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Brennan AT, Nattey C, Kileel EM, Rosen S, Maskew M, Stokes AC, Fox MP, Venter WD. Change in body weight and risk of hypertension after switching from efavirenz to dolutegravir in adults living with HIV: evidence from routine care in Johannesburg, South Africa. EClinicalMedicine 2023; 57:101836. [PMID: 36816348 PMCID: PMC9932660 DOI: 10.1016/j.eclinm.2023.101836] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/09/2023] [Accepted: 01/09/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The integrase strand transfer inhibitor (INSTI) dolutegravir is recommended in World Health Organization guidelines, but is associated with weight gain. We evaluated weight change in patients switching from efavirenz to dolutegravir in first-line antiretroviral therapy (ART) in Johannesburg, South Africa. METHODS We conducted a prospective cohort study of adults (≥16 years) of black African ancestry with HIV who initiated ART between January 2010-December 2020. Patients were propensity score-matched 1:1 (unexposed i.e. remaining on efavirenz: exposed i.e. switched from efavirenz to dolutegravir) on sex, age, months on ART, first ART regimen, haemoglobin, body mass index (BMI), blood pressure, viral load and CD4 count. We used linear regression to assess the effect of switching from efavirenz to dolutegravir on weight change and hypertension 12 months after exposure. FINDINGS We matched 794 patients switching to dolutegravir to 794 remaining on efavirenz. Exposed patients had a higher mean change in weight (1.78 kg; 95% confidence interval (CI):1.04,2.52 kg) from start of follow-up to 12 months vs. unexposed. We also found a 14.2 percentage point increase (95% CI: 10.6,17.7) in the risk of hypertension in those exposed to dolutegravir vs those that remained on efavirenz. INTERPRETATION In a real-world population, patients gained more weight and were at higher risk of hypertension after switching from efavirenz to dolutegravir than those remaining on efavirenz. Longer follow-up is needed, however, to determine if INSTI-associated weight gain is associated with changes in non-communicable disease risk over the long-term, or whether weight gain is sustained, as seen in clinical trials. FUNDING This study has been made possible by the generous support of the American People and the President's Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID), under the terms of cooperative agreement cooperative Agreement 72067419CA00004. In addition to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) 1K01MH105320-01A1.
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Affiliation(s)
- Alana T. Brennan
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
- Corresponding author. Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center, 3rd Floor, Boston, MA 02119, USA.
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Emma M. Kileel
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew C. Stokes
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Matthew P. Fox
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Willem D.F. Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Pascoe S, Fox M, Kane J, Mngadi S, Manganye P, Long LC, Metz K, Allen T, Sardana S, Greener R, Zheng A, Thea DM, Murray LK. Study protocol: A randomised trial of the effectiveness of the Common Elements Treatment Approach (CETA) for improving HIV treatment outcomes among women experiencing intimate partner violence in South Africa. BMJ Open 2022; 12:e065848. [PMID: 36549749 PMCID: PMC9772682 DOI: 10.1136/bmjopen-2022-065848] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Intimate partner violence (IPV) is a barrier to consistent HIV treatment in South Africa. Previous trials have established that the Common Elements Treatment Approach (CETA), a cognitive-behavioural-based intervention, is effective in reducing mental and behavioural health problems but has not been trialled for effectiveness in improving HIV outcomes. This paper describes the protocol for a randomised trial that is testing the effectiveness of CETA in improving HIV treatment outcomes among women experiencing IPV in South Africa. METHODS AND ANALYSIS We are conducting a randomised trial among HIV-infected women on antiretroviral therapy, who have experienced sexual and/or physical IPV, to test the effect of CETA on increasing retention and viral suppression and reducing IPV. Women living with HIV who have an unsuppressed viral load or are at high risk for poor adherence and report experiencing recent IPV, defined as at least once within in the last 12 months, will be recruited from HIV clinics and randomised 1:1 to receive CETA or an active attention control (text message reminders). All participants will be followed for 24 months. Follow-up HIV data will be collected passively using routinely collected medical records. HIV outcomes will be assessed at 12 and 24 months post-baseline. Questionnaires on violence, substance use and mental health will be administered at baseline, post-CETA completion and at 12 months post-baseline. Our primary outcome is retention and viral suppression (<50 copies/mL) by 12 months post-baseline. We will include 400 women which will give us 80% power to detect an absolute 21% difference between arms. Our primary analysis will be an intention-to-treat comparison of intervention and control by risk differences with 95% CIs. ETHICS AND DISSEMINATION Ethics approval provided by University of the Witwatersrand Human Research Ethics Committee (Medical), Boston University Institutional Review Board and Johns Hopkins School Institutional Review Board. Results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04242992.
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Affiliation(s)
- Sophie Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jeremy Kane
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Sithabile Mngadi
- Department of Internal Medicine, Faculty of Health Sciences University of the Witwatersrand, Johannesburg, South Africa
| | - Pertunia Manganye
- Department of Internal Medicine, Faculty of Health Sciences University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence C Long
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Boston University, Boston, Massachusetts, USA
| | - Kristina Metz
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Taylor Allen
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Srishti Sardana
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ross Greener
- Department of Internal Medicine, Faculty of Health Sciences University of the Witwatersrand, Johannesburg, South Africa
| | - Amy Zheng
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Laura K Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Murphy JP, Shumba K, Jamieson L, Nattey C, Pascoe S, Fox MP, Miot J, Maskew M. Assessment of facility-level antiretroviral treatment patient status utilizing a national-level laboratory cohort: Toward an understanding of system-level tracking and clinic switching in South Africa. Front Public Health 2022; 10:959481. [PMID: 36590005 PMCID: PMC9798405 DOI: 10.3389/fpubh.2022.959481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022] Open
Abstract
Background Most estimates of HIV retention are derived at the clinic level through antiretroviral (ART) patient management systems, which capture ART clinic visit data, yet these cannot account for silent transfers across HIV treatment sites. Patient laboratory monitoring visits may also be observed in routinely collected laboratory data, which include ART monitoring tests such as CD4 count and HIV viral load, key to our work here. Methods In this analysis, we utilized the NHLS National HIV Cohort (a system-wide viewpoint) to investigate the accuracy of facility-level estimates of retention in care for adult patients accessing care (defined using clinic visit data on patients under ART recorded in an electronic patient management system) at Themba Lethu Clinic (TLC). Furthermore, we describe patterns of facility switching among all patients and those patients classified as lost to follow-up (LTFU) at the facility level. Results Of the 43,538 unique patients in the TLC dataset, we included 20,093 of 25,514 possible patient records (78.8%) in our analysis that were linked with the NHLS National Cohort, and we restricted the analytic sample to patients initiating ART between 1 January 2007 and 31 December 2017. Most (60%) patients were female, and the median age (IQR) at ART initiation was 37 (31-45) years. We found the laboratory records augmented retention estimates by a median of 860 additional active records (about 8% of all median active records across all years) from the facility viewpoint; this augmentation was more noticeable from the system-wide viewpoint, which added evidence of activity of about one-third of total active records in 2017. In 2017, we found 7.0% misclassification at the facility-level viewpoint, a gap which is potentially solvable through data integration/triangulation. We observed 1,134/20,093 (5.6%) silent transfers; these were noticeably more female and younger than the entire dataset. We also report the most common locations for clinic switching at a provincial level. Discussion Integration of multiple data sources has the potential to reduce the misclassification of patients as being lost to care and help understand situations where clinic switching is common. This may help in prioritizing interventions that would assist patients moving between clinics and hopefully contribute to services that normalize formal transfers and fewer silent transfers.
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Affiliation(s)
- Joshua P. Murphy
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,*Correspondence: Joshua P. Murphy
| | - Khumbo Shumba
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,Department of Global Health, School of Public Health, Boston University, Boston, MA, United States
| | - Jacqui Miot
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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MacLeod WB, Bor J, Candy S, Maskew M, Fox MP, Bulekova K, Brennan AT, Potter J, Nattey C, Onoya D, Mlisana K, Stevens W, Carmona S. Cohort profile: the South African National Health Laboratory Service (NHLS) National HIV Cohort. BMJ Open 2022; 12:e066671. [PMID: 36261238 PMCID: PMC9582381 DOI: 10.1136/bmjopen-2022-066671] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE South Africa's National Health Laboratory Service (NHLS) National HIV Cohort was established in 2015 to facilitate monitoring, evaluation and research on South Africa's National HIV Treatment Programme. In South Africa, 84.8% of people living with HIV know their HIV status; 70.7% who know their status are on ART; and 87.4% on ART are virologically suppressed. PARTICIPANTS The NHLS National HIV Cohort includes the laboratory data of nearly all patients receiving HIV care in the public sector since April 2004. Patients are included in the cohort if they have received a CD4 count or HIV RNA viral load (VL) test. Using an anonymised unique patient identifier that we have developed and validated to linked test results, we observe patients prospectively through their laboratory results as they receive HIV care and treatment. Patients in HIV care are seen for laboratory monitoring every 6-12 months. Data collected include age, sex, facility location and test results for CD4 counts, VLs and laboratory tests used to screen for potential treatment complications. FINDINGS TO DATE From April 2004 to April 2018, 63 million CD4 count and VL tests were conducted at 5483 facilities. 12.6 million unique patients had at least one CD4 count or VL, indicating they had accessed HIV care, and 7.1 million patients had a VL test indicating they had started antiretroviral therapy. The creation of NHLS National HIV Cohort has enabled longitudinal research on all lab-monitored patients in South Africa's national HIV programme, including analyses of (1) patient health at presentation; (2) care outcomes such as 'CD4 recovery', 'retention in care' and 'viral resuppression'; (3) patterns of transfer and re-entry into care; (4) facility-level variation in care outcomes; and (5) impacts of policies and guideline changes. FUTURE PLANS Continuous updating of the cohort, integration with available clinical data, and expansion to include tuberculosis and other lab-monitored comorbidities.
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Affiliation(s)
- William B MacLeod
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Jacob Bor
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
- Departments of Global Health and Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sue Candy
- Centre for HIV and STIs, National Institute for Communicable Diseases, Sandringham, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
- Departments of Global Health and Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Katia Bulekova
- Research Computing Services, IS&T, Boston University, Boston, Massachusetts, USA
| | - Alana T Brennan
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
- Departments of Global Health and Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - James Potter
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Koleka Mlisana
- Academic Affairs, Research & Quality Assurance, National Health Laboratory Service, Johannesburg, South Africa
| | - Wendy Stevens
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
- National Priority Programmes, National Health Laboratory Service, Sandringham, South Africa
| | - Sergio Carmona
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
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Bor J, Kluberg SA, LaValley MP, Evans D, Hirasen K, Maskew M, Long L, Fox MP. One Pill, Once a Day: Simplified Treatment Regimens and Retention in HIV Care. Am J Epidemiol 2022; 191:999-1008. [PMID: 35081613 PMCID: PMC9989337 DOI: 10.1093/aje/kwac006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 10/27/2021] [Accepted: 01/10/2022] [Indexed: 01/04/2023] Open
Abstract
Simplified drug regimens may improve retention in care for persons with chronic diseases. In April 2013, South Africa adopted a once-daily single-pill human immunodeficiency virus (HIV) treatment regimen as the standard of care, replacing a multiple-pill regimen. Because the regimens had similar biological efficacy, the shift to single-pill therapy offered a real-world test of the impact of simplified drug-delivery mechanisms on patient behavior. Using a quasi-experimental regression discontinuity design, we assessed retention in care among patients starting HIV treatment just before and just after the guideline change. The study included 4,484 patients starting treatment at a large public sector clinic in Johannesburg, South Africa. The share of patients prescribed a single-pill regimen increased by over 40 percentage points between March and April 2013. Initiating treatment after the policy change was associated with 11.7-percentage-points' higher retention at 12 months (95% confidence interval: -2.2, 29.4). Findings were robust to different measures of retention, different bandwidths, and different statistical models. Patients starting treatment early in HIV infection-a key population in the test-and-treat era-experienced the greatest improvements in retention from single-pill regimens.
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Affiliation(s)
- Jacob Bor
- Correspondence to Dr. Jacob Bor, Departments of Global Health and Epidemiology, School of Public Health, Boston University, 801 Massachusetts Avenue, Boston, MA 02118 (e-mail: )
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Clouse K, Malope-Kgokong B, Bor J, Nattey C, Mudau M, Maskew M. The South African National HIV Pregnancy Cohort: evaluating continuity of care among women living with HIV. BMC Public Health 2020; 20:1662. [PMID: 33153468 PMCID: PMC7643452 DOI: 10.1186/s12889-020-09679-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND South Africa is home to more people living with HIV than any other country, including nearly one in three pregnant women attending antenatal care. Access to antiretroviral therapy (ART) has increased substantially since the start of the national ART program in 2004, with > 95% ART coverage during pregnancy and delivery, and vertical transmission of HIV greatly reduced. However, women who initiate ART during pregnancy are at heightened risk of dropping out of care, particularly after delivery, leading to the potential for viral transmission, morbidity and mortality. It is difficult to evaluate the success of policies of expanded access to ART care, and assess continuity of care, due to the lack of a national longitudinal HIV care database. Also, patient movement between unlinked facilities. For the first time on a national level, we propose to utilize routinely-collected laboratory data to develop and validate a cohort of pregnant women living with HIV in South Africa in a way that is uniquely robust to facility transfer. METHODS Using laboratory test data matched to facility type, we will identify entry to antenatal care to build the cohort, then describe key treatment milestones, including 1) engagement in antenatal care, 2) initiation of ART, 3) HIV viremia, and 4) continuity of HIV care in the postpartum period. Second, we will measure the effect of system-wide factors impacting continuity of care among pregnant women. We will assess policies of expanded treatment access on continuity of care using regression-discontinuity analyses. We then will assess mobility and its effect on continuity of care during and after pregnancy. Third, we will identify individual-level risk factors for loss from HIV care in order to develop targeted interventions to improve engagement in HIV care. DISCUSSION This work will create the world's largest national cohort of pregnant women living with HIV. This novel cohort will be a powerful tool available to policymakers, clinicians and researchers for improving our understanding of engagement in care among pregnant women in South Africa and assessing the performance of the South African national ART program in caring for pregnant women living with HIV. TRIAL REGISTRATION N/A (not a clinical trial).
