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Facha W, Tadesse T, Wolka E, Astatkie A. Viral load non-suppression status among women exposed to Dolutegravir-based versus Efavirenz-based regimens in Ethiopia: A before-and-after study. PLoS One 2024; 19:e0305331. [PMID: 38857273 PMCID: PMC11164349 DOI: 10.1371/journal.pone.0305331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/28/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND High viral load during pregnancy and breastfeeding period is the risk factor for vertical transmission of human immunodeficiency virus (HIV). Currently, Dolutegravir (DTG)-based regimens are recommended to attain adequate viral load suppression (VLS) among women. However, its effect on VLS has not been investigated among women in PMTCT care in Ethiopia. OBJECTIVE This study aimed to investigate the rate of viral load non-suppression among women exposed to DTG-based versus Efavirenz (EFV)-based regimens in Ethiopia. METHODS An uncontrolled before-and-after study design was conducted among 924 women (462 on EFV-based and 462 on DTG-based regimens) enrolled in PMTCT care from September 2015 to February 2023. The outcome variable was the viral load (VL) non-suppression among women on PMTCT care. A modified Poisson regression model was employed, and the proportion was computed to compare the rate of VL non-suppression in both groups. The risk ratio (RR) with a 95% confidence interval (CI) was calculated to assess viral load non-suppression among women on DTG-based and EFV-based regimens by adjusting for other variables. RESULTS The overall rate of non-suppressed VL was 16.2% (95% CI: 14.0-18.8%). Mothers on DTG-based regimens had approximately a 30% (adjusted risk ratio (aRR): 0.70; 95% CI: 0.52-0.94) lesser risk of developing non-suppressed VL than women on EFV-based regimens. Besides, older women were 1.38 times (aRR: 1.38; 95% CI: 1.04-1.83); mothers who did not disclose their HIV status to their partners were 2.54 times (aRR: 2.54; 95% CI: 1.91-3.38); and mothers who had poor or fair adherence to antiretroviral (ARV) drugs were 2.11 times (aRR: 2.11; 95% CI: 1.45-3.07) at higher risk of non-suppressed VL. CONCLUSION Women on DTG-based regimens had a significantly suppressed VL compared to those on EFV-based regimens. Thus, administering DTG-based first-line ART regimens should be strengthened to achieve global and national targets on VLS.
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Affiliation(s)
- Wolde Facha
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Takele Tadesse
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Eskinder Wolka
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Ayalew Astatkie
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
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O'Connell KA, Sherani S, Kisteneff A, Bhat K, Slater J, Klein CF, Lavey B, Malone A, Qayyum R, Derber CJ. Factors Affecting Adherence With Follow-up Appointments in HIV Patients. Cureus 2022; 14:e29424. [PMID: 36299938 PMCID: PMC9586838 DOI: 10.7759/cureus.29424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 11/30/2022] Open
Abstract
Currently, the majority of new human immunodeficiency virus (HIV) infections are transmitted by individuals with untreated HIV. In this retrospective study, we examined associations between demographic factors, viral suppression, acquired immunodeficiency syndrome (AIDS) status (CD4 count <200), and adherence to clinical follow-up in individuals living with HIV. Of the 489 patients, 135 (27.6%) were females, 235 (48.1%) were over 50 years old, 191 (39.1%) had Medicaid, Medicare, or Ryan White Insurance, 25 (5.1%) had CD4 counts below 200, and 207 (42.3%) were adherent to their clinic appointments. In univariable logistic regression analysis, age and viral load detectability were significantly associated with patient adherence to their clinic appointment. In multivariable analysis, only age remained significantly associated with clinic appointment adherence (Odds Ratio=2.1; 95% Confidence Interval=1.4, 3.1; P<0.001). Patients 50 years old or younger were half as likely to be adherent to their clinic appointments than patients over 50 years old. Gender and insurance status were not associated with viral suppression or AIDS status. The results illustrate the need for increased age-specific outreach to improve clinical adherence in younger individuals.
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Alebel A, Demant D, Petrucka P, Sibbritt D. Does undernutrition increase the risk of lost to follow-up in adults living with HIV in sub-Saharan Africa? Protocol for a systematic review and meta-analysis. BMJ Open 2021; 11:e048022. [PMID: 34907042 PMCID: PMC8671928 DOI: 10.1136/bmjopen-2020-048022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Undernutrition is considered a marker for poor prognosis among people living with HIV (PLHIV), particularly in sub-Saharan Africa (SSA), where undernutrition and HIV are both highly prevalent. Evidence suggests that undernutrition (body mass index <18.5 kg/m2) is one of the main factors that significantly increases the risk of lost to follow-up (LTFU) in PLHIV. However, primary studies in SSA have reported inconsistent findings on the relationship between undernutrition and LTFU among adults living with HIV. To the best of our knowledge, no systematic review which aimed to summarise the available evidence. Hence, this review aims to determine the pooled effect of undernutrition on LTFU among adults living with HIV in SSA. METHODS AND ANALYSIS PubMed, EMBASE, Web of Science, Scopus, and, for grey literature, Google Scholar will be systematically searched to include relevant articles published since 2005. Studies reporting the effect of undernutrition on LTFU in adults living with HIV in SSA will be included. The Newcastle-Ottawa Scale will be used for quality assessment. Data from eligible studies will be extracted using a standardised data extraction tool. Heterogeneity between included studies will be assessed using Cochrane Q-test and I2 statistics. The Egger's and Begg's tests at a 5% significance level will be used to evaluate publication bias. As heterogeneity is anticipated, the pooled effect size will be estimated using a random-effects model. The final effect size will be reported using the adjusted HR with a 95% CI. ETHICS AND DISSEMINATION Ethical approval is not required for a protocol for a systematic review. The results of this systematic review will be published in a peer-reviewed journal and will be publicly available. PROSPERO REGISTRATION NUMBER CRD42021277741.
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Affiliation(s)
- Animut Alebel
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
- School of Public Helath, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Daniel Demant
- School of Public Helath, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
- School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | - Pammla Petrucka
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
| | - David Sibbritt
- School of Public Helath, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
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Abstract
PURPOSE OF REVIEW The age of people with HIV) continues to rise, and yet older people have tended to be under-represented or excluded from premarketing studies of antiretroviral therapy (ART). In this review, we highlight special considerations for the use of ART in older people with HIV, with a focus on toxicities associated with specific antiretroviral agents or drug classes as well as key research questions moving forward. RECENT FINDINGS Like all people with HIV, older people with HIV should be started on ART as soon as possible, regardless of CD4 count, and with a regimen that includes an integrase strand transfer inhibitor (INSTI) and two nucleoside reverse transcriptase inhibitors. Important toxicities to consider when choosing an ART regimen include bone and renal effects related to tenofovir, weight gain related to INSTIs and tenofovir alafenamide, neurocognitive and neuropsychiatric toxicities related to efavirenz, and increased cardiovascular risk associated with abacavir and boosted protease inhibitors. With the ongoing importance of INSTIs as a component of preferred ART regimens, further characterization of INSTI-related weight gain is a critical current research priority in understanding ART toxicity. SUMMARY There are multiple potential toxicities of ART to consider when selecting a regimen for older people. Specific agents or drug classes have been implicated in adverse bone or renal effects, weight gain, neuropsychiatric and neurocognitive effects, and cardiovascular risk.
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Thomas R, Probert WJM, Sauter R, Mwenge L, Singh S, Kanema S, Vanqa N, Harper A, Burger R, Cori A, Pickles M, Bell-Mandla N, Yang B, Bwalya J, Phiri M, Shanaube K, Floyd S, Donnell D, Bock P, Ayles H, Fidler S, Hayes RJ, Fraser C, Hauck K. Cost and cost-effectiveness of a universal HIV testing and treatment intervention in Zambia and South Africa: evidence and projections from the HPTN 071 (PopART) trial. Lancet Glob Health 2021; 9:e668-e680. [PMID: 33721566 PMCID: PMC8050197 DOI: 10.1016/s2214-109x(21)00034-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 12/15/2020] [Accepted: 01/21/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The HPTN 071 (PopART) trial showed that a combination HIV prevention package including universal HIV testing and treatment (UTT) reduced population-level incidence of HIV compared with standard care. However, evidence is scarce on the costs and cost-effectiveness of such an intervention. METHODS Using an individual-based model, we simulated the PopART intervention and standard care with antiretroviral therapy (ART) provided according to national guidelines for the 21 trial communities in Zambia and South Africa (for all individuals aged >14 years), with model parameters and primary cost data collected during the PopART trial and from published sources. Two intervention scenarios were modelled: annual rounds of PopART from 2014 to 2030 (PopART 2014-30; as the UNAIDS Fast-Track target year) and three rounds of PopART throughout the trial intervention period (PopART 2014-17). For each country, we calculated incremental cost-effectiveness ratios (ICERs) as the cost per disability-adjusted life-year (DALY) and cost per HIV infection averted. Cost-effectiveness acceptability curves were used to indicate the probability of PopART being cost-effective compared with standard care at different thresholds of cost per DALY averted. We also assessed budget impact by projecting undiscounted costs of the intervention compared with standard care up to 2030. FINDINGS During 2014-17, the mean cost per person per year of delivering home-based HIV counselling and testing, linkage to care, promotion of ART adherence, and voluntary medical male circumcision via community HIV care providers for the simulated population was US$6·53 (SD 0·29) in Zambia and US$7·93 (0·16) in South Africa. In the PopART 2014-30 scenario, median ICERs for PopART delivered annually until 2030 were $2111 (95% credible interval [CrI] 1827-2462) per HIV infection averted in Zambia and $3248 (2472-3963) per HIV infection averted in South Africa; and $593 (95% CrI 526-674) per DALY averted in Zambia and $645 (538-757) per DALY averted in South Africa. In the PopART 2014-17 scenario, PopART averted one infection at a cost of $1318 (1098-1591) in Zambia and $2236 (1601-2916) in South Africa, and averted one DALY at $258 (225-298) in Zambia and $326 (266-391) in South Africa, when outcomes were projected until 2030. The intervention had almost 100% probability of being cost-effective at thresholds greater than $700 per DALY averted in Zambia, and greater than $800 per DALY averted in South Africa, in the PopART 2014-30 scenario. Incremental programme costs for annual rounds until 2030 were $46·12 million (for a mean of 341 323 people) in Zambia and $30·24 million (for a mean of 165 852 people) in South Africa. INTERPRETATION Combination prevention with universal home-based testing can be delivered at low annual cost per person but accumulates to a considerable amount when scaled for a growing population. Combination prevention including UTT is cost-effective at thresholds greater than $800 per DALY averted and can be an efficient strategy to reduce HIV incidence in high-prevalence settings. FUNDING US National Institutes of Health, President's Emergency Plan for AIDS Relief, International Initiative for Impact Evaluation, Bill & Melinda Gates Foundation.
