1
|
Saura-Lázaro A, Augusto O, Fernández-Luis S, López-Varela E, Fuente-Soro L, Bila D, Tovela M, Macuacua N, Vaz P, Couto A, Bruno C, Naniche D. HIV care retention in three multi-month ART dispensing: a retrospective cohort study in Mozambique. AIDS 2024; 38:1402-1411. [PMID: 38652496 PMCID: PMC11216376 DOI: 10.1097/qad.0000000000003913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/14/2024] [Accepted: 03/21/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Evaluate the effect of three multimonth dispensing (3MMD) of antiretroviral therapy (ART) on HIV care retention in southern Mozambique. DESIGN Retrospective cohort study. METHODS We analyzed routine health data from people with HIV (PWH) aged 10 years old and older who started ART between January 2018 and March 2021. Individuals were followed until December 2021. Cox proportional-hazards models were used to compare attrition (lost to follow-up, death, and transfer out) between 3MMD and monthly ART dispensing. Results were stratified by time on ART before 3MMD enrolment: 'early enrollers' (<6 months on ART) and 'established enrollers' (≥6 months on ART), and age groups: adolescents and youth (AYLHIV) (10-24 years) and adults (≥25 years). RESULTS We included 7378 PWH (25% AYLHIV, 75% adults), with 59% and 62% enrolled in 3MMD, respectively. Median follow-up time was 11.3 [interquartile range (IQR): 5.7-21.6] months for AYLHIV and 10.2 (IQR: 4.8-20.9) for adults. Attrition was lower in PWH enrolled in 3MMD compared with monthly ART dispensing, in both established (aHR AYLHIV = 0.65; 95% CI: 0.54-0.78 and aHR adults = 0.50; 95% confidence interval (CI): 0.44-0.56) and early enrollers (aHR AYLHIV = 0.70; 95% CI: 0.58-0.85 and aHR adults = 0.63; 95% CI: 0.57-0.70). Among individuals in 3MMD, male gender (aHR = 1.30; 95% CI: 1.18-1.44) and receiving care in a medium-volume/low-volume healthcare facility (aHR = 1.18; 95% CI: 1.03-1.34) increased attrition risk. Conversely, longer ART time before 3MMD enrolment (aHR = 0.93; 95% CI: 0.92-0.94 per 1 month increase) and age at least 45 years (aHR = 0.77, 95% CI: 0.67-0.89) reduced risk of attrition. CONCLUSION 3MMD improves retention in care compared with monthly dispensing among established and early enrollers, although to a lesser extent among the latter.
Collapse
Affiliation(s)
- Anna Saura-Lázaro
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Orvalho Augusto
- Centro de Investigação em Saúde de Manhiça (CISM)
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Sheila Fernández-Luis
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM)
| | - Elisa López-Varela
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM)
| | - Laura Fuente-Soro
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM)
| | - Dulce Bila
- Fundação Ariel Glaser Contra o SIDA Pediatrico
| | | | | | - Paula Vaz
- Fundação Ariel Glaser Contra o SIDA Pediatrico
| | - Aleny Couto
- Programa Nacional de Controle de HIV/SIDA, Ministério da Saúde
| | - Carmen Bruno
- Direcção Provincial de Saúde, Maputo, Mozambique
| | - Denise Naniche
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM)
| |
Collapse
|
2
|
Murphy RA, Bedesi PH, Perumal N, Gosnell BI, Hatlen TJ, Brijkumar J. Dolutegravir Resistance in African Programmatic Settings Among Patients With Failure of Dolutegravir-based ART. Open Forum Infect Dis 2024; 11:ofae321. [PMID: 38947737 PMCID: PMC11214099 DOI: 10.1093/ofid/ofae321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 06/04/2024] [Indexed: 07/02/2024] Open
Abstract
Dolutegravir resistance is emerging in routine clinical contexts in southern Africa, primarily in patients with prior treatment experience failing dolutegravir-based antiretroviral therapy (ART). This potential issue was raised by The Nucleosides and Darunavir/Dolutegravir in Africa trial that compared dolutegravir and boosted protease inhibitor-based therapy as second-line ART, in which new dolutegravir resistance was observed at failure. However, recent data suggest that also at risk are patients who were transitioned to dolutegravir from non-nucleoside reverse transcriptase inhibitor-based ART while viremic. Identifying patients experiencing failure of dolutegravir with resistance will be difficult given current gaps in viral load monitoring and limited capacity for genotypic resistance testing. As a result, in the short term, most patients affected will go unrecognized, with particularly important implications for patients affected who have advanced HIV or who are pregnant/breastfeeding. Prospective research is needed to understand the scope of the problem, identify additional risk factors, and determine best management. In the short term, for most patients with dolutegravir resistance and prior non-nucleoside reverse transcriptase inhibitor exposure, the best option will be a timely switch to a regimen anchored by a boosted protease inhibitor, with a high genetic barrier to resistance.