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Affiliation(s)
- Kate Clouse
- Vanderbilt University School of Nursing, Nashville, TN USA
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN USA
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Babatyi Malope-Kgokong
- Academic Affairs and Research, National Health Laboratory Service, Johannesburg, South Africa
| | - Jacob Bor
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA USA
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Maanda Mudau
- Academic Affairs and Research, National Health Laboratory Service, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Methazia J, Ngamasana EL, Utembe W, Ogunrombi M, Nyasulu P. An investigation of maternal anaemia among HIV infected pregnant women on antiretroviral treatment in Johannesburg, South Africa. Pan Afr Med J 2020; 37:93. [PMID: 33425126 PMCID: PMC7757230 DOI: 10.11604/pamj.2020.37.93.22244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/18/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION maternal anaemia is a major public health problem in developing countries. Data suggests that anaemia contributes to the progression of Human Immunodeficiency Virus (HIV)-infection. The aim of this study was to investigate if pregnancy was an aggravating factor for anaemia among HIV-positive women on anti-retroviral treatment (ART). METHODS we analyzed data of all HIV-positive women aged 18-49 years receiving ART at Themba Lethu Clinic, Helen Joseph Hospital, Johannesburg, South Africa, from 1st April 2004- 30t hApril 2011. HIV-positive pregnant women were matched with non-pregnant women using the year of initiation of treatment. The outcome of interest ´anaemia´ was defined as "no anaemia", "anaemia" and "moderate/severe anaemia". We fitted an ordered logistic regression model to predict the likelihood of having severe/moderate anaemia versus no anaemia. We included pregnancy status as a predictor of the outcome and controlled the effect of other covariates in the analysis. RESULTS the study included 236 HIV positive patients, of which half (n=118, 50%) were pregnant. At baseline, about (n=143, 60%) of patients were anaemic. The proportion of pregnant women classified as anaemic (anaemia, moderate/severe) differed significantly (p=0.02) from that of non-pregnant women. The following characteristics were significantly associated with anaemia at baseline: Body mass index (BMI) category (p=0.01); World Health Organization (WHO) stage (p=0.001) and CD4 count (p=0.001). Seven months after initiation of treatment, the proportion of HIV positive women with anaemia decreased significantly. CONCLUSION anaemia is a significant risk factor for untoward health outcomes, especially among HIV-positive pregnant women. Early ART access might result in a significant decrease in anaemia in pregnancy.
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Affiliation(s)
- Jewelle Methazia
- Ibis Reproductive Health, Parktown, Johannesburg, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Emery Ladi Ngamasana
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Wells Utembe
- National Institute for Occupational Health, National Health Laboratory Services, Johannesburg, South Africa
| | - Modupe Ogunrombi
- Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Peter Nyasulu
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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8
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Hirasen K, Fox MP, Hendrickson CJ, Sineke T, Onoya D. HIV Treatment Outcomes Among Patients Initiated on Antiretroviral Therapy Pre and Post-Universal Test and Treat Guidelines in South Africa. Ther Clin Risk Manag 2020; 16:169-180. [PMID: 32184609 PMCID: PMC7061415 DOI: 10.2147/tcrm.s227290] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/06/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Officially rolled out on 01 September 2016, South Africa’s Universal Test and Treat (UTT) policy calls for first-line antiretroviral treatment (ART) initiation among all known HIV-positive patients, irrespective of CD4 cell count. We evaluate treatment outcomes of patients initiated on first-line ART directly before and after the implementation of UTT. Methods We analysed prospectively collected clinical cohort data among ART-naïve adult patients within two HIV clinics in Johannesburg, South Africa. We compare two groups: 1) an unexposed pre-UTT group initiating treatment from 01 December 2014 to 31 May 2015; and 2) an exposed UTT group initiating treatment from 01 December 2016 to 31 May 2017. Primary treatment outcomes included lost to follow-up (LTFU) (>90 days late for the last scheduled visit with no subsequent clinical visit). Cox proportional hazards models were used to estimate the association between pre-UTT vs UTT initiation on LTFU by 12 months. Results We included 2410 patients. A total of 1267 (52.6%) patients initiated ART before UTT implementation and 1143 (47.4%) after the change in policy. LTFU (adjusted Hazard Ratio (aHR): 1.51; 95% Confidence Interval (CI): 1.16–1.98) between groups and specifically among those initiating with a CD4 cell count ≤500 cells/mm3 (aHR: 1.59; 95% CI: 1.21–2.10) was higher among patients initiating ART under UTT. Conclusion LTFU under UTT proved higher than that of previous periods. Patients initiating first-line therapy under the treat-all policy may often start treatment in better health, subsequently not perceiving a direct benefit to treatment which may deter patients from consistent engagement in HIV treatment programmes.
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Affiliation(s)
- Kamban Hirasen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Cheryl J Hendrickson
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Hirasen K, Evans D, Jinga N, Grabe R, Turner J, Mashamaite S, Long LC, Fox MP. Using a Self-Administered Electronic Adherence Questionnaire to Identify Poor Adherence Amongst Adolescents and Young Adults on First-Line Antiretroviral Therapy in Johannesburg, South Africa. Patient Prefer Adherence 2020; 14:133-151. [PMID: 32021124 PMCID: PMC6987979 DOI: 10.2147/ppa.s210404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 09/18/2019] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The best method to measure adherence to antiretroviral therapy (ART) in resource-limited settings has not yet been established, particularly among adolescents and young adults (AYAs). The use of mobile technology may address the need for standardized tools in measuring adherence in this often marginalized population. METHODS We conducted a cross-sectional validation study among AYAs (18-35 years) attending a South African HIV clinic between 07/2015-09/2017. We determine the diagnostic accuracy of two modes of delivering an adherence questionnaire (self-administered electronic vs interviewer-administered paper-adherence questionnaire) comprising two self-reported adherence tools (South African National Department of Health (NDoH) adherence questionnaire and the Simplified Medication Adherence Questionnaire (SMAQ)) to identify poor adherence compared to; 1) a detectable viral load (≥1000 copies/mL) and 2) a sub-optimal concentration of efavirenz (EFV) (EFV ≤1.00 µg/mL) measured by therapeutic drug monitoring (TDM). RESULTS Of 278 included participants, 7.1% and 7.3% completing the electronic- and paper-questionnaires had a detectable viral load, while 14.7% and 16.5% had a sub-optimal concentration of EFV, respectively. According to viral load monitoring, the electronic-adherence questionnaire had a higher sensitivity (Se) in detecting poor adherence than the paper-based version across the NDoH adherence questionnaire (Se: 63.6% vs 33.3%) and SMAQ (Se: 90.9% vs 66.7%). In contrast, when using blood drug concentration (EFV ≤1.00 µg/mL), the paper-adherence questionnaire produced a higher sensitivity across both adherence tools; namely the NDoH adherence questionnaire (Se: 50.0% vs 38.1%) and SMAQ (Se: 75.0% vs 57.1%). CONCLUSION When using more accurate real-time measures of poor adherence such as TDM in this young adult population, we observe a higher sensitivity of an interviewer-administered paper-adherence questionnaire than an identical set of self-administered adherence questions on an electronic tablet. An interviewer-administered questionnaire may elicit more accurate responses from participants through a sense of increased accountability when engaging with health care workers.
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Affiliation(s)
- Kamban Hirasen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Correspondence: Denise Evans Tel +27 10 001 0637 Email
| | - Nelly Jinga
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rita Grabe
- Right to Care, Johannesburg, South Africa
| | | | | | - Lawrence C Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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Kaplan S, Nteso KS, Ford N, Boulle A, Meintjes G. Loss to follow-up from antiretroviral therapy clinics: A systematic review and meta-analysis of published studies in South Africa from 2011 to 2015. South Afr J HIV Med 2019; 20:984. [PMID: 31956435 PMCID: PMC6956684 DOI: 10.4102/sajhivmed.v20i1.984] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/20/2019] [Indexed: 11/05/2022] Open
Abstract
Background South Africa has the largest antiretroviral therapy (ART) programme in the world. To optimise programme outcomes, it is critical that patients are retained in care and that retention is accurately measured. Objectives To identify all studies published in South Africa from 2011 to 2015 that used loss to follow-up (LTFU) as an indicator or outcome to describe the variation in definitions and to estimate the proportion of patients lost to care across studies. Method All studies published between 01 January 2011 and October 2015 that included loss to follow-up or default from ART care in a South African cohort were included by use of a broad search strategy across multiple databases. To be included, the cohort had to include any patient ART data, including follow-up time, from 01 January 2010. Two authors, working independently, extracted data and assessed risk of bias from all manuscripts. Meta-analysis was performed for studies stratified by the same loss to follow-up definition. Results Forty-eight adult, 15 paediatric and 4 pregnant cohorts were included. Median cohort size was 3737; follow-up time ranged from 9 weeks to 5 years. Meta-analysis did not reveal an important difference in LTFU estimates in adult cohorts at 1 year between loss to follow-up defined as 3 months (11.0%, n = 4; 95% CI 10.7% – 11.2%) compared with 6 months (12.0%, n = 4; 95% CI 11.8% – 12.2%). Only two cohorts reported reliable LTFU estimates at 5 years: this was 25.1% (95% CI 24.8% – 25.4%). Conclusion South Africa should standardise a LTFU definition. This would aid in monitoring and evaluation of ART programmes, with the broader goal of improving patient outcomes.
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Affiliation(s)
- Samantha Kaplan
- Department of Internal Medicine, University of Washington, Seattle, United States
| | - Katleho S Nteso
- Medical Care Development International, Maseru, Lesotho, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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11
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Mokhele I, Mashamaite S, Majuba P, Xulu T, Long L, Onoya D. Effective public-private partnerships for sustainable antiretroviral therapy: outcomes of the Right to Care health services GP down-referral program. BMC Public Health 2019; 19:1471. [PMID: 31699063 PMCID: PMC6836664 DOI: 10.1186/s12889-019-7660-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/20/2019] [Indexed: 11/14/2022] Open
Abstract
Background The recently increased access to antiretroviral therapy (ART) in South Africa has placed additional strain on human and infrastructure resources of the public health sector. Capacity from private-sector General Practitioners (GPs) could be leveraged to ease the current burden on the public health sector. Methods We conducted a retrospective record review of routine electronic medical record data on a systematic sample of HIV-infected adults (≥18 years old) initiated on ART at a tertiary hospital outpatient HIV clinic in Johannesburg, South Africa and down-referred to private-GPs for continued care after stabilization on ART. We compared these patients (“GP down-referred”) to a control-cohort who remained at the referring site (“Clinic A”) and patients from a regional hospital outpatient HIV clinic not offering down-referral to GPs (“Clinic B”). Study outcomes assessed are viral load suppression (VL < 50 copies/ml) and attrition from care (all-cause-mortality or > 90-days late for a last-scheduled visit) by 12 months of follow-up following down-referral or eligibility. Results A total of 3685 patients, comprising 373 (10.1%) GP down-referred, 2599 (70.5%) clinic A controls, and 713 (19.4%) clinic B controls were included in the analysis. Overall, 1535 patients (53.3%) had a suppressed viral load. A higher portion of GP down-referred patients had a suppressed viral load compared to clinic A and B patients (65.7% vs 49.1% vs 58.9%). After adjusting for demographic and baseline clinical covariates, we found no difference in viral load suppression between GP down-referred and control patients (adjusted relative risk [aRR] for clinic A vs GP down-referred 1.0; 95% CI: 0.9–1.1), (aRR for clinic B vs GP down-referred 1.0; 95% CI: 0.9–1.2). Clinic B controls experienced the highest attrition compared to GP down-referred and clinic A controls (33.2% vs 11.3% vs 5.9%) and had a higher risk of attrition compared to GP down-referred patients (adjusted hazard ratio [aHR] 4.2; 95% CI: 2.8–6.5), whereas clinic B controls had a lower risk of attrition (aHR 0.5; 95% CI: 0.3–0.7). Conclusions and recommendations Our results show that private-GPs can contribute to caring for stabilized public sector HIV patients on life-long ART. However, they require special efforts to improve retention in care.
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Affiliation(s)
- Idah Mokhele
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | | | | | | | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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12
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Pascoe SJS, Fox MP, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser‐Hurt N. Differentiated HIV care in South Africa: the effect of fast-track treatment initiation counselling on ART initiation and viral suppression as partial results of an impact evaluation on the impact of a package of services to improve HIV treatment adherence. J Int AIDS Soc 2019; 22:e25409. [PMID: 31691521 PMCID: PMC6831947 DOI: 10.1002/jia2.25409] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 09/06/2019] [Accepted: 09/25/2019] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION In response to suboptimal adherence and retention, South Africa's National Department of Health developed and implemented National Adherence Guidelines for Chronic Diseases. We evaluated the effect of a package of adherence interventions beginning in January 2016 and report on the impact of Fast-Track Treatment Initiation Counselling (FTIC) on ART initiation, adherence and retention. METHODS We conducted a cluster-randomized mixed-methods evaluation in 4 provinces at 12 intervention sites which implemented FTIC and 12 control facilities providing standard of care. Follow-up was by passive surveillance using clinical records. We included data on subjects eligible for FTIC between 08 Jan 2016 and 07 December 2016. We adjusted for pre-intervention differences using difference-in-differences (DiD) analyses controlling for site-level clustering. RESULTS We enrolled 362 intervention and 368 control arm patients. Thirty-day ART initiation was 83% in the intervention and 82% in the control arm (RD 0.5%; 95% CI: -5.0% to 6.0%). After adjusting for baseline ART initiation differences and covariates using DiD we found a 6% increase in ART initiation associated with FTIC (RD 6.3%; 95% CI: -0.6% to 13.3%). We found a small decrease in viral suppression within 18 months (RD -2.8%; 95% CI: -9.8% to 4.2%) with no difference after adjustment (RD: -1.9%; 95% CI: -9.1% to 5.4%) or when considering only those with a viral load recorded (84% intervention vs. 86% control). We found reduced crude 6-month retention in intervention sites (RD -7.2%; 95% CI: -14.0% to -0.4%). However, differences attenuated by 12 months (RD: -3.6%; 95% CI: -11.1% to 3.9%). Qualitative data showed FTIC counselling was perceived as beneficial by patients and providers. CONCLUSIONS We saw a short-term ART-initiation benefit to FTIC (particularly in districts where initiation prior to intervention was lower), with no reductions but also no improvement in longer-term retention and viral suppression. This may be due to lack of fidelity to implementation and delivery of those components that support retention and adherence. FTIC must continue to be implemented alongside other interventions to achieve the 90-90-90 cascade and fidelity to post-initiation counselling sessions must be monitored to determine impact on longer-term outcomes. Understanding the cost-benefit and role of FTIC may then be warranted.
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Affiliation(s)
- Sophie JS Pascoe
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
| | - Amy N Huber
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | | | - Sydney Rosen
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | | | - Yogan Pillay
- National Department of HealthPretoriaSouth Africa
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13
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Growth curve modelling to determine distinct BMI trajectory groups in HIV-positive adults on antiretroviral therapy in South Africa. AIDS 2019; 33:2049-2059. [PMID: 31577571 DOI: 10.1097/qad.0000000000002302] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Obesity is a major long-term concern in HIV-positive patients due to the pathogenic link between obesity and noncommunicable chronic diseases (NCDs). We aim to characterize changes in BMI over time on antiretroviral therapy (ART) and investigate the association between weight gain and survival in South Africa. DESIGN AND METHODS A prospective cohort study among HIV-positive adults on first-line ART between April 2004 and 2015 in Johannesburg, South Africa. We used latent-class growth modelling (adjusted for age, sex and CD4 cell count) to identify groups of individuals with similar patterns of change in BMI over time. RESULTS Eleven thousand, two hundred and sixty-three patients were included. The best fit model involved two linear and two quadratic trajectories. Thirty-five percent of patients were categorized into group one (mean BMI at ART initiation, 20.4 kg/m; mean BMI after 8 years of follow-up, 20.9 kg/m), 38% into group two (24.5-26.2 kg/m), 21% into group three (29.5-32.6 kg/m) and 6% into group four (36.5-40.0 kg/m). Over the 8 years of follow-up, 6% of our cohort went down in BMI standard category, while 45% went up. The largest increase occurred in the first 12 months on ART. In years 2 through 8, we saw a more gradual increase in BMI. CONCLUSION The largest gain in BMI in HIV patients occurred in the first year on ART. During follow-up, over 50% of our population changed BMI categories putting them at an increased risk for NCDs. Consistent counselling on nutritional and lifestyle changes could help improve ART patients' long-term health outcomes.