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Affiliation(s)
- Ranjeeta Thomas
- Department of Health Policy, London School of Economics and Political Science, London, UK.
| | - William J M Probert
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rafael Sauter
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Surya Singh
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Nosivuyile Vanqa
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Abigail Harper
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Ronelle Burger
- Department of Economics, Stellenbosch University, Cape Town, South Africa
| | - Anne Cori
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Michael Pickles
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Nomtha Bell-Mandla
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Blia Yang
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | | | | | | | - Sian Floyd
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Peter Bock
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Helen Ayles
- Zambart, University of Zambia, Lusaka, Zambia; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Sarah Fidler
- Department of Infectious Disease, Imperial College London, London, UK
| | - Richard J Hayes
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Christophe Fraser
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Katharina Hauck
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK; Abdul Latif Jameel Institute for Disease and Emergency Analytics, School of Public Health, Imperial College London, London, UK
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Bahemana E, Esber A, Dear N, Ganesan K, Parikh A, Reed D, Maganga L, Khamadi S, Mizinduko M, Lwilla A, Mkondoo D, Mwaisanga G, Somi N, Owouth J, Maswai J, Kiweewa F, Iroezindu M, Ake JA, Crowell TA, Valcour VG, Polyak CS. Impact of age on CD4 recovery and viral suppression over time among adults living with HIV who initiated antiretroviral therapy in the African Cohort Study. AIDS Res Ther 2020; 17:66. [PMID: 33183355 PMCID: PMC7664082 DOI: 10.1186/s12981-020-00323-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/03/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION With increased use of antiretroviral therapy (ART), HIV mortality rates are declining and people living with HIV (PLWH) are surviving longer. We characterized CD4 recovery and viral suppression among adults aged < 50 and ≥ 50 years living with HIV who initiated ART in the African Cohort Study (AFRICOS). METHODS Beginning in January 2013, PLWH at twelve clinics in Kenya, Uganda, Tanzania and Nigeria underwent medical history review, CD4 and viral load testing as part of the ongoing African Cohort Study (AFRICOS). ART-naïve PLWH who initiated ART within 30 days of enrollment and had at least one year of follow-up were included in these analyses. To compare ART response in participants < 50 years and ≥ 50 years old, changes in CD4 count and viral load suppression after ART initiation were examined at different time points using linear and binomial regression with generalized estimating equations. Variables for time since ART initiation and the interaction between age group and time on ART were included in the model to evaluate longitudinal changes in CD4 recovery and viral suppression by age. RESULTS Between January 2013 and September 2019, 2918 PLHV were enrolled in the cohort. Of these, 443 were ART naïve and initiated on ART within 30 days of enrollment, with 90% (n = 399) aged < 50 years old at ART initiation. At ART initiation, participants aged 50 and older had a higher median CD4 count compared to participants younger than 50 years of age although it did not reach statistical significance (306 cells/mm3, IQR:130-547 vs. 277cells/mm3, IQR: 132-437). In adjusted models examining CD4 recovery and viral suppression there were no significant differences by age group over time. By the end of follow-up viral suppression was high among both groups of adults (96% of adults ≥ 50 years old and 92% of adults < 50 years old). CONCLUSION This study found no difference in long-term CD4 recovery or viral suppression by age at ART initiation. We found that particularly among younger adults participants had lower median CD4 counts at ART initiation, suggesting the importance of identifying and putting this population on treatment earlier in the disease course.
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Affiliation(s)
- Emmanuel Bahemana
- HJF Medical Research International, Inc., Mbeya, Tanzania.
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.
| | - Allahna Esber
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA.
| | - Nicole Dear
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Kavitha Ganesan
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Ajay Parikh
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Domonique Reed
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Lucas Maganga
- National Institute for Medical Research-Mbeya Medical Research Center, Mbeya, Tanzania
| | - Samoel Khamadi
- HJF Medical Research International, Inc., Mbeya, Tanzania
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Mucho Mizinduko
- Muhimbili University of Health and Allied Science-Dar-Es-Salaam, Dar-Es-Salaam, Tanzania
| | - Anange Lwilla
- HJF Medical Research International, Inc., Mbeya, Tanzania
| | - Dorothy Mkondoo
- HJF Medical Research International, Inc., Mbeya, Tanzania
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Gwamaka Mwaisanga
- HJF Medical Research International, Inc., Mbeya, Tanzania
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Nancy Somi
- HJF Medical Research International, Inc., Mbeya, Tanzania
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - John Owouth
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- HJF Medical Research International, Kisumu, Kenya
| | - Jonah Maswai
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- HJF Medical Research International, Kericho, Kenya
| | | | - Michael Iroezindu
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- HJF Medical Research International, Abuja, Nigeria
| | - Julie A Ake
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Trevor A Crowell
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Victor G Valcour
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, CA, USA
| | - Christina S Polyak
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
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Immunological and Virological Responses in Older HIV-Infected Adults Receiving Antiretroviral Therapy: An Evidence-Based Meta-Analysis. J Acquir Immune Defic Syndr 2020; 83:323-333. [PMID: 31913990 DOI: 10.1097/qai.0000000000002266] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Millions of people living with the HIV have received antiretroviral therapy (ART). Older adults make up a significant portion of these individuals; however, the immunological and virological responses to ART for older patients still need to be clarified. DESIGN Meta-analysis. METHODS In this article, we systematically reviewed research articles published between 2001 and 2018 that reported immunological and virological responses and AIDS-related mortality among HIV- infected adults (including individuals aged 50 years and older) receiving ART, using meta-analysis. ART efficiency was measured using 3 outcomes: (1) immunological response, (2) virological response, and (3) mortality. RESULTS We identified 4937 citations, and 40 studies were eventually selected to investigate ART efficiency in older HIV-infected patients, comprising more than 888,151 patients initiating ART. We report that older patients showed poor immunological responses, with CD4 counts and the restoration of CD4 counts after ART initiation being significantly lower than seen in younger patients. However, older patients exhibited better viral suppression rates (risk ratio: 1.04; 95% confidence intervals: 1.01 to 1.08) after 36 months following ART initiation. In addition, older adults had a higher risk of AIDS-related death (adjusted hazard ratio: 1.44, 95% confidence interval: 1.30 to 1.60). CONCLUSIONS Older age after ART initiation was associated with a poorer immunological response and a higher risk of mortality, suggesting the need to increase early diagnosis and treatment among older HIV patients.
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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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Bhatta M, Nandi S, Dutta N, Dutta S, Saha MK. HIV Care Among Elderly Population: Systematic Review and Meta-Analysis. AIDS Res Hum Retroviruses 2020; 36:475-489. [PMID: 32027170 DOI: 10.1089/aid.2019.0098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Elderly people living with HIV are increasing. At present in the United States, nearly half of newly diagnosed HIV-infected people are aged >50 years. Diagnosis and treatment of HIV-infected elderly patients tends to be delayed by several health care factors as several life-threatening diseases are common in elderly people. This study aimed to find the pooled HIV prevalence in elderly population and the present situation of continuum care for the elderly HIV patients through systematic review and meta-analysis. All previously published articles from 2000 to 2018 are retrieved using MEDLINE, PUBMED, Cochrane Library, EMBASE, and Google Scholar. DerSimonian and Laird Random Effects model are used to critically appraise articles. STATA 13.0 is used to perform the meta-analysis and quantum-geographic information system (Q-GIS) is used to prepare desired map. I2 statistics has been used to test heterogeneity and publication biases. Results have been presented using forest plots. A total of 28 studies are included in this meta-analysis. Present analysis revealed pooled prevalence of HIV in elderly population as 15.79% with a lower rate of viral suppression as 11.524% (95% confidence interval, CI: 11.199-11.855), where a moderate number 38.643% (95% CI: 38.289-38.997) of elderly patients received antiretroviral therapy (ART) globally. The ART retention rate was 12.769% (95% CI: 12.540-13.001) with 6.15% (95% CI: 6.089-6.212) mortality. Despite successful administration of ART in developing part of the world that have relatively higher retention rates among HIV-infected elderly patients only a small percentage are virally suppressed, largely due to elderly drugs interact with ART and several comorbidities reduce the life span of the elderly people.
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Affiliation(s)
- Mihir Bhatta
- Divisions of Virology and ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Srijita Nandi
- Divisions of Virology and ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Nalok Dutta
- Divisions of Virology and ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Shanta Dutta
- Divisions of Bacteriology, ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Malay Kumar Saha
- Divisions of Virology and ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
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Retention in Care Trajectories of HIV-Positive Individuals Participating in a Universal Test-and-Treat Program in Rural South Africa (ANRS 12249 TasP Trial). J Acquir Immune Defic Syndr 2019; 80:375-385. [PMID: 30570525 PMCID: PMC6410969 DOI: 10.1097/qai.0000000000001938] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Supplemental Digital Content is Available in the Text. Objective: To study retention in care (RIC) trajectories and associated factors in
patients eligible for antiretroviral therapy (ART) in a universal
test-and-treat setting (TasP trial, South Africa, 2012–2016). Design: A cluster-randomized trial whereby individuals identified HIV positive after
home-based testing were invited to initiate ART immediately (intervention)
or following national guidelines (control). Methods: Exiting care was defined as ≥3 months late for a clinic appointment,
transferring elsewhere, or death. Group-based trajectory modeling was
performed to estimate RIC trajectories over 18 months and associated factors
in 777 ART-eligible patients. Results: Four RIC trajectory groups were identified: (1) group 1
“remained” in care (reference, n = 554, 71.3%), (2) group
2 exited care then “returned” after [median (interquartile
range)] 4 (3–9) months (n = 40, 5.2%), (3) group 3
“exited care rapidly” [after 4 (4–6) months, n =
98, 12.6%], and (4) group 4 “exited care later” [after 11
(9–13) months, n = 85, 10.9%]. Group 2 patients were less likely
to have initiated ART within 1 month and more likely to be male, young
(<29 years), without a regular partner, and to have a CD4 count
>350 cells/mm3. Group 3 patients were more likely to be
women without social support, newly diagnosed, young, and less likely to
have initiated ART within 1 month. Group 4 patients were more likely to be
newly diagnosed and aged 39 years or younger. Conclusions: High CD4 counts at care initiation were not associated with a higher risk of
exiting care. Prompt ART initiation and special support for young and newly
diagnosed patients with HIV are needed to maximize RIC.
