1
|
Bakoyannis G, Elul B, Wools-Kaloustian KK, Brown S, Semeere A, Castelnuovo B, Diero L, Nakigozi G, Lyamuya R, Yiannoutsos CT. Modeling the HIV Cascade of Care Using Routinely Collected Clinical Data to Guide Programmatic Interventions and Policy Decisions. J Acquir Immune Defic Syndr 2024; 96:223-230. [PMID: 38905474 DOI: 10.1097/qai.0000000000003413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/05/2023] [Indexed: 06/23/2024]
Abstract
BACKGROUND The HIV care cascade is a framework to examine effectiveness of HIV programs and progress toward global targets to end the epidemic but has been conceptualized as a unidirectional process that ignores cyclical care patterns. We present a dynamic cascade that accounts for patient "churn" and apply novel analytic techniques to readily available clinical data to robustly estimate program outcomes and efficiently assess progress toward global targets. METHODS Data were assessed for 35,649 people living with HIV and receiving care at 78 clinics in East Africa between 2014 and 2020. Patients were aged ≥15 years and had ≥1 viral load measurements. We used multi-state models to estimate the probability of being in 1 of 5 states of a dynamic HIV cascade: (1) in HIV care but not on antiretroviral therapy (ART), (2) on ART, (3) virally suppressed, (4) in a gap-in-care, and (5) deceased and compared these among subgroups. To assess progress toward global targets, we summed those probabilities across patients and generated population-level proportions of patients on ART and virally suppressed in mid-2020. RESULTS One year after enrollment, 2.8% of patients had not initiated ART, 86.7% were receiving ART, 57.4% were virally suppressed, 10.2% were disengaged from care, and 0.3% had died. At 5 years, the proportion on ART remained steady but viral suppression increased to 77.2%. Of those aged 15-25, >20% had disengaged from care and <60% were virally suppressed. In mid-2020, 90.1% of the cohort was on ART, 90.7% of whom had suppressed virus. CONCLUSIONS Novel analytic approaches can characterize patient movement through a dynamic HIV cascade and, importantly, by capitalizing on readily available data from clinical cohorts, offer an efficient approach to estimate population-level proportions of patients on ART and virally suppressed. Significant progress toward global targets was observed in our cohort but challenges remain among younger patients.
Collapse
Affiliation(s)
| | - Batya Elul
- Mailman School of Public Health, Columbia University, New York, NY
| | | | - Steven Brown
- Indiana University School of Medicine, Indianapolis, IN
| | - Aggrey Semeere
- Infectious Disease Institutes, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Barbara Castelnuovo
- Infectious Disease Institutes, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lameck Diero
- Department of Medicine, Moi University School of Medicine, Eldoret, Kenya
| | | | | | | |
Collapse
|
2
|
Brazier E, Tymejczyk O, Wools-Kaloustian K, Jiamsakul A, Torres MTL, Lee JS, Abuogi L, Khol V, Mejía Cordero F, Althoff KN, Law MG, Nash D. Long-term HIV care outcomes under universal HIV treatment guidelines: A retrospective cohort study in 25 countries. PLoS Med 2024; 21:e1004367. [PMID: 38498589 PMCID: PMC10962811 DOI: 10.1371/journal.pmed.1004367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 03/25/2024] [Accepted: 02/22/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND While national adoption of universal HIV treatment guidelines has led to improved, timely uptake of antiretroviral therapy (ART), longer-term care outcomes are understudied. There is little data from real-world service delivery settings on patient attrition, viral load (VL) monitoring, and viral suppression (VS) at 24 and 36 months after HIV treatment initiation. METHODS AND FINDINGS For this retrospective cohort analysis, we used observational data from 25 countries in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium's Asia-Pacific, Central Africa, East Africa, Central/South America, and North America regions for patients who were ART naïve and aged ≥15 years at care enrollment between 24 months before and 12 months after national adoption of universal treatment guidelines, occurring 2012 to 2018. We estimated crude cumulative incidence of loss-to-clinic (CI-LTC) at 12, 24, and 36 months after enrollment among patients enrolling in care before and after guideline adoption using competing risks regression. Guideline change-associated hazard ratios of LTC at each time point after enrollment were estimated via cause-specific Cox proportional hazards regression models. Modified Poisson regression was used to estimate relative risks of retention, VL monitoring, and VS at 12, 24, and 36 months after ART initiation. There were 66,963 patients enrolling in HIV care at 109 clinics with ≥12 months of follow-up time after enrollment (46,484 [69.4%] enrolling before guideline adoption and 20,479 [30.6%] enrolling afterwards). More than half (54.9%) were females, and median age was 34 years (interquartile range [IQR]: 27 to 43). Mean follow-up time was 51 months (standard deviation: 17 months; range: 12, 110 months). Among patients enrolling before guideline adoption, crude CI-LTC was 23.8% (95% confidence interval [95% CI] 23.4, 24.2) at 12 months, 31.0% (95% CI [30.6, 31.5]) at 24 months, and 37.2% (95% [CI 36.8, 37.7]) at 36 months after enrollment. Adjusting for sex, age group, enrollment CD4, clinic location and type, and country income level, enrolling in care and initiating ART after guideline adoption was associated with increased hazard of LTC at 12 months (adjusted hazard ratio [aHR] 1.25 [95% CI 1.08, 1.44]; p = 0.003); 24 months (aHR 1.38 [95% CI 1.19, 1.59]; p < .001); and 36 months (aHR 1.34 [95% CI 1.18, 1.53], p < .001) compared with enrollment before guideline adoption, with no before-after differences among patients with no record of ART initiation by end of follow-up. Among patients retained after ART initiation, VL monitoring was low, with marginal improvements associated with guideline adoption only at 12 months after ART initiation. Among those with VL monitoring, VS was high at each time point among patients enrolling before guideline adoption (86.0% to 88.8%) and afterwards (86.2% to 90.3%), with no substantive difference associated with guideline adoption. Study limitations include lags in and potential underascertainment of care outcomes in real-world service delivery data and potential lack of generalizability beyond IeDEA sites and regions included in this analysis. CONCLUSIONS In this study, adoption of universal HIV treatment guidelines was associated with lower retention after ART initiation out to 36 months of follow-up, with little change in VL monitoring or VS among retained patients. Monitoring long-term HIV care outcomes remains critical to identify and address causes of attrition and gaps in HIV care quality.
Collapse
Affiliation(s)
- Ellen Brazier
- City University of New York, Institute for Implementation Science in Population Health (ISPH), New York, New York, United States of America
- City University of New York, Graduate School of Public Health and Health Policy, New York, New York, United States of America
| | - Olga Tymejczyk
- City University of New York, Institute for Implementation Science in Population Health (ISPH), New York, New York, United States of America
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | | | - Marco Tulio Luque Torres
- Department of Pediatrics, Instituto Hondureño de Seguridad Social and Hospital Escuela Universitario, Tegucigalpa, Honduras
| | - Jennifer S. Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Lisa Abuogi
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado, United States of America
| | - Vohith Khol
- National Center for HIV/AIDS, Dermatology and STDs, Phnom Penh, Cambodia
| | - Fernando Mejía Cordero
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Keri N. Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Matthew G. Law
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Denis Nash
- City University of New York, Institute for Implementation Science in Population Health (ISPH), New York, New York, United States of America
- City University of New York, Graduate School of Public Health and Health Policy, New York, New York, United States of America
| | | |
Collapse
|
3
|
Beres LK, Mwamba C, Bolton-Moore C, Kennedy CE, Simbeza S, Topp SM, Sikombe K, Mukamba N, Mody A, Schwartz SR, Geng E, Holmes CB, Sikazwe I, Denison JA. Trajectories of re-engagement: factors and mechanisms enabling patient return to HIV care in Zambia. J Int AIDS Soc 2023; 26:e26067. [PMID: 36840391 PMCID: PMC9958345 DOI: 10.1002/jia2.26067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/31/2023] [Indexed: 02/26/2023] Open
Abstract
INTRODUCTION While disengagement from HIV care threatens the health of persons living with HIV (PLWH) and incidence-reduction targets, re-engagement is a critical step towards positive outcomes. Studies that establish a deeper understanding of successful return to clinical care among previously disengaged PLWH and the factors supporting re-engagement are essential to facilitate long-term care continuity. METHODS We conducted narrative, patient-centred, in-depth interviews between January and June 2019 with 20 PLWH in Lusaka, Zambia, who had disengaged and then re-engaged in HIV care, identified through electronic medical records (EMRs). We applied narrative analysis techniques, and deductive and inductive thematic analysis to identify engagement patterns and enablers of return. RESULTS We inductively identified five trajectories of care engagement, suggesting patterns in patient characteristics, experienced barriers and return facilitators that may aid intervention targeting including: (1) intermittent engagement;(2) mostly engaged; (3) delayed linkage after testing; (4) needs time to initiate antiretroviral therapy (ART); and (5) re-engagement with ART initiation. Patient-identified periods of disengagement from care did not always align with care gaps indicated in the EMR. Key, interactive re-engagement facilitators experienced by participants, with varied importance across trajectories, included a desire for physical wellness and social support manifested through verbal encouragement, facility outreach or personal facility connections and family instrumental support. The mechanisms through which facilitators led to return were: (1) the promising of living out one's life priorities; (2) feeling valued; (3) fostering interpersonal accountability; (4) re-entry navigation support; (5) facilitated care and treatment access; and (6) management of significant barriers, such as depression. CONCLUSIONS While preliminary, the identified trajectories may guide interventions to support re-engagement, such as offering flexible ART access to patients with intermittent engagement patterns instead of stable patients only. Further, for re-engagement interventions to achieve impact, they must activate mechanisms underlying re-engagement behaviours. For example, facility outreach that reminds a patient to return to care but does not affirm a patient's value or navigate re-entry is unlikely to be effective. The demonstrated importance of positive health facility connections reinforces a growing call for patient-centred care. Additionally, interventions should consider the important role communities play in fostering treatment motivation and overcoming practical barriers.
