1
|
Masaba RO, Herrera N, Siamba S, Ouma M, Okal C, Mayi A, Kose J, Ndimbii J, Ochanda B, Mwangi E, Okomo G, Woelk G. Advanced HIV disease in Homa Bay County, Kenya: Characteristics of newly-diagnosed and antiretroviral therapy-experienced clients. Medicine (Baltimore) 2023; 102:e36716. [PMID: 38134082 PMCID: PMC10735128 DOI: 10.1097/md.0000000000036716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023] Open
Abstract
Advanced HIV disease (AHD) remains a significant burden, despite the widespread use of antiretroviral therapy (ART) programs. Individuals with AHD are at a high risk of death even after starting ART. We characterized treatment naïve and treatment experienced clients presenting with AHD in western Kenya to inform service delivery and program improvement. We conducted a retrospective study using routinely collected program data from October 2016 to September 2019 for AHD clients in eight facilities in Homa Bay County, Kenya. Demographic and clinical data were abstracted from the medical records of AHD clients, defined as HIV-positive clients aged ≥ 5 years with documented CD4 count < 200 cells/mm3 and/or WHO clinical stage II/IV. Associations were assessed using Pearson's chi-square and Mann-Whitney Rank-Sum tests at 5% level of significance. Of the 19,427 HIV clients at the eight facilities, 6649 (34%) had a CD4 count < 200 cells/mm3 or a WHO III/IV stage. Of these, 1845 were randomly selected for analysis. Over half (991) of participants were aged 45 + years and 1040 (56%) were female. The median age was 46.0 years (interquartile range: 39.2-54.5); 1553 (84%) were in care at county and sub-county hospitals; and 1460 (79%) were WHO stage III/IV at enrollment. At ART initiation, 241 (13%) had tuberculosis, 192 (10%) had chronic diarrhea, and 94 (5%) had Pneumocystis jiroveci pneumonia. At the time of data collection, 89 (5%) participants had died and 140 (8%) were lost to follow-up. Eighteen percent (330) of participants were ART-experienced (on ART for ≥ 3 months). The proportions of ART-experienced and -naïve clients regarding age, sex and marital status were similar. However, a higher proportion of ART-experienced clients received care at primary care facilities, (93(28%) vs. 199 (13%); P < .001); were WHO stage 3/4 at AHD diagnosis, 273 (84%) vs. 1187 (79%) (P = .041); and had died or been LTFU, (124 (38%) vs. 105 (7%); P < .001). With increasing prevalence of patients on ART, the proportion of AHD treatment-experienced clients may increase without effective interventions to ensure that these patients remain in care.
Collapse
Affiliation(s)
| | - Nicole Herrera
- Elizabeth Glaser Pediatrics AIDS Foundation, Washington, D.C., USA
| | - Stephen Siamba
- Elizabeth Glaser Pediatrics AIDS Foundation, Nairobi , Kenya
| | - Millicent Ouma
- Elizabeth Glaser Pediatrics AIDS Foundation, Nairobi , Kenya
| | | | - Allan Mayi
- Elizabeth Glaser Pediatrics AIDS Foundation, Nairobi , Kenya
| | - Judith Kose
- Elizabeth Glaser Pediatrics AIDS Foundation, Nairobi , Kenya
- Erasmus MC, Department of Viroscience, Rotterdam University, Rotterdam, Netherlands
| | - James Ndimbii
- Elizabeth Glaser Pediatrics AIDS Foundation, Nairobi , Kenya
| | - Boniface Ochanda
- US Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV & TB, Kisumu, Kenya
| | - Eliud Mwangi
- Elizabeth Glaser Pediatrics AIDS Foundation, Nairobi , Kenya
| | | | - Godfrey Woelk
- Elizabeth Glaser Pediatrics AIDS Foundation, Washington, D.C., USA
| |
Collapse
|
2
|
Thomadakis C, Yiannoutsos CT, Pantazis N, Diero L, Mwangi A, Musick BS, Wools-Kaloustian K, Touloumi G. The Effect of HIV Treatment Interruption on Subsequent Immunological Response. Am J Epidemiol 2023; 192:1181-1191. [PMID: 37045803 PMCID: PMC10326612 DOI: 10.1093/aje/kwad076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 11/03/2022] [Accepted: 03/27/2023] [Indexed: 04/14/2023] Open
Abstract
Recovery of CD4-positive T lymphocyte count after initiation of antiretroviral therapy (ART) has been thoroughly examined among people with human immunodeficiency virus infection. However, immunological response after restart of ART following care interruption is less well studied. We compared CD4 cell-count trends before disengagement from care and after ART reinitiation. Data were obtained from the East Africa International Epidemiology Databases to Evaluate AIDS (IeDEA) Collaboration (2001-2011; n = 62,534). CD4 cell-count trends before disengagement, during disengagement, and after ART reinitiation were simultaneously estimated through a linear mixed model with 2 subject-specific knots placed at the times of disengagement and treatment reinitiation. We also estimated CD4 trends conditional on the baseline CD4 value. A total of 10,961 patients returned to care after disengagement from care, with the median gap in care being 2.7 (interquartile range, 2.1-5.4) months. Our model showed that CD4 cell-count increases after ART reinitiation were much slower than those before disengagement. Assuming that disengagement from care occurred 12 months after ART initiation and a 3-month treatment gap, CD4 counts measured at 3 years since ART initiation would be lower by 36.5 cells/μL than those obtained under no disengagement. Given that poorer CD4 restoration is associated with increased mortality/morbidity, specific interventions targeted at better retention in care are urgently required.
Collapse
Affiliation(s)
- Christos Thomadakis
- Correspondence to Dr. Christos Thomadakis, Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece (e-mail: )
| | | | | | | | | | | | | | | |
Collapse
|
3
|
Chamberlin S, Mphande M, Phiri K, Kalande P, Dovel K. How HIV Clients Find Their Way Back to the ART Clinic: A Qualitative Study of Disengagement and Re-engagement with HIV Care in Malawi. AIDS Behav 2022; 26:674-685. [PMID: 34403022 PMCID: PMC8840926 DOI: 10.1007/s10461-021-03427-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2021] [Indexed: 01/15/2023]
Abstract
Retention in antiretroviral therapy (ART) services is critical to achieving positive health outcomes for individuals living with HIV, but accumulating evidence indicates that individuals are likely to miss ART appointments over time. Thus, it is important to understand why individuals miss appointments and how they re-engage in HIV care. We used in-depth interviews with 44 ART clients in Malawi who recently missed an ART appointment (> 14 days) but eventually re-engaged in care (within 60 days) to explore reasons for missed appointments and barriers and facilitators to re-engagement. We found that most individuals missed ART appointments due to unexpected life events such as funerals, work, and illness for both clients and their treatment guardians who were also unable to attend facilities. Several reasons differed by gender-work-related travel was common for men, while caring for sick family members was common for women. Barriers to re-engagement included continued travel, illness, and restricted clinic schedules and/or staff shortages that led to repeat facility visits before being able to re-engage in care. Strong internal motivation combined with social support and reminders from community health workers facilitated re-engagement in HIV care.