Collapse
Affiliation(s)
- Richard A Murphy
- Division of Infectious Diseases, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Division of Infectious Diseases, White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
| | | | | | - Bernadett I Gosnell
- Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
| | - Timothy J Hatlen
- Division of HIV, Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles Medical Center, Torrance, California, USA
| | | |
Collapse
|
3
|
Beres LK, Mwamba C, Bolton-Moore C, Kennedy CE, Simbeza S, Topp SM, Sikombe K, Mukamba N, Mody A, Schwartz SR, Geng E, Holmes CB, Sikazwe I, Denison JA. Trajectories of re-engagement: factors and mechanisms enabling patient return to HIV care in Zambia. J Int AIDS Soc 2023; 26:e26067. [PMID: 36840391 PMCID: PMC9958345 DOI: 10.1002/jia2.26067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/31/2023] [Indexed: 02/26/2023] Open
Abstract
INTRODUCTION While disengagement from HIV care threatens the health of persons living with HIV (PLWH) and incidence-reduction targets, re-engagement is a critical step towards positive outcomes. Studies that establish a deeper understanding of successful return to clinical care among previously disengaged PLWH and the factors supporting re-engagement are essential to facilitate long-term care continuity. METHODS We conducted narrative, patient-centred, in-depth interviews between January and June 2019 with 20 PLWH in Lusaka, Zambia, who had disengaged and then re-engaged in HIV care, identified through electronic medical records (EMRs). We applied narrative analysis techniques, and deductive and inductive thematic analysis to identify engagement patterns and enablers of return. RESULTS We inductively identified five trajectories of care engagement, suggesting patterns in patient characteristics, experienced barriers and return facilitators that may aid intervention targeting including: (1) intermittent engagement;(2) mostly engaged; (3) delayed linkage after testing; (4) needs time to initiate antiretroviral therapy (ART); and (5) re-engagement with ART initiation. Patient-identified periods of disengagement from care did not always align with care gaps indicated in the EMR. Key, interactive re-engagement facilitators experienced by participants, with varied importance across trajectories, included a desire for physical wellness and social support manifested through verbal encouragement, facility outreach or personal facility connections and family instrumental support. The mechanisms through which facilitators led to return were: (1) the promising of living out one's life priorities; (2) feeling valued; (3) fostering interpersonal accountability; (4) re-entry navigation support; (5) facilitated care and treatment access; and (6) management of significant barriers, such as depression. CONCLUSIONS While preliminary, the identified trajectories may guide interventions to support re-engagement, such as offering flexible ART access to patients with intermittent engagement patterns instead of stable patients only. Further, for re-engagement interventions to achieve impact, they must activate mechanisms underlying re-engagement behaviours. For example, facility outreach that reminds a patient to return to care but does not affirm a patient's value or navigate re-entry is unlikely to be effective. The demonstrated importance of positive health facility connections reinforces a growing call for patient-centred care. Additionally, interventions should consider the important role communities play in fostering treatment motivation and overcoming practical barriers.
Collapse
Affiliation(s)
- Laura K Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Stephanie M Topp
- College of Public Health Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Kombatende Sikombe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Aaloke Mody
- University of Washington St. Louis, St. Louis, Missouri, USA
| | - Sheree R Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elvin Geng
- University of Washington St. Louis, St. Louis, Missouri, USA
| | - Charles B Holmes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Georgetown University, Washington, DC, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Julie A Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
4
|
Gopalsamy SN, Shah NS, Marconi VC, Armstrong WS, del Rio C, Pennisi E, Wortley P, Colasanti JA. The Impact of Churn on HIV Outcomes in a Southern United States Clinical Cohort. Open Forum Infect Dis 2022; 9:ofac338. [PMID: 35899283 PMCID: PMC9314921 DOI: 10.1093/ofid/ofac338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/07/2022] [Indexed: 12/02/2022] Open
Abstract
Background Persons with human immunodeficiency virus (PWH) may experience a cycle of engaging and disengaging in care referred to as “churn.” While human immunodeficiency virus (HIV) churn is predicted to be more prevalent in the southern United States (US), it has not been well characterized in this region. Methods We conducted a retrospective cohort study involving PWH newly establishing care at a large urban clinic in Atlanta, Georgia, from 2012 to 2017, with follow-up data collected through 2019. The primary exposure was churn, defined as a ≥12-month gap between routine clinic visits or viral load (VL) measurements. We compared HIV metrics before and after churn and assessed the risk of future churn or loss to follow-up. Results Of 1303 PWH newly establishing care, 81.7% were male and 84.9% were Black; 200 (15.3%) experienced churn in 3.3 years of median follow-up time. The transmissible viremia (TV) rate increased from 28.6% prechurn to 66.2% postchurn (P < .0001). The 122 PWH having TV on reengagement had delayed time to subsequent viral suppression (adjusted hazard ratio, 0.59 [95% confidence interval {CI}, .48–.73]), and PWH returning to care contributed disproportionately to the community viral load (CVL) (proportion of CVL/proportion of patients, 1.96). Churn was not associated with an increased risk of subsequent churn (adjusted odds ratio [aOR], 1.53 [95% CI, .79–2.97]) or loss to follow-up (aOR, 1.04 [95% CI, .60–1.79]). Conclusions The rate of churn in a southern US clinic was high, and those who experienced churn had increased TV at reentry and disproportionately contributed to the CVL and likely contributing to ongoing HIV transmission.
Collapse
Affiliation(s)
| | - N Sarita Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University , Atlanta, GA , USA
| | - Vincent C Marconi
- Division of Infectious Diseases, Department of Medicine and Department of Global Health, Rollins School of Public Health, Emory University , Atlanta, GA , USA
- Atlanta VA Medical Center , Decatur, GA , USA
| | - Wendy S Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University , Atlanta, GA , USA
- Grady Health System , Atlanta, GA , USA
| | - Carlos del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University , Atlanta, GA , USA
- Grady Health System , Atlanta, GA , USA
| | - Eugene Pennisi
- HIV/AIDS Epidemiology Section, Georgia Department of Public Health , Atlanta, GA , USA
| | - Pascale Wortley
- HIV/AIDS Epidemiology Section, Georgia Department of Public Health , Atlanta, GA , USA
| | - Jonathan A Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University , Atlanta, GA , USA
- Grady Health System , Atlanta, GA , USA
| |
Collapse
|
5
|
Odayar J, Chi BH, Phillips TK, Mukonda E, Hsiao NY, Lesosky M, Myer L. Transfer of Patients on Antiretroviral Therapy Attending Primary Health Care Services in South Africa. J Acquir Immune Defic Syndr 2022; 90:309-315. [PMID: 35298449 DOI: 10.1097/qai.0000000000002950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/22/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients stable on antiretroviral therapy (ART) may require transfer between health care facilities to maintain continuous care, yet data on the frequency, predictors, and virologic outcomes of transfers are limited. METHODS Data for all viral load (VL) testing at public sector health facilities in the Western Cape Province (2011-2018) were obtained. Participant inclusion criteria were a first VL between 2011 and 2013, age >15 years at ART initiation, and >1 VL within 5 years of ART initiation, of which ≥1 was at a primary health care facility. Two successive VLs taken at different facilities indicated a transfer. We assessed predictors of transfer using generalized estimating equations with Poisson regression and the association between transfer and subsequent VL> 1000 copies/mL using generalized mixed effects. RESULTS Overall 84,814 participants (median age at ART initiation 34 years and 68% female) were followed up for up to 4.5 years after their first VL: 34% (n = 29,056) transferred at least once, and among these, 26% transferred twice and 11% transferred thrice or more. Female sex, age <30 years, and first VL > 1000 copies/mL were independently associated with an increased rate of transfer [adjusted rate ratio 1.24, 95% confidence interval (CI): 1.21 to 1.26; 1.34, 95% CI: 1.31 to 1.36; and 1.42, 95% CI: 1.38 to 1.45, respectively]. Adjusting for age, sex, and disengagement, transfer was associated with an increased relative odds of VL > 1000 copies/mL (odds ratio 1.35, 95% CI: 1.29 to 1.42). CONCLUSIONS Approximately one-third of participants transferred and virologic outcomes were poor post-transfer. Stable patients who transfer may require additional support to maintain adherence.
