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Fraser HL, Feldhaus I, Edoka IP, Wade AN, Kohli-Lynch CN, Hofman K, Verguet S. Extended cost-effectiveness analysis of interventions to improve uptake of diabetes services in South Africa. Health Policy Plan 2024; 39:253-267. [PMID: 38252592 DOI: 10.1093/heapol/czae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 12/07/2023] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
The rising prevalence of diabetes in South Africa (SA), coupled with significant levels of unmet need for diagnosis and treatment, results in high rates of diabetes-associated complications. Income status is a determinant of utilization of diagnosis and treatment services, with transport costs and loss of wages being key barriers to care. A conditional cash transfer (CCT) programme, targeted to compensate for such costs, may improve service utilization. We applied extended cost-effectiveness analysis (ECEA) methods and used a Markov model to compare the costs, health benefits and financial risk protection (FRP) attributes of a CCT programme. A population was simulated, drawing from SA-specific data, which transitioned yearly through various health states, based on specific probabilities obtained from local data, over a 45-year time horizon. Costs and disability-adjusted life years (DALYs) were applied to each health state. Three CCT programme strategies were simulated and compared to a 'no programme' scenario: (1) covering diagnosis services only; (2) covering treatment services only; (3) covering both diagnosis and treatment services. Cost-effectiveness was reported as incremental net monetary benefit (INMB) using a cost-effectiveness threshold of USD3015 per DALY for SA, while FRP outcomes were reported as catastrophic health expenditure (CHE) cases averted. Distributions of the outcomes were reported by income quintile and sex. Covering both diagnosis and treatment services for the bottom two quintiles resulted in the greatest INMB (USD22 per person) and the greatest CHE cases averted. There were greater FRP benefits for women compared to men. A CCT programme covering diabetes diagnosis and treatment services was found to be cost-effective, when provided to the poorest 40% of the SA population. ECEA provides a useful platform for including equity considerations to inform priority setting and implementation policies in SA.
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Affiliation(s)
- Heather L Fraser
- Health Economics and Health Technology Assessment, School of Health and Wellbeing, University of Glasgow, Clarice Pears Building (Level 3), 90 Byres Road, United Kingdom
- SA MRC/Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
| | - Isabelle Feldhaus
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Ijeoma P Edoka
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terrace, Johannesburg 2193, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
| | - Alisha N Wade
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
- Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Ciaran N Kohli-Lynch
- SA MRC/Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 680 N. Lake Shore Drive, Chicago, IL 60611, United States
| | - Karen Hofman
- SA MRC/Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
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Zemariam AB, Abebe GK, Alamaw AW. Incidence and predictors of attrition among human immunodeficiency virus infected children on antiretroviral therapy in Amhara comprehensive specialized hospitals, Northwest Ethiopia, 2022: a retrospective cohort study. Sci Rep 2024; 14:4366. [PMID: 38388643 PMCID: PMC10883953 DOI: 10.1038/s41598-024-54229-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
Attrition rate is higher in developing nations and it leftovers a major obstacle to enhance the benefits of therapy and achieve the 90-90-90 plan targets. Despite this fact, data on the incidence and its predictors of attrition among human immune deficiency virus infected children on antiretroviral therapy are limited in developing countries including Ethiopia especially after the test and treat strategy implemented. This study aimed to assess the incidence and predictors of attrition among human immune deficiency virus infected children on antiretroviral therapy in Amhara Comprehensive Specialized Hospitals, Northwest Ethiopia. A retrospective follow-up study was conducted among 359 children on ART from June 14, 2014, to June 14, 2022. Study participants were selected using simple random sampling method and the data were collected using Kobo Toolbox software and analysis was done by STATA version 14. Both bi-variable and multivariable Cox regression models were fitted to ascertain predictors. Lastly, an AHR with a 95% CI was computed and variables with a p-value of < 0.05 were took an account statistically key predictors of attrition. The overall incidence of attrition rate was 9.8 (95% CI 7.9, 11.9) per 100 PYO. Children having baseline hemoglobin < 10 mg/dl (AHR 3.94; 95% CI 2.32, 6.7), suboptimal adherence (AHR 1.96; 95% CI 1.23, 3.13), baseline opportunistic infection (AHR 1.8; 95% CI 1.17, 2.96), and children who had experienced drug side effects (AHR 8.3; 95% CI 4.93, 13.84) were established to be a significant predictors of attrition. The attrition rate was relatively high. Decreased hemoglobin, suboptimal adherence, presence of drug side effects and baseline opportunistic infection were predictors of attrition. Therefore, it is crucial to detect and give special emphasis to those identified predictors promptly.
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Affiliation(s)
- Alemu Birara Zemariam
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, Woldia University, Woldia, Ethiopia.
| | - Gebremeskel Kibret Abebe
- Department of Emergency and Critical Care Nursing, School of Nursing, College of Medicine and Health Sciences, Woldia University, Woldia, Ethiopia
| | - Addis Wondmagegn Alamaw
- Department of Emergency and Critical Care Nursing, School of Nursing, College of Medicine and Health Sciences, Woldia University, Woldia, Ethiopia
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Hamooya BM, Mutembo S, Muyunda B, Mweebo K, Kancheya N, Sikazwe L, Sakala M, Mvula J, Kunda S, Kabesha S, Cheelo C, Fwemba I, Banda C, Masenga SK. HIV test-and-treat policy improves clinical outcomes in Zambian adults from Southern Province: a multicenter retrospective cohort study. Front Public Health 2023; 11:1244125. [PMID: 37900026 PMCID: PMC10600392 DOI: 10.3389/fpubh.2023.1244125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/11/2023] [Indexed: 10/31/2023] Open
Abstract
Background Globally, most countries have implemented a test-and-treat policy to reduce morbidity and mortality associated with HIV infection. However, the impact of this strategy has not been critically appraised in many settings, including Zambia. We evaluated the retention and clinical outcomes of adults enrolled in antiretroviral therapy (ART) and assessed the impact of the test-and-treat policy. Methods We conducted a retrospective cohort study among 6,640 individuals who initiated ART between January 1, 2014 and July 31, 2016 [before test-and-treat cohort (BTT), n = 2,991] and between August 1, 2016 and October 1, 2020 [after test-and-treat cohort (ATT), n = 3,649] in 12 districts of the Southern province. To assess factors associated with retention, we used logistic regression (xtlogit model). Results The median age [interquartile range (IQR)] was 34.8 years (28.0, 42.1), and 60.2% (n = 3,995) were women. The overall retention was 83.4% [95% confidence interval (CI) 82.6, 84.4], and it was significantly higher among the ATT cohort, 90.6 vs. 74.8%, p < 0.001. The reasons for attrition were higher in the BTT compared to the ATT cohorts: stopped treatment (0.3 vs. 0.1%), transferred out (9.3 vs. 3.2%), lost to follow-up (13.5 vs. 5.9%), and death (1.4 vs. 0.2%). Retention in care was significantly associated with the ATT cohort, increasing age and baseline body mass index (BMI), rural residence, and WHO stage 2, while non-retention was associated with never being married, divorced, and being in WHO stage 3. Conclusion The retention rate and attrition factors improved in the ATT compared to the BTT cohorts. Drivers of retention were test-and-treat policy, older age, high BMI, rural residence, marital status, and WHO stage 1. Therefore, there is need for interventions targeting young people, urban residents, non-married people, and those in the symptomatic WHO stages and with low BMI. Our findings highlight improved ART retention after the implementation of the test-and-treat policy.
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Affiliation(s)
- Benson M. Hamooya
- School of Medicine and Health Sciences, Mulungushi University, Livingstone, Zambia
| | - Simon Mutembo
- International Vaccine Access Center, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Brian Muyunda
- Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Keith Mweebo
- Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Nzali Kancheya
- Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Lyapa Sikazwe
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Morgan Sakala
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Johanzi Mvula
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Salazeh Kunda
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Shem Kabesha
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Chilala Cheelo
- School of Medicine and Health Sciences, Mulungushi University, Livingstone, Zambia
| | - Isaac Fwemba
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Clive Banda
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Sepiso K. Masenga
- School of Medicine and Health Sciences, Mulungushi University, Livingstone, Zambia
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Touré F, Etheredge GD, Brennan C, Parris K, Diallo MO, Ouffoue AF, Ekra A, Prao H, Assamoua NV, Gnongoue C, Kone F, Koffi C, Kamagaté F, Rivadeneira E, Carpenter D. Retention and Predictors of Attrition Among HIV-infected Children on Antiretroviral Therapy in Côte d'Ivoire Between 2012 and 2016. Pediatr Infect Dis J 2023; 42:299-304. [PMID: 36689665 DOI: 10.1097/inf.0000000000003839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND An estimated 21,000 children 0-14 years of age were living with HIV in Côte d'Ivoire in 2020, of whom only 49% have been diagnosed and are receiving antiretroviral therapy (ART). Retention in HIV care and treatment is key to optimize clinical outcomes. We evaluated pediatric retention in select care and treatment centers (CTCs) in Côte d'Ivoire. METHODS We retrospectively reviewed medical records using 2-stage cluster sampling for children under 15 years initiated on ART between 2012 and 2016. Kaplan-Meier time-to-event analysis was done to estimate cumulative attrition rates per total person-years of observation. Cox proportional hazard regression was performed to identify factors associated with attrition. RESULTS A total of 1198 patient records from 33 CTCs were reviewed. Retention at 12, 24, 36, 48 and 60 months after ART initiation was 91%, 84%, 74%, 72% and 70%, respectively. A total of 309 attrition events occurred over 3169 person-years of follow-up [266 children were lost to follow-up (LTFU), 29 transferred to another facility and 14 died]. LTFU determinants included attending a "public-private" CTC [adjusted hazard ratio (aHR) 6.05; 95% confidence interval (CI): 4.23-8.65], receiving care at a CTC without an on-site laboratory (aHR: 4.01; 95% CI: 1.70-9.46) or attending a CTC without an electronic medical record (EMR) system (aHR: 2.22; 95% CI: 1.59-3.12). CONCLUSIONS In Cote d'Ivoire, patients attending a CTC that is public-private, does not have on-site laboratory or EMR system were likely to be LTFU. Decentralization of laboratory services and scaling use of EMR systems could help to improve pediatric retention.
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Affiliation(s)
- Fatoumata Touré
- From the Global Health and Population Business Unit, FHI 360, Abidjan, Côte d'Ivoire
| | - Gina D Etheredge
- Global Health and Population Business Unit, FHI 360, Washington, DC
| | - Claire Brennan
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Atlanta, Georgia
| | - KaeAnne Parris
- Food Security and Agriculture Division, RTI, Durham, North Carolina
| | - Mamadou Otto Diallo
- US President's Malaria Initiative (PMI), US Centers for Disease Control and Prevention, USAID, Liberia
| | | | - Alexandre Ekra
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - Herve Prao
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - N'Da Viviane Assamoua
- Service Recherche, Programme National de Lutte contre le Sida (PNLS), Abidjan, Côte d'Ivoire
| | | | - Foungnigue Kone
- Service Recherche, Programme National de Lutte contre le Sida (PNLS), Abidjan, Côte d'Ivoire
| | - Christian Koffi
- Service Recherche, Programme National de Lutte contre le Sida (PNLS), Abidjan, Côte d'Ivoire
| | - Fathim Kamagaté
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
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Predictors of the observed high prevalence of loss to follow-up in ART-experienced adult PLHIV: a retrospective longitudinal cohort study in the Tanga Region, Tanzania. BMC Infect Dis 2023; 23:92. [PMID: 36788523 PMCID: PMC9926646 DOI: 10.1186/s12879-023-08063-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/08/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) programs have expanded rapidly, and they are now accessible free of charge, yet "loss to follow-up, LTFU" is still a national public health issue. LTFU may result in treatment failure, hospitalization, increased risk of opportunistic infections and drug-resistant strains, and shortening the quality of life. This study described the rates and predictors of LTFU among adults living with human immunodeficiency virus (PLHIV) on ART in the Tanga region, Tanzania. METHODS A retrospective longitudinal cohort study was conducted between October 2018 and December 2020 in Tanga's care and treatment health services facilities. The participants were HIV adult PLHIV aged 15 years and above on ART and attended the clinic at least once after ART initiation. LTFU was defined as not taking ART refills for 3 months or beyond from the last attendance of a refill and not yet classified as dead or transferred out. Cox proportional hazard regression models were employed to identify risk factors for LTFU. P values were two-sided, and we considered a p < 0.05 statistically significant. RESULTS 57,173 adult PLHIV were on ART of them, 15,111 (26.43%) were LTFU, of whom 10,394 (68.78%) were females, and 4717 (31.22%) were males. Factors independently associated with LTFU involved age between 15 and 19 years (HR: 1.85, 95% CI 1.66-2.07), male sex (HR: 2.00 95% CI 1.51-2.62), divorce (HR: 1.35, 95% CI 1.24-1.48), second-line drug type (HR: 1.13, 95% CI 1.09-1.18), poor drug adherence (HR: 1.50, 95% CI 1.23-1.75), unsuppressed viral load (HR: 2.15, 95% CI 2.02-2.29), not on DTG-related drug (HR: 7.51, 95% CI 5.88-10.79), advanced HIV disease WHO stage III and IV (HR: 2.51, 95% CI 2.32-2.72). In contrast to cohabiting, ART duration < 1 year, and being pregnant showed a reduced likelihood of LTFU. CONCLUSION A high prevalence of LTFU was observed in this study. Young age, not using DTG-based regimen, WHO clinical stage IV, poor drug adherence, male sex, unsuppressed viral load, divorcee, and second-line regime were independently associated with LTFU. To reduce LTFU, evidence-based interventions targeting the identified risk factors should be employed.
