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Bassett IV, Yan J, Govere S, Khumalo A, Shazi Z, Nzuza M, Aung T, Rahman K, Zionts D, Dube N, Tshabalala S, Bogart LM, Parker RA. Does type of antiretroviral therapy pick-up point influence 12-month virologic suppression in South Africa? AIDS Care 2024; 36:1518-1527. [PMID: 38861653 PMCID: PMC11343678 DOI: 10.1080/09540121.2024.2361817] [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: 12/08/2023] [Accepted: 05/24/2024] [Indexed: 06/13/2024]
Abstract
We assessed the impact of community- versus clinic-based medication pick-up on rates of virologic suppression in an observational cohort of adults on ART enrolled in a decentralized antiretroviral therapy program (CCMDD) in South Africa. Participants either attended clinics where they were given the choice to pick up ART in community venues or traditional clinics, or clinics where this pathway was assigned. Among 1856 participants, 977 (53%) opted for community ART pick-up at enrollment, and 1201 (86%) were virologically suppressed at one year. Because of missing data on virologic suppression, primary results are based on a model incorporating multiple imputation. In addition to age and gender, distance from clinic and year of HIV diagnosis were included in the multivariable model. There was no difference in opting for clinic- vs. community-based pick-up with regard to achieving 12-month virologic suppression (aRR 1.02, 95% CI 0.98-1.05) in clinics offering choice. There was no impact of assigning all participants to an external pick-up point (aRR 1.00, 95% CI 0.95-1.06), but virologic suppression was reduced in the clinic that assigned participants to clinic pick-up (aRR 0.87, 95% CI 0.81-0.92). These results suggest that provision of community-based ART has not reduced continued virologic suppression in the population enrolled in the CCMDD program.
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Affiliation(s)
- Ingrid V. Bassett
- Massachusetts General Hospital, Division of Infectious Diseases, Boston, Massachusetts, USA
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, Massachusetts, USA
- Center for AIDS Research (CFAR), Harvard University, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Africa Health Research Institute, Durban, South Africa
| | - Joyce Yan
- Massachusetts General Hospital, Biostatistics Center, Boston, Massachusetts, USA
| | | | | | - Zinhle Shazi
- AIDS Healthcare Foundation, Durban, South Africa
| | | | - Taing Aung
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, Massachusetts, USA
| | - Kashfia Rahman
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, Massachusetts, USA
| | - Dani Zionts
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, Massachusetts, USA
| | - Nduduzo Dube
- AIDS Healthcare Foundation, Durban, South Africa
| | - Sandile Tshabalala
- South Africa Department of Health, Province of KwaZulu-Natal, South Africa
| | | | - Robert A. Parker
- Center for AIDS Research (CFAR), Harvard University, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital, Biostatistics Center, Boston, Massachusetts, USA
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Pascoe S, Fox M, Kane J, Mngadi S, Manganye P, Long LC, Metz K, Allen T, Sardana S, Greener R, Zheng A, Thea DM, Murray LK. Study protocol: A randomised trial of the effectiveness of the Common Elements Treatment Approach (CETA) for improving HIV treatment outcomes among women experiencing intimate partner violence in South Africa. BMJ Open 2022; 12:e065848. [PMID: 36549749 PMCID: PMC9772682 DOI: 10.1136/bmjopen-2022-065848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Intimate partner violence (IPV) is a barrier to consistent HIV treatment in South Africa. Previous trials have established that the Common Elements Treatment Approach (CETA), a cognitive-behavioural-based intervention, is effective in reducing mental and behavioural health problems but has not been trialled for effectiveness in improving HIV outcomes. This paper describes the protocol for a randomised trial that is testing the effectiveness of CETA in improving HIV treatment outcomes among women experiencing IPV in South Africa. METHODS AND ANALYSIS We are conducting a randomised trial among HIV-infected women on antiretroviral therapy, who have experienced sexual and/or physical IPV, to test the effect of CETA on increasing retention and viral suppression and reducing IPV. Women living with HIV who have an unsuppressed viral load or are at high risk for poor adherence and report experiencing recent IPV, defined as at least once within in the last 12 months, will be recruited from HIV clinics and randomised 1:1 to receive CETA or an active attention control (text message reminders). All participants will be followed for 24 months. Follow-up HIV data will be collected passively using routinely collected medical records. HIV outcomes will be assessed at 12 and 24 months post-baseline. Questionnaires on violence, substance use and mental health will be administered at baseline, post-CETA completion and at 12 months post-baseline. Our primary outcome is retention and viral suppression (<50 copies/mL) by 12 months post-baseline. We will include 400 women which will give us 80% power to detect an absolute 21% difference between arms. Our primary analysis will be an intention-to-treat comparison of intervention and control by risk differences with 95% CIs. ETHICS AND DISSEMINATION Ethics approval provided by University of the Witwatersrand Human Research Ethics Committee (Medical), Boston University Institutional Review Board and Johns Hopkins School Institutional Review Board. Results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04242992.
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Affiliation(s)
- Sophie Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jeremy Kane
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Sithabile Mngadi
- Department of Internal Medicine, Faculty of Health Sciences University of the Witwatersrand, Johannesburg, South Africa
| | - Pertunia Manganye
- Department of Internal Medicine, Faculty of Health Sciences University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence C Long
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Boston University, Boston, Massachusetts, USA
| | - Kristina Metz
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Taylor Allen
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Srishti Sardana
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ross Greener
- Department of Internal Medicine, Faculty of Health Sciences University of the Witwatersrand, Johannesburg, South Africa
| | - Amy Zheng
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Laura K Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Lowane MP, Lebese RT. Why adult patients on antiretroviral therapy miss clinical appointments in rural villages of Limpopo Province, South Africa: An exploratory study. Health SA 2022; 27:1989. [DOI: 10.4102/hsag.v27i0.1989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/15/2022] [Indexed: 11/07/2022] Open
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MacLeod WB, Bor J, Candy S, Maskew M, Fox MP, Bulekova K, Brennan AT, Potter J, Nattey C, Onoya D, Mlisana K, Stevens W, Carmona S. Cohort profile: the South African National Health Laboratory Service (NHLS) National HIV Cohort. BMJ Open 2022; 12:e066671. [PMID: 36261238 PMCID: PMC9582381 DOI: 10.1136/bmjopen-2022-066671] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE South Africa's National Health Laboratory Service (NHLS) National HIV Cohort was established in 2015 to facilitate monitoring, evaluation and research on South Africa's National HIV Treatment Programme. In South Africa, 84.8% of people living with HIV know their HIV status; 70.7% who know their status are on ART; and 87.4% on ART are virologically suppressed. PARTICIPANTS The NHLS National HIV Cohort includes the laboratory data of nearly all patients receiving HIV care in the public sector since April 2004. Patients are included in the cohort if they have received a CD4 count or HIV RNA viral load (VL) test. Using an anonymised unique patient identifier that we have developed and validated to linked test results, we observe patients prospectively through their laboratory results as they receive HIV care and treatment. Patients in HIV care are seen for laboratory monitoring every 6-12 months. Data collected include age, sex, facility location and test results for CD4 counts, VLs and laboratory tests used to screen for potential treatment complications. FINDINGS TO DATE From April 2004 to April 2018, 63 million CD4 count and VL tests were conducted at 5483 facilities. 12.6 million unique patients had at least one CD4 count or VL, indicating they had accessed HIV care, and 7.1 million patients had a VL test indicating they had started antiretroviral therapy. The creation of NHLS National HIV Cohort has enabled longitudinal research on all lab-monitored patients in South Africa's national HIV programme, including analyses of (1) patient health at presentation; (2) care outcomes such as 'CD4 recovery', 'retention in care' and 'viral resuppression'; (3) patterns of transfer and re-entry into care; (4) facility-level variation in care outcomes; and (5) impacts of policies and guideline changes. FUTURE PLANS Continuous updating of the cohort, integration with available clinical data, and expansion to include tuberculosis and other lab-monitored comorbidities.