Collapse
Affiliation(s)
- Stephanie Chamberlin
- Department of Health and Behavioral Sciences, University of Colorado Denver, Campus Box 188, P.O. Box 173364, Denver, CO, 80217-3364, USA.
| | | | - Khumbo Phiri
- Partners in Hope Medical Center, Lilongwe, Malawi
| | | | - Kathryn Dovel
- Partners in Hope Medical Center, Lilongwe, Malawi
- Department of Medicine and Division of Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
4
|
Beres LK, Mody A, Sikombe K, Nicholas LH, Schwartz S, Eshun-Wilson I, Somwe P, Simbeza S, Pry JM, Kaumba P, McGready J, Holmes CB, Bolton-Moore C, Sikazwe I, Denison JA, Geng EH. The effect of tracer contact on return to care among adult, "lost to follow-up" patients living with HIV in Zambia: an instrumental variable analysis. J Int AIDS Soc 2021; 24:e25853. [PMID: 34921515 PMCID: PMC8683971 DOI: 10.1002/jia2.25853] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 11/17/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Tracing patients lost to follow-up (LTFU) from HIV care is widely practiced, yet we have little knowledge of its causal effect on care engagement. In a prospective, Zambian cohort, we examined the effect of tracing on return to care within 2 years of LTFU. METHODS We traced a stratified, random sample of LTFU patients who had received HIV care between August 2013 and July 2015. LTFU was defined as a gap of >90 days from last scheduled appointment in the routine electronic medical record. Extracting 2 years of follow-up visit data through 2017, we identified patients who returned. Using random selection for tracing as an instrumental variable (IV), we used conditional two-stage least squares regression to estimate the local average treatment effect of tracer contact on return. We examined the observational association between tracer contact and return among patient sub-groups self-confirmed as disengaged from care. RESULTS Of the 24,164 LTFU patients enumerated, 4380 were randomly selected for tracing and 1158 were contacted by a tracer within a median of 14.8 months post-loss. IV analysis found that patients contacted by a tracer because they were randomized to tracing were no more likely to return than those not contacted (adjusted risk difference [aRD]: 3%, 95% CI: -2%, 8%, p = 0.23). Observational data showed that among contacted, disengaged patients, the rate of return was higher in the week following tracer contact (IR 5.74, 95% CI: 3.78-8.71) than in the 2 weeks to 1-month post-contact (IR 2.28, 95% CI: 1.40-3.72). There was a greater effect of tracing among patients lost for >6 months compared to those contacted within 3 months of loss. CONCLUSIONS Overall, tracer contact did not causally increase LTFU patient return to HIV care, demonstrating the limited impact of tracing in this program, where contact occurred months after patients were LTFU. However, observational data suggest that tracing may speed return among some LTFU patients genuinely out-of-care. Further studies may improve tracing effectiveness by examining the mechanisms underlying the impact of tracing on return to care, the effect of tracing at different times-since-loss and using more accurate identification of patients who are truly disengaged to target tracing.
Collapse
Affiliation(s)
- Laura K Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Aaloke Mody
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Lauren Hersch Nicholas
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ingrid Eshun-Wilson
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Jake M Pry
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.,Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Paul Kaumba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - John McGready
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Charles B Holmes
- Center for Innovation in Global Health, Georgetown University, Washington, DC, USA.,Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, 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
| | - Elvin H Geng
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| |
Collapse
|
5
|
Sikazwe I, Eshun-Wilson I, Sikombe K, Beres LK, Somwe P, Mody A, Simbeza S, Bukankala C, Glidden DV, Mulenga LB, Padian N, Ehrenkranz P, Bolton-Moore C, Holmes CB, Geng EH. Patient-reported Reasons for Stopping Care or Switching Clinics in Zambia: A Multisite, Regionally Representative Estimate Using a Multistage Sampling-based Approach in Zambia. Clin Infect Dis 2021; 73:e2294-e2302. [PMID: 33011803 PMCID: PMC8492131 DOI: 10.1093/cid/ciaa1501] [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: 06/18/2020] [Accepted: 10/01/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Understanding patient-reported reasons for lapses of retention in human immunodeficiency virus (HIV) treatment can drive improvements in the care cascade. A systematic assessment of outcomes among a random sample of patients lost to follow-up (LTFU) from 32 clinics in Zambia to understand the reasons for silent transfers and disengagement from care was undertaken. METHODS We traced a simple random sample of LTFU patients (>90 days from last scheduled visit) as determined from clinic-based electronic medical records from a probability sample of facilities. Among patients found in person, we solicited reasons for either stopping or switching care and predictors for re-engagement. We coded reasons into structural, psychosocial, and clinic-based barriers. RESULTS Among 1751 LTFU patients traced and found alive, 31% of patients starting antiretroviral therapy (ART) between 1 July 2013 and 31 July 2015 silently transferred or were disengaged (40% male; median age, 35 years; median CD4 level, 239 cells/μL); median time on ART at LTFU was 480 days (interquartile range, 110-1295). Among the 544 patients not in care, median prevalences for patient-reported structural, psychosocial, and clinic-level barriers were 27.3%, 13.9%, and 13.4%, respectively, and were highly variable across facilities. Structural reasons, including, "relocated to a new place" were mostly cited among 289 patients who silently transferred (35.5%). We found that men were less likely to re-engage in care than women (odds ratio, .39; 95% confidence interval, .22-.67; P = .001). CONCLUSIONS Efforts to improve retention of patients on ART may need to be tailored at the facility level to address patient-reported barriers.