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Lin CY, Shih FC, Ho YH. Applying the Balanced Scorecard to Build Service Performance Measurements of Medical Institutions: An AHP-DEMATEL Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1022. [PMID: 36673778 PMCID: PMC9859192 DOI: 10.3390/ijerph20021022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/03/2023] [Accepted: 01/04/2023] [Indexed: 06/17/2023]
Abstract
The main purpose of this study is to explore the application of the balanced scorecard (BSC) to service performance measurements of medical institutions using the analytic hierarchy process (AHP) and decision making and trial evaluation laboratory (DEMATEL). According to the concept of BSC, a total of four evaluation dimensions and twenty-two indicators of medical service performance measurements were developed. To collect data, this study delivered expert questionnaires to medical-related professional supervisors, deans, and heads of medical institutions in Taiwan. By combining the AHP and DEMATEL, the priority and causality of service performance standards in medical institutions were obtained. The results of this study show that the customer dimension is the most important service performance measurement dimension for medical institutions. The seven key service performance measurement indicators that are most important for medical institutions, in order, are "complete and comfortable equipment", "competitiveness of the medical profession", "continuity of patient-to-hospital treatment", "classification of medical profession according to customers (VIP system)", "complete medical service", "complete salary, remuneration, and policy", and "medical incomes of institutions". In terms of causality, provided the complete services of medical institutions are improved, the continuity of patient-to-hospital treatment, the competitiveness of the medical profession, and the medical incomes of institutions would be influenced.
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Affiliation(s)
- Chieh-Yu Lin
- Department of International Business, Chang Jung Christian University, Tainan 71101, Taiwan
| | - Fu-Chiang Shih
- Ph.D. Program in Business and Operations Management, Chang Jung Christian University, Tainan 71101, Taiwan
| | - Yi-Hui Ho
- Department of International Business, Chang Jung Christian University, Tainan 71101, Taiwan
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Akpan U, Kakanfo K, Ekele OD, Ukpong K, Toyo O, Nwaokoro P, James E, Pandey S, Olatubosun K, Bateganya M. Predictors of treatment interruption among patients on antiretroviral therapy in Akwa Ibom, Nigeria: outcomes after 12 months. AIDS Care 2023; 35:114-122. [PMID: 35765160 DOI: 10.1080/09540121.2022.2093826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Understanding the characteristics of people living with HIV who interrupt antiretroviral therapy (ART) is critical for designing client-centered services to ensure optimal outcomes. We assessed predictors of treatment interruption in 22 HIV clinics in Nigeria. We reviewed records of HIV-positive patients aged ≥15 years who started ART 1 January and 31 March 2019. We determined treatment status over 12 months as either active, or interrupted treatment (defined as interruption in treatment up to 28 days or longer). Potential predictors were assessed using Cox hazard regression models. Overall, 1185 patients were enrolled on ART, 829 (70%) were female, and median age was 32 years. Retention at 1, 3, 6, 9, and 12 months was 85%, 80%, 76%, 72%, and 68%, respectively. Predictors of treatment interruption were post-secondary education (p = 0.04), diagnosis through voluntary counseling and testing (p < 0.001), receiving care at low-volume facilities (p < 0.001), lack of access to a peer counselor (p < 0.001), and residing outside the clinic catchment area (p = 0.03). Treatment interruption was common but can be improved by focusing on lower volume health facilities, providing peer support especially to those with higher education, and client-centered HIV services for those who live further from clinics..
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Affiliation(s)
- Uduak Akpan
- Achieving Health Nigeria Initiative, Akwa Ibom, Nigeria
| | | | - Oche D Ekele
- Achieving Health Nigeria Initiative, Akwa Ibom, Nigeria
| | - Kufre Ukpong
- Achieving Health Nigeria Initiative, Akwa Ibom, Nigeria
| | - Otoyo Toyo
- Achieving Health Nigeria Initiative, Akwa Ibom, Nigeria
| | | | - Ezekiel James
- United States Agency for International Development, Abuja, Nigeria
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Nimwesiga C, Taremwa IM, Nakanjako D, Nasuuna E. Factors Associated with Retention in HIV Care Among HIV-Positive Adolescents in Public Antiretroviral Therapy Clinics in Ibanda District, Rural South Western Uganda. HIV AIDS (Auckl) 2023; 15:71-81. [PMID: 36910020 PMCID: PMC9994664 DOI: 10.2147/hiv.s401611] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/26/2023] [Indexed: 03/06/2023] Open
Abstract
Background Retention in antiretroviral therapy (ART) care is a key indicator of Human Immunodeficiency Virus (HIV) treatment success as it improves adherence, critical for better treatment outcomes and prevention of drug resistance. HIV treatment among adolescents living with HIV (ALHIV) is characterized by loss to follow-up, poor ART adherence, and eventual death. This study assessed retention in ART care and the associated factors among ALHIV in Ibanda district, rural South Western Uganda. Methods This was a retrospective cohort study using clinical data from ALHIV enrolled from 2019 to 2020 in eight health facilities in Ibanda district. Data from the Electronic Medical Record (EMR) system was extracted to assess the associated factors and participants' status two years after enrollment. Data were analyzed using EPIdata version 3.1 in which Univariate and multivariate cox proportional hazard regression analyses were determined. A hazard ratio (HR) at a 95% confidence interval was obtained, and a P-value <0.05 was considered statistically significant. Results Eighty-four ALHIV comprising 86.9% (N = 73) females were enrolled. The majority 63.1% (N = 53) resided in semi/peri-urban, and 44.0% (N = 37) stayed less than 5 km from the facility. Only 35.7% (N = 30) were active on ART, while 17 (20.2%) and 36 (42.9%) were lost to follow-up and transfer-outs, respectively. Factors associated with low retention were: ALHIV that moved 5-10Km (HR = 5.371; 95% CI: 1.227-23.5050, p = 0.026), used differential service delivery model was Facility-Based Group (FBG) (HR = 12.419; 95% CI: 4.034-38.236, p < 0.001) and those enrolled on the Young Adolescent Program Support (YAPs) (HR = 4.868; 95CI:1.851-12.803; p = 0.001). Retention reduced with increasing ART duration, ALHIV on (TDF/3TC/EFV) (p < 0.001), lived more than 10Km (p = 0.043) and did not benefit from any intervention (p < 0.001). Conclusion Results showed low retention in care and the urgent need to strengthen individual case management strategies for ALHIV, thus interventions focusing on peer support are desired.
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Affiliation(s)
- Christine Nimwesiga
- Uganda Nurses and Midwives Council, Ministry of Health, Kampala, Uganda.,Infectious Diseases Institute, Kampala, Uganda.,Institute of Allied Health Sciences, Clarke International University, Kampala, Uganda
| | - Ivan Mugisha Taremwa
- Institute of Allied Health Sciences, Clarke International University, Kampala, Uganda
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Limbada M, Bwalya C, Macleod D, Floyd S, Schaap A, Situmbeko V, Hayes R, Fidler S, Ayles H. A comparison of different community models of antiretroviral therapy delivery with the standard of care among stable HIV+ patients: rationale and design of a non-inferiority cluster randomized trial, nested in the HPTN 071 (PopART) study. Trials 2021; 22:52. [PMID: 33430928 PMCID: PMC7802215 DOI: 10.1186/s13063-020-05010-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/29/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Following the World Health Organization's (WHO) 2015 guidelines recommending initiation of antiretroviral therapy (ART) irrespective of CD4 count for all people living with HIV (PLHIV), many countries in sub-Saharan Africa have adopted this strategy to reach epidemic control. As the number of PLHIV on ART rises, maintenance of viral suppression on ART for over 90% of PLHIV remains a challenge to government health systems in resource-limited high HIV burden settings. Non facility-based antiretroviral therapy (ART) delivery for stable HIV+ patients may increase sustainable ART coverage in resource-limited settings. Within the HPTN 071 (PopART) trial, two models, home-based delivery (HBD) or adherence clubs (AC), were offered to assess whether they achieved similar viral load suppression (VLS) to standard of care (SoC). In this paper, we describe the trial design and discuss the methodological issues and challenges. METHODS A three-arm cluster randomized non-inferiority trial, nested in two urban HPTN 071 trial communities in Zambia, randomly allocated 104 zones to SoC (35), HBD (35), or AC (34). ART and adherence support were delivered 3-monthly at home (HBD), adherence clubs (AC), or clinic (SoC). Adult HIV+ patients defined as "stable" on ART were eligible for inclusion. The primary endpoint was the proportion of PLHIV with virological suppression (≤ 1000 copies HIV RNA/ml) at 12 months (± 3months) after study entry across all three arms. Viral load measurement was done at the routine government laboratories in accordance with national guidelines, annually. The study was powered to determine if either of the community-based interventions would yield a viral suppression rate drop compared to SoC of no more than 5% in its absolute value. Both community-based interventions were delivered by community HIV providers (CHiPs). An additional qualitative study using observations, interviews with PLHIV, and FGDs with community HIV providers was nested in this study to complement the quantitative data. DISCUSSION This trial was designed to provide rigorous randomized evidence of safety and efficacy of non-facility-based delivery of ART for stable PLHIV in high-burden resource-limited settings. This trial will inform policy regarding best practices and what is needed to strengthen scale-up of differentiated models of ART delivery in resource-limited settings. TRIAL REGISTRATION ClinicalTrials.gov NCT03025165 . Registered on 19 January 2017.
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Affiliation(s)
- Mohammed Limbada
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia.
| | - Chiti Bwalya
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Ab Schaap
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Vasty Situmbeko
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Imperial College and Imperial College NIHR BRC, London, UK
| | - Helen Ayles
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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Bimer KB, Sebsibe GT, Desta KW, Zewde A, Sibhat MM. Incidence and predictors of attrition among children attending antiretroviral follow-up in public hospitals, Southern Ethiopia, 2020: a retrospective study. BMJ Paediatr Open 2021; 5:e001135. [PMID: 34514177 PMCID: PMC8386224 DOI: 10.1136/bmjpo-2021-001135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/31/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND It is a global challenge to enrol and retain paediatric patients in HIV/AIDS care. Attrition causes preventable transmission, stoppable morbidity and death, undesirable treatment outcomes, increased cost of care and drug resistance. Thus, this study intended to investigate the incidence and predictors of attrition among children receiving antiretroviral treatment (ART). METHOD A retrospective follow-up study was conducted among children <15 years who had ART follow-up in Gedeo public hospitals. After collection, data were entered into Epi-data V.4.6, then exported to and analysed using STATA V.14. Data were described using the Kaplan-Meier statistics, life table and general descriptive statistics. The analysis was computed using the Cox proportional hazard regression model. Covariates having <0.25 p values in the univariate analysis (such as developmental stage, nutritional status, haemoglobin level, adherence, etc) were fitted to multivariable analysis. Finally, statistical significance was declared at a p value of <0.05. RESULTS An overall 254 child charts were analysed. At the end of follow-up, attrition from ART care was 36.2% (92 of 254), of which 70 (76.1%) were lost to follow-up, and 22 (23.9%) children died. About 8145.33 child-months of observations were recorded with an incidence attrition rate of 11.3 per 1000 child-months (95% CI: 9.2 to 13.9), whereas the median survival time was 68.73 months. Decreased haemoglobin level (<10 g/dl) (adjusted HR (AHR)=3.1; 95% CI: 1.4 to 6.9), delayed developmental milestones (AHR=3.6; 95% CI: 1.2 to 10.7), underweight at baseline (AHR=5.9; 95% CI: 1.6 to 21.7), baseline CD4 count ≤200 (AHR=4.4; 95% CI: 1.6 to 12.2), and poor or fair ART adherence (AHR=3.5; 95% CI: 1.5 to 7.9) were significantly associated with attrition. CONCLUSION AND RECOMMENDATION Retention to ART care is challenging in the paediatrics population, with such a high attrition rate. Immune suppression, anaemia, underweight, delayed developmental milestones and ART non-adherence were independent predictors of attrition to ART care. Hence, it is crucial to detect and control the identified predictors promptly. Serious adherence support and strengthened nutritional provision with monitoring strategies are also essential.