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Affiliation(s)
- William B MacLeod
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Jacob Bor
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
- Departments of Global Health and Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sue Candy
- Centre for HIV and STIs, National Institute for Communicable Diseases, Sandringham, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
- Departments of Global Health and Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Katia Bulekova
- Research Computing Services, IS&T, Boston University, Boston, Massachusetts, USA
| | - Alana T Brennan
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
- Departments of Global Health and Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - James Potter
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Koleka Mlisana
- Academic Affairs, Research & Quality Assurance, National Health Laboratory Service, Johannesburg, South Africa
| | - Wendy Stevens
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
- National Priority Programmes, National Health Laboratory Service, Sandringham, South Africa
| | - Sergio Carmona
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
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Mugglin C, Kläger D, Gueler A, Vanobberghen F, Rice B, Egger M. The HIV care cascade in sub-Saharan Africa: systematic review of published criteria and definitions. J Int AIDS Soc 2021; 24:e25761. [PMID: 34292649 PMCID: PMC8297382 DOI: 10.1002/jia2.25761] [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: 07/16/2020] [Revised: 05/14/2021] [Accepted: 05/25/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The HIV care cascade examines the attrition of people living with HIV from diagnosis to the use of antiretroviral therapy (ART) and suppression of viral replication. We reviewed the literature from sub-Saharan Africa to assess the definitions used for the different steps in the HIV care cascade. METHODS We searched PubMed, Embase and CINAHL for articles published from January 2004 to December 2020. Longitudinal and cross-sectional studies were included if they reported on at least one step of the UNAIDS 90-90-90 cascade or two steps of an extended 7-step cascade. A step was clearly defined if authors reported definitions for numerator and denominator, including the description of the eligible population and methods of assessment or measurement. The review protocol has been published and registered in Prospero. RESULTS AND DISCUSSION Overall, 3364 articles were screened, and 82 studies from 19 countries met the inclusion criteria. Most studies were from Southern (38 studies, 34 from South Africa) and East Africa (29 studies). Fifty-eight studies (71.6%) were longitudinal, with a median follow-up of three years. The medium number of steps covered out of 7 steps was 3 (interquartile range [IQR] 2 to 4); the median year of publication was 2015 (IQR 2013 to 2019). The number of different definitions for the numerators ranged from four definitions (for step "People living with HIV") to 21 (step "Viral suppression"). For the denominators, it ranged from three definitions ("Diagnosed and aware of HIV status") to 14 ("Viral suppression"). Only 12 studies assessed all three of the 90-90-90 steps. Most studies used longitudinal data, but denominator-denominator or denominator-numerator linkages over several steps were rare. Also, cascade data are lacking for many countries. Our review covers the academic literature but did not consider other data, such as government reports on the HIV care cascade. Also, it did not examine disengagement and reengagement in care. CONCLUSIONS The proportions of patients retained at each step of the HIV care cascade cannot be compared between studies, countries and time periods, nor meta-analysed, due to the many different definitions used for numerators and denominators. There is a need for standardization of methods and definitions.
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Affiliation(s)
- Catrina Mugglin
- Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
| | - Delia Kläger
- Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
| | - Aysel Gueler
- Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
| | - Fiona Vanobberghen
- Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
- Swiss Tropical and Public Health InstituteBaselSwitzerland
- University of BaselBaselSwitzerland
| | - Brian Rice
- Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Matthias Egger
- Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
- Centre for Infectious Disease Epidemiology and Research (CIDER)University of Cape TownCape TownSouth Africa
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
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Abstract
PURPOSE OF REVIEW Biological and societal influences are different for men and women leading to different HIV outcomes and related infectious and non-infectious complications. This review evaluates sex differences in the epidemiology and immunological response to HIV and looks at major complications and coinfections, as well as care delivery systems focusing on low- and middle-income countries (LMICs) where most people with HIV live. RECENT FINDINGS More women than men access testing and treatment services in LMIC; women are more likely to be virologically suppressed in that environment. There is a growing recognition that the enhanced immunological response to several pathogens including HIV may result in improved outcomes for infectious comorbidities but may result in a greater burden of non-communicable diseases. Men and women have different requirements for HIV care. Attention to these differences may improve outcomes for all.
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Kaplan S, Nteso KS, Ford N, Boulle A, Meintjes G. Loss to follow-up from antiretroviral therapy clinics: A systematic review and meta-analysis of published studies in South Africa from 2011 to 2015. South Afr J HIV Med 2019; 20:984. [PMID: 31956435 PMCID: PMC6956684 DOI: 10.4102/sajhivmed.v20i1.984] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/20/2019] [Indexed: 11/05/2022] Open
Abstract
Background South Africa has the largest antiretroviral therapy (ART) programme in the world. To optimise programme outcomes, it is critical that patients are retained in care and that retention is accurately measured. Objectives To identify all studies published in South Africa from 2011 to 2015 that used loss to follow-up (LTFU) as an indicator or outcome to describe the variation in definitions and to estimate the proportion of patients lost to care across studies. Method All studies published between 01 January 2011 and October 2015 that included loss to follow-up or default from ART care in a South African cohort were included by use of a broad search strategy across multiple databases. To be included, the cohort had to include any patient ART data, including follow-up time, from 01 January 2010. Two authors, working independently, extracted data and assessed risk of bias from all manuscripts. Meta-analysis was performed for studies stratified by the same loss to follow-up definition. Results Forty-eight adult, 15 paediatric and 4 pregnant cohorts were included. Median cohort size was 3737; follow-up time ranged from 9 weeks to 5 years. Meta-analysis did not reveal an important difference in LTFU estimates in adult cohorts at 1 year between loss to follow-up defined as 3 months (11.0%, n = 4; 95% CI 10.7% – 11.2%) compared with 6 months (12.0%, n = 4; 95% CI 11.8% – 12.2%). Only two cohorts reported reliable LTFU estimates at 5 years: this was 25.1% (95% CI 24.8% – 25.4%). Conclusion South Africa should standardise a LTFU definition. This would aid in monitoring and evaluation of ART programmes, with the broader goal of improving patient outcomes.
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Affiliation(s)
- Samantha Kaplan
- Department of Internal Medicine, University of Washington, Seattle, United States
| | - Katleho S Nteso
- Medical Care Development International, Maseru, Lesotho, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Pascoe SJS, Fox MP, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser‐Hurt N. Differentiated HIV care in South Africa: the effect of fast-track treatment initiation counselling on ART initiation and viral suppression as partial results of an impact evaluation on the impact of a package of services to improve HIV treatment adherence. J Int AIDS Soc 2019; 22:e25409. [PMID: 31691521 PMCID: PMC6831947 DOI: 10.1002/jia2.25409] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 09/06/2019] [Accepted: 09/25/2019] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION In response to suboptimal adherence and retention, South Africa's National Department of Health developed and implemented National Adherence Guidelines for Chronic Diseases. We evaluated the effect of a package of adherence interventions beginning in January 2016 and report on the impact of Fast-Track Treatment Initiation Counselling (FTIC) on ART initiation, adherence and retention. METHODS We conducted a cluster-randomized mixed-methods evaluation in 4 provinces at 12 intervention sites which implemented FTIC and 12 control facilities providing standard of care. Follow-up was by passive surveillance using clinical records. We included data on subjects eligible for FTIC between 08 Jan 2016 and 07 December 2016. We adjusted for pre-intervention differences using difference-in-differences (DiD) analyses controlling for site-level clustering. RESULTS We enrolled 362 intervention and 368 control arm patients. Thirty-day ART initiation was 83% in the intervention and 82% in the control arm (RD 0.5%; 95% CI: -5.0% to 6.0%). After adjusting for baseline ART initiation differences and covariates using DiD we found a 6% increase in ART initiation associated with FTIC (RD 6.3%; 95% CI: -0.6% to 13.3%). We found a small decrease in viral suppression within 18 months (RD -2.8%; 95% CI: -9.8% to 4.2%) with no difference after adjustment (RD: -1.9%; 95% CI: -9.1% to 5.4%) or when considering only those with a viral load recorded (84% intervention vs. 86% control). We found reduced crude 6-month retention in intervention sites (RD -7.2%; 95% CI: -14.0% to -0.4%). However, differences attenuated by 12 months (RD: -3.6%; 95% CI: -11.1% to 3.9%). Qualitative data showed FTIC counselling was perceived as beneficial by patients and providers. CONCLUSIONS We saw a short-term ART-initiation benefit to FTIC (particularly in districts where initiation prior to intervention was lower), with no reductions but also no improvement in longer-term retention and viral suppression. This may be due to lack of fidelity to implementation and delivery of those components that support retention and adherence. FTIC must continue to be implemented alongside other interventions to achieve the 90-90-90 cascade and fidelity to post-initiation counselling sessions must be monitored to determine impact on longer-term outcomes. Understanding the cost-benefit and role of FTIC may then be warranted.
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Affiliation(s)
- Sophie JS Pascoe
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
| | - Amy N Huber
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | | | - Sydney Rosen
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | | | - Yogan Pillay
- National Department of HealthPretoriaSouth Africa
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Enderis BO, Hebo SH, Debir MK, Sidamo NB, Shimber MS. Predictors of Time to First Line Antiretroviral Treatment Failure among Adult Patients Living with HIV in Public Health Facilities of Arba Minch Town, Southern Ethiopia. Ethiop J Health Sci 2019; 29:175-186. [PMID: 31011265 PMCID: PMC6460441 DOI: 10.4314/ejhs.v29i2.4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Antiretroviral therapy is a proven medication given for Human Immunodeficiency Virus positive individuals. However, first-line antiretroviral treatment failure becomes a public health issue and early detection of treatment failure is crucial for timely actions. Therefore, this study aimed to identify the predictors of time to first-line antiretroviral treatment failure among adult patients living with HIV in public health facilities of Arba Minch Town. Methods Institution-based retrospective cohort study was employed among 396 adult patients that were selected using simple random sampling. The data on relevant variables were extracted from patient medical cards. Bi-variable and multi-variable Cox proportional hazard regression analyses were used to identify predictors. Results The median survival time was 21 months. Substance use (AHR=2.94, 95% CI=1.62 to 5.32), disclosure status (AHR=1.98, 95% CI=1.03 to 3.79), time since HIV diagnosis (AHR=2.19 95% CI=1.01 to 4.79), WHO clinical stage (AHR=2.02, 95% CI=1.02 to 4.00), opportunistic infection (AHR=2.27, 95% CI=1.23 to 4.19), nutritional status (AHR=3.78, 95% CI=1.99 to 7.17), functional status (AHR=2.71 95% CI=1.33 to 5.51), CD4 count (AHR=1.99, 95% CI=1.05 to 3.75), and adherence level (AHR=1.99, 95% CI=1.05 to 3.76) were independent predictors of time to first line ART treatment failure. Conclusion History of substance use, lack of disclosure status, time since HIV diagnosis, advanced WHO clinical staging, low CD4 counts, opportunistic infection, functional status, poor adherence to ART and under-nutrition affect the time to first-line treatment failure among adult patients living with HIV. Therefore, preventive interventions, and information and counseling focusing on high risk groups of HIV infected adult are very important.
