. Mooney
- Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA USA
| | - Hailey J. Gilmore
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Emily Agnew
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Jessica S. Grignon
- Department of Global Health, University of Washington, Seattle, WA USA
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Julia deKadt
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Starley B. Shade
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Mary Jane Ratlhagana
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Jeri Sumitani
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, WA USA
| | - Wayne T. Steward
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Sheri A. Lippman
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
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Nardell MF, Hedt-Gauthier B, Earnshaw VA, Bogart LM, Dietrich JJ, Courtney I, Tshabalala G, Bor J, Orrell C, Gray G, Bangsberg DR, Katz IT. Understanding Repeat Positive HIV Testing in South Africa Under Changing Treatment Guidelines. AIDS Behav 2022; 26:1366-1376. [PMID: 34705150 PMCID: PMC9007825 DOI: 10.1007/s10461-021-03493-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 01/06/2023]
Abstract
Some people with HIV (PWH) test positive multiple times without initiating antiretroviral therapy (ART). We surveyed 496 ART-eligible PWH following routine HIV testing at three clinics in Soweto and Gugulethu, South Africa in 2014-2015. Among repeat positive testers (RPTs) in this cohort, we compared rates of treatment initiation by prior treatment eligibility and assessed psychosocial predictors of treatment initiation in logistic regression models. RPTs represented 33.8% of PWH in this cohort. Less than half of those who reported eligibility for ART on prior testing started treatment upon retesting, in contrast to two thirds of RPTs who were previously ineligible for treatment who started treatment once they learned of their eligibility. Those who reported coping through substance use were more likely to decline treatment versus those not using substances. PWH who test repeatedly represent a vulnerable population at risk for ART non-initiation who may benefit from interventions addressing individualized coping strategies.
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Affiliation(s)
- Maria F Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, Thorn Building 14th Floor, Boston, MA, 02120, USA.
- Harvard Medical School, Boston, USA.
- Department of Medicine, Brigham and Women's Hospital, Boston, USA.
| | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
- Massachusetts General Hospital Center for Global Health, Boston, USA
| | - Valerie A Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, Newark, USA
| | | | - Janan J Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Western Cape, South Africa
| | - Ingrid Courtney
- Desmond Tutu Health Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Gugulethu Tshabalala
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, USA
| | - Catherine Orrell
- Desmond Tutu Health Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Glenda Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Office of the President, South African Medical Research Council, Western Cape, South Africa
| | - David R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, USA
| | - Ingrid T Katz
- Harvard Medical School, Boston, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, USA
- Massachusetts General Hospital Center for Global Health, Boston, USA
- Harvard Global Health Institute, Cambridge, USA
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