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Affiliation(s)
- Kirubel Biweta Bimer
- Pediatrics and Child Health Nursing, Dilla University College of Health Sciences, Dilla, Ethiopia
| | - Girum Teshome Sebsibe
- School of nursing and midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Kalkidan Wondwossen Desta
- School of nursing and midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ashenafi Zewde
- Pediatrics and Child Health Nursing, Dilla University College of Health Sciences, Dilla, Ethiopia
| | - Migbar Mekonnen Sibhat
- Pediatrics and Child Health Nursing, Dilla University College of Health Sciences, Dilla, Ethiopia
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Effects of the implementation of the HIV Treat All guidelines on key ART treatment outcomes in Namibia. PLoS One 2020; 15:e0243749. [PMID: 33370313 PMCID: PMC7769455 DOI: 10.1371/journal.pone.0243749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 11/25/2020] [Indexed: 11/19/2022] Open
Abstract
Background This study aimed to help the Namibian government understand the impact of Treat All implementation (started on April 1, 2017) on key antiretroviral therapy (ART) outcomes, and how this transition impacts progress toward the UNAIDS’s 90-90-90 HIV targets. Methods We collected clinical records from two separate cohorts (before and after treat-all) of ART patients in 10 high- and medium-volume facilities in 6 northern Namibia districts. Each cohort contains 12-month data on patients’ scheduled appointments and visits, health status, and viral load results. We also measured patients’ wait time and perceptions of service quality using exit interviews with 300 randomly selected patients (per round). We compared ART outcomes of the two cohorts: ART initiation within 7 days from diagnosis, loss to follow-up (LTFU), missed scheduled appointments for at least 30 days, and viral suppression using unadjusted and adjusted analyses. Results Among new ART clients (on ART for less than 3 months or had not yet initiated treatment as of the start date for the ART record review period), rapid ART initiation (within 7 days from diagnosis) was 5.2 times higher after Treat All than that among clients assessed before the policy took effect [AOR: 5.2 (3.8–6.9)]. However, LTFU was higher after Treat All roll-out compared to before Treat All [AOR: 1.9 (1.3–2.8)]. Established ART clients (on ART treatment for at least three months at the start date of the ART record review period) had over 3 times greater odds of achieving viral suppression after Treat All roll-out compared to established ART clients assessed before Treat All [AOR: 3.1 (1.6–5.9)]. Conclusions and recommendations The findings indicate positive effect of the “Treat All” implementation on ART initiation and viral suppression, and negative effect on LTFU. Additionally, by April 2018, Namibia seems to have reached the UNAIDS’s 90-90-90 targets.
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Mukamba N, Beres LK, Mwamba C, Law JW, Topp SM, Simbeza S, Sikombe K, Padian N, Holmes CB, Geng EH, Sikazwe I. How might improved estimates of HIV programme outcomes influence practice? A formative study of evidence, dissemination and response. Health Res Policy Syst 2020; 18:121. [PMID: 33066785 PMCID: PMC7568347 DOI: 10.1186/s12961-020-00640-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/30/2020] [Indexed: 11/15/2022] Open
Abstract
Background While HIV programmes have started millions of persons on life-saving antiretroviral therapy in Africa, longitudinal health information systems are frail and, therefore, data about long-term survival is often inaccurate or unknown to HIV programmes. The ‘Better Information for Health in Zambia’ (BetterInfo) Study – a regional sampling-based survey to assess retention and mortality in HIV programmes in Zambia – found both retention and mortality to be higher than prevailing estimates from national surveillance systems. We sought to understand how Zambian health decision-makers at different health system levels would respond to these new data, with a view to informing research translation. Methods We interviewed 25 purposefully sampled health decision-makers from community, facility, district, provincial and national levels. During the interviews, we shared retention and mortality estimates from both routine programme surveillance and those generated by the study. Transcripts were analysed for inductive and deductive themes, the latter drawing on Weiss’s framework that policy-makers interpret and apply evidence as ‘warning’, ‘guidance’, ‘reconceptualisation’ or ‘mobilisation of support’. Findings All decision-makers found study findings relevant and important. Decision-makers viewed the underestimates of mortality to be a warning about the veracity and informativeness of routine data systems. Decision-makers felt guided by the findings to improve data monitoring and, acknowledging limitations of routine data, utilised episodic patient tracing to support improved data accuracy. Findings catalysed renewed motivation and mobilisation by national level decision-makers for differentiated models of HIV care to improve patient outcomes and also improved data management systems to better capture patient outcomes. Inductive analysis highlighted a programmatic application data interpretation, in which study findings can influence facility and patient-level decision-making, quality of care and routine data management. Conclusions New epidemiological data on patient outcomes were widely seen as informative and relevant and can potentially catalyse health system action such as using evaluations to supplement electronic medical record data to improve HIV programmes. Formative evidence suggests that targeting research dissemination at different levels of the health system will elicit different responses. Researchers supporting the translation of evidence to action should leverage all relevant levels of the health system to facilitate both policy and programmatic action.
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Affiliation(s)
- Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
| | - Laura K Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Jeanna Wallenta Law
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Stephanie M Topp
- College of Public Health, Medicine and Veterinary Sciences, James Cook University, Townsville, Australia
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Nancy Padian
- Division of Epidemiology, University of California, Berkeley, Berkeley, CA, United States of America
| | - Charles B Holmes
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.,Centre for Global Health and Quality, Georgetown University Medical Center, Washington, DC, United States of America
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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Allorant A, Parrish C, Desforges G, Robin E, Honore JG, Puttkammer N. Closing the gap in implementation of HIV clinical guidelines in a low resource setting using electronic medical records. BMC Health Serv Res 2020; 20:804. [PMID: 32847575 PMCID: PMC7449080 DOI: 10.1186/s12913-020-05613-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/31/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Universal health coverage promises equity in access to and quality of health services. However, there is variability in the quality of the care (QoC) delivered at health facilities in low and middle-income countries (LMICs). Detecting gaps in implementation of clinical guidelines is key to prioritizing the efforts to improve quality of care. The aim of this study was to present statistical methods that maximize the use of existing electronic medical records (EMR) to monitor compliance with evidence-based care guidelines in LMICs. METHODS We used iSanté, Haiti's largest EMR to assess adherence to treatment guidelines and retention on treatment of HIV patients across Haitian HIV care facilities. We selected three processes of care - (1) implementation of a 'test and start' approach to antiretroviral therapy (ART), (2) implementation of HIV viral load testing, and (3) uptake of multi-month scripting for ART, and three continuity of care indicators - (4) timely ART pick-up, (5) 6-month ART retention of pregnant women and (6) 6-month ART retention of non-pregnant adults. We estimated these six indicators using a model-based approach to account for their volatility and measurement error. We added a case-mix adjustment for continuity of care indicators to account for the effect of factors other than medical care (biological, socio-economic). We combined the six indicators in a composite measure of appropriate care based on adherence to treatment guidelines. RESULTS We analyzed data from 65,472 patients seen in 89 health facilities between June 2016 and March 2018. Adoption of treatment guidelines differed greatly between facilities; several facilities displayed 100% compliance failure, suggesting implementation issues. Risk-adjusted continuity of care indicators showed less variability, although several facilities had patient retention rates that deviated significantly from the national average. Based on the composite measure, we identified two facilities with consistently poor performance and two star performers. CONCLUSIONS Our work demonstrates the potential of EMRs to detect gaps in appropriate care processes, and thereby to guide quality improvement efforts. Closing quality gaps will be pivotal in achieving equitable access to quality care in LMICs.
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Affiliation(s)
- Adrien Allorant
- Institute for Health Metrics and Evaluation, Department of Global Health, University of Washington, 2301 5th Avenue, Seattle, WA 98121 USA
| | - Canada Parrish
- Department of Health Services Research, UW, Seattle, WA USA
| | - Gracia Desforges
- Ministère de la Santé Publique et de la Population (MSPP), Port-au-Prince, Haiti
| | - Ermane Robin
- Ministère de la Santé Publique et de la Population (MSPP), Port-au-Prince, Haiti
| | - Jean Guy Honore
- Centre Haïtien pour le Renforcement du Système de Santé (CHARESS), Port-au-Prince, Haiti
| | - Nancy Puttkammer
- Department of Global Health, International Training and Education Center for Health (I-TECH), UW, Seattle, WA USA
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Makurumidze R, Mutasa-Apollo T, Decroo T, Choto RC, Takarinda KC, Dzangare J, Lynen L, Van Damme W, Hakim J, Magure T, Mugurungi O, Rusakaniko S. Retention and predictors of attrition among patients who started antiretroviral therapy in Zimbabwe's national antiretroviral therapy programme between 2012 and 2015. PLoS One 2020; 15:e0222309. [PMID: 31910445 PMCID: PMC6946589 DOI: 10.1371/journal.pone.0222309] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/17/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The last evaluation to assess outcomes for patients receiving antiretroviral therapy (ART) through the Zimbabwe public sector was conducted in 2011, covering the 2007-2010 cohorts. The reported retention at 6, 12, 24 and 36 months were 90.7%, 78.1%, 68.8% and 64.4%, respectively. We report findings of a follow-up evaluation for the 2012-2015 cohorts to assess the implementation and impact of recommendations from this prior evaluation. METHODS A nationwide retrospective study was conducted in 2016. Multi-stage proportional sampling was used to select health facilities and study participants records. The data extracted from patient manual records included demographic, baseline clinical characteristics and patient outcomes (active on treatment, died, transferred out, stopped ART and lost to follow-up (LTFU)) at 6, 12, 24 and 36 months. The data were analysed using Stata/IC 14.2. Retention was estimated using survival analysis. The predictors associated with attrition were determined using a multivariate Cox regression model. RESULTS A total of 3,810 participants were recruited in the study. The median age in years was 35 (IQR: 28-42). Overall, retention increased to 92.4% (p-value = 0.060), 86.5% (p-value<0.001), 79.2% (p-value<0.001) and 74.4% (p-value<0.001) at 6, 12, 24 and 36 months respectively. LTFU accounted for 98% of attrition. Being an adolescent or a young adult (15-24 years) (vs adult;1.41; 95% CI:1.14-1.74), children (<15years) (vs adults; aHR 0.64; 95% CI:0.46-0.91), receiving care at primary health care facility (vs central and provincial facility; aHR 1.23; 95% CI:1.01-1.49), having initiated ART between 2014-2015 (vs 2012-2013; aHR1.45; 95%CI:1.24-1.69), having WHO Stage IV (vs Stage I-III; aHR2.06; 95%CI:1.51-2.81) and impaired functional status (vs normal status; aHR1.25; 95%CI:1.04-1.49) predicted attrition. CONCLUSION The overall retention was higher in comparison to the previous 2007-2010 evaluation. Further studies to understand why attrition was found to be higher at primary health care facilities are warranted. Implementation of strategies for managing patients with advanced HIV disease, differentiated care for adolescents and young adults and tracking of LTFU clients should be prioritised to further improve retention.
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Affiliation(s)
- Richard Makurumidze
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
- Institute of Tropical Medicine, Antwerp, Belgium
- Gerontology, Faculty of Medicine & Pharmacy, Free University of Brussels (VUB), Brussels, Belgium
| | | | - Tom Decroo
- Institute of Tropical Medicine, Antwerp, Belgium
- Research Foundation of Flanders, Brussels, Belgium
| | - Regis C. Choto
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
| | - Kudakwashe C. Takarinda
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Janet Dzangare
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
| | | | - Wim Van Damme
- Institute of Tropical Medicine, Antwerp, Belgium
- Gerontology, Faculty of Medicine & Pharmacy, Free University of Brussels (VUB), Brussels, Belgium
| | - James Hakim
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | - Owen Mugurungi
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
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Cele MA, Archary M. Acceptability of short text messages to support treatment adherence among adolescents living with HIV in a rural and urban clinic in KwaZulu-Natal. South Afr J HIV Med 2019; 20:976. [PMID: 31616573 PMCID: PMC6779962 DOI: 10.4102/sajhivmed.v20i1.976] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 07/16/2019] [Indexed: 01/04/2023] Open
Abstract
Background The use of mobile communication technologies (mHealth) has improved adherence and viral suppression among HIV-infected adults. Adolescents have disproportionally lower levels of adherence and viral suppression compared with adults, potentially impacting the goal of 90% viral suppression by 2030. Objectives The aim of this study was to evaluate the acceptability of using short message service (SMS)-based mHealth interventions as a tool to improve adherence in HIV-infected adolescents in a rural and urban clinic in KwaZulu-Natal (KZN). Method A cross-sectional study with a sample size of 100 participants was conducted in a rural and urban clinic in KZN, from January 2018 to June 2019. Fifty participants were sequentially enrolled from each clinic. A questionnaire was self-administered with the assistance of the treating clinician depending on the adolescent's level of understanding. Informed consent was obtained from guardians and questionnaires were anonymised. Appropriate descriptive and comparative statistics were used. Results The mean age of participants was 15 years, with 88% having access to a mobile device (MOD). There was no significant difference in MOD ownership between rural and urban participants. Majority of participants (65%) were willing to receive SMS-based adherence support with no difference between rural and urban area. Conclusion With high rates of MOD ownership and acceptability (willingness to use mHealth to improve health status), SMS-based mHealth interventions have the potential to improve adherence and viral suppression in adolescents living with HIV in both rural and urban KZN. Further studies with a larger sample size need to be conducted to further explore these findings.