Collapse
Affiliation(s)
- Jasantha Odayar
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; and
| | - Tamsin K Phillips
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elton Mukonda
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nei-Yuan Hsiao
- Division of Medical Virology, National Health Laboratory Service, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Maia Lesosky
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
6
|
Beres LK, Mody A, Sikombe K, Nicholas LH, Schwartz S, Eshun-Wilson I, Somwe P, Simbeza S, Pry JM, Kaumba P, McGready J, Holmes CB, Bolton-Moore C, Sikazwe I, Denison JA, Geng EH. The effect of tracer contact on return to care among adult, "lost to follow-up" patients living with HIV in Zambia: an instrumental variable analysis. J Int AIDS Soc 2021; 24:e25853. [PMID: 34921515 PMCID: PMC8683971 DOI: 10.1002/jia2.25853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 11/17/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Tracing patients lost to follow-up (LTFU) from HIV care is widely practiced, yet we have little knowledge of its causal effect on care engagement. In a prospective, Zambian cohort, we examined the effect of tracing on return to care within 2 years of LTFU. METHODS We traced a stratified, random sample of LTFU patients who had received HIV care between August 2013 and July 2015. LTFU was defined as a gap of >90 days from last scheduled appointment in the routine electronic medical record. Extracting 2 years of follow-up visit data through 2017, we identified patients who returned. Using random selection for tracing as an instrumental variable (IV), we used conditional two-stage least squares regression to estimate the local average treatment effect of tracer contact on return. We examined the observational association between tracer contact and return among patient sub-groups self-confirmed as disengaged from care. RESULTS Of the 24,164 LTFU patients enumerated, 4380 were randomly selected for tracing and 1158 were contacted by a tracer within a median of 14.8 months post-loss. IV analysis found that patients contacted by a tracer because they were randomized to tracing were no more likely to return than those not contacted (adjusted risk difference [aRD]: 3%, 95% CI: -2%, 8%, p = 0.23). Observational data showed that among contacted, disengaged patients, the rate of return was higher in the week following tracer contact (IR 5.74, 95% CI: 3.78-8.71) than in the 2 weeks to 1-month post-contact (IR 2.28, 95% CI: 1.40-3.72). There was a greater effect of tracing among patients lost for >6 months compared to those contacted within 3 months of loss. CONCLUSIONS Overall, tracer contact did not causally increase LTFU patient return to HIV care, demonstrating the limited impact of tracing in this program, where contact occurred months after patients were LTFU. However, observational data suggest that tracing may speed return among some LTFU patients genuinely out-of-care. Further studies may improve tracing effectiveness by examining the mechanisms underlying the impact of tracing on return to care, the effect of tracing at different times-since-loss and using more accurate identification of patients who are truly disengaged to target tracing.
Collapse
Affiliation(s)
- Laura K Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Aaloke Mody
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Lauren Hersch Nicholas
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ingrid Eshun-Wilson
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Jake M Pry
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.,Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Paul Kaumba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - John McGready
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Charles B Holmes
- Center for Innovation in Global Health, Georgetown University, Washington, DC, USA.,Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Julie A Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elvin H Geng
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| |
Collapse
|
7
|
Mody A, Tram KH, Glidden DV, Eshun-Wilson I, Sikombe K, Mehrotra M, Pry JM, Geng EH. Novel Longitudinal Methods for Assessing Retention in Care: a Synthetic Review. Curr HIV/AIDS Rep 2021; 18:299-308. [PMID: 33948789 DOI: 10.1007/s11904-021-00561-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW Retention in care is both dynamic and longitudinal in nature, but current approaches to retention often reduce these complex histories into cross-sectional metrics that obscure the nuanced experiences of patients receiving HIV care. In this review, we discuss contemporary approaches to assessing retention in care that captures its dynamic nature and the methodological and data considerations to do so. RECENT FINDINGS Enhancing retention measurements either through patient tracing or "big data" approaches (including probabilistic matching) to link databases from different sources can be used to assess longitudinal retention from the perspective of the patient when they transition in and out of care and access care at different facilities. Novel longitudinal analytic approaches such as multi-state and group-based trajectory analyses are designed specifically for assessing metrics that can change over time such as retention in care. Multi-state analyses capture the transitions individuals make in between different retention states over time and provide a comprehensive depiction of longitudinal population-level outcomes. Group-based trajectory analyses can identify patient subgroups that follow distinctive retention trajectories over time and highlight the heterogeneity of retention patterns across the population. Emerging approaches to longitudinally measure retention in care provide nuanced assessments that reveal unique insights into different care gaps at different time points over an individuals' treatment. These methods help meet the needs of the current scientific agenda for retention and reveal important opportunities for developing more tailored interventions that target the varied care challenges patients may face over the course of lifelong treatment.
