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Factors Associated with Retention of HIV Patients on Antiretroviral Therapy in Care: Evidence from Outpatient Clinics in Two Provinces of the Democratic Republic of the Congo (DRC). Trop Med Infect Dis 2022; 7:tropicalmed7090229. [PMID: 36136640 PMCID: PMC9504336 DOI: 10.3390/tropicalmed7090229] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 12/02/2022] Open
Abstract
Interruptions in the continuum of care for HIV can inadvertently increase a patient’s risk of poor health outcomes such as uncontrolled viral load and a greater likelihood of developing drug resistance. Retention of people living with HIV (PLHIV) in care and determinants of attrition, such as adherence to treatment, are among the most critical links strengthening the continuum of care, reducing the risk of treatment failure, and assuring viral load suppression. Objective: To analyze the variation in, and factors associated with, retention of patients enrolled in HIV services at outpatient clinics in the provinces of Kinshasa and Haut-Katanga, Democratic Republic of the Congo (DRC). Methods: Data for the last visit of 51,286 patients enrolled in Centers for Disease Control (CDC)-supported outpatient HIV clinics in 18 health zones in Haut-Katanga and Kinshasa, DRC were extracted in June 2020. Chi-square tests and multivariable logistic regressions were performed. Results: The results showed a retention rate of 78.2%. Most patients were classified to be at WHO clinical stage 1 (42.1%), the asymptomatic stage, and only 3.2% were at stage 4, the severest stage of AIDS. Odds of retention were significantly higher for patients at WHO clinical stage 1 compared to stage 4 (adjusted odds ratio (AOR), 1.325; confidence interval (CI), 1.13−1.55), women as opposed to men (AOR, 2.00; CI, 1.63−2.44), and women who were not pregnant (vs. pregnant women) at the start of antiretroviral therapy (ART) (AOR, 2.80; CI, 2.04−3.85). Odds of retention were significantly lower for patients who received a one-month supply rather than multiple months (AOR, 0.22; CI, 0.20−0.23), and for patients in urban health zones (AOR, 0.75; CI, 0.59−0.94) rather than rural. Compared to patients 55 years of age or older, the odds of retention were significantly lower for patients younger than 15 (AOR, 0.35; CI, 0.30−0.42), and those aged 15 and <55 (AOR, 0.75; CI, 0.68−0.82). Conclusions: Significant variations exist in the retention of patients in HIV care by patient characteristics. There is evidence of strong associations of many patient characteristics with retention in care, including clinical, demographic, and other contextual variables that may be beneficial for improvements in HIV services in DRC.
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Firth's Logistic Regression of Interruption in Treatment before and after the Onset of COVID-19 among People Living with HIV on ART in Two Provinces of DRC. Healthcare (Basel) 2022; 10:healthcare10081516. [PMID: 36011173 PMCID: PMC9407772 DOI: 10.3390/healthcare10081516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 11/17/2022] Open
Abstract
The impact of the COVID-19 pandemic extends beyond the immediate physical effects of the virus, including service adjustments for people living with the human immunodeficiency virus (PLHIV) on antiretroviral therapy (ART). Purpose: To compare treatment interruptions in the year immediately pre-COVID-19 and after the onset of COVID-19 (10 April 2020 to 30 March 2021). Methods: We analyze quantitative data covering 36,585 persons with HIV who initiated antiretroviral treatment (ART) between 1 April 2019 and 30 March 2021 at 313 HIV/AIDS care clinics in the Haut-Katanga and Kinshasa provinces of the Democratic Republic of Congo (DRC), using Firth’s logistic regression. Results: Treatment interruption occurs in 0.9% of clients and tuberculosis (TB) is detected in 1.1% of clients. The odds of treatment interruption are significantly higher (adjusted odds ratio: 12.5; 95% confidence interval, CI (8.5−18.3)) in the pre-COVID-19 period compared to during COVID-19. The odds of treatment interruption are also higher for clients with TB, those receiving ART at urban clinics, those younger than 15 years old, and female clients (p < 0.05). Conclusions: The clients receiving ART from HIV clinics in two provinces of DRC had a lower risk of treatment interruption during COVID-19 than the year before COVID-19, attributable to program adjustments.