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Affiliation(s)
- Mthokozisi A Cele
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
| | - Moherndran Archary
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
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Chandiwana N, Sawry S, Chersich M, Kachingwe E, Makhathini B, Fairlie L. High loss to follow-up of children on antiretroviral treatment in a primary care HIV clinic in Johannesburg, South Africa. Medicine (Baltimore) 2018; 97:e10901. [PMID: 30024494 PMCID: PMC6086461 DOI: 10.1097/md.0000000000010901] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Outcomes of HIV-infected children have improved dramatically over the past decade, but are undermined by patient loss to follow-up (LTFU). We assessed patterns of LTFU among HIV-infected children receiving antiretroviral treatment (ART) at a large inner-city HIV clinic in Johannesburg, South Africa between 2005 and 2014.Demographic and clinical data were extracted from clinic records of children under 12 years. Differences between characteristics of children retained in care and LTFU were assessed using Wilcoxon rank sum tests or Pearson χ tests. Cox proportional hazard models then identified characteristics associated with LTFU.Of 135 children, the median age at ART initiation was 21.5 months (IQR: 6.3-47.7) with a median follow-up time of 3.3 years (IQR: 1.4-5.0). The incidence rate of LTFU was 10.8 per 100 person-years (95% CI: 8.2-14.4); cumulatively 36% of children were LTFU. Almost a third (n = 39) of children missed a clinic visit, but then returned to care; 77% of these were eventually LTFU. In total, 18% of children had elevated viral loads after 6 or more months of ART. Older age at ART initiation (18-59 months: aHR 1.6, 95% CI: 3.9-14.2) and ever missing a clinic visit (aHR 7.4 95% CI: 3.9-14.2) were independent predictors of LTFU.High rates of LTFU were observed in this primary care clinic. Risks for LTFU included older age (>18 months old) and missed clinic visits. Identifying children who miss scheduled visits and developing strategies directed at retaining them in care is critical to improving long-term pediatric HIV outcomes.
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Affiliation(s)
- Nomathemba Chandiwana
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | - Shobna Sawry
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | - Matthew Chersich
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | - Elizabeth Kachingwe
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | | | - Lee Fairlie
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
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Brown R, Deeks SG, Eyal N. Maximising the global health impact of future HIV cure-related interventions through advance planning. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30266-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Brown R, Deeks SG, Eyal N. Maximising the global health impact of future HIV cure-related interventions through advance planning. J Virus Erad 2018; 4:182-185. [PMID: 30050682 PMCID: PMC6038126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Thinking about public health impact should inform HIV curative investigations. Should an effective HIV cure or sustained viral remission intervention emerge from ongoing investigations, implementation strategies aimed at ensuring global access will be needed if these approaches are to be impactful, and planning accordingly makes sense now. Specifically, we discuss three key access barriers to future cure-related interventions: high cost of the strategy; non-financial challenges to procurement, distribution and point-of-care delivery; and non-adherence and the need for long-term monitoring. As we argue, plans and decision-making for overcoming each of these barriers will need to be developed in advance. An evaluation of remaining barriers and likely global impact of the leading strategies under investigation should inform decisions on which strategy might receive funding priority. Among the strategies being investigated, implementation barriers for latency-reversing agents, immunotherapy and combination antiretroviral therapy (ART) may be overcome on a global scale with some effort. Overcoming implementation barriers for medically complex and high-risk interventions, such as stem cell and, to some degree, gene therapy, may be less feasible.
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Affiliation(s)
- Regina Brown
- University of Massachusetts Medical School,
Worcester, MA,
USA,Corresponding author: Regina Brown,
55 Lake Ave North,
Worcester,
MA01655,
USA
| | - Steven G Deeks
- University of California, San Francisco, School of Medicine,
San Francisco, CA,
USA
| | - Nir Eyal
- Harvard T. H. Chan School of Public Health,
Boston, MA,
USA
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Ayah R. Scaling up implementation of ART: Organizational culture and early mortality of patients initiated on ART in Nairobi, Kenya. PLoS One 2018; 13:e0190344. [PMID: 29293578 PMCID: PMC5749788 DOI: 10.1371/journal.pone.0190344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 12/13/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Scaling up the antiretroviral (ART) program in Kenya has involved a strategy of using clinical guidelines coupled with decentralization of treatment sites. However decentralization pushes clinical responsibility downwards to health facilities run by lower cadre staff. Whether the organizational culture in health facilities affects the outcomes despite the use of clinical guidelines has not been explored. This study aimed to demonstrate the relationship between organizational culture and early mortality and those lost to follow up (LTFU) among patients enrolled for HIV care. METHODS AND MATERIALS A stratified sample of 31 health facilities in Nairobi County offering ART services were surveyed. Data of patients enrolled on ART and LTFU for the 12 months ending 30th June 2013 were abstracted. Mortality and LTFU were determined and used to rank health facilities. In the facilities with the lowest and highest mortality and LTFU key informant interviews were conducted using a tool adapted from team climate assessment measurement questionnaire and competing value framework tool to assess organizational culture. The strength of association between early mortality, LTFU and organizational culture was tested. RESULTS Half (51.8%) of the 5,808 patients enrolled into care in 31 health facilities over the 12-month study period were started on ART. Of these 48 (1.6% 95% CI 0.8%-2.4%) died within three months of starting treatment, while a further 125 (4.2% 95% CI 2.1%-6.6%) were LTFU giving an attrition rate of 5.7% (95% CI 3.3%-8.6%). Tuberculosis was the most common comorbidity associated with high early mortality and high LTFU. Organizational culture, specifically an adhocratic type was found to be associated with low early mortality and low LTFU of patients enrolled for HIV care (P = 0.034). CONCLUSION The use of ART clinical guidelines in a decentralized health systems are not sufficient to achieve required service delivery outcomes. The attrition rate above would mean 85,000 Kenyans missing care based on current HIV disease burden figures. Deliberate efforts to improve individual health facility leadership and inculcate an adhocratic culture may lower mortality and morbidity associated with initiating ART.
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Affiliation(s)
- Richard Ayah
- School of Public Health, College of Health Sciences, University of Nairobi, KNH, Nairobi, Kenya
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When patients fail UNAIDS' last 90 - the "failure cascade" beyond 90-90-90 in rural Lesotho, Southern Africa: a prospective cohort study. J Int AIDS Soc 2017; 20:21803. [PMID: 28777506 PMCID: PMC5577637 DOI: 10.7448/ias.20.1.21803] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Introduction: HIV-infected individuals on first-line antiretroviral therapy (ART) in resource-limited settings who do not achieve the last “90” (viral suppression) enter a complex care cascade: enhanced adherence counselling (EAC), repetition of viral load (VL) and switch to second-line ART aiming to achieve resuppression. This study describes the “failure cascade” in patients in Lesotho. Methods: Patients aged ≥16 years on first-line ART at 10 facilities in rural Lesotho received a first-time VL in June 2014. Those with VL ≥80 copies/mL were included in a cohort. The care cascade was assessed at four points: attendance of EAC, result of follow-up VL after EAC, switch to second-line in case of sustained unsuppressed VL and outcome 18 months after the initial unsuppressed VL. Multivariate logistic regression was used to assess predictors of being retained in care with viral resuppression at follow-up. Results: Out of 1563 patients who underwent first-time VL, 138 (8.8%) had unsuppressed VL in June 2014. Out of these, 124 (90%) attended EAC and 116 (84%) had follow-up VL (4 died, 2 transferred out, 11 lost, 5 switched to second-line before follow-up VL). Among the 116 with follow-up VL, 36 (31%) achieved resuppression. Out of the 80 with sustained unsuppressed VL, 58 were switched to second-line, the remaining continued first line. At 18 months’ follow-up in December 2015, out of the initially 138 with unsuppressed VL, 56 (41%) were in care and virally suppressed, 37 (27%) were in care with unsuppressed VL and the remaining 45 (33%) were lost, dead, transferred to another clinic or without documented VL. Achieving viral resuppression after EAC (adjusted odds ratio (aOR): 5.02; 95% confidence interval: 1.14–22.09; p = 0.033) and being switched to second-line in case of sustained viremia after EAC (aOR: 7.17; 1.90–27.04; p = 0.004) were associated with being retained in care and virally suppressed at 18 months of follow-up. Age, gender, education, time on ART and level of VL were not associated. Conclusions: In this study in rural Lesotho, outcomes along the “failure cascade” were poor. To improve outcomes in this vulnerable patient group who fails the last “90”, programmes need to focus on timely EAC and switch to second line for cases with continuous viremia despite EAC.
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Auld AF, Valerie Pelletier, Robin EG, Shiraishi RW, Dee J, Antoine M, Desir Y, Desforges G, Delcher C, Duval N, Joseph N, Francois K, Griswold M, Domercant JW, Patrice Joseph YA, Van Onacker JD, Deyde V, Lowrance DW, And The Groupe d'Analyses Salvh. Retention Throughout the HIV Care and Treatment Cascade: From Diagnosis to Antiretroviral Treatment of Adults and Children Living with HIV-Haiti, 1985-2015. Am J Trop Med Hyg 2017; 97:57-70. [PMID: 29064357 PMCID: PMC5676635 DOI: 10.4269/ajtmh.17-0116] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Monitoring retention of people living with HIV (PLHIV) in the HIV care and treatment cascade is essential to guide program strategy and evaluate progress toward globally-endorsed 90–90–90 targets (i.e., 90% of PLHIV diagnosed, 81% on sustained antiretroviral therapy (ART), and 73% virally suppressed). We describe national retention from diagnosis throughout the cascade for patients receiving HIV services in Haiti during 1985–2015, with a focus on those receiving HIV services during 2008–2015. Among the 266,256 newly diagnosed PLHIV during 1985–2015, 49% were linked-to-care, 30% started ART, and 18% were retained on ART by the time of database closure. Similarly, among the 192,187 newly diagnosed HIV-positive patients during 2008–2015, 50% were linked to care, 31% started ART, and 19% were retained on ART by the time of database closure. Most patients (90–92%) at all cascade steps were adults (≥ 15 years old), among whom the majority (60–61%) were female. During 2008–2015, outcomes varied significantly across 42 administrative districts (arrondissements) of residence; cumulative linkage-to-care ranged from 23% to 69%, cumulative ART initiation among care enrollees ranged from 2% to 80%, and cumulative ART retention among ART enrollees ranged from 30% to 88%. Compared with adults, children had lower cumulative incidence of ART initiation among care enrollees (64% versus 47%) and lower cumulative retention among ART enrollees (64% versus 50%). Cumulative linkage-to-care was low and should be prioritized for improvement. Variations in outcomes by arrondissement and between adults and children require further investigation and programmatic response.
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Affiliation(s)
- Andrew F Auld
- Division of Global HIV & Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Valerie Pelletier
- Division of Global HIV & Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Port au Prince, Haiti
| | - Ermane G Robin
- Programme National de Lutte contre le VIH/SIDA (National AIDS Program), Ministère de la Sante Publique et de la Population (Ministry of Health), Port au Prince, Haiti
| | - Ray W Shiraishi
- Division of Global HIV & Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jacob Dee
- Division of Global HIV & Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mayer Antoine
- Division of Global HIV & Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Port au Prince, Haiti
| | - Yrvel Desir
- National Alliance of State and Territorial AIDS Directors (NASTAD), Port-au-Prince, Haiti
| | - Gracia Desforges
- Programme National de Lutte contre le VIH/SIDA (National AIDS Program), Ministère de la Sante Publique et de la Population (Ministry of Health), Port au Prince, Haiti
| | - Chris Delcher
- Department of Health Outcomes and Policy, University of Florida, Gainesville, Florida.,National Alliance of State and Territorial AIDS Directors (NASTAD), Port-au-Prince, Haiti
| | - Nirva Duval
- Programme National de Lutte contre le VIH/SIDA (National AIDS Program), Ministère de la Sante Publique et de la Population (Ministry of Health), Port au Prince, Haiti
| | - Nadjy Joseph
- National Alliance of State and Territorial AIDS Directors (NASTAD), Port-au-Prince, Haiti
| | - Kesner Francois
- Programme National de Lutte contre le VIH/SIDA (National AIDS Program), Ministère de la Sante Publique et de la Population (Ministry of Health), Port au Prince, Haiti
| | - Mark Griswold
- National Alliance of State and Territorial AIDS Directors (NASTAD), Washington, District of Columbia
| | - Jean Wysler Domercant
- Division of Global HIV & Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Port au Prince, Haiti
| | - Yves Anthony Patrice Joseph
- Division of Global HIV & Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Port au Prince, Haiti
| | - Joelle Deas Van Onacker
- Programme National de Lutte contre le VIH/SIDA (National AIDS Program), Ministère de la Sante Publique et de la Population (Ministry of Health), Port au Prince, Haiti
| | - Varough Deyde
- Division of Global HIV & Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Port au Prince, Haiti
| | - David W Lowrance
- Division of Global HIV & Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Port au Prince, Haiti
| | - And The Groupe d'Analyses Salvh
- Programme National de Lutte contre le VIH/SIDA (National AIDS Program), Ministère de la Sante Publique et de la Population (Ministry of Health), Port au Prince, Haiti
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Takarinda KC, Choto RC, Harries AD, Mutasa-Apollo T, Chakanyuka-Musanhu C. Routine implementation of isoniazid preventive therapy in HIV-infected patients in seven pilot sites in Zimbabwe. Public Health Action 2017; 7:55-60. [PMID: 28775944 PMCID: PMC5526481 DOI: 10.5588/pha.16.0102] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 02/05/2017] [Indexed: 11/10/2022] Open
Abstract
Setting: Seven pilot sites in Zimbabwe implementing 6 months of isoniazid preventive therapy (IPT) for people living with the human immunodeficiency virus (PLHIV). Objectives: To determine, among PLHIV started on IPT, the completion rates for a 6-month course of IPT and factors associated with non-adherence. Design: A retrospective cohort study. Results: Of 578 patients, 466 (81%) completed IPT. Of the 112 patients who failed to complete IPT, 69 (60%) were lost to follow-up, 30 (27%) stopped treatment with no documented reasons, 8 (7%) developed toxicity/adverse reactions, 5 (5%) were documented as having drug stock-outs and the remainder transferred out or refused to continue treatment. Currently being on antiretroviral therapy (ART) (aOR 0.09, 95%CI 0.03-0.28) and receiving a ⩾2 month supply of isoniazid at the start of treatment were associated with a lower risk of not completing IPT, while missing clinic visits prior to starting IPT (aOR 5.25, 95%CI 2.10-13.14) was associated with a higher risk of non-completion. Conclusion: IPT completion rates in seven pilot sites of Zimbabwe were comparatively high, showing that IPT roll-out in public health facilities is feasible. Enhanced adherence counselling or active tracing among pre-ART patients and those with a history of loss to follow-up may improve IPT completion rates, along with synchronising IPT and ART resupplies.