Collapse
Affiliation(s)
- Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Kombatende Sikombe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Aaloke Mody
- Washington University in St Louis, St Louis, Missouri, USA
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Chama Bukankala
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | | | - Nancy Padian
- University of California Berkeley, Berkeley, California, USA
| | | | | | - Charles B Holmes
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Johns Hopkins University, Baltimore, Maryland, USA
- Georgetown University, Washington, D.C., USA
| | - Elvin H Geng
- Washington University in St Louis, St Louis, Missouri, USA
| |
Collapse
|
6
|
Nalubega S, Kyenkya J, Bagaya I, Nabukenya S, Ssewankambo N, Nakanjako D, Kiragga AN. COVID-19 may exacerbate the clinical, structural and psychological barriers to retention in care among women living with HIV in rural and peri-urban settings in Uganda. BMC Infect Dis 2021; 21:980. [PMID: 34544389 PMCID: PMC8451386 DOI: 10.1186/s12879-021-06684-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 09/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Retention of pregnant and breastfeeding women and their infants in HIV care still remains low in Uganda. Recent literature has shown that the effects of COVID-19 mitigation measures may increase disease burden of common illnesses including HIV, Tuberculosis, Malaria and other key public health outcomes such as maternal mortality. A research program was undertaken to locate disengaged HIV positive women on option B+ and supported them to reengage in care. A 1 year follow up done following the tracing revealed that some women still disengaged from care. We aimed to establish the barriers to and facilitators for reengagement in care among previously traced women on option B+, and how these could have been impacted by the COVID-19 pandemic. METHODS This was a cross sectional qualitative study using individual interviews conducted in June and July, 2020, a period when the COVID-19 response measures such as lockdown and restrictions on transport were being observed in Uganda. Study participants were drawn from nine peri-urban and rural public healthcare facilities. Purposive sampling was used to select women still engaged in and those who disengaged from care approximately after 1 year since they were last contacted. Seventeen participants were included. Data was analysed using the content analysis approach. RESULTS Women reported various barriers that affected their reengagement and retention in care during the COVID-19 pandemic. These included structural barriers such as transport difficulties and financial constraints; clinical barriers which included unsupportive healthcare workers, short supply of drugs, clinic delays, lack of privacy and medicine side effects; and psychosocial barriers such as perceived or experienced stigma and non-disclosure of HIV sero-status. Supportive structures such as family, community-based medicine distribution models, and a friendly healthcare environment were key facilitators to retention in care among this group. The COVID-19 pandemic was reported to exacerbate the barriers to retention in care. CONCLUSIONS COVID-19 may exacerbate barriers to retention in HIV care among those who have experienced previous disengagement. We recommend community-based models such as drop out centres, peer facilitated distribution and community outreaches as alternative measures for access to ART during the COVID-19 pandemic.
Collapse
Affiliation(s)
- Sylivia Nalubega
- Department of Nursing, School of Health Sciences, Soroti University, Po Box, 211, Soroti, Uganda.
| | - Joshua Kyenkya
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Irene Bagaya
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sylvia Nabukenya
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Nelson Ssewankambo
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Damalie Nakanjako
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Agnes N Kiragga
- Research Department, Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| |
Collapse
|
7
|
Ford N, Eshun-Wilson I, Ameyan W, Newman M, Vojnov L, Doherty M, Geng E. Future directions for HIV service delivery research: Research gaps identified through WHO guideline development. PLoS Med 2021; 18:e1003812. [PMID: 34555010 PMCID: PMC8496797 DOI: 10.1371/journal.pmed.1003812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 10/07/2021] [Indexed: 11/19/2022] Open
Abstract
Nathan Ford and co-authors discuss the systematic identification of research gaps in improving HIV service delivery.
Collapse
Affiliation(s)
- Nathan Ford
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Wole Ameyan
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Morkor Newman
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Lara Vojnov
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Meg Doherty
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Elvin Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America
| |
Collapse
|
8
|
Long-Distance Travel for HIV-Related Care-Burden or Choice?: A Mixed Methods Study in Tanzania. AIDS Behav 2021; 25:2071-2083. [PMID: 33415657 DOI: 10.1007/s10461-020-03136-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2020] [Indexed: 10/22/2022]
Abstract
Decentralization of HIV care across sub-Saharan Africa has increased access to anti-retroviral therapy (ART). Although traveling for care has traditionally been viewed as a barrier, some individuals may choose to travel for care due to stigma and fear of HIV status disclosure. We sought to understand the prevalence of traveling long distances for HIV care, as well as reasons for engaging in such travel. Using a concurrent embedded mixed-methods study design, individuals receiving care at two HIV care and treatment clinics in Tanzania completed a quantitative survey (n = 196), and a sub-set of participants reporting long-distance travel for care were interviewed (n = 31). Overall 58.2% of participants (n = 114/196) reported knowing of a closer clinic than the one they chose to attend. Having experienced enacted stigma was significantly associated with traveling for care (OR 2.31, 95% CI 1.12, 4.75, p = 0.02). Reasons for clinic choice centered on three main themes: clinic familiarity, quality of care, and stigma. Traveling for care was often viewed as an enabling strategy for remaining engaged in care by helping overcome other barriers, including stigma and suboptimal quality of care.
Collapse
|
9
|
Genberg BL, Wachira J, Steingrimsson JA, Pastakia S, Tran DNT, Said JA, Braitstein P, Hogan JW, Vedanthan R, Goodrich S, Kafu C, Wilson-Barthes M, Galárraga O. Integrated community-based HIV and non-communicable disease care within microfinance groups in Kenya: study protocol for the Harambee cluster randomised trial. BMJ Open 2021; 11:e042662. [PMID: 34006540 PMCID: PMC8137246 DOI: 10.1136/bmjopen-2020-042662] [Citation(s) in RCA: 6] [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: 12/26/2022] Open
Abstract
INTRODUCTION In Kenya, distance to health facilities, inefficient vertical care delivery and limited financial means are barriers to retention in HIV care. Furthermore, the increasing burden of non-communicable diseases (NCDs) among people living with HIV complicates chronic disease treatment and strains traditional care delivery models. Potential strategies for improving HIV/NCD treatment outcomes are differentiated care, community-based care and microfinance (MF). METHODS AND ANALYSIS We will use a cluster randomised trial to evaluate integrated community-based (ICB) care incorporated into MF groups in medium and high HIV prevalence areas in western Kenya. We will conduct baseline assessments with n=900 HIV positive members of 40 existing MF groups. Group clusters will be randomised to receive either (1) ICB or (2) standard of care (SOC). The ICB intervention will include: (1) clinical care visits during MF group meetings inclusive of medical consultations, NCD management, distribution of antiretroviral therapy (ART) and NCD medications, and point-of-care laboratory testing; (2) peer support for ART adherence and (3) facility referrals as needed. MF groups randomised to SOC will receive regularly scheduled care at a health facility. Findings from the two trial arms will be compared with follow-up data from n=300 matched controls. The primary outcome will be VS at 18 months. Secondary outcomes will be retention in care, absolute mean change in systolic blood pressure and absolute mean change in HbA1c level at 18 months. We will use mediation analysis to evaluate mechanisms through which MF and ICB care impact outcomes and analyse incremental cost-effectiveness of the intervention in terms of cost per HIV suppressed person-time, cost per patient retained in care and cost per disability-adjusted life-year saved. ETHICS AND DISSEMINATION The Moi University Institutional Research and Ethics Committee approved this study (IREC#0003054). We will share data via the Brown University Digital Repository and disseminate findings via publication. TRIAL REGISTRATION NUMBER NCT04417127.
