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Buck WC, Schindele A, Taibo E, Perez P, de Deus MIJT, Matsinhe M, Cowan J, Simione TB, Couto A. Advanced disease programming brings much needed attention and improvements to inpatient paediatric HIV care in Mozambique. J Int AIDS Soc 2024; 27:e26203. [PMID: 38193651 PMCID: PMC10775621 DOI: 10.1002/jia2.26203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/14/2023] [Indexed: 01/10/2024] Open
Affiliation(s)
- W Chris Buck
- University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | | | | | | | | | - Mércia Matsinhe
- United States Agency for International Development, Maputo, Mozambique
| | - Jessica Cowan
- Centers for Disease Control and Prevention, Maputo, Mozambique
| | | | - Aleny Couto
- Mozambique Ministry of Health, Maputo, Mozambique
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Brijkumar J, Edwards JA, Johnson BA, Ordonez C, Sunpath H, Lee M, Dudgeon MR, Rautman L, Pillay S, Moodley P, Sun YV, Castillo-Mancilla J, Li JZ, Kuritzkes DR, Moosa MYS, Marconi VC. Comparing effectiveness of first-line antiretroviral therapy between peri-urban and rural clinics in KwaZulu-Natal, South Africa. HIV Med 2022; 23:727-737. [PMID: 35023287 PMCID: PMC9353676 DOI: 10.1111/hiv.13231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 12/02/2021] [Accepted: 12/23/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Viral suppression (VS) is the hallmark of successful antiretroviral therapy (ART) programmes. We sought to compare clinic retention, virological outcomes, drug resistance and mortality between peri-urban and rural settings in South Africa after first-line ART. METHODS Beginning in July 2014, 1000 (500 peri-urban and 500 rural) ART-naïve patients with HIV were enrolled and managed according to local standard of care. Clinic retention, virological suppression, virological failure (VF), genotypic drug resistance and mortality were assessed. The definition of VS was a viral load ≤1000 copies/ml. Time to event analyses were stratified by site, median age and gender. Kaplan-Meier curves were calculated and graphed with log-rank modelling to compare curves. RESULTS Based on 2741 patient-years of follow-up, retention and mortality did not differ between sites. Among all 1000 participants, 47%, 84% and 91% had achieved VS by 6, 12 and 24 months, respectively, which was observed earlier in the peri-urban site. At both sites, men aged < 32 years had the highest proportion of VF (15.5%), while women aged > 32 years had the lowest, at 7.1% (p = 0.018). Among 55 genotypes, 42 (76.4%) had at one or more resistance mutations, which did not differ by site. K103N (59%) and M184V (52%) were the most common mutations, followed by V106M and K65R (31% each). Overall, death was infrequent (< 4%). CONCLUSIONS No significant differences in treatment outcomes between peri-urban and rural clinics were observed. In both settings, young men were especially susceptible to clinic attrition and VF. More effective adherence support for this important demographic group is needed to achieve UNAIDS targets.
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Affiliation(s)
- Jaysingh Brijkumar
- University of KwaZulu Natal, Nelson R Mandela School of Medicine, Durban, South Africa
| | - Johnathan A. Edwards
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA,Emory University School of Medicine, Atlanta, Georgia, USA,University of Lincoln, School of Health and Social Care, Lincoln International Institute for Rural Health, Lincoln, UK
| | | | - Claudia Ordonez
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Henry Sunpath
- University of KwaZulu Natal, Nelson R Mandela School of Medicine, Durban, South Africa
| | - Mitch Lee
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Mathew R. Dudgeon
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Lydia Rautman
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Selvan Pillay
- University of KwaZulu Natal, Nelson R Mandela School of Medicine, Durban, South Africa
| | - Pravi Moodley
- University of KwaZulu-Natal, School of Laboratory Medicine and Medical Sciences, National Health Laboratory Service, Durban, South Africa
| | - Y. V. Sun
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Jonathan Z. Li
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel R. Kuritzkes
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamed Y. S. Moosa
- University of KwaZulu Natal, Nelson R Mandela School of Medicine, Durban, South Africa
| | - Vincent Charles Marconi
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA,Emory University School of Medicine, Atlanta, Georgia, USA,Emory Vaccine Center, Atlanta, Georgia, USA
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Izco S, Murias‐Closas A, Jordan AM, Greene G, Catorze N, Chiconela H, Garcia JI, Blanco‐Arevalo A, Febrer A, Casellas A, Saavedra B, Chiller T, Nhampossa T, Garcia‐Basteiro A, Letang E. Improved detection and management of advanced HIV disease through a community adult TB-contact tracing intervention with same-day provision of the WHO-recommended package of care including ART initiation in a rural district of Mozambique. J Int AIDS Soc 2021; 24:e25775. [PMID: 34347366 PMCID: PMC8336616 DOI: 10.1002/jia2.25775] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 06/02/2021] [Accepted: 07/05/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION AIDS-mortality remains unacceptably high in sub-Saharan Africa, largely driven by advanced HIV disease (AHD). We nested a study in an existing tuberculosis (TB) contact-tracing intervention (Xpatial-TB). The aim was