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Affiliation(s)
- K C Takarinda
- AIDS and TB Department, Ministry of Health and Child Care, Harare, Zimbabwe
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - R C Choto
- AIDS and TB Department, Ministry of Health and Child Care, Harare, Zimbabwe
| | - A D Harries
- International Union Against Tuberculosis and Lung Disease, Paris, France
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - T Mutasa-Apollo
- AIDS and TB Department, Ministry of Health and Child Care, Harare, Zimbabwe
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Chung NC, Sikazwe I, Bolton-Moore C, Chilengi R, Kasaro MP, Stringer JSA, Chi BH. Patient engagement in HIV care and treatment in Zambia, 2004-2014. Trop Med Int Health 2017; 22:332-339. [PMID: 28102027 PMCID: PMC6506213 DOI: 10.1111/tmi.12832] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe engagement along the HIV continuum of care using a large network of clinics in Zambia. METHODS We employed a practical framework to describe retention along the HIV treatment cascade, using routinely collected clinical data available in resource-constrained settings. We included health facilities in four Zambian provinces with more than 300 enrolled patients over the age of 5 years. We described attrition at each step, from HIV enrolment to 720 days after ART initiation. The population was further stratified by year of enrolment to describe temporal trends in patient engagement. RESULTS From January 2004 to December 2014, 444 439 individuals over the age of 5 years sought HIV care at 75 eligible health facilities. Among those enrolled into HIV care, 82.1% (95% confidence interval [CI]: 79.4-84.5%) were fully assessed for ART eligibility within 180 days of enrolment and 63.6% (95% CI: 61.7-65.3) were found to be eligible for ART based on the HIV treatment guidelines at the time. Of those patients eligible for ART, 81.1% (95% CI: 79.5-82.7%) initiated ART within 180 days. Patient retention in ART programme was 81.2% (95% CI: 80.4-81.9%) at 90 days, 70.0% (95% CI: 68.7-71.2%) at 360 days and 61.6% (95% CI: 60.0-63.2%) at 720 days. We noted a steady decline in proportions assessed for ART eligibility and deemed eligible for ART in the time frame. Proportions that started ART and remained in care remained relatively consistent. CONCLUSION We describe a simple approach for assessing patient engagement after enrolment into HIV care. Using limited types of data routinely available, we demonstrate an important and replicable approach to monitoring programmes in resource-constrained settings.
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Affiliation(s)
- Neo Christopher Chung
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of Alabama at Birmingham, Birmingham, USA
| | - Roma Chilengi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | | | | | - Benjamin H. Chi
- University of North Carolina at Chapel Hill, Chapel Hill, USA
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Ankomah A, Ganle JK, Lartey MY, Kwara A, Nortey PA, Okyerefo MPK, Laar AK. ART access-related barriers faced by HIV-positive persons linked to care in southern Ghana: a mixed method study. BMC Infect Dis 2016; 16:738. [PMID: 27927183 PMCID: PMC5142337 DOI: 10.1186/s12879-016-2075-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 11/29/2016] [Indexed: 04/03/2023] Open
Abstract
Background Timely and enduring access to antiretroviral therapy (ART) by HIV-infected individuals has been shown to substantially reduce HIV transmission risk, HIV-related morbidity and mortality. However, there is evidence that in addition to limited supply of antiretrovirals (ARVs) and linkage to ART in many low-income countries, HIV+ persons often encounter barriers in accessing ART-related services even in contexts where these services are freely available. In Ghana, limited research evidence exists regarding the barriers HIV+ persons already linked to ART face. This paper explores ART access–related barriers that HIV+ persons linked to care in southern Ghana face. Methods A mixed method study design, involving a cross-sectional survey and qualitative in-depth interviews, was conducted to collect data from four healthcare providers and a total of 540 adult HIV+ persons receiving ART at four treatment centres in Ghana. We used univariate analysis to generate descriptive tabulations for key variables from the survey. Data from qualitative in-depth interviews were thematically analysed. Results from the survey and in-depth interviews were brought together to illuminate the challenges of the HIV+ persons. Results All (100%) the HIV+ persons interviewed were ARV-exposed and linked to ART. Reasons for taking ARVs ranged from beliefs that they will suppress the HIV virus, desire to maintain good health and prolong life, and desire to prevent infection in unborn children, desire both to avoid death and to become good therapeutic citizens (abide by doctors’ advice). Despite this, more than half of the study participants (63.3%) reported seven major factors as barriers hindering access to ART. These were high financial costs associated with accessing and receiving ART (26%), delays associated with receiving care from treatment centres (24%), shortage of drugs and other commodities (23%), stigma (8.8%), fear of side effects of taking ARVs (7.9%), job insecurity arising from regular leave of absence to receive ART (5.3%), and long distance to treatment centres (4.9%). Conclusions The results in this study suggest that efforts to provide and scale-up ART to all HIV+ persons must be accompanied by interventions that address structural and individual level access barriers. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-2075-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Augustine Ankomah
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | - John Kuumuori Ganle
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | - Margaret Yaa Lartey
- Department of Medicine, University of Ghana School of Medicine & Dentistry, University of Ghana, Legon, Accra, Ghana
| | - Awewura Kwara
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Priscilla Awo Nortey
- Department of Epidemiology and Disease Control, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | | | - Amos Kankponang Laar
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Legon, Accra, Ghana.
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Dalhatu I, Onotu D, Odafe S, Abiri O, Debem H, Agolory S, Shiraishi RW, Auld AF, Swaminathan M, Dokubo K, Ngige E, Asadu C, Abatta E, Ellerbrock TV. Outcomes of Nigeria's HIV/AIDS Treatment Program for Patients Initiated on Antiretroviral Treatment between 2004-2012. PLoS One 2016; 11:e0165528. [PMID: 27829033 PMCID: PMC5102414 DOI: 10.1371/journal.pone.0165528] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 10/13/2016] [Indexed: 12/20/2022] Open
Abstract
Background The Nigerian Antiretroviral therapy (ART) program started in 2004 and now ranks among the largest in Africa. However, nationally representative data on outcomes have not been reported. Methods We evaluated retrospective cohort data from a nationally representative sample of adults aged ≥15 years who initiated ART during 2004 to 2012. Data were abstracted from 3,496 patient records at 35 sites selected using probability-proportional-to-size (PPS) sampling. Analyses were weighted and controlled for the complex survey design. The main outcome measures were mortality, loss to follow-up (LTFU), and retention (the proportion alive and on ART). Potential predictors of attrition were assessed using competing risk regression models. Results At ART initiation, 66.4 percent (%) were females, median age was 33 years, median weight 56 kg, median CD4 count 161 cells/mm3, and 47.1% had stage III/IV disease. The percentage of patients retained at 12, 24, 36 and 48 months was 81.2%, 74.4%, 67.2%, and 61.7%, respectively. Over 10,088 person-years of ART, mortality, LTFU, and overall attrition (mortality, LTFU, and treatment stop) rates were 1.1 (95% confidence interval (CI): 0.7–1.8), 12.3 (95%CI: 8.9–17.0), and 13.9 (95% CI: 10.4–18.5) per 100 person-years (py) respectively. Highest attrition rates of 55.4/100py were witnessed in the first 3 months on ART. Predictors of LTFU included: lower-than-secondary level education (reference: Tertiary), care in North-East and South-South regions (reference: North-Central), presence of moderate/severe anemia, symptomatic functional status, and baseline weight <45kg. Predictor of mortality was WHO stage higher than stage I. Male sex, severe anemia, and care in a small clinic were associated with both mortality and LTFU. Conclusion Moderate/Advanced HIV disease was predictive of attrition; earlier ART initiation could improve program outcomes. Retention interventions targeting men and those with lower levels of education are needed. Further research to understand geographic and clinic size variations with outcome is warranted.
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Affiliation(s)
- Ibrahim Dalhatu
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
| | - Dennis Onotu
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
| | - Solomon Odafe
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
- * E-mail:
| | - Oseni Abiri
- School of Biomedical Informatics, University of Texas, Houston, Texas, United States of America
| | - Henry Debem
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
| | - Simon Agolory
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
| | - Ray W. Shiraishi
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
| | - Andrew F. Auld
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
| | - Mahesh Swaminathan
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
| | - Kainne Dokubo
- School of Biomedical Informatics, University of Texas, Houston, Texas, United States of America
| | - Evelyn Ngige
- National AIDS & STIs Control Program, Federal Ministry of Health, Abuja, Nigeria
| | - Chukwuemeka Asadu
- National AIDS & STIs Control Program, Federal Ministry of Health, Abuja, Nigeria
| | - Emmanuel Abatta
- National AIDS & STIs Control Program, Federal Ministry of Health, Abuja, Nigeria
| | - Tedd V. Ellerbrock
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
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Adetunji AA, Muyibi SA, Imhansoloeva M, Ibraheem OM, Sunmola A, Kolawole OO, Akinrinsola OO, Ojo-Osagie JO, Mosuro OA, Abiolu JO, Irabor AE, Okonkwo P, Adewole IF, Taiwo BO. Mobile phone use for a social strategy to improve antiretroviral refill experience at a low-resource HIV clinic: patient responses from Nigeria. AIDS Care 2016; 29:575-578. [PMID: 27632470 DOI: 10.1080/09540121.2016.1226476] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In sub-Saharan African areas where antiretroviral (ARV) drugs are not available through community pharmacies, clinic-based pharmacies are often the primary source of ARV drug refills. Social pressure is mounting on treatment providers to adjust ARV refill services towards user-friendly approaches which prioritize patients' convenience and engage their resourcefulness. By this demand, patients may be signalling dissatisfaction with the current provider-led model of monthly visits to facility-based pharmacies for ARV refill. Mobile phones are increasingly popular in sub-Saharan Africa, and have been used to support ARV treatment goals in this setting. A patient-centred response to on-going social pressure requires treatment providers to view ARV refill activities through the eyes of patients who are negotiating the challenges of day-to-day life while contemplating their next refill appointment. Using focus groups of five categories of adult patients receiving combination ARV therapy, we conducted this cross-sectional qualitative study to provide insight into modifiable gaps between patients' expectations and experiences of the use of mobile phones in facility-based ARV refill service at a public HIV clinic in Nigeria. A notable finding was patients' preference for harnessing informal social support (through intermediaries with mobile phones) to maintain adherence to ARV refill appointments when they could not present in person. This evolving social support strategy also has the potential to enhance defaulter tracking. Our study findings may inform the development of ARV refill strategies and the design of future qualitative studies on client-provider communication by mobile phones in under-resourced HIV treatment programmes.