Collapse
Affiliation(s)
- Becky L Genberg
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Juddy Wachira
- Behavioral Sciences, Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Jon A Steingrimsson
- Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Sonak Pastakia
- Center for Health Equity and Innovation, Purdue University College of Pharmacy, Indianapolis, Indiana, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Dan N Tina Tran
- Center for Health Equity and Innovation, Purdue University College of Pharmacy, Indianapolis, Indiana, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jamil AbdulKadir Said
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Internal Medicine, Moi University School of Medicine, Eldoret, Kenya
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Epidemiology, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Joseph W Hogan
- Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Rajesh Vedanthan
- Global Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Suzanne Goodrich
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Catherine Kafu
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Marta Wilson-Barthes
- Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Omar Galárraga
- Health Services, Policy and Practice, Brown University School of Public Health, 121 South Main St. Box G-S121-2 Providence, Rhode Island, USA
| |
Collapse
|
10
|
Baye M, Fisseha B, Bayisa M, Abebe SM, Janakiraman B. Experience of fatigue and associated factors among adult people living with HIV attending ART clinic: a hospital-based cross-sectional study in Ethiopia. BMJ Open 2020; 10:e042029. [PMID: 33087381 PMCID: PMC7580062 DOI: 10.1136/bmjopen-2020-042029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE This study aimed to determine the prevalence of fatigue and the factors associated among adult people living with HIV attending antiretroviral therapy clinic in Gondar town, Ethiopia. DESIGN Cross-sectional. SETTING Governmental health facility that provides HIV care in Gondar town. OUTCOME MEASURE Fatigue is defined by nine items version Fatigue Severity Scale. PARTICIPANTS Adult (aged 18 and above) people living with HIV in Gondar town (n=392). RESULT A total of 408 HIV seropositive adults were approached for consent, among which 392 participants consented to participate in this study, with a response rate of 96.1%. The mean age of the participants was 40.5±8.5 years. The prevalence of HIV-related fatigue was 53.3% and about 66% of women living with HIV experienced fatigue. The factors associated with fatigue experience were; female gender (adjusted OR (AOR): 2.61, 95% CI 1.01 to 5.3), being married (AOR: 0.18, 95% CI 0.10 to 0.9), low income (AOR: 7.1, 95% CI 4.6 to 22.15), unemployed (AOR: 2.79, 95% CI 1.19 to 9.84), parity (AOR: 4.87, 95% CI 2.18 to 17.9), being anaemic (AOR: 12.45, 95% CI 5.6 to 41.01), depression (AOR: 4.51, 95% CI 1.91 to 11.20), mild weight loss (AOR: 4.2 95% CI 2.56 to 13.9) and moderate weight loss (AOR: 5.1, 95% CI 1.85 to 16.12), respectively. CONCLUSION The findings of this study revealed that experiencing fatigue is quite common among adult people living with HIV. It is important for the healthcare professionals and people living with HIV to understand; the possible causes of fatigue, remedies and ways to reclaim energy. The predisposing factors and complications that cause fatigue should be aggressively diagnosed and treated by the clinicians. Further qualitative studies exploring the reasons for experiencing HIV-related fatigue might help designing interventions.
Collapse
Affiliation(s)
- Moges Baye
- Department of Physiotherapy, School of Medicine, College of Medicine and Health Sciences, and Specialized Hospital, Gondar, Amhara, Ethiopia
| | - Berihu Fisseha
- Department of Physiotherapy, School of Medicine, College of Health Sciences and Ayder Comprehensive Specialized Hospital, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Mulugeta Bayisa
- Department of Physiotherapy, School of Medicine, College of Medicine and Health Sciences, and Specialized Hospital, Gondar, Amhara, Ethiopia
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
| | - Solomon Mekonnen Abebe
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Balamurugan Janakiraman
- Department of Physiotherapy, School of Medicine, College of Health Sciences and Ayder Comprehensive Specialized Hospital, Mekelle University, Mekelle, Tigray, Ethiopia
| |
Collapse
|
11
|
Baldé A, Lièvre L, Maiga AI, Diallo F, Maiga IA, Costagliola D, Abgrall S. Re-engagement in care of people living with HIV lost to follow-up after initiation of antiretroviral therapy in Mali: Who returns to care? PLoS One 2020; 15:e0238687. [PMID: 32911516 PMCID: PMC7482938 DOI: 10.1371/journal.pone.0238687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/21/2020] [Indexed: 01/26/2023] Open
Abstract
Objectives We assessed cumulative incidence rates of and factors associated with re-engagement in HIV care for PLHIV lost to follow-up in Mali. Methods HIV-1-infected individuals lost to follow-up before 31/12/2013, ≥ 18 years old, who started ART from 2006 to 2012 at one of 16 care centres were considered. Loss to follow-up (LTFU) was defined as an interruption of ≥ 6 months during follow-up. The re-engagement in care in PLHIV lost to follow-up before 31/12/2013 was defined as having at least one clinical visit after LTFU. The cumulative incidence rates of re-engagement in care was estimated by Kaplan-Meier and its predictive factors were assessed using Cox models. Socio-demographic characteristics, clinical and immune status, period, region, centre expertise level, and distance from home at the start of ART plus a combined variable of duration of ART until LTFU and 12-month change in CD4 count were assessed. Multiple imputation was used to deal with missing data. Results We included 3,650 PLHIV lost to follow-up before December 2013, starting ART in nine outpatient clinics and seven hospitals (5+2 in Bamako and 4+5 in other regions): 35% male, median (IQR) age 35 (29–43), and duration of ART until LTFU 11 months (5–22). Among these PLHIV, 1,975 (54%) were definitively LTFU and 1,675 (46%) subsequently returned to care. The cumulative incidence rates of re-engagement in care rose from 39.0% at one year to 47.0% at three years after LTFU. Predictors of re-engagement in care were starting ART with WHO stage 1–2 and CD4 counts ≥ 200 cells/μL, being treated for ≥ 12 months with CD4 count gain ≥ 50 cells/μL, or being followed in Bamako. People followed at regional hospitals or outpatient clinics ≥ 5 km away, or being treated for ≥ 12 months with CD4 count gain < 50 cells/μL were less likely to return to care. Conclusions Starting ART with a higher CD4 count, better gain in CD4 count, and being followed either in Bamako or close to home in the regions were associated with re-engagement in care.