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11
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Greenblatt R, Bacchetti P, Boylan R, Kober K, Springer G, Anastos K, Busch M, Cohen M, Kassaye S, Gustafson D, Aouizerat B. Genetic and clinical predictors of CD4 lymphocyte recovery during suppressive antiretroviral therapy: Whole exome sequencing and antiretroviral therapy response phenotypes. PLoS One 2019; 14:e0219201. [PMID: 31415590 PMCID: PMC6695188 DOI: 10.1371/journal.pone.0219201] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/18/2019] [Indexed: 12/12/2022] Open
Abstract
Increase of peripheral blood CD4 lymphocyte counts is a key goal of combined antiretroviral therapy (cART); most, but not all, recipients respond adequately and promptly. A small number of studies have examined specific genetic factors associated with the extent of CD4 recovery. We report a genome-wide examination of factors that predict CD4 recovery in HIV-infected women. We identified women in in a cohort study who were on cART with viral load below 400 copies, and drew racially and ethnically matched samples of those with good CD4 response over 2 years or poor response. We analyzed the exomes of those women employing next generation sequencing for genes associated with CD4 recovery after controlling for non-genetic factors identified through forward stepwise selection as important. We studied 48 women with good CD4 recovery and 42 with poor CD4 recovery during virologically-suppressive cART. Stepwise logistic regression selected only age as a statistically significant (p<0.05) non-genetic predictor of response type (each additional year of age reduced the odds of good recovery by 11% (OR = 0.89, CI = 0.84–0.96, p = 0.0009). After adjustment for age and genomic estimates of race and ethnicity, 41 genes harbored variations associated with CD4 recovery group (p≤0.001); 5 of these have been previously reported to be associated with HIV infection, 4 genes would likely influence CD4 homeostasis, and 13 genes either had known functions or were members of product families that had functions for which interactions with HIV or effects on lymphocyte homeostasis were biologically plausible. Greater age was the strongest acquired factor that predicted poor CD4 cell recovery. Sequence variations spanning 41 genes were independently predictive of CD4 recovery. Many of these genes have functions that impact the cell cycle, apoptosis, lymphocyte migration, or have known interactions with HIV. These findings may help inform new hypotheses related to responses to HIV therapy and CD4 lymphocyte homeostasis.
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Affiliation(s)
- Ruth Greenblatt
- UCSF School of Pharmacy, Department of Clinical Pharmacy, San Francisco, CA, United States of America
- UCSF School of Medicine, Department of Epidemiology and Biostatistics, San Francisco, CA, United States of America
- UCSF School of Medicine, Department of Medicine, San Francisco, CA, United States of America
- * E-mail:
| | - Peter Bacchetti
- UCSF School of Medicine, Department of Epidemiology and Biostatistics, San Francisco, CA, United States of America
| | - Ross Boylan
- UCSF School of Medicine, Department of Epidemiology and Biostatistics, San Francisco, CA, United States of America
| | - Kord Kober
- UCSF School of Nursing, Department of Physiological Nursing, San Francisco, CA, United States of America
| | - Gayle Springer
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, United States of America
| | - Kathryn Anastos
- Albert Einstein College of Medicine and Montefiore Health Systems, Bronx, NY, United States of America
| | - Michael Busch
- UCSF School of Medicine, Department of Epidemiology and Biostatistics, San Francisco, CA, United States of America
- Blood Systems Research Institute, San Francisco, CA, United States of America
| | - Mardge Cohen
- Stroger Hospital, Chicago, IL, United States of America
| | - Seble Kassaye
- Georgetown University Medical Center, Department of Medicine, Washington, DC, United States of America
| | - Deborah Gustafson
- State University of New York, Downstate Medical Center, Department of Neurology, Brooklyn, NY, United States of America
| | - Bradley Aouizerat
- New York University School of Dentistry and Bluestone Center for Clinical Research, NY, NY, United States of America
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12
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Rohr JK, Manne-Goehler J, Gómez-Olivé FX, Wagner RG, Rosenberg M, Geldsetzer P, Kabudula C, Kahn K, Tollman S, Bärnighausen T, Salomon JA. HIV treatment cascade for older adults in rural South Africa. Sex Transm Infect 2019; 96:271-276. [PMID: 31243144 DOI: 10.1136/sextrans-2018-053925] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 05/14/2019] [Accepted: 06/02/2019] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES The HIV treatment cascade is a powerful framework for understanding progress from initial diagnosis to successful treatment. Data sources for cascades vary and often are based on clinical cohorts, population cohorts linked to clinics, or self-reported information. We use both biomarkers and self-reported data from a large population-based cohort of older South Africans to establish the first HIV cascade for this growing segment of the HIV-positive population and compare results using the different data sources. METHODS Data came from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) 2015 baseline survey of 5059 adults aged 40+ years. Dried blood spots (DBS) were screened for HIV, antiretroviral drugs and viral load. In-home surveys asked about HIV testing, diagnosis and antiretroviral therapy (ART) use. We calculated proportions and CIs for each stage of the cascade, conditional on attainment of the previous stage, using (1) biomarkers, (2) self-report and (3) both biomarkers and self-report, and compared with UNAIDS 90-90-90 targets. RESULTS 4560 participants had DBS results, among whom 1048 (23%) screened HIV-positive and comprised the denominator for each cascade. The biomarker cascade showed 63% (95% CI 60 to 66) on ART and 72% (95% CI 69 to 76) of those on ART with viral suppression. Self-reports underestimated testing, diagnosis and ART, with only 47% (95% CI 44 to 50) of HIV-positive individuals reporting ART use. The combined cascade indicated high HIV testing (89% (95% CI 87 to 91)), but lower knowledge of HIV-positive status (71% (95% CI 68 to 74)). CONCLUSIONS Older South Africans need repeated HIV testing and sustained ART to reach 90-90-90 targets. HIV cascades relying on self-reports are likely to underestimate true cascade attainment, and biomarkers provide substantial improvements to cascade estimates.
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Affiliation(s)
- Julia K Rohr
- Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, USA
| | - Jennifer Manne-Goehler
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Francesc Xavier Gómez-Olivé
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ryan G Wagner
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Molly Rosenberg
- Department of Epidemiology and Biostatistics, Indiana University Bloomington School of Public Health, Bloomington, Indiana, USA
| | - Pascal Geldsetzer
- Department of Global Health and Population, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Chodziwadziwa Kabudula
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Centre for Global Health Research, Umea University, Umea, Sweden
| | - Stephen Tollman
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Centre for Global Health Research, Umea University, Umea, Sweden
| | - Till Bärnighausen
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Heidelberg Insititute of Global Health, University of Heidelberg, Heidelberg, Germany.,Africa Health Research Institute, Mtubatuba, South Africa
| | - Joshua A Salomon
- Department of Medicine, Stanford University, Stanford, California, USA
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13
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Rahmalia A, Price MH, Hartantri Y, Alisjahbana B, Wisaksana R, van Crevel R, van der Ven AJAM. Are there differences in HIV retention in care between female and male patients in Indonesia? A multi-state analysis of a retrospective cohort study. PLoS One 2019; 14:e0218781. [PMID: 31237899 PMCID: PMC6592601 DOI: 10.1371/journal.pone.0218781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 06/11/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Little is known about HIV treatment outcomes in Indonesia, which has one of the most rapidly growing HIV epidemics worldwide. METHODS We examined possible differences in loss to follow-up (LTFU) and survival between HIV-infected females and males over a 7-year period in an HIV clinic in Bandung, West Java. Data imputation was performed on missing covariates and a multi-state Cox regression was used to investigate the effects of sex and other covariates on patient transitions among four states: (1) clinic enrollment with HIV, (2) initiation/continuation/re-initiation of antiretroviral therapy (ART), (3) LTFU, and (4) death. RESULTS We followed 3215 patients (33% females), for a total of 8430 person-years. ART was used by 59% of patients at some point. One-year retention was 73% for females and 77% for males (p = 0.06). One-year survival was 98% for both females and males (p = 0.15). Females experienced a higher relative hazard to transition from HIV to LTFU (adjusted hazard ratio 1.21; 95% confidence interval 1.00-1.45), but this decreased after adjustments for clinical variables (aHR 0.94; 95% CI 0.79-1.11). Similarly, a lower relative hazard in females to transition from ART to death (aHR 0.59; 95% CI 0.35-0.99) decreased after adjustments for demographic variables. CONCLUSION This Indonesian cohort has low ART uptake and poor overall pre- and post-ART retention. Female-male differences in survival and retention were gone after adjusting for clinical and sociodemographic factors such as CD4 count and education level. Efforts should be made to improve retention among patients with lower education.
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Affiliation(s)
- Annisa Rahmalia
- Infectious Disease Research Center, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michael Holton Price
- Department of Anthropology, Pennsylvania State University, University Park, Pennsylvania, United States of America
- Santa Fe Institute, Santa Fe, New Mexico, United States of America
| | - Yovita Hartantri
- Infectious Disease Research Center, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
- Department of Internal Medicine, Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Bachti Alisjahbana
- Infectious Disease Research Center, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
- Department of Internal Medicine, Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Rudi Wisaksana
- Infectious Disease Research Center, Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
- Department of Internal Medicine, Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Reinout van Crevel
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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14
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Torgersen J, Bellamy SL, Ratshaa B, Han X, Mosepele M, Zuppa AF, Vujkovic M, Steenhoff A, Bisson GP, Gross R. Impact of Efavirenz Metabolism on Loss to Care in Older HIV+ Africans. Eur J Drug Metab Pharmacokinet 2019; 44:179-187. [PMID: 30168000 PMCID: PMC6420397 DOI: 10.1007/s13318-018-0507-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVE: Efavirenz is commonly used in Africa and is frequently associated with neurocognitive toxicity, which may compromise clinical outcomes. Older individuals are at increased risk for drug toxicity and clinical outcomes may be worse in older age, particularly among those individuals with cytochrome P450 (CYP) 2B6 polymorphisms associated with slower efavirenz metabolism. The aim of this study was to determine if the CYP2B6 polymorphisms differentially impacts loss to care in older people. METHODS We conducted a prospective cohort study of 914 treatment-naïve HIV+ adults initiating efavirenz-based antiretroviral treatment at public HIV clinics in Gaborone, Botswana between 2009 and 2013. Older age, defined as age ≥ 50 years, was the primary exposure and loss to care at 6 months was the primary outcome. Interaction between age and CYP2B6 516G>T and 983T>C polymorphisms, defined as extensive, intermediate, and slow metabolism, was assessed. Neurocognitive toxicity was measured using a symptom questionnaire. Age-stratified logistic regression was performed to identify factors associated with loss to care. RESULTS Older age was associated with loss to care (OR 1.95, 95% CI 1.30-2.92). Age modified the effect of CYP2B6 genotype on loss to care with older, slow metabolizers at over four-fold higher risk when compared to older, intermediate metabolizers (OR 4.06 95% CI 1.38-11.89); neurocognitive toxicity did not mediate this risk. CYP2B6 metabolism genotype did not increase risk of loss to care in younger participants. CONCLUSION Older age was associated with loss to care, especially among those with slow efavirenz metabolism. Understanding the relationship between older age and CYP2B6 genotype will be important to improving outcomes in an aging population initiating efavirenz-based ART in similar settings.