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14
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Mbengue MAS, Chasela C, Onoya D, Mboup S, Fox MP, Evans D. Clinical predictor score to identify patients at risk of poor viral load suppression at six months on antiretroviral therapy: results from a prospective cohort study in Johannesburg, South Africa. Clin Epidemiol 2019; 11:359-373. [PMID: 31191029 PMCID: PMC6511618 DOI: 10.2147/clep.s197741] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/27/2019] [Indexed: 02/05/2023] Open
Abstract
Purpose: As countries work toward 90:90:90 targets, early identification of patients with inadequate response to antiretroviral therapy (ART) is critical for achieving optimal HIV treatment outcomes. We developed and evaluated a clinical prediction score (CPS) to identify HIV-positive patients at risk of poor viral load suppression at 6 months on ART. Patients and methods: We conducted a prospective cohort study of HIV-positive ART naïve adults (≥18 years) initiating standard first-line ART between February 2012 and April 2014 at Themba Lethu Clinic in Johannesburg, South Africa. We used Modified Poisson regression to estimate the association between patient characteristics and poor viral load suppression, defined as a viral load ≥400 copies/mL at 6 months on ART. We developed a CPS following the Spiegel Halter and Knill-Jones approach and determined the diagnostic accuracy compared to viral load as the "gold standard". We identified the optimal cutoff at which the CPS would identify those at risk of poor viral load suppression. Results: Among 353 patients, 67.7% had a viral load measurement at 6 months on ART and 30.1% of these were viremic (≥400 copies/mL). Male gender, platelet count <150 cells/mm3, ≥7 days late for ≥2 ARV visits, visual analog scale (VAS) <90% and <14.5 fL increase in mean cell volume from baseline to 6 months were included in the CPS. The optimal cutoff was 5 (≥5 vs <5; sensitivity [Se] 65.3%, specificity [Sp] 46.7%) and the CPS performed better than standard measures of adherence (eg, VAS Se 24.5%; Simplified Medication Adherence Questionnaire Se 26.5%). Conclusion: Our findings suggest a 6-month CPS may have the potential to identify patients at risk of poor viral load suppression. The CPS may be used to target patients who need intensive adherence support, with the caveat that there may be a three- to four-fold increase in the pool of patients identified for adherence counseling.
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Affiliation(s)
- Mouhamed Abdou Salam Mbengue
- Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Biostatistics and Health Economics, IRESSEF: Institute of Health Research, Epidemiologic Surveillance and Training, Dakar, Senegal
| | - Charles Chasela
- Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Epidemiology and Strategic Information, HIV/AIDS, STIs & TB, Human Sciences Research Council, Pretoria, South Africa
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Souleymane Mboup
- Department of Biostatistics and Health Economics, IRESSEF: Institute of Health Research, Epidemiologic Surveillance and Training, Dakar, Senegal
| | - Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Magidson JF, Iyer HS, Regenauer KS, Grelotti DJ, Dietrich JJ, Courtney I, Tshabalala G, Orrell C, Gray GE, Bangsberg DR, Katz IT. Recreational ART use among individuals living with HIV/AIDS in South Africa: Examining longitudinal ART initiation and viral suppression. Drug Alcohol Depend 2019; 198:192-198. [PMID: 30953938 PMCID: PMC6644059 DOI: 10.1016/j.drugalcdep.2019.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/30/2019] [Accepted: 02/03/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND South Africa has the highest number of people living with HIV (PLWH) and one of the largest antiretroviral therapy (ART) programs globally. High rates of substance use comorbidity exist, including speculation of recreational ART use (i.e., mixing ART with other illicit drugs). Recreational ART use may affect viral load among PLWH due to ART nonadherence and/or viral resistance; however, prior quantitative research has not examined rates of recreational ART use, nor associations with HIV treatment outcomes longitudinally. METHODS Data were drawn from a prospective, observational cohort study (n = 500) of ART-eligible adults recruited from two HIV voluntary counseling and testing centers in Cape Town, and Johannesburg, South Africa. Multiple logistic regression models assessed recreational ART use as a predictor of ART initiation over six months and viral load suppression over nine months, above and beyond other substance use (binge drinking and illicit drug use). RESULTS Approximately 5% (n = 24) reported recreational ART use, which was less frequent in Cape Town compared to Johannesburg (AOR = 0.025; 95%CI: 0.003-0.19; p < 0.001). Recreational ART use was not significantly associated with ART initiation or viral suppression. Other substance use, but not recreational ART use, was significantly associated with lower odds of ART initiation (AOR = 0.54; 95%CI: 0.33-0.87; p = .01) and viral suppression (AOR = 0.47; 95%CI: 0.25-0.89; p = .02). CONCLUSIONS Recreational ART use was infrequent and not uniquely associated with ART initiation or viral suppression. Findings suggest that comorbid use of other substances is ultimately what may make recreational ART use problematic for ongoing engagement in care and viral suppression.
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Affiliation(s)
- Jessica F Magidson
- Department of Psychology, University of Maryland, College Park, 4095 Campus Drive, College Park, MD, USA.
| | - Hari S Iyer
- Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, USA.
| | - Kristen S Regenauer
- Department of Psychiatry, Massachusetts General Hospital, One Bowdoin Square, Boston, MA, USA.
| | - David J Grelotti
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA.
| | - Janan J Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
| | - Ingrid Courtney
- Department of Medicine and the Institute of Infectious Disease and Molecular Medicine, Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, ZA, South Africa.
| | - Gugu Tshabalala
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
| | - Catherine Orrell
- Department of Medicine and the Institute of Infectious Disease and Molecular Medicine, Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, ZA, South Africa.
| | - Glenda E Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Office of the President, South African Medical Research Council, Western Cape, ZA, South Africa.
| | - David R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA.
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Massachusetts General Hospital Center for Global Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Hendrickson C, Moolla A, Maskew M, Long L, Fox MP, Sanne I, Majuba P, Pascoe S. "Even if you're HIV-positive there's life after if you take your medication": experiences of people on long-term ART in South Africa: a short report. AIDS Care 2019; 31:973-978. [PMID: 30913899 DOI: 10.1080/09540121.2019.1597960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
South Africa's national antiretroviral treatment (ART) programme, initiated in 2004, is the largest HIV treatment programme in the world with an estimated 4.2 million people on ART. Today, an HIV diagnosis is no longer associated with certain death, but is rather a manageable chronic disease, with all HIV-positive patients now eligible to receive treatment. In this study, we explore patient experiences at the onset of the ART programme, including facilitators and barriers around decision-making along the HIV care cascade (HIV testing, ART initiation, retention, and adherence). We conducted twenty-four in-depth interviews among adults (≥18 years old) who initiated ART between April 2004 and March 2005 and were alive, on treatment at enrolment (October 2015-March 2016) at a large public-sector clinic in Johannesburg, South Africa. Data were analysed using a thematic analysis approach. Patients cited physical wellbeing, responsibility for raising children, supportive clinic staff and noticeable improvements in health on ART as key facilitators to continued care. In contrast, changing clinic conditions, fear of side-effects and stigma were mentioned as barriers. This study provides a unique lens through which to evaluate factors associated with long-term retention and adherence to ART at a crucial time in ART programming when more people will be initiating life-long treatment. We must continue to focus on supportive and empathetic clinic environments, more convenient ways to access medication for patients, and developing tools or interventions that continue to address the issues of stigma and discrimination and build the support networks for all those on treatment.
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Affiliation(s)
- C Hendrickson
- a Health Economics and Epidemiology Research Office, Faculty of Health Sciences, Department of Internal Medicine, School of Clinical Medicine , University of the Witwatersrand , Johannesburg , South Africa
| | - A Moolla
- a Health Economics and Epidemiology Research Office, Faculty of Health Sciences, Department of Internal Medicine, School of Clinical Medicine , University of the Witwatersrand , Johannesburg , South Africa
| | - M Maskew
- a Health Economics and Epidemiology Research Office, Faculty of Health Sciences, Department of Internal Medicine, School of Clinical Medicine , University of the Witwatersrand , Johannesburg , South Africa
| | - L Long
- a Health Economics and Epidemiology Research Office, Faculty of Health Sciences, Department of Internal Medicine, School of Clinical Medicine , University of the Witwatersrand , Johannesburg , South Africa.,b Department of Global Health , Boston University School of Public Health , Boston , MA , USA
| | - M P Fox
- a Health Economics and Epidemiology Research Office, Faculty of Health Sciences, Department of Internal Medicine, School of Clinical Medicine , University of the Witwatersrand , Johannesburg , South Africa.,b Department of Global Health , Boston University School of Public Health , Boston , MA , USA.,c Department of Epidemiology , Boston University School of Public Health , Boston , MA , USA
| | - I Sanne
- a Health Economics and Epidemiology Research Office, Faculty of Health Sciences, Department of Internal Medicine, School of Clinical Medicine , University of the Witwatersrand , Johannesburg , South Africa.,d Right to Care , Johannesburg , South Africa.,e Clinical HIV Research Unit, Faculty of Health Sciences, Department of Internal Medicine, School of Clinical Medicine , University of the Witwatersrand , Johannesburg , South Africa
| | - P Majuba
- d Right to Care , Johannesburg , South Africa
| | - S Pascoe
- a Health Economics and Epidemiology Research Office, Faculty of Health Sciences, Department of Internal Medicine, School of Clinical Medicine , University of the Witwatersrand , Johannesburg , South Africa
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Abstract
Introduction Understanding the occurrence of antiretroviral (ARV)-related adverse events (AEs) among patients receiving second-line antiretroviral therapy (ART) is important in preventing switches to more limited and expensive third-line regimens. Objective This study aimed to estimate the rates and examine predictors of AEs among adult HIV-1-infected patients receiving second-line ART in the Right to Care (RTC) clinical cohort in South Africa. Methods This was a cohort study of HIV-1-infected adult patients (≥ 18 years of age) initiating standard second-line ART in South Africa from 1 April 2004 to 10 January 2016. Our primary outcome was the development of an AE within 24 months of initiating second-line therapy. We used Kaplan–Meier survival analysis to determine AE incidence in the first 24 months of second-line ART. Predictors of AEs were modelled using a Cox proportional hazards model. Results A total of 7708 patients initiated second-line ART, with 44.5% developing at least one AE over the first 24 months of second-line treatment. The highest AE incidence was observed among patients receiving abacavir (ABC) + lamivudine (3TC) + ritonavir-boosted lopinavir/atazanavir (LPVr/ATVr) (52.7/100 person-years (PYs), 95% confidence interval (CI): 42.9–64.8), while patients initiated on a tenofovir (TDF) + emtricitabine (FTC)/3TC + LPVr regimen had the lowest rate of AEs (26.4/100 PYs, 95% CI: 24.9–28.3). Clinical predictors of AEs included experiencing AEs when receiving first-line ART (adjusted hazard ratio (aHR) 2.3, 95% CI: 1.9–2.8), lower CD4 cell count (0–199 vs. ≥ 350 cells/mm3; aHR 1.4, 95% CI: 1.4–1.8), and switching to second-line therapy from an ABC-base first-line regimen (ABC + 3TC + efavirenz/nevirapine [EFV/NVP] vs. TDF + 3TC/FTC + EFV/NVP; aHR 3.4, 95% CI: 1.1–11.1). Conclusions The rates of AEs were lowest among patients receiving a TDF-based second-line regimen. Patients with poorer health at the time of switch were at higher risk of AEs when receiving second-line ART and may require closer monitoring to improve the durability of second-line therapy.
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Butler I, MacLeod W, Majuba PP, Tipping B. Human immunodeficiency virus infection and older adults: A retrospective single-site cohort study from Johannesburg, South Africa. South Afr J HIV Med 2018; 19:838. [PMID: 30568838 PMCID: PMC6295827 DOI: 10.4102/sajhivmed.v19i1.838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 06/08/2018] [Indexed: 11/01/2022] Open
Abstract
Introduction HIV-infected adults aged over 50 years in South Africa are increasing. This study explored differences between baseline characteristics and 12-month outcomes of younger and older HIV-infected adults initiated on antiretroviral therapy (ART). Additionally, associations with outcomes within the older group were sought. Methods We retrospectively reviewed treatment-naive HIV-infected adult patients at ART initiation. Patients aged 18.0-39.9 years were compared to patients aged over 50 years using log-binomial regression for baseline characteristics and 12-month outcomes. Within the older group, outcome associations were found using multivariate regression. Results The older cohort (n = 1635) compared to the younger cohort (n = 10726) comprised more males (47.2% vs. 35.4%, PR 1.52, p < 0.05), smokers (12.9% vs. 9.7%, PR 1.32, p < 0.05) and overweight patients (26.0% vs. 20.0%, PR 1.32, p < 0.05). Fewer older patients had tuberculosis (10.2% vs. 15.3%, PR 0.67, p < 0.05), other opportunistic infections (16.9% vs. 23.3%, PR 0.70, p < 0.05), World Health Organization stage 3/4 disease (39.9% vs. 43.2%, PR 0.89, p < 0.05), anaemia (22.8% vs. 28.4%, PR 0.77, p < 0.05), liver dysfunction (17.1% vs. 21.3%, PR 0.83, p < 0.05) or low CD4+ count < 100 cells/mm3 (56.3% vs. 59.9%, PR 0.71, p < 0.05).Mortality was higher in the older cohort (11.3% vs. 7.5%, PR 1.48, p < 0.05). Virological suppression was greater in the older cohort (89.5% vs. 86.5%, PR 1.28, p < 0.05) but CD4+ restitution was lower (62.8% vs. 75.0%, PR 0.61, p < 0.05). There was no difference in treatment complications between the groups.Within the older cohort, associations with death were as follows: age > 55 years (PR 1.47, p < 0.05), an AIDS-defining condition (PR 2.28, p < 0.05), raised ALT (PR 1.53, p < 0.05) and CD4+ < 100 cells/mm3 (PR 2.15, p < 0.05). Associations with favourable treatment response at 12 months were unemployment (PR 1.18, p < 0.05) and raised ALT (PR 1.19, p < 0.05). Associations with a treatment complication at 12 months were unemployment (PR 1.12, p < 0.05), smoking (PR 1.20, p < 0.05) and nevirapine use (PR 1.36, p < 0.05) but secondary education was protective (PR 0.87, p < 0.05). Conclusion HIV-infected South African adults aged over 50 years differ in characteristics and outcomes compared to their younger counterparts and justify specialised management within HIV treatment facilities.