Collapse
Affiliation(s)
- Aliou Baldé
- Sorbonne Université, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP, Paris, France
- * E-mail:
| | - Laurence Lièvre
- Sorbonne Université, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP, Paris, France
| | - Almoustapha Issiaka Maiga
- Unité d'épidémiologie moléculaire de la résistance du VIH aux ARV du Centre de Recherche et de Formation sur le VIH/SIDA et la tuberculose (SEREFO), Université des Sciences, des Techniques et des Technologies de Bamako (USTTB), Bamako, Mali
| | - Fodié Diallo
- Association de Recherche, de Communication, d’Accompagnement à Domicile des Personnes Vivant avec le VIH (ARCAD-SIDA), Bamako, Mali
| | - Issouf Alassane Maiga
- Ensemble pour une Solidarité Thérapeutique Hospitalière en Réseau (ESTHER)/Expertise France, Bamako, Mali
| | - Dominique Costagliola
- Sorbonne Université, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP, Paris, France
| | - Sophie Abgrall
- Sorbonne Université, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, IPLESP, Paris, France
- AP-HP, Hôpital Antoine Béclère, Service de Médecine Interne, Clamart, INSERM, Université Paris Sud, Université Paris Saclay, France
| |
Collapse
|
12
|
Fuente-Soro L, López-Varela E, Augusto O, Bernardo EL, Sacoor C, Nhacolo A, Ruiz-Castillo P, Alfredo C, Karajeanes E, Vaz P, Naniche D. Loss to follow-up and opportunities for reengagement in HIV care in rural Mozambique: A prospective cohort study. Medicine (Baltimore) 2020; 99:e20236. [PMID: 32443358 PMCID: PMC7254184 DOI: 10.1097/md.0000000000020236] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Patients lost to follow-up (LTFU) over the human immunodeficiency virus (HIV) cascade have poor clinical outcomes and contribute to onward HIV transmission. We assessed true care outcomes and factors associated with successful reengagement in patients LTFU in southern Mozambique.Newly diagnosed HIV-positive adults were consecutively recruited in the Manhiça District. Patients LTFU within 12 months after HIV diagnosis were visited at home from June 2015 to July 2016 and interviewed for ascertainment of outcomes and reasons for LTFU. Factors associated with reengagement in care within 90 days after the home visit were analyzed by Cox proportional hazards model.Among 1122 newly HIV-diagnosed adults, 691 (61.6%) were identified as LTFU. Of those, 557 (80.6%) were approached at their homes and 321 (57.6%) found at home. Over 50% had died or migrated, 10% had been misclassified as LTFU, and 252 (78.5%) were interviewed. Following the visit, 79 (31.3%) reengaged in care. Having registered in care and a shorter time between LTFU and visit were associated with reengagement in multivariate analyses: adjusted hazards ratio of 3.54 [95% confidence interval (CI): 1.81-6.92; P < .001] and 0.93 (95% CI: 0.87-1.00; P = .045), respectively. The most frequently reported barriers were the lack of trust in the HIV-diagnosis, the perception of being in good health, and fear of being badly treated by health personnel and differed by type of LTFU.Estimates of LTFU in rural areas of sub-Saharan Africa are likely to be overestimated in the absence of active tracing strategies. Home visits are resource-intensive but useful strategies for reengagement for at least one-third of LTFU patients when applied in the context of differentiated care for those LTFU individuals who had already enrolled in HIV care at some point.
Collapse
Affiliation(s)
- Laura Fuente-Soro
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic –00 Universitat de Barcelona, Barcelona, Spain
| | - Elisa López-Varela
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic –00 Universitat de Barcelona, Barcelona, Spain
| | - Orvalho Augusto
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Edson Luis Bernardo
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- Manhiça District Health Services
| | | | - Ariel Nhacolo
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Paula Ruiz-Castillo
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic –00 Universitat de Barcelona, Barcelona, Spain
| | | | | | - Paula Vaz
- Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo, Mozambique
| | - Denise Naniche
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic –00 Universitat de Barcelona, Barcelona, Spain
| |
Collapse
|
13
|
Yonga P, Kalya S, Lynen L, Decroo T. Temporary disengagement and re-engagement in human immunodeficiency virus care in a rural county serving pastoralist communities in Kenya: a retrospective cohort study. Int Health 2020; 12:95-100. [PMID: 31227824 PMCID: PMC7057135 DOI: 10.1093/inthealth/ihz049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/14/2019] [Accepted: 05/22/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Pastoralist communities are known to be hard to reach. The magnitude of temporary disengagement from human immunodeficiency virus (HIV) care is understudied. METHODS We conducted a retrospective cohort study of temporary disengagement (2 weeks late for a next appointment), virologic response, lost to follow-up (6 months late) and re-engagement in care among patients who started antiretroviral therapy between 2014 and 2016 in Baringo County, Kenya. Predictors of re-engagement after disengagement were estimated using logistic regression. RESULTS Of 342 patients, 76.9% disengaged at least once (range 0-7). Of 218 patients with a viral load (VL), 78.0% had a suppressed VL. Those with a history of temporary disengagement from care were less likely to suppress their VL (p=0.002). Six patients had treatment failure (two consecutive VLs >1000 copies/mm3) and all had disengaged at least once. After disengagement from care, male patients (adjusted odds ratio [aOR] 0.3 [95% confidence interval {CI} 0.2 to 0.6]; p<0.001) and patients with World Health Organization stage III-IV (aOR 0.3 [95% CI 0.1 to 0.5; p<0.001) were less likely to re-engage in care. CONCLUSIONS Temporary disengagement was frequent in this pastoralist setting. This indicator is often overlooked, as most studies only report binary outcomes, such as retention in care. Innovative strategies are required to achieve HIV control in rural settings like this pastoralist setting.