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Whembolua GLS, Muvuka B, Tshiswaka DI, Conserve DF. Socio-Structural Factors Influencing the Prevention of Mother-to-Child Transmission of HIV in the Democratic Republic of the Congo: A Systematic Review. Matern Child Health J 2019; 23:880-889. [PMID: 30600507 DOI: 10.1007/s10995-018-2688-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Introduction The Democratic Republic of the Congo (DRC) had the second-highest mother-to-child HIV transmission rate in Sub-Saharan Africa at 29% in 2013, however the uptake of preventive services for mother-to-child transmission of HIV (PMTCT) remains suboptimal. This systematic review explores socio-cultural and structural factors influencing PMTCT service uptake in the DRC. Methods We conducted a search of electronic databases. The PEN-3 model was used as a framework to synthesize factors influencing PMTCT service uptake into perceptions, enablers, and nurturers. Results Sixteen studies, 14 quantitative and two qualitative, were retained. Maternal, socio-economic, structural, and cultural factors were found to influence PMTCT service uptake in the DRC. Cost, accessibility, and quality of PMTCT services were key barriers to service uptake. Integration, male partner involvement, and evolving PMTCT policies improved PMTCT service delivery and uptake. This review also revealed several socio-cultural challenges in involving male partners in PMTCT programs. Discussion Findings highlight the need to address barriers and reinforce enablers of PMTCT uptake. Creating culturally appropriate, male-friendly, and family-oriented PMTCT programs will improve service uptake in the DRC.
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Affiliation(s)
- Guy-Lucien S Whembolua
- Department of Africana Studies, University of Cincinnati, 3605 French Hall West, Cincinnati, OH, 45221, USA.
| | - Baraka Muvuka
- Department of Health Promotion and Behavioral Sciences, School of Public Health and Information Sciences, University of Louisville, 485 East Gray Street, Louisville, KY, 40202, USA
| | - Daudet Ilunga Tshiswaka
- Department of Public Health, University of West Florida, Building 38, Room 104, Pensacola, FL, USA
| | - Donaldson F Conserve
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Discovery I, Office #534 B, 915 Greene st, Columbia, SC, 29208, USA
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Apangu P, Izudi J, Bajunirwe F, Mulogo E, Batwala V. Retention of HIV exposed infants in care at Arua regional referral hospital, Uganda: a retrospective cohort study. BMC Public Health 2019; 19:436. [PMID: 31023290 PMCID: PMC6485049 DOI: 10.1186/s12889-019-6754-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 04/08/2019] [Indexed: 11/21/2022] Open
Abstract
Background Retention of HIV Exposed Infants (HEIs) in care ensures adequate care. Data on retention of HEIs at large referral hospitals in Uganda is limited. We investigated the retention level of HEIs and associated factors. Methods We conducted a retrospective cohort study on 352 HEIs in care (January 2014 and April 2015) at Arua Regional Referral Hospital, North-western Uganda. Electronic medical data were retrieved and analyzed with Stata. Chi-square, Fisher’s exact, and Students t-tests were used for bivariate analysis. Logistic regression was performed to determine factors independently associated with retention. Results 236 (67.0%) HEIs were delivered in a health facility and 306 (86.9%) received Nevirapine prophylaxis from birth until 6-weeks. Of mothers, 270 (76.7%) were 25–46 years, 202 (57.4%) attended antenatal care (ANC) at recent pregnancy, and 328 (93.2%) were on life-long anti-retroviral therapy. At 18-months, 277 (78.7%) HEIs were retained in care. Maternal age (25–46 years) (Adjusted Odds Ratio (AOR), 2.32; 95% CI, 1.32–4.06), ANC attendance during recent pregnancy (AOR, 2.01; 95% CI, 1.19–4.3.41) and Nevirapine prophylaxis initiation from birth until 6-weeks (AOR, 3.07; 95% CI, 1.50–6.26) were associated with retention. Conclusion Retention was suboptimal. Older maternal age, ANC visits at last pregnancy, and timely NVP initiation increased retention.
