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Olislagers Q, van Leth F, Shabalala F, Dlamini N, Simelane N, Masilela N, Gomez GB, Pell C, Vernooij E, Reis R, Molemans M. Reasons for, and factors associated with, positive HIV retesting: a cross-sectional study in Eswatini. AIDS Care 2022:1-8. [PMID: 36449635 DOI: 10.1080/09540121.2022.2142930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Eswatini has a high HIV prevalence but has made progress towards improving HIV-status awareness, ART uptake and viral suppression. However, there is still a delay in ART initiation, which could partly be attributed to positive HIV-retesting. This study examines reasons for, and factors associated with, positive HIV-retesting among MaxART participants in Eswatini. Data from 601 participants is included in this cross-sectional study. Descriptive statistics and logistic regressions were used. Of the participants, 32.8% has ever retested after a previous positive result. Most participants who retested did this because they could not accept their results (61.9% of all retesters). Other main reasons are related to external influences, gender or the progression of their HIV infection (respectively 18.3%, 10.2%, and 6.1% of all retesters). Participants without a current partner and participants with less time since their first positive test have lower odds of retesting. To decrease retesting and reduce the delay in ART initiation resulting from it, efforts could be made on increasing the acceptance of positive HIV results. Providing more information on the process of testing and importance of early ART initiation, could be part of the solution.
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Affiliation(s)
- Quint Olislagers
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | - Frank van Leth
- Department of health sciences, VU University, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Fortunate Shabalala
- Department of Community Health Nursing Sciences, Faculty of Health Sciences, University of Eswatini, Mbabane, Eswatini
| | - Njabuliso Dlamini
- National Emergency Response Council on HIV and AIDS (NERCHA), Mbabane, Eswatini
| | | | - Nelisiwe Masilela
- Department of Community Health Nursing Sciences, Faculty of Health Sciences, University of Eswatini, Mbabane, Eswatini
| | - Gabriela B. Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
- Department of Global Health Amsterdam, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Eva Vernooij
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
| | - Ria Reis
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, Netherlands
- The Children’s Institute, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Marjan Molemans
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
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Mshweshwe-Pakela NT, Mabuto T, Shankland L, Fischer A, Tsukudu D, Hoffmann CJ. Digitally supported HIV self-testing increases facility-based HIV testing capacity in Ekurhuleni, South Africa. South Afr J HIV Med 2022; 23:1352. [PMID: 35923609 PMCID: PMC9257703 DOI: 10.4102/sajhivmed.v23i1.1352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/24/2022] [Indexed: 12/03/2022] Open
Abstract
Background HIV testing is the first step for linkage to HIV prevention or treatment services. Facility-based HIV testing is the most utilised method, but faces challenges such as limited work space and human resources. Digitally supported HIV self-testing (HIVST) provided in clinics shifts testing to the client, potentially empowering the client, and addresses such constraints. Objectives The study primary objective was to determine the feasibility of integrating digitally supported HIVST into the clinic. Secondary objectives were to describe HIV testing volume, populations reached, and antiretroviral treatment (ART) initiation. Method We conducted an analysis of prospectively collected data during implementation of digitally supported HIVST in two healthcare facilities based in South Africa from June 2019 to September 2019. We described implementation and client characteristics using HIVST and compared testing before and during implementation. Results During the 4-month implementation period there were 35 248 client visits. A total of 6997 (19.9%) of these visits involved HIV testing. Of those testing, 2278 (32.5%) used HIVST. Of the 2267 analysed, 264 (11.6%) were positive: 182 (12%) women and 82 (11%) men. Of those, 230 (95.4%) were confirmed HIV positive and 150 (65%) initiated ART within 14 days. During a four-month pre-implementation period, 14.5% of the clients tested for HIV. Compared to the pre-implementation period, we observed a 25% increase in HIV testing. Conclusion Digitally supported HIVST increased the number of clients completing HIV testing in the health facility, without a need to significantly increase staff or space. Facility-based digitally assisted HIVST has the potential to increase HIV testing in high HIV prevalence clinic populations.
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Affiliation(s)
- Nolundi T Mshweshwe-Pakela
- Department of Implementation Research, The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand Johannesburg, South Africa
| | - Tonderai Mabuto
- Department of Implementation Research, The Aurum Institute, Johannesburg, South Africa
| | | | | | - Dikeledi Tsukudu
- Department of Health Systems, The Aurum Institute, Johannesburg, South Africa
| | - Christopher J Hoffmann
- Department of Implementation Research, The Aurum Institute, Johannesburg, South Africa
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
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Chekole B, Belachew A, Geddif A, Amsalu E, Tigabu A. Survival status and predictors of mortality among HIV-positive children initiated antiretroviral therapy in Bahir Dar town public health facilities Amhara region, Ethiopia, 2020. SAGE Open Med 2022; 10:20503121211069477. [PMID: 35096391 PMCID: PMC8793112 DOI: 10.1177/20503121211069477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 12/09/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Although there is a presence of governmental and non-governmental organizations running to provide quality HIV care services to reduce HIV-related mortality, there is rapid disease progression and death among children in developing countries including Ethiopia. Thus, this study was aimed to assess the mortality predictors of children living with HIV at Bahir Dar town public health facilities. METHOD A facility-based retrospective follow-up study was conducted among 588 children who were enrolled in the HIV care clinic from 1 September 2010 to 30 August 2019. Data were entered into the Epi-Data entry 3.1 and then exported to STATA version 14 for analysis. Multiple imputation models were employed to handle missing data using the multivariate imputation Chained Equations technique. The Kaplan-Meier survival curve and log-rank test were used to estimate and compare the survival time of categorical variables. RESULT About 27 (4.6%) (95% confidence interval: 2.9-6.5) deaths were observed from the 30,062.3 person-months follow-up period, and the overall incidence density rate of 0.9 per 1000 child-months (95% confidence interval: 0.6-1.3). Advanced WHO clinical stage (adjusted hazard ratio = 3.18; 95% confidence interval: 1.07-9.43), hemoglobin level less than 8 g/dL (adjusted hazard ratio = 3.54; 95% confidence interval: 1.27-8.85), children having a weight for age of <-2z (adjusted hazard ratio = 2.81; 95% confidence interval: 1.19-6.6), children with poor adherence (adjusted hazard ratio = 3.91; 95% confidence interval: 1.41-10.8), and starting the treatment beyond 1 week of being eligible (adjusted hazard ratio = 3.22; 95% confidence interval: 1.21-8.53) were predictors of HIV-related mortality among children initiated antiretroviral therapy. CONCLUSION The hazard of mortality was higher among HIV-infected children in the early period of initiation. Enhancing antiretroviral therapy drug adherence, monitoring Hgb level, and timely initiation of antiretroviral therapy reduce HIV-related mortality.