Collapse
Affiliation(s)
- Paul Yonga
- Baringo County Referral Hospital, Ministry of Health Kenya, Kabarnet, Baringo County, P.O. BOX 67039 City Square, Postal Code, Nairobi, Kenya
| | - Stephen Kalya
- Baringo County Referral Hospital, Ministry of Health Kenya, Kabarnet, Baringo County, P.O. BOX 67039 City Square, Postal Code, Nairobi, Kenya
| | - Lutgarde Lynen
- Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Nationalestraat 140, Postal Code, Antwerp, Belgium
| | - Tom Decroo
- Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Nationalestraat 140, Postal Code, Antwerp, Belgium.,Research Foundation Flanders, Brussels, Belgium
| |
Collapse
|
14
|
Gebreyesus T, Belay A, Berhe G, Haile G. Burden of fatigue among adults living with HIV/AIDS attending antiretroviral therapy in Ethiopia. BMC Infect Dis 2020; 20:280. [PMID: 32295546 PMCID: PMC7161178 DOI: 10.1186/s12879-020-05008-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Fatigue is one of the most common and devastating Human Immuno-deficiency Virus (HIV) - related symptoms, with a varying prevalence in different study areas. In Ethiopia, there is a paucity of information on the magnitude and factors associated with fatigue among HIV/Acquired Immune Deficiency Syndrome (AIDS) patients. This may lead to under-diagnosis and eventually under-management of the symptom. METHODS Institution based cross-sectional study design was conducted among 609 HIV/AIDS patients who were selected by using a systematic random sampling method. Data were collected by using interviewer administered structured questionnaire. Level of fatigue was measured by Fatigue Severity Scale. RESULTS The prevalence of fatigue was found to be 51.7%. The factors associated with fatigue were: Parity [AOR = 2.01; 95% CI: 1.09-3.71], CD4 count 200-499 cells/mm3 [AOR = 2.81; 95% CI: 1.58-4.99], anemia [AOR = 4.90 95% CI: 2.40-9.97], co-morbidities [AOR = 3.65; 95% CI: 1.71-7.78], depression [AOR = 3.68 95% CI: 1.99-6.79], not being physically active [AOR = 3.20 95% CI: 1.50-6.81], clinical stage II or IV HIV [AOR = 3.11; 95% CI: 1.51-6.40] and [AOR = 4.08; 95% CI: 1.37-12.14], respectively. CONCLUSION The finding of this study revealed that fatigue is a common health problem among adult People Living with HIV (PLHIV). Factors associated with fatigue included: Parity, CD4 count 200-499 cells/mm3, Clinical Stage II or IV HIV, anemia, co-morbidities, depression, and not being physically active. The health care service needs to address the predisposing factors by provision integrated care including timely detection and treatment of comorbidities, mental health problems, and promote physical activity to slow down disease progression and then reduce exposure to fatigue.
Collapse
Affiliation(s)
- Tsiwaye Gebreyesus
- Department of Physiotherapy, School of Medicine, College of Health Sciences and Ayder Comprehensive Specialized Hospital, Mekelle University, P.O.Box: 1871, Mekelle, Ethiopia
| | - Addisalem Belay
- Department of Physiotherapy, School of Medicine, College of Health Sciences and Ayder Comprehensive Specialized Hospital, Mekelle University, P.O.Box: 1871, Mekelle, Ethiopia
| | - Gebretsadik Berhe
- Department of Epidemiology, School of Public Health, College of Health Sciences and Ayder Comprehensive Specialized Hospital, Mekelle University, Mekelle, Ethiopia
| | - Gebremedhin Haile
- Department of Physiotherapy, School of Medicine, College of Health Sciences and Ayder Comprehensive Specialized Hospital, Mekelle University, P.O.Box: 1871, Mekelle, Ethiopia
| |
Collapse
|
15
|
Retention in Care Trajectories of HIV-Positive Individuals Participating in a Universal Test-and-Treat Program in Rural South Africa (ANRS 12249 TasP Trial). J Acquir Immune Defic Syndr 2019; 80:375-385. [PMID: 30570525 PMCID: PMC6410969 DOI: 10.1097/qai.0000000000001938] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Supplemental Digital Content is Available in the Text. Objective: To study retention in care (RIC) trajectories and associated factors in
patients eligible for antiretroviral therapy (ART) in a universal
test-and-treat setting (TasP trial, South Africa, 2012–2016). Design: A cluster-randomized trial whereby individuals identified HIV positive after
home-based testing were invited to initiate ART immediately (intervention)
or following national guidelines (control). Methods: Exiting care was defined as ≥3 months late for a clinic appointment,
transferring elsewhere, or death. Group-based trajectory modeling was
performed to estimate RIC trajectories over 18 months and associated factors
in 777 ART-eligible patients. Results: Four RIC trajectory groups were identified: (1) group 1
“remained” in care (reference, n = 554, 71.3%), (2) group
2 exited care then “returned” after [median (interquartile
range)] 4 (3–9) months (n = 40, 5.2%), (3) group 3
“exited care rapidly” [after 4 (4–6) months, n =
98, 12.6%], and (4) group 4 “exited care later” [after 11
(9–13) months, n = 85, 10.9%]. Group 2 patients were less likely
to have initiated ART within 1 month and more likely to be male, young
(<29 years), without a regular partner, and to have a CD4 count
>350 cells/mm3. Group 3 patients were more likely to be
women without social support, newly diagnosed, young, and less likely to
have initiated ART within 1 month. Group 4 patients were more likely to be
newly diagnosed and aged 39 years or younger. Conclusions: High CD4 counts at care initiation were not associated with a higher risk of
exiting care. Prompt ART initiation and special support for young and newly
diagnosed patients with HIV are needed to maximize RIC.