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Affiliation(s)
- Jessie Torgersen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Scarlett L. Bellamy
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA
| | | | - Xiaoyan Han
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Athena F Zuppa
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marijana Vujkovic
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrew Steenhoff
- Botswana UPenn Partnership, Gaborone, Botswana
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gregory P. Bisson
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Gross
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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15
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Comparison of Antiretroviral Therapy Adherence Among HIV-Infected Older Adults with Younger Adults in Africa: Systematic Review and Meta-analysis. AIDS Behav 2019; 23:445-458. [PMID: 29971732 PMCID: PMC6373524 DOI: 10.1007/s10461-018-2196-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
As access to antiretroviral treatment in low- and middle-income countries improves, the number of older adults (aged ≥ 50 years) living with HIV is increasing. This study compares the adherence to antiretroviral treatment among older adults to that of younger adults living in Africa. We searched PubMed, Medline, Cochrane CENTRAL, CINAHL, Google Scholar and EMBASE for keywords (HIV, ART, compliance, adherence, age, Africa) on publications from 1st Jan 2000 to 1st March 2016. Eligible studies were pooled for meta-analysis using a random-effects model, with the odds ratio as the primary outcome. Twenty studies were included, among them were five randomised trials and five cohort studies. Overall, we pooled data for 148,819 individuals in two groups (older and younger adults) and found no significant difference in adherence between them [odds ratio (OR) 1.01; 95% CI 0.94–1.09]. Subgroup analyses of studies using medication possession ratio and clinician counts to measure adherence revealed higher proportions of older adults were adherent to medication regimens compared with younger adults (OR 1.06; 95% CI 1.02–1.11). Antiretroviral treatment adherence levels among older and younger adults in Africa are comparable. Further research is required to identify specific barriers to adherence in the aging HIV affected population in Africa which will help in development of interventions to improve their clinical outcomes and quality of life.
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16
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Ahn MY, Jiamsakul A, Khusuwan S, Khol V, Pham TT, Chaiwarith R, Avihingsanon A, Kumarasamy N, Wong WW, Kiertiburanakul S, Pujari S, Nguyen KV, Lee MP, Kamarulzaman A, Zhang F, Ditangco R, Merati TP, Yunihastuti E, Ng OT, Sim BLH, Tanuma J, Ratanasuwan W, Ross J, Choi JY. The influence of age-associated comorbidities on responses to combination antiretroviral therapy in older people living with HIV. J Int AIDS Soc 2019; 22:e25228. [PMID: 30803162 PMCID: PMC6389354 DOI: 10.1002/jia2.25228] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 12/19/2018] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Multiple comorbidities among HIV-positive individuals may increase the potential for polypharmacy causing drug-to-drug interactions and older individuals with comorbidities, particularly those with cognitive impairment, may have difficulty in adhering to complex medications. However, the effects of age-associated comorbidities on the treatment outcomes of combination antiretroviral therapy (cART) are not well known. In this study, we investigated the effects of age-associated comorbidities on therapeutic outcomes of cART in HIV-positive adults in Asian countries. METHODS Patients enrolled in the TREAT Asia HIV Observational Database cohort and on cART for more than six months were analysed. Comorbidities included hypertension, diabetes, dyslipidaemia and impaired renal function. Treatment outcomes of patients ≥50 years of age with comorbidities were compared with those <50 years and those ≥50 years without comorbidities. We analysed 5411 patients with virological failure and 5621 with immunologic failure. Our failure outcomes were defined to be in-line with the World Health Organization 2016 guidelines. Cox regression analysis was used to analyse time to first virological and immunological failure. RESULTS The incidence of virologic failure was 7.72/100 person-years. Virological failure was less likely in patients with better adherence and higher CD4 count at cART initiation. Those acquiring HIV through intravenous drug use were more likely to have virological failure compared to those infected through heterosexual contact. On univariate analysis, patients aged <50 years without comorbidities were more likely to experience virological failure than those aged ≥50 years with comorbidities (hazard ratio 1.75, 95% confidence interval (CI) 1.31 to 2.33, p < 0.001). However, the multivariate model showed that age-related comorbidities were not significant factors for virological failure (hazard ratio 1.31, 95% CI 0.98 to 1.74, p = 0.07). There were 391 immunological failures, with an incidence of 2.75/100 person-years. On multivariate analysis, those aged <50 years without comorbidities (p = 0.025) and age <50 years with comorbidities (p = 0.001) were less likely to develop immunological failure compared to those aged ≥50 years with comorbidities. CONCLUSIONS In our Asia regional cohort, age-associated comorbidities did not affect virologic outcomes of cART. Among those with comorbidities, patients <50 years old showed a better CD4 response.
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Affiliation(s)
- Mi Young Ahn
- Department of Internal MedicineYonsei University College of MedicineSeoulSouth Korea
- AIDS Research InstituteYonsei University College of MedicineSeoulSouth Korea
- Department of Internal MedicineSeoul Medical CenterSeoulSouth Korea
| | | | | | - Vohith Khol
- National Center for HIV/AIDS, Dermatology & STDsPhnom PenhCambodia
| | | | | | | | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site (CART CRS)YRGCARE Medical CentreVHSChennaiIndia
| | | | | | | | | | - Man Po Lee
- Queen Elizabeth HospitalHong Kong SARChina
| | | | - Fujie Zhang
- Beijing Ditan HospitalCapital Medical UniversityBeijingChina
| | - Rossana Ditangco
- Research Institute for Tropical MedicineMuntinlupa CityPhilippines
| | - Tuti P Merati
- Faculty of Medicine Udayana University & Sanglah HospitalBaliIndonesia
| | - Evy Yunihastuti
- Faculty of Medicine Universitas Indonesia ‐ Dr. Cipto Mangunkusumo General HospitalJakartaIndonesia
| | - Oon Tek Ng
- Tan Tock Seng HospitalSingapore CitySingapore
| | | | - Junko Tanuma
- National Center for Global Health and MedicineTokyoJapan
| | - Winai Ratanasuwan
- Faculty of MedicineSiriraj HospitalMahidol UniversityBangkokThailand
| | - Jeremy Ross
- TREAT AsiaamfAR ‐ The Foundation for AIDS ResearchBangkokThailand
| | - Jun Yong Choi
- Department of Internal MedicineYonsei University College of MedicineSeoulSouth Korea
- AIDS Research InstituteYonsei University College of MedicineSeoulSouth Korea
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17
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Bolukcu S, Mete B, Gunduz A, Karaosmanoglu HK, Sargin F, Durdu B, Aydin OA, Yildiz D, Dokmetas I, Aslan T, Tabak F. Assessment of the 24th Week Success of Anti-Retroviral Therapy in the Action against HIV in Istanbul Database: Results from a Region with Increasing Incidence. Jpn J Infect Dis 2019; 72:173-178. [PMID: 30700656 DOI: 10.7883/yoken.jjid.2018.105] [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: 11/17/2022]
Abstract
We aimed to assess the 24-week virological and immunological success of the treatment of treatment-naive and treatment-experienced patients included in the Action against HIV in Istanbul (ACTHIV-IST) database. The ACTHIV-IST database was screened retrospectively from January 2012 to January 2014. The data for these patients such as age, sex, treatment-naive or treatment-experienced status, date of diagnosis, date of commencing antiretroviral therapy, antiretroviral therapy regimen, CD4+ cell count, and viral load before and after therapy were analyzed. In the 24th week of antiretroviral therapy, there were 40 (17.9%) and 29 (14.1%) virological and immunological failures, respectively. Virological failure (VF) was associated with a baseline viral load > 100,000 copies (p = 0.004). A CD4+ cell count lower than 200 cells/μl was not found to be associated with VF (p = 0.843). Immunological failure was substantially rare in patients with a baseline CD4+ cell count > 200 cells/μl (p = 0.005). Although an HIV-RNA ≤ 100,000 copies/ml was protective against VF in the 24th week, in individuals with an HIV-RNA > 100,000 copies/ml, VF was 3.2 times more likely to occur. Baseline VF was the most predictive parameter to estimate 24th week virological success and VF. VF is an important prognostic parameter resulting in CD4+ cell depletion, AIDS-related events, and increased mortality.