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Affiliation(s)
- Bogale Chekole
- Department of Nursing, College of Medicine and Health Science, Wolkite University, Wolkite, Ethiopia
| | - Amare Belachew
- Department of Pediatric Nursing, School of Health Science, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
| | - Azeb Geddif
- Department of Pediatric Nursing, School of Health Science, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
| | - Eden Amsalu
- Department of Pediatric and Child Health Nursing, School of Health Science, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
| | - Agmasie Tigabu
- Department of Adult Health Nursing, College of Medicine and Health Science, Debre Tabor University, Bahir Dar, Ethiopia
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Seekaew P, Phanuphak N, Teeratakulpisarn N, Amatavete S, Lujintanon S, Teeratakulpisarn S, Pankam T, Nampaisan O, Jomja P, Prabjunteuk C, Plodgratoke P, Ramautarsing R, Phanuphak P. Same-day antiretroviral therapy initiation hub model at the Thai Red Cross Anonymous Clinic in Bangkok, Thailand: an observational cohort study. J Int AIDS Soc 2021; 24:e25869. [PMID: 34967504 PMCID: PMC8717692 DOI: 10.1002/jia2.25869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 12/14/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction WHO has recommended rapid antiretroviral therapy (ART) initiation, including same‐day ART (SDART). However, data on the feasibility in real‐world settings are limited. We implemented a cohort study at a stand‐alone HIV testing centre to examine its applicability and effectiveness. Methods Data were collected from the Thai Red Cross Anonymous Clinic in Bangkok, Thailand, between July 2017 and July 2018 from clients who were ART‐naïve and could return for follow‐up visits. Baseline laboratory tests and chest X‐ray were performed according to national guidelines, and clinical eligibility was determined based on physical examination and chest X‐ray findings. Primary outcomes were retention in care and viral load suppression at 3, 6 and 12 months. Results During the study period, 2427 people tested HIV positive. Of these, 2107 (2207/2427, 86.8%) met logistical criteria, and 1904 (1904/2427, 78.5%) agreed to SDART. One thousand seven hundred and twenty‐nine (1729/2427, 71.2%) were placed on ART, with 1257 received same‐day initiation and 1576 initiated ART within 7 days; 1198 clients were successfully referred to free, sustained ART sites. Retention among eligible clients who accepted SDART service at months 3, 6 and 12 was 79.8%, 75.2% and 75.3%, respectively. Conclusions Same‐day ART initiation hub model at a stand‐alone HIV testing centre in an urban setting in Bangkok, Thailand, is highly feasible and has a potential for scaling up. Clinical Trial Number NCT04032028
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Affiliation(s)
- Pich Seekaew
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA.,Institute of HIV Research and Innovation, Bangkok, Thailand
| | | | | | | | | | | | | | | | - Pintip Jomja
- Thai Red Cross AIDS Research Centre, Bangkok, Thailand
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Mishra A, Mshweshwe-Pakela N, Kubeka G, Hansoti B, Mabuto T, Hoffmann CJ. Systems Analysis to Increase HIV Testing Delivery and HIV Diagnosis in Primary Care Clinics in South Africa. J Acquir Immune Defic Syndr 2021; 87:1048-1054. [PMID: 33871412 DOI: 10.1097/qai.0000000000002692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 03/17/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Provider-initiated testing and counseling remains highly underused in many South African health facilities. We implemented a systems analysis to investigate whether simple adjustments to HIV testing services (HTS) delivery can increase HTS provision. SETTING Ten primary care facilities in the Ekurhuleni District in South Africa. METHODS Following a baseline HTS assessment that showed limited offering of HTS by clinicians, clinic staff had the option to adopt several change approaches to increase HTS delivery using existing human resources. Approaches included adjusting HTS timing, strengthening HTS promotion, counsellor management, and implementing reward systems. Evaluation was conducted identically to the baseline study using patient exit interviews to quantify HTS engagement and value stream mapping to map patient flow through the clinic. RESULTS We conducted 2163 exit interviews and followed 352 patients for value stream mapping. After change implementation, a significantly higher proportion of patients reported being offered HTS (742/2163, 34.3% vs. 231/2206, 10.5% during the baseline period; χ2P < 0.001) and having undertaken testing (527/2163, 24.4% vs. 197/2206, 8.9% during the baseline period; χ2P < 0.001) with only a 3-percentage point decrease in HIV-positive yield (14.0% vs. 17.1% during the baseline period). The median time to HTS offer decreased from 77 minutes to 3 minutes after clinic arrival during the intervention (χ2P = 0.001). CONCLUSIONS A systems approach can be an effective and appropriate implementation strategy to augment HTS delivery and increase HIV diagnoses. This low-cost approach may be extended to optimize other aspects of clinic service delivery.
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Affiliation(s)
- Anant Mishra
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Griffiths Kubeka
- Implementation Research Division, the Aurum Institute, Johannesburg, South Africa
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Tonderai Mabuto
- Implementation Research Division, the Aurum Institute, Johannesburg, South Africa
- The University of the Witwatersrand School of Public Health, Johannesburg, South Africa; and
| | - Christopher J Hoffmann
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Implementation Research Division, the Aurum Institute, Johannesburg, South Africa
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Is HIV Post-test Counselling Aligned with Universal Test and Treat Goals? A Qualitative Analysis of Counselling Session Content and Delivery in South Africa. AIDS Behav 2021; 25:1583-1596. [PMID: 33241450 DOI: 10.1007/s10461-020-03075-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 11/27/2022]
Abstract
Early identification of people living with HIV (PLHIV) and subsequent engagement into HIV treatment is a key to reducing HIV-related illness, HIV-related deaths, and HIV transmission through universal test and treat approaches. With the scale-up of antiretroviral therapy (ART) programmes, counselling that is provided immediately after the diagnosis of HIV (post-test counselling) is well placed to facilitate linkage to care and ART initiation. We sought to assess whether the current delivery of post-test counselling in a routine HIV programme was aligned with the goals of universal test and treat as articulated in local and international HIV testing service guidelines. We analysed transcripts of 40 post-test counselling sessions for HIV-positive clients, performed by 34 counsellors in ten public sector health facilities in the Ekurhuleni District of South Africa. We used thematic analysis to identify key aspects of counselling techniques and content provided to the client. We identified five key themes of counselling messages: (1) specific behaviour changes that are required to maintain or improve health when living with HIV, (2) the benefits of ART, (3) behaviour changes required for ART to be effective, (4) the need for clients to disclose their HIV status, and (5) a need for caution with ART due to a wide range of severe side effects. The counselling sessions were highly didactic, which limited the opportunities for clients to express concerns or counsellors to address client's needs during the counselling session. Based on our observations, a substantial re-adjustment is needed to deliver best-practice counselling. This may include a combination of digital media-based counselling, counselling scripts, and truly client-centred counselling for a sub-set of individuals who are at risk of not linking to care, or not initiated ART within a specified period.
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Grant AD, Charalambous S, Tlali M, Karat AS, Dorman SE, Hoffmann CJ, Johnson S, Vassall A, Churchyard GJ, Fielding KL. Algorithm-guided empirical tuberculosis treatment for people with advanced HIV (TB Fast Track): an open-label, cluster-randomised trial. Lancet HIV 2020; 7:e27-e37. [PMID: 31727580 DOI: 10.1016/s2352-3018(19)30266-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 07/16/2019] [Accepted: 07/30/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tuberculosis, which is often undiagnosed, is the major cause of death among HIV-positive people. We aimed to test whether the use of a clinical algorithm enabling the initiation of empirical tuberculosis treatment by nurses in primary health-care clinics would reduce mortality compared with standard of care for adults with advanced HIV disease. METHODS In this open-label cluster-randomised controlled trial, we recruited individuals from 24 primary health-care clinics in South Africa. The clinics were randomly assigned (1:1) to either deliver an intervention or routine care (control) using computer-generated random numbers. Eligible participants were HIV-positive adults (aged ≥18 years) with CD4 counts of 150 cells per μL or less, who had not had antiretroviral therapy (ART) in the past 6 months or tuberculosis treatment in the past 3 months, and did not require urgent hospital referral. In intervention clinics, study nurses assessed participants on the basis of tuberculosis symptoms, body-mass index, point-of-care haemoglobin concentrations, and urine lipoarabinomannan assay results. Participants classified by a study algorithm as having high probability of tuberculosis (positive urine lipoarabinomannan assay, body-mass index <18·5 kg/m2, or haemoglobin concentration <100 g/L) were recommended to start tuberculosis treatment immediately followed by ART 2 weeks later; participants classified as medium probability (tuberculosis symptoms, no high probability criteria) were recommended to have symptom-guided investigation; and participants classified as low probability (no tuberculosis symptoms or high probability criteria) were recommended to start ART immediately. In standard-of-care clinics, participants received treatment in accordance with South African guidelines. Investigators and participants were aware of treatment allocation. The primary outcome was all-cause mortality at 6 months, assessed in the intention-to-treat population. Safety was also analysed in the intention-to treat population. This trial is registered with the ISRCTN registry, ISRCTN35344604, and the South African National Clinical Trials Register, DOH-27-0812-3902. FINDINGS Between Dec 19, 2012, and Dec 18, 2014, 3091 individuals were screened for eligibility, of whom 3053 were recruited, and 3022 (1507 participants in the intervention group and 1515 participants in the control group) were analysed for the primary outcome. 930 (61·7%) of 1507 participants in the intervention group versus 172 (11·4%) of 1515 participants in the control group had started tuberculosis treatment by 2 months. At 6 months, the mortality rate was 19·0 deaths per 100 person-years for the intervention group versus 21·6 deaths per 100 person-years in the control group (unadjusted hazard ratio [HR] 0·92, 95% CI 0·67-1·26, p=0·58; adjusted HR 0·87, 0·61-1·24, p=0·41). 28 (1·9%) of 1507 participants in the intervention group and ten (0·7%) of 1515 participants in the control group reported serious or severe adverse events. Grade 3 or 4 nausea and vomiting was the most common adverse event (ten participants in the intervention group and four participants in the control group). Among participants with adverse events, eight participants (six participants in the intervention group and two participants in the control group) died; none of the six deaths in the intervention group were attributed to the study intervention. INTERPRETATION Our intervention substantially increased coverage of tuberculosis treatment in this high-risk population, but did not reduce mortality. FUNDING Joint Global Health Trials (Medical Research Council, Department for International Development, Wellcome Trust).