to assess the burden of AHD among high-risk people living with HIV (PLHIV) identified and to evaluate the provision of the WHO-recommended package of care to this population. METHODS All PLHIV ≥14 years old identified between June and December 2018 in Manhiça District by Xpatial-TB were offered to participate in the study if ART naïve or had suboptimal ART adherence. Consenting individuals were screened for AHD. Patients with AHD (CD4 < 200 cells/μL or WHO stage 3 or 4) were offered a package of interventions in a single visit, including testing for cryptococcal antigen (CrAg) and TB-lipoarabinomannan (TB-LAM), prophylaxis and treatment for opportunistic infections, adherence support or accelerated ART initiation. We collected information on follow-up visits carried out under routine programmatic conditions for six months. RESULTS A total of 2881 adults were identified in the Xpatial TB-contact intervention. Overall, 23% (673/2881) were HIV positive, including 351 TB index (64.2%) and 322 TB contacts (13.8%). Overall, 159/673 PLHIV (24%) were ART naïve or had suboptimal ART adherence, of whom 155 (97%, 124 TB index and 31 TB-contacts) consented to the study and were screened for AHD. Seventy percent of TB index-patients (87/124) and 16% of TB contacts (5/31) had CD4 < 200 cells/µL. Four (13%) of the TB contacts had TB, giving an overall AHD prevalence among TB contacts of 29% (9/31). Serum-CrAg was positive in 4.6% (4/87) of TB-index patients and in zero TB contacts. All ART naïve TB contacts without TB initiated ART within 48 hours of HIV diagnosis. Among TB cases, ART timing was tailored to the presence of TB and cryptococcosis. Six-month mortality was 21% among TB-index cases and zero in TB contacts. CONCLUSIONS A TB contact-tracing outreach intervention identified undiagnosed HIV and AHD in TB patients and their contacts, undiagnosed cryptococcosis among TB patients, and resulted in an adequate provision of the WHO-recommended package of care in this rural Mozambican population. Same-day and accelerated ART initiation was feasible and safe in this population including among those with AHD.
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Affiliation(s)
- Santiago Izco
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | | | - Alexander M Jordan
- Mycotic Diseases BranchUnited States Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | - Gregory Greene
- Mycotic Diseases BranchUnited States Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | - Nteruma Catorze
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | | | - Juan Ignacio Garcia
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
- PhD Program in Methodology of Biomedical ResearchFaculty of MedicineUniversity of BarcelonaBarcelonaSpain
| | | | - Anna Febrer
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
| | - Aina Casellas
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
| | - Belén Saavedra
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | - Tom Chiller
- Mycotic Diseases BranchUnited States Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | | | - Alberto Garcia‐Basteiro
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | - Emilio Letang
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Department of Infectious Diseases Hospital del MarHospital del Mar Research Institute (IMIM)BarcelonaSpain
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Low mortality rates at two years in HIV-infected individuals undergoing systematic tuberculosis testing with rapid assays at initiation of antiretroviral treatment in Mozambique. Int J Infect Dis 2020; 99:386-392. [PMID: 32791208 DOI: 10.1016/j.ijid.2020.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/30/2020] [Accepted: 08/05/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Few studies have evaluated the mortality rate in individuals with HIV initiating antiretroviral therapy (ART), undergoing screening with combined or repeated rapid tests for tuberculosis (TB). METHODS All individuals with HIV starting ART, irrespective of the presence of TB-related symptoms, received two consecutive Xpert tests plus a rapid test for the detection of mycobacterial lipoarabinomannan in urine (LAM). Mortality was evaluated by Kaplan-Meier analysis using the log-rank test in univariate analyses and Cox regression models with time-dependent covariates in multivariate analyses. RESULTS Among 972 individuals screened with combined tests, 98 (10.1%) tested positive for TB with Xpert, LAM, or both. At the end of the study, 780 (80.2%) had completed 2 years of follow-up, 39 (4.0%) had died, and 153 (15.7%) were lost to follow-up. In the multivariate analyses, the factors significantly associated with mortality were missed ART (hazard ratio (HR) 7.05, 95% confidence interval (CI) 2.33-21.35), symptomatic HIV disease (WHO-HIV stage >1) (HR 3.31, 95% CI 1.28-8.54), and low CD4 count (<200/mm3) (HR 2.72, 95% CI 1.21-6.13), with no significant effect of TB status. In the subgroup of the 98 TB-positive individuals, only missed ART (HR 4.12, 95% CI 1.03-16.46) and missed anti-TB treatment (HR 9.25, 95% CI 2.65-32.28) were significantly associated with mortality. CONCLUSIONS A low mortality rate was observed among individuals with HIV undergoing systematic testing for TB at initiation of ART. After adjusting for confounders, mortality was significantly associated with missed ART, advanced disease, and missed anti-TB treatment. These findings reinforce the need to promote early diagnosis of HIV and the adoption of screening strategies for TB that prevent presentation with severe disease.