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Affiliation(s)
- Adedotun A Adetunji
- a Department of Family Medicine , University College Hospital , Ibadan , Nigeria
| | - Sufiyan A Muyibi
- a Department of Family Medicine , University College Hospital , Ibadan , Nigeria
| | - Martins Imhansoloeva
- b Department of Epidemiology and Medical Statistics, College of Medicine , University of Ibadan , Ibadan , Nigeria
| | | | - Adegbenga Sunmola
- d Department of Psychology , University of Ibadan , Ibadan , Nigeria
| | | | | | | | - Olusola A Mosuro
- a Department of Family Medicine , University College Hospital , Ibadan , Nigeria
| | | | - Achiaka E Irabor
- a Department of Family Medicine , University College Hospital , Ibadan , Nigeria
| | - Prosper Okonkwo
- e AIDS Prevention Initiative in Nigeria Ltd. Gte ., Abuja , Nigeria
| | - Isaac F Adewole
- c APIN Plus , University College Hospital , Ibadan , Nigeria
| | - Babafemi O Taiwo
- f Division of Infectious Diseases, Feinberg School of Medicine , Northwestern University , Chicago , USA
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Identifying common barriers and facilitators to linkage and retention in chronic disease care in western Kenya. BMC Public Health 2016; 16:741. [PMID: 27503191 PMCID: PMC4977618 DOI: 10.1186/s12889-016-3462-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 08/05/2016] [Indexed: 11/27/2022] Open
Abstract
Background Sub-Saharan Africa is increasingly being challenged in providing care and treatment for chronic diseases, both communicable and non-communicable. In order to address the challenges of linkage to and retention in chronic disease management, there is the need to understand the factors that can influence engagement in care. We conducted a qualitative study to identify barriers and facilitators to linkage and retention in chronic care for HIV, tuberculosis (TB) and Hypertension (HTN) as part of the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya. Methods In-depth interviews and focus group discussions were conducted July 2012-August 2013. Study participants were purposively sampled from three AMPATH clinics and included patients within the AMPATH program receiving HIV, TB, and HTN care, as well as caregivers of children with HIV, community leaders, and healthcare providers. A set of interview guides were developed to explore perceived barriers and facilitators to chronic disease management, particularly related to linkage to and retention in HIV, TB and HTN care. Data were coded and various themes were identified. We organized the concepts and themes generated using the Andersen-Newman Framework of Health Services Utilization. Results A total of 235 participants including 110 individuals living with HIV (n = 50), TB (n = 39), or HTN (n = 21); 24 caregivers; 10 community leaders; and 62 healthcare providers participated. Barriers and facilitators were categorized as predisposing characteristics, enabling resources and need factors. Many of the facilitators and barriers reported in this study were consistently reported across disease categories including personal drive, patient-provider relationships and the need for social and peer support. Conclusions Our findings provide insight into the individual as well as broader structural factors that can deter or encourage linkage and retention that are relevant across communicable and non-communicable chronic diseases. The findings of the present study suggest that interventions should consider the logistical aspects of accessing care in addition to predisposing and need factors that may affect an individuals’ decision to seek out and remain in appropriate care.
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Moyo F, Chasela C, Brennan AT, Ebrahim O, Sanne IM, Long L, Evans D. Treatment outcomes of HIV-positive patients on first-line antiretroviral therapy in private versus public HIV clinics in Johannesburg, South Africa. Clin Epidemiol 2016; 8:37-47. [PMID: 27051316 PMCID: PMC4807894 DOI: 10.2147/clep.s93014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Despite the widely documented success of antiretroviral therapy (ART), stakeholders continue to face the challenges of poor HIV treatment outcomes. While many studies have investigated patient-level causes of poor treatment outcomes, data on the effect of health systems on ART outcomes are scarce. OBJECTIVE We compare treatment outcomes among patients receiving HIV care and treatment at a public and private HIV clinic in Johannesburg, South Africa. PATIENTS AND METHODS This was a retrospective cohort analysis of ART naïve adults (≥18.0 years), initiating ART at a public or private clinic in Johannesburg between July 01, 2007 and December 31, 2012. Cox proportional-hazards regression was used to identify baseline predictors of mortality and loss to follow-up (>3 months late for the last scheduled visit). Generalized estimating equations were used to determine predictors of failure to suppress viral load (≥400 copies/mL) while the Wilcoxon rank-sum test was used to compare the median absolute change in CD4 count from baseline to 12 months post-ART initiation. RESULTS 12,865 patients initiated ART at the public clinic compared to 610 at the private clinic. The patients were similar in terms of sex and age at initiation. Compared to public clinic patients, private clinic patients initiated ART at higher median CD4 counts (159 vs 113 cells/mm(3)) and World Health Organization stage I/II (76.1% vs 58.5%). Adjusted hazard models showed that compared to public clinic patients, private clinic patients were less likely to die (adjusted hazard ratio [aHR] 0.50; 95% confidence interval [CI] 0.35-0.70) but were at increased risk of loss to follow-up (aHR 1.80; 95% CI 1.59-2.03). By 12 months post-ART initiation, private clinic patients were less likely to have a detectable viral load (adjusted relative risk 0.65; 95% CI 0.49-0.88) and recorded higher median CD4 change from baseline (184 cells/mm(3) interquartile range 101-300 vs 158 cells/mm(3) interquartile range 91-244), when compared to public clinic patients. CONCLUSION We identified differences in treatment outcomes between the two HIV clinics. Findings suggest that the type of clinic at which ART patients initiate and receive treatment can have an impact on treatment outcomes. Further research is necessary to provide more conclusive results.
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Affiliation(s)
- Faith Moyo
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Charles Chasela
- Epidemiology and Biostatistics Department, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Epidemiology and Strategic Information (ESI), HIV/AIDS/STIs and TB, Human Sciences Research Council, Pretoria, South Africa
| | - Alana T Brennan
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Center for Global Health and Development, Boston University, Boston, MA, USA
| | | | - Ian M Sanne
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Right to Care, Helen Joseph Hospital, Westdene, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Denise Evans
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Sawe HR, Mfinanga JA, Ringo FH, Mwafongo V, Reynolds TA, Runyon MS. HIV counselling and testing practices for children seen in an urban emergency department of a tertiary referral hospital in Dar es Salaam, Tanzania: a retrospective cross-sectional study. BMJ Open 2016; 6:e010298. [PMID: 26880672 PMCID: PMC4762082 DOI: 10.1136/bmjopen-2015-010298] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/21/2015] [Accepted: 01/15/2016] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES To describe the HIV counselling and testing practices for children presenting to an emergency department (ED) in a low-income country. SETTING The ED of a large east African national referral hospital. PARTICIPANTS This retrospective review of all paediatric (<18 years old) ED visits in 2012 enrolled patients who had an HIV test ordered and excluded those without testing. Files were available for 5540/5774 (96%) eligible patients and 1632 (30%) were tested for HIV, median age 1.3 years (IQR 9 months to 4 years), 58% <18 months old and 61% male. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measure was documentation of pretest and post-test counselling, or deferral of counselling, for children tested for HIV in the ED. Secondary measures included the overall rate of HIV testing, rate of counselling documented in the inpatient record when deferred in the ED, rate of counselling documented when testing was initiated by the inpatient service, rate of counselling documented by test result (positive vs negative) and the rate of referral to follow-up HIV care among patients testing positive. RESULTS Of 418 patients tested in the ED, counselling, or deferral of counselling, was documented for 70 (17%). When deferred to the ward, subsequent counselling was documented for 15/42 (36%). Counselling was documented in 33% of patients testing positive versus 1.1% patients testing negative (OR 43 (95% CI 23 to 83). Of 199 patients who tested positive and survived to hospital discharge, 76 (38%) were referred for follow-up at the HIV clinic on discharge. CONCLUSIONS Physicians documented the provision, or deferral, of counselling for <20% of children tested for HIV in the ED. Counselling was much more likely to be documented when the test result was positive. Less than 40% of those testing positive were referred for follow-up care.
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Affiliation(s)
- Hendry R Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Juma A Mfinanga
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Faith H Ringo
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Victor Mwafongo
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Teri A Reynolds
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Emergency Medicine and Global Health Sciences, University of California, San Francisco, California, USA
| | - Michael S Runyon
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
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Treves-Kagan S, Steward WT, Ntswane L, Haller R, Gilvydis JM, Gulati H, Barnhart S, Lippman SA. Why increasing availability of ART is not enough: a rapid, community-based study on how HIV-related stigma impacts engagement to care in rural South Africa. BMC Public Health 2016; 16:87. [PMID: 26823077 PMCID: PMC4730651 DOI: 10.1186/s12889-016-2753-2] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/19/2016] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Stigma is a known barrier to HIV testing and care. Because access to antiretroviral therapy reduces overt illness and mortality, some scholars theorized that HIV-related stigma would decrease as treatment availability increased. However, the association between ART accessibility and stigma has not been as straightforward as originally predicted. METHODS We conducted a "situational analysis"--a rapid, community-based qualitative assessment to inform a combination HIV prevention program in high prevalence communities. In the context of this community-based research, we conducted semi-structured interviews and focus groups with 684 individuals in four low-resource sub-districts in North West Province, South Africa. In addition to using this data to inform programming, we examined the impact of stigma on the uptake of services. RESULTS Findings suggested that anticipated stigma remains a barrier to care. Although participants reported less enacted stigma, or hostility toward people living with HIV, they also felt that HIV remains synonymous with promiscuity and infidelity. Participants described community members taking steps to avoid being identified as HIV-positive, including avoiding healthcare facilities entirely, using traditional healers, or paying for private doctors. Such behaviors led to delays in testing and accessing care, and problems adhering to medications, especially for men and youth with no other health condition that could plausibly account for their utilization of medical services. CONCLUSIONS We conclude that providing access to ART alone will not end HIV-related stigma. Instead, individuals will remain hesitant to seek care as long as they fear that doing so will lead to prejudice and discrimination. It is critical to combat this trend by increasing cultural acceptance of being seropositive, integrating HIV care into general primary care and normalizing men and youths' accessing health care.
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Affiliation(s)
- Sarah Treves-Kagan
- University of California, San Francisco, Center for AIDS Prevention Studies, San Francisco, CA, USA.
| | - Wayne T Steward
- University of California, San Francisco, Center for AIDS Prevention Studies, San Francisco, CA, USA.
| | - Lebogang Ntswane
- University of Washington, International Training and Education Center for Health (ITECH) - South Africa, Pretoria, South Africa.
| | - Robin Haller
- University of California, San Francisco, Global Health Sciences, San Francisco, CA, USA.
| | - Jennifer M Gilvydis
- University of Washington, International Training and Education Center for Health (ITECH) - South Africa, Pretoria, South Africa.
| | - Harnik Gulati
- University of Washington, International Training and Education Center for Health, Seattle, WA, USA.
| | - Scott Barnhart
- University of Washington, International Training and Education Center for Health, Seattle, WA, USA.
| | - Sheri A Lippman
- University of California, San Francisco, Center for AIDS Prevention Studies, San Francisco, CA, USA.
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Time and Money: The True Costs of Health Care Utilization for Patients Receiving "Free" HIV/Tuberculosis Care and Treatment in Rural KwaZulu-Natal. J Acquir Immune Defic Syndr 2015; 70:e52-60. [PMID: 26371611 DOI: 10.1097/qai.0000000000000728] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND HIV and tuberculosis (TB) services are provided free of charge in many sub-Saharan African countries, but patients still incur costs. METHODS Patient-exit interviews were conducted in primary health care clinics in rural South Africa with representative samples of 200 HIV-infected patients enrolled in a pre-antiretroviral treatment (pre-ART) program, 300 patients receiving antiretroviral treatment (ART), and 300 patients receiving TB treatment. For each group, we calculated health expenditures across different spending categories, time spent traveling to and using services, and how patients financed their spending. Associations between patient group and costs were assessed in multivariate regression models. RESULTS Total monthly health expenditures [1 USD = 7.3 South African Rand (ZAR)] were ZAR 171 [95% confidence interval (CI): 134 to 207] for pre-ART, ZAR 164 (95% CI: 141 to 187) for ART, and ZAR 122 (95% CI: 105 to 140) for TB patients (P = 0.01). Total monthly time costs (in hours) were 3.4 (95% CI: 3.3 to 3.5) for pre-ART, 5.0 (95% CI: 4.7 to 5.3) for ART, and 3.2 (95% CI: 2.9 to 3.4) for TB patients (P < 0.01). Although overall patient costs were similar across groups, pre-ART patients spent on average ZAR 29.2 more on traditional healers and ZAR 25.9 more on chemists and private doctors than ART patients, whereas ART patients spent ZAR 34.0 more than pre-ART patients on transport to clinics (P < 0.05 for all results). Thirty-one percent of pre-ART, 39% of ART, and 41% of TB patients borrowed money or sold assets to finance health care. CONCLUSIONS Patients receiving nominally free care for HIV/TB face large private costs, commonly leading to financial distress. Subsidized transport, fewer clinic visits, and drug pick-up points closer to home could reduce costs for ART patients, potentially improving retention and adherence. Large expenditure on alternative care among pre-ART patients suggests that transitioning patients to ART earlier, as under HIV treatment-as-prevention policies, may not substantially increase patients' financial burden.
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Dovel K, Thompson K. Financial obligations and economic barriers to antiretroviral therapy experienced by HIV-positive women who participated in a job-creation programme in northern Uganda. CULTURE, HEALTH & SEXUALITY 2015; 18:654-68. [PMID: 26652011 PMCID: PMC4837002 DOI: 10.1080/13691058.2015.1104386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Economic costs are commonly cited as barriers to women's use of antiretroviral therapy (ART) in sub-Saharan Africa; however, little is known about how changes in women's income influence economic barriers to care. We analysed in-depth interviews with 17 HIV-positive women who participated in a job-creation programme in northern Uganda and two key informant interviews with programme staff to examine lingering economic barriers to care experienced after programme enrollment. We found that participants continued to experience economic barriers even after receiving a steady income and improving their economic status. Two themes emerged: first, limited resources in health facilities (e.g. drug and staff shortages) led participants to view ART utilisation as a primarily economic endeavour where clients made informal payments for prompter service or sought treatment in private facilities where ART was readily available; second, increased economic status among participants increased expectations of economic reciprocity among participants' social networks. Financial obligations often manifested themselves in the form of caring for additional dependents, limiting the resources women could allocate toward their HIV treatment. When paired with limited resources in health facilities, increased financial obligations perpetuated the economic barriers experienced by participants. Job-creation programmes should consider how health institutions interact with participants' financial obligations to influence women's access to HIV services.