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Affiliation(s)
- Pontius Apangu
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Box 1410, Mbarara, Uganda
| | - Jonathan Izudi
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Box 1410, Mbarara, Uganda. .,Institute of Public Health and Management, Clarke International University, Box 7782, Kampala, Uganda.
| | - Francis Bajunirwe
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Box 1410, Mbarara, Uganda
| | - Edgar Mulogo
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Box 1410, Mbarara, Uganda
| | - Vincent Batwala
- Directorate of Research and Graduate Training, Mbarara University of Science and Technology, Box 1410, Mbarara, Uganda
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5
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Technau KG, Strehlau R, Patel F, Shiau S, Burke M, Conradie M, Sorour G, Sherman GG, Coovadia A, Murnane PM, Abrams EJ, Kuhn L. 12-month outcomes of HIV-infected infants identified at birth at one maternity site in Johannesburg, South Africa: an observational cohort study. Lancet HIV 2018; 5:e706-e714. [PMID: 30416043 DOI: 10.1016/s2352-3018(18)30251-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 08/20/2018] [Accepted: 09/10/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Initiation of antiretroviral therapy (ART) following diagnosis of HIV infection at birth is an emerging area of paediatric HIV care. We present outcomes of HIV-infected infants identified at birth at Rahima Moosa Mother and Child Hospital in Johannesburg, South Africa. METHODS From September, 2013 (era 1), only high-risk HIV-exposed infants were offered diagnostic HIV PCR tests at birth. From June, 2014 (era 2), all HIV-exposed infants were offered laboratory-based diagnostic PCR tests. From October, 2014 (era 3), point of care (POC) diagnostic PCR tests were also done if staff availability allowed. We describe time to ART initiation, mortality, retention in care, and viral suppression among the HIV-infected infants identified across these eras. FINDINGS We tested 5449 HIV-exposed infants who were born between Sept 1, 2013, and June 30, 2016. 88 neonates with confirmed HIV infection were identified and included in the study, of which 86 (98%) started ART. Median age at ART initiation decreased from 9 days (IQR 6-25) in eras 1 and 2 to 2 days (1-8) in era 3. In era 3, more neonates who were co-tested with POC testing started ART within 48 h of birth (29 [83%] of 35; median 1 day [IQR 1-2]) than infants who were not co-tested (one [4%] of 29; median 6 days [5-10]). The probability of mortality by 12 months across the eras was 14% (95% CI 8-24) and did not differ by era. Of the 72 infants who survived and initiated ART at the site, 56 (78%) were retained at 12 months. Of the 56 infants retained in care, 40 (71%) had a viral load less than 400 copies per mL at 12 months, with no differences between eras (p=0·23). INTERPRETATION HIV-infected infants can be identified at birth and ART can be initiated within hours to days. Although most infants in our cohort started ART, mortality remained unacceptably high with suboptimal retention and viral suppression. Reducing mortality and improving retention and viral suppression remain urgent priorities. FUNDING Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institute of Allergy and Infectious Disease, National Institutes of Health, USAID/PEPfAR, and the South African National HIV Programme.