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Risk factors for loss to follow-up from antiretroviral therapy programmes in low-income and middle-income countries. AIDS 2020; 34:1261-1288. [PMID: 32287056 DOI: 10.1097/qad.0000000000002523] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Loss to follow-up (LTFU) rates from antiretroviral treatment (ART) programmes in low- and middle-income countries (LMIC) are high, leading to poor treatment outcomes and onward transmission of HIV. Knowledge of risk factors is required to address LTFU. In this systematic review, risk factors for LTFU are identified and meta-analyses performed. METHODS PubMed, Embase, Psycinfo and Cochrane were searched for studies that report on potential risk factors for LTFU in adults who initiated ART in LMICs. Meta-analysis was performed for risk factors evaluated by at least five studies. Pooled effect estimates and their 95% confidence intervals (95% CI) were calculated using random effect models with inverse variance weights. Risk of bias was assessed and sensitivity analyses performed. RESULTS Eighty studies were included describing a total of 1 605 320 patients of which 87.4% from sub-Saharan Africa. The following determinants were significantly associated with an increased risk of LTFU in meta-analysis: male sex, older age, being single, unemployment, lower educational status, advanced WHO stage, low weight, worse functional status, poor adherence, nondisclosure, not receiving cotrimoxazole prophylactic therapy when indicated, receiving care at secondary level and more recent year of initiation. No association was seen for CD4 cell count, tuberculosis at baseline, regimen, and geographical setting. CONCLUSION There are several sociodemographic, clinical, patient behaviour, treatment-related and system level risk factors for LTFU from ART programs. Knowledge of risk factors should be used to better target retention interventions and develop tools to identify high-risk patients.
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Cobre AF, Pedro CDAA, Fachi MM, Vilhena RO, Marson BM, Nicobue V, Tonin FS, Pontarolo R. Five-year survival analysis and predictors of death in HIV-positive serology patients attending the Military Hospital of Nampula, Mozambique. AIDS Care 2020; 32:1379-1387. [PMID: 32397744 DOI: 10.1080/09540121.2020.1761938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
An observational retrospective study was conducted over a 5-year period to assess survival and predictors of death in people with HIV-positive serology undergoing antiretroviral treatment with first-line regimens at the Military Hospital of Nampula, Mozambique. We collected data from 332 patient records. Kaplan-Meier boundary product estimator, log-rank, Gehan-Breslow, Tarone-Ware, time-dependent Cox models and estimates of hazard ratios (HR), with 95% confidence interval (CI) were calculated. Meantime survival for females and males was 54.8 months [95% CI 50.32-55.40] and 49.7 months [95% CI 45.89-53.53], respectively. Cox regressions indicated higher death rates significantly or potentially associated with: male sex (HR = 1.3; [95% CI 0.7-2.39]); suspected diagnosis reported only by the physician (HR = 3.6; [95% CI 1.8-7.4]); disease stages III (HR=1.2 [95% CI 0.3-3.6]) or IV (HR 1.4 [95% CI 0.4-5.8]); first TCD4+ lymphocyte count lower than 350 cells per ml (HR = 3.2; [95% CI 0.9-11.2]) or between 350-500 cells per ml (HR = 1.3; [95% CI 0.3-5.8]); or do not present cells count (HR = 3.6; [95% CI 1.2-10.2]). The above variables were significant for HIV prognosis and as predictors of death and should be considered in the clinical care of these patients.