Collapse
Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA.
| | - Khai Hoan Tram
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
| | - Kombatende Sikombe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
- Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Megha Mehrotra
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Jake M Pry
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
| |
Collapse
|
8
|
Mugglin C, Kläger D, Gueler A, Vanobberghen F, Rice B, Egger M. The HIV care cascade in sub-Saharan Africa: systematic review of published criteria and definitions. J Int AIDS Soc 2021; 24:e25761. [PMID: 34292649 PMCID: PMC8297382 DOI: 10.1002/jia2.25761] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 05/14/2021] [Accepted: 05/25/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The HIV care cascade examines the attrition of people living with HIV from diagnosis to the use of antiretroviral therapy (ART) and suppression of viral replication. We reviewed the literature from sub-Saharan Africa to assess the definitions used for the different steps in the HIV care cascade. METHODS We searched PubMed, Embase and CINAHL for articles published from January 2004 to December 2020. Longitudinal and cross-sectional studies were included if they reported on at least one step of the UNAIDS 90-90-90 cascade or two steps of an extended 7-step cascade. A step was clearly defined if authors reported definitions for numerator and denominator, including the description of the eligible population and methods of assessment or measurement. The review protocol has been published and registered in Prospero. RESULTS AND DISCUSSION Overall, 3364 articles were screened, and 82 studies from 19 countries met the inclusion criteria. Most studies were from Southern (38 studies, 34 from South Africa) and East Africa (29 studies). Fifty-eight studies (71.6%) were longitudinal, with a median follow-up of three years. The medium number of steps covered out of 7 steps was 3 (interquartile range [IQR] 2 to 4); the median year of publication was 2015 (IQR 2013 to 2019). The number of different definitions for the numerators ranged from four definitions (for step "People living with HIV") to 21 (step "Viral suppression"). For the denominators, it ranged from three definitions ("Diagnosed and aware of HIV status") to 14 ("Viral suppression"). Only 12 studies assessed all three of the 90-90-90 steps. Most studies used longitudinal data, but denominator-denominator or denominator-numerator linkages over several steps were rare. Also, cascade data are lacking for many countries. Our review covers the academic literature but did not consider other data, such as government reports on the HIV care cascade. Also, it did not examine disengagement and reengagement in care. CONCLUSIONS The proportions of patients retained at each step of the HIV care cascade cannot be compared between studies, countries and time periods, nor meta-analysed, due to the many different definitions used for numerators and denominators. There is a need for standardization of methods and definitions.
Collapse
Affiliation(s)
- Catrina Mugglin
- Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
| | - Delia Kläger
- Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
| | - Aysel Gueler
- Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
| | - Fiona Vanobberghen
- Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
- Swiss Tropical and Public Health InstituteBaselSwitzerland
- University of BaselBaselSwitzerland
| | - Brian Rice
- Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Matthias Egger
- Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
- Centre for Infectious Disease Epidemiology and Research (CIDER)University of Cape TownCape TownSouth Africa
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | | |
Collapse
|
9
|
Beres LK, Schwartz S, Simbeza S, McGready J, Eshun-Wilson I, Mwamba C, Sikombe K, Topp SM, Somwe P, Mody A, Mukamba N, Ehrenkranz PD, Padian N, Pry J, Moore CB, Holmes CB, Sikazwe I, Denison JA, Geng E. Patterns and Predictors of Incident Return to HIV Care Among Traced, Disengaged Patients in Zambia: Analysis of a Prospective Cohort. J Acquir Immune Defic Syndr 2021; 86:313-322. [PMID: 33149000 PMCID: PMC7878284 DOI: 10.1097/qai.0000000000002554] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/28/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dynamic movement of patients in and out of HIV care is prevalent, but there is limited information on patterns of patient re-engagement or predictors of return to guide HIV programs to better support patient engagement. METHODS From a probability-based sample of lost to follow-up, adult patients traced by peer educators from 31 Zambian health facilities, we prospectively followed disengaged HIV patients for return clinic visits. We estimated the cumulative incidence of return and the time to return using Kaplan-Meier methods. We used univariate and multivariable Cox proportional hazards regression to conduct a risk factor analysis identifying predictors of incident return across a social ecological framework. RESULTS Of the 556 disengaged patients, 73.0% [95% confidence interval (CI): 61.0 to 83.8] returned to HIV care. The median follow-up time from disengagement was 32.3 months (interquartile range: 23.6-38.9). The rate of return decreased with time postdisengagement. Independent predictors of incident return included a previous gap in care [adjusted Hazard Ratio (aHR): 1.95, 95% CI: 1.23 to 3.09] and confronting a stigmatizer once in the past year (aHR: 2.14, 95% CI: 1.25 to 3.65). Compared with a rural facility, patients were less likely to return if they sought care from an urban facility (aHR: 0.68, 95% CI: 0.48 to 0.96) or hospital (aHR: 0.52, 95% CI: 0.33 to 0.82). CONCLUSIONS Interventions are needed to hasten re-engagement in HIV care. Early and differential interventions by time since disengagement may improve intervention effectiveness. Patients in urban and tertiary care settings may need additional support. Improving patient resilience, outreach after a care gap, and community stigma reduction may facilitate return. Future re-engagement research should include causal evaluation of identified factors.
Collapse
Affiliation(s)
- Laura K. Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | - John McGready
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | | | - Stephanie M. Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia;
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | - Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | | | - Nancy Padian
- Division of Epidemiology, University of California Berkeley, Berkeley, CA; and
| | - Jake Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL
| | - Charles B. Holmes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
- Department of Medicine, Georgetown University, Washington, DC
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | - Julie A. Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
| | - Elvin Geng
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| |
Collapse
|
10
|
Phillips TK, Myer L, Chi BH. All the viral loads we cannot see. Lancet HIV 2021; 8:e246-e247. [PMID: 33581777 DOI: 10.1016/s2352-3018(20)30336-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, 7925, South Africa.