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Affiliation(s)
- Bilcha Oumer Enderis
- Arba Minch College of Health Sciences, Department of Midwifery, Arba Minch, Ethiopia
| | - Sultan Hussen Hebo
- Arba Minch University, College of Medicine & Health Sciences, Department of Public Health, Arba Minch, Ethiopia
| | - Mesfin Kote Debir
- Arba Minch University, College of Medicine & Health Sciences, Department of Public Health, Arba Minch, Ethiopia
| | - Negussie Boti Sidamo
- Arba Minch University, College of Medicine & Health Sciences, Department of Public Health, Arba Minch, Ethiopia
| | - Mulugeta Shegaze Shimber
- Arba Minch University, College of Medicine & Health Sciences, Department of Public Health, Arba Minch, Ethiopia
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10
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Bassett IV, Xu A, Giddy J, Bogart LM, Boulle A, Millham L, Losina E, Parker RA. Assessing rates and contextual predictors of 5-year mortality among HIV-infected and HIV-uninfected individuals following HIV testing in Durban, South Africa. BMC Infect Dis 2019; 19:751. [PMID: 31455229 PMCID: PMC6712739 DOI: 10.1186/s12879-019-4373-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/12/2019] [Indexed: 01/06/2023] Open
Abstract
Background Little is known about contextual factors that predict long-term mortality following HIV testing in resource-limited settings. We evaluated the impact of contextual factors on 5-year mortality among HIV-infected and HIV-uninfected individuals in Durban, South Africa. Methods We used data from the Sizanani trial (NCT01188941) in which adults (≥18y) were enrolled prior to HIV testing at 4 outpatient sites. We ascertained vital status via the South African National Population Register. We used random survival forests to identify the most influential predictors of time to death and incorporated these into a Cox model that included age, gender, HIV status, CD4 count, healthcare usage, health facility type, mental health, and self-identified barriers to care (i.e., service delivery, financial, logistical, structural and perceived health). Results Among 4816 participants, 39% were HIV-infected. Median age was 31y and 49% were female. 380 of 2508 with survival information (15%) died during median follow-up of 5.8y. For both HIV-infected and HIV-uninfected participants, each additional barrier domain increased the HR of dying by 11% (HR 1.11, 95% CI 1.05–1.18). Every 10-point increase in mental health score decreased the HR by 7% (HR 0.93, 95% CI 0.89–0.97). The hazard ratio (HR) for death of HIV-infected versus HIV-uninfected varied by age: HR of 6.59 (95% CI: 4.79–9.06) at age 20 dropping to a HR of 1.13 (95% CI: 0.86–1.48) at age 60. Conclusions Independent of serostatus, more self-identified barrier domains and poorer mental health increased mortality risk. Additionally, the impact of HIV on mortality was most pronounced in younger persons. These factors may be used to identify high-risk individuals requiring intensive follow up, regardless of serostatus. Trial registration Clinical Trials.gov Identifier NCT01188941. Registered 26 August 2010. Electronic supplementary material The online version of this article (10.1186/s12879-019-4373-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ingrid V Bassett
- Division of Infectious Diseases, Massachusetts General Hospital, 100 Cambridge Street, 16th Floor, Boston, MA, 02114, USA. .,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Harvard University Center for AIDS Research, Harvard University, Boston, MA, USA.
| | - Ai Xu
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Andrew Boulle
- Centre for Infectious Diseases, Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Lucia Millham
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Elena Losina
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Robert A Parker
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard University Center for AIDS Research, Harvard University, Boston, MA, USA.,Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
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11
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Butler I, MacLeod W, Majuba PP, Tipping B. Human immunodeficiency virus infection and older adults: A retrospective single-site cohort study from Johannesburg, South Africa. South Afr J HIV Med 2018; 19:838. [PMID: 30568838 PMCID: PMC6295827 DOI: 10.4102/sajhivmed.v19i1.838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 06/08/2018] [Indexed: 11/01/2022] Open
Abstract
Introduction HIV-infected adults aged over 50 years in South Africa are increasing. This study explored differences between baseline characteristics and 12-month outcomes of younger and older HIV-infected adults initiated on antiretroviral therapy (ART). Additionally, associations with outcomes within the older group were sought. Methods We retrospectively reviewed treatment-naive HIV-infected adult patients at ART initiation. Patients aged 18.0-39.9 years were compared to patients aged over 50 years using log-binomial regression for baseline characteristics and 12-month outcomes. Within the older group, outcome associations were found using multivariate regression. Results The older cohort (n = 1635) compared to the younger cohort (n = 10726) comprised more males (47.2% vs. 35.4%, PR 1.52, p < 0.05), smokers (12.9% vs. 9.7%, PR 1.32, p < 0.05) and overweight patients (26.0% vs. 20.0%, PR 1.32, p < 0.05). Fewer older patients had tuberculosis (10.2% vs. 15.3%, PR 0.67, p < 0.05), other opportunistic infections (16.9% vs. 23.3%, PR 0.70, p < 0.05), World Health Organization stage 3/4 disease (39.9% vs. 43.2%, PR 0.89, p < 0.05), anaemia (22.8% vs. 28.4%, PR 0.77, p < 0.05), liver dysfunction (17.1% vs. 21.3%, PR 0.83, p < 0.05) or low CD4+ count < 100 cells/mm3 (56.3% vs. 59.9%, PR 0.71, p < 0.05).Mortality was higher in the older cohort (11.3% vs. 7.5%, PR 1.48, p < 0.05). Virological suppression was greater in the older cohort (89.5% vs. 86.5%, PR 1.28, p < 0.05) but CD4+ restitution was lower (62.8% vs. 75.0%, PR 0.61, p < 0.05). There was no difference in treatment complications between the groups.Within the older cohort, associations with death were as follows: age > 55 years (PR 1.47, p < 0.05), an AIDS-defining condition (PR 2.28, p < 0.05), raised ALT (PR 1.53, p < 0.05) and CD4+ < 100 cells/mm3 (PR 2.15, p < 0.05). Associations with favourable treatment response at 12 months were unemployment (PR 1.18, p < 0.05) and raised ALT (PR 1.19, p < 0.05). Associations with a treatment complication at 12 months were unemployment (PR 1.12, p < 0.05), smoking (PR 1.20, p < 0.05) and nevirapine use (PR 1.36, p < 0.05) but secondary education was protective (PR 0.87, p < 0.05). Conclusion HIV-infected South African adults aged over 50 years differ in characteristics and outcomes compared to their younger counterparts and justify specialised management within HIV treatment facilities.
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Affiliation(s)
- India Butler
- Division of Geriatric Medicine, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - William MacLeod
- Health Economics and Epidemiology Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | | | - Brent Tipping
- Division of Geriatric Medicine, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
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12
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Fox MP, Pascoe SJS, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Effectiveness of interventions for unstable patients on antiretroviral therapy in South Africa: results of a cluster-randomised evaluation. Trop Med Int Health 2018; 23:1314-1325. [PMID: 30281882 DOI: 10.1111/tmi.13152] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND As loss from HIV care is an ongoing challenge globally, interventions are needed for patients who don't achieve or maintain ART stability. The 2015 South African National Adherence Guidelines (AGL) for Chronic Diseases include two interventions targeted at unstable patients: early tracing of patients who miss visits (TRIC) and enhanced adherence counselling (EAC). METHODS As part of a cluster-randomised evaluation at 12 intervention and 12 control clinics in four provinces, intervention sites implemented the AGL interventions, while control sites retained standard care. We report on outcomes of EAC for patients with an elevated viral load (>400 copies/ml) and for TRIC patients who missed a visit by >5 days. We estimated risk differences (RD) of 3 and 12-month viral resuppression (<400 copies/ml) and 12-month retention with cluster adjustment using generalised estimating equations and controlled for imbalances using difference-in-differences compared to all eligible in 2015, prior to intervention roll-out. RESULTS For EAC, we had 358 intervention and 505 control site patients (61% female, median ART initiation CD4 count 154 cells/μl). We found no difference between arms in 3-month resuppression (RD: -1.7%; 95%CI: -4.3% to 0.9%), but <20% of patients had a repeat viral load within 3 months (19.8% intervention, 13.5% control). Including the entire clinic population eligible for EAC with a repeat viral load at all evaluation sites (n = 934), intervention sites showed a small increase in 3-month resuppression (28% vs. 25%, RD 3.0%; 95%CI: -2.7% to 8.8%). Adjusting for baseline differences increased the RD to 8.1% (95% CI: -0.1% to 17.2%). However, we found no differences in 12-month suppression (RD: 1.5%; 95% CI: -14.1% to 17.1% but suppression was low overall at 40%) or retention (RD: 2.8%; 95% CI: -7.5% to 13.2%). For TRIC, we enrolled 155 at intervention sites and 248 at control sites (44% >40 years, 67% female, median CD4 count 212 cells/μl). We found no difference between groups in return to care by 12 months (RD: -6.8%; 95% CI: -17.7% to 4.8%). During the study period, control sites continued to use tracing within standard care, however, potentially masking intervention effects. CONCLUSIONS Enhanced adherence counselling showed no benefit over 12 months. Implementation of the tracing intervention under the new guidelines was similar to the standard of care. Interventions that aim to return unstable patients to care should incorporate active monitoring to determine if the interventions are effective.