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Affiliation(s)
- Karl-Günter Technau
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Renate Strehlau
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Faeezah Patel
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Stephanie Shiau
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Megan Burke
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Martie Conradie
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Gillian Sorour
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Gayle G Sherman
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa; Centre for HIV and Sexually Transmitted Infections, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Ashraf Coovadia
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Pamela M Murnane
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa; Gertrude H Sergievsky Center, College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA; Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, CA, USA
| | - Elaine J Abrams
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa; ICAP at Columbia, Mailman School of Public Health, and Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Louise Kuhn
- Empilweni Services and Research Unit, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, South Africa; Gertrude H Sergievsky Center, College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
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Vrazo AC, Firth J, Amzel A, Sedillo R, Ryan J, Phelps BR. Interventions to significantly improve service uptake and retention of HIV-positive pregnant women and HIV-exposed infants along the prevention of mother-to-child transmission continuum of care: systematic review. Trop Med Int Health 2017; 23:136-148. [PMID: 29164754 DOI: 10.1111/tmi.13014] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Despite the success of Prevention of Mother-to-Child Transmission of HIV (PMTCT) programmes, low uptake of services and poor retention pose a formidable challenge to achieving the elimination of vertical HIV transmission in low- and middle-income countries. This systematic review summarises interventions that demonstrate statistically significant improvements in service uptake and retention of HIV-positive pregnant and breastfeeding women and their infants along the PMTCT cascade. METHODS Databases were systematically searched for peer-reviewed studies. Outcomes of interest included uptake of services, such as antiretroviral therapy (ART) such as initiation, early infant diagnostic testing, and retention of HIV-positive pregnant and breastfeeding women and their infants. Interventions that led to statistically significant outcomes were included and mapped to the PMTCT cascade. An eight-item assessment tool assessed study rigour. PROSPERO ID CRD42017063816. RESULTS Of 686 citations reviewed, 11 articles met inclusion criteria. Ten studies detailed maternal outcomes and seven studies detailed infant outcomes in PMTCT programmes. Interventions to increase access to antenatal care (ANC) and ART services (n = 4) and those using lay cadres (n = 3) were most common. Other interventions included quality improvement (n = 2), mHealth (n = 1), and counselling (n = 1). One study described interventions in an Option B+ programme. Limitations included lack of HIV testing and counselling and viral load monitoring outcomes, small sample size, geographical location, and non-randomized assignment and selection of participants. CONCLUSIONS Interventions including ANC/ART integration, family-centred approaches, and the use of lay healthcare providers are demonstrably effective in increasing service uptake and retention of HIV-positive mothers and their infants in PMTCT programmes. Future studies should include control groups and assess whether interventions developed in the context of earlier 'Options' are effective in improving outcomes in Option B+ programmes.
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Affiliation(s)
- Alexandra C Vrazo
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Jacqueline Firth
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Anouk Amzel
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Rebecca Sedillo
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Julia Ryan
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - B Ryan Phelps
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
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HIV transmission and retention in care among HIV-exposed children enrolled in Malawi's prevention of mother-to-child transmission programme. J Int AIDS Soc 2017; 20:21947. [PMID: 28884524 PMCID: PMC5640313 DOI: 10.7448/ias.20.1.21947] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction: In Malawi, HIV-infected pregnant and breastfeeding women are offered lifelong antiretroviral therapy (ART) regardless of CD4 count or clinical stage (Option B+). Their HIV-exposed children are enrolled in the national prevention of mother-to-child transmission (PMTCT) programme, but many are lost to follow-up. We estimated the cumulative incidence of vertical HIV transmission, taking loss to follow-up into account. Methods: We abstracted data from HIV-exposed children enrolled into care between September 2011 and June 2014 from patient records at 21 health facilities in central and southern Malawi. We used competing risk models to estimate the probability of loss to follow-up, death, ART initiation and discharge, and used pooled logistic regression and inverse probability of censoring weighting to estimate the vertical HIV transmission risk. Results: A total of 11,285 children were included; 9285 (82%) were born to women who initiated ART during pregnancy. At age 30 months, an estimated 57.9% (95% CI 56.6–59.2) of children were lost to follow-up, 0.8% (0.6–1.0) had died, 2.6% (2.3–3.0) initiated ART, 36.5% (35.2–37.9) were discharged HIV-negative and 2.2% (1.5–2.8) continued follow-up. We estimated that 5.3% (95% CI 4.7–5.9) of the children who enrolled were HIV-infected by the age of 30 months, but only about half of these children (2.6%; 95% CI 2.3–2.9) were diagnosed. Conclusions: Confirmed mother-to-child transmission rates were low, but due to poor retention only about half of HIV-infected children were diagnosed. Tracing of children lost to follow-up and HIV testing in outpatient clinics should be scaled up to ensure that all HIV-positive children have access to early ART.