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Affiliation(s)
- Alison D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK; Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Salome Charalambous
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; The Aurum Institute, Johannesburg, South Africa
| | - Mpho Tlali
- The Aurum Institute, Johannesburg, South Africa
| | - Aaron S Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Susan E Dorman
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Suzanne Johnson
- Foundation for Professional Development, Pretoria, South Africa
| | - Anna Vassall
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Gavin J Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; The Aurum Institute, Johannesburg, South Africa; Advancing Care and Treatment for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
| | - Katherine L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Mabuto T, Hansoti B, Kerrigan D, Mshweshwe‐Pakela N, Kubeka G, Charalambous S, Hoffmann C. HIV testing services in healthcare facilities in South Africa: a missed opportunity. J Int AIDS Soc 2019; 22:e25367. [PMID: 31599495 PMCID: PMC6785782 DOI: 10.1002/jia2.25367] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 07/11/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION South Africa (SA) has the world's highest burden of HIV infection (approximately 7.2 million), yet it is estimated that 23.5% women and 31.5% of men are unaware that they are living with HIV. The 2015 national South African HIV testing guidelines mandate the universal offer of HIV testing services (HTS) in all healthcare facilities. METHODS A multi-prong approach was used from January 2017 to June 2017 to evaluate the current implementation of HTS in ten facilities in the Ekurhuleni District of SA. First, we conducted patient exit interviews to quantify engagement in HTS services. Second, we systematically mapped the flow of individual patients through the clinic. RESULTS We conducted a total of 2989 exit interviews and followed 568 patients for value stream mapping. Overall self-reported testing acceptance was high at 84.7% (244), but <10% of the patients (288) were offered testing. Female patients were more likely to be offered testing (233/2046, 11.4% vs. 55/943, 5.8% in males; chi-square p < 0.005), and also more likely to accept testing (203/233, 87.1% vs. 41/55, 74.6% in males; chi-square p = 0.02). Value stream mapping revealed that patients offered HIV testing had a total visit time of 51 minutes more (95% CI: 30-72) compared to those not offered testing. CONCLUSIONS The poor delivery of HTS appears to be due to a failure to recommend HTS and the added time burden placed on those accepting testing. There were significant differences in both the offer and acceptance of testing by gender. Health system issues need to be addressed to improve HTS delivery.
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Affiliation(s)
- Tonderai Mabuto
- Implementation Research DivisionThe Aurum InstituteJohannesburgSouth Africa
- The University of the Witwatersrand School of Public HealthJohannesburgSouth Africa
| | - Bhakti Hansoti
- Department of Emergency MedicineJohns Hopkins School of MedicineBaltimoreMDUSA
- Department of International HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | | | | | - Griffiths Kubeka
- Implementation Research DivisionThe Aurum InstituteJohannesburgSouth Africa
| | - Salome Charalambous
- Implementation Research DivisionThe Aurum InstituteJohannesburgSouth Africa
- The University of the Witwatersrand School of Public HealthJohannesburgSouth Africa
| | - Christopher Hoffmann
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
- Department of Health, Behavior, and SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
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Stafford KA, Nganga LW, Tulli T, Foreit KGF. Factors Associated with Outcomes of Pre-ART HIV Care. J Int Assoc Provid AIDS Care 2019. [PMID: 29534654 PMCID: PMC6748496 DOI: 10.1177/2325958218759602] [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] [Indexed: 11/25/2022] Open
Abstract
The World Health Organization recommended removing all CD4 requirements for initiation of
antiretroviral therapy (ART) in resource-limited settings. We examined the pre-ART period
to identify and assess factors associated with outcomes of pre-ART care. Four modes of
transition out of pre-ART care were considered. Beta estimates from the competing risks
Cox models were used to investigate whether the effects of covariates differed by mode of
transition. Median CD4 counts at entry showed no meaningful change over time. Advanced
disease progression and presence of opportunistic infections were significant predictors
of pre-ART mortality. Men were more likely to die before initiating ART, transfer to
another facility, or be lost to follow-up than were women. Removing CD4 thresholds is not
likely to substantially reduce program mortality prior to ART initiation unless and until
patients enroll earlier in disease progression. Care programs should focus on diagnosis
and treatment of opportunistic infections to reduce pre-ART mortality.
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Affiliation(s)
- Kristen A Stafford
- 1 Division of Clinical Care & Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Tuhuma Tulli
- 3 The Palladium Group, Dar es Salaam, United Republic of Tanzania
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Phanuphak N, Seekaew P, Phanuphak P. Optimising treatment in the test-and-treat strategy: what are we waiting for? Lancet HIV 2019; 6:e715-e722. [PMID: 31515166 DOI: 10.1016/s2352-3018(19)30236-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 06/10/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
Abstract
To move from science to guidelines, more than a decade was spent debating the clinical benefits, public health benefits, client autonomy, ethical conflicts, and adherence challenges for the HIV test-and-treat strategy. 2 years after WHO recommended antiretroviral therapy (ART) initiation for all, only 66% of countries reported full implementation. Many countries with the highest HIV burden, with increasing new HIV infections and HIV-related deaths, have not yet adopted or fully implemented the strategy. Whether to implement rapid or same-day ART should not follow the same cycle of debate. Now that there is strong evidence and high policy adoption, the test-and-treat strategy must be implemented as efficiently as possible. More research is needed to optimise-not delay-its implementation.
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Affiliation(s)
- Nittaya Phanuphak
- PREVENTION, Thai Red Cross AIDS Research Centre, Pathumwan, Bangkok 10330, Thailand.
| | - Pich Seekaew
- PREVENTION, Thai Red Cross AIDS Research Centre, Pathumwan, Bangkok 10330, Thailand
| | - Praphan Phanuphak
- PREVENTION, Thai Red Cross AIDS Research Centre, Pathumwan, Bangkok 10330, Thailand
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Strategies to Accelerate HIV Care and Antiretroviral Therapy Initiation After HIV Diagnosis: A Randomized Trial. J Acquir Immune Defic Syndr 2017; 75:540-547. [PMID: 28471840 DOI: 10.1097/qai.0000000000001428] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Determine the effectiveness of strategies to increase linkage to care after testing HIV positive at mobile HIV testing in South Africa. DESIGN Unmasked randomized controlled trial. METHODS Recruitment of adults testing HIV positive and not currently in HIV care occurred at 7 mobile HIV counseling and testing units in urban, periurban, and rural South Africa with those consenting randomized 1:1:1:1 into 1 of 4 arms. Three strategies were compared with standard of care (SOC): point-of-care CD4 count testing (POC CD4), POC CD4 plus longitudinal strengths-based counseling (care facilitation; CF), and POC CD4 plus transport reimbursement (transport). Participants were followed up telephonically and through clinic records and analyzed with an intention-to-treat analysis. RESULTS From March 2013 to October 2014, 2558 participants were enrolled, of whom 160 were excluded postrandomization. Compared with the SOC arm where 298 (50%) reported having entered care, linkage to care was 319 (52%) for POC CD4, hazard ratio (HR) 1.0 [95% confidence interval (CI): 0.89 to 1.2, P = 0.6]; 331 (55%) for CF, HR: 1.1 (95% CI: 0.84 to 1.3, P = 0.2); and 291 (49%) for transport, HR 0.97 (95% CI: 0.83 to 1.1, P = 0.7). Linkage to care verified with clinical records that occurred for 172 (29%) in the SOC arm; 187 (31%) in the POC CD4 arm, HR: 1.0 (95% CI: 0.86 to 1.3, P = 0.6); 225 (38%) in the CF arm, HR: 1.4 (95% CI: 1.1 to 1.7, P = 0.001); and 180 (31%) in the transport arm, HR: 1.1 (95% CI: 0.88 to 1.3, P = 0.5). CONCLUSIONS CF improved verified linkage to care from 29% to 38%.