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Affiliation(s)
- Alexandre F Cobre
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
| | | | - Mariana M Fachi
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
| | - Raquel O Vilhena
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
| | - Breno M Marson
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
| | - Victor Nicobue
- Department of Pharmacy, Universidade Lúrio, Nampula, Mozambique
| | - Fernanda S Tonin
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
| | - Roberto Pontarolo
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
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Arinze F, Gong W, Green AF, De Schacht C, Carlucci JG, Silva W, Claquin G, Tique JA, Stefanutto M, Graves E, Van Rompaey S, Alvim MFS, Tomo S, Moon TD, Wester CW. Immunodeficiency at Antiretroviral Therapy Start: Five-Year Adult Data (2012-2017) Based on Evolving National Policies in Rural Mozambique. AIDS Res Hum Retroviruses 2020; 36:39-47. [PMID: 31359762 PMCID: PMC9836686 DOI: 10.1089/aid.2019.0043] [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] [Indexed: 01/22/2023] Open
Abstract
Before the 2015 implementation of "Test and Start," the initiation of combination antiretroviral therapy (ART) was guided by specific CD4 cell count thresholds. As scale-up efforts progress, the prevalence of advanced HIV disease at ART initiation is expected to decline. We analyzed the temporal trends in the median CD4 cell counts among adults initiating ART and described factors associated with initiating ART with severe immunodeficiency in Zambézia Province, Mozambique. We included all HIV-positive, treatment-naive adults (age ≥ 15 years) who initiated ART at a Friends in Global Health (FGH)-supported health facility between September 2012 and September 2017. Quantile regression and multivariable logistic regression models were applied to ascertain the median change in CD4 cell count and odds of initiating ART with severe immunodeficiency, respectively. A total of 68,332 patients were included in the analyses. The median change in CD4 cell count under "Test and Start" was higher at +68 cells/mm3 (95% CI: 57.5-78.4) compared with older policies. Younger age and female sex (particularly those pregnant/lactating) were associated with higher median CD4 cell counts at ART initiation. Male sex, advanced age, WHO Stage 4 disease, and referrals to the health facility through inpatient provider-initiated testing and counseling (PITC) were associated with higher odds of initiating ART with severe immunodeficiency. Although there were reassuring trends in increasing median CD4 cell counts with ART initiation, ongoing efforts are needed that target universal HIV testing to ensure the early initiation of ART in men and older patients.
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Affiliation(s)
- Folasade Arinze
- Department of Internal Medicine, WellStar Health System, Marietta, Georgia.,Department of Medicine, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee
| | - Wu Gong
- Department of Biostatistics, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee
| | - Ann F. Green
- Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee
| | | | - James G. Carlucci
- Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee.,Department of Pediatrics, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee
| | - Wilson Silva
- Friends in Global Health (FGH), Maputo, Mozambique.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee
| | - Gael Claquin
- Friends in Global Health (FGH), Maputo, Mozambique
| | | | | | - Erin Graves
- Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee
| | | | | | - Simão Tomo
- Direcção Provincial de Saúde Zambézia (DPS-Z), Quelimane, Mozambique
| | - Troy D. Moon
- Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee.,Department of Pediatrics, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee
| | - C. William Wester
- Department of Medicine, Vanderbilt University Medical Center (VUMC), Nashville, Tennessee.,Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee.,Address correspondence to: C. William Wester, MD, MPH, Vanderbilt Institute for Global Health (VIGH), 2525 West End Avenue, Suite 750, Nashville, TN 37203
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Ha JH, Van Lith LM, Mallalieu EC, Chidassicua J, Pinho MD, Devos P, Wirtz AL. Gendered relationship between HIV stigma and HIV testing among men and women in Mozambique: a cross-sectional study to inform a stigma reduction and male-targeted HIV testing intervention. BMJ Open 2019; 9:e029748. [PMID: 31594877 PMCID: PMC6797434 DOI: 10.1136/bmjopen-2019-029748] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Increasing and sustaining engagement in HIV care for people living with HIV are critical to both individual therapeutic benefit and epidemic control. Men are less likely to test for HIV compared with women in sub-Saharan African countries, and ultimately have delayed entry to HIV care. Stigma is known to impede such engagement, placing an importance on understanding and addressing stigma to improve HIV testing and care outcomes. This study aimed to assess the gendered differences in the relationship between stigma and HIV testing. DESIGN AND SETTING A cross-sectional, household probability survey was implemented between November and December 2016 in the Sofala province of Mozambique. PARTICIPANTS Data were restricted to men and women participants who reported no prior diagnosis of HIV infection (N=2731). MEASURES Measures of sociodemographic characteristics, stigma and past exposure to HIV interventions were included in gender-stratified logistic regression models to estimate the relationship between stigma and recent testing for HIV, as well as to identify other relevant correlates. RESULTS Significantly fewer men (38.3%) than women (47.6%; p<0.001) had recently tested for HIV. Men who reported previous engagement in community group discussions about HIV had an increased odds of testing in the past 12 months compared to those who had not participated (adjusted OR (aOR)=1.92; 95% CI 1.51 to 2.44). Concerns about stigma were not a commonly reported barrier to HIV testing; however, men who expressed anticipated individual HIV stigma had a 35% lower odds of recent HIV testing (aOR=0.65; 95% CI 0.44 to 0.96). This association was not observed among women. CONCLUSIONS Men have lower uptake of HIV testing in Mozambique when compared to women. Even amidst the beneficial effects of HIV messaging, individual stigma is negatively associated with recent HIV testing among men. Intervention efforts that target the unique challenges and needs of men are essential in promoting men's engagement into the HIV care continuum in sub-Saharan Africa.