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8
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Austin PC, Fine JP. Practical recommendations for reporting Fine-Gray model analyses for competing risk data. Stat Med 2017; 36:4391-4400. [PMID: 28913837 PMCID: PMC5698744 DOI: 10.1002/sim.7501] [Citation(s) in RCA: 616] [Impact Index Per Article: 88.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/11/2017] [Accepted: 08/25/2017] [Indexed: 11/06/2022]
Abstract
In survival analysis, a competing risk is an event whose occurrence precludes the occurrence of the primary event of interest. Outcomes in medical research are frequently subject to competing risks. In survival analysis, there are 2 key questions that can be addressed using competing risk regression models: first, which covariates affect the rate at which events occur, and second, which covariates affect the probability of an event occurring over time. The cause‐specific hazard model estimates the effect of covariates on the rate at which events occur in subjects who are currently event‐free. Subdistribution hazard ratios obtained from the Fine‐Gray model describe the relative effect of covariates on the subdistribution hazard function. Hence, the covariates in this model can also be interpreted as having an effect on the cumulative incidence function or on the probability of events occurring over time. We conducted a review of the use and interpretation of the Fine‐Gray subdistribution hazard model in articles published in the medical literature in 2015. We found that many authors provided an unclear or incorrect interpretation of the regression coefficients associated with this model. An incorrect and inconsistent interpretation of regression coefficients may lead to confusion when comparing results across different studies. Furthermore, an incorrect interpretation of estimated regression coefficients can result in an incorrect understanding about the magnitude of the association between exposure and the incidence of the outcome. The objective of this article is to clarify how these regression coefficients should be reported and to propose suggestions for interpreting these coefficients.
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Affiliation(s)
- Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Schulich Heart Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Jason P Fine
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, North Carolina, USA
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9
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Hauser BM, Miller WC, Tweya H, Speight C, Mtande T, Phiri S, Ball LM, Hosseinipour MC, Hoffman IF, Rosenberg NE. Assessing Option B+ retention and infant follow-up in Lilongwe, Malawi. Int J STD AIDS 2017; 29:185-194. [PMID: 28750577 DOI: 10.1177/0956462417721658] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Malawi launched Option B+, a program for all pregnant or breastfeeding HIV-positive women to begin lifelong combination antiretroviral therapy (cART), in July 2011. This study characterises a portion of the continuum of care within an antenatal setting in Lilongwe. Women testing HIV-positive and having a cART initiation record at Bwaila Antenatal Clinic from July 2013 to January 2014 were included. Using logistic regression models, we analysed relationships between maternal characteristics and return for infant testing. Among 490 HIV-positive women with a cART initiation record, 360 (73%) were retained at three months. Of these, 203 (56%) were adherent. Records of infant testing were located for 204 women (42%). Women who were not retained were less likely to have an early infant diagnosis record (aOR = 0.20; 95% CI: 0.10, 0.41). Among the women retained, there was a non-significant association between maternal adherence and infant testing (OR = 1.35; 95% CI: 0.89, 2.06). Women lost at earlier continuum stages, who are at higher risk for mother-to-child-transmission, were less likely to bring infants for testing. Even with a test-and-treat program, many women did not remain in care or bring their infant for testing. Facilitating strategies to improve these measures remains an important unmet need.
