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Stöger L, Katende A, Mapesi H, Kalinjuma AV, van Essen L, Klimkait T, Battegay M, Weisser M, Letang E. Persistent High Burden and Mortality Associated With Advanced HIV Disease in Rural Tanzania Despite Uptake of World Health Organization "Test and Treat" Guidelines. Open Forum Infect Dis 2022; 9:ofac611. [PMID: 36540386 PMCID: PMC9757676 DOI: 10.1093/ofid/ofac611] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Information about burden, characteristics, predictors, and outcomes of advanced human immunodeficiency virus disease (AHD) is scarce in rural settings of sub-Saharan Africa. Human immunodeficiency virus (HIV) infections and associated deaths remain high despite specific guidelines issued by the World Health Organization (WHO). METHODS Burden of AHD and 6-month death/loss to follow-up (LTFU) were described among 2498 antiretroviral therapy (ART)-naive nonpregnant people with HIV (PWH) aged >15 years enrolled in the Kilombero Ulanga Antiretroviral Cohort in rural Tanzania between 2013 and 2019. Baseline characteristics associated with AHD and predictors of death/LTFU among those with AHD were analyzed using multivariate logistic and Cox regression, respectively. RESULTS Of the PWH, 62.2% had AHD at diagnosis (66.8% before vs 55.7% after national uptake of WHO "test and treat" guidelines in 2016). At baseline, older age, male sex, lower body mass index, elevated aminotransferase aspartate levels, severe anemia, tachycardia, decreased glomerular filtration rate, clinical complaints, impaired functional status, and enrollment into care before 2018 were independently associated with AHD. Among people with AHD, incidence of mortality, and LTFU were 16 and 34 per 100 person-years, respectively. WHO clinical stage 3 or 4, CD4 counts <100 cells/µL, severe anemia, tachypnea, and liver disease were associated with death/LTFU. CONCLUSIONS More than 50% of PWH enrolled in our cohort after test and treat implementation still had AHD at diagnosis. Increasing HIV testing and uptake and implementation of the WHO-specific guidelines on AHD for prevention, diagnosis, treatment of opportunistic infections, and reducing the risks of LTFU are urgently needed to reduce morbidity and mortality.
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Affiliation(s)
- Linda Stöger
- ISGlobal, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | | | - Herry Mapesi
- Ifakara Health Institute, Ifakara, Tanzania,Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Aneth V Kalinjuma
- Ifakara Health Institute, Ifakara, Tanzania,Faculty of Health Sciences, Department of Epidemiology and Biostatistics, University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Liselot van Essen
- Gerion, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Thomas Klimkait
- Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland
| | - Manuel Battegay
- Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Maja Weisser
- Ifakara Health Institute, Ifakara, Tanzania,Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland,Swiss Tropical and Public Health Institute, Basel, Switzerland,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Emilio Letang
- Correspondence: Emilio Letang, MD, MPH, PhD, Barcelona Institute for Global Health, Rosselló 132, 4.1, Barcelona 08036, Spain ()
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Carlucci JG, De Schacht C, Graves E, González P, Bravo M, Yu Z, Amorim G, Arinze F, Silva W, Tique JA, Alvim MFS, Simione B, Fernando AN, Wester CW. CD4 Trends With Evolving Treatment Initiation Policies Among Children Living With HIV in Zambézia Province, Mozambique, 2012-2018. J Acquir Immune Defic Syndr 2022; 89:288-296. [PMID: 34840319 PMCID: PMC8826612 DOI: 10.1097/qai.0000000000002870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/02/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Historically, antiretroviral therapy (ART) initiation was based on CD4 criteria, but this has been replaced with "Test and Start" wherein all people living with HIV are offered ART. We describe the baseline immunologic status among children relative to evolving ART policies in Mozambique. METHODS This retrospective evaluation was performed using routinely collected data. Children living with HIV (CL aged 5-14 years) with CD4 data in the period of 2012-2018 were included. ART initiation "policy periods" corresponded to implementation of evolving guidelines: in period 1 (2012-2016), ART was recommended for CD4 <350 cells/mm3; during period 2 (2016-2017), the CD4 threshold increased to <500 cells/mm3; Test and Start was implemented in period 3 (2017-2018). We described temporal trends in the proportion of children with severe immunodeficiency (CD4 <200 cells/mm3) at enrollment and at ART initiation. Multivariable regression models were used to estimate associations with severe immunodeficiency. RESULTS The cohort included 1815 children with CD4 data at enrollment and 1922 at ART initiation. The proportion of children with severe immunodeficiency decreased over time: 20% at enrollment into care in period 1 vs. 16% in period 3 (P = 0.113) and 21% at ART initiation in period 1 vs. 15% in period 3 (P = 0.004). Children initiating ART in period 3 had lower odds of severe immunodeficiency at ART initiation compared with those in period 1 [adjusted odds ratio (aOR) = 0.67; 95% CI: 0.51 to 0.88]. Older age was associated with severe immunodeficiency at enrollment (aOR = 1.13; 95% CI: 1.06 to 1.20) and at ART initiation (aOR = 1.14; 95% CI: 1.08 to 1.21). CONCLUSIONS The proportion of children with severe immunodeficiency at ART initiation decreased alongside more inclusive ART initiation guidelines. Earlier treatment of children living with HIV is imperative.
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Affiliation(s)
- James G. Carlucci
- Vanderbilt University Medical Center, Department of Pediatrics, Division of Pediatric Infectious Diseases, Nashville, TN
- Vanderbilt University Medical Center, Institute for Global Health, Nashville, TN
| | | | - Erin Graves
- Vanderbilt University Medical Center, Institute for Global Health, Nashville, TN
| | | | | | - Zhihong Yu
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN;
| | - Gustavo Amorim
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN;
| | | | | | | | | | - Beatriz Simione
- Ministry of Health, National Directorate of Public Health, Maputo, Mozambique;
| | | | - C. William Wester
- Vanderbilt University Medical Center, Institute for Global Health, Nashville, TN
- Vanderbilt University Medical Center, Department of Medicine, Division of Infectious Diseases, Nashville, TN
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