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Relationship Between Time to Initiation of Antiretroviral Therapy and Treatment Outcomes: A Cohort Analysis of ART Eligible Adolescents in Zimbabwe. J Acquir Immune Defic Syndr 2017; 74:390-398. [PMID: 28002183 PMCID: PMC5321111 DOI: 10.1097/qai.0000000000001274] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is Available in the Text. Background: Age-specific retention challenges make antiretroviral therapy (ART) initiation in adolescents difficult, often requiring a lengthy preparation process. This needs to be balanced against the benefits of starting treatment quickly. The optimal time to initiation duration in adolescents is currently unknown. Objective: To assess the effect of time to ART initiation on mortality and loss to follow-up (LTFU) among treatment eligible adolescents. Methods: We conducted a retrospective cohort analysis among 1499 ART eligible adolescents aged ≥10 to <19 years registered in a public sector HIV program in Bulawayo, Zimbabwe, between 2004 and 2011. Hazard ratios (HR) for mortality and LTFU were calculated for different time to ART durations using multivariate Cox regression models. Results: Median follow-up duration was 1.6 years. Mortality HRs of patients who initiated at 0 to ≤7 days, >14 days to ≤1 month, >1 to ≤2 months, >2 months, and before initiation were 1.59, 1.19, 1.56, 1.08, and 0.94, respectively, compared with the reference group of >7 to ≤14 days. LTFU HRs were 1.02, 1.07, 0.85, 0.97, and 3.96, respectively. Among patients not on ART, 88% of deaths and 85% of LTFU occurred during the first 3 months after becoming ART eligible, but only 37% and 29% among adolescents on ART, respectively. Conclusions: Neither mortality or LTFU was associated with varying time to ART. The initiation process can be tailored to the adolescents' needs and individual life situations without risking to increase poor treatment outcomes. Early mortality was high despite rapid ART initiation, calling for earlier rather than faster initiation through HIV testing scale-up.
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Desai MA, Okal DO, Rose CE, Ndivo R, Oyaro B, Otieno FO, Williams T, Chen RT, Zeh C, Samandari T. Effect of point-of-care CD4 cell count results on linkage to care and antiretroviral initiation during a home-based HIV testing campaign: a non-blinded, cluster-randomised trial. Lancet HIV 2017; 4:e393-e401. [PMID: 28579225 DOI: 10.1016/s2352-3018(17)30091-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 04/14/2017] [Accepted: 04/20/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND HIV disease staging with referral laboratory-based CD4 cell count testing is a key barrier to the initiation of antiretroviral treatment (ART). Point-of-care CD4 cell counts can improve linkage to HIV care among people living with HIV, but its effect has not been assessed with a randomised controlled trial in the context of home-based HIV counselling and testing (HBCT). METHODS We did a two-arm, cluster-randomised, controlled efficacy trial in two districts of western Kenya with ongoing HBCT. Housing compounds were randomly assigned (1:1) to point-of-care CD4 cell counts (366 compounds with 417 participants) or standard-of-care (318 compounds with 353 participants) CD4 cell counts done at one of three referral laboratories serving the study catchment area. In each compound, we enrolled people with HIV not engaged in care in the previous 6 months. All participants received post-test counselling and referral for HIV care. Point-of-care test participants received additional counselling on the result, including ART eligibility if CD4 was less than 350 cells per μL, the cutoff in Kenyan guidelines. Participants were interviewed 6 months after enrolment to ascertain whether they sought HIV care, verified through chart reviews at 23 local clinics. The prevalence of loss to follow-up at 6 months (LTFU) was listed as the main outcome in the study protocol. We analysed linkage to care at 6 months (defined as 1-LTFU) as the primary outcome. All analyses were by intention to treat. This trial is registered at ClinicalTrials.gov, number NCT02515149. FINDINGS We enrolled 770 participants between July 1, 2013, and Feb 28, 2014. 692 (90%) had verified linkage to care status and 78 (10%) were lost to follow-up. Of 371 participants in the point-of-care group, 215 (58%) had linked to care within 6 months versus 108 (34%) of 321 in the standard-of-care group (Cox proportional multivariable hazard ratio [HR] 2·14, 95% CI 1·67-2·74; log rank p<0·0001). INTERPRETATION Point-of-care CD4 cell counts in a resource-limited HBCT setting doubled linkage to care and thereby improved ART initiation. Given the substantial economic and logistic hindrances to providing ART for all people with HIV in resource-limited settings in the near term, point of care CD4 cell counts might have a role in prioritising care and improving linkage to care. FUNDING US Centers for Disease Control and Prevention.
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Affiliation(s)
- Mitesh A Desai
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | | | - Charles E Rose
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Boaz Oyaro
- Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Tiffany Williams
- ICF International, Assigned to Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Robert T Chen
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Clement Zeh
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Taraz Samandari
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
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Gu D, Mao Y, Tang Z, Montaner J, Shen Z, Zhu Q, Detels R, Jin X, Xiong R, Xu J, Ling W, Erinoff L, Lindblad R, Liu D, Van Veldhuisen P, Hasson A, Wu Z. Loss to Follow-Up from HIV Screening to ART Initiation in Rural China. PLoS One 2016; 11:e0164346. [PMID: 27768710 PMCID: PMC5074455 DOI: 10.1371/journal.pone.0164346] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 09/23/2016] [Indexed: 02/01/2023] Open
Abstract
Background Patients who are newly screened HIV positive by EIA are lost to follow-up due to complicated HIV testing procedures. Because this is the first step in care, it affects the entire continuum of care. This is a particular concern in rural China. Objective(s) To assess the routine HIV testing completeness and treatment initiation rates at 18 county-level general hospitals in rural Guangxi. Methods We reviewed original hospital HIV screening records. Investigators also engaged with hospital leaders and key personnel involved in HIV prevention activities to characterize in detail the routine care practices in place at each county. Results 699 newly screened HIV-positive patients between January 1 and June 30, 2013 across the 18 hospitals were included in the study. The proportion of confirmatory testing across the 18 hospitals ranged from 14% to 87% (mean of 43%), and the proportion of newly diagnosed individuals successfully initiated antiretroviral treatment across the hospitals ranged from 3% to 67% (mean of 23%). The average interval within hospitals for individuals to receive the Western Blot (WB) and CD4 test results from HIV positive screening (i.e. achieving testing completion) ranged from 14–116 days (mean of 41.7 days) across the hospitals. The shortest interval from receiving a positive EIA screening test result to receiving WB and CD4 testing and counseling was 0 day and the longest was 260 days. Conclusion The proportion of patients newly screened HIV positive that completed the necessary testing procedures for HIV confirmation and received ART was very low. Interventions are urgently needed to remove barriers so that HIV patients can have timely access to HIV/AIDS treatment and care in rural China.