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, 7925, South Africa
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
11
|
Bakoyannis G, Diero L, Mwangi A, Wools-Kaloustian KK, Yiannoutsos CT. A semiparametric method for the analysis of outcomes during a gap in HIV care under incomplete outcome ascertainment. ACTA ACUST UNITED AC 2020; 12. [PMID: 34113423 DOI: 10.1515/scid-2019-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Estimation of the cascade of HIV care is essential for evaluating care and treatment programs, informing policy makers and assessing targets such as 90-90-90. A challenge to estimating the cascade based on electronic health record concerns patients "churning" in and out of care. Correctly estimating this dynamic phenomenon in resource-limited settings, such as those found in sub-Saharan Africa, is challenging because of the significant death under-reporting. An approach to partially recover information on the unobserved deaths is a double-sampling design, where a small subset of individuals with a missed clinic visit is intensively outreached in the community to actively ascertain their vital status. This approach has been adopted in several programs within the East Africa regional IeDEA consortium, the context of our motivating study. The objective of this paper is to propose a semiparametric method for the analysis of competing risks data with incomplete outcome ascertainment. Methods Based on data from double-sampling designs, we propose a semiparametric inverse probability weighted estimator of key outcomes during a gap in care, which are crucial pieces of the care cascade puzzle. Results Simulation studies suggest that the proposed estimators provide valid estimates in settings with incomplete outcome ascertainment under a set of realistic assumptions. These studies also illustrate that a naïve complete-case analysis can provide seriously biased estimates. The methodology is applied to electronic health record data from the East Africa IeDEA Consortium to estimate death and return to care during a gap in care. Conclusions The proposed methodology provides a robust approach for valid inferences about return to care and death during a gap in care, in settings with death under-reporting. Ultimately, the resulting estimates will have significant consequences on program construction, resource allocation, policy and decision making at the highest levels.
Collapse
Affiliation(s)
- Giorgos Bakoyannis
- Indiana University Purdue University at Indianapolis, Biostatistics, 410 West 10th Street, Suite 3000, Indianapolis, 46202, IN, USA
| | | | | | | | | |
Collapse
|
12
|
Long-Term Outcomes of HIV-Infected Women Receiving Antiretroviral Therapy After Transferring Out of an Integrated Maternal and Child Health Service in South Africa. J Acquir Immune Defic Syndr 2020; 83:202-209. [PMID: 31725060 DOI: 10.1097/qai.0000000000002236] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Integrated maternal and child health (MCH) services improve women's postpartum antiretroviral therapy (ART) outcomes during breastfeeding; however, long-term outcomes after transfer to general ART services remain unknown. METHODS The MCH-ART trial demonstrated that maternal retention and viral suppression at 12-months postpartum were improved significantly among women randomized to integrated MCH services continued in the antenatal clinic through cessation of breastfeeding (MCH-ART arm) compared with immediate transfer to general ART services postpartum (standard of care). We reviewed electronic health records for all women who participated in the MCH-ART trial to ascertain retention and gaps in care and invited all women for a study visit 36- to 60-months postpartum including viral load testing. RESULTS Of 471 women in MCH-ART, 450 (96%) contributed electronic health record data and 353 (75%) completed the study visit (median 44-month postpartum). At this time, outcomes were identical in both trial arms: 67% retained in care (P = 0.994) and 56% with viral loads <50 copies/mL (P = 0.751). Experiencing a gap in care after delivery was delayed in the MCH-ART arm with 17%, 36%, and 45% of women experienced a gap in care by 12-, 24-, and 36-months postpartum compared with 35%, 48%, and 57% in the standard of care arm, respectively. CONCLUSIONS The benefits of integrated maternal HIV and child health care did not persist after transfer to general ART services. The transfer of women postpartum to routine adult care is a critical period requiring interventions to support continuity of HIV care.
Collapse
|
13
|
Fuente-Soro L, López-Varela E, Augusto O, Bernardo EL, Sacoor C, Nhacolo A, Ruiz-Castillo P, Alfredo C, Karajeanes E, Vaz P, Naniche D. Loss to follow-up and opportunities for reengagement in HIV care in rural Mozambique: A prospective cohort study. Medicine (Baltimore) 2020; 99:e20236. [PMID: 32443358 PMCID: PMC7254184 DOI: 10.1097/md.0000000000020236] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Patients lost to follow-up (LTFU) over the human immunodeficiency virus (HIV) cascade have poor clinical outcomes and contribute to onward HIV transmission. We assessed true care outcomes and factors associated with successful reengagement in patients LTFU in southern Mozambique.Newly diagnosed HIV-positive adults were consecutively recruited in the Manhiça District. Patients LTFU within 12 months after HIV diagnosis were visited at home from June 2015 to July 2016 and interviewed for ascertainment of outcomes and reasons for LTFU. Factors associated with reengagement in care within 90 days after the home visit were analyzed by Cox proportional hazards model.Among 1122 newly HIV-diagnosed adults, 691 (61.6%) were identified as LTFU. Of those, 557 (80.6%) were approached at their homes and 321 (57.6%) found at home. Over 50% had died or migrated, 10% had been misclassified as LTFU, and 252 (78.5%) were interviewed. Following the visit, 79 (31.3%) reengaged in care. Having registered in care and a shorter time between LTFU and visit were associated with reengagement in multivariate analyses: adjusted hazards ratio of 3.54 [95% confidence interval (CI): 1.81-6.92; P < .001] and 0.93 (95% CI: 0.87-1.00; P = .045), respectively. The most frequently reported barriers were the lack of trust in the HIV-diagnosis, the perception of being in good health, and fear of being badly treated by health personnel and differed by type of LTFU.Estimates of LTFU in rural areas of sub-Saharan Africa are likely to be overestimated in the absence of active tracing strategies. Home visits are resource-intensive but useful strategies for reengagement for at least one-third of LTFU patients when applied in the context of differentiated care for those LTFU individuals who had already enrolled in HIV care at some point.