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Affiliation(s)
- Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Sophie J S Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy N Huber
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
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13
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Hendrickson CJ, Pascoe SJS, Huber AN, Moolla A, Maskew M, Long LC, Fox MP. "My future is bright…I won't die with the cause of AIDS": ten-year patient ART outcomes and experiences in South Africa. J Int AIDS Soc 2018; 21:e25184. [PMID: 30318848 PMCID: PMC6186968 DOI: 10.1002/jia2.25184] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 08/13/2018] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION South Africa is moving into a new era of HIV treatment with "treat all" policies where people may be on treatment for most of their lives. We need to understand treatment outcomes and facilitators of long-term antiretroviral treatment (ART) adherence and retention-in-care in the South African context. In one of the first studies to investigate long-term treatment outcomes in South Africa, we aimed to describe ten-year patient outcomes at a large public-sector HIV clinic in Johannesburg and explore patient experiences of the treatment programme over this time in order to ascertain factors that may aid or hinder long-term adherence and retention. METHODS We conducted a cohort analysis (n = 6644) and in-depth interviews (n = 24) among HIV-positive adults initiating first-line ART between April 2004 and March 2007. Using clinical records, we ascertained twelve-month and ten-year all-cause mortality and loss to follow-up (LTF). Cox proportional hazards regression was used to identify baseline predictors of attrition (mortality and LTF (>3 months late for the last scheduled visit)) at twelve months and ten years. Twenty-four patients were purposively selected and interviewed to explore treatment programme experiences over ten years on ART. RESULTS Excluding transfers, 79.5% (95% confidence intervals (CI): 78.5 to 80.5) of the cohort were alive, in care at twelve months dropping to 35.1% (95% CI: 33.7 to 36.4) at ten years. Over 44% of deaths occurred within 12 months. Ten-year all-cause mortality increased, while LTF decreased slightly, with age. Year and age at ART initiation, sex, nationality, baseline CD4 count, anaemia, body mass index and initiating regimen were predictors of ten-year attrition. Among patients interviewed, the pretreatment clinic environment, feelings of gratitude and good fortune, support networks, and self-efficacy were facilitators of care; side effects, travel and worsening clinical conditions were barriers. Participants were generally optimistic about their futures and were committed to continued care. CONCLUSIONS This study demonstrates the complexities of long-term chronic HIV treatment with declining all-cause mortality and increasing LTF over ten years. Barriers to long-term retention still present a significant challenge. As more people become eligible for ART in South Africa under "treatment for all," new healthcare delivery challenges will arise; interventions are needed to ensure long-term programme successes continue.
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Affiliation(s)
- Cheryl J Hendrickson
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sophie J S Pascoe
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Amy N Huber
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Aneesa Moolla
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Mhairi Maskew
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Lawrence C Long
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Matthew P Fox
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
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14
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Clouse K, Fox MP, Mongwenyana C, Motlhatlhedi M, Buthelezi S, Bokaba D, Norris SA, Bassett J, Lurie MN, Aronoff DM, Vermund SH. "I will leave the baby with my mother": Long-distance travel and follow-up care among HIV-positive pregnant and postpartum women in South Africa. J Int AIDS Soc 2018; 21 Suppl 4:e25121. [PMID: 30027665 PMCID: PMC6053484 DOI: 10.1002/jia2.25121] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 05/12/2018] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION It is common in urban African settings for postpartum women to temporarily return to family in distant settings. We sought to explore mobility among peripartum HIV-positive women to understand the timing and motivation of travel, particularly vis-à-vis delivery, and how it may affect healthcare access. METHODS Using the same mobility measurements within three different studies, we examined long-distance travel of mother and infant before and after delivery in three diverse clinics within greater Johannesburg, South Africa (n = 150). Participants were interviewed prior to delivery at two sites (n = 125) and after delivery at one (n = 25). Quantitative and qualitative results are reported. RESULTS Among 150 women, median age was 29 years (IQR: 26 to 34) and 36.3% were employed. Overall, 76.7% of the participants were born in South Africa: 32.7% in Gauteng Province (Johannesburg area) and 44.0% in other South African provinces, but birthplace varied greatly by site. Almost half (44.0%) planned to travel around delivery; nearly all after delivery. Median duration of stay was 30 days (IQR: 24 to 90) overall, but varied from 60 days at two sites to just 7 days at another. Participants discussed travel to eight of South Africa's nine provinces and four countries. Travel most frequently was to visit family, typically to receive help with the new baby. Nearly all the employed participants planned to return to work in Johannesburg after delivery, sometimes leaving the infant in the care of family outside of Johannesburg. All expressed their intent to continue HIV care for themselves and their infant, but few planned to seek care at the destination site, and care for the infant was emphasized over care for the mother. CONCLUSIONS We identified frequent travel in the peripartum period with substantial differences in travel patterns by site. Participants more frequently discussed seeking care for the infant than for themselves. HIV-exposed children often were left in the care of family members in distant areas. Our results show the frequent mobility of women and infants in the peripartum period. This underscores the challenge of ensuring a continuity of HIV care in a fragmented healthcare system that is not adapted for a mobile population.
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Affiliation(s)
- Kate Clouse
- Vanderbilt Institute for Global HealthVanderbilt UniversityNashvilleTNUSA
- Division of Infectious DiseasesDepartment of MedicineVanderbilt UniversityNashvilleTNUSA
- Department of Internal MedicineHealth Economics and Epidemiology Research Office (HERO)School of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Matthew P Fox
- Department of Internal MedicineHealth Economics and Epidemiology Research Office (HERO)School of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBoston UniversityBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBoston UniversityBostonMAUSA
| | - Constance Mongwenyana
- Department of Internal MedicineHealth Economics and Epidemiology Research Office (HERO)School of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Molebogeng Motlhatlhedi
- MRC/Wits Developmental Pathways for Health Research UnitUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | - Dorah Bokaba
- Hikhensile ClinicCity of JohannesburgJohannesburgSouth Africa
| | - Shane A Norris
- MRC/Wits Developmental Pathways for Health Research UnitUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Jean Bassett
- Witkoppen Health and Welfare CentreJohannesburgSouth Africa
| | - Mark N Lurie
- Department of EpidemiologyBrown University School of Public HealthProvidenceRIUSA
| | - David M Aronoff
- Division of Infectious DiseasesDepartment of MedicineVanderbilt UniversityNashvilleTNUSA
| | - Sten H Vermund
- Department of Epidemiology of Microbial Diseases and Center for Interdisciplinary Research on AIDSYale University School of Public HealthNew HavenCTUSA
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15
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Fox MP, Pascoe SJ, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Assessing the impact of the National Department of Health's National Adherence Guidelines for Chronic Diseases in South Africa using routinely collected data: a cluster-randomised evaluation. BMJ Open 2018; 8:e019680. [PMID: 29358446 PMCID: PMC5781226 DOI: 10.1136/bmjopen-2017-019680] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION In 2016, South Africa's National Department of Health (NDOH) launched the National Adherence Guidelines for Chronic Diseases for phased implementation throughout South Africa. Early implementation of a 'minimum package' of eight interventions in the Adherence Guidelines for patients with HIV is being undertaken at 12 primary health clinics and community health centres in four provinces. NDOH and its partners are evaluating the impact of five of the interventions in four provinces in South Africa. METHODS AND ANALYSIS The minimum package is being delivered at the 12 health facilities under NDOH guidance and through local health authorities. The five evaluation interventions are: (1) fast track initiation counselling for patients eligible for antiretroviral therapy (ART); (2) adherence clubs for stable ART patients; (3) decentralised medication delivery for stable ART patients; (4) enhanced adherence counselling for unstable ART patients; and (5) early tracing of patients who miss an appointment by ≥5 days. For evaluation, NDOH matched the 12 intervention clinics with 12 comparison clinics and randomly allocated one member of each pair to intervention or comparison (standard of care) status within pairs, allowing evaluation of the interventions using a matched cluster-randomised design. The evaluation uses data routinely collected by the clinics, with no study interaction with subjects to prevent influencing the primary outcomes. Enrolment began on 20 June 2016 and was completed on 16 December 2016. A total of 3456 patients were enrolled and will now be followed for 14 months to estimate effects on short-term and final outcomes. Primary outcomes include viral suppression, retention and medication pickups, evaluated at two time points during follow-up. ETHICS AND DISSEMINATION The study received approval from the University of Witwatersrand Human Research Ethics Committee and Boston University Institutional Review Board. Results will be presented to key stakeholders and at international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02536768; Pre-results.