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Affiliation(s)
- Diane Gu
- The National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China
| | - Yurong Mao
- The National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China
| | - Zhenzhu Tang
- Guangxi Center of Disease Control and Prevention, Nanning, Guangxi, China
| | - Julio Montaner
- BC Center for Excellence in HIV/AIDS, University of British Columbia, Vancouver, BC, Canada
| | - Zhiyong Shen
- Guangxi Center of Disease Control and Prevention, Nanning, Guangxi, China
| | - Qiuying Zhu
- Guangxi Center of Disease Control and Prevention, Nanning, Guangxi, China
| | - Roger Detels
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, United States of America
| | - Xia Jin
- The National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China
| | - Ran Xiong
- The National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China
| | - Juan Xu
- The National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China
| | - Walter Ling
- Integrated Substance Abuse Programs, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Lynda Erinoff
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, USA
| | - Robert Lindblad
- The EMMES Corporation, Rockville, MD, United States of America
| | - David Liu
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, USA
| | | | - Albert Hasson
- Integrated Substance Abuse Programs, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Zunyou Wu
- The National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China
- * E-mail:
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Woodd SL, Kelly P, Koethe JR, Praygod G, Rehman AM, Chisenga M, Siame J, Heimburger DC, Friis H, Filteau S. Risk factors for mortality among malnourished HIV-infected adults eligible for antiretroviral therapy. BMC Infect Dis 2016; 16:562. [PMID: 27733134 PMCID: PMC5062813 DOI: 10.1186/s12879-016-1894-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 10/01/2016] [Indexed: 12/02/2022] Open
Abstract
Background A substantial proportion of HIV-infected adults starting antiretroviral therapy (ART) in sub-Saharan Africa are malnourished. We aimed to increase understanding of the factors affecting their high mortality, particularly in the high-risk period before ART initiation. Methods We analysed potential risk factors for mortality of Zambian and Tanzanian participants enrolled in the NUSTART clinical trial. Malnourished adults (n = 1815; body mass index [BMI] <18.5 kg/m2) were recruited at referral to ART and randomised to receive different nutritional supplements. Demographics, measures of body composition, blood electrolytes and clinical conditions were investigated as potential risk factors using Poisson regression models. Results The mortality rate was higher in the period from referral to starting ART (121 deaths/100 person-years; 95 % CI 103, 142) than during the first 12 weeks of ART (66; 95 % CI 57, 76) and was not affected by trial study arm. In adjusted analyses, lower CD4 count, BMI and mid-arm circumference and raised C-reactive protein were associated with an increased risk of mortality throughout the study. Male sex and lower hand-grip strength carried an increased risk in the pre-ART period. Participants on tuberculosis treatment at referral had a lower mortality rate (adjusted Rate Ratio 0.44; 95 % CI 0.31, 0.63). Conclusion Among malnourished ART-eligible adults, pre-ART mortality was twice that in the early post-ART period, suggesting many early ART deaths represent advanced HIV disease rather than treatment-related events. Therefore, more efforts are needed to promote earlier diagnosis and immediate initiation of ART, as recently recommended by WHO for all persons with HIV worldwide. The positive effect of tuberculosis treatment suggests undiagnosed tuberculosis is a contributor to mortality in this population. Trial registration Pan African Clinical Trials Registry, PACTR201106000300631; registered on 1st June 2011. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1894-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Susannah L Woodd
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Paul Kelly
- Barts & the London School of Medicine and Queen Mary University of London, London, UK
| | | | - George Praygod
- National Institute for Medical Research, Mwanza, Tanzania
| | - Andrea M Rehman
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | | | | | | | | | - Suzanne Filteau
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Ford N, Nsanzimana S. Accelerating initiation of antiretroviral therapy. Lancet HIV 2016; 3:e504-e505. [PMID: 27658872 DOI: 10.1016/s2352-3018(16)30152-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 07/07/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Nathan Ford
- Department of HIV, World Health Organization, Geneva 1211, Switzerland.
| | - Sabin Nsanzimana
- Rwanda Biomedical Center, Institute of HIV Disease Prevention and Control, Kigali, Rwanda; Basel Institute for Clinical Epidemiology and Biostatistics, Basel, Switzerland; Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
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Oo MM, Gupta V, Aung TK, Kyaw NTT, Oo HN, Kumar AM. Alarming attrition rates among HIV-infected individuals in pre-antiretroviral therapy care in Myanmar, 2011-2014. Glob Health Action 2016; 9:31280. [PMID: 27562473 PMCID: PMC4999509 DOI: 10.3402/gha.v9.31280] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 07/26/2016] [Accepted: 07/26/2016] [Indexed: 12/17/2022] Open
Abstract
Background High retention rates have been documented among patients receiving antiretroviral therapy (ART) in Myanmar. However, there is no information on human immunodeficiency virus (HIV)-infected individuals in care before initiation of ART (pre-ART care). We assessed attrition (loss-to-follow-up [LTFU] and death) rates among HIV-infected individuals in pre-ART care and their associated factors over a 4-year period. Design In this retrospective cohort study, we extracted routinely collected data of HIV-infected adults (>15 years old) entering pre-ART care (June 2011–June 2014) as part of an Integrated HIV Care (IHC) programme, Myanmar. Attrition rates per 100 person-years and cumulative incidence of attrition were calculated. Factors associated with attrition were examined by calculating hazard ratios (HRs). Results Of 18,037 HIV-infected adults enrolled in the IHC programme, 11,464 (63%) entered pre-ART care (60% men, mean age 37 years, median cluster of differentiation 4 (CD4) cell count 160 cells/µL). Of the 11,464 eligible participants, 3,712 (32%) underwent attrition of which 43% were due to deaths and 57% were due to LTFU. The attrition rate was 78 per 100 person-years (95% CI, 75–80). The cumulative incidence of attrition was 70% at the end of a 4-year follow-up, of which nearly 90% occurred in the first 6 months. Male sex (HR 1.5, 95% CI 1.4–1.6), WHO clinical Stage 3 and 4, CD4 count <200 cells/µL, abnormal BMI, and anaemia were statistically significant predictors of attrition. Conclusions Pre-ART care attrition among persons living with HIV in Myanmar was alarmingly high – with most attrition occurring within the first 6 months. Strategies aimed at improving early HIV diagnosis and initiation of ART are needed. Suggestions include comprehensive nutrition support and intensified monitoring to prevent pre-ART care attrition by tracking patients who do not return for pre-ART care appointments. It is high time that Myanmar moves towards a ‘test and treat’ approach and ultimately eliminates the need for pre-ART care.
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Affiliation(s)
- Myo Minn Oo
- International Union Against Tuberculosis and Lung Disease, Mandalay, Myanmar;
| | - Vivek Gupta
- International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office, New Delhi, India.,International Union Against Tuberculosis and Lung Disease, Paris, France.,Community Ophthalmology, Dr. RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Thet Ko Aung
- International Union Against Tuberculosis and Lung Disease, Mandalay, Myanmar
| | - Nang Thu Thu Kyaw
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | | | - Ajay Mv Kumar
- International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office, New Delhi, India.,International Union Against Tuberculosis and Lung Disease, Paris, France
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Initiating Antiretroviral Therapy for HIV at a Patient's First Clinic Visit: The RapIT Randomized Controlled Trial. PLoS Med 2016; 13:e1002015. [PMID: 27163694 PMCID: PMC4862681 DOI: 10.1371/journal.pmed.1002015] [Citation(s) in RCA: 219] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 03/22/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND High rates of patient attrition from care between HIV testing and antiretroviral therapy (ART) initiation have been documented in sub-Saharan Africa, contributing to persistently low CD4 cell counts at treatment initiation. One reason for this is that starting ART in many countries is a lengthy and burdensome process, imposing long waits and multiple clinic visits on patients. We estimated the effect on uptake of ART and viral suppression of an accelerated initiation algorithm that allowed treatment-eligible patients to be dispensed their first supply of antiretroviral medications on the day of their first HIV-related clinic visit. METHODS AND FINDINGS RapIT (Rapid Initiation of Treatment) was an unblinded randomized controlled trial of single-visit ART initiation in two public sector clinics in South Africa, a primary health clinic (PHC) and a hospital-based HIV clinic. Adult (≥18 y old), non-pregnant patients receiving a positive HIV test or first treatment-eligible CD4 count were randomized to standard or rapid initiation. Patients in the rapid-initiation arm of the study ("rapid arm") received a point-of-care (POC) CD4 count if needed; those who were ART-eligible received a POC tuberculosis (TB) test if symptomatic, POC blood tests, physical exam, education, counseling, and antiretroviral (ARV) dispensing. Patients in the standard-initiation arm of the study ("standard arm") followed standard clinic procedures (three to five additional clinic visits over 2-4 wk prior to ARV dispensing). Follow up was by record review only. The primary outcome was viral suppression, defined as initiated, retained in care, and suppressed (≤400 copies/ml) within 10 mo of study enrollment. Secondary outcomes included initiation of ART ≤90 d of study enrollment, retention in care, time to ART initiation, patient-level predictors of primary outcomes, prevalence of TB symptoms, and the feasibility and acceptability of the intervention. A survival analysis was conducted comparing attrition from care after ART initiation between the groups among those who initiated within 90 d. Three hundred and seventy-seven patients were enrolled in the study between May 8, 2013 and August 29, 2014 (median CD4 count 210 cells/mm3). In the rapid arm, 119/187 patients (64%) initiated treatment and were virally suppressed at 10 mo, compared to 96/190 (51%) in the standard arm (relative risk [RR] 1.26 [1.05-1.50]). In the rapid arm 182/187 (97%) initiated ART ≤90 d, compared to 136/190 (72%) in the standard arm (RR 1.36, 95% confidence interval [CI], 1.24-1.49). Among 318 patients who did initiate ART within 90 d, the hazard of attrition within the first 10 mo did not differ between the treatment arms (hazard ratio [HR] 1.06; 95% CI 0.61-1.84). The study was limited by the small number of sites and small sample size, and the generalizability of the results to other settings and to non-research conditions is uncertain. CONCLUSIONS Offering single-visit ART initiation to adult patients in South Africa increased uptake of ART by 36% and viral suppression by 26%. This intervention should be considered for adoption in the public sector in Africa. TRIAL REGISTRATION ClinicalTrials.gov NCT01710397, and South African National Clinical Trials Register DOH-27-0213-4177.