Collapse
Affiliation(s)
- Laura Fuente-Soro
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic –00 Universitat de Barcelona, Barcelona, Spain
| | - Elisa López-Varela
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic –00 Universitat de Barcelona, Barcelona, Spain
| | - Orvalho Augusto
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Edson Luis Bernardo
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- Manhiça District Health Services
| | | | - Ariel Nhacolo
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Paula Ruiz-Castillo
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic –00 Universitat de Barcelona, Barcelona, Spain
| | | | | | - Paula Vaz
- Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo, Mozambique
| | - Denise Naniche
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic –00 Universitat de Barcelona, Barcelona, Spain
| |
Collapse
|
14
|
Odayar J, Myer L. Transfer of primary care patients receiving chronic care: the next step in the continuum of care. Int Health 2020; 11:432-439. [PMID: 31081907 DOI: 10.1093/inthealth/ihz014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/11/2019] [Indexed: 12/26/2022] Open
Abstract
The burden of chronic conditions is increasing rapidly in low- and middle-income countries. Chronic conditions require long-term and continuous care, including for patients transferring between facilities. Patient transfer is particularly important in the context of health service decentralization, which has led to increasing numbers of primary care facilities at which patients can access care, and high levels of migration, which suggest that patients might require care at multiple facilities. This article provides a critical review of existing evidence regarding transfer of stable patients receiving primary care for chronic conditions. Patient transfer has received limited consideration in people living with HIV, with growing concern that patients who transfer are at risk of poor outcomes; this appears similar for people with TB, although studies are few. There are minimal data on transfer of patients with non-communicable diseases, including diabetes. Patient transfer for chronic conditions has thus received surprisingly little attention from researchers; considering the potential risks, more research is urgently required regarding reasons for and outcomes of transfers, transfer processes and interventions to optimize transfers, for different chronic conditions. Ultimately, it is the responsibility of health systems to facilitate successful transfers, and this issue requires increased attention from researchers and policy-makers.
Collapse
Affiliation(s)
- Jasantha Odayar
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
15
|
Phillips TK, Myer L. Shifting to the long view: engagement of pregnant and postpartum women living with HIV in lifelong antiretroviral therapy services. Expert Rev Anti Infect Ther 2019; 17:349-361. [PMID: 30978126 DOI: 10.1080/14787210.2019.1607296] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: The advent of policies promoting lifelong antiretroviral therapy (ART) for all pregnant and postpartum women living with HIV has shifted focus from short-term prevention of mother-to-child transmission (PMTCT) to lifelong engagement in ART services. However, disengagement from care threatens the long-term treatment and prevention benefits of lifelong ART. Areas covered: A framework for considering the unique aspects of ART for pregnant and postpartum women is presented along with a review of the literature on maternal engagement in care in sub-Saharan Africa and a discussion of potential interventions to sustain engagement in lifelong ART. Expert opinion: Engaging women and mothers in ART services for life is critical for maternal health, PMTCT, and prevention of sexual transmission. Evidence-based interventions exist to support engagement in care but most focus on periods of mother-to-child transmission risk. In the long term, life transitions and health-care transfers are inevitable. Thus, interventions that can reach beyond a single facility or provide a bridge between health services should be prioritized. Multicomponent interventions will also be essential to address the numerous intersecting barriers to sustained engagement in ART services.
Collapse
Affiliation(s)
- Tamsin K Phillips
- a Division of Epidemiology & Biostatistics and Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
| | - Landon Myer
- a Division of Epidemiology & Biostatistics and Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine , University of Cape Town , Cape Town , South Africa
| |
Collapse
|
16
|
Chimukangara B, Lessells RJ, Rhee SY, Giandhari J, Kharsany AB, Naidoo K, Lewis L, Cawood C, Khanyile D, Ayalew KA, Diallo K, Samuel R, Hunt G, Vandormael A, Stray-Pedersen B, Gordon M, Makadzange T, Kiepiela P, Ramjee G, Ledwaba J, Kalimashe M, Morris L, Parikh UM, Mellors JW, Shafer RW, Katzenstein D, Moodley P, Gupta RK, Pillay D, Abdool Karim SS, de Oliveira T. Trends in Pretreatment HIV-1 Drug Resistance in Antiretroviral Therapy-naive Adults in South Africa, 2000-2016: A Pooled Sequence Analysis. EClinicalMedicine 2019; 9:26-34. [PMID: 31143879 PMCID: PMC6510720 DOI: 10.1016/j.eclinm.2019.03.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 03/01/2019] [Accepted: 03/05/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND South Africa has the largest public antiretroviral therapy (ART) programme in the world. We assessed temporal trends in pretreatment HIV-1 drug resistance (PDR) in ART-naïve adults from South Africa. METHODS We included datasets from studies conducted between 2000 and 2016, with HIV-1 pol sequences from more than ten ART-naïve adults. We analysed sequences for the presence of 101 drug resistance mutations. We pooled sequences by sampling year and performed a sequence-level analysis using a generalized linear mixed model, including the dataset as a random effect. FINDINGS We identified 38 datasets, and retrieved 6880 HIV-1 pol sequences for analysis. The pooled annual prevalence of PDR remained below 5% until 2009, then increased to a peak of 11·9% (95% confidence interval (CI) 9·2-15·0) in 2015. The pooled annual prevalence of non-nucleoside reverse-transcriptase inhibitor (NNRTI) PDR remained below 5% until 2011, then increased to 10.0% (95% CI 8.4-11.8) by 2014. Between 2000 and 2016, there was a 1.18-fold (95% CI 1.13-1.23) annual increase in NNRTI PDR (p < 0.001), and a 1.10-fold (95% CI 1.05-1.16) annual increase in nucleoside reverse-transcriptase inhibitor PDR (p = 0.001). INTERPRETATION Increasing PDR in South Africa presents a threat to the efforts to end the HIV/AIDS epidemic. These findings support the recent decision to modify the standard first-line ART regimen, but also highlights the need for broader public health action to prevent the further emergence and transmission of drug-resistant HIV. SOURCE OF FUNDING This research project was funded by the South African Medical Research Council (MRC) with funds from National Treasury under its Economic Competitiveness and Support Package. DISCLAIMER The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of CDC.