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Affiliation(s)
- Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie J Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy N Huber
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
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16
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Fox MP, Maskew M, Brennan AT, Evans D, Onoya D, Malete G, MacPhail P, Bassett J, Ebrahim O, Mabotja D, Mashamaite S, Long L, Sanne I. Cohort profile: the Right to Care Clinical HIV Cohort, South Africa. BMJ Open 2017; 7:e015620. [PMID: 28601835 PMCID: PMC5724130 DOI: 10.1136/bmjopen-2016-015620] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 02/26/2017] [Accepted: 04/03/2017] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The research objectives of the Right to Care Clinical HIV Cohort analyses are to: (1) monitor treatment outcomes (including death, loss to follow-up, viral suppression and CD4 count gain among others) for patients on antiretroviral therapy (ART); (2) evaluate the impact of changes in the national treatment guidelines around when to initiate ART on HIV treatment outcomes; (3) evaluate the impact of changes in the national treatment guidelines around what ART regimens to initiate on drug switches; (4) evaluate the cost and cost-effectiveness of HIV treatment delivery models; (5) evaluate the need for and outcomes on second-line and third-line ART; (6) evaluate the impact of comorbidity with non-communicable diseases on HIV treatment outcomes and (7) evaluate the impact of the switch to initiating all patients onto ART regardless of CD4 count. PARTICIPANTS The Right to Care Clinical HIV Cohort is an open cohort of data from 10 clinics in two provinces within South Africa. All clinics include data from 2004 onwards. The cohort currently has data on over 115 000 patients initiated on HIV treatment and patients are followed up every 3-6 months for clinical and laboratory monitoring. FINDINGS TO DATE Cohort data includes information on demographics, clinical visit, laboratory data, medication history and clinical diagnoses. The data have been used to identify rates and predictors of first-line failure, to identify predictors of mortality for patients on second-line (eg, low CD4 counts) and to show that adolescents and young adults are at increased risk of unsuppressed viral loads compared with adults. FUTURE PLANS Future analyses will inform national models of HIV care and treatment to improve HIV care policy in South Africa.
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Affiliation(s)
- Matthew P Fox
- Department of Global Health, Boston University School of Public Health, , Boston , , Massachusetts, , USA
- Department of Epidemiology, Boston University, , Boston , , Massachusetts, , USA
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Mhairi Maskew
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Alana T Brennan
- Department of Global Health, Boston University School of Public Health, , Boston , , Massachusetts, , USA
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
- Department of Epidemiology, Boston University, , Boston , , Massachusetts, , USA
| | - Denise Evans
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Dorina Onoya
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Given Malete
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Patrick MacPhail
- Right to Care, , Johannesburg , , South Africa
- Department of Medicine, Clinical HIV Research Unit, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Jean Bassett
- Witkoppen Health and Welfare Centre, , Johannesburg , , South Africa
| | | | | | | | - Lawrence Long
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Ian Sanne
- Department of Medicine, Clinical HIV Research Unit, University of the Witwatersrand, , Johannesburg , , South Africa
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17
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Loss to Follow-up Trends in HIV-Positive Patients Receiving Antiretroviral Treatment in Asia From 2003 to 2013. J Acquir Immune Defic Syndr 2017; 74:555-562. [PMID: 28129256 DOI: 10.1097/qai.0000000000001293] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Over time, there has been a substantial improvement in antiretroviral treatment (ART) programs, including expansion of services and increased patient engagement. We describe time trends in, and factors associated with, loss to follow-up (LTFU) in HIV-positive patients receiving ART in Asia. METHODS Analysis included HIV-positive adults initiating ART in 2003-2013 at 7 ART programs in Asia. Patients LTFU had not attended the clinic for ≥180 days, had not died, or transferred to another clinic. Patients were censored at recent clinic visit, follow-up to January 2014. We used cumulative incidence to compare LTFU and mortality between years of ART initiation. Factors associated with LTFU were evaluated using a competing risks regression model, adjusted for clinical site. RESULTS A total of 8305 patients were included. There were 743 patients LTFU and 352 deaths over 26,217 person-years (pys), a crude LTFU, and mortality rate of 2.83 (2.64-3.05) per 100 pys and 1.34 (1.21-1.49) per 100 pys, respectively. At 24 months, the cumulative LTFU incidence increased from 4.3% (2.9%-6.1%) in 2003-05 to 8.1% (7.1%-9.2%) in 2006-09 and then decreased to 6.7% (5.9%-7.5%) in 2010-13. Concurrently, the cumulative mortality incidence decreased from 6.2% (4.5%-8.2%) in 2003-05 to 3.3% (2.8%-3.9%) in 2010-13. The risk of LTFU reduced in 2010-13 compared with 2006-09 (adjusted subhazard ratio = 0.73, 0.69-0.99). CONCLUSIONS LTFU rates in HIV-positive patients receiving ART in our clinical sites have varied by the year of ART initiation, with rates declining in recent years whereas mortality rates have remained stable. Further increases in site-level resources are likely to contribute to additional reductions in LTFU for patients initiating in subsequent years.
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18
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Chung NC, Sikazwe I, Bolton-Moore C, Chilengi R, Kasaro MP, Stringer JSA, Chi BH. Patient engagement in HIV care and treatment in Zambia, 2004-2014. Trop Med Int Health 2017; 22:332-339. [PMID: 28102027 PMCID: PMC6506213 DOI: 10.1111/tmi.12832] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe engagement along the HIV continuum of care using a large network of clinics in Zambia. METHODS We employed a practical framework to describe retention along the HIV treatment cascade, using routinely collected clinical data available in resource-constrained settings. We included health facilities in four Zambian provinces with more than 300 enrolled patients over the age of 5 years. We described attrition at each step, from HIV enrolment to 720 days after ART initiation. The population was further stratified by year of enrolment to describe temporal trends in patient engagement. RESULTS From January 2004 to December 2014, 444 439 individuals over the age of 5 years sought HIV care at 75 eligible health facilities. Among those enrolled into HIV care, 82.1% (95% confidence interval [CI]: 79.4-84.5%) were fully assessed for ART eligibility within 180 days of enrolment and 63.6% (95% CI: 61.7-65.3) were found to be eligible for ART based on the HIV treatment guidelines at the time. Of those patients eligible for ART, 81.1% (95% CI: 79.5-82.7%) initiated ART within 180 days. Patient retention in ART programme was 81.2% (95% CI: 80.4-81.9%) at 90 days, 70.0% (95% CI: 68.7-71.2%) at 360 days and 61.6% (95% CI: 60.0-63.2%) at 720 days. We noted a steady decline in proportions assessed for ART eligibility and deemed eligible for ART in the time frame. Proportions that started ART and remained in care remained relatively consistent. CONCLUSION We describe a simple approach for assessing patient engagement after enrolment into HIV care. Using limited types of data routinely available, we demonstrate an important and replicable approach to monitoring programmes in resource-constrained settings.
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Affiliation(s)
- Neo Christopher Chung
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of Alabama at Birmingham, Birmingham, USA
| | - Roma Chilengi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | | | | | - Benjamin H. Chi
- University of North Carolina at Chapel Hill, Chapel Hill, USA
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Gross R, Bellamy SL, Ratshaa B, Han X, Steenhoff AP, Mosepele M, Bisson GP. Effects of sex and alcohol use on antiretroviral therapy outcomes in Botswana: a cohort study. Addiction 2017; 112:73-81. [PMID: 27447841 PMCID: PMC5205535 DOI: 10.1111/add.13538] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 01/20/2016] [Accepted: 07/15/2016] [Indexed: 11/27/2022]
Abstract
AIMS To determine alcohol use effect on HIV treatment success and whether alcohol use mediates the relation between male sex and treatment failure. DESIGN Longitudinal cohort study. SETTING Eight HIV clinics in and near Gaborone, Botswana. PARTICIPANTS A total of 938 HIV-infected treatment-naive adults initiating regimens containing the antiretroviral medication efavirenz between June 2009 and February 2013, including 478 (51%) males, median age 38 years, and plasma HIV RNA 4.9 log10 copies/ml. MEASUREMENTS Primary outcome was a composite of treatment failure over 6 months including death, lost to care or plasma HIV RNA > 25 copies/ml. Exposures included alcohol use and gender. FINDINGS Failure in 339 (36%) participants included 40 (4%) deaths, 194 (21%) lost to care and 105 (11%) with HIV RNA > 25 copies/ml. Both hazardous alcohol use in the past year [adjusted odds ratio (aOR) = 1.4, 95% confidence interval (CI) = 1.0, 1.9] and male sex (aOR = 2.1, 95% CI = 1.5, 2.9) were associated with failure. Hazardous alcohol use in the year prior to enrollment was more common in men (57%) than women (24%), P < 0.001. There was no difference in alcohol use effect on failure between sexes (P for interaction > 0.5). Controlling for hazardous alcohol use did not change the relation between sex and failure. CONCLUSION Alcohol use among HIV-infected adults in Botswana appears to worsen HIV treatment outcomes. Alcohol use does not appear to have either a mediating or a moderating effect on the relation between gender and HIV treatment outcome failure.