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Affiliation(s)
- Kathryn Dovel
- Department of Health and Behavioral Sciences, University of Colorado Denver, Denver, USA
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Meintjes G, Kerkhoff AD, Burton R, Schutz C, Boulle A, Van Wyk G, Blumenthal L, Nicol MP, Lawn SD. HIV-Related Medical Admissions to a South African District Hospital Remain Frequent Despite Effective Antiretroviral Therapy Scale-Up. Medicine (Baltimore) 2015; 94:e2269. [PMID: 26683950 PMCID: PMC5058922 DOI: 10.1097/md.0000000000002269] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 10/23/2015] [Accepted: 11/16/2015] [Indexed: 11/25/2022] Open
Abstract
The public sector scale-up of antiretroviral therapy (ART) in South Africa commenced in 2004. We aimed to describe the hospital-level disease burden and factors contributing to morbidity and mortality among hospitalized HIV-positive patients in the era of widespread ART availability. Between June 2012 and October 2013, unselected patients admitted to medical wards at a public sector district hospital in Cape Town were enrolled in this cross-sectional study with prospective follow-up. HIV testing was systematically offered and HIV-infected patients were systematically screened for TB. The spectrum of admission diagnoses among HIV-positive patients was documented, vital status at 90 and 180 days ascertained and factors independently associated with death determined. Among 1018 medical admissions, HIV status was ascertained in 99.5%: 60.1% (n = 609) were HIV-positive and 96.1% (n = 585) were enrolled. Of these, 84.4% were aware of their HIV-positive status before admission. ART status was naive in 35.7%, current in 45.0%, and interrupted in 19.3%. The most frequent primary clinical diagnoses were newly diagnosed TB (n = 196, 33.5%), other bacterial infection (n = 100, 17.1%), and acquired immunodeficiency syndrome (AIDS)-defining illnesses other than TB (n = 64, 10.9%). By 90 days follow-up, 175 (29.9%) required readmission and 78 (13.3%) died. Commonest causes of death were TB (37.2%) and other AIDS-defining illnesses (24.4%). Independent predictors of mortality were AIDS-defining illnesses other than TB, low hemoglobin, and impaired renal function. HIV still accounts for nearly two-thirds of medical admissions in this South African hospital and is associated with high mortality. Strategies to improve linkage to care, ART adherence/retention and TB prevention are key to reducing HIV-related hospitalizations in this setting.
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Affiliation(s)
- Graeme Meintjes
- From the Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine (GM, CS, LB); Department of Medicine, Faculty of Health Sciences, University of Cape Town (GM, RB, CS, SDL); Department of Medicine, Khayelitsha District Hospital, South Africa (GM, RB); Department of Medicine, Imperial College London, London, UK (GM); The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, South Africa (ADK, SDL); Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA (ADK); Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, The Netherlands (ADK); School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town (AB); Health Impact Assessment Directorate, Western Cape Department of Health (AB); Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town (AB); Department of Medicine, Mitchells Plain Hospital (GVW); Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town (MPN); National Health Laboratory Service, South Africa (MPN); and Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK (SDL)
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Kessler J, Nucifora K, Li L, Uhler L, Braithwaite S. Impact and Cost-Effectiveness of Hypothetical Strategies to Enhance Retention in Care within HIV Treatment Programs in East Africa. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:946-955. [PMID: 26686778 PMCID: PMC4696404 DOI: 10.1016/j.jval.2015.09.2940] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/21/2015] [Accepted: 09/18/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Attrition from care among HIV infected patients can lead to poor clinical outcomes. Our objective was to evaluate hypothetical interventions seeking to improve retention-in-care (RIC) for HIV-infected patients in East Africa, asking whether they could offer favorable value compared to earlier ART initiation. METHODS We used a micro-simulation model to analyze two RIC focused strategies within an East African HIV treatment program--"risk reduction," defined as intervention(s) that decrease the risk of attrition from care; and "outreach," defined as interventions that find patients and relink them with care. We compared this to earlier ART treatment as a measure of the potential health benefits forgone (e.g., opportunity cost). RESULTS Reducing attrition by 40% at an average cost of $10 per person remains a less efficient use of resources compared to ensuring full access to ART (cost- effectiveness ratio $1300 vs $3700) for ART eligible patients. An outreach intervention had limited clinical benefit in our simulation. If intervention costs are <$10 per person, however, an intervention able to achieve a 40% (or greater) reduction in attrition may be a cost-effective next implementation option following implementation of earlier ART treatment. CONCLUSIONS Our results suggest that programs should consider retention focused programs once they have already achieved high degrees of ART coverage among eligible patients. It is important that decision makers understand the epidemiology and associated outcomes of those patients who are classified as lost to follow up in their systems prior to implementation in order to achieve the highest value.
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Affiliation(s)
- Jason Kessler
- Department of Population Health, New York University School of Medicine, New York, NY, USA.
| | - Kimberly Nucifora
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Lingfeng Li
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Lauren Uhler
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Scott Braithwaite
- Department of Population Health, New York University School of Medicine, New York, NY, USA
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Ahonkhai AA, Banigbe B, Adeola J, Onwuatuelo I, Bassett IV, Losina E, Freedberg KA, Okonkwo P, Regan S. High rates of unplanned interruptions from HIV care early after antiretroviral therapy initiation in Nigeria. BMC Infect Dis 2015; 15:397. [PMID: 26424505 PMCID: PMC4589963 DOI: 10.1186/s12879-015-1137-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 09/21/2015] [Indexed: 01/12/2023] Open
Abstract
Background Unplanned care interruption (UCI) challenges effective HIV treatment. We determined the frequency and risk factors for UCI in Nigeria. Methods We conducted a retrospective-cohort study of adults initiating antiretroviral therapy (ART) between January 2009 and December 2011. At censor, patients were defined as in care, UCI, or inactive. Associations between baseline factors and UCI rates were quantified using Poisson regression. Results Among 2,496 patients, 44 % remained in care, 35 % had ≥1 UCI, and 21 % became inactive. UCI rates were higher in the first year on ART (39/100PY), than the second (19/100PY), third (16/100PY), and fourth (14/100PY) years (p < 0.001). In multivariate analysis, baseline CD4 > 350/uL (IRR 3.21, p < 0.0001), being a student (IRR 1.95, p < 0.0001), and less education (IRR 1.58, p = 0.001) increased risk for UCI. Fifty-five percent of patients with UCI and viral load data had HIV viral load > 1,000 copies/ml upon return to care. Discussion UCI were observed in over one-third of patients treated, and were most common in the first year on ART. High baseline CD4 count at ART initiation was the greatest predictor of subsequent UCI. Conclusions Interventions focused on the first year on ART are needed to improve continuity of HIV care.
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Affiliation(s)
- Aimalohi A Ahonkhai
- Division of Infectious Disease, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, USA. .,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.
| | - Bolanle Banigbe
- AIDS Prevention Initiative in Nigeria (APIN), Abuja, Nigeria.
| | - Juliet Adeola
- AIDS Prevention Initiative in Nigeria (APIN), Abuja, Nigeria.
| | | | - Ingrid V Bassett
- Division of Infectious Disease, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, USA. .,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA. .,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA. .,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.
| | - Elena Losina
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA. .,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA. .,Departments of Biostatistics and Epidemiology, Boston University School of Public Health, Boston, MA, USA.
| | - Kenneth A Freedberg
- Division of Infectious Disease, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA, USA. .,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA. .,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA. .,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA. .,Departments of Biostatistics and Epidemiology, Boston University School of Public Health, Boston, MA, USA. .,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Prosper Okonkwo
- AIDS Prevention Initiative in Nigeria (APIN), Abuja, Nigeria.
| | - Susan Regan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA. .,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA. .,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.
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Mekuria LA, Prins JM, Yalew AW, Sprangers MAG, Nieuwkerk PT. Retention in HIV Care and Predictors of Attrition from Care among HIV-Infected Adults Receiving Combination Anti-Retroviral Therapy in Addis Ababa. PLoS One 2015; 10:e0130649. [PMID: 26114436 PMCID: PMC4482764 DOI: 10.1371/journal.pone.0130649] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 05/22/2015] [Indexed: 02/07/2023] Open
Abstract
Background Patient retention in chronic HIV care is a major challenge following the rapid expansion of combination antiretroviral therapy (cART) in Ethiopia. Objective To describe the proportion of patients who are retained in HIV care and characterize predictors of attrition among HIV-infected adults receiving cART in Addis Ababa. Method A retrospective analysis was conducted among 836 treatment naïve patients, who started cART between May 2009 and April 2012. Patients were randomly selected from ten health-care facilities, and their current status in HIV care was determined based on routinely available data in the medical records. Patients lost to follow-up (LTFU) were traced by telephone. Kaplan-Meier technique was used to estimate survival probabilities of retention and Cox proportional hazards regression was performed to identify the predictors of attrition. Results Based on individual patient data from the medical records, nearly 80% (95%CI: 76.7, 82.1) of the patients were retained in care in the first 3 and half years of antiretroviral therapy. After successfully tracing more than half of the LTFU patients, the updated one year retention in care estimate became 86% (95% CI: 83.41%, 88.17%). In the multivariate Cox regression analyses, severe immune deficiency at enrolment in care/or at cART initiation and ‘bed-ridden’ or ‘ambulatory’ functional status at the start of cART predicted attrition. Conclusion Retention in HIV care in Addis Ababa is comparable with or even better than previous findings from other resource-limited as well as EU/USA settings. However, measures to detect and enroll patients in HIV care as early as possible are still necessary.
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Affiliation(s)
- Legese A. Mekuria
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Epidemiology, Netherlands Institute for Health Sciences/Erasmus University Medical Center, Rotterdam, The Netherlands
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
- * E-mail:
| | - Jan M. Prins
- Department of Internal Medicine, Division of Infectious Diseases, Trop Med & AIDS, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Mirjam A. G. Sprangers
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Pythia T. Nieuwkerk
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Lay Social Resources for Support of Adherence to Antiretroviral Prophylaxis for HIV Prevention Among Serodiscordant Couples in sub-Saharan Africa: A Qualitative Study. AIDS Behav 2015; 19:811-20. [PMID: 25267114 PMCID: PMC4415942 DOI: 10.1007/s10461-014-0899-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Effectiveness of antiretroviral pre-exposure prophylaxis (PrEP) for HIV prevention will require high adherence. Using qualitative data, this paper identifies potential lay social resources for support of PrEP adherence by HIV serodiscordant couples in Uganda, laying the groundwork for incorporation of these resources into adherence support initiatives as part of implementation. The qualitative analysis characterizes support for PrEP adherence provided by HIV-infected spouses, children, extended family members, and the larger community. Results suggest social resources for support of PrEP adherence in Africa are plentiful outside formal health care settings and health systems and that couples will readily use them. The same shortage of health professionals that impeded scale-up of antiretroviral treatment for HIV/AIDS in Africa promises to challenge delivery of PrEP. Building on the treatment scale-up experience, implementers can address this challenge by examining the value of lay social resources for adherence support in developing strategies for delivery of PrEP.
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Rachlis B, Ochieng D, Geng E, Rotich E, Ochieng V, Maritim B, Ndege S, Naanyu V, Martin JN, Keter A, Ayuo P, Diero L, Nyambura M, Braitstein P. Implementation and operational research: evaluating outcomes of patients lost to follow-up in a large comprehensive care treatment program in western Kenya. J Acquir Immune Defic Syndr 2015; 68:e46-55. [PMID: 25692336 PMCID: PMC4348019 DOI: 10.1097/qai.0000000000000492] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Academic Model Providing Access To Healthcare (AMPATH) program provides comprehensive HIV care and treatment services. Approximately, 30% of patients have become lost to follow-up (LTFU). We sought to actively trace and identify outcomes for a sample of these patients. METHODS LTFU was defined as missing a scheduled visit by ≥3 months. A randomly selected sample of 17% of patients identified as LTFU between January 2009 and June 2011 was generated, with sample stratification on age, antiretroviral therapy (ART) status at last visit, and facility. Chart reviews were conducted followed by active tracing. Tracing was completed by trained HIV-positive outreach workers July 2011 to February 2012. Outcomes were compared between adults and children and by ART status. RESULTS Of 14,811 LTFU patients, 2540 were randomly selected for tracing (2179 adults, 1071 on ART). The chart reviews indicated that 326 (12.8%) patients were not actually LTFU. Outcomes for 71% of sampled patients were determined including 85% of those physically traced. Of those with known outcomes, 21% had died, whereas 29% had disengaged from care for various reasons. The remaining patients had moved away (n = 458, 25%) or were still receiving HIV care (n = 443 total, 25%). CONCLUSIONS Our findings demonstrate the feasibility of a large-scale sampling-based approach. A significant proportion of patients were found not to be LTFU, and further, high numbers of patients who were LTFU could not be located. Over a quarter of patients disengaged from care for various reasons including access challenges and familial influences.