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Affiliation(s)
- Sibel Bolukcu
- Department of Infectious Diseases and Clinical Microbiology, Bezmialem Vakif University, Faculty of Medicine
| | - Bilgul Mete
- Department of Infectious Diseases and Clinical Microbiology, Istanbul University, Cerrahpasa Medical School
| | - Alper Gunduz
- Department of Infectious Diseases and Clinical Microbiology, Sisli Etfal Education and Research Hospital
| | - Hayat Kumbasar Karaosmanoglu
- Department of Infectious Diseases and Clinical Microbiology, Bakirkoy Dr. Sadi Konuk Education and Research Hospital
| | - Fatma Sargin
- Department of Infectious Diseases and Clinical Microbiology, Medeniyet University, Goztepe Education and Research Hospital
| | - Bulent Durdu
- Department of Infectious Diseases and Clinical Microbiology, Bezmialem Vakif University, Faculty of Medicine
| | - Ozlem Altuntas Aydin
- Department of Infectious Diseases and Clinical Microbiology, Bakirkoy Dr. Sadi Konuk Education and Research Hospital
| | - Dilek Yildiz
- Department of Infectious Diseases and Clinical Microbiology, Sisli Etfal Education and Research Hospital
| | - Ilyas Dokmetas
- Department of Infectious Diseases and Clinical Microbiology, Sisli Etfal Education and Research Hospital
| | - Turan Aslan
- Department of Infectious Diseases and Clinical Microbiology, Bezmialem Vakif University, Faculty of Medicine
| | - Fehmi Tabak
- Department of Infectious Diseases and Clinical Microbiology, Istanbul University, Cerrahpasa Medical School
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18
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Bernard C, Balestre E, Coffie PA, Eholie SP, Messou E, Kwaghe V, Okwara B, Sawadogo A, Abo Y, Dabis F, de Rekeneire N. Aging with HIV: what effect on mortality and loss to follow-up in the course of antiretroviral therapy? The IeDEA West Africa Cohort Collaboration. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2018; 10:239-252. [PMID: 30532600 PMCID: PMC6247956 DOI: 10.2147/hiv.s172198] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Reporting mortality and lost to follow-up (LTFU) by age is essential as older HIV-positive patients might be at risk of long-term effects of living with HIV and/or taking antiretroviral therapy (ART). As age effects might not be linear and might impact HIV outcomes in the oldest more severely, people living with HIV (PLHIV) aged 50-59 years and PLHIV aged >60 years were considered separately. Setting Seventeen adult HIV/AIDS clinics spread over nine countries in West Africa. Methods Data were collected within the International Epidemiological Databases to Evaluate AIDS West Africa Collaboration. ART-naïve PLHIV-1 adults aged >16 years initiating ART and attending ≥2 clinic visits were included (N=73,525). Age was divided into five groups: 16-29/30-39/40-49/50-59/≥60 years. The age effect on mortality and LTFU was evaluated with Kaplan-Meier curves and multivariable Cox proportional hazard regressions. Results At month 36, 5.9% of the patients had died and 47.3% were LTFU. Patients aged ≥60 (N=1,736) and between 50-59 years old (N=6,792) had an increased risk of death in the first 36 months on ART (adjusted hazard ratio=1.66; 95% CI: 1.36-2.03 and adjusted hazard ratio=1.31; 95% CI: 1.15-1.49, respectively; reference: <30 years old). Patients ≥60 years old tend to be more often LTFU. Conclusion The oldest PLHIV presented the poorest outcomes, suggesting that the PLHIV aged >50 years old should not be considered as a unique group irrespective of their age. Tailored programs focusing on improving the care services for older PLHIV in Sub-Saharan Africa are clearly needed to improve basic program outcomes.
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Affiliation(s)
- Charlotte Bernard
- INSERM, Centre INSERM U1219-Epidémiologie-Biostatistique, Bordeaux, France, .,University of Bordeaux, School of Public Health (ISPED), Bordeaux, France,
| | - Eric Balestre
- INSERM, Centre INSERM U1219-Epidémiologie-Biostatistique, Bordeaux, France, .,University of Bordeaux, School of Public Health (ISPED), Bordeaux, France,
| | - Patrick A Coffie
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Côte d'Ivoire.,Unit of Infectious and Tropical Diseases, Treichville University Teaching Hospital, Abidjan, Côte d'Ivoire.,Programme PAC-CI, Treichville University Teaching Hospital, Abidjan, Ivory Coast
| | - Serge Paul Eholie
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Côte d'Ivoire.,Unit of Infectious and Tropical Diseases, Treichville University Teaching Hospital, Abidjan, Côte d'Ivoire
| | - Eugène Messou
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Côte d'Ivoire.,Unit of Infectious and Tropical Diseases, Treichville University Teaching Hospital, Abidjan, Côte d'Ivoire.,Programme PAC-CI, Treichville University Teaching Hospital, Abidjan, Ivory Coast.,Center of Care, Research and Training (CePReF), Yopougon-Attié Hospital, Abidjan, Ivory Coast
| | | | - Benson Okwara
- University of Benin City Teaching Hospital, Benin City, Nigeria
| | - Adrien Sawadogo
- Institut Supérieur des Sciences de la Santé (INSSA), Bobo-Dioulasso Polytechnic University, Bobo-Dioulasso, Burkina Faso
| | - Yao Abo
- National Blood Transfusion Center (CNTS), Abidjan, Ivory Coast
| | - François Dabis
- INSERM, Centre INSERM U1219-Epidémiologie-Biostatistique, Bordeaux, France, .,University of Bordeaux, School of Public Health (ISPED), Bordeaux, France,
| | - Nathalie de Rekeneire
- INSERM, Centre INSERM U1219-Epidémiologie-Biostatistique, Bordeaux, France, .,University of Bordeaux, School of Public Health (ISPED), Bordeaux, France,
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Obiri-Yeboah D, Pappoe F, Baidoo I, Arthur F, Hayfron-Benjamin A, Essien-Baidoo S, Kwakye-Nuako G, Ayisi Addo S. Immunologic and virological response to ART among HIV infected individuals at a tertiary hospital in Ghana. BMC Infect Dis 2018; 18:230. [PMID: 29783953 PMCID: PMC5963173 DOI: 10.1186/s12879-018-3142-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/10/2018] [Indexed: 01/17/2023] Open
Abstract
Background The need to study the outcome of Antiretroviral Therapy (ART) among Human Immunodeficiency Virus (HIV) infected individuals in Ghana, a sub-Saharan African country crucial in the era of the “Treat All” policy. The aim of this study was to analyze selected determinants of immunological and virological response to ART among HIV infected individuals in a tertiary facility in Cape Coast, Ghana. Methods An analytical cross sectional study with a retrospective component was conducted in the Cape Coast Teaching Hospital (CCTH), Central Region. Clients aged 18 years and above attending the HIV Clinics for ART and who were on ART for 6 months or more were recruited. The viral loads, CD4 count and other socio-demographic data were analyzed using STATA version 13 (STATA Corp, Texas USA). Descriptive analysis was done and presented with appropriate measures of central tendencies. In addition, bivariate and multivariate analysis was carried out with p value of 0.05 interpreted as evidence of association between variables. Results A total of 440 participants were included in this study with a mean age of 45.5 (±11.6) years. The mean CD4 count at baseline, 6 months on ART and currently at study recruitment were 215.1 cells/mm3 (±152.6), 386.6 cells/mm3 (±178.5), and 579.6 cells/mm3 (±203.0) respectively. After 6 months and 12 months on ART, the number who had achieved viral copies < 1000/ml were 149 (47.0%) and 368 (89.6%) respectively. There was strong evidence of an association between having CD4 count < 350 cells/mm3 after 6 months on ART and having a diagnosis of tuberculosis since HIV diagnosis (aOR 8.5, 95% CI 1.1–73.0, p = 0.05) and clients having plasma viral load > 1000 copies/ml after 6 months on ART (aOR 2.0, 95% CI 1.2–3.2, p = 0.01). Conclusion There was good response to ART among clients, high virological suppression and immunological recovery hence low rates of change to second line ART regimen in this cohort studied. With strict adherence to the national policy on HIV testing, management of positive clients and full implementation of the “Treat All” policy, Ghana could achieve, if nothing at all, the third “90, 90, 90” target by 2020. Electronic supplementary material The online version of this article (10.1186/s12879-018-3142-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dorcas Obiri-Yeboah
- Department of Microbiology and Immunology, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana.
| | - Faustina Pappoe
- Department of Microbiology and Immunology, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Ibrahim Baidoo
- Public Health Unit, Cape Coast Teaching Hospital, Cape Coast, Ghana
| | - Francis Arthur
- Microbiology Unit, Cape Coast Teaching Hospital, Cape Coast, Ghana
| | - Anna Hayfron-Benjamin
- Department of Maternal and Child Health, School of Nursing and Midwifery, University of Cape Coast, Cape Coast, Ghana
| | - Samuel Essien-Baidoo
- Department of Laboratory Technology, University of Cape Coast, Cape Coast, Ghana
| | - Godwin Kwakye-Nuako
- Department of Biomedical Sciences, University of Cape Coast, Cape Coast, Ghana
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Predictors of Retention in HIV Care Among Youth (15-24) in a Universal Test-and-Treat Setting in Rural Kenya. J Acquir Immune Defic Syndr 2018; 76:e15-e18. [PMID: 28394821 DOI: 10.1097/qai.0000000000001390] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Ng’ang’a PW, Mathai M, Obondo A, Mutavi T, Kumar M. Undetected psychiatric morbidity among HIV/AIDS patients attending Comprehensive Care Clinic (CCC) in Nairobi Kenya: towards an integrated mental health care. Ann Gen Psychiatry 2018; 17:11. [PMID: 29507598 PMCID: PMC5833144 DOI: 10.1186/s12991-018-0179-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 02/12/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Psychiatric morbidity is commonly associated with HIV disease and may have adverse effects. This aspect may be overlooked at comprehensive HIV care centers in Low and Middle-Income Countries. OBJECTIVES The aim of this study was to determine the prevalence of undetected psychiatric morbidity among HIV/AIDS adult patients attending Comprehensive Care Centre in a semi-urban clinic, in Nairobi, Kenya. DESIGN Descriptive cross-sectional study of adult HIV patients not receiving any psychiatric treatment was conducted. PARTICIPANTS/METHODS The participants consisted of consecutive sample of adults (n = 245) attending HIV Comprehensive Care Clinic at Kangemi Health Centre, Nairobi. The Mini International Neuropsychiatric Interview (MINI) was administered to screen for undetected psychiatric morbidity. Socio-demographic characteristics were recorded in a questionnaire. Sample descriptive analysis was performed and prevalence of undetected psychiatric morbidity calculated. Chi-square test for independence was used to examine the associations between patient characteristics and undetected morbidity. Multivariable logistic regression analysis was performed to determine independent predictors of undetected psychiatric morbidity. RESULTS The mean age of our participants was 37.3 years (SD 9.2) Three-quarters (75.9%) of participants were females and median duration of HIV illness was 5 years. The prevalence of (previously undetected) psychiatric morbidity was 71.4% (95% CI 65.3-77). The leading psychiatric disorders were MDD (32.2%), PTSD (18.4%), Dysthymia (17.6%), and OCD (17.6%). Overall psychiatric morbidity was associated with low income ( CONCLUSION The burden of psychiatric morbidity in Kenyan HIV patients remains high and is most significantly associated with lower socioeconomic status. There is need to provide holistic care including screening for mental well-being all through the treatment of HIV patients in low-income settings.