Collapse
Affiliation(s)
- Laura K Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Stephanie M Topp
- College of Public Health Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Kombatende Sikombe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Aaloke Mody
- University of Washington St. Louis, St. Louis, Missouri, USA
| | - Sheree R Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elvin Geng
- University of Washington St. Louis, St. Louis, Missouri, USA
| | - Charles B Holmes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Georgetown University, Washington, DC, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Julie A Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
4
|
Brothers S, DiDomizio E, Nichols L, Brooks R, Villanueva M. Perceptions Towards HCV Treatment with Direct Acting Antivirals (DAAs): A Qualitative Analysis with Persons with HIV/HCV Co-infection Who Delay or Refuse Treatment. AIDS Behav 2023; 27:119-133. [PMID: 35776253 PMCID: PMC9663279 DOI: 10.1007/s10461-022-03749-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 01/24/2023]
Abstract
In the United States, approximately 25% of people with HIV (PWH) are co-infected with hepatitis C (HCV). Since 2014, highly effective and well-tolerated direct-acting antivirals (DAAs) have revolutionized HCV treatment. Uptake of DAAs by people with HIV/HCV co-infection has improved but remains suboptimal due to system, provider, and patient-level barriers. To explore patient-level issues by better understanding their attitudes towards DAA treatment, we conducted qualitative interviews with 21 persons with HIV/HCV co-infection who did not consent to DAA treatment or delayed treatment for at least 1 year after diagnosis. We found PWH perceived DAA treatment barriers and facilitators on multiple levels of the social-ecological environment: the individual (HCV disease and treatment literacy), interpersonal (peer influence), institutional (media and healthcare provider relationship), and structural levels (treatment cost and adherence support). Recommendations to improve DAA treatment uptake include HCV-treatment adherence support, HCV disease and treatment literacy training (particularly for substance use and DAA treatment interactions), and encouraging PWH who have successfully completed DAA treatment to speak with their peers.
Collapse
Affiliation(s)
- Sarah Brothers
- Department of Sociology, Pennsylvania State University, 316 Oswald Tower, University Park, PA, 16802, USA.
- HIV/AIDS Program, Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA.
| | - Elizabeth DiDomizio
- HIV/AIDS Program, Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | - Lisa Nichols
- HIV/AIDS Program, Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | - Ralph Brooks
- HIV/AIDS Program, Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | - Merceditas Villanueva
- HIV/AIDS Program, Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| |
Collapse
|
5
|
Gopalsamy SN, Shah NS, Marconi VC, Armstrong WS, del Rio C, Pennisi E, Wortley P, Colasanti JA. The Impact of Churn on HIV Outcomes in a Southern United States Clinical Cohort. Open Forum Infect Dis 2022; 9:ofac338. [PMID: 35899283 PMCID: PMC9314921 DOI: 10.1093/ofid/ofac338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/07/2022] [Indexed: 12/02/2022] Open
Abstract
Background Persons with human immunodeficiency virus (PWH) may experience a cycle of engaging and disengaging in care referred to as “churn.” While human immunodeficiency virus (HIV) churn is predicted to be more prevalent in the southern United States (US), it has not been well characterized in this region. Methods We conducted a retrospective cohort study involving PWH newly establishing care at a large urban clinic in Atlanta, Georgia, from 2012 to 2017, with follow-up data collected through 2019. The primary exposure was churn, defined as a ≥12-month gap between routine clinic visits or viral load (VL) measurements. We compared HIV metrics before and after churn and assessed the risk of future churn or loss to follow-up. Results Of 1303 PWH newly establishing care, 81.7% were male and 84.9% were Black; 200 (15.3%) experienced churn in 3.3 years of median follow-up time. The transmissible viremia (TV) rate increased from 28.6% prechurn to 66.2% postchurn (P < .0001). The 122 PWH having TV on reengagement had delayed time to subsequent viral suppression (adjusted hazard ratio, 0.59 [95% confidence interval {CI}, .48–.73]), and PWH returning to care contributed disproportionately to the community viral load (CVL) (proportion of CVL/proportion of patients, 1.96). Churn was not associated with an increased risk of subsequent churn (adjusted odds ratio [aOR], 1.53 [95% CI, .79–2.97]) or loss to follow-up (aOR, 1.04 [95% CI, .60–1.79]). Conclusions The rate of churn in a southern US clinic was high, and those who experienced churn had increased TV at reentry and disproportionately contributed to the CVL and likely contributing to ongoing HIV transmission.