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Hernández-Romieu AC, del Rio C, Hernández-Ávila JE, Lopez-Gatell H, Izazola-Licea JA, Uribe Zúñiga P, Hernández-Ávila M. CD4 Counts at Entry to HIV Care in Mexico for Patients under the "Universal Antiretroviral Treatment Program for the Uninsured Population," 2007-2014. PLoS One 2016; 11:e0152444. [PMID: 27027505 PMCID: PMC4814060 DOI: 10.1371/journal.pone.0152444] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 03/14/2016] [Indexed: 01/24/2023] Open
Abstract
In Mexico, public health services have provided universal access to antiretroviral therapy (ART) since 2004. For individuals receiving HIV care in public healthcare facilities, the data are limited regarding CD4 T-lymphocyte counts (CD4e) at the time of entry into care. Relevant population-based estimates of CD4e are needed to inform strategies to maximize the impact of Mexico's national ART program, and may be applicable to other countries implementing universal HIV treatment programs. For this study, we retrospectively analyzed the CD4e of persons living with HIV and receiving care at state public health facilities from 2007 to 2014, comparing CD4e by demographic characteristics and the marginalization index of the state where treatment was provided, and assessing trends in CD4e over time. Our sample included 66,947 individuals who entered into HIV care between 2007 and 2014, of whom 79% were male. During the study period, the male-to-female ratio increased from 3.0 to 4.3, reflecting the country's HIV epidemic; the median age at entry decreased from 34 years to 32 years. Overall, 48.6% of individuals entered care with a CD4≤200 cells/μl, ranging from 42.2% in states with a very low marginalization index to 52.8% in states with a high marginalization index, and from 38.9% among individuals aged 18-29 to 56.5% among those older than 50. The adjusted geometric mean (95% confidence interval) CD4e increased among males from 135 (131,142) cells/μl in 2007 to 148 (143,155) cells/μl in 2014 (p-value<0.0001); no change was observed among women, with a geometric mean of 178 (171,186) and 171 (165,183) in 2007 and 2014, respectively. There have been important gains in access to HIV care and treatment; however, late entry into care remains an important barrier in achieving optimal outcomes of ART in Mexico. The geographic, socioeconomic, and demographic differences observed reflect important inequities in timely access to HIV prevention, care, and treatment services, and highlight the need to develop contextual and culturally appropriate prevention and HIV testing strategies and linkage programs.
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Affiliation(s)
- Alfonso C. Hernández-Romieu
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Carlos del Rio
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
- Center for AIDS Research, Emory University, Atlanta, GA, United States of America
| | | | | | - José Antonio Izazola-Licea
- National Center for Prevention and Control of HIV/AIDS (CENSIDA), Mexico City, Mexico
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Evaluation and Economics Division, Geneva, Switzerland
| | - Patricia Uribe Zúñiga
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Evaluation and Economics Division, Geneva, Switzerland
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The clock is ticking: the rate and timeliness of antiretroviral therapy initiation from the time of treatment eligibility in Kenya. J Int AIDS Soc 2015; 18:20019. [PMID: 26507824 PMCID: PMC4623278 DOI: 10.7448/ias.18.1.20019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 08/23/2015] [Accepted: 09/08/2015] [Indexed: 12/17/2022] Open
Abstract
Introduction Understanding the determinants of timely antiretroviral therapy (ART) initiation is useful for HIV programmes intent on developing models of care that reduce delays in treatment initiation while maintaining a high quality of care. We analysed patient- and facility-level determinants of time to ART initiation among patients who initiated ART in Kenya. Methods We collected facility-level information and conducted a retrospective chart review of adults initiating ART between 2007 and 2012 at 51 health facilities in Kenya. We evaluated the association between patient- and facility-level covariates at the time of ART eligibility and time to ART initiation. We also explored the determinants associated with timeliness of ART initiation. Results The analysis included 11,942 patients. The median age at the time eligibility was first determined was 37 years (interquartile range [IQR] 31–45). Overall, 75% of patients initiated ART within two months of eligibility. The median CD4 cell count at the time eligibility was first determined rose from 132 (IQR 51–217) in 2007 to 195 (IQR 91–286) in 2011 to 2012 (p<0.001). The cumulative probability of ART initiation among treatment-eligible patients increased over time: 87.1% (95% confidence interval [CI] 85.1–89.0%) in 2007; 96.8% (96.0–97.5%) in 2008; 97.1% (96.3–97.7%) in 2009; 98.5% (98.0 −98.9%) in 2010; and 99.7% (95% CI 99.4 −99.8%) in 2011 to 2012 (p<0.0001). In multivariate analyses, attending a health facility with high ART patient volumes within two months of eligibility was considered the key facility-level determinant of ART initiation (adjusted odds ratio 0.57, 95% CI 0.45–0.72, p<0.001). Patient-level determinants included being eligible for ART in the years subsequent to 2007, advanced World Health Organization clinical stage and low CD4 cell count at the time eligibility was first determined. Conclusions Overall, the time between treatment eligibility and ART initiation decreased substantially in Kenya between 2007 and 2012, with uniform gains across different types of health facilities. Our findings highlight the slow increase in CD4 cell counts at the time of ART eligibility over time, indicating that a large number of patients are still beginning ART with advanced HIV disease. Our findings also support the decentralisation of ART services at all health facilities that have the capacity to initiate treatment. Continued evaluation of programme- and country-level data is needed to monitor timeliness of ART initiation as countries continue to expand treatment access.