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Affiliation(s)
- Pauline W. Ng’ang’a
- Department of Psychiatry, College of Health Sciences, University of Nairobi, P O Box 19676, Nairobi, 00202 Kenya
| | - Muthoni Mathai
- Department of Psychiatry, College of Health Sciences, University of Nairobi, P O Box 19676, Nairobi, 00202 Kenya
| | - Anne Obondo
- Department of Psychiatry, College of Health Sciences, University of Nairobi, P O Box 19676, Nairobi, 00202 Kenya
| | - Teresia Mutavi
- Department of Psychiatry, College of Health Sciences, University of Nairobi, P O Box 19676, Nairobi, 00202 Kenya
| | - Manasi Kumar
- Department of Psychiatry, College of Health Sciences, University of Nairobi, P O Box 19676, Nairobi, 00202 Kenya
- Research Department of Clinical Health and Educational Psychology, University College London, London, WC1E 7HB UK
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Wong NS, Mao J, Cheng W, Tang W, Cohen MS, Tucker JD, Xu H. HIV Linkage to Care and Retention in Care Rate Among MSM in Guangzhou, China. AIDS Behav 2018; 22:701-710. [PMID: 28849284 DOI: 10.1007/s10461-017-1893-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Quantifying HIV service provision along the HIV care continuum is increasingly important for monitoring and evaluating HIV interventions. We examined factors associated with linkage and retention in care longitudinally among MSM (n = 1974, 4933 person-years) diagnosed and living in Guangzhou, China, in 2008-2014. We measured longitudinal change of retention in care (≥2 CD4 tests per year) from linkage and antiretroviral therapy initiation (ART). We examined factors associated with linkage using logistic regression and with retention using generalized estimating equations. The rate of linkage to care was 89% in 2014. ART retention rate dropped from 71% (year 1) to 46% (year 2), suggesting that first-year retention measures likely overestimate retention over longer periods. Lower CD4 levels and older age predicted retention in ART care. These data can inform interventions to improve retention about some subgroups.
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Affiliation(s)
- Ngai Sze Wong
- Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- University of North Carolina Project-China, Guangzhou, Guangdong, China
- Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong, China
| | - Jessica Mao
- David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Weibin Cheng
- Department of AIDS/STD Control and Prevention, Guangzhou Center for Disease Control and Prevention, No.1 Qide Road, Jiahe Street, Baiyun District, Guangzhou, 510440, Guangdong, China
| | - Weiming Tang
- Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- University of North Carolina Project-China, Guangzhou, Guangdong, China
| | - Myron S Cohen
- Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joseph D Tucker
- Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- University of North Carolina Project-China, Guangzhou, Guangdong, China
| | - Huifang Xu
- Department of AIDS/STD Control and Prevention, Guangzhou Center for Disease Control and Prevention, No.1 Qide Road, Jiahe Street, Baiyun District, Guangzhou, 510440, Guangdong, China.
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Performance of self-reported HIV status in determining true HIV status among older adults in rural South Africa: a validation study. J Int AIDS Soc 2017; 20:21691. [PMID: 28782333 PMCID: PMC5577734 DOI: 10.7448/ias.20.1.21691] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Introduction: In South Africa, older adults make up a growing proportion of people living with HIV. HIV programmes are likely to reach older South Africans in home-based interventions where testing is not always feasible. We evaluate the accuracy of self-reported HIV status, which may provide useful information for targeting interventions or offer an alternative to biomarker testing. Methods: Data were taken from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) baseline survey, which was conducted in rural Mpumalanga province, South Africa. A total of 5059 participants aged ≥40 years were interviewed from 2014 to 2015. Self-reported HIV status and dried bloodspots for HIV biomarker testing were obtained during at-home interviews. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for self-reported status compared to “gold standard” biomarker results. Log-binomial regression explored associations between demographic characteristics, antiretroviral therapy (ART) status and sensitivity of self-report. Results: Most participants (93%) consented to biomarker testing. Of those with biomarker results, 50.9% reported knowing their HIV status and accurately reported it. PPV of self-report was 94.1% (95% confidence interval (CI): 92.0–96.0), NPV was 87.2% (95% CI: 86.2–88.2), sensitivity was 51.2% (95% CI: 48.2–54.3) and specificity was 99.0% (95% CI: 98.7–99.4). Participants on ART were more likely to report their HIV-positive status, and participants reporting false-negatives were more likely to have older HIV tests. Conclusions: The majority of participants were willing to share their HIV status. False-negative reports were largely explained by lack of testing, suggesting HIV stigma is retreating in this setting, and that expansion of HIV testing and retesting is still needed in this population. In HIV interventions where testing is not possible, self-reported status should be considered as a routine first step to establish HIV status.
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Wong NS, Chan KCW, Cheung EKH, Wong KH, Lee SS. Immune recovery of middle-aged HIV patients following antiretroviral therapy: An observational cohort study. Medicine (Baltimore) 2017; 96:e7493. [PMID: 28700495 PMCID: PMC5515767 DOI: 10.1097/md.0000000000007493] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
In HIV-infected persons, age is negatively associated with optimal CD4 recovery following antiretroviral therapy. Our understanding of the situation in older adults, especially the middle-aged is, however, limited. We undertook to examine the latter's pattern of CD4/CD8 recovery following antiretroviral therapy.Retrospective clinical cohort data of HIV patients diagnosed between 1985 and 2014 in Hong Kong were collected. They were categorized by age at treatment initiation, viz., young adults (age 18-49), middle-aged (age 50-64), and elderly (≥65 years' old). Predictors of immune recovery (CD4 count, CD8 count, CD4/CD8 ratio) over time were examined using multivariable linear generalized estimating equations.A total of 2754 patients (aged ≥18) have been on antiretroviral therapy, with baseline characteristics similar between middle-aged and the elderly. Late diagnosis, defined as progression to AIDS within 3 months of HIV diagnosis, was less common in middle-aged (odds ratio = 0.58, 95% confidence interval = 0.37-0.91). Among Chinese patients who have been on treatment for ≥4 years (n = 913), 80.6%, 14.6%, and 4.8% were young adults, middle-aged, and elderly respectively. Late treatment initiation, defined as AIDS diagnosis or CD4 count ≤100 cells/μL before treatment, was common in middle-aged and elderly, the former however had faster CD4 recovery (3.95 vs. 3.36 cells/μL/month), but slower CD8 decline (-1.76 vs. -4.34 cells/μL/month) and CD4/CD8 normalization (0.009 vs. 0.0101/month).As a transitional age group, the immune recovery of middle-aged patients lagged behind young adults largely because of late treatment initiation. Following adoption of early and non-CD4-guided treatment initiation, their long-term clinical outcome is expected to improve.
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Affiliation(s)
- Ngai Sze Wong
- Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Kenny Chi Wai Chan
- Special Preventive Programme, Centre for Health Protection, Department of Health, Hong Kong Special Administrative Region Government, Hong Kong, China
| | - Edward Ka Hin Cheung
- Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Ka Hing Wong
- Special Preventive Programme, Centre for Health Protection, Department of Health, Hong Kong Special Administrative Region Government, Hong Kong, China
| | - Shui Shan Lee
- Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Masa R, Chowa G, Nyirenda V. Barriers and facilitators of antiretroviral therapy adherence in rural Eastern province, Zambia: the role of household economic status. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2017. [PMID: 28639469 DOI: 10.2989/16085906.2017.1308386] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In Zambia, more people living with HIV now have access to lifesaving antiretroviral therapy than ever before. However, progress in HIV treatment and care has not always resulted in lower mortality. Adherence remains a critical barrier to treatment success. The objective of this study was to examine the barriers and facilitators of antiretroviral therapy adherence, particularly the role of household economic status. The study included a cross-sectional sample of 101 people living with HIV (PLHIV) in two rural communities in eastern Zambia. Adherence was measured using patient self-assessment and pharmacy information. Household economic status included components such as occupation, income, assets, food security, and debt. Multivariable logistic regression was conducted to examine the associations between household economic factors and adherence. Our findings suggest that the role of economic status on adherence appears to be a function of the economic component. Debt and non-farming-related occupation were consistently associated with non-adherence. The association between assets and adherence depends on the type of asset. Owning more transportation-related assets was consistently associated with non-adherence, whereas owning more livestock was associated with self-reported adherence. Additionally, living in a community with fewer economic opportunities was associated with non-adherence. The associations between place of residence and pharmacy refill adherence and between transportation assets and self-reported adherence were statistically significant. Improving adherence requires a multifaceted strategy that addresses the role of economic status as a potential barrier and facilitator. Programmes that provide economic opportunities and life-skills training may help PLHIV to overcome economic, social, and psychological barriers.
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Affiliation(s)
- Rainier Masa
- a School of Social Work , University of North Carolina at Chapel Hill , Chapel Hill , North Carolina , USA.,b Global Social Development Innovations , University of North Carolina at Chapel Hill , Chapel Hill , North Carolina , USA
| | - Gina Chowa
- a School of Social Work , University of North Carolina at Chapel Hill , Chapel Hill , North Carolina , USA.,b Global Social Development Innovations , University of North Carolina at Chapel Hill , Chapel Hill , North Carolina , USA
| | - Victor Nyirenda
- b Global Social Development Innovations , University of North Carolina at Chapel Hill , Chapel Hill , North Carolina , USA
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Underutilisation of routinely collected data in the HIV programme in Zambia: a review of quantitatively analysed peer-reviewed articles. Health Res Policy Syst 2017; 15:51. [PMID: 28610616 PMCID: PMC5470192 DOI: 10.1186/s12961-017-0221-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 05/30/2017] [Indexed: 01/23/2023] Open
Abstract
Background The extent to which routinely collected HIV data from Zambia has been used in peer-reviewed published articles remains unexplored. This paper is an analysis of peer-reviewed articles that utilised routinely collected HIV data from Zambia within six programme areas from 2004 to 2014. Methods Articles on HIV, published in English, listed in the Directory of open access journals, African Journals Online, Google scholar, and PubMed were reviewed. Only articles from peer-reviewed journals, that utilised routinely collected data and included quantitative data analysis methods were included. Multi-country studies involving Zambia and another country, where the specific results for Zambia were not reported, as well as clinical trials and intervention studies that did not take place under routine care conditions were excluded, although community trials which referred patients to the routine clinics were included. Independent extraction was conducted using a predesigned data collection form. Pooled analysis was not possible due to diversity in topics reviewed. Results A total of 69 articles were extracted for review. Of these, 7 were excluded. From the 62 articles reviewed, 39 focused on HIV treatment and retention in care, 15 addressed prevention of mother-to-child transmission, 4 assessed social behavioural change, and 4 reported on voluntary counselling and testing. In our search, no articles were found on condom programming or voluntary male medical circumcision. The most common outcome measures reported were CD4+ count, clinical failure or mortality. The population analysed was children in 13 articles, women in 16 articles, and both adult men and women in 33 articles. Conclusion During the 10 year period of review, only 62 articles were published analysing routinely collected HIV data in Zambia. Serious consideration needs to be made to maximise the utility of routinely collected data, and to benefit from the funds and efforts to collect these data. This could be achieved with government support of operational research and publication of findings based on routinely collected Zambian HIV data.