Collapse
Affiliation(s)
- Benjamin Chimukangara
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Virology, National Health Laboratory Service, University of KwaZulu-Natal, Durban, South Africa
- Corresponding authors at: KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Science, University of KwaZulu-Natal, 719 Umbilo Road, Durban 4001, South Africa.
| | - Richard J. Lessells
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Soo-Yon Rhee
- Department of Medicine, Stanford University, Stanford, CA, United States of America
| | - Jennifer Giandhari
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Ayesha B.M. Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council (SAMRC)-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Lara Lewis
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Cherie Cawood
- Epicentre AIDS Risk Management (Pty) Limited, PO Box 3484, Paarl, Cape Town, South Africa
| | - David Khanyile
- Epicentre AIDS Risk Management (Pty) Limited, PO Box 3484, Paarl, Cape Town, South Africa
| | | | - Karidia Diallo
- Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Reshmi Samuel
- Department of Virology, National Health Laboratory Service, University of KwaZulu-Natal, Durban, South Africa
| | - Gillian Hunt
- Centre for HIV and STIs, National Institute for Communicable Diseases (NICD), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alain Vandormael
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Babill Stray-Pedersen
- Institute of Clinical Medicine, University of Oslo, Oslo University Hospital, Oslo, Norway
| | - Michelle Gordon
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Tariro Makadzange
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Cambridge, MA, United States of America
| | - Photini Kiepiela
- HIV Prevention Research Unit, Medical Research Council, Durban, South Africa
| | - Gita Ramjee
- HIV Prevention Research Unit, Medical Research Council, Durban, South Africa
| | - Johanna Ledwaba
- Centre for HIV and STIs, National Institute for Communicable Diseases (NICD), Johannesburg, South Africa
| | - Monalisa Kalimashe
- Centre for HIV and STIs, National Institute for Communicable Diseases (NICD), Johannesburg, South Africa
| | - Lynn Morris
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Centre for HIV and STIs, National Institute for Communicable Diseases (NICD), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Urvi M. Parikh
- Department of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - John W. Mellors
- Department of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Robert W. Shafer
- Department of Medicine, Stanford University, Stanford, CA, United States of America
| | - David Katzenstein
- Department of Medicine, Stanford University, Stanford, CA, United States of America
| | - Pravi Moodley
- Department of Virology, National Health Laboratory Service, University of KwaZulu-Natal, Durban, South Africa
| | - Ravindra K. Gupta
- Department of Infection, University College London, United Kingdom of Great Britain and Northern Ireland
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Deenan Pillay
- Department of Infection, University College London, United Kingdom of Great Britain and Northern Ireland
- Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Salim S. Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Tulio de Oliveira
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Corresponding authors at: KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Department of Laboratory Medicine & Medical Science, University of KwaZulu-Natal, 719 Umbilo Road, Durban 4001, South Africa.
| |
Collapse
|
17
|
McMahon JH, Spelman T, Ford N, Greig J, Mesic A, Ssonko C, Casas EC, O’Brien DP. Risk factors for unstructured treatment interruptions and association with survival in low to middle income countries. AIDS Res Ther 2016; 13:25. [PMID: 27408611 PMCID: PMC4940870 DOI: 10.1186/s12981-016-0109-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 06/30/2016] [Indexed: 12/17/2022] Open
Abstract
Background Antiretroviral therapy (ART) treatment interruptions lead to poor clinical outcomes with unplanned or unstructured TIs (uTIs) likely to be underreported. This study describes; uTIs, their risk factors and association with survival. Methods Analysis of ART programmatic data from 11 countries across Asia and Africa between 2003 and 2013 where an uTI was defined as a ≥90-day patient initiated break from ART calculated from the last day the previous ART prescription would have run out until the date of the next ART prescription. Factors predicting uTI were assessed with a conditional risk-set multiple failure time-to-event model to account for repeated events per subject. Association between uTI and mortality was assessed using Cox proportional hazards, with a competing risks extension to test for the influence of lost to follow-up (LTFU). Results 40,632 patients were included from 11 countries across 33 sites (17 Africa, 16 Asia). Median duration of follow-up was 1.61 years (IQR 0.54–3.31 years), 3386 (8.3 %) patients died, and 3453 (8.5 %) were LTFU. There were 14,817 uTIs, with 10,162 (25 %) patients having more than one uTI. In the adjusted model males were at lower risk of uTI (aHR 0.94, p < 0.01, and age 20–59 was protective compared to <20 years (20–39 years aHR 0.87, p < 0.01; 40–59 years aHR 0.86, p < 0.01). Preserved immune function, as measured by higher CD4 cell count, was associated with a reduced rate of uTI compared to CD4 <200 cells/μL (CD4 200–350 cells/μL aHR 0.89, p < 0.01; CD4 >350 cells/μL aHR 0.87, p < 0.01), whereas advanced clinical disease was associated with increased uTI rate (WHO stage 3 aHR 1.10, p < 0.01; WHO stage 4 aHR 1.21, p < 0.01). There was no relationship between uTI and mortality after adjusting for disease status and considering LTFU as a competing risk. Conclusions uTIs were frequent in people in ART programs in low-middle income countries and associated with younger age, female gender and advanced HIV. uTI did not predict survival when loss to follow-up was considered a competing risk. Further evaluation of uTI predictors and interventions to reduce their occurrence is warranted.
Collapse
|
18
|
Gill MJ, Ody M, Lynch T, Jessiman-Perreault L, Krentz HB. Maintaining the continuity of HIV-care records for patients transferring care between centers: challenges, workloads, needs and risks. AIDS Care 2016; 28:1073-8. [PMID: 26829326 DOI: 10.1080/09540121.2016.1139042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
With improved life expectancy, the medical records of HIV-infected patients are likely to be transferred repeatedly between HIV caregivers. The challenges, and risk for introducing medical error from incomplete record transfers are poorly understood. We measured number of requests for record transfer, the workload incurred, and explore, using genotypic antiretroviral resistance testing results (GART), the potential risk of incomplete records. Using retrospective database and chart review, we examined all patients followed at the Southern Alberta Clinic between 1 January 2004 and 1 January 2015, and determined how many patients transferred care into and out our program, the associated requests and the workload for record transfer. Using a complete record of all GART tests, the potential importance of absent historic records in current treatment decisions was analyzed. The annual churn rate was 22 ± 3.4%. We received requests for only 70% of patient records who had left our care. Median time for receipt of incoming medical records was 28 days; average clerical time for processing data was 2 hours/record. Of all GART results, 25% exhibited resistance. Of 111 patients with potentially misleading GART results (i.e., documented historical resistance not visible on more recent GART), 34 (30.6%) had moved in from elsewhere. Rigorous maintenance of the continuity of the HIV record is not universally practiced. Resources, costs and logistic challenges as well as a lack of appreciation of risks clearly shown by GART testing, may be relevant barriers. Addressing such issues is pressing as aging and transfers of care are increasingly common.