Collapse
Affiliation(s)
| | - N Sarita Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University , Atlanta, GA , USA
| | - Vincent C Marconi
- Division of Infectious Diseases, Department of Medicine and Department of Global Health, Rollins School of Public Health, Emory University , Atlanta, GA , USA
- Atlanta VA Medical Center , Decatur, GA , USA
| | - Wendy S Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University , Atlanta, GA , USA
- Grady Health System , Atlanta, GA , USA
| | - Carlos del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University , Atlanta, GA , USA
- Grady Health System , Atlanta, GA , USA
| | - Eugene Pennisi
- HIV/AIDS Epidemiology Section, Georgia Department of Public Health , Atlanta, GA , USA
| | - Pascale Wortley
- HIV/AIDS Epidemiology Section, Georgia Department of Public Health , Atlanta, GA , USA
| | - Jonathan A Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University , Atlanta, GA , USA
- Grady Health System , Atlanta, GA , USA
| |
Collapse
|
6
|
Odayar J, Chi BH, Phillips TK, Mukonda E, Hsiao NY, Lesosky M, Myer L. Transfer of Patients on Antiretroviral Therapy Attending Primary Health Care Services in South Africa. J Acquir Immune Defic Syndr 2022; 90:309-315. [PMID: 35298449 DOI: 10.1097/qai.0000000000002950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/22/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients stable on antiretroviral therapy (ART) may require transfer between health care facilities to maintain continuous care, yet data on the frequency, predictors, and virologic outcomes of transfers are limited. METHODS Data for all viral load (VL) testing at public sector health facilities in the Western Cape Province (2011-2018) were obtained. Participant inclusion criteria were a first VL between 2011 and 2013, age >15 years at ART initiation, and >1 VL within 5 years of ART initiation, of which ≥1 was at a primary health care facility. Two successive VLs taken at different facilities indicated a transfer. We assessed predictors of transfer using generalized estimating equations with Poisson regression and the association between transfer and subsequent VL> 1000 copies/mL using generalized mixed effects. RESULTS Overall 84,814 participants (median age at ART initiation 34 years and 68% female) were followed up for up to 4.5 years after their first VL: 34% (n = 29,056) transferred at least once, and among these, 26% transferred twice and 11% transferred thrice or more. Female sex, age <30 years, and first VL > 1000 copies/mL were independently associated with an increased rate of transfer [adjusted rate ratio 1.24, 95% confidence interval (CI): 1.21 to 1.26; 1.34, 95% CI: 1.31 to 1.36; and 1.42, 95% CI: 1.38 to 1.45, respectively]. Adjusting for age, sex, and disengagement, transfer was associated with an increased relative odds of VL > 1000 copies/mL (odds ratio 1.35, 95% CI: 1.29 to 1.42). CONCLUSIONS Approximately one-third of participants transferred and virologic outcomes were poor post-transfer. Stable patients who transfer may require additional support to maintain adherence.