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Affiliation(s)
- Robert Gross
- Department of Medicine (ID), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Botswana-University of Pennsylvania Partnership, Gaborone, Botswana,Philadelphia Veterans Administration Medical Center, Philadelphia, PA
| | - Scarlett L. Bellamy
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Bakgaki Ratshaa
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Xiaoyan Han
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Andrew P. Steenhoff
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana,Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Mosepele Mosepele
- Department of Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Gregory P. Bisson
- Department of Medicine (ID), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
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Tsegaye AT, Wubshet M, Awoke T, Addis Alene K. Predictors of treatment failure on second-line antiretroviral therapy among adults in northwest Ethiopia: a multicentre retrospective follow-up study. BMJ Open 2016; 6:e012537. [PMID: 27932339 PMCID: PMC5168604 DOI: 10.1136/bmjopen-2016-012537] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The number of patients using second-line antiretroviral therapy (ART) has increased over time. In Ethiopia, 1.5% of HIV infected patients on ART are using a second-line regimen and little is known about its effect in this setting. OBJECTIVE To estimate the rate and predictors of treatment failure on second-line ART among adults living with HIV in northwest Ethiopia. SETTING An institution-based retrospective follow-up study was conducted at three tertiary hospitals in northwest Ethiopia from March to May 2015. PARTICIPANTS 356 adult patients participated and 198 (55.6%) were males. Individuals who were on second-line ART for at least 6 months of treatment were included and the data were collected by reviewing their records. PRIMARY OUTCOME MEASURE The primary outcome was treatment failure defined as immunological failure, clinical failure, death, or lost to follow-up. To assess our outcome, we used the definitions of the WHO 2010 guideline. RESULT The mean±SD age of participants at switch was 36±8.9 years. The incidence rate of failure was 61.7/1000 person years. The probability of failure at the end of 12 and 24 months were 5.6% and 13.6%, respectively. Out of 67 total failures, 42 (62.7%) occurred in the first 2 years. The significant predictors of failure were found to be: WHO clinical stage IV at switch (adjusted HR (AHR) 2.1, 95% CI 1.1 to 4.1); CD4 count <100 cells/mm3 at switch (AHR 2.0, 95% CI 1.2 to 3.5); and weight change (AHR 0.92, 95% CI 0.88 to 0.95). CONCLUSIONS The rate of treatment failure was highest during the first 2 years of treatment. WHO clinical stage, CD4 count at switch, and change in weight were found to be predictors of treatment failure.
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Affiliation(s)
- Adino Tesfahun Tsegaye
- Department of Epidemiology and Biostatistics, University of Gondar, College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Mamo Wubshet
- Department of Public Health, University of Gondar, College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Tadesse Awoke
- Department of Statistics and Biostatistics, University of Gondar, College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Kefyalew Addis Alene
- Department of Epidemiology and Biostatistics, University of Gondar, College of Medicine and Health Sciences, Gondar, Ethiopia
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Shearer K, Evans D, Moyo F, Rohr JK, Berhanu R, Van Den Berg L, Long L, Sanne I, Fox MP. Treatment outcomes of over 1000 patients on second-line, protease inhibitor-based antiretroviral therapy from four public-sector HIV treatment facilities across Johannesburg, South Africa. Trop Med Int Health 2016; 22:221-231. [PMID: 27797443 PMCID: PMC5288291 DOI: 10.1111/tmi.12804] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objectives To report predictors of outcomes of second‐line ART for HIV treatment in a resource‐limited setting. Methods All adult ART‐naïve patients who initiated standard first‐line treatment between April 2004 and February 2012 at four public‐sector health facilities in Johannesburg, South Africa, experienced virologic failure and initiated standard second‐line therapy were included. We assessed predictors of attrition (death and loss to follow‐up [≥3 months late for a scheduled visit]) using Cox proportional hazards regression and predictors of virologic suppression (viral load <400 copies/ml ≥3 months after switch) using modified Poisson regression with robust error estimation at 1 year and ever after second‐line ART initiation. Results A total of 1236 patients switched to second‐line treatment in a median (IQR) of 1.9 (0.9‐4.6) months after first‐line virologic failure. Approximately 13% and 45% of patients were no longer in care at 1 year and at the end of follow‐up, respectively. Patients with low CD4 counts (<50 vs. ≥200, aHR: 1.85; 95% CI: 1.03–3.32) at second‐line switch were at greater risk for attrition by the end of follow‐up. About 75% of patients suppressed by 1 year, and 85% had ever suppressed by the end of follow‐up. Conclusions Patients with poor immune status at switch to second‐line ART were at greater risk of attrition and were less likely to suppress. Additional adherence support after switch may improve outcomes.
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Affiliation(s)
- Kate Shearer
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Faith Moyo
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Julia K Rohr
- Center for Global Health & Development, Boston University, Boston, MA, USA
| | | | | | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ian Sanne
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Right to Care, Johannesburg, South Africa.,Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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22
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Zanoni BC, Archary M, Buchan S, Katz IT, Haberer JE. Systematic review and meta-analysis of the adolescent HIV continuum of care in South Africa: the Cresting Wave. BMJ Glob Health 2016; 1:e000004. [PMID: 28588949 PMCID: PMC5321340 DOI: 10.1136/bmjgh-2015-000004] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 06/23/2016] [Accepted: 08/08/2016] [Indexed: 11/03/2022] Open
Abstract
CONTEXT South Africa has the most HIV infections of any country in the world, yet little is known about the adolescent continuum of care from HIV diagnosis through viral suppression. OBJECTIVE To determine the adolescent HIV continuum of care in South Africa. DATA SOURCES We searched PubMed, Google Scholar and online conference proceedings from International AIDS Society (IAS), International AIDS Conference (AIDS) and Conference on Retrovirology and Opportunistic Infections (CROI) from 1 January 2005 to 31 July 2015. DATA EXTRACTION We selected published literature containing South African cohorts and epidemiological data reporting primary data for youth (15-24 years of age) at any stage of the HIV continuum of care (ie, diagnosis, treatment, retention, viral suppression). For the meta-analysis we used six sources for retention in care and nine for viral suppression. RESULTS Among the estimated 867 283 HIV-infected youth from 15 to 24 years old in South Africa in 2013, 14% accessed antiretroviral therapy (ART). Of those on therapy, ∼83% were retained in care and 81% were virally suppressed. Overall, we estimate that 10% of HIV-infected youth in South Africa in 2013 were virally suppressed. LIMITATIONS This analysis relies on published data from large mostly urban South Africa cohorts limiting the generalisability to all adolescents. CONCLUSIONS Despite a large increase in ART programmes in South Africa that have relatively high retention rates and viral suppression rates among HIV-infected youth, only a small percentage are virally suppressed, largely due to low numbers of adolescents and young adults accessing ART.
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Affiliation(s)
- Brian C Zanoni
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Moherndran Archary
- University of KwaZulu-Natal Nelson Mandela School of Medicine, Durban, South Africa
- Department of Pediatrics, King Edward Hospital, Durban, South Africa
| | - Sarah Buchan
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Ingrid T Katz
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jessica E Haberer
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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23
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Fox MP, Berhanu R, Steegen K, Firnhaber C, Ive P, Spencer D, Mashamaite S, Sheik S, Jonker I, Howell P, Long L, Evans D. Intensive adherence counselling for HIV-infected individuals failing second-line antiretroviral therapy in Johannesburg, South Africa. Trop Med Int Health 2016; 21:1131-7. [PMID: 27383454 DOI: 10.1111/tmi.12741] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE In resource-limited settings, where genotypic drug resistance testing is rarely performed and poor adherence is the most common reason for treatment failure, programmatic approaches to handling treatment failure are essential. This study was performed to describe one such approach to adherence optimisation. METHODS This was a single-arm study of patients on second-line protease inhibitor (PI)-based antiretroviral therapy (ART) with a HIV-1 RNA ≥400 copies/ml in Johannesburg, South Africa, between 1 March 2012 and 1 December 2013. Patients underwent enhanced adherence counselling. Those with improved adherence and a repeat viral load of >1000 copies/ml underwent HIV-1 drug resistance testing. We describe results using simple proportions and 95% confidence intervals. RESULTS Of the 400 patients who underwent targeted adherence counselling after an elevated viral load on second-line ART, 388 (97%) underwent repeat viral load testing. Most of these (n = 249; 64%, 95% CI 59-69) resuppressed (<400 copies/ml) on second line. By the end of follow-up (1 March 2014), among the 139 (36%, 95% CI: 31-41%), who did not initially resuppress after being targeted, 106 had a viral load >400 copies/ml, 11 switched to third line, 5 were awaiting third line, 4 had died and 13 were lost to follow-up. Among the unsuppressed, 48 successfully underwent resistance testing with some resistance detected in most (41/48). CONCLUSIONS Most (64%) second-line treatment failure in this clinic is related to adherence and can be overcome with careful adherence support. Controlled interventions are needed to determine what the optimal approach is to improving second-line outcomes and reducing the need for third-line ART.
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Affiliation(s)
- Matthew P Fox
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Rebecca Berhanu
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Right to Care, Johannesburg, South Africa
| | - Kim Steegen
- Department of Haematology and Molecular Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cindy Firnhaber
- Right to Care, Johannesburg, South Africa.,Clinical HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Prudence Ive
- Clinical HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Ingrid Jonker
- Witkoppen Health and Welfare Center, Johannesburg, South Africa
| | - Pauline Howell
- Department of Haematology and Molecular Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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24
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Brief Report: Does Most Mortality in Patients on ART Occur in Care or After Lost to Follow-Up? Evidence From the Themba Lethu Clinic, South Africa. J Acquir Immune Defic Syndr 2016; 70:323-8. [PMID: 26181816 PMCID: PMC4627171 DOI: 10.1097/qai.0000000000000755] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Supplemental Digital Content is Available in the Text. In resource-limited settings, early mortality on antiretroviral therapy (ART) is approximately 10%; yet, it is unclear how much of that mortality occurs in care or after lost to follow-up. We assessed mortality rates and predictors of death among 12,222 nonpregnant ART-naive adults initiating first-line ART between April 2004 and May 2012 in South Africa, stratified by person-years in care and lost. We found 14.6% of patients died and being lost accounted for a minority of deaths across multiple definitions of loss (population attributable-risk percent ranged from 10.4% to 42.5%). Although mortality rates in patients lost were much higher than in care, most ART-related mortality occurred on treatment.