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Affiliation(s)
- Blake M Hauser
- 1 Department of Environmental Sciences and Engineering, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA
| | - William C Miller
- 2 Department of Medicine, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.,3 Department of Epidemiology, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA
| | - Hannock Tweya
- 4 Lighthouse Trust, Lilongwe, Malawi.,5 The International Union against Tuberculosis and Lung Disease, Paris, France
| | | | - Tiwonge Mtande
- 6 156288 University of North Carolina Project , Lilongwe, Malawi
| | - Sam Phiri
- 2 Department of Medicine, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.,4 Lighthouse Trust, Lilongwe, Malawi.,7 Department of Public Health, College of Medicine, School of Public Health and Family Medicine, University of Malawi, Lilongwe, Malawi
| | - L M Ball
- 1 Department of Environmental Sciences and Engineering, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA
| | - Mina C Hosseinipour
- 2 Department of Medicine, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.,6 156288 University of North Carolina Project , Lilongwe, Malawi
| | - Irving F Hoffman
- 2 Department of Medicine, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.,6 156288 University of North Carolina Project , Lilongwe, Malawi
| | - Nora E Rosenberg
- 2 Department of Medicine, 2331 University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.,6 156288 University of North Carolina Project , Lilongwe, Malawi
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Early Antiretroviral Therapy Initiation and Mortality Among Infants Diagnosed With HIV in the First 12 Weeks of Life: Experiences From Kinshasa, DR Congo and Blantyre, Malawi. Pediatr Infect Dis J 2017; 36:654-658. [PMID: 28060044 PMCID: PMC5468473 DOI: 10.1097/inf.0000000000001539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Based on clinical trial results, the World Health Organization recommends infant HIV testing at age 4-6 weeks and immediate antiretroviral therapy (ART) initiation in all HIV-infected infants. Little is known about the outcomes of HIV-infected infants diagnosed with HIV in the first weeks of life in resource-limited settings. We assessed ART initiation and mortality in the first year of life among infants diagnosed with HIV by 12 weeks of age. METHODS Cohort of HIV-infected infants in Kinshasa and Blantyre diagnosed before 12 weeks to estimate 12-month cumulative incidences of ART initiation and mortality, accounting for competing risks. Multivariate models were used to estimate associations between infant characteristics and timing of ART initiation. RESULTS One hundred and twenty-one infants were diagnosed at a median age of 7 weeks (interquartile range, 6-8). The cumulative incidence of ART initiation was 46% [95% confidence interval (CI), 36%, 55%] at 6 months and 70% (95% CI 60%, 78%) at 12 months. Only age at HIV diagnosis was associated with ART initiation by age 6 months, with a subdistribution hazard ratio of 0.70 (95% CI 0.52, 0.91) for each week increase in age at DNA polymerase chain reaction test. The 12-month cumulative incidence of mortality was 20% (95% CI 13%, 28%). CONCLUSIONS Despite early diagnosis of HIV, ART initiation was slow and mortality remained high, underscoring the complexity in translating clinical trial findings and World Health Organization's guidance into real-life practice. Novel and creative health system interventions will be required to ensure that all HIV-infected infants achieve optimal treatment outcomes under routine care settings.
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11
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Smith C, McFarland EJ. Update on Pediatric Human Immunodeficiency Virus Infection: Paradigms in Treatment and Prevention. Adv Pediatr 2016; 63:147-71. [PMID: 27426899 DOI: 10.1016/j.yapd.2016.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Christiana Smith
- Section of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 055, Aurora, CO 80045, USA
| | - Elizabeth J McFarland
- Section of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 055, Aurora, CO 80045, USA.
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12
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Ng'ambi WF, Ade S, Harries AD, Midiani D, Owiti P, Takarinda KC, Gugsa S, Phiri S. Follow-up and programmatic outcomes of HIV-exposed infants registered in a large HIV centre in Lilongwe, Malawi: 2012-2014. Trop Med Int Health 2016; 21:995-1002. [PMID: 27197651 DOI: 10.1111/tmi.12727] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess follow-up and programmatic outcomes of HIV-exposed infants at Martin Preuss Centre, Lilongwe, from 2012 to 2014. METHODS Retrospective cohort study using routinely collected HIV-exposed infant data. Data were analysed using frequencies and percentages in Stata v.13. RESULTS Of 1035 HIV-exposed infants registered 2012-2014, 79% were available to be tested for HIV and 76% were HIV-tested either with DNA-PCR or rapid HIV test serology by 24 months of age. Sixty-five infants were found to be HIV-positive and 43% were started on antiretroviral therapy (ART) at different ages from 6 weeks to 24 months. Overall, 48% of HIV-exposed infants were declared lost-to-follow-up in the database. Of these, 69% were listed for tracing; of these, 78% were confirmed as lost-to-follow-up through patient charts; of these, 51% were traced; and of these, 62% were truly not in care, the remainder being wrongly classified. Commonest reasons for being truly not in care were mother/guardian unavailability to bring infants to Martin Preuss Centre, forgetting clinic appointments and transport expenses. Of these 86 patients, 36% were successfully brought back to care and 64% remained lost-to-follow-up. CONCLUSION Loss to follow-up remains a huge challenge in the care of HIV-exposed infants. Active tracing facilitates the return of some of these infants to care. However, programmatic data documentation must be urgently improved to better follow-up and link HIV-positive children to ART.