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Affiliation(s)
- India Butler
- Division of Geriatric Medicine, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - William MacLeod
- Health Economics and Epidemiology Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | | | - Brent Tipping
- Division of Geriatric Medicine, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
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Fox MP, Pascoe SJS, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Effectiveness of interventions for unstable patients on antiretroviral therapy in South Africa: results of a cluster-randomised evaluation. Trop Med Int Health 2018; 23:1314-1325. [PMID: 30281882 DOI: 10.1111/tmi.13152] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND As loss from HIV care is an ongoing challenge globally, interventions are needed for patients who don't achieve or maintain ART stability. The 2015 South African National Adherence Guidelines (AGL) for Chronic Diseases include two interventions targeted at unstable patients: early tracing of patients who miss visits (TRIC) and enhanced adherence counselling (EAC). METHODS As part of a cluster-randomised evaluation at 12 intervention and 12 control clinics in four provinces, intervention sites implemented the AGL interventions, while control sites retained standard care. We report on outcomes of EAC for patients with an elevated viral load (>400 copies/ml) and for TRIC patients who missed a visit by >5 days. We estimated risk differences (RD) of 3 and 12-month viral resuppression (<400 copies/ml) and 12-month retention with cluster adjustment using generalised estimating equations and controlled for imbalances using difference-in-differences compared to all eligible in 2015, prior to intervention roll-out. RESULTS For EAC, we had 358 intervention and 505 control site patients (61% female, median ART initiation CD4 count 154 cells/μl). We found no difference between arms in 3-month resuppression (RD: -1.7%; 95%CI: -4.3% to 0.9%), but <20% of patients had a repeat viral load within 3 months (19.8% intervention, 13.5% control). Including the entire clinic population eligible for EAC with a repeat viral load at all evaluation sites (n = 934), intervention sites showed a small increase in 3-month resuppression (28% vs. 25%, RD 3.0%; 95%CI: -2.7% to 8.8%). Adjusting for baseline differences increased the RD to 8.1% (95% CI: -0.1% to 17.2%). However, we found no differences in 12-month suppression (RD: 1.5%; 95% CI: -14.1% to 17.1% but suppression was low overall at 40%) or retention (RD: 2.8%; 95% CI: -7.5% to 13.2%). For TRIC, we enrolled 155 at intervention sites and 248 at control sites (44% >40 years, 67% female, median CD4 count 212 cells/μl). We found no difference between groups in return to care by 12 months (RD: -6.8%; 95% CI: -17.7% to 4.8%). During the study period, control sites continued to use tracing within standard care, however, potentially masking intervention effects. CONCLUSIONS Enhanced adherence counselling showed no benefit over 12 months. Implementation of the tracing intervention under the new guidelines was similar to the standard of care. Interventions that aim to return unstable patients to care should incorporate active monitoring to determine if the interventions are effective.
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Affiliation(s)
- Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Sophie J S Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy N Huber
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
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20
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Hendrickson CJ, Pascoe SJS, Huber AN, Moolla A, Maskew M, Long LC, Fox MP. "My future is bright…I won't die with the cause of AIDS": ten-year patient ART outcomes and experiences in South Africa. J Int AIDS Soc 2018; 21:e25184. [PMID: 30318848 PMCID: PMC6186968 DOI: 10.1002/jia2.25184] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 08/13/2018] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION South Africa is moving into a new era of HIV treatment with "treat all" policies where people may be on treatment for most of their lives. We need to understand treatment outcomes and facilitators of long-term antiretroviral treatment (ART) adherence and retention-in-care in the South African context. In one of the first studies to investigate long-term treatment outcomes in South Africa, we aimed to describe ten-year patient outcomes at a large public-sector HIV clinic in Johannesburg and explore patient experiences of the treatment programme over this time in order to ascertain factors that may aid or hinder long-term adherence and retention. METHODS We conducted a cohort analysis (n = 6644) and in-depth interviews (n = 24) among HIV-positive adults initiating first-line ART between April 2004 and March 2007. Using clinical records, we ascertained twelve-month and ten-year all-cause mortality and loss to follow-up (LTF). Cox proportional hazards regression was used to identify baseline predictors of attrition (mortality and LTF (>3 months late for the last scheduled visit)) at twelve months and ten years. Twenty-four patients were purposively selected and interviewed to explore treatment programme experiences over ten years on ART. RESULTS Excluding transfers, 79.5% (95% confidence intervals (CI): 78.5 to 80.5) of the cohort were alive, in care at twelve months dropping to 35.1% (95% CI: 33.7 to 36.4) at ten years. Over 44% of deaths occurred within 12 months. Ten-year all-cause mortality increased, while LTF decreased slightly, with age. Year and age at ART initiation, sex, nationality, baseline CD4 count, anaemia, body mass index and initiating regimen were predictors of ten-year attrition. Among patients interviewed, the pretreatment clinic environment, feelings of gratitude and good fortune, support networks, and self-efficacy were facilitators of care; side effects, travel and worsening clinical conditions were barriers. Participants were generally optimistic about their futures and were committed to continued care. CONCLUSIONS This study demonstrates the complexities of long-term chronic HIV treatment with declining all-cause mortality and increasing LTF over ten years. Barriers to long-term retention still present a significant challenge. As more people become eligible for ART in South Africa under "treatment for all," new healthcare delivery challenges will arise; interventions are needed to ensure long-term programme successes continue.
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Affiliation(s)
- Cheryl J Hendrickson
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sophie J S Pascoe
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Amy N Huber
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Aneesa Moolla
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Mhairi Maskew
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Lawrence C Long
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Matthew P Fox
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
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21
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Shearer K, Evans D, Xhosa B, Hirasen K, Bracken C, Mahomed K, Long L, Fox MP. Low prevalence of depressive symptoms among stable patients on antiretroviral therapy in Johannesburg, South Africa. PLoS One 2018; 13:e0203797. [PMID: 30252844 PMCID: PMC6155448 DOI: 10.1371/journal.pone.0203797] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 08/28/2018] [Indexed: 11/27/2022] Open
Abstract
Background Depression is a leading cause of disability and may be associated with decreased adherence to ART. We sought to describe the prevalence of depressive symptoms and outcomes one year after screening among patients receiving ART at a large HIV Clinic in Johannesburg, South Africa. Methods Adult (≥18) patients who had been on first-line ART between 6–18 months who could communicate in English were eligible. Depressive symptoms were evaluated using the Patient Health Questionnaire (PHQ)-9 and a score ≥10 indicated depression. Results 97 patients enrolled. Patients had been on ART for a median (IQR) of 8 (7–10) months, 61% were female, the median (IQR) age at enrollment was 38 (33–42) years, and the median (IQR) CD4 count at ART initiation was 154.5 (65–263) cells/mm3. 7 (7%) patients were found to have symptoms of depression; 4 (4%) had symptoms of moderate depression (PHQ score of 10–14) and 3 (3%) had symptoms of moderate/severe depression (PHQ score of 15–19). Women (10%) were more likely to have symptoms of depression than men (3%; prevalence difference [PD]: 7.5%; 95% confidence interval [CI]:-1.7%-16.8%); as were patients under the age of 30 (14%) compared to those 30–39 (4%; PD: -10.2; 95% CI: -29.4–9.0%) or ≥40 (9%; PD: -5.5%; -26.1%-15.2%), those with lower CD4 counts at ART initiation (<200 cells/mm3 vs ≥200 cells/mm3: 8% vs 3%; PD: 4.8%; 95% CI: -4.5%-14.0%), and those with high viral loads (>1000 copies/mL vs. <400 copies/mL: 40% vs. 5%; PD: 34.6%; 95% CI: -8.6%-77.6%). No relationship between depressive symptoms and retention in HIV care one year after screening was observed. Conclusions We found a lower prevalence of depressive symptoms compared to findings from other HIV-positive populations in South Africa but more than one-third of patients with an elevated viral load had evidence of depression. Further research on the relationship between depression, adherence, and viral failure is warranted as this may present an opportunity for early interventions to improve treatment outcomes and reduce the need for second-line treatment.
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Affiliation(s)
- Kate Shearer
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Barbara Xhosa
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kamban Hirasen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Craig Bracken
- Department of Psychiatry, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
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de Waal R, Cohen K, Boulle A, Fox MP, Maartens G, Igumbor EU, Davies MA. Routine data underestimates the incidence of first-line antiretroviral drug discontinuations due to adverse drug reactions: Observational study in two South African cohorts. PLoS One 2018; 13:e0203530. [PMID: 30183766 PMCID: PMC6124775 DOI: 10.1371/journal.pone.0203530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/22/2018] [Indexed: 02/06/2023] Open
Abstract
Introduction Estimating the incidence of antiretroviral discontinuations due to adverse drug reactions (ADRs) is important to inform antiretroviral treatment (ART) regimen recommendations, and to guide prescribing and monitoring policies. Routinely collected clinical data is a useful source of pharmacovigilance data. We estimated the incidences of first-line antiretroviral discontinuations due to ADRs using routine clinical data, and compared them with incidences estimated using data enhanced by folder review, in two South African cohorts. Methods We included patients 16 years and older on first-line ART. We selected a stratified random sample of 25% for checking of ART prescription data and reasons for antiretroviral discontinuations retrospectively, including folders reviews where required (enhanced-data sample). We estimated the incidence of antiretroviral discontinuations using Kaplan-Meier and competing risk analyses. Results In 15396 patients, 40% had a first-line antiretroviral discontinuation by three years on ART. We could determine the reason for 65% of discontinuations using routine data only, and 84% of discontinuations, in the enhanced-data sample of 3837 patients. ADR was the most common reason for discontinuations. In the enhanced-data sample, the cumulative incidence of discontinuations due to ADRs by three years was 30.4% (95% CI: 24.4–36.6) for stavudine; 2.0% (95% CI: 1.5–2.6) for tenofovir, and 1.3% (95% CI: 0.8–2.1) for efavirenz. Using routine data only, the cumulative incidences of discontinuations due to ADRs by three years for stavudine, tenofovir, and efavirenz respectively were 23.9% (95% CI: 20.3–27.7), 1.2% (95% CI: 0.9–1.4) and 0.5% (95% CI: 0.3–0.7). Conclusions Although the relative rankings were similar using routine or enhanced data, lack of checking for missing reasons for discontinuation resulted in underestimates of the incidence of antiretroviral discontinuations due to ADRs. Systems to improve data collection of reasons for regimen changes prospectively would increase the capacity of routine data to answer pharmacovigilance questions.
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Affiliation(s)
- Reneé de Waal
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Matthew P. Fox
- Boston University Departments of Epidemiology and Global Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ehimario U. Igumbor
- US Centers for Disease Control and Prevention, Division of Global HIV & TB, Pretoria, South Africa
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
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Fox MP, Bor J, Brennan AT, MacLeod WB, Maskew M, Stevens WS, Carmona S. Estimating retention in HIV care accounting for patient transfers: A national laboratory cohort study in South Africa. PLoS Med 2018; 15:e1002589. [PMID: 29889844 PMCID: PMC5995345 DOI: 10.1371/journal.pmed.1002589] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 05/17/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Systematic reviews have described high rates of attrition in patients with HIV receiving antiretroviral therapy (ART). However, migration and clinical transfer may lead to an overestimation of attrition (death and loss to follow-up). Using a newly linked national laboratory database in South Africa, we assessed national retention in South Africa's national HIV program. METHODS AND FINDINGS Patients receiving care in South Africa's national HIV program are monitored through regular CD4 count and viral load testing. South Africa's National Health Laboratory Service has maintained a database of all public-sector CD4 count and viral load results since 2004. We linked individual laboratory results to patients using probabilistic matching techniques, creating a national HIV cohort. Validation of our approach in comparison to a manually matched dataset showed 9.0% undermatching and 9.5% overmatching. We analyzed data on patients initiating ART in the public sector from April 1, 2004, to December 31, 2006, when ART initiation could be determined based on first viral load among those whose treatment followed guidelines. Attrition occurred on the date of a patient's last observed laboratory measure, allowing patients to exit and reenter care prior to that date. All patients had 6 potential years of follow-up, with an additional 2 years to have a final laboratory measurement to be retained at 6 years. Data were censored at December 31, 2012. We assessed (a) national retention including all laboratory tests regardless of testing facility and (b) initiating facility retention, where laboratory tests at other facilities were ignored. We followed 55,836 patients initiating ART between 2004 and 2006. At ART initiation, median age was 36 years (IQR: 30-43), median CD4 count was 150 cells/mm3 (IQR: 81-230), and 66.7% were female. Six-year initiating clinic retention was 29.1% (95% CI: 28.7%-29.5%). After allowing for transfers, national 6-year retention was 63.3% (95% CI: 62.9%-63.7%). Results differed little when tightening or relaxing matching procedures. We found strong differences in retention by province, ranging from 74.2% (95% CI: 73.2%-75.2%) in Western Cape to 52.2% (95% CI: 50.6%-53.7%) in Mpumalanga at 6 years. National attrition was higher among patients initiating at lower CD4 counts and higher viral loads, and among patients initiating ART at larger facilities. The study's main limitation is lack of perfect cohort matching, which may lead to over- or underestimation of retention. We also did not have data from KwaZulu-Natal province prior to 2010. CONCLUSIONS In this study, HIV care retention was substantially higher when viewed from a national perspective than from a facility perspective. Our results suggest that traditional clinical cohorts underestimate retention.
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Affiliation(s)
- Matthew P. Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Alana T. Brennan
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - William B. MacLeod
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Wendy S. Stevens
- National Health Laboratory Service, Johannesburg, South Africa
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
| | - Sergio Carmona
- National Health Laboratory Service, Johannesburg, South Africa
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Evans D, Hirasen K, Berhanu R, Malete G, Ive P, Spencer D, Badal-Faesen S, Sanne IM, Fox MP. Predictors of switch to and early outcomes on third-line antiretroviral therapy at a large public-sector clinic in Johannesburg, South Africa. AIDS Res Ther 2018; 15:10. [PMID: 29636106 PMCID: PMC5891887 DOI: 10.1186/s12981-018-0196-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While efficacy data exist, there are limited data on the outcomes of patients on third-line antiretroviral therapy (ART) in sub-Saharan Africa in actual practice. Being able to identify predictors of switch to third-line ART will be essential for planning for future need. We identify predictors of switch to third-line ART among patients with significant viraemia on a protease inhibitor (PI)-based second-line ART regimen. Additionally, we describe characteristics of all patients on third-line at a large public sector HIV clinic and present their early outcomes. METHODS Retrospective analysis of adults (≥ 18 years) on a PI-based second-line ART regimen at Themba Lethu Clinic, Johannesburg, South Africa as of 01 August 2012, when third-line treatment became available in South Africa, with significant viraemia on second-line ART (defined as at least one viral load ≥ 1000 copies/mL on second-line ART after 01 August 2012) to identify predictors of switch to third-line (determined by genotype resistance testing). Third-line ART was defined as a regimen containing etravirine, raltegravir or ritonavir boosted darunavir, between August 2012 and January 2016. To assess predictors of switch to third-line ART we used Cox proportional hazards regression among those with significant viraemia on second-line ART after 01 August 2012. Then among all patients on third-line ART we describe viral load suppression, defined as a viral load < 400 copies/mL, after starting third-line ART. RESULTS Among 719 patients in care and on second-line ART as of August 2012 (with at least one viral load ≥ 1000 copies/mL after 01 August 2012), 36 (5.0% over a median time of 54 months) switched to third-line. Time on second-line therapy (≥ 96 vs. < 96 weeks) (adjusted Hazard Ratio (aHR): 2.53 95% CI 1.03-6.22) and never reaching virologic suppression while on second-line ART (aHR: 3.37 95% CI 1.47-7.73) were identified as predictors of switch. In a separate cohort of patients on third-line ART, 78.3% (47/60) and 83.3% (35/42) of those in care and with a viral load suppressed their viral load at 6 and 12 months, respectively. CONCLUSIONS Our results show that the need for third-line is low (5%), but that patients' who switch to third-line ART have good early treatment outcomes and are able to suppress their viral load. Adherence counselling and resistance testing should be prioritized for patients that are at risk of failure, in particular those who never suppress on second-line and those who have been on PI-based regimen for extended periods.