Collapse
|
16
|
Mody A, Eshun-Wilson I, Sikombe K, Schwartz SR, Beres LK, Simbeza S, Mukamba N, Somwe P, Bolton-Moore C, Padian N, Holmes CB, Sikazwe I, Geng EH. Longitudinal engagement trajectories and risk of death among new ART starters in Zambia: A group-based multi-trajectory analysis. PLoS Med 2019; 16:e1002959. [PMID: 31661487 PMCID: PMC6818762 DOI: 10.1371/journal.pmed.1002959] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 10/07/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Retention in HIV treatment must be improved to advance the HIV response, but research to characterize gaps in retention has focused on estimates from single time points and population-level averages. These approaches do not assess the engagement patterns of individual patients over time and fail to account for both their dynamic nature and the heterogeneity between patients. We apply group-based trajectory analysis-a special application of latent class analysis to longitudinal data-among new antiretroviral therapy (ART) starters in Zambia to identify groups defined by engagement patterns over time and to assess their association with mortality. METHODS AND FINDINGS We analyzed a cohort of HIV-infected adults who newly started ART between August 1, 2013, and February 1, 2015, across 64 clinics in Zambia. We performed group-based multi-trajectory analysis to identify subgroups with distinct trajectories in medication possession ratio (MPR, a validated adherence metric based on pharmacy refill data) over the past 3 months and loss to follow-up (LTFU, >90 days late for last visit) among patients with at least 180 days of observation time. We used multinomial logistic regression to identify baseline factors associated with belonging to particular trajectory groups. We obtained Kaplan-Meier estimates with bootstrapped confidence intervals of the cumulative incidence of mortality stratified by trajectory group and performed adjusted Poisson regression to estimate adjusted incidence rate ratios (aIRRs) for mortality by trajectory group. Inverse probability weights were applied to all analyses to account for updated outcomes ascertained from tracing a random subset of patients lost to follow-up as of July 31, 2015. Overall, 38,879 patients (63.3% female, median age 35 years [IQR 29-41], median enrollment CD4 count 280 cells/μl [IQR 146-431]) were included in our cohort. Analyses revealed 6 trajectory groups among the new ART starters: (1) 28.5% of patients demonstrated consistently high adherence and retention; (2) 22.2% showed early nonadherence but consistent retention; (3) 21.6% showed gradually decreasing adherence and retention; (4) 8.6% showed early LTFU with later reengagement; (5) 8.7% had early LTFU without reengagement; and (6) 10.4% had late LTFU without reengagement. Identified groups exhibited large differences in survival: after adjustment, the "early LTFU with reengagement" group (aIRR 3.4 [95% CI 1.2-9.7], p = 0.019), the "early LTFU" group (aIRR 6.4 [95% CI 2.5-16.3], p < 0.001), and the "late LTFU" group (aIRR 4.7 [95% CI 2.0-11.3], p = 0.001) had higher rates of mortality as compared to the group with consistently high adherence/retention. Limitations of this study include using data observed after baseline to identify trajectory groups and to classify patients into these groups, excluding patients who died or transferred within the first 180 days, and the uncertain generalizability of the data to current care standards. CONCLUSIONS Among new ART starters in Zambia, we observed 6 patient subgroups that demonstrated distinctive engagement trajectories over time and that were associated with marked differences in the subsequent risk of mortality. Further efforts to develop tailored intervention strategies for different types of engagement behaviors, monitor early engagement to identify higher-risk patients, and better understand the determinants of these heterogeneous behaviors can help improve care delivery and survival in this population.
Collapse
Affiliation(s)
- Aaloke Mody
- Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
- * E-mail:
| | - Ingrid Eshun-Wilson
- Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
| | | | - Sheree R. Schwartz
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Laura K. Beres
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sandra Simbeza
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Njekwa Mukamba
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Paul Somwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, University of Alabama at Birmingham, Alabama, United States of America
| | - Nancy Padian
- Division of Epidemiology, University of California, Berkeley, California, United States of America
| | - Charles B. Holmes
- Department of Medicine, Georgetown University, Washington, District of Columbia, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Elvin H. Geng
- Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
| |
Collapse
|
17
|
Brown LB, Getahun M, Ayieko J, Kwarisiima D, Owaraganise A, Atukunda M, Olilo W, Clark T, Bukusi EA, Cohen CR, Kamya MR, Petersen ML, Charlebois ED, Havlir DV, Camlin CS. Factors predictive of successful retention in care among HIV-infected men in a universal test-and-treat setting in Uganda and Kenya: A mixed methods analysis. PLoS One 2019; 14:e0210126. [PMID: 30673744 PMCID: PMC6343966 DOI: 10.1371/journal.pone.0210126] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/17/2018] [Indexed: 11/23/2022] Open
Abstract
Background Previous research indicates clinical outcomes among HIV-infected men in sub-Saharan Africa are sub-optimal. The SEARCH test and treat trial (NCT01864603) intervention included antiretroviral care delivery designed to address known barriers to HIV-care among men by decreasing clinic visit frequency and providing flexible, patient-centered care with retention support. We sought to understand facilitators and barriers to retention in care in this universal treatment setting through quantitative and qualitative data analysis. Methods We used a convergent mixed methods study design to evaluate retention in HIV care among adults (age > = 15) during the first year of the SEARCH (NCT01864603) test and treat trial. Cox proportional hazards regression was used to evaluate predictors of retention in care. Longitudinal qualitative data from n = 190 in-depth interviews with HIV-positive individuals and health care providers were analyzed to identify facilitators and barriers to HIV care engagement. Results There were 1,863 men and 3,820 women who linked to care following baseline testing. Retention in care was 89.7% (95% CI 87.0–91.8%) among men and 89.0% (86.8–90.9%) among women at one year. In both men and women older age was associated with higher rates of retention in care at one year. Additionally, among men higher CD4+ at ART initiation and decreased time between testing and ART initiation was associated with higher rates of retention. Maintaining physical health, a patient-centered treatment environment, supportive partnerships, few negative consequences to disclosure, and the ability to seek care in facilities outside of their community of residence were found to promote retention in care. Conclusions Features of the ART delivery system in the SEARCH intervention and social and structural advantages emerged as facilitators to retention in HIV care among men. Messaging around the health benefits of early ART start, decreasing logistical barriers to HIV care, support of flexible treatment environments, and accelerated linkage to care, are important to men’s success in ART treatment programs. Men already benefit from increased social support following disclosure of their HIV-status. Future efforts to shift gender norms towards greater equity are a potential strategy to support high levels of engagement in care for both men and women.
Collapse
Affiliation(s)
- Lillian B Brown
- Division of HIV, ID and Global Medicine, University of California San Francisco, San Francisco, California, United States of America.,Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California, United States of America
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | | | | | | | | | | | - Tamara Clark
- Division of HIV, ID and Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | | | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda.,Makerere University College of Health Sciences, Kampala, Uganda
| | - Maya L Petersen
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | - Edwin D Charlebois
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California, United States of America
| | - Diane V Havlir
- Division of HIV, ID and Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Carol S Camlin
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California, United States of America.,Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| |
Collapse
|
18
|
Ayieko J, Brown L, Anthierens S, Van Rie A, Getahun M, Charlebois ED, Petersen ML, Clark TD, Kamya MR, Cohen CR, Bukusi EA, Havlir DV, Camlin CS. "Hurdles on the path to 90-90-90 and beyond": Qualitative analysis of barriers to engagement in HIV care among individuals in rural East Africa in the context of test-and-treat. PLoS One 2018; 13:e0202990. [PMID: 30161172 PMCID: PMC6116983 DOI: 10.1371/journal.pone.0202990] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/12/2018] [Indexed: 11/19/2022] Open
Abstract
Background Despite substantial progress, gaps in the HIV care cascade remain large: globally, while about 36.7 million people were living with HIV in 2015, 11.9 million of these individuals did not know their HIV status, 12.7 million were in need of antiretroviral therapy (ART) and 13.0 million were not virally suppressed. We sought to deepen understanding of the barriers to care engagement at three critical steps of the care cascade proposed to make greatest impact for attaining the UNAIDS 90-90-90 targets aimed at shutting down the HIV epidemic. Methods Analyses were conducted among HIV-infected adults in rural East Africa. Qualitative data were collected using in-depth interviews among 63 individuals participating in an ongoing test-and treat trial (NCT01864683) in its baseline year (July 2013-June 2014). Audio recordings were transcribed, translated into English, and coded using Atlas.ti software. Data were analyzed using a thematic framework for explaining barriers to care engagement that drew upon both theory and prior empirical research in similar settings. Results Multiple barriers to engagement in care were observed. HIV-related stigma across dimensions of anticipated, internalized and enacted stigma manifested in denial and fears of disclosure, and influenced lapses in care engagement across multiple steps in the cascade. Poverty (lack of food and transport), lack of social support, work interference, prior negative experiences with health services, drug side effects, and treatment fatigue also negatively affected ART adherence and viral suppression. Gender differences were observed, with work interference and denial disproportionately affecting men compared to women. Conclusion Multiple barriers to HIV care engagement still pervade rural sub-Saharan settings threatening the realization of the UNAIDS 90-90-90 targets. To control the epidemic, efforts need to be accelerated to combat stigma. Patient economic empowerment, innovative drug formulations, as well as more patient-responsive health systems, may help overcome barriers to engagement in care.