Collapse
Affiliation(s)
- Jasantha Odayar
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; and
| | - Tamsin K Phillips
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elton Mukonda
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nei-Yuan Hsiao
- Division of Medical Virology, National Health Laboratory Service, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Maia Lesosky
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
7
|
Edwards RJ, Lyons N, Samaroo-Francis W, Lavia LO, John I, Todd S, Edwards J, Boyce G. The expansion of a patient tracer programme to identify and return patients loss to follow up at a large HIV clinic in Trinidad. AIDS Res Ther 2021; 18:20. [PMID: 33892747 PMCID: PMC8063284 DOI: 10.1186/s12981-021-00341-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 04/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients who default from HIV care are usually poorly adherent to antiretroviral treatment which results in suboptimal viral suppression. The study assessed the outcomes of retention in care and viral suppression by expansion of an intervention using two patient tracers to track patients lost to follow up at a large HIV clinic in Trinidad. METHODS Two Social Workers were trained as patient tracers and hired for 15 months (April 2017-June 2018) to call patients who were lost to follow up for 30 days or more during the period July 2016-May 2018 at the HIV clinic Medical Research Foundation of Trinidad and Tobago. RESULTS Over the 15-month period, of the of 2473 patients who missed their scheduled visits for 1 month or more, 261 (10.6%) patients were no longer in active care-89 patients dead, 65 migrated, 55 hospitalized, 33 transferred to another treatment clinic and 19 incarcerated. Of the remaining 2212 patients eligible for tracing, 1869 (84.5%) patients were returned to care, 1278 (68.6%) were virally unsuppressed (viral load > 200 copies/ml) and 1727 (92.4%) were re-initiated on ART. Twelve months after their return, 1341 (71.7%) of 1869 patients were retained in care and 1154 (86.1%) of these were virally suppressed. Multivariate analysis using logistic regression showed that persons were more likely to be virally suppressed if they were employed (OR, 1.39; 95% CI 1.07-1.80), if they had baseline CD4 counts < 200 cells/mm3 (OR, 1.71; 95% CI 1.26-2.32) and if they were retained in care at 12 months (OR, 2.48; 95% CI 1.90-3.24). Persons initiated on ART for 4-6 years (OR, 3.09; 95% CI 1.13-8.48,), 7-9 years (OR, 3.97; 95% CI 1.39-11.31), > 10 years (OR, 5.99; 95% CI 1.74-20.64 were more likely to be retained in care. CONCLUSIONS Patient Tracing is a feasible intervention to identify and resolve the status of patients who are loss to follow up and targeted interventions such as differentiated care models may be important to improve retention in care.
Collapse
|
8
|
Beres LK, Schwartz S, Simbeza S, McGready J, Eshun-Wilson I, Mwamba C, Sikombe K, Topp SM, Somwe P, Mody A, Mukamba N, Ehrenkranz PD, Padian N, Pry J, Moore CB, Holmes CB, Sikazwe I, Denison JA, Geng E. Patterns and Predictors of Incident Return to HIV Care Among Traced, Disengaged Patients in Zambia: Analysis of a Prospective Cohort. J Acquir Immune Defic Syndr 2021; 86:313-322. [PMID: 33149000 PMCID: PMC7878284 DOI: 10.1097/qai.0000000000002554] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/28/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dynamic movement of patients in and out of HIV care is prevalent, but there is limited information on patterns of patient re-engagement or predictors of return to guide HIV programs to better support patient engagement. METHODS From a probability-based sample of lost to follow-up, adult patients traced by peer educators from 31 Zambian health facilities, we prospectively followed disengaged HIV patients for return clinic visits. We estimated the cumulative incidence of return and the time to return using Kaplan-Meier methods. We used univariate and multivariable Cox proportional hazards regression to conduct a risk factor analysis identifying predictors of incident return across a social ecological framework. RESULTS Of the 556 disengaged patients, 73.0% [95% confidence interval (CI): 61.0 to 83.8] returned to HIV care. The median follow-up time from disengagement was 32.3 months (interquartile range: 23.6-38.9). The rate of return decreased with time postdisengagement. Independent predictors of incident return included a previous gap in care [adjusted Hazard Ratio (aHR): 1.95, 95% CI: 1.23 to 3.09] and confronting a stigmatizer once in the past year (aHR: 2.14, 95% CI: 1.25 to 3.65). Compared with a rural facility, patients were less likely to return if they sought care from an urban facility (aHR: 0.68, 95% CI: 0.48 to 0.96) or hospital (aHR: 0.52, 95% CI: 0.33 to 0.82). CONCLUSIONS Interventions are needed to hasten re-engagement in HIV care. Early and differential interventions by time since disengagement may improve intervention effectiveness. Patients in urban and tertiary care settings may need additional support. Improving patient resilience, outreach after a care gap, and community stigma reduction may facilitate return. Future re-engagement research should include causal evaluation of identified factors.
Collapse
Affiliation(s)
- Laura K. Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | - John McGready
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | | | - Stephanie M. Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia;
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | - Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | | | - Nancy Padian
- Division of Epidemiology, University of California Berkeley, Berkeley, CA; and
| | - Jake Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL
| | - Charles B. Holmes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
- Department of Medicine, Georgetown University, Washington, DC
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | - Julie A. Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
| | - Elvin Geng
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| |
Collapse
|