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Evans D, Dahlberg S, Berhanu R, Sineke T, Govathson C, Jonker I, Lönnermark E, Fox MP. Social and behavioral factors associated with failing second-line ART - results from a cohort study at the Themba Lethu Clinic, Johannesburg, South Africa. AIDS Care 2018; 30:863-870. [PMID: 29463102 DOI: 10.1080/09540121.2017.1417527] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Poor adherence is a main challenge to successful second-line ART in South Africa. Studies have shown that patients can re-suppress their viral load following intensive adherence counselling. We identify factors associated with failure to re-suppress on second-line ART. The study was a retrospective cohort study which included HIV-positive adults who experienced an elevated viral load ≥400 copies/ml on second-line ART between January 2013-July 2014, had completed an adherence counselling questionnaire and had a repeat viral load result recorded within 6 months of intensive adherence counselling. Log-binomial regression was used to evaluate the association between patient characteristics and social, behavioral or occupational factors and failure to suppress viral load (≥400 copies/ml). A total of 128 patients were included in the analysis, and of these 39% (n = 50) failed to re-suppress their viral load. Compared to those who suppressed, far more patients who failed to suppress reported living with family (44.2% vs. 23.7%), missing a dose in the past week (53.3% vs. 30.0%), using traditional/herbal medications (63.2% vs. 34.3%) or had symptoms suggestive of depression (57.7% vs. 34.3%). These patient-related factors could be targeted for interventions to reduce the risk for treatment failure and prevent switching to expensive third-line ART.
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Affiliation(s)
- Denise Evans
- a Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Sara Dahlberg
- b Department of Infectious Diseases , Sahlgrenska Academy, University of Gothenburg , Göteborg , Sweden
| | - Rebecca Berhanu
- c Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Tembeka Sineke
- a Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Caroline Govathson
- a Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Ingrid Jonker
- c Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Elisabet Lönnermark
- b Department of Infectious Diseases , Sahlgrenska Academy, University of Gothenburg , Göteborg , Sweden
| | - Matthew P Fox
- d Center for Global Health & Development , Boston University , Boston , USA.,e Department of Epidemiology , Boston University School of Public Health , Boston , USA
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Nnambalirwa M, Govathson C, Evans D, McNamara L, Maskew M, Nyasulu P. Markers of poor adherence among adults with HIV attending Themba Lethu HIV Clinic, Helen Joseph Hospital, Johannesburg, South Africa. Trans R Soc Trop Med Hyg 2018; 110:696-704. [PMID: 28938050 PMCID: PMC5914359 DOI: 10.1093/trstmh/trx003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 02/05/2017] [Indexed: 11/15/2022] Open
Abstract
Background To date, there is no consensus on ideal ways to measure antiretroviral treatment (ART) adherence in resource limited settings. This study aimed to identify markers of poor adherence to ART. Methods Retrospective data of HIV-positive ART-naïve adults initiating standard first-line ART at Themba Lethu Clinic, Helen Joseph Hospital, Johannesburg, South Africa from April 2004 to December 2011 were analysed. Poisson regression models with robust error variance were used to assessed the following potential markers of poor adherence ‘last self-reported adherence, missed clinic visits, mean corpuscular volume (MCV), CD4 count against definition of adherence, suppressed HIV viral load using traditional test metrics’. Results A total of 11 724 patients were eligible; 1712 (14.6%) had unsuppressed viral load within 6 months after initiating ART. The main marker of poor adherence was a combination of change in CD4 count and MCV; change in CD4 ≥expected and change in MCV <14.5 fL (RR 2.82, 95% CI 2.16–3.67), change in CD4 <expected and change in MCV <14.5 fL (RR 5.49, 95% CI 4.13–7.30) compared to change in CD4 ≥expected and change in MCV ≥14.5 fL. Conclusions A combination of less than expected increase in CD4 and MCV at 6 months after treatment initation was found to be a marker of poor adherence. This could help identify and monitor poor treatment adherence in the absence of viral load testing.
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Affiliation(s)
- Maria Nnambalirwa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Caroline Govathson
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lynne McNamara
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Peter Nyasulu
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Public Health, School of Health Sciences, Monash University, Johannesburg, South Africa
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Fox MP, Pascoe SJ, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Assessing the impact of the National Department of Health's National Adherence Guidelines for Chronic Diseases in South Africa using routinely collected data: a cluster-randomised evaluation. BMJ Open 2018; 8:e019680. [PMID: 29358446 PMCID: PMC5781226 DOI: 10.1136/bmjopen-2017-019680] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION In 2016, South Africa's National Department of Health (NDOH) launched the National Adherence Guidelines for Chronic Diseases for phased implementation throughout South Africa. Early implementation of a 'minimum package' of eight interventions in the Adherence Guidelines for patients with HIV is being undertaken at 12 primary health clinics and community health centres in four provinces. NDOH and its partners are evaluating the impact of five of the interventions in four provinces in South Africa. METHODS AND ANALYSIS The minimum package is being delivered at the 12 health facilities under NDOH guidance and through local health authorities. The five evaluation interventions are: (1) fast track initiation counselling for patients eligible for antiretroviral therapy (ART); (2) adherence clubs for stable ART patients; (3) decentralised medication delivery for stable ART patients; (4) enhanced adherence counselling for unstable ART patients; and (5) early tracing of patients who miss an appointment by ≥5 days. For evaluation, NDOH matched the 12 intervention clinics with 12 comparison clinics and randomly allocated one member of each pair to intervention or comparison (standard of care) status within pairs, allowing evaluation of the interventions using a matched cluster-randomised design. The evaluation uses data routinely collected by the clinics, with no study interaction with subjects to prevent influencing the primary outcomes. Enrolment began on 20 June 2016 and was completed on 16 December 2016. A total of 3456 patients were enrolled and will now be followed for 14 months to estimate effects on short-term and final outcomes. Primary outcomes include viral suppression, retention and medication pickups, evaluated at two time points during follow-up. ETHICS AND DISSEMINATION The study received approval from the University of Witwatersrand Human Research Ethics Committee and Boston University Institutional Review Board. Results will be presented to key stakeholders and at international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02536768; Pre-results.
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Affiliation(s)
- Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie J Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy N Huber
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
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Hirasen K, Evans D, Maskew M, Sanne IM, Shearer K, Govathson C, Malete G, Kluberg SA, Fox MP. The right combination - treatment outcomes among HIV-positive patients initiating first-line fixed-dose antiretroviral therapy in a public sector HIV clinic in Johannesburg, South Africa. Clin Epidemiol 2017; 10:17-29. [PMID: 29296098 PMCID: PMC5739109 DOI: 10.2147/clep.s145983] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Long-term antiretroviral therapy (ART) adherence is critical for achieving optimal HIV treatment outcomes. Fixed-dose combination (FDC) single-pill regimens, introduced in South Africa in April 2013, has simplified pill taking. We evaluated treatment outcomes among patients initiated on a FDC compared to a similar multi-pill ART regimen in Johannesburg, South Africa. Methods We conducted a retrospective cohort study of ART-naïve HIV-positive non-pregnant adult (≥18 years) patients without tuberculosis who initiated first-line ART on tenofovir and emtricitabine or lamivudine with efavirenz at Themba Lethu Clinic in Johannesburg, South Africa. We compared those initiated on a multi-pill ART regimen (3–5 pills/day; September 1, 2011–August 31, 2012) to those initiated on a FDC ART regimen (one pill/day; September 1, 2013–August 31, 2014). Treatment outcomes included attrition (combination of lost to follow-up and mortality), missed medical visits, and virologic suppression (viral load <400 copies/mL) by 12 months post-ART initiation. Cox proportional hazards models and Poisson regression were used to estimate the association between FDCs vs multiple pills and treatment outcomes. Results We included 3151 patients in our analysis; 2230 (70.8%) patients initiated multi-pill ART and 921 (29.2%) patients initiated on a FDC. By 12 months post-initiation, attrition (adjusted hazard ratio: 0.98; 95% CI: 0.77–1.24) was similar across regimen types (FDC vs multi-pill). Although not significant, patients on a FDC were marginally more likely to achieve viral suppression by 6 (adjusted relative rate [aRR]: 1.10; 95% CI: 0.99–1.23) and 12 months (aRR: 1.12; 95% CI: 0.92–1.36) on ART. Patients initiated on a FDC were significantly less likely to miss medical visits during the first 12 months of treatment (aRR: 0.66; 95% CI: 0.52–0.83). Conclusion Our results suggest FDCs may have a role to play in supporting patient adherence and medical monitoring through improved medical visit attendance. This may potentially improve treatment outcomes later on in treatment.
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Affiliation(s)
- Kamban Hirasen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ian M Sanne
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Right to Care, Johannesburg, South Africa.,Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kate Shearer
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Caroline Govathson
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Given Malete
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sheryl A Kluberg
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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Rohner E, Sengayi M, Goeieman B, Michelow P, Firnhaber C, Maskew M, Bohlius J. Cervical cancer risk and impact of Pap-based screening in HIV-positive women on antiretroviral therapy in Johannesburg, South Africa. Int J Cancer 2017; 141:488-496. [PMID: 28440019 PMCID: PMC5504282 DOI: 10.1002/ijc.30749] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 04/07/2017] [Accepted: 04/13/2017] [Indexed: 12/28/2022]
Abstract
Data on invasive cervical cancer (ICC) incidence in HIV-positive women and the effect of cervical cancer screening in sub-Saharan Africa are scarce. We estimated i) ICC incidence rates in women (≥18 years) who initiated antiretroviral therapy (ART) at the Themba Lethu Clinic (TLC) in Johannesburg, South Africa, between 2004 and 2011 and ii) the effect of a Pap-based screening program. We included 10,640 women; median age at ART initiation: 35 years [interquartile range (IQR) 30-42], median CD4 count at ART initiation: 113 cells/µL (IQR 46-184). During 27,257 person-years (pys), 138 women were diagnosed with ICC; overall incidence rate: 506/100,000 pys [95% confidence interval (CI) 428-598]. The ICC incidence rate was highest (615/100,000 pys) in women who initiated ART before cervical cancer screening became available in 04/2005 and was lowest (260/100,000 pys) in women who initiated ART from 01/2009 onward when the cervical cancer screening program and access to treatment of cervical lesions was expanded [adjusted hazard ratio (aHR) 0.42, 95% CI 0.20-0.87]. Advanced HIV/AIDS stage (4 versus 1, aHR 1.95, 95% CI 1.17-3.24) and middle age at ART initiation (36-45 versus 18-25 years, aHR 2.51, 95% CI 1.07-5.88) were risk factors for ICC. The ICC incidence rate substantially decreased with the implementation of a Pap-based screening program and improved access to treatment of cervical lesions. However, the risk of developing ICC after ART initiation remained high. To inform and improve ICC prevention and care for HIV-positive women in sub-Saharan Africa, implementation and monitoring of cervical cancer screening programs are essential.
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Affiliation(s)
- Eliane Rohner
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | - Mazvita Sengayi
- National Cancer Registry, National Health Laboratory Service, Johannesburg, South Africa
| | | | - Pamela Michelow
- Cytology Unit, Department of Anatomical Pathology, University of the Witwatersrand, Johannesburg, South Africa
- Cytology Unit, National Health Laboratory Service, Johannesburg, South Africa
| | - Cynthia Firnhaber
- Right to Care, Johannesburg, South Africa
- Department of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Julia Bohlius
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
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Fox MP, Maskew M, Brennan AT, Evans D, Onoya D, Malete G, MacPhail P, Bassett J, Ebrahim O, Mabotja D, Mashamaite S, Long L, Sanne I. Cohort profile: the Right to Care Clinical HIV Cohort, South Africa. BMJ Open 2017; 7:e015620. [PMID: 28601835 PMCID: PMC5724130 DOI: 10.1136/bmjopen-2016-015620] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 02/26/2017] [Accepted: 04/03/2017] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The research objectives of the Right to Care Clinical HIV Cohort analyses are to: (1) monitor treatment outcomes (including death, loss to follow-up, viral suppression and CD4 count gain among others) for patients on antiretroviral therapy (ART); (2) evaluate the impact of changes in the national treatment guidelines around when to initiate ART on HIV treatment outcomes; (3) evaluate the impact of changes in the national treatment guidelines around what ART regimens to initiate on drug switches; (4) evaluate the cost and cost-effectiveness of HIV treatment delivery models; (5) evaluate the need for and outcomes on second-line and third-line ART; (6) evaluate the impact of comorbidity with non-communicable diseases on HIV treatment outcomes and (7) evaluate the impact of the switch to initiating all patients onto ART regardless of CD4 count. PARTICIPANTS The Right to Care Clinical HIV Cohort is an open cohort of data from 10 clinics in two provinces within South Africa. All clinics include data from 2004 onwards. The cohort currently has data on over 115 000 patients initiated on HIV treatment and patients are followed up every 3-6 months for clinical and laboratory monitoring. FINDINGS TO DATE Cohort data includes information on demographics, clinical visit, laboratory data, medication history and clinical diagnoses. The data have been used to identify rates and predictors of first-line failure, to identify predictors of mortality for patients on second-line (eg, low CD4 counts) and to show that adolescents and young adults are at increased risk of unsuppressed viral loads compared with adults. FUTURE PLANS Future analyses will inform national models of HIV care and treatment to improve HIV care policy in South Africa.