Collapse
Affiliation(s)
- James Ayieko
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- * E-mail:
| | - Lillian Brown
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Sibyl Anthierens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Annelies Van Rie
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Monica Getahun
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Edwin D. Charlebois
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Maya L. Petersen
- Department of Biostatistics and Epidemiology, University of California Berkeley, Berkeley, California, United States of America
| | - Tamara D. Clark
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Moses R. Kamya
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Elizabeth A. Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| |
Collapse
|
19
|
Wood TJ, Koester KA, Christopoulos KA, Sauceda JA, Neilands TB, Johnson MO. If someone cares about you, you are more apt to come around: improving HIV care engagement by strengthening the patient-provider relationship. Patient Prefer Adherence 2018; 12:919-927. [PMID: 29872277 PMCID: PMC5973398 DOI: 10.2147/ppa.s157003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The patient-provider relationship is a central factor that can promote or hinder long-term engagement in care among people living with chronic illnesses. In this paper, we explore characteristics of the patient-provider relationship that facilitated or hindered engagement in care among patients receiving care at HIV specialty clinics. PATIENTS AND METHODS We conducted 6 focus group discussions with a total of 43 well-retained and less well-retained HIV+ patients in San Francisco, Seattle, and Birmingham, to elicit a wide range of perspectives on engagement in HIV care. Borrowing from the field of psychotherapy, we examined patient-provider relationship characteristics through the lens of the therapeutic alliance, and with regard to their therapeutic efficacy and impact on patient engagement. RESULTS The majority of participants emphasized how a strong patient-provider relationship defined by trust, intimacy, and collaboration promoted engagement, while a weak patient-provider relationship impeded engagement. CONCLUSION We discuss practical strategies and therapeutic techniques that may be helpful to providers in building strong patient-provider relationship and contend that a strong patient-provider relationship is crucial for patients to feel cared for during clinical encounters, which can promote long-term and sustained engagement in HIV care.
Collapse
Affiliation(s)
- Troy J Wood
- Department of Medicine, University of California, San Francisco, CA, USA
- Correspondence: Troy J Wood, Department of Medicine, University of California, San Francisco, UCSF Box 0886, 550 16th Street, 3rd Floor, San Francisco, CA 94143, USA, Tel +1 415 476 6402, Email
| | - Kimberly A Koester
- AIDS Policy Research Center, Department of Medicine, University of California, San Francisco, CA, USA
| | - Katerina A Christopoulos
- Zuckerberg San Francisco General Hospital, Division of HIV, ID and Global Medicine, University of California, San Francisco, CA, USA
| | - John A Sauceda
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Torsten B Neilands
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Mallory O Johnson
- Department of Medicine, University of California, San Francisco, CA, USA
| |
Collapse
|
20
|
Rebeiro PF, Bakoyannis G, Musick BS, Braithwaite RS, Wools-Kaloustian KK, Nyandiko W, Some F, Braitstein P, Yiannoutsos CT. Observational Study of the Effect of Patient Outreach on Return to Care: The Earlier the Better. J Acquir Immune Defic Syndr 2017; 76:141-148. [PMID: 28604501 PMCID: PMC5597469 DOI: 10.1097/qai.0000000000001474] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The burden of HIV remains heaviest in resource-limited settings, where problems of losses to care, silent transfers, gaps in care, and incomplete mortality ascertainment have been recognized. METHODS Patients in care at Academic Model Providing Access to Healthcare (AMPATH) clinics from 2001-2011 were included in this retrospective observational study. Patients missing an appointment were traced by trained staff; those found alive were counseled to return to care (RTC). Relative hazards of RTC were estimated among those having a true gap: missing a clinic appointment and confirmed as neither dead nor receiving care elsewhere. Sample-based multiple imputation accounted for missing vital status. RESULTS Among 34,522 patients lost to clinic, 15,331 (44.4%) had a true gap per outreach, 2754 (8.0%) were deceased, and 837 (2.4%) had documented transfers. Of 15,600 (45.2%) remaining without active ascertainment, 8762 (56.2%) with later RTC were assumed to have a true gap. Adjusted cause-specific hazard ratios (aHRs) showed early outreach (a ≤8-day window, defined by grid-search approach) had twice the hazard for RTC vs. those without (aHR = 2.06; P < 0.001). HRs for RTC were lower the later the outreach effort after disengagement (aHR = 0.86 per unit increase in time; P < 0.001). Older age, female sex (vs. male), antiretroviral therapy use (vs. none), and HIV status disclosure (vs. none) were also associated with greater likelihood of RTC, and higher enrollment CD4 count with lower likelihood of RTC. CONCLUSION Patient outreach efforts have a positive impact on patient RTC, regardless of when undertaken, but particularly soon after the patient misses an appointment.
Collapse
Affiliation(s)
| | - Giorgos Bakoyannis
- Indiana University Fairbanks School of Public Health, Indianapolis, IN, USA
| | | | - Ronald S. Braithwaite
- New York University School of Medicine, New York City, NY, USA
- Moi University School of Medicine, Eldoret, Kenya
| | | | | | - Fatma Some
- Moi University School of Medicine, Eldoret, Kenya
| | - Paula Braitstein
- Indiana University Fairbanks School of Public Health, Indianapolis, IN, USA
- Moi University School of Medicine, Eldoret, Kenya
- University of Toronto Dalla Lana School of Public Health, Toronto, ON, Canada
| | | |
Collapse
|