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Affiliation(s)
| | - Serge Ade
- International Union Against Tuberculosis and Lung Disease, Paris, France.,National Tuberculosis Programme, Cotonou, Benin
| | - Anthony D Harries
- International Union Against Tuberculosis and Lung Disease, Paris, France.,London School of Hygiene and Tropical Medicine, London, UK
| | | | - Philip Owiti
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Kudakwashe C Takarinda
- International Union Against Tuberculosis and Lung Disease, Paris, France.,AIDS and TB Department, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Salem Gugsa
- The Lighthouse Trust, Kamuzu Central Hospital, Lilongwe, Malawi.,International Training and Education Center for Health, Seattle, WA, USA
| | - Sam Phiri
- The Lighthouse Trust, Kamuzu Central Hospital, Lilongwe, Malawi
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13
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Edmonds A, Feinstein L, Okitolonda V, Thompson D, Kawende B, Behets F. Implementation and Operational Research: Decentralization Does Not Assure Optimal Delivery of PMTCT and HIV-Exposed Infant Services in a Low Prevalence Setting. J Acquir Immune Defic Syndr 2015; 70:e130-9. [PMID: 26262776 PMCID: PMC4856046 DOI: 10.1097/qai.0000000000000781] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The consequences of decentralizing prevention of mother-to-child HIV transmission and HIV-exposed infant services to antenatal care (ANC)/labor and delivery (L&D) sites from dedicated HIV care and treatment (C&T) centers remain unknown, particularly in low prevalence settings. METHODS In a cohort of mother-infant pairs, we compared delivery of routine services at ANC/L&D and C&T facilities in Kinshasa, Democratic Republic of Congo from 2010-2013, using methods accounting for competing risks (eg, death). Women could opt to receive interventions at 90 decentralized ANC/L&D sites, or 2 affiliated C&T centers. Additionally, we assessed decentralization's population-level impacts by comparing proportions of women and infants receiving interventions before (2009-2010) and after (2011-2013) decentralization. RESULTS Among newly HIV-diagnosed women (N = 1482), the 14-week cumulative incidence of receiving the package of CD4 testing and zidovudine or antiretroviral therapy was less at ANC/L&D [66%; 95% confidence interval (CI): 63% to 69%] than at C&T (88%; 95% CI: 83% to 92%) sites (subdistribution hazard ratio, 0.62; 95% CI: 0.55 to 0.69). Delivery of cotrimoxazole and DNA polymerase chain reaction testing to HIV-exposed infants (N = 1182) was inferior at ANC/L&D sites (subdistribution hazard ratio, 0.84; 95% CI: 0.76 to 0.92); the 10-month cumulative incidence of the package at ANC/L&D sites was 89% (95% CI: 82% to 93%) versus 97% (95% CI: 93% to 99%) at C&T centers. Receipt of the pregnancy (20% of 1518, to 64% of 1405) and infant (16%-31%) packages improved post decentralization. CONCLUSIONS Services were delivered less efficiently at ANC/L&D sites than C&T centers. Although access improved with decentralization, its potential cannot be realized without sufficient and sustained support.
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Affiliation(s)
- Andrew Edmonds
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lydia Feinstein
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Vitus Okitolonda
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Deidre Thompson
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Bienvenu Kawende
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Frieda Behets
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
- School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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