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Simplified HIV Testing and Treatment in China: Analysis of Mortality Rates Before and After a Structural Intervention. PLoS Med 2015; 12:e1001874. [PMID: 26348214 PMCID: PMC4562716 DOI: 10.1371/journal.pmed.1001874] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 08/03/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Multistage stepwise HIV testing and treatment initiation procedures can result in lost opportunities to provide timely antiretroviral therapy (ART). Incomplete patient engagement along the continuum of HIV care translates into high levels of preventable mortality. We aimed to evaluate the ability of a simplified test and treat structural intervention to reduce mortality. METHODS AND FINDINGS In the "pre-intervention 2010" (from January 2010 to December 2010) and "pre-intervention 2011" (from January 2011 to December 2011) phases, patients who screened HIV-positive at health care facilities in Zhongshan and Pubei counties in Guangxi, China, followed the standard-of-care process. In the "post-intervention 2012" (from July 2012 to June 2013) and "post-intervention 2013" (from July 2013 to June 2014) phases, patients who screened HIV-positive at the same facilities were offered a simplified test and treat intervention, i.e., concurrent HIV confirmatory and CD4 testing and immediate initiation of ART, irrespective of CD4 count. Participants were followed for 6-18 mo until the end of their study phase period. Mortality rates in the pre-intervention and post-intervention phases were compared for all HIV cases and for treatment-eligible HIV cases. A total of 1,034 HIV-positive participants (281 and 339 in the two pre-intervention phases respectively, and 215 and 199 in the two post-intervention phases respectively) were enrolled. Following the structural intervention, receipt of baseline CD4 testing within 30 d of HIV confirmation increased from 67%/61% (pre-intervention 2010/pre-intervention 2011) to 98%/97% (post-intervention 2012/post-intervention 2013) (all p < 0.001 [i.e., for all comparisons between a pre- and post-intervention phase]), and the time from HIV confirmation to ART initiation decreased from 53 d (interquartile range [IQR] 27-141)/43 d (IQR 15-113) to 5 d (IQR 2-12)/5 d (IQR 2-13) (all p < 0.001). Initiation of ART increased from 27%/49% to 91%/89% among all cases (all p < 0.001) and from 39%/62% to 94%/90% among individuals with CD4 count ≤ 350 cells/mm3 or AIDS (all p < 0.001). Mortality decreased from 27%/27% to 10%/10% for all cases (all p < 0.001) and from 40%/35% to 13%/13% for cases with CD4 count ≤ 350 cells/mm3 or AIDS (all p < 0.001). The simplified test and treat intervention was significantly associated with decreased mortality rates compared to pre-intervention 2011 (adjusted hazard ratio [aHR] 0.385 [95% CI 0.239-0.620] and 0.380 [95% CI 0.233-0.618] for the two post-intervention phases, respectively, for all newly diagnosed HIV cases [both p < 0.001], and aHR 0.369 [95% CI 0.226-0.603] and 0.361 [95% CI 0.221-0.590] for newly diagnosed treatment-eligible HIV cases [both p < 0.001]). The unit cost of an additional patient receiving ART attributable to the intervention was US$83.80. The unit cost of a death prevented because of the intervention was US$234.52. CONCLUSIONS Our results demonstrate that the simplified HIV test and treat intervention promoted successful engagement in care and was associated with a 62% reduction in mortality. Our findings support the implementation of integrated HIV testing and immediate access to ART irrespective of CD4 count, in order to optimize the impact of ART.
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Wilkinson L, Duvivier H, Patten G, Solomon S, Mdani L, Patel S, de Azevedo V, Baert S. Outcomes from the implementation of a counselling model supporting rapid antiretroviral treatment initiation in a primary healthcare clinic in Khayelitsha, South Africa. South Afr J HIV Med 2015; 16:367. [PMID: 29568589 PMCID: PMC5843199 DOI: 10.4102/sajhivmed.v16i1.367] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 05/13/2015] [Indexed: 02/04/2023] Open
Abstract
Background Lengthy antiretroviral treatment (ART) preparation contributes to high losses to care between communicating ART eligibility and initiating ART. To address this shortfall, Médecins Sans Frontières implemented a revised approach to ART initiation counselling preparation (integrated for TB co-infected patients), shifting the emphasis from pre-initiation sessions to addressing common barriers to adherence and strengthening post-initiation support in a primary healthcare facility in Khayelitsha, South Africa. Methods An observational cohort study was conducted using routinely collected data for all ART-eligible patients attending their first counselling session between 23 July 2012 and 30 April 2013 to assess losses to care prior to and post ART initiation. Viral load completion and suppression rates of those retained on ART were also calculated. Results Overall, 449 patients enrolled in the study, of whom 3.6% did not return to the facility to initiate ART. Of those who were initiated, 96.7% were retained at their first ART refill visit and 85.9% were retained 6 months post ART initiation. Of those retained, 80.2% had a viral load taken within 6 months of initiating ART, with 95.4% achieving viral load suppression. Conclusions Adapting counselling to enable rapid ART initiation is feasible and has the potential to reduce losses to care prior to ART initiation without increasing short-term losses thereafter or compromising patient adherence.
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Affiliation(s)
| | - Helene Duvivier
- Médecins Sans Frontières, South African Mission, South Africa
| | | | - Suhair Solomon
- Médecins Sans Frontières, Khayelitsha Project, South Africa
| | - Leticia Mdani
- Médecins Sans Frontières, Khayelitsha Project, South Africa
| | - Shariefa Patel
- City of Cape Town Health Department, Khayelitsha, South Africa
| | | | - Saar Baert
- Médecins Sans Frontières, South African Medical Unit, Belgium
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Abstract
Within Mozambique's current HIV care system, there are numerous opportunities for a person to become lost to follow-up (LTFU) prior to initiating antiretroviral therapy (pre-ART). We explored pre-ART LTFU in Zambézia province utilizing quantitative and qualitative methods. Patients were deemed LTFU if they were more than 60 days late for either a scheduled appointment or a CD4+ cell count blood draw, according to national guidelines. Among 13,968 adult patients registered for care, 211 (1.8 %) died, one transferred, 2,196 (15.7 %) initiated ART, and 9,195 (65.8 %) were LTFU during the first year. Being male, younger, less educated, and/or having no home electricity were associated with LTFU. Qualitative interviews revealed that poor clinical care, logistics and competing priorities contribute to attrition. In addition, many expressed fears of stigma and/or rejection by family or community members because they were HIV-infected. At 66 %, pre-ART LTFU in Zambézia, Mozambique is a significant problem. This study highlights characteristics of lost patients and discusses barriers requiring consideration to improve retention.
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Fielding KL, Charalambous S, Hoffmann CJ, Johnson S, Tlali M, Dorman SE, Vassall A, Churchyard GJ, Grant AD. Evaluation of a point-of-care tuberculosis test-and-treat algorithm on early mortality in people with HIV accessing antiretroviral therapy (TB Fast Track study): study protocol for a cluster randomised controlled trial. Trials 2015; 16:125. [PMID: 25872501 PMCID: PMC4394596 DOI: 10.1186/s13063-015-0650-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 03/13/2015] [Indexed: 11/10/2022] Open
Abstract
Background Early mortality for HIV-positive people starting antiretroviral therapy (ART) remains high in resource-limited settings, with tuberculosis the most important cause. Existing rapid diagnostic tests for tuberculosis lack sensitivity among HIV-positive people, and consequently, tuberculosis treatment is either delayed or started empirically (without bacteriological confirmation). We developed a management algorithm for ambulatory HIV-positive people, based on body mass index and point-of-care tests for haemoglobin and urine lipoarabinomannan (LAM), to identify those at high risk of tuberculosis and mortality. We designed a clinical trial to test whether implementation of this algorithm reduces six-month mortality among HIV-positive people with advanced immunosuppression. Methods/design The TB Fast Track study is an open, pragmatic, cluster randomised superiority trial, with 24 primary health clinics randomised to implement the intervention or standard of care. Adults (aged ≥18 years) with a CD4 count of 150 cells/μL or less, who have not received any tuberculosis treatment in the last three months, or ART in the last six months, are eligible. In intervention clinics, the study algorithm is used to classify individuals as at high, medium or low probability of tuberculosis. Those classified as high probability start tuberculosis treatment immediately, followed by ART after two weeks. Medium-probability patients follow the South African guidelines for test-negative tuberculosis and are reviewed within a week, to be re-categorised as low or high probability. Low-probability patients start ART as soon as possible. The primary outcome is all-cause mortality at six months. Secondary outcomes include severe morbidity, time to ART start and cost-effectiveness. Discussion This trial will test whether a primary care-friendly management algorithm will enable nurses to identify HIV-positive patients at the highest risk of tuberculosis, to facilitate prompt treatment and reduce early mortality. There remains an urgent need for better diagnostic tests for tuberculosis, especially for people with advanced HIV disease, which may render empirical treatment unnecessary. Trial registration This trial was registered with Current Controlled Trials (identifier: ISRCTN35344604) on 12 September 2012.
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Affiliation(s)
- Katherine L Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | | | - Christopher J Hoffmann
- School of Medicine, Johns Hopkins University, 1503 E. Jefferson Street, Baltimore, Maryland, 21231, USA.
| | - Suzanne Johnson
- Technical Assistance Cluster, Foundation for Professional Development, 173 Mary Road, Pretoria, 0184, South Africa.
| | - Mpho Tlali
- Aurum Institute, 29 Queens Road, Johannesburg, 2041, South Africa.
| | - Susan E Dorman
- School of Medicine, Johns Hopkins University, 1503 E. Jefferson Street, Baltimore, Maryland, 21231, USA.