Collapse
Affiliation(s)
- M John Gill
- a Southern Alberta HIV Clinic, Alberta Health Services , Calgary , Canada.,b Department of Medicine , University of Calgary , Calgary , Alberta , Canada.,c Department of Microbiology, Immunology, and Infectious Diseases , University of Calgary , Calgary , Canada
| | - Meagan Ody
- a Southern Alberta HIV Clinic, Alberta Health Services , Calgary , Canada
| | - Tarah Lynch
- a Southern Alberta HIV Clinic, Alberta Health Services , Calgary , Canada.,d Department of Pathology and Laboratory Medicine , University of Calgary , Calgary , Canada
| | | | - Hartmut B Krentz
- a Southern Alberta HIV Clinic, Alberta Health Services , Calgary , Canada.,b Department of Medicine , University of Calgary , Calgary , Alberta , Canada
| |
Collapse
|
19
|
Ocampo JMF, Smart JC, Allston A, Bhattacharjee R, Boggavarapu S, Carter S, Castel AD, Collmann J, Flynn C, Hamp A, Jordan D, Kassaye S, Kharfen M, Lum G, Pemmaraju R, Rhodes A, Stover J, Young MA. Improving HIV Surveillance Data for Public Health Action in Washington, DC: A Novel Multiorganizational Data-Sharing Method. JMIR Public Health Surveill 2016; 2:e3. [PMID: 27227157 PMCID: PMC4869245 DOI: 10.2196/publichealth.5317] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 12/14/2015] [Accepted: 12/14/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The National HIV/AIDS Strategy calls for active surveillance programs for human immunodeficiency virus (HIV) to more accurately measure access to and retention in care across the HIV care continuum for persons living with HIV within their jurisdictions and to identify persons who may need public health services. However, traditional public health surveillance methods face substantial technological and privacy-related barriers to data sharing. OBJECTIVE This study developed a novel data-sharing approach to improve the timeliness and quality of HIV surveillance data in three jurisdictions where persons may often travel across the borders of the District of Columbia, Maryland, and Virginia. METHODS A deterministic algorithm of approximately 1000 lines was developed, including a person-matching system with Enhanced HIV/AIDS Reporting System (eHARS) variables. Person matching was defined in categories (from strongest to weakest): exact, very high, high, medium high, medium, medium low, low, and very low. The algorithm was verified using conventional component testing methods, manual code inspection, and comprehensive output file examination. Results were validated by jurisdictions using internal review processes. RESULTS Of 161,343 uploaded eHARS records from District of Columbia (N=49,326), Maryland (N=66,200), and Virginia (N=45,817), a total of 21,472 persons were matched across jurisdictions over various strengths in a matching process totaling 21 minutes and 58 seconds in the privacy device, leaving 139,871 uniquely identified with only one jurisdiction. No records matched as medium low or low. Over 80% of the matches were identified as either exact or very high matches. Three separate validation methods were conducted for this study, and they all found ≥90% accuracy between records matched by this novel method and traditional matching methods. CONCLUSIONS This study illustrated a novel data-sharing approach that may facilitate timelier and better quality HIV surveillance data for public health action by reducing the effort needed for traditional person-matching reviews without compromising matching accuracy. Future analyses will examine the generalizability of these findings to other applications.
Collapse
Affiliation(s)
- Joanne Michelle F Ocampo
- The Office of the Senior Vice President for ResearchGeorgetown UniversityWashington, DCUnited States
| | - J C Smart
- Department of Computer ScienceGeorgetown UniversityWashington, DCUnited States
| | - Adam Allston
- The HIV/AIDS, Hepatitis, STD and TB AdministrationDistrict of Columbia Department of HealthWashington, DCUnited States
| | - Reshma Bhattacharjee
- Prevention and Health Promotion AdministrationMaryland Department of Health and Mental HygieneBaltimore, MDUnited States
| | - Sahithi Boggavarapu
- Division of Disease PreventionVirginia Department of HealthRichmond, VAUnited States
| | - Sharon Carter
- Division of Disease PreventionVirginia Department of HealthRichmond, VAUnited States
| | - Amanda D Castel
- Milken Institute School of Public HealthDepartment of Epidemiology and BiostatisticsThe George Washington UniversityWashington, DCUnited States
| | - Jeff Collmann
- The Office of the Senior Vice President for ResearchGeorgetown UniversityWashington, DCUnited States
| | - Colin Flynn
- Prevention and Health Promotion AdministrationMaryland Department of Health and Mental HygieneBaltimore, MDUnited States
| | - Auntré Hamp
- The HIV/AIDS, Hepatitis, STD and TB AdministrationWashington District of Columbia Department of HealthWashington, DCUnited States
| | - Diana Jordan
- Division of Disease PreventionVirginia Department of HealthRichmond, VAUnited States
| | - Seble Kassaye
- The Washington DC Metropolitan Women's Interagency HIV StudyGeorgetown University Medical CenterWashington, DCUnited States
| | - Michael Kharfen
- The HIV/AIDS, Hepatitis, STD and TB AdministrationWashington District of Columbia Department of HealthWashington, DCUnited States
| | - Garret Lum
- The HIV/AIDS, Hepatitis, STD and TB AdministrationWashington District of Columbia Department of HealthWashington, DCUnited States
| | - Raghu Pemmaraju
- University Information ServicesGeorgetown UniversityWashington, DCUnited States
| | - Anne Rhodes
- Division of Disease PreventionVirginia Department of HealthRichmond, VAUnited States
| | - Jeff Stover
- Division of Disease PreventionVirginia Department of HealthRichmond, VAUnited States
| | - Mary A Young
- The Washington DC Metropolitan Women's Interagency HIV StudyGeorgetown University Medical CenterWashington, DCUnited States
| |
Collapse
|