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25
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Retention of Adult Patients on Antiretroviral Therapy in Low- and Middle-Income Countries: Systematic Review and Meta-analysis 2008-2013. J Acquir Immune Defic Syndr 2015; 69:98-108. [PMID: 25942461 DOI: 10.1097/qai.0000000000000553] [Citation(s) in RCA: 255] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND We previously published systematic reviews of retention in care after antiretroviral therapy initiation among general adult populations in sub-Saharan Africa. We estimated 36-month retention at 73% for publications from 2007 to 2010. This report extends the review to cover 2008-2013 and expands it to all low- and middle-income countries. METHODS We searched PubMed, Embase, Cochrane Register, and ISI Web of Science from January 1, 2008, to December 31, 2013, and abstracts from AIDS and IAS from 2008-2013. We estimated retention across cohorts using simple averages and interpolated missing times through the last time reported. We estimated all-cause attrition (death, loss to follow-up) for patients receiving first-line antiretroviral therapy in routine settings in low- and middle-income countries. RESULTS We found 123 articles and abstracts reporting retention for 154 patient cohorts and 1,554,773 patients in 42 countries. Overall, 43% of all patients not retained were known to have died. Unweighted averages of reported retention were 78%, 71%, and 69% at 12, 24, and 36 months, after treatment initiation, respectively. We estimated 36-month retention at 65% in Africa, 80% in Asia, and 64% in Latin America and the Caribbean. From lifetable analysis, we estimated retention at 12, 24, 36, 48, and 60 months at 83%, 74%, 68%, 64%, and 60%, respectively. CONCLUSIONS Retention at 36 months on treatment averages 65%-70%. There are several important gaps in the evidence base, which could be filled by further research, especially in terms of geographic coverage and duration of follow-up.
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26
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CD4+ gain percentile curves for monitoring response to antiretroviral therapy in HIV-infected adults. AIDS 2015; 29:1067-75. [PMID: 26125140 DOI: 10.1097/qad.0000000000000649] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We constructed CD4 cell count gain percentile distributions standardized by baseline CD4 cell count and assessed the association between poor CD4 cell count gain and subsequent death and virological failure on antiretroviral therapy (ART). DESIGN Secondary analysis of 10 years of clinical data from a cohort of adults initiated on ART at the Themba Lethu clinic in Johannesburg, South Africa. METHODS The generalized additive model for location, scale and shape was used to construct percentile curves for CD4 cell count gain standardized by baseline CD4 cell count in the first 28 months of ART. Cox proportional models were used to assess the association between lower percentiles (<50th) of CD4 cell count gain, and subsequent death and virological failure. RESULTS Among 9640 nonpregnant adults 7406, with available CD4 cell count results for CD4 gain calculation at 4 months of ART, 843 (8.7%) died subsequently and 1101 (11.4%) experienced virologic failure, respectively. For CD4 gains below the third percentile, the adjusted hazard ratios at different time points ranged between 2.72 and 5.73 for death, and between 1.48 and 6.93 for virologic failure. The CD4 percentile curves revealed a gradient of increasing risk of subsequent death and virological failure, with lower CD4 gain percentiles and increasing time on ART, and were more informative than the WHO criteria for immunological failure or current CD4 cell count. CONCLUSION Percentile curves of CD4 cell count gain provide a simple tool for healthcare workers in low-resource settings to monitor response to ART with improved information regarding risk of death and virological failure compared to current WHO criteria for immunological failure.
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27
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Telisinghe L, Hippner P, Churchyard GJ, Gresak G, Grant AD, Charalambous S, Fielding KL. Outcomes of on-site antiretroviral therapy provision in a South African correctional facility. Int J STD AIDS 2015; 27:1153-1161. [PMID: 25941052 DOI: 10.1177/0956462415584467] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 03/31/2015] [Indexed: 12/15/2022]
Abstract
We evaluated a novel on-site antiretroviral therapy (ART) programme in a South African correctional facility using routinely collected programme data, from a retrospective cohort of adult inmates starting ART between 03/2007 and 03/2009 followed-up to 09/2009. We report (1) mortality (using survival analysis); (2) retention in the programme (to 09/2009); and (3) virological suppression at six and 12 months (<400 copies/ml) following ART initiation. In total, 404 started ART (median age 33 years; 91.3% men; median baseline CD4 cell count 152 cells/µl [interquartile range 85-225]). Among 299 starting ART for the first time (ART-naïve), 23 deaths occurred during 252 person-years (median follow-up nine months). Mortality rates were 17.2 at 0-6 months (95% confidence interval 10.9-26.9) and 2.8 at >6 months (95% confidence interval 1.1-7.5)/100 person-years; p < 0.001. At 09/2009, 35.6% (144/404) remained in the correctional facility, with 94.4% (136/144) retained in the programme; 38.4% (155/404) were released; and 20.0% (81/404) transferred to another facility. ART-naïve patients in care six and 12 months after ART initiation, 94.7% (124/131) and 92.5% (74/80) were virologically suppressed, respectively. High early mortality warrants the early identification and management of HIV-positive inmates. The high mobility of inmates necessitates systems for facilitating continuity of care. Good virological responses and retention supports decentralising HIV care to correctional facilities.
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Affiliation(s)
- Lilanganee Telisinghe
- The Aurum Institute, Johannesburg, South Africa .,CAPRISA, University of KwaZulu-Natal, Durban, South Africa
| | | | - Gavin J Churchyard
- The Aurum Institute, Johannesburg, South Africa.,London School of Hygiene and Tropical Medicine, London, UK.,School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | | | - Alison D Grant
- London School of Hygiene and Tropical Medicine, London, UK
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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28
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Fox MP, Shearer K, Maskew M, Meyer-Rath G, Clouse K, Sanne I. Attrition through multiple stages of pre-treatment and ART HIV care in South Africa. PLoS One 2014; 9:e110252. [PMID: 25330087 PMCID: PMC4203772 DOI: 10.1371/journal.pone.0110252] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 09/15/2014] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION While momentum for increasing treatment thresholds is growing, if patients cannot be retained in HIV care from the time of testing positive through long-term adherence to antiretroviral therapy (ART), such strategies may fall short of expected gains. While estimates of retention on ART exist, few cohorts have data on retention from testing positive through long-term ART care. METHODS We explored attrition (loss or death) at the Themba Lethu HIV clinic, Johannesburg, South Africa in 3 distinct cohorts enrolled at HIV testing, pre-ART initiation, and ART initiation. RESULTS Between March 2010 and August 2012 we enrolled 380 patients testing HIV+, 206 initiating pre-ART care, and 185 initiating ART. Of the 380 patients enrolled at testing HIV-positive, 38.7% (95%CI: 33.9-43.7%) returned for eligibility staging within ≤3 months of testing. Of the 206 enrolled at pre-ART care, 84.5% (95%CI: 79.0-88.9%) were ART eligible at their first CD4 count. Of those, 87.9% (95%CI: 82.4-92.2%) initiated ART within 6 months. Among patients not ART eligible at their first CD4 count, 50.0% (95%CI: 33.1-66.9%) repeated their CD4 count within one year of the first ineligible CD4. Among the 185 patients in the ART cohort, 22 transferred out and were excluded from further analysis. Of the remaining 163, 81.0% (95%CI: 74.4-86.5%) were retained in care through two years on treatment. CONCLUSIONS Our findings from a well-resourced clinic demonstrate continual loss from all stages of HIV care and strategies to reduce attrition from all stages of care are urgently needed.
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Affiliation(s)
- Matthew P. Fox
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Kate Shearer
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gesine Meyer-Rath
- Center for Global Health & Development, Boston University, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kate Clouse
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Ian Sanne
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Stevens W, Gous N, Ford N, Scott LE. Feasibility of HIV point-of-care tests for resource-limited settings: challenges and solutions. BMC Med 2014; 12:173. [PMID: 25197773 PMCID: PMC4157150 DOI: 10.1186/s12916-014-0173-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 08/11/2014] [Indexed: 11/10/2022] Open
Abstract
Improved access to anti-retroviral therapy increases the need for affordable monitoring using assays such as CD4 and/or viral load in resource-limited settings. Barriers to accessing treatment, high rates of loss to initiation and poor retention in care are prompting the need to find alternatives to conventional centralized laboratory testing in certain countries. Strong advocacy has led to a rapidly expanding repertoire of point-of-care tests for HIV. point-of-care testing is not without its challenges: poor regulatory control, lack of guidelines, absence of quality monitoring and lack of industry standards for connectivity, to name a few. The management of HIV increasingly requires a multidisciplinary testing approach involving hematology, chemistry, and tests associated with the management of non-communicable diseases, thus added expertise is needed. This is further complicated by additional human resource requirements and the need for continuous training, a sustainable supply chain, and reimbursement strategies. It is clear that to ensure appropriate national implementation either in a tiered laboratory model or a total decentralized model, clear country-specific assessments need to be conducted.