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Affiliation(s)
- Judy H Ha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lynn M Van Lith
- Johns Hopkins University Center for Communication Programs, Baltimore, Maryland, USA
| | - Elizabeth C Mallalieu
- Johns Hopkins University Center for Communication Programs, Baltimore, Maryland, USA
| | - Jose Chidassicua
- Johns Hopkins University Center for Communication Programs, Baltimore, Maryland, USA
| | - Maria Dirce Pinho
- Johns Hopkins University Center for Communication Programs, Baltimore, Maryland, USA
| | - Patrick Devos
- Johns Hopkins University Center for Communication Programs, Baltimore, Maryland, USA
| | - Andrea L Wirtz
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Minn AC, Kyaw NTT, Aung TK, Mon OM, Htun T, Oo MM, Moe J, Mon AA, Satyanarayana S, Oo HN. Attrition among HIV positive children enrolled under integrated HIV care programme in Myanmar: 12 years cohort analysis. Glob Health Action 2019; 11:1510593. [PMID: 30191749 PMCID: PMC6136349 DOI: 10.1080/16549716.2018.1510593] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: In Myanmar, HIV seropositive children are being enrolled in an integrated HIV care (IHC) Program for HIV treatment and care since 2005. Objectives: To assess the: (a) attrition (death or loss-to-follow-up) rates among children (aged ≥ 18 months to < 15 years) enrolled into the programme before and after initiation of anti-retroviral therapy (ART) (pre-ART and ART periods); (b) demographic and clinical factors associated with attrition during these two periods. Methods: Children enrolled in IHC Programme and their status (death, lost to follow-up, regular follow-up or transferred out) was assessed as on 30 June 2017. Attrition rates (per 100 person-years) at pre – ART and ART periods were calculated and the association between demographic and clinical characteristics with attrition was assessed using Cox proportional hazards model. Results: Among 2,736 children enrolled, pre-ART attrition rate was 19 per 100 person-years of follow-up (95% CI: 17–21) and ART attrition rate was 4 per 100 person-years of follow-up (95% CI: 3–4) with higher levels during the initial few months of enrolment. The 36-month retention rates during pre-ART period was 75% (95% CI: 72–78) and during ART period was 87% (95% CI: 86–88). The children ‘at enrolment’ with relatively lower levels of haemoglobin, immune deficiency, underweight for age, higher WHO clinical stages, presence of hepatitis B infection had higher hazards of attrition in both periods. Conclusion: The attrition rates are high particularly among children with relatively poorer clinical, nutritional profiles at enrolment. The study suggests the urgent need for improving adherence counselling especially during the initial few months of enrolment and early ART initiation.
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Affiliation(s)
- Aung Chan Minn
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Nang Thu Thu Kyaw
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Thet Ko Aung
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Ohn Mar Mon
- b Ministry of Health and Sports (MOHS) , 550 bedded Children Hospital , Mandalay , Myanmar
| | - Thurain Htun
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Myo Minn Oo
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - July Moe
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Aye Aye Mon
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Srinath Satyanarayana
- c Center for Operational Research , International Union Against Tuberculosis and Lung Diseases , Paris , France
| | - Htun Nyunt Oo
- d National AIDS Program, Department of Public Health , Ministry of Health and Sports , Nay Pyi Taw , Myanmar
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10
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Audet CM, Salato J, Vermund SH, Amico KR. Adapting an adherence support workers intervention: engaging traditional healers as adherence partners for persons enrolled in HIV care and treatment in rural Mozambique. Implement Sci 2017. [PMID: 28407813 DOI: 10.1186/s13012-017-0582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Systematic adaptation of evidence-informed interventions that increase retention in care and improve adherence to antiretroviral therapy (ART) are essential to ending the HIV epidemic in rural sub-Saharan Africa. We selected and adapted an adherence support worker intervention employed in Malawi for use by traditional healers in rural Mozambique. Given the levels of trust and dependence previously expressed by persons living with HIV (PLHIV) for traditional medicine, we adapted the program to engage traditional healers within the allopathic health system. METHODS Adaption followed a theoretically driven approach to intervention adaption: the Assessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing (ADAPT-ITT) model. Three rounds of performance feedback, based on theater presentations of the adapted intervention for stakeholders and idea generation, were completed with 12 groups from March to July 2016 to develop the final model. We offered healer support to 180 newly diagnosed HIV-infected patients. RESULTS Traditional healers were an acceptable group of community health workers to assist with patient adherence and retention. Traditional healers, clinicians, and interested community members suggested novel strategies to tailor the adherence support worker intervention, revealing a local culture of HIV denialism, aversion to the health system, and dislike of healthcare providers, as well as a preference for traditional treatments. Proposed changes to the intervention included modifications to the training language and topics, expanded community-based activities to support acceptability of an HIV diagnosis and to facilitate partner disclosure, and accompaniment to the health facility by healers to encourage delivery of respectful clinical care. PLHIV, healers, and clinicians deemed the intervention socially acceptable during focus groups. We subsequently recruited 180 newly diagnosed HIV-infected patients into the program: 170 (94%) accepted. CONCLUSIONS Systematic translation of interventions, even between regions with similar social and economic environments, is an important first step to successful program implementation. Efforts previously limited to community health workers can be tailored for use by traditional healers-an underutilized and often maligned health workforce. It proved feasible to use theater-based performances to demonstrate delivery of the intervention in low-literacy populations, generating discussions about social norms, community concerns, and the merits of an acceptable strategy to improve retention and adherence to ART.