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Affiliation(s)
- Matthew P Fox
- Department of Global Health, Boston University School of Public Health, , Boston , , Massachusetts, , USA
- Department of Epidemiology, Boston University, , Boston , , Massachusetts, , USA
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Mhairi Maskew
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Alana T Brennan
- Department of Global Health, Boston University School of Public Health, , Boston , , Massachusetts, , USA
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
- Department of Epidemiology, Boston University, , Boston , , Massachusetts, , USA
| | - Denise Evans
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Dorina Onoya
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Given Malete
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Patrick MacPhail
- Right to Care, , Johannesburg , , South Africa
- Department of Medicine, Clinical HIV Research Unit, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Jean Bassett
- Witkoppen Health and Welfare Centre, , Johannesburg , , South Africa
| | | | | | | | - Lawrence Long
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Ian Sanne
- Department of Medicine, Clinical HIV Research Unit, University of the Witwatersrand, , Johannesburg , , South Africa
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Changes in estimated glomerular filtration rate over time in South African HIV-1-infected patients receiving tenofovir: a retrospective cohort study. J Int AIDS Soc 2017; 20:21317. [PMID: 28406595 PMCID: PMC5515088 DOI: 10.7448/ias.20.01/21317] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Introduction: Tenofovir has been associated with decline in kidney function, but in patients with low baseline kidney function, improvements over time have been reported. Additionally, the magnitude and trajectory of estimated glomerular filtration rate (eGFR) changes may differ according to how eGFR is calculated. We described changes in eGFR over time, and the incidence of, and risk factors for, kidney toxicity, in a South African cohort. Methods: We included antiretroviral-naïve patients ≥16 years old who started tenofovir-containing antiretroviral therapy (ART) between 2002 and 2013. We calculated eGFR using the Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), and Cockcroft-Gault equations. We described changes in eGFR from ART initiation using linear mixed effects regression. We described the incidence of eGFR <30 mL/min on treatment, and identified associations with low eGFR using Cox regression. Results: We included 15156 patients with median age of 35.4 years (IQR 29.9–42.0), median CD4 cell count of 168 cells/µL (IQR 83–243), and median eGFR (MDRD) of 98.6 mL/min (IQR 84.4–115.6). Median duration of follow up on tenofovir was 12.9 months (IQR 5.1–23.3). Amongst those with a baseline and subsequent eGFR available, mean eGFR change from baseline at 12 months was −4.4 mL/min (95% CI −4.9 to −4.0), −2.3 (−2.5 to −2.1), and 0.6 (0.04 to 1.2) in those with baseline eGFR ≥90 mL/min; and 11.9 mL/min (11.0 to 12.7), 14.6 (13.5 to 15.7), and 11.0 (10.3 to 11.7) in those with baseline eGFR <90 mL/min, according to the MDRD, CKD-EPI (n = 11 112), and Cockcroft-Gault (n = 9 283) equations, respectively. Overall, 292 (1.9%) patients developed eGFR <30 mL/min. Significant associations with low eGFR included older age, baseline eGFR <60 mL/min, CD4 count <200 cells/µL, body weight <60 kg, and concomitant protease inhibitor use. Conclusions: Patients on tenofovir with baseline eGFR ≥90 mL/min experienced small but significant declines in eGFR over time when eGFR was estimated using the MDRD or CKD-EPI equations. However, eGFR increased in patients with eGFR <90 mL/min, regardless of which estimating equation was used. Decreases to below 30 mL/min were uncommon. In settings with limited access to laboratory testing, monitoring guidelines should consider focusing on higher risk patients.
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Onoya D, Nattey C, Budgell E, van den Berg L, Maskew M, Evans D, Hirasen K, Long LC, Fox MP. Predicting the Need for Third-Line Antiretroviral Therapy by Identifying Patients at High Risk for Failing Second-Line Antiretroviral Therapy in South Africa. AIDS Patient Care STDS 2017; 31:205-212. [PMID: 28445088 PMCID: PMC5446602 DOI: 10.1089/apc.2016.0291] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Although third-line antiretroviral therapy (ART) is available in South Africa's public sector, its cost is substantially higher than first and second line. Identifying risk factors for failure on second-line treatment remains crucial to reduce the need for third-line drugs. We conducted a case-control study including 194 adult patients (≥18 years; 70 cases and 124 controls) who initiated second-line ART in Johannesburg, South Africa. Unconditional logistic regression was used to assess predictors of virologic failure (defined as 2 consecutive viral load measures ≥1000 copies/mL, ≥3 months after switching to second line). Variables included a social instability index, ART adherence, self-reported as well as diagnosed adverse drug reactions (ADRs), HIV disclosure, depression, and factors affecting access to HIV clinics. Overall 60.0% of cases and 54.0% of controls were female. Mean ages of cases and controls were 41.8 ± 9.6 and 43.3 ± 8.0, respectively. Virologic failure was predicted by ART adherence <90% [odds ratio (OR) 4.7; 95% confidence interval (95% CI): 2.1-10.5], younger age (<40 years of age; OR 0.6; 95% CI: 0.3-1.1), high social instability (OR 3.8; 95% CI: 1.30-11.5), self-reported ADR (OR 1.9; 95% CI: 1.0-3.5), disclosure to friends/colleagues rather than partner/relatives (OR 3.4; 95% CI: 1.3-9.1), and medium/high depression compared to low/no depression (OR 4.4; 95% CI: 1.5-13.4). Our results suggest complex socioeconomic factors contributing to risk of virologic failure, possibly by impacting ART adherence, among patients on second-line therapy in South Africa. Identifying patients with possible indicators of nonadherence could facilitate targeted interventions to reduce the risk of second-line treatment failure and mitigate the demand for third-line regimens.
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Affiliation(s)
- Dorina Onoya
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Eric Budgell
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kamban Hirasen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence C. Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
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Jamieson L, Evans D, Brennan AT, Moyo F, Spencer D, Mahomed K, Maskew M, Long L, Rosen S, Fox MP. Changes in elevated cholesterol in the era of tenofovir in South Africa: risk factors, clinical management and outcomes. HIV Med 2017; 18:595-603. [PMID: 28332270 DOI: 10.1111/hiv.12495] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2016] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Antiretroviral therapy (ART) has been associated with unfavourable lipid profile changes and increased risk of cardiovascular disease (CVD). With a growing population on ART in South Africa, there has been concern about the increase in noncommunicable diseases such as CVD. We determined risk factors associated with increased total cholesterol (TC) in a large cohort on ART and describe the clinical management thereof. METHODS We conducted an observational cohort study of ART-naïve adults initiating standard first-line ART in a large urban clinic in Johannesburg, South Africa. TC was measured annually for most patients. A proportional hazards regression model was used to determine risk factors associated with incident high TC (≥ 6 mmol/L). RESULTS Significant risk factors included initial regimen non-tenofovir vs. tenofovir [hazard ratio (HR) 1.54; 95% confidence interval (CI) 1.14-2.08], age ≥40 vs. <30 years (HR 3.22; 95% CI 2.07-4.99), body mass index (BMI) ≥ 30 kg/m2 (HR 1.65; 95% CI 1.18-2.31) and BMI 25-29.9 kg/m2 (HR 1.70; 95% CI 1.30-2.23) vs. 18-24.9 kg/m2 , and baseline CD4 count < 50 cells/μL (HR 1.55; 95% CI 1.10-2.20) and 50-99 cells/μL (HR 1.40; 95% CI 1.00-1.97) vs. > 200 cells/μL. Two-thirds of patients with high TC were given cholesterol-lowering drugs, after repeat TC measurements about 12 months apart, while 31.8% were likely to have received dietary counselling only. CONCLUSIONS Older age, higher BMI, lower CD4 count and a non-tenofovir regimen were risk factors for incident elevated TC. Current guidelines do not indicate regular cholesterol testing at ART clinic visits, which are the main exposure to regular clinical monitoring for most HIV-positive individuals. If regular cholesterol monitoring is conducted, improvements can be made to identify and treat patients sooner.
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Affiliation(s)
- L Jamieson
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - D Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - A T Brennan
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - F Moyo
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - D Spencer
- Right to Care, Johannesburg, South Africa
| | - K Mahomed
- Right to Care, Johannesburg, South Africa
| | - M Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - L Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - S Rosen
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - M P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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Shearer K, Clouse K, Meyer-Rath G, MacLeod W, Maskew M, Sanne I, Long L, Fox MP. Citizenship status and engagement in HIV care: an observational cohort study to assess the association between reporting a national ID number and retention in public-sector HIV care in Johannesburg, South Africa. BMJ Open 2017; 7:e013908. [PMID: 28119389 PMCID: PMC5278236 DOI: 10.1136/bmjopen-2016-013908] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE In many resource-limited settings, people from rural areas migrate to urban hubs in search of work. Thus, urban public-sector HIV clinics in South Africa (SA) often cater to both local residents and patients from other provinces and/or countries. The objective of this analysis was to compare programmatic treatment outcomes by citizenship status in an urban clinic in SA. SETTING An urban public-sector HIV treatment facility in Johannesburg, SA. PARTICIPANTS We included all antiretroviral therapy (ART)-naïve, non-pregnant patients who initiated standard first-line treatment from January 2008 to December 2013. 12 219 patients were included and 59.5% were women. PRIMARY OUTCOME MEASURE Patients were followed from ART initiation until death, transfer, loss to follow-up (LTF), or data set closure. We describe attrition (mortality and LTF) stratified by SA citizenship status (confirmed SA citizens (with national ID number), unconfirmed SA citizens (no ID), and foreign nationals) and model the risk of attrition using Cox proportional hazards regression. RESULTS 70% of included patients were confirmed SA citizens, 19% were unconfirmed SA citizens, and 11% were foreign nationals. Unconfirmed SA citizens were far more likely to die or become LTF than other patients. A similar proportion of foreign nationals (18.2%) and confirmed SA citizens (17.7%) had left care at 1 year compared with 47.0% of unconfirmed SA citizens (adjusted hazard ratio (aHR) unconfirmed SA vs confirmed SA: 2.68; 95% CI 2.42 to 2.97). By the end of follow-up, 75.5% of unconfirmed SA citizens had left care, approximately twice that of any other group. CONCLUSIONS Unconfirmed SA citizens were more likely to drop out of care after ART initiation than other patients. Further research is needed to determine whether this observed attrition is representative of migration and/or self-transfer to another HIV clinic as such high rates of attrition pose challenges for the success of the national ART programme.
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Affiliation(s)
- Kate Shearer
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kate Clouse
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, USA
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - William MacLeod
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ian Sanne
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Right to Care, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
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Maskew M, Bor J, Hendrickson C, MacLeod W, Bärnighausen T, Pillay D, Sanne I, Carmona S, Stevens W, Fox MP. Imputing HIV treatment start dates from routine laboratory data in South Africa: a validation study. BMC Health Serv Res 2017; 17:41. [PMID: 28095905 PMCID: PMC5240407 DOI: 10.1186/s12913-016-1940-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 12/08/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Poor clinical record keeping hinders health systems monitoring and patient care in many low resource settings. We develop and validate a novel method to impute dates of antiretroviral treatment (ART) initiation from routine laboratory data in South Africa's public sector HIV program. This method will enable monitoring of the national ART program using real-time laboratory data, avoiding the error potential of chart review. METHODS We developed an algorithm to impute ART start dates based on the date of a patient's "ART workup", i.e. the laboratory tests used to determine treatment readiness in national guidelines, and the time from ART workup to initiation based on clinical protocols (21 days). To validate the algorithm, we analyzed data from two large clinical HIV cohorts: Hlabisa HIV Treatment and Care Programme in rural KwaZulu-Natal; and Right to Care Cohort in urban Gauteng. Both cohorts contain known ART initiation dates and laboratory results imported directly from the National Health Laboratory Service. We assessed median time from ART workup to ART initiation and calculated sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) of our imputed start date vs. the true start date within a 6 month window. Heterogeneity was assessed across individual clinics and over time. RESULTS We analyzed data from over 80,000 HIV-positive adults. Among patients who had a workup and initiated ART, median time to initiation was 16 days (IQR 7,31) in Hlabisa and 21 (IQR 8,43) in RTC cohort. Among patients with known ART start dates, SE of the imputed start date was 83% in Hlabisa and 88% in RTC, indicating this method accurately predicts ART start dates for about 85% of all ART initiators. In Hlabisa, PPV was 95%, indicating that for patients with a lab workup, true start dates were predicted with high accuracy. SP (100%) and NPV (92%) were also very high. CONCLUSIONS Routine laboratory data can be used to infer ART initiation dates in South Africa's public sector. Where care is provided based on protocols, laboratory data can be used to monitor health systems performance and improve accuracy and completeness of clinical records.
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Affiliation(s)
- Mhairi Maskew
- Heath Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jacob Bor
- Heath Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. .,Department of Global Health, Boston University School of Public Health, Boston, MA, USA. .,Africa Health Research Institute, Somkhele, South Africa. .,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.
| | - Cheryl Hendrickson
- Heath Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - William MacLeod
- Heath Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Till Bärnighausen
- Africa Health Research Institute, Somkhele, South Africa.,Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, South Africa.,Division of Infection and Immunity, University College London, London, UK
| | - Ian Sanne
- Heath Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, Clinical HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sergio Carmona
- National Health Laboratory Service, Johannesburg, South Africa
| | - Wendy Stevens
- National Health Laboratory Service, Johannesburg, South Africa.,Department of Molecular Medicine and Hematology, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Heath Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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Brennan AT, Bor J, Davies MA, Conradie F, Maskew M, Long L, Sanne I, Fox MP. Tenofovir stock shortages have limited impact on clinic- and patient-level HIV treatment outcomes in public sector clinics in South Africa. Trop Med Int Health 2016; 22:241-251. [PMID: 27862762 DOI: 10.1111/tmi.12811] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Using data from four public sector clinics in South Africa, we sought to investigate provider- and patient-level outcomes, to understand how the 2012 tenofovir stock shortage affected the HIV care and monitoring of ART patients. METHODS Prospective cohort analysis of ART-naïve, non-pregnant, HIV-infected patients >18 years initiating first-line ART between 1 July 2011-31 March 2013. Linear regression was used for all outcomes (number of ART initiates, days between pharmacy visits, transfers, single-drug substitutions, treatment interruptions, missed pharmacy visits, loss to follow-up and elevated viral load). We fit splines to smooth curves with knots at the beginning (1 February 2012) and end (31 August 2012) of the stock shortage and displayed results graphically by clinic. Difference-in-difference models were used to evaluate the effect of the stock shortage on outcomes. RESULTS Results suggest a potential shift in the management of patients during the shortage, mainly fewer average days between visits during the shortage vs. before or after at all four clinics, and a significant difference in the proportion of patients missing visits during vs. before (RD: 1.2%; 95% CI: 0.5%, 2.0%). No significant difference was seen in other outcomes. CONCLUSION While South Africa has made great strides to extend access to ART and increase the quality of the health services provided, patient care can be affected when stock shortages/outs occur. While our results show little effect on treatment outcomes, this most likely reflects the clinics' ability to mitigate the crisis by continuing to keep patient care and treatment as consistent as possible.