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30
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Johnston V, Cohen K, Wiesner L, Morris L, Ledwaba J, Fielding KL, Charalambous S, Churchyard G, Phillips A, Grant AD. Viral suppression following switch to second-line antiretroviral therapy: associations with nucleoside reverse transcriptase inhibitor resistance and subtherapeutic drug concentrations prior to switch. J Infect Dis 2014; 209:711-20. [PMID: 23943851 PMCID: PMC3923537 DOI: 10.1093/infdis/jit411] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 06/28/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND High rates of second-line antiretroviral treatment (ART) failure are reported. The association with resistance and nonadherence on switching to second-line ART requires clarification. METHODS Using prospectively collected data from patients in South Africa, we constructed a cohort of patients switched to second-line ART (1 January 2003 through 31 December 2008). Genotyping and drug concentrations (lamivudine, nevirapine, and efavirenz) were measured on stored samples preswitch. Their association with viral load (VL) <400 copies/mL by 15 months was assessed using modified Poisson regression. RESULTS One hundred twenty-two of 417 patients (49% male; median age, 36 years) had genotyping (n = 115) and/or drug concentrations (n = 80) measured. Median CD4 count and VL at switch were 177 cells/µL (interquartile range [IQR], 77-263) and 4.3 log10 copies/mL (IQR, 3.8-4.7), respectively. Fifty-five percent (n = 44/80) had subtherapeutic drug concentrations preswitch. More patients with therapeutic vs subtherapeutic ART had resistance (n = 73): no major mutations (3% vs 51%), nonnucleoside reverse transcriptase inhibitor (94% vs 44%), M184V/I (94% vs 26%), and ≥ 1 thymidine analogue mutations (47% vs 18%), all P = .01; and nucleoside reverse transcriptase inhibitor (NRTI) cross-resistance mutations (26% vs 13%, P = .23). Following switch, 68% (n = 83/122) achieved VL <400 copies/mL. Absence of NRTI mutations and subtherapeutic ART preswitch were associated with failure to achieve VL <400 copies/mL. CONCLUSIONS Nonadherence, suggested by subtherapeutic ART with/without major resistance mutations, significantly contributed to failure when switching regimen. Unresolved nonadherence, not NRTI resistance, drives early second-line failure.
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Affiliation(s)
- Victoria Johnston
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, United Kingdom
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Commentary: Antiretroviral therapy initiation criteria in low resource settings--from 'when to start' to 'when not to start'. AIDS 2014; 28 Suppl 2:S101-4. [PMID: 24849468 DOI: 10.1097/qad.0000000000000237] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Manicklal S, van Niekerk AM, Kroon SM, Hutto C, Novak Z, Pati SK, Chowdhury N, Hsiao NY, Boppana SB. Birth prevalence of congenital cytomegalovirus among infants of HIV-infected women on prenatal antiretroviral prophylaxis in South Africa. Clin Infect Dis 2014; 58:1467-72. [PMID: 24567248 DOI: 10.1093/cid/ciu096] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A high rate of congenital cytomegalovirus (CMV) has been documented in human immunodeficiency virus (HIV)-exposed infants in industrialized settings, both in the pre- and post-highly active antiretroviral therapy (HAART) era. Only limited data on the birth prevalence of congenital CMV among infants of HIV-infected women on prenatal antiretroviral (ARV) prophylaxis are available from sub-Saharan Africa, despite a high prevalence of both infections. We evaluated the prevalence of congenital CMV in HIV-exposed infants in the Western Cape, South Africa. METHODS HIV-infected mothers were recruited in the immediate postnatal period at a referral maternity hospital between April and October 2012. Maternal and infant clinical data and newborn saliva swabs were collected. Saliva swabs were assayed by real-time polymerase chain reaction for CMV. Data were analyzed using univariate and multivariate logistic regression analyses to determine specific demographic, maternal, and newborn characteristics associated with congenital CMV. RESULTS CMV was detected in 22 of 748 newborn saliva swabs (2.9%; 95% confidence interval [CI], 1.9%-4.4%). Overall, 96% of mothers used prenatal ARV prophylaxis (prenatal zidovudine, 43.9%; HAART, 52.1%). Maternal age, gestational age, prematurity (<37 weeks' gestation), type of ARV prophylaxis, length of ARV prophylaxis, birth weight, small for gestational age, and infant feeding choice were not significantly different between CMV-infected and -uninfected infants. Maternal CD4 count <200 cells/μL during pregnancy was independently associated with congenital CMV (adjusted odds ratio, 2.9; 95% CI, 1.2-7.3). A negative correlation between CMV load in saliva and maternal CD4 count was observed (r = -0.495, n = 22, P = .019). CONCLUSIONS The birth prevalence of congenital CMV was high despite prenatal ARV prophylaxis, and was associated with advanced maternal immunosuppression.
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Affiliation(s)
- S Manicklal
- Division of Medical Virology, Department of Clinical Laboratory Sciences, University of Cape Town
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Rosen S, Larson B, Rohr J, Sanne I, Mongwenyana C, Brennan AT, Galárraga O. Effect of antiretroviral therapy on patients' economic well being: five-year follow-up. AIDS 2014; 28:417-24. [PMID: 24076660 PMCID: PMC3893293 DOI: 10.1097/qad.0000000000000053] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 08/30/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Evaluate the effect of antiretroviral therapy (ART) on South African HIV patients' economic well being, as indicated by symptoms, normal activities, employment, and external support, during the first 5 years on treatment. METHODS Prospective cohort study of 879 adult patients at public or nongovernmental clinics enrolled before ART initiation or on ART less than 6 months and followed for 5.5 years or less. Patients were interviewed during routine clinic visits. Outcomes were estimated using population-averaged logistic regression and reported as proportions of the cohort experiencing outcomes by duration on ART. RESULTS For patients remaining in care, outcomes improved continuously and substantially, with all differences between baseline and 5 years statistically significant (P < 0.05) and continued significant improvement between year 3 and year 5. The probability of reporting pain last week fell from 69% during the three months before starting ART to 17% after 5 years on ART and fatigue from 62 to 7%. The probability of not being able to perform normal activities in the previous week fell from 47 to 5% and of being employed increased from 32 to 44%; difficulty with job performance among those employed fell from 56 to 6%. As health improved, the probability of relying on a caretaker declined from 81 to less than 1%, and receipt of a disability grant, which initially increased, fell slightly over time on ART. CONCLUSION Results from one of the longest prospective cohorts tracking economic outcomes of HIV treatment in Africa suggest continuous improvement during the first 5 years on treatment, confirming the sustained economic benefits of providing large-scale treatment.
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Affiliation(s)
- Sydney Rosen
- aCenter for Global Health & Development, Boston University, Boston, Massachusetts, USA bHealth Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa cBrown University, School of Public Health, Providence, Rhode Island, USA
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Lessells RJ, Mutevedzi PC, Iwuji CC, Newell ML. Reduction in early mortality on antiretroviral therapy for adults in rural South Africa since change in CD4+ cell count eligibility criteria. J Acquir Immune Defic Syndr 2014; 65:e17-24. [PMID: 23756374 PMCID: PMC3867341 DOI: 10.1097/qai.0b013e31829ceb14] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 05/21/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To explore the impact of expanded eligibility criteria for antiretroviral therapy (ART) on median CD4⁺ cell count at ART initiation and early mortality on ART. METHODS Analyses included all adults (≥16 years) initiated on first-line ART between August 2004 and July 2012. CD4⁺ cell count threshold 350 cells per microliter for all adults was implemented in August 2011. Early mortality was defined as any death within 91 days of ART initiation. Trends in baseline CD4⁺ cell count and early mortality were examined by year (August to July) of ART initiation. Competing risks analysis was used to examine early mortality. RESULTS A total of 19,080 adults (67.6% female) initiated ART. Median CD4⁺ cell count at ART initiation was 110-120 cells per microliter over the first 6 years, increasing marginally to 145 cells per microliter in 2010-2011 and more significantly to 199 cells per microliter in 2011-2012. Overall, there were 875 deaths within 91 days of ART initiation; early mortality rate was 19.4 per 100 person-years [95% confidence interval (CI) 18.2 to 20.7]. After adjustment for sex, age, baseline CD4⁺ cell count, and concurrent tuberculosis (TB), there was a 46% decrease in early mortality for those who initiated ART in 2011-2012 compared with the reference period 2008-2009 (subhazard ratio, 0.54; 95% CI: 0.41 to 0.71). CONCLUSIONS Since the expansion of eligibility criteria, there is evidence of earlier access to ART and a significant reduction in early mortality rate in this primary health care programme. These findings provide strong support for national ART policies and highlight the importance of earlier ART initiation for achieving reductions in HIV-related mortality.
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Affiliation(s)
- Richard J. Lessells
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Portia C. Mutevedzi
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
- Department of Infection and Population Health, University College London, London, United Kingdom
| | - Collins C. Iwuji
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
- The Brighton Doctoral College, Brighton and Sussex Medical School, United Kingdom; and
| | - Marie-Louise Newell
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
- University College London Institute of Child Health, London, United Kingdom
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Govindasamy D, Kranzer K, Ford N. Strengthening the HIV cascade to ensure an effective future ART response in sub-Saharan Africa. Trans R Soc Trop Med Hyg 2013; 108:1-3. [PMID: 24284954 DOI: 10.1093/trstmh/trt105] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Timely linkage to antiretroviral therapy (ART) care is critical for reducing HIV-related morbidity, mortality and transmission. Studies investigating interventions to improve linkage to, and retention in, pre-ART care in sub-Saharan Africa were reviewed. Certain interventions used to overcome economic barriers for ART-patients (i.e. integration of services, medical and food incentives, intensified counselling and peer support) have also shown favourable results in the pre-ART period. A combined package of interventions found to be effective in the pre-ART and ART period might be effective for reducing attrition in both periods. Further operational research in this area is needed to identify local solutions.
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Affiliation(s)
- Darshini Govindasamy
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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