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Loss to Follow-up Trends in HIV-Positive Patients Receiving Antiretroviral Treatment in Asia From 2003 to 2013. J Acquir Immune Defic Syndr 2017; 74:555-562. [PMID: 28129256 DOI: 10.1097/qai.0000000000001293] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Over time, there has been a substantial improvement in antiretroviral treatment (ART) programs, including expansion of services and increased patient engagement. We describe time trends in, and factors associated with, loss to follow-up (LTFU) in HIV-positive patients receiving ART in Asia. METHODS Analysis included HIV-positive adults initiating ART in 2003-2013 at 7 ART programs in Asia. Patients LTFU had not attended the clinic for ≥180 days, had not died, or transferred to another clinic. Patients were censored at recent clinic visit, follow-up to January 2014. We used cumulative incidence to compare LTFU and mortality between years of ART initiation. Factors associated with LTFU were evaluated using a competing risks regression model, adjusted for clinical site. RESULTS A total of 8305 patients were included. There were 743 patients LTFU and 352 deaths over 26,217 person-years (pys), a crude LTFU, and mortality rate of 2.83 (2.64-3.05) per 100 pys and 1.34 (1.21-1.49) per 100 pys, respectively. At 24 months, the cumulative LTFU incidence increased from 4.3% (2.9%-6.1%) in 2003-05 to 8.1% (7.1%-9.2%) in 2006-09 and then decreased to 6.7% (5.9%-7.5%) in 2010-13. Concurrently, the cumulative mortality incidence decreased from 6.2% (4.5%-8.2%) in 2003-05 to 3.3% (2.8%-3.9%) in 2010-13. The risk of LTFU reduced in 2010-13 compared with 2006-09 (adjusted subhazard ratio = 0.73, 0.69-0.99). CONCLUSIONS LTFU rates in HIV-positive patients receiving ART in our clinical sites have varied by the year of ART initiation, with rates declining in recent years whereas mortality rates have remained stable. Further increases in site-level resources are likely to contribute to additional reductions in LTFU for patients initiating in subsequent years.
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Czaicki NL, Holmes CB, Sikazwe I, Bolton C, Savory T, wa Mwanza M, Moyo C, Padian NS, Geng EH. Nonadherence to antiretroviral therapy among HIV-infected patients in Zambia is concentrated among a minority of patients and is highly variable across clinics. AIDS 2017; 31:689-696. [PMID: 28225707 DOI: 10.1097/qad.0000000000001347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The distribution of adherence to antiretroviral therapy (ART) can indicates whether barriers are concentrated or more distributed. We quantified the medication possession ratio (MPR) and characterized the distribution of medication nonpossession in a network of clinics in Zambia to identify 'hotspots' and predictors of poorer adherence. METHODS We analyzed a population of adults on ART for more than 3 months who made at least one clinic visit between 1 January 2013 and 28 February 2015. Pharmacy refill and clinical information were obtained through the electronic medical record system used in routine care. We constructed a Lorenz curve to visualize the distribution of poor adherence and used a multilevel logistic regression model to examine factors associated with MPR. RESULTS Among 131 767 patients in 56 clinics [64% women, median age 34 years (interquartile range (IQR) 29-41), median CD4 cell count at ART initiation 351 cells/μl (IQR 220-517)], the median MPR was 85.8% (IQR 70.8-96.8). During months 7-12 on ART, 45.6% of patients had 100% MPR and 10.5% accounted for 50% of medication nonpossession. Across clinics, median MPR ranged from 49.1 to 98.5, and clinic accounted for 12% of the variability in adherence after adjusting for individual and clinic-level characteristics. CONCLUSION A small fraction of patients account for the majority of days of medication nonpossession. Further characterization of these subpopulations is needed to target interventions. Clinic also accounted for much variability in MPR. Health systems interventions targeting clinic 'hot spots' may represent an efficient use of resources to improve ART adherence.
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Sempa JB, Ujeneza EL, Nieuwoudt M. Systematic review of statistically-derived models of immunological response in HIV-infected adults on antiretroviral therapy in Sub-Saharan Africa. PLoS One 2017; 12:e0171658. [PMID: 28199360 PMCID: PMC5310790 DOI: 10.1371/journal.pone.0171658] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 01/24/2017] [Indexed: 12/31/2022] Open
Abstract
Introduction In Sub-Saharan African (SSA) resource limited settings, Cluster of Differentiation 4 (CD4) counts continue to be used for clinical decision making in antiretroviral therapy (ART). Here, HIV-infected people often remain with CD4 counts <350 cells/μL even after 5 years of viral load suppression. Ongoing immunological monitoring is necessary. Due to varying statistical modeling methods comparing immune response to ART across different cohorts is difficult. We systematically review such models and detail the similarities, differences and problems. Methods ‘Preferred Reporting Items for Systematic Review and Meta-Analyses’ guidelines were used. Only studies of immune-response after ART initiation from SSA in adults were included. Data was extracted from each study and tabulated. Outcomes were categorized into 3 groups: ‘slope’, ‘survival’, and ‘asymptote’ models. Wordclouds were drawn wherein the frequency of variables occurring in the reviewed models is indicated by their size and color. Results 69 covariates were identified in the final models of 35 studies. Effect sizes of covariates were not directly quantitatively comparable in view of the combination of differing variables and scale transformation methods across models. Wordclouds enabled the identification of qualitative and semi-quantitative covariate sets for each outcome category. Comparison across categories identified sex, baseline age, baseline log viral load, baseline CD4, ART initiation regimen and ART duration as a minimal consensus set. Conclusion Most models were different with respect to covariates included, variable transformations and scales, model assumptions, modelling strategies and reporting methods, even for the same outcomes. To enable comparison across cohorts, statistical models would benefit from the application of more uniform modelling techniques. Historic efforts have produced results that are anecdotal to individual cohorts only. This study was able to define ‘prior’ knowledge in the Bayesian sense. Such information has value for prospective modelling efforts.
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Affiliation(s)
- Joseph B. Sempa
- South African Department of Science and Technology/National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- * E-mail:
| | - Eva L. Ujeneza
- South African Department of Science and Technology/National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Martin Nieuwoudt
- South African Department of Science and Technology/National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
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Agaba PA, Meloni ST, Sule HM, Agbaji OO, Sagay AS, Okonkwo P, Idoko JA, Kanki PJ. Treatment Outcomes Among Older Human Immunodeficiency Virus-Infected Adults in Nigeria. Open Forum Infect Dis 2017; 4:ofx031. [PMID: 29497627 PMCID: PMC5780650 DOI: 10.1093/ofid/ofx031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 02/09/2017] [Indexed: 02/07/2023] Open
Abstract
Background Older age at initiation of combination antiretroviral therapy (cART) has been associated with poorer clinical outcomes. Our objectives were to compare outcomes between older and younger patients in our clinical cohort in Jos, Nigeria. Methods This retrospective cohort study evaluated patients enrolled on cART at the Jos University Teaching Hospital, Nigeria between 2004 and 2012. We compared baseline and treatment differences between older (≥50 years) and younger (15–49 years) patients. Kaplan-Meier analysis and Cox proportional hazard models estimated survival and loss to follow-up (LTFU) and determined factors associated with these outcomes at 24 months. Results Of 8352 patients, 643 (7.7%) were aged ≥50 years. The median change in CD4 count from baseline was 151 vs 132 (P = .0005) at 12 months and 185 vs 151 cells/mm3 (P = .03) at 24 months for younger and older patients, respectively. A total of 68.9% vs 71.6% (P = .13) and 69.6% vs 74.8% (P = .005) of younger and older patients achieved viral suppression at 12 and 24 months, with similar incidence of mortality and LTFU. In adjusted hazard models, factors associated with increased risk of mortality were male sex, World Health Organization (WHO) stage III/IV, and having a gap in care, whereas being fully suppressed was protective. The risk of being LTFU was lower for older patients, those fully suppressed virologically and with adherence rates >95%. Male sex, lack of education, WHO stage III/IV, body mass index <18.5 kg/m2, and having a gap in care independently predicted LTFU. Conclusions Older patients achieved better viral suppression, and older age was not associated with increased mortality or LTFU in this study.
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Affiliation(s)
- Patricia A Agaba
- Departments of Family Medicine.,APIN Centre, Jos University Teaching Hospital, Nigeria
| | - Seema T Meloni
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; and
| | - Halima M Sule
- Departments of Family Medicine.,APIN Centre, Jos University Teaching Hospital, Nigeria
| | - Oche O Agbaji
- Medicine, and.,APIN Centre, Jos University Teaching Hospital, Nigeria
| | - Atiene S Sagay
- Obstetrics and Gynaecology, University of Jos/Jos University Teaching Hospital, Nigeria.,APIN Centre, Jos University Teaching Hospital, Nigeria
| | | | | | - Phyllis J Kanki
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; and
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Tchounga BK, Hønge BL, Eholie SP, Coffie PA, Jespersen S, Wejse C, Dabis F, Geoffrey GS, Ekouevi DK. Effect of sex and age on outcomes among HIV-2-infected patients starting antiretroviral therapy in West Africa. AIDS 2016; 30:2707-2714. [PMID: 27536979 PMCID: PMC5841585 DOI: 10.1097/qad.0000000000001232] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES HIV-2-infected individuals usually initiate antiretroviral therapy (ART) at an advanced age compared with HIV-1 patients, with a potential impact on treatment outcomes. This study aimed to investigate the effect of sex and age on mortality and loss to follow-up (LTFU) among HIV-2-infected individuals initiating ART. METHODS Analyses were conducted using the database of the International Epidemiological Databases to Evaluate AIDS's collaboration in West Africa. LTFU was considered if the interval between the last visit and the closing date for this analysis was more than 180 days. Probability of death and LTFU were estimated with Kaplan-Meier methods. A Cox regression model was used to identify factors associated with death and LTFU over the first 24 months on ART. RESULTS A total of 1825 HIV-2-infected individuals, including 60% women were considered for this analysis. The median age, baseline CD4 cell count, and follow-up duration were 45 years [interquartile range (IQR; 38-52)], 185 cells/μl [IQR (95-297)], and 28.8 months [IQR (9.8-58.9)], respectively. Over the first 24 months, the mortality rate was 5.2/100 person-years of observation [95% confidence interval (CI; 4.4-6.1)] and 469 (25.7%) were LTFU. Male sex [hazard ratio (HR) = 1.9; 95% CI (1.4; 2.8)], baseline CD4 cell count less than 100 cell/μl [HR = 4.4 95% CI (1.7; 11.1); ref at least 350 cell/μl], haemoglobin 7.5-10 g/dl [HR = 2.4 95% CI (1.3; 4.4); ref at least 12 g/dl], and BMI less than 18 kg/m [HR = 2.1 95% CI (1.3; 3.4); ref = 18-25 kg/m] were associated with higher mortality over the first 24 months. Similar associations were found for LTFU. CONCLUSION Mortality and LTFU are high among ART-receiving HIV-2-infected individuals and higher in men than in women. There is a critical need to further determine the causes of poor retention and implement sex-specific solutions that improve outcomes in HIV-2 ART programmes.