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Affiliation(s)
- Alana T Brennan
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, Cape Town, South Africa
| | - Francesca Conradie
- Clinical HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ian Sanne
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Clinical HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa.,Right to Care, Johannesburg, South Africa
| | - Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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Shearer K, Evans D, Moyo F, Rohr JK, Berhanu R, Van Den Berg L, Long L, Sanne I, Fox MP. Treatment outcomes of over 1000 patients on second-line, protease inhibitor-based antiretroviral therapy from four public-sector HIV treatment facilities across Johannesburg, South Africa. Trop Med Int Health 2016; 22:221-231. [PMID: 27797443 PMCID: PMC5288291 DOI: 10.1111/tmi.12804] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objectives To report predictors of outcomes of second‐line ART for HIV treatment in a resource‐limited setting. Methods All adult ART‐naïve patients who initiated standard first‐line treatment between April 2004 and February 2012 at four public‐sector health facilities in Johannesburg, South Africa, experienced virologic failure and initiated standard second‐line therapy were included. We assessed predictors of attrition (death and loss to follow‐up [≥3 months late for a scheduled visit]) using Cox proportional hazards regression and predictors of virologic suppression (viral load <400 copies/ml ≥3 months after switch) using modified Poisson regression with robust error estimation at 1 year and ever after second‐line ART initiation. Results A total of 1236 patients switched to second‐line treatment in a median (IQR) of 1.9 (0.9‐4.6) months after first‐line virologic failure. Approximately 13% and 45% of patients were no longer in care at 1 year and at the end of follow‐up, respectively. Patients with low CD4 counts (<50 vs. ≥200, aHR: 1.85; 95% CI: 1.03–3.32) at second‐line switch were at greater risk for attrition by the end of follow‐up. About 75% of patients suppressed by 1 year, and 85% had ever suppressed by the end of follow‐up. Conclusions Patients with poor immune status at switch to second‐line ART were at greater risk of attrition and were less likely to suppress. Additional adherence support after switch may improve outcomes.
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Affiliation(s)
- Kate Shearer
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Faith Moyo
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Julia K Rohr
- Center for Global Health & Development, Boston University, Boston, MA, USA
| | | | | | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ian Sanne
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Right to Care, Johannesburg, South Africa.,Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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Can Short-Term Use of Electronic Patient Adherence Monitoring Devices Improve Adherence in Patients Failing Second-Line Antiretroviral Therapy? Evidence from a Pilot Study in Johannesburg, South Africa. AIDS Behav 2016; 20:2717-2728. [PMID: 27146828 PMCID: PMC5069329 DOI: 10.1007/s10461-016-1417-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
High levels of adherence are required to achieve the full benefit of ART. We assess the effectiveness of electronic adherence monitoring devices among patients failing second-line ART, as measured by viral load suppression. Cohort study of Wisepill™ real-time adherence monitoring in addition to intensified adherence counselling over 3 months in adults with a viral load ≥400 copies/ml on second-line ART in Johannesburg, South Africa between August 2013 and January 2014. Patients were sent SMS reminders upon missing a scheduled dose. We compared outcomes to earlier historical cohorts receiving either intensified adherence counselling or adherence counselling alone. Overall, 63 % of the participants (31/49) took >80 % of their prescribed medication; this dropped from 76 to 53 and 49 % at 1, 2 and 3 months post-enrolment respectively. Compared to those with good adherence (>80 %), participants with poor adherence (≤80 %) had a higher risk for a subsequently elevated viral load ≥400 copies/ml (relative risk (RR) 1.47 95 % CI 0.97–2.23). Participants found the intervention “acceptable and useful” but by 6 months after eligibility they were only slightly more likely to be alive, in care and virally suppressed compared to those who received intensified adherence counselling (44.9 vs. 38.5 %; RR 1.19; 95 % CI 0.85–1.67) or adherence counselling alone (44.9 vs. 40.9 %; RR 1.12; 95 % CI 0.81–1.56). In patients with an elevated viral load on second-line ART electronic adherence monitoring was associated with a modest, but not significant, improvement in viral suppression.
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Insights into Adherence among a Cohort of Adolescents Aged 12-20 Years in South Africa: Reported Barriers to Antiretroviral Treatment. AIDS Res Treat 2016; 2016:4161738. [PMID: 27867661 PMCID: PMC5102702 DOI: 10.1155/2016/4161738] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/05/2016] [Indexed: 12/27/2022] Open
Abstract
Adolescents experience disproportionately high rates of poor ART outcomes compared to adults despite prolonged use of antiretroviral therapy in Southern African treatment programs, presenting a significant challenge to national attempts to meet the UNAIDS 90-90-90 targets for 2020. This cohort study among adolescents aged 12-20 years accessing ART care at two urban public-sector clinics in Johannesburg between September and November 2013 aimed to identify factors potentially associated with poor attendance at clinic visits. Patients were followed up through routine medical records to identify missed visits (failing to attend clinic within 30 days of scheduled visit date) up to 2 years after enrolment. We enrolled 126 adolescents on ART for a median of 6.3 years (IQR: 2.7-8.4). A total of 47 (38%) adolescents missed a scheduled visit within 24 months of enrolment. Older adolescents (18-20 years) were more likely to miss a visit compared to adolescents aged 12-14 years (risk ratio (RR) = 1.72; 95% CI: 1.00-2.95). Those who were identified to have difficulty in taking medication (RR = 1.57; 95% CI: 1.13-2.18) as a barrier to care were more likely to miss a visit compared to adolescents who did not. Awareness of treatment fatigue, challenges to taking ART, and caregiver difficulties is important when considering interventions to improve treatment outcomes among adolescents.
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Platt MO, Evans D, Keegan PM, McNamara L, Parker IK, Roberts LM, Caulk AW, Gleason RL, Seifu D, Amogne W, Penny C. Low-Cost Method to Monitor Patient Adherence to HIV Antiretroviral Therapy Using Multiplex Cathepsin Zymography. Mol Biotechnol 2016; 58:56-64. [PMID: 26589706 DOI: 10.1007/s12033-015-9903-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Monitoring patient adherence to HIV antiretroviral therapy (ART) by patient survey is inherently error prone, justifying a need for objective, biological measures affordable in low-resource settings where HIV/AIDS epidemic is highest. In preliminary studies conducted in Ethiopia and South Africa, we observed loss of cysteine cathepsin activity in peripheral blood mononuclear cells of HIV-positive patients on ART. We optimized a rapid protocol for multiplex cathepsin zymography to quantify cysteine cathepsins, and prospectively enrolled 350 HIV-positive, ART-naïve adults attending the Themba Lethu Clinic, Johannesburg, South Africa, to test if suppressed cathepsin activity could be a biomarker of ART adherence (103 patients were included in final analysis). Poor adherence was defined as detectable viral load (>400 copies/ml) or simplified medication adherence questionnaire, 4-6 months after ART initiation. 86 % of patients with undetectable viral loads after 6 months were cathepsin negative, and cathepsin-positive patients were twice as likely to have detectable viral loads (RR 2.32 95 % CI 1.26-4.29). Together, this demonstrates proof of concept that multiplex cathepsin zymography may be an inexpensive, objective method to monitor patient adherence to ART. Low cost of this electrophoresis-based assay makes it a prime candidate for implementation in resource-limited settings.
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Affiliation(s)
- Manu O Platt
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 315 Ferst Drive, IBB 1308, Atlanta, GA, 30332, USA. .,The Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, USA.
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Philip M Keegan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 315 Ferst Drive, IBB 1308, Atlanta, GA, 30332, USA.,The Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, USA
| | - Lynne McNamara
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Ivana K Parker
- The Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, USA.,The George W. Woodruff School of Mechanical Engineering, Atlanta, GA, USA
| | - LaDeidra M Roberts
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 315 Ferst Drive, IBB 1308, Atlanta, GA, 30332, USA.,The Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, USA
| | - Alexander W Caulk
- The Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, USA.,The George W. Woodruff School of Mechanical Engineering, Atlanta, GA, USA
| | - Rudolph L Gleason
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 315 Ferst Drive, IBB 1308, Atlanta, GA, 30332, USA.,The Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, USA.,The George W. Woodruff School of Mechanical Engineering, Atlanta, GA, USA
| | - Daniel Seifu
- Department of Biochemistry, Addis Ababa University, Addis Ababa, Ethiopia
| | - Wondwossen Amogne
- Department of Internal Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Clement Penny
- Oncology Division, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
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Fox MP, Berhanu R, Steegen K, Firnhaber C, Ive P, Spencer D, Mashamaite S, Sheik S, Jonker I, Howell P, Long L, Evans D. Intensive adherence counselling for HIV-infected individuals failing second-line antiretroviral therapy in Johannesburg, South Africa. Trop Med Int Health 2016; 21:1131-7. [PMID: 27383454 DOI: 10.1111/tmi.12741] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE In resource-limited settings, where genotypic drug resistance testing is rarely performed and poor adherence is the most common reason for treatment failure, programmatic approaches to handling treatment failure are essential. This study was performed to describe one such approach to adherence optimisation. METHODS This was a single-arm study of patients on second-line protease inhibitor (PI)-based antiretroviral therapy (ART) with a HIV-1 RNA ≥400 copies/ml in Johannesburg, South Africa, between 1 March 2012 and 1 December 2013. Patients underwent enhanced adherence counselling. Those with improved adherence and a repeat viral load of >1000 copies/ml underwent HIV-1 drug resistance testing. We describe results using simple proportions and 95% confidence intervals. RESULTS Of the 400 patients who underwent targeted adherence counselling after an elevated viral load on second-line ART, 388 (97%) underwent repeat viral load testing. Most of these (n = 249; 64%, 95% CI 59-69) resuppressed (<400 copies/ml) on second line. By the end of follow-up (1 March 2014), among the 139 (36%, 95% CI: 31-41%), who did not initially resuppress after being targeted, 106 had a viral load >400 copies/ml, 11 switched to third line, 5 were awaiting third line, 4 had died and 13 were lost to follow-up. Among the unsuppressed, 48 successfully underwent resistance testing with some resistance detected in most (41/48). CONCLUSIONS Most (64%) second-line treatment failure in this clinic is related to adherence and can be overcome with careful adherence support. Controlled interventions are needed to determine what the optimal approach is to improving second-line outcomes and reducing the need for third-line ART.
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Affiliation(s)
- Matthew P Fox
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Rebecca Berhanu
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Right to Care, Johannesburg, South Africa
| | - Kim Steegen
- Department of Haematology and Molecular Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cindy Firnhaber
- Right to Care, Johannesburg, South Africa.,Clinical HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Prudence Ive
- Clinical HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Ingrid Jonker
- Witkoppen Health and Welfare Center, Johannesburg, South Africa
| | - Pauline Howell
- Department of Haematology and Molecular Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Implementation and Operational Research: Implementation of Multiple Point-of-Care Testing in 2 HIV Antiretroviral Treatment Clinics in South Africa. J Acquir Immune Defic Syndr 2016; 71:e34-43. [PMID: 26484742 DOI: 10.1097/qai.0000000000000872] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A plethora of point-of-care (POC) tests exist in the HIV and tuberculosis diagnostic pipeline which require rigorous evaluation to ensure performance in the field. The accuracy and feasibility of nurse-operated multidisciplinary-POC testing for HIV antiretroviral therapy (ART) initiation/monitoring was evaluated. METHODS Random HIV-positive adult patients presenting at 2 treatment clinics in South Africa for ART initiation/monitoring were consented and enrolled. POCT was performed by a dedicated nurse on a venipuncture specimen; Pima (CD4), HemoCue (hemoglobin), Reflotron (alanine aminotransferase, creatinine), Accutrend (lactate) and compared with laboratory testing. External quality assessment, training, workflow, and errors were assessed. RESULTS n = 324 enrolled at site1; n = 469 enrolled at site 2. Clinical data on n = 305 participants: 65% (n = 198) female with a mean age of 39.8 (21-61) years; mean age of males 43.2 (26-61) years; 70% of patients required 3 or more POC tests/visit. External quality assessment material was suitable for POCT. CD4, hemoglobin and alanine aminotransferase testing showed good agreement with predicate methodology; creatinine and lactate had increased variability. Pima CD4 misclassified up to 11.6% of patients at 500 cells per microliter and reported 4.3%-6% error rate. A dedicated nurse could perform POCT on 7 patients/day; inclusion of Pima CD4 increased time for testing from 6 to 110 minutes. Transcription error rate was 1%. CONCLUSIONS Nurses can accurately perform multidisciplinary POCT for HIV ART initiation/monitoring. This will however, require a dedicated nurse as current duties will increase if POC is added to workflow. The use of Pima CD4 will increase patients initiated on ART. Connectivity will be central to ensure quality management of results, but overall impact will need to still be addressed.
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Initiating Antiretroviral Therapy for HIV at a Patient's First Clinic Visit: The RapIT Randomized Controlled Trial. PLoS Med 2016; 13:e1002015. [PMID: 27163694 PMCID: PMC4862681 DOI: 10.1371/journal.pmed.1002015] [Citation(s) in RCA: 220] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 03/22/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND High rates of patient attrition from care between HIV testing and antiretroviral therapy (ART) initiation have been documented in sub-Saharan Africa, contributing to persistently low CD4 cell counts at treatment initiation. One reason for this is that starting ART in many countries is a lengthy and burdensome process, imposing long waits and multiple clinic visits on patients. We estimated the effect on uptake of ART and viral suppression of an accelerated initiation algorithm that allowed treatment-eligible patients to be dispensed their first supply of antiretroviral medications on the day of their first HIV-related clinic visit. METHODS AND FINDINGS RapIT (Rapid Initiation of Treatment) was an unblinded randomized controlled trial of single-visit ART initiation in two public sector clinics in South Africa, a primary health clinic (PHC) and a hospital-based HIV clinic. Adult (≥18 y old), non-pregnant patients receiving a positive HIV test or first treatment-eligible CD4 count were randomized to standard or rapid initiation. Patients in the rapid-initiation arm of the study ("rapid arm") received a point-of-care (POC) CD4 count if needed; those who were ART-eligible received a POC tuberculosis (TB) test if symptomatic, POC blood tests, physical exam, education, counseling, and antiretroviral (ARV) dispensing. Patients in the standard-initiation arm of the study ("standard arm") followed standard clinic procedures (three to five additional clinic visits over 2-4 wk prior to ARV dispensing). Follow up was by record review only. The primary outcome was viral suppression, defined as initiated, retained in care, and suppressed (≤400 copies/ml) within 10 mo of study enrollment. Secondary outcomes included initiation of ART ≤90 d of study enrollment, retention in care, time to ART initiation, patient-level predictors of primary outcomes, prevalence of TB symptoms, and the feasibility and acceptability of the intervention. A survival analysis was conducted comparing attrition from care after ART initiation between the groups among those who initiated within 90 d. Three hundred and seventy-seven patients were enrolled in the study between May 8, 2013 and August 29, 2014 (median CD4 count 210 cells/mm3). In the rapid arm, 119/187 patients (64%) initiated treatment and were virally suppressed at 10 mo, compared to 96/190 (51%) in the standard arm (relative risk [RR] 1.26 [1.05-1.50]). In the rapid arm 182/187 (97%) initiated ART ≤90 d, compared to 136/190 (72%) in the standard arm (RR 1.36, 95% confidence interval [CI], 1.24-1.49). Among 318 patients who did initiate ART within 90 d, the hazard of attrition within the first 10 mo did not differ between the treatment arms (hazard ratio [HR] 1.06; 95% CI 0.61-1.84). The study was limited by the small number of sites and small sample size, and the generalizability of the results to other settings and to non-research conditions is uncertain. CONCLUSIONS Offering single-visit ART initiation to adult patients in South Africa increased uptake of ART by 36% and viral suppression by 26%. This intervention should be considered for adoption in the public sector in Africa. TRIAL REGISTRATION ClinicalTrials.gov NCT01710397, and South African National Clinical Trials Register DOH-27-0213-4177.