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Affiliation(s)
- Beth Rachlis
- *Academic Model Providing Access To Healthcare, Eldoret, Kenya; †Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; ‡Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA; §Moi University School of Public Health, Kenya; Departments of ‖Behavioral Sciences; and ¶Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
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Wilkinson LS, Skordis-Worrall J, Ajose O, Ford N. Self-transfer and mortality amongst adults lost to follow-up in ART programmes in low- and middle-income countries: systematic review and meta-analysis. Trop Med Int Health 2015; 20:365-79. [PMID: 25418366 DOI: 10.1111/tmi.12434] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To ascertain estimates of adult patients, recorded as lost to follow-up (LTFU) within antiretroviral treatment (ART) programmes, who have self-transferred care, died or truly stopped ART in low- and middle-income countries. METHODS PubMed, EMBASE, Web of Science, Science Direct, LILACS, IndMed and AIM databases (2003-2013) and IAS/AIDS conference abstracts (2011-2013) were searched for tracing studies reporting the proportion of traced patients found to have self-transferred, died or stopped ART. These estimates were then combined using random-effects meta-analysis. Risk of bias was assessed through subgroup and sensitivity analyses. RESULTS Twenty eight studies were eligible for inclusion, reporting true outcomes for 10,806 traced patients attending approximately 258 ART facilities. None were from outside sub-Saharan Africa. Twenty three studies reported 4.5-54.4% traced LTFU patients self-transferring care, providing a pooled estimate of 18.6% (95% CI 15.8-22.0%). A significant positive association was found between rates of self-transfer and LTFU in the ART cohort. The pooled estimates for unreported deaths were 38.8% (95% CI 30.8-46.8%; 27 studies) and 28.6% (95% CI 21.9-36.0%; 20 studies) for patients stopping ART. A significant decrease in unreported deaths from 50.0% (95% CI 41.5-58.4%) to 30.0% (95% CI 21.1-38.9%) was found comparing study periods before and after 31 December 2007. CONCLUSIONS Substantial unaccounted for transfers and deaths amongst patients LTFU confirms that retention and mortality is underestimated where the true outcomes of LTFU patients are not ascertained.
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Affiliation(s)
- Lynne S Wilkinson
- UCL Institute for Global Health, London, UK; Medecins Sans Frontieres, Khayelitsha, South Africa
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Mortality among adults transferred and lost to follow-up from antiretroviral therapy programmes in South Africa: a multicenter cohort study. J Acquir Immune Defic Syndr 2015; 67:e67-75. [PMID: 24977471 DOI: 10.1097/qai.0000000000000269] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Little is known about outcomes after transfer out (TFO) and loss to follow-up (LTF) and how differential outcomes might bias mortality estimates, as analyses generally censor or exclude TFOs/LTF. Using data linked to the National Population Register, we explored mortality among TFO and LTF patients compared with patients who were retained and investigated how linkage impacted on mortality estimates. METHODS A cohort analysis of routine data on adults with civil identification numbers starting antiretroviral therapy (ART) 2004-2009 in 4 large South African ART cohorts. The number, proportion, timing, and mortality of TFOs and LTF were reported. Mortality was compared using Kaplan-Meier curves, Cox's proportional hazards, and competing risks regression. RESULTS Before linkage, 1207 patients (6%) had died, 2624 (13%) were LTF, 1067 (5%) were TFO and 14,583 (75%) were retained. Compared with retained, mortality risk was 3 times higher among TFO patients [adjusted hazard ratio (aHR), 3.11; 95% confidence interval (CI): 2.42 to 3.99] and 20 times higher among LTF patients (aHR, 22.03; 95% CI: 20.05 to 24.21). Excluding early deaths after TFO or LTF, the risk was comparable among TFOs and retained (aHR, 0.75; 95% CI: 0.54 to 1.03) and higher among LTF (aHR, 2.85; 95% CI: 2.43 to 3.33). After linkage, corrected mortality was higher than site-reported mortality. Censoring did not, however, lead to substantial underestimation of mortality among TFOs. CONCLUSIONS Although TFO and LTF predicted mortality, the lower incidence of TFO and subsequent death compared with LTF meant that censoring TFOs did not bias mortality estimates. Future cohort analyses should explicitly consider proportions of TFO/LTF and mortality event rates.
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Cost-effectiveness of socioeconomic support as part of HIV care for the poor in an urban community-based antiretroviral program in Uganda. J Acquir Immune Defic Syndr 2015; 67:e76-83. [PMID: 25032486 DOI: 10.1097/qai.0000000000000280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Socioeconomic support reduced nonretention in a community-based antiretroviral therapy (ART) program in Uganda. However, resource implications of expanding socioeconomic support are large, and cost-effectiveness analysis can inform budget priorities. We compared the incremental benefits and costs of providing education, food, or both forms of support (dual support) with existing ART services from a health care provider's perspective. METHODS Costs and outcome data were collected from a cohort of 2371 adult patients with HIV receiving education, food, or dual support from Reach Out Mbuya between 2004 and 2010. The primary outcome was averted loss to follow-up. The number of follow-up days was calculated for each patient along with accrued service and fixed program costs for the alternative forms of socioeconomic support in USD by standard costing methods. The socioeconomic support types were compared incrementally over the study period. RESULTS After 7 years, 762 (33%) of the patients were loss to follow-up with 42% of them receiving food. In the presence of providing ART, education support was less costly and more effective than the alternatives. The average unit cost for education, food, and dual support were $237, $538, and $776, respectively. The average total annual costs were $88,643 for education, $538,005 for food, and $103,045 for dual support. CONCLUSIONS Compared with food or dual support, investing in education of the children of ART patients is less costly and more effective in improving patient retention. Reach Out Mbuya should embrace this paradigm shift and channel its resources more efficiently and effectively by focusing on education support.
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Tulloch O, Taegtmeyer M, Ananworanich J, Chasombat S, Kosalaraksa P, Theobald S. What can volunteer co-providers contribute to health systems? The role of people living with HIV in the Thai paediatric HIV programme. Soc Sci Med 2014; 145:184-92. [PMID: 25239008 DOI: 10.1016/j.socscimed.2014.09.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 08/14/2014] [Accepted: 09/09/2014] [Indexed: 11/30/2022]
Abstract
In Thailand people living with HIV (PLHIV) have played a major role in shaping policy and practice. They have acted as volunteer co-providers, although their potential in terms of paediatric service provision has seldom been explored from a health systems perspective. We describe the Thai paediatric HIV care system and use both demand- and supply-side perspectives to explore the impact, opportunities and challenges of PLHIV acting as volunteer co-providers. We employed qualitative methods to assess experiences and perceptions and triangulate stakeholder perspectives. Data were collected in Khon Kaen province, in the poorest Northeastern region of Thailand: three focus group discussions and two workshops (total participants n = 31) with co-providers and hospital staff; interviews with ART service-users (n = 35). Nationally, key informant interviews were conducted with policy actors (n = 20). Volunteer co-providers were found to be ideally placed to broker the link between clinic and communities for HIV infected children and played an important part in the vital psychosocial support component of HIV care. As co-providers they were recognized as having multiple roles linking and delivering services in clinics and communities. Clear emerging needs include strengthened coordination and training as well as strategies to support funding. Using motivated volunteers with a shared HIV status as co-providers for specific clinical services can contribute to strengthening health systems in Asia; they are critical players in delivering care (supply side) and being responsive to service-users needs (demand side). Co-providers blur the boundaries between these two spheres. Sustaining and optimising co-providers' contribution to health systems strengthening requires a health systems approach. Our findings help to guide policy makers and service providers on how to balance clinical priorities with psycho-social responsiveness and on how best to integrate the views and experience of volunteers into a holistic model of care.
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Affiliation(s)
- Olivia Tulloch
- Department of International Public Health, Liverpool School of Tropical Medicine, UK.
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, UK
| | | | - Sanchai Chasombat
- Bureau of AIDS, Tuberculosis and Sexually Transmitted Infections, Department of Disease Control, Ministry of Public Health, Nonthaburi, Thailand
| | - Pope Kosalaraksa
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, UK
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Layer EH, Brahmbhatt H, Beckham SW, Ntogwisangu J, Mwampashi A, Davis WW, Kerrigan DL, Kennedy CE. "I pray that they accept me without scolding:" experiences with disengagement and re-engagement in HIV care and treatment services in Tanzania. AIDS Patient Care STDS 2014; 28:483-8. [PMID: 25093247 DOI: 10.1089/apc.2014.0077] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
HIV care and treatment programs in sub-Saharan Africa have been remarkably successful, but disengagement from care by people living with HIV (PLHIV) remains high. The goal of this study was to explore the experiences of PLHIV who disengaged from HIV care in Iringa, Tanzania. We conducted a series of three longitudinal, semi-structured interviews with 14 PLHIV who had disengaged from ART programs for a total of 37 interviews. Narrative analysis was used to identify key themes. Our findings indicate that an individual's decision to disengage from care often resulted from harsh and disrespectful treatment from providers following missed appointments. Once disengaged, participants reported a strong desire to re-engage in care but also reluctance to return due to fear of further mistreatment. Participants who successfully re-engaged in care during the course of this study leveraged social support networks to facilitate this process, but often felt guilt and shame for breaking clinic rules and believed themselves to be at fault for disengagement. Developing strategies to minimize disengagement and facilitate re-engagement through more flexible attendance policies, improved client-provider interactions, and outreach and support for disengaged clients could increase retention and re-engagement in HIV care and treatment programs.
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Affiliation(s)
- Erica H. Layer
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Heena Brahmbhatt
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah W. Beckham
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jacob Ntogwisangu
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ard Mwampashi
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Wendy W. Davis
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Deanna L. Kerrigan
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Caitlin E. Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Chan AK, Ford D, Namata H, Muzambi M, Nkhata MJ, Abongomera G, Mambule I, South A, Revill P, Grundy C, Mabugu T, Chiwaula L, Cataldo F, Hakim J, Seeley J, Kityo C, Reid A, Katabira E, Sodhi S, Gilks CF, Gibb DM. The Lablite project: a cross-sectional mapping survey of decentralized HIV service provision in Malawi, Uganda and Zimbabwe. BMC Health Serv Res 2014; 14:352. [PMID: 25138583 PMCID: PMC4148932 DOI: 10.1186/1472-6963-14-352] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 07/29/2014] [Indexed: 12/05/2022] Open
Abstract
Background In sub-Saharan Africa antiretroviral therapy (ART) is being decentralized from tertiary/secondary care facilities to primary care. The Lablite project supports effective decentralization in 3 countries. It began with a cross-sectional survey to describe HIV and ART services. Methods 81 purposively sampled health facilities in Malawi, Uganda and Zimbabwe were surveyed. Results The lowest level primary health centres comprised 16/20, 21/39 and 16/22 facilities included in Malawi, Uganda and Zimbabwe respectively. In Malawi and Uganda most primary health facilities had at least 1 medical assistant/clinical officer, with average 2.5 and 4 nurses/midwives for median catchment populations of 29,275 and 9,000 respectively. Primary health facilities in Zimbabwe were run by nurses/midwives, with average 6 for a median catchment population of 8,616. All primary health facilities provided HIV testing and counselling, 50/53 (94%) cotrimoxazole preventive therapy (CPT), 52/53 (98%) prevention of mother-to-child transmission of HIV (PMTCT) and 30/53 (57%) ART management (1/30 post ART-initiation follow-up only). All secondary and tertiary-level facilities provided HIV and ART services. In total, 58/81 had ART provision. Stock-outs during the 3 months prior to survey occurred across facility levels for HIV test-kits in 55%, 26% and 9% facilities in Malawi, Uganda and Zimbabwe respectively; for CPT in 58%, 32% and 9% and for PMTCT drugs in 26%, 10% and 0% of facilities (excluding facilities where patients were referred out for either drug). Across all countries, in facilities with ART stored on-site, adult ART stock-outs were reported in 3/44 (7%) facilities compared with 10/43 (23%) facility stock-outs of paediatric ART. Laboratory services at primary health facilities were limited: CD4 was used for ART initiation in 4/9, 5/6 and 13/14 in Malawi, Uganda and Zimbabwe respectively, but frequently only in selected patients. Routine viral load monitoring was not used; 6/58 (10%) facilities with ART provision accessed centralised viral loads for selected patients. Conclusions Although coverage of HIV testing, PMTCT and cotrimoxazole prophylaxis was high in all countries, decentralization of ART services was variable and incomplete. Challenges of staffing and stock management were evident. Laboratory testing for toxicity and treatment effectiveness monitoring was not available in most primary level facilities. Electronic supplementary material The online version of this article (doi:10.1186/1472-6963-14-352) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Deborah Ford
- MRC Clinical Trials Unit at University College London, London, U,K.
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Follow-Up Visit Patterns in an Antiretroviral Therapy (ART) programme in Zomba