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Gavin J Churchyard
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. .,Aurum Institute, 29 Queens Road, Johannesburg, 2041, South Africa.
| | - Alison D Grant
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
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Parchure R, Kulkarni V, Kulkarni S, Gangakhedkar R. Pattern of linkage and retention in HIV care continuum among patients attending referral HIV care clinic in private sector in India. AIDS Care 2015; 27:716-22. [PMID: 25559639 DOI: 10.1080/09540121.2014.996518] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Continued engagement throughout the HIV care continuum, from HIV diagnosis through retention on antiretroviral therapy (ART), is crucial for enhancing impact of HIV care programs. We assessed linkage and retention in HIV care among people living with HIV (PLHIV) enrolled at a private HIV care clinic in Pune, India. Of 1220 patients, 28% delayed linkage after HIV diagnosis with a median delay of 24 months (IQR = 8-43). Younger people, women, low socioeconomic status, and those diagnosed at facilities other than the study clinic were more likely to delay linkage. Those with advanced HIV disease at diagnosis and testing for HIV due to HIV-related illness were linked to care immediately. Of a total of 629 patients eligible for ART at first CD4 count, 68% initiated ART within 3 months. Among those not eligible for ART, only 46% of patients sought subsequent CD4 count in time. Multivariate logistic regression analysis revealed that patients with initial CD4 count of 350-500 cells/cu mm (OR: 2, 95% CI: 1.1-3.5) and >500 cells/cu mm (OR: 2.1, 95% CI: 1.2-3.7) were less likely to do subsequent CD4 test on time as compared to those with CD4 < 50 cells/cu mm. Among patients not eligible for ART, those having >12 years of education (OR: 0.4, 95% CI: 0.2-0.9) were more likely to have timely uptake of subsequent CD4 count. Among ART eligible patients, being an unskilled laborer (OR: 2.2, 95% CI: 1.1-4.2) predicted lower uptake. The study highlights a long delay from HIV diagnosis to linkage and further attrition during pre-ART and ART phases. It identifies need for newer approaches aimed at timely linkage and continued retention for patients with low education, unskilled laborers, and importantly, asymptomatic patients.
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Ying R, Barnabas RV, Williams BG. Modeling the implementation of universal coverage for HIV treatment as prevention and its impact on the HIV epidemic. Curr HIV/AIDS Rep 2014; 11:459-67. [PMID: 25249293 PMCID: PMC4301303 DOI: 10.1007/s11904-014-0232-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The Joint United Nations Programme on HIV/AIDS (UNAIDS) recently updated its global targets for antiretroviral therapy (ART) coverage for HIV-positive persons under which 90 % of HIV-positive people are tested, 90 % of those are on ART, and 90 % of those achieve viral suppression. Treatment policy is moving toward treating all HIV-infected persons regardless of CD4 cell count-otherwise known as treatment as prevention-in order to realize the full therapeutic and preventive benefits of ART. Mathematical models have played an important role in guiding the development of these policies by projecting long-term health impacts and cost-effectiveness. To guide future policy, new mathematical models must consider the barriers patients face in receiving and taking ART. Here, we describe the HIV care cascade and ART delivery supply chain to examine how mathematical modeling can provide insight into cost-effective strategies for scaling-up ART coverage in sub-Saharan Africa and help achieve universal ART coverage.
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Affiliation(s)
- Roger Ying
- Department of Global Health, University of Washington, Box 359927, 325 Ninth Avenue, Seattle, WA, 98104, USA,
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Better adherence to pre-antiretroviral therapy guidelines after implementing an electronic medical record system in rural Kenyan HIV clinics: a multicenter pre-post study. Int J Infect Dis 2014; 33:109-13. [PMID: 25281905 PMCID: PMC4987124 DOI: 10.1016/j.ijid.2014.06.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 05/30/2014] [Accepted: 06/03/2014] [Indexed: 12/17/2022] Open
Abstract
Introduction The monitoring of pre-antiretroviral therapy (pre-ART) is a key indicator of HIV quality of care. This study investigated the association of an electronic medical record system (EMR) with adherence to pre-ART guidelines in rural HIV clinics in Kenya. Methods A retrospective study was carried out to assess the quality of pre-ART care using three indicators: (1) the performance of a baseline CD4 test, (2) time from enrollment in care to first CD4 test, and (3) time from baseline CD4 to second CD4 test. A comparison of these indicators was made pre and post the introduction of an EMR system in 17 rural HIV clinics. Results A total of 18 523 patients were receiving pre-ART care, of whom 38.8% in the paper group had had at least one CD4 test compared to 53.4% in the EMR group (p < 0.001). The adjusted odds of performing a CD4 test in clinics using an EMR was 1.59 (95% confidence interval 1.49–1.69). The median time from enrolment into HIV care to first CD4 test was 1.40 months (interquartile range (IQR) 0.47–4.87) for paper vs. 0.93 months (IQR 0.43–3.37) for EMR. The median time from baseline to first CD4 follow-up was 7.5 months (IQR 5.97–10.73) for paper and 6.53 months (IQR 5.57–7.87) for EMR. Conclusion The use of the EMR system was associated with better compliance to HIV guidelines for pre-ART care. EMRs have a potential positive impact on quality of care for HIV patients in resource-constrained settings.
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Treatment outcomes in a decentralized antiretroviral therapy program: a comparison of two levels of care in north central Nigeria. AIDS Res Treat 2014; 2014:560623. [PMID: 25028610 PMCID: PMC4083764 DOI: 10.1155/2014/560623] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 05/18/2014] [Indexed: 02/02/2023] Open
Abstract
Background. Decentralization of antiretroviral therapy (ART) services is a key strategy to achieving universal access to treatment for people living with HIV/AIDS. Our objective was to assess clinical and laboratory outcomes within a decentralized program in Nigeria. Methods. Using a tiered hub-and-spoke model to decentralize services, a tertiary hospital scaled down services to 13 secondary-level hospitals using national and program guidelines. We obtained sociodemographic, clinical, and immunovirologic data on previously antiretroviral drug naïve patients aged ≥15 years that received HAART for at least 6 months and compared treatment outcomes between the prime and satellite sites. Results. Out of 7,747 patients, 3729 (48.1%) were enrolled at the satellites while on HAART, prime site patients achieved better immune reconstitution based on CD4+ cell counts at 12 (P < 0.001) and 24 weeks (P < 0.001) with similar responses at 48 weeks (P = 0.11) and higher rates of viral suppression (<400 c/mL) at 12 (P < 0.001) and 48 weeks (P = 0.03), but similar responses at 24 weeks (P = 0.21). Mortality was 2.3% versus 5.0% (P < 0.001) at prime and satellite sites, while transfer rate was 8.7% versus 5.5% (P = 0.001) at prime and satellites. Conclusion. ART decentralization is feasible in resource-limited settings, but efforts have to be intensified to maintain good quality of care.
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Predictors of delayed antiretroviral therapy initiation, mortality, and loss to followup in HIV infected patients eligible for HIV treatment: data from an HIV cohort study in India. BIOMED RESEARCH INTERNATIONAL 2013; 2013:849042. [PMID: 24288689 PMCID: PMC3830789 DOI: 10.1155/2013/849042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 09/20/2013] [Indexed: 11/18/2022]
Abstract
Studies from Sub-Saharan Africa have shown that a substantial number of HIV patients eligible for antiretroviral therapy (ART) do not start treatment. However, data from other low- or middle-income countries are scarce. In this study, we describe the outcomes of 4105 HIV patients who became ART eligible from January 2007 to November 2011 in an HIV cohort study in India. After three years of ART eligibility, 78.4% started ART, 9.3% died before ART initiation, and 10.3% were lost to followup. Diagnosis of tuberculosis, being homeless, lower CD4 count, longer duration of pre-ART care, belonging to a disadvantaged community, being widowed, and not living near a town were associated with delayed ART initiation. Diagnosis of tuberculosis, being homeless, lower CD4 count, shorter duration of pre-ART care, belonging to a disadvantaged community, illiteracy, and age >45 years were associated with mortality. Being homeless, being single, not living near a town, having a CD4 count <150 cells/μL, and shorter duration of pre-ART care were associated with loss to followup. These results highlight the need to improve the timely initiation of ART in HIV programmes in India, especially in ART eligible patients with tuberculosis, low CD4 counts, living in rural areas, or having a low socioeconomic status.
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