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Affiliation(s)
- Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA.
- Departments of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - José Salato
- Friends in Global Health, Quelimane, Mozambique
- Friends in Global Health, Maputo, Mozambique
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Departments of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - K Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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11
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Audet CM, Salato J, Vermund SH, Amico KR. Adapting an adherence support workers intervention: engaging traditional healers as adherence partners for persons enrolled in HIV care and treatment in rural Mozambique. Implement Sci 2017; 12:50. [PMID: 28407813 PMCID: PMC5390357 DOI: 10.1186/s13012-017-0582-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 04/06/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Systematic adaptation of evidence-informed interventions that increase retention in care and improve adherence to antiretroviral therapy (ART) are essential to ending the HIV epidemic in rural sub-Saharan Africa. We selected and adapted an adherence support worker intervention employed in Malawi for use by traditional healers in rural Mozambique. Given the levels of trust and dependence previously expressed by persons living with HIV (PLHIV) for traditional medicine, we adapted the program to engage traditional healers within the allopathic health system. METHODS Adaption followed a theoretically driven approach to intervention adaption: the Assessment-Decision-Administration-Production-Topical Experts-Integration-Training-Testing (ADAPT-ITT) model. Three rounds of performance feedback, based on theater presentations of the adapted intervention for stakeholders and idea generation, were completed with 12 groups from March to July 2016 to develop the final model. We offered healer support to 180 newly diagnosed HIV-infected patients. RESULTS Traditional healers were an acceptable group of community health workers to assist with patient adherence and retention. Traditional healers, clinicians, and interested community members suggested novel strategies to tailor the adherence support worker intervention, revealing a local culture of HIV denialism, aversion to the health system, and dislike of healthcare providers, as well as a preference for traditional treatments. Proposed changes to the intervention included modifications to the training language and topics, expanded community-based activities to support acceptability of an HIV diagnosis and to facilitate partner disclosure, and accompaniment to the health facility by healers to encourage delivery of respectful clinical care. PLHIV, healers, and clinicians deemed the intervention socially acceptable during focus groups. We subsequently recruited 180 newly diagnosed HIV-infected patients into the program: 170 (94%) accepted. CONCLUSIONS Systematic translation of interventions, even between regions with similar social and economic environments, is an important first step to successful program implementation. Efforts previously limited to community health workers can be tailored for use by traditional healers-an underutilized and often maligned health workforce. It proved feasible to use theater-based performances to demonstrate delivery of the intervention in low-literacy populations, generating discussions about social norms, community concerns, and the merits of an acceptable strategy to improve retention and adherence to ART.
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Affiliation(s)
- Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA. .,Departments of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - José Salato
- Friends in Global Health, Quelimane, Mozambique.,Friends in Global Health, Maputo, Mozambique
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA.,Departments of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - K Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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12
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Mancinelli S, Nielsen-Saines K, Germano P, Guidotti G, Buonomo E, Scarcella P, Lunghi R, Sangare H, Orlando S, Liotta G, Marazzi MC, Palombi L. Who will be lost? Identifying patients at risk of loss to follow-up in Malawi. The DREAM Program Experience. HIV Med 2017; 18:573-579. [PMID: 28150466 DOI: 10.1111/hiv.12492] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Retention of subjects in HIV treatment programmes is crucial for the success of treatment. We evaluated retention/loss to follow-up (LTFU) in subjects receiving established care in Malawi. METHODS Data for HIV-positive patients registered in Drug Resource Enhancement Against AIDS and Malnutrition centres in Malawi prior to 2014 were reviewed. Visits entailing HIV testing/counselling, laboratory evaluations, nutritional evaluation/supplementation, community support, peer education, and antiretroviral (ART) monitoring/pharmacy were noted. LTFU was defined as > 90 days without an encounter. Parameters potentially associated with LTFU were explored, with univariate/multivariate logistic regression analyses being performed. RESULTS Fifteen thousand and ninety-nine patients registered before 2014; 202 (1.3%) were lost to follow-up (LTFU) (1.3%). Nine (0.5%) of 1744 paediatric patients were LTFU vs. 1.4% (n = 193) of 13 355 adults (P < 0.001). Subjects who were LTFU had fewer days in care than retained subjects (1338 vs. 1544, respectively; P < 0.001) and a longer duration of ART (1530 vs. 1300 days, respectively; P < 0.001). Subjects who were LTFU had higher baseline HIV viral loads (P = 0.016) and higher body mass indexes (P < 0.001), were more likely to live in urban settings (88% of patients who were LTFU lived in urban settings) with better housing [relative risk (RR) 2.3; 95% confidence interval (CI) 1.67-3.09; P < 0.001], and were more likely to be educated (RR 1.88; 95% CI 1.42-2.50; P < 0.001). Distance to the centre and cost of transportation were associated with LTFU (RR 3.4; 95% CI 2.84-5.37; P < 0.001), as was absence of a maternal figure (RR 1.57; 95% CI 1.17-2.09; P < 0.001). Viral load, distance index, education and a maternal figure were predictive of LTFU. CONCLUSIONS Educated, urbanized HIV-infected adults living far from programme centres are at high risk of LTFU, particularly if there is no maternal figure in the household. These variables must be taken into consideration when developing retention strategies.
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Affiliation(s)
- S Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - K Nielsen-Saines
- Department of Pediatrics-Infectious Disease, University of California Los Angeles, Los Angeles, CA, USA
| | | | | | - E Buonomo
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - P Scarcella
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - R Lunghi
- DREAM Programme, Blantyre, Malawi
| | | | | | - G Liotta
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - L Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
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13
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Audet CM, Blevins M, Chire YM, Aliyu MH, Vaz LME, Antonio E, Alvim F, Bechtel R, Wester CW, Vermund SH. Engagement of Men in Antenatal Care Services: Increased HIV Testing and Treatment Uptake in a Community Participatory Action Program in Mozambique. AIDS Behav 2016; 20:2090-100. [PMID: 26906021 PMCID: PMC4995150 DOI: 10.1007/s10461-016-1341-x] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Uptake of HIV testing and antiretroviral therapy (ART) services during antenatal care (ANC) in rural Mozambique is disappointing. To nurture supportive male engagement in ANC services, we partnered with traditional birth attendants and trained a new type of male-to-male community health agent, "Male Champions", who focused on counseling male partners to create new, male-friendly community norms around engagement in spousal/partner pregnancies. We assessed ANC service uptake using a pre-post intervention design. The intervention was associated with increases in: (1) uptake of provider-initiated counseling and testing among pregnant woman (81 vs. 92 %; p < 0.001); (2) male engagement in ANC (5 vs. 34 %; p < 0.001); and (3) uptake of ART (8 vs. 19 %; p < 0.001). When men accepted HIV testing, rates of testing rose markedly among pregnant women. With the challenges in scale-up of Option B+ in sub-Saharan Africa, similar interventions may increase testing and treatment acceptability during pregnancy.
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Affiliation(s)
- Carolyn M Audet
- Vanderbilt Institute for Global Health, 2525 West End Avenue, Suite 750, Nashville, TN, 37203-1738, USA.
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - Meridith Blevins
- Vanderbilt Institute for Global Health, 2525 West End Avenue, Suite 750, Nashville, TN, 37203-1738, USA
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Yazalde Manuel Chire
- Friends in Global Health, Maputo, Mozambique
- Friends in Global Health, Quelimane, Mozambique
| | - Muktar H Aliyu
- Vanderbilt Institute for Global Health, 2525 West End Avenue, Suite 750, Nashville, TN, 37203-1738, USA
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Lara M E Vaz
- Vanderbilt Institute for Global Health, 2525 West End Avenue, Suite 750, Nashville, TN, 37203-1738, USA
| | - Elisio Antonio
- Friends in Global Health, Maputo, Mozambique
- Friends in Global Health, Quelimane, Mozambique
| | - Fernanda Alvim
- Friends in Global Health, Maputo, Mozambique
- Friends in Global Health, Quelimane, Mozambique
| | - Ruth Bechtel
- Friends in Global Health, Maputo, Mozambique
- Friends in Global Health, Quelimane, Mozambique
| | - C William Wester
- Vanderbilt Institute for Global Health, 2525 West End Avenue, Suite 750, Nashville, TN, 37203-1738, USA
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, 2525 West End Avenue, Suite 750, Nashville, TN, 37203-1738, USA
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
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14
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Audet CM, Hamilton E, Hughart L, Salato J. Engagement of Traditional Healers and Birth Attendants as a Controversial Proposal to Extend the HIV Health Workforce. Curr HIV/AIDS Rep 2015; 12:238-45. [PMID: 25855337 PMCID: PMC4430841 DOI: 10.1007/s11904-015-0258-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
"Medical pluralism" is the use of multiple health systems and is common among people living with HIV/AIDS in sub-Saharan Africa. Healers and traditional birth attendants (TBAs) often are a patient's first and/or preferred line of treatment; this often results in delayed, interrupted, or abandoned diagnosis and therapy. Literature from the study of medical pluralism suggests that HIV care and treatment programs are infrequently and inconsistently engaging healers around the world. Mistrust and misunderstanding among patients, clinical providers, and traditional practitioners make the development of effective partnerships difficult, particularly regarding early HIV diagnosis and antiretroviral therapy. We provide recommendations for the development of successful collaboration health workforce efforts based on both published articles and case studies from our work in rural Mozambique.
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Affiliation(s)
- Carolyn M Audet
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, 2525 West End Avenue, Suite 750, Nashville, TN, 37203-1738, USA,
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Aliyu MH, Blevins M, Megazzini KM, Parrish DD, Audet CM, Chan N, Odoh C, Gebi UI, Muhammad MY, Shepherd BE, Wester CW, Vermund SH. Pregnant women with HIV in rural Nigeria have higher rates of antiretroviral treatment initiation, but similar loss to follow-up as non-pregnant women and men. Int Health 2015; 7:405-11. [PMID: 26012740 DOI: 10.1093/inthealth/ihv032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 04/01/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We examined antiretroviral therapy (ART) initiation and retention by sex and pregnancy status in rural Nigeria. METHODS We studied HIV-infected ART-naïve patients aged ≥15 years entering care from June 2009 to September 2013. We calculated the probability of early ART initiation and cumulative incidence of loss to follow-up (LTFU) during the first year of ART, and examined the association between LTFU and sex/pregnancy using Cox regression. RESULTS The cohort included 3813 ART-naïve HIV-infected adults (2594 women [68.0%], 273 [11.8%] of them pregnant). The proportion of pregnant clients initiating ART within 90 days of enrollment (78.0%, 213/273) was higher than among non-pregnant women (54.3%,1261/2321) or men (53.0%, 650/1219), both p<0.001. Pregnant women initiated ART sooner than non-pregnant women and men (median [IQR] days from enrollment to ART initiation for pregnant women=7 days [0-21] vs 14 days [7-49] for non-pregnant women and 14 days [7-42] for men; p<0.001). Cumulative incidence of LTFU during the first year post-ART initiation was high and did not differ by sex and pregnancy status. Persons who were unemployed, bedridden, had higher CD4+ counts, and/or in earlier WHO clinical stages were more likely to be LTFU. CONCLUSIONS Pregnant women with HIV in rural Nigeria were more likely to initiate ART but were no more likely to be retained in care. Our findings underscore the importance of effective retention strategies across all patient groups, regardless of sex and pregnancy status.
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Affiliation(s)
- Muktar H Aliyu
- Vanderbilt Institute for Global Health Departments of Health Policy
| | - Meridith Blevins
- Vanderbilt Institute for Global Health Department of Biostatistics
| | | | - Deidra D Parrish
- Vanderbilt Institute for Global Health Departments of Health Policy
| | - Carolyn M Audet
- Vanderbilt Institute for Global Health Departments of Health Policy
| | - Naomi Chan
- Vanderbilt Institute for Global Health Department of Human and Organizational Development
| | - Chisom Odoh
- Department of Health Administration and Health Sciences, Tennessee State University, 330 10th Avenue North, Suite D-400, Nashville, TN 37203, USA
| | - Usman I Gebi
- Friends for Global Health Initiative, Abuja, Nigeria
| | | | - Bryan E Shepherd
- Vanderbilt Institute for Global Health Department of Biostatistics
| | | | - Sten H Vermund
- Vanderbilt Institute for Global Health Department of Pediatrics, Vanderbilt University, 2525 West End Avenue, Suite 750, Nashville, TN 37203, USA
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