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Affiliation(s)
- Boris K Tchounga
- aUniversité. Bordeaux, ISPED, Centre INSERM U1219-Epidémiologie-Biostatistique, Bordeaux bINSERM, ISPED, Centre INSERM U1219-Epidemiologie-Biostatistique, Bordeaux, France cProgramme PACCI, site de recherche ANRS, Abidjan, Côte d'Ivoire dBandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau eDepartment of Infectious Diseases fDepartment of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark gService des Maladies Infectieuses et Tropicales, CHU de Treichville, Abidjan, Côte d'Ivoire hDepartments of Medicine & Global Health, University of Washington, Seattle, Washington, USA iDépartement des Sciences Fondamentales et Santé Publique, Université de Lomé, Lomé, Togo. *See supplemental information for the list of the IeDEA West Africa collaboration members, http://links.lww.com/QAD/A970
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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.
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Determinants of time to antiretroviral treatment initiation and subsequent mortality on treatment in a cohort in rural northern Malawi. AIDS Res Ther 2016; 13:24. [PMID: 27398087 PMCID: PMC4938927 DOI: 10.1186/s12981-016-0110-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 06/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To optimise care HIV patients need to be promptly initiated on antiretroviral therapy (ART) and subsequently retained on treatment. In this study we report on the interval between enrolment and treatment initiation, and investigate subsequent attrition and mortality of patients on ART at a rural clinic in Malawi. METHODS HIV-positive individuals were recruited to a cohort study between January 2008 and August 2011 at Chilumba Rural Hospital (CRH). Outcomes were ascertained, up to 7 years after enrolment, through follow-up and by linkage to ART registers and the Karonga Health and Demographic Surveillance System (KHDSS). Kaplan-Meier methods and Cox regression were used to examine ART initiation after enrolment, mortality after ART initiation, and attrition after ART initiation. RESULTS Of the 617 individuals recruited, 523 initiated ART between January 2008 and January 2015. Median time from HIV testing to commencement of ART was 59 days (IQR: 10-330). By a year after enrolment 74.2 % (95 % CI 70.6-77.7 %) had initiated ART. Baseline clinical data at ART initiation and data on attrition was only available for the 438 individuals who initiated ART during active follow-up, between January 2008 and August 2011. Of these individuals, 6 were missing Ministry of Health numbers, leaving 432 included in analyses of attrition and mortality. At 4 years after ART initiation 71.3 % (95 % CI 65.7-76.2 %) of these patients were retained on treatment at the CRH and 17.2 % (95 % CI 13.8-21.4 %) had died. Participants who had a lower CD4 count at enrolment (≤350 cells/μl), enrolled in 2008, or tested for HIV at the CRH rather than through serosurveys, initiated treatment faster. Once on treatment, mortality rates were higher in patients who were HIV tested at the CRH, male, older (≥35 years), missing a CD4 count, or underweight (BMI < 18.5) at ART initiation. CONCLUSIONS Through linkage to the KHDSS and ART registers it was possible to continue follow-up beyond the end of the initial cohort study. Annual mortality after ART initiation remained considerable over a period of 4 years. Greater access to HIV and CD4 testing alongside initiation at higher CD4 counts, as planned in the test and treat strategy, could reduce this mortality.
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Ding Y, Duan S, Wu Z, Ye R, Yang Y, Yao S, Wang J, Xiang L, Jiang Y, Lu L, Jia M, Detels R, He N. Timing of antiretroviral therapy initiation after diagnosis of recent human immunodeficiency virus infection and CD4(+) T-cell recovery. Clin Microbiol Infect 2015; 22:290.e5-8. [PMID: 26627338 DOI: 10.1016/j.cmi.2015.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 10/09/2015] [Accepted: 11/15/2015] [Indexed: 10/22/2022]
Abstract
We retrospectively examined the timing of antiretroviral therapy (ART) initiation and CD4(+) T-cell recovery over 36 months among recent human immunodeficiency virus (HIV) infections using BED (HIV-1 subtypes B, E and D) immunoglobulin G capture enzyme immunoassay (BED-CEIA). Regardless of baseline CD4(+) counts, individuals (n = 393) who initiated ART >2 months after diagnosis had significantly decreased probability and rate of achieving CD4(+) counts ≥900 cells/μL or ≥600 cells/μL than those individuals (n = 135) who started ART earlier (≤2 months). But the mean CD4(+) counts in two groups converged after 30 months of treatment. Early ART initiation leads to accelerated CD4(+) recovery, but does not offer a long-term advantage in CD4(+) counts.
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Affiliation(s)
- Y Ding
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - S Duan
- Dehong Prefecture Centre for Disease Control and Prevention, Mangshi, Yunnan Province, China
| | - Z Wu
- National Centre for AIDS/STD Control and Prevention (NCAIDS), Chinese Centre for Disease Control and Prevention (China CDC), Beijing, China
| | - R Ye
- Dehong Prefecture Centre for Disease Control and Prevention, Mangshi, Yunnan Province, China
| | - Y Yang
- Dehong Prefecture Centre for Disease Control and Prevention, Mangshi, Yunnan Province, China
| | - S Yao
- Dehong Prefecture Centre for Disease Control and Prevention, Mangshi, Yunnan Province, China
| | - J Wang
- Dehong Prefecture Centre for Disease Control and Prevention, Mangshi, Yunnan Province, China
| | - L Xiang
- Dehong Prefecture Centre for Disease Control and Prevention, Mangshi, Yunnan Province, China
| | - Y Jiang
- National Centre for AIDS/STD Control and Prevention (NCAIDS), Chinese Centre for Disease Control and Prevention (China CDC), Beijing, China
| | - L Lu
- Yunnan Centre for Disease Control and Prevention, Kuming, Yunnan Province, China
| | - M Jia
- Yunnan Centre for Disease Control and Prevention, Kuming, Yunnan Province, China
| | - R Detels
- Department of Epidemiology, School of Public Health, University of California, Los Angeles, Los Angeles, USA
| | - N He
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China.
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Thao VP, Quang VM, Wolbers M, Anh ND, Shikuma C, Farrar J, Dunstan S, Chau NVV, Day J, Thwaites G, Le T. Second-Line HIV Therapy Outcomes and Determinants of Mortality at the Largest HIV Referral Center in Southern Vietnam. Medicine (Baltimore) 2015; 94:e1715. [PMID: 26512561 PMCID: PMC4985375 DOI: 10.1097/md.0000000000001715] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The growing numbers of HIV-infected patients requiring second-line antiretroviral therapy (ART) in Vietnam make essential the evaluation of treatment efficacy to guide treatment strategies.We evaluated all patients aged ≥15 years who initiated second-line ART after documented failure of first-line therapy at the Hospital for Tropical Diseases in Ho Chi Minh City. The primary outcome was time from second-line ART initiation to death, or to a new or reoccurrence of a WHO-defined immunological or clinical failure event, whichever occurred first. Risks of treatment failure and death were evaluated using Cox proportional hazards modeling.Data from 326 of 373 patients initiating second-line ART between November 2006 and August 2011 were included in this analysis. The median age was 32 years (IQR: 28-36). Eighty one percent were men. The median CD4 count was 44 cells/μL (IQR: 16-84). During a median follow-up of 29 months (IQR: 15-44), 60 (18.4%) patients experienced treatment failure, including 12 immunological failures, 4 WHO stage IV AIDS events, and 44 deaths (13.5%). Sixty percent of deaths occurred during the first 6-12 months. The Kaplan-Meier estimates of treatment failure after 1, 2, 3, and 4 years were 13.1% (95% CI: 9.2-16.8), 18.6% (95% CI: 14.0-23.1), 20.4% (95% CI: 15.4-25.1), and 22.8% (95% CI: 17.2-28.1), respectively. Older age, history of injection drug use, lower CD4 count, medication adherence <95%, and previous protease inhibitor use independently predicted treatment failure.While treatment efficacy was similar to that reported from other resource-limited settings, mortality was higher. Early deaths may be averted by prioritizing second-line therapy for those with lower CD4 counts and by improving treatment adherence support.
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Affiliation(s)
- Vu Phuong Thao
- From the Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit (VPT, MW, NDA, JF, JD, GT, TLE); Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam (VMQ, NVVC); Hawaii Centre for AIDS, University of Hawaii at Manoa, Honolulu, Hawaii (CS, TLE); and Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Australia (SD)
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Coinfection by Hepatitis C Is Strongly Associated with Abnormal CD4/CD8 Ratio in HIV Patients under Stable ART in Salvador, Brazil. J Immunol Res 2015; 2015:174215. [PMID: 26355305 PMCID: PMC4556079 DOI: 10.1155/2015/174215] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 07/16/2015] [Indexed: 11/24/2022] Open
Abstract
Proper immune restoration (CD4 count >500 and normal CD4/8 ratio) is reached only by a fraction of HIV patients, despite stable viral suppression. Methods. We present a case-control study to compare HIV patients with viral suppression >1 year, according to immune restoration pattern: adequate response (AR) defined by CD4 > 500 cells/mm3 and CD4/8 ratio >1; partial response (PR = patients with CD4 > 500, but CD4/8 ratio <1); inadequate response (IR = CD4 < 500 cells). Results. We evaluated 293 consecutive patients (89 AR, 112 PR, and 92 IR), 70% males. Male gender (p < 0.01), lower mean CD4 nadir (p < 0.001), higher baseline VL (p = 0.01), previous diagnosis of Tb (p = 0.03), or HCV (p < 0.01) was associated with IR. Likelihood of AR/PR was similar regardless of gender, after adjusting for nadir CD4+ cells count. Longer time under suppressive ART was also associated with a greater chance of AR, but logistic regression identified coinfection by HCV as the main factor associated with abnormal CD4/CD8 ratio. Conclusion. Early initiation of ART and longer time since first undetectable PVL were predictors of AR. Previous HCV diagnosis significantly increases the risk of abnormal CD4/CD8 ratio.
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