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McNamara L, Takuva S, Chirwa T, MacPhail P. Prevalence of common vitamin D receptor gene polymorphisms in HIV-infected and uninfected South Africans. INTERNATIONAL JOURNAL OF MOLECULAR EPIDEMIOLOGY AND GENETICS 2016; 7:74-80. [PMID: 27186331 PMCID: PMC4858619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 02/29/2016] [Indexed: 06/05/2023]
Abstract
BACKGROUND Host genetic factors may a play role in susceptibility to infection. Vitamin-D is an immunomodulator that may play a role in HIV infection. Vitamin-D action is mediated by the vitamin-D receptor. We establish prevalence of ApaI, BsmI, FokI and TaqI polymorphisms (VDRPs) amongst a black southern African HIV+ve population and investigate polymorphic differences between HIV+ve and -ve people. METHODS Seventy-nine sex and age-group matched HIV+ve patients of African origin initiating antiretroviral therapy (ART) and 79 HIV-ve participants, also of African origin, were recruited from a public sector HIV testing and treatment clinic and investigated for the 4 polymorphisms. The genotype frequencies were compared, odds ratios and 95% confidence intervals of the association of HIV status and each genotype were calculated. Both dominant, co-dominant, recessive and allele models were tested. RESULTS We found no evidence of difference in distribution and association between HIV infection and the genotypes of the BsmI, FokI and TaqI VDR polymorphisms. The genotype distributions were consistent with Hardy-Weinberg equilibrium for these genotypes. The ApaI genotype showed differences in distribution by HIV status in the dominant and co-dominant models. However this finding is cautiously stated as the ApaI genotype violated the Hardy-Weinberg equilibrium and frequency of the minor variant was unexpectedly low in this population. CONCLUSION We do not show convincing differences in distribution of the VDR genotypes among HIV+ve and HIV-ve black southern African persons. Future studies need to be replicated in larger study populations as understanding polymorphic differences and similarities may offer insights into the different susceptibility and progression of HIV in southern African populations.
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Affiliation(s)
- Lynne McNamara
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of The WitwatersrandJohannesburg, South Africa
| | - Simbarashe Takuva
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of The WitwatersrandJohannesburg, South Africa
| | - Tobias Chirwa
- School of Public Health, Faculty of Health Sciences, University of The WitwatersrandJohannesburg, South Africa
| | - Patrick MacPhail
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of The WitwatersrandJohannesburg, South Africa
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Moyo F, Chasela C, Brennan AT, Ebrahim O, Sanne IM, Long L, Evans D. Treatment outcomes of HIV-positive patients on first-line antiretroviral therapy in private versus public HIV clinics in Johannesburg, South Africa. Clin Epidemiol 2016; 8:37-47. [PMID: 27051316 PMCID: PMC4807894 DOI: 10.2147/clep.s93014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Despite the widely documented success of antiretroviral therapy (ART), stakeholders continue to face the challenges of poor HIV treatment outcomes. While many studies have investigated patient-level causes of poor treatment outcomes, data on the effect of health systems on ART outcomes are scarce. OBJECTIVE We compare treatment outcomes among patients receiving HIV care and treatment at a public and private HIV clinic in Johannesburg, South Africa. PATIENTS AND METHODS This was a retrospective cohort analysis of ART naïve adults (≥18.0 years), initiating ART at a public or private clinic in Johannesburg between July 01, 2007 and December 31, 2012. Cox proportional-hazards regression was used to identify baseline predictors of mortality and loss to follow-up (>3 months late for the last scheduled visit). Generalized estimating equations were used to determine predictors of failure to suppress viral load (≥400 copies/mL) while the Wilcoxon rank-sum test was used to compare the median absolute change in CD4 count from baseline to 12 months post-ART initiation. RESULTS 12,865 patients initiated ART at the public clinic compared to 610 at the private clinic. The patients were similar in terms of sex and age at initiation. Compared to public clinic patients, private clinic patients initiated ART at higher median CD4 counts (159 vs 113 cells/mm(3)) and World Health Organization stage I/II (76.1% vs 58.5%). Adjusted hazard models showed that compared to public clinic patients, private clinic patients were less likely to die (adjusted hazard ratio [aHR] 0.50; 95% confidence interval [CI] 0.35-0.70) but were at increased risk of loss to follow-up (aHR 1.80; 95% CI 1.59-2.03). By 12 months post-ART initiation, private clinic patients were less likely to have a detectable viral load (adjusted relative risk 0.65; 95% CI 0.49-0.88) and recorded higher median CD4 change from baseline (184 cells/mm(3) interquartile range 101-300 vs 158 cells/mm(3) interquartile range 91-244), when compared to public clinic patients. CONCLUSION We identified differences in treatment outcomes between the two HIV clinics. Findings suggest that the type of clinic at which ART patients initiate and receive treatment can have an impact on treatment outcomes. Further research is necessary to provide more conclusive results.
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Affiliation(s)
- Faith Moyo
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Charles Chasela
- Epidemiology and Biostatistics Department, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Epidemiology and Strategic Information (ESI), HIV/AIDS/STIs and TB, Human Sciences Research Council, Pretoria, South Africa
| | - Alana T Brennan
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Center for Global Health and Development, Boston University, Boston, MA, USA
| | | | - Ian M Sanne
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Right to Care, Helen Joseph Hospital, Westdene, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Brief Report: Does Most Mortality in Patients on ART Occur in Care or After Lost to Follow-Up? Evidence From the Themba Lethu Clinic, South Africa. J Acquir Immune Defic Syndr 2016; 70:323-8. [PMID: 26181816 PMCID: PMC4627171 DOI: 10.1097/qai.0000000000000755] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Supplemental Digital Content is Available in the Text. In resource-limited settings, early mortality on antiretroviral therapy (ART) is approximately 10%; yet, it is unclear how much of that mortality occurs in care or after lost to follow-up. We assessed mortality rates and predictors of death among 12,222 nonpregnant ART-naive adults initiating first-line ART between April 2004 and May 2012 in South Africa, stratified by person-years in care and lost. We found 14.6% of patients died and being lost accounted for a minority of deaths across multiple definitions of loss (population attributable-risk percent ranged from 10.4% to 42.5%). Although mortality rates in patients lost were much higher than in care, most ART-related mortality occurred on treatment.
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Koller M, Fatti G, Chi BH, Keiser O, Hoffmann CJ, Wood R, Prozesky H, Stinson K, Giddy J, Mutevedzi P, Fox MP, Law M, Boulle A, Egger M. Implementation and Operational Research: Risk Charts to Guide Targeted HIV-1 Viral Load Monitoring of ART: Development and Validation in Patients From Resource-Limited Settings. J Acquir Immune Defic Syndr 2016; 70:e110-9. [PMID: 26470034 DOI: 10.1097/qai.0000000000000748] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND HIV-1 RNA viral load (VL) testing is recommended to monitor antiretroviral therapy (ART) but not available in many resource-limited settings. We developed and validated CD4-based risk charts to guide targeted VL testing. METHODS We modeled the probability of virologic failure up to 5 years of ART based on current and baseline CD4 counts, developed decision rules for targeted VL testing of 10%, 20%, or 40% of patients in 7 cohorts of patients starting ART in South Africa, and plotted cutoffs for VL testing on colour-coded risk charts. We assessed the accuracy of risk chart-guided VL testing to detect virologic failure in validation cohorts from South Africa, Zambia, and the Asia-Pacific. RESULTS In total, 31,450 adult patients were included in the derivation and 25,294 patients in the validation cohorts. Positive predictive values increased with the percentage of patients tested: from 79% (10% tested) to 98% (40% tested) in the South African cohort, from 64% to 93% in the Zambian cohort, and from 73% to 96% in the Asia-Pacific cohort. Corresponding increases in sensitivity were from 35% to 68% in South Africa, from 55% to 82% in Zambia, and from 37% to 71% in Asia-Pacific. The area under the receiver operating curve increased from 0.75 to 0.91 in South Africa, from 0.76 to 0.91 in Zambia, and from 0.77 to 0.92 in Asia-Pacific. CONCLUSIONS CD4-based risk charts with optimal cutoffs for targeted VL testing maybe useful to monitor ART in settings where VL capacity is limited.
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Affiliation(s)
- Manuel Koller
- *Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; †Kheth'Impilo, Cape Town, South Africa; ‡Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; §Aurum Institute for Health Research, Johannesburg, South Africa; ‖Gugulethu ART Programme and Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa; ¶Division of Infectious Diseases, Department of Medicine, University of Stellenbosch and Tygerberg Academic Hospital, Cape Town, South Africa; #Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa; **Sinikithemba Clinic, McCord Hospital, Durban, South Africa; ††Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa; ‡‡Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa; §§Center for Global Health & Development and Department of Epidemiology, Boston University, Boston, MA; ‖‖Biostatistics and Databases Program, The Kirby Institute, Faculty of Medicine, The University of New South Wales, Sydney, Australia; and ¶¶Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
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Jong E, Sanne IM, van Rie A, Menezes CN. A hospital-based tuberculosis focal point to improve tuberculosis care provision in a very high burden setting. Public Health Action 2015; 3:51-5. [PMID: 26392996 DOI: 10.5588/pha.12.0073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 01/22/2013] [Indexed: 11/10/2022] Open
Abstract
SETTING A hospital-based tuberculosis focal point (TBFP) at a tertiary hospital in Johannesburg, South Africa. OBJECTIVE To describe the possible tasks and impact of a hospital-based TBFP as well as staffing and infrastructure requirements for setting up a hospital-based TBFP. ACTIVITIES A TBFP can centralize the notification and referral of new TB cases, perform human immunodeficiency virus counseling and testing, assessment of difficult to diagnose TB suspects and management of complicated TB cases, and it can provide an ideal setting for research and health care worker training. RESULTS The number of TB suspects assessed by sputum initially increased, followed by a decrease starting in 2010, which correlates with the globally decreasing TB incidence. The proportion of TB cases who failed to link to TB care decreased from 23% to 14% between 2009 and 2012. Almost 40% of cases with hepatotoxicity required an adjusted treatment regimen. Roll-out of Xpert(®) MTB/RIF testing and decentralized drug-resistant TB treatment increased the number of rifampicin monoresistant and sputum smear-negative multidrug-resistant TB cases treated on an out-patient basis. CONCLUSION A hospital-based TBFP complements care at primary care level by coordinating TB care for a vulnerable population of patients diagnosed in a hospital setting, and by coordinating the diagnosis and treatment of complex TB cases.
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Affiliation(s)
- E Jong
- Clinical HIV Research Unit, Department of Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - I M Sanne
- Clinical HIV Research Unit, Department of Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - A van Rie
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - C N Menezes
- Helen Joseph Hospital, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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d'Elia A, Evans D, McNamara L, Berhanu R, Sanne I, Lönnermark E. Predictive and prognostic properties of TB-LAM among HIV-positive patients initiating ART in Johannesburg, South Africa. Pan Afr Med J 2015; 22:4. [PMID: 26600904 PMCID: PMC4643149 DOI: 10.11604/pamj.2015.22.4.6075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 08/26/2015] [Indexed: 02/04/2023] Open
Abstract
While the diagnostic properties of the TB LAM urine assay (LAM) have been well-described, little is known about its predictive and prognostic properties at ART initiation in a routine clinic setting. We describe the predictive and prognostic properties of LAM in HIV-positive patients initiating ART at an urban hospital in Johannesburg, South Africa. Retrospective study of HIV-positive adults (>18 years) who initiated standard first-line ART between February 2012 and April 2013 and had a LAM test at initiation. In HIV-positive patients with no known TB at ART initiation, we assessed the sensitivity, specificity and positive/negative likelihood ratios of LAM to predict incident TB within 6 months of ART initiation. In addition, in patients with a TB diagnosis and on TB treatment <3 months at ART initiation, we measured the CD4 response at 6 months on ART. Of the 274 patients without TB at ART initiation, 65% were female with median CD4 count of 213 cells/mm3. Among the 14 (5.1%) patients who developed active TB, none were urine LAM +ve at baseline. LAM had poor sensitivity (0.0% 95% CI 0.00-23.2) to predict incident TB within 6 months of initiation. We analyzed 22 patients with a confirmed TB diagnosis at initiation separately. Of these, LAM +ve patients (27%) showed lower CD4 gains compared to LAM negative patients (median increase 103 vs 199 cells/mm3; p = 0.08). LAM has limited value for accurately predicting incident TB in patients with higher CD4 counts after ART initiation. LAM may help identify TB/HIV co-infected patients at ART initiation who respond more slowly to treatment and require targeted interventions to improve treatment outcomes. Larger studies with longer patient follow-up are needed.
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Affiliation(s)
- Alexander d'Elia
- Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, 40032, Sweden
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa
| | - Lynne McNamara
- Clinical HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa
| | - Rebecca Berhanu
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa ; Right To Care, Helen Joseph Hospital, Perth Road, Johannesburg, 2092, South Africa
| | - Ian Sanne
- Clinical HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa ; Right To Care, Helen Joseph Hospital, Perth Road, Johannesburg, 2092, South Africa
| | - Elisabet Lönnermark
- Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, 40032, Sweden
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Van Rie A, Westreich D, Sanne I. Impact of three empirical anti-tuberculosis treatment strategies for people initiating antiretroviral therapy. Int J Tuberc Lung Dis 2015; 18:1340-6. [PMID: 25299868 DOI: 10.5588/ijtld.14.0153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early mortality in people initiating antiretroviral treatment (ART) remains high. Empirical anti-tuberculosis treatment strategies aim to reduce early mortality by initiating anti-tuberculosis treatment in individuals at high risk of death from undiagnosed TB. METHODS Using data from 16 913 individuals starting ART under program conditions, we simulated the impact of three empirical treatment strategies (two clinical trials and a pragmatic approach), assuming that 50% of early deaths and 100% of incident TB are averted in those eligible. RESULTS Compared to starting anti-tuberculosis treatment on clinical or mycobacteriological grounds, 4.4-31.4% more individuals were eligible for anti-tuberculosis treatment, 5.5-25.4% of deaths were averted and 10.9-57.3% of incident TB cases were prevented under empirical anti-tuberculosis treatment strategies. The proportion receiving any anti-tuberculosis treatment during the first 6 months of ART increased from the observed 24.0% to an estimated 27.5%, 40.4% and 51.3%, under the PrOMPT, REMEMBER and pragmatic approach, respectively. CONCLUSION The impact of empirical anti-tuberculosis treatment strategies depends greatly on the eligibility criteria chosen. The additional strain placed on anti-tuberculosis treatment facilities and the relatively limited impact of some empirical TB strategies raise the question as to whether the benefits will outweigh the risks at population level.
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Affiliation(s)
- A Van Rie
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - D Westreich
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - I Sanne
- Clinical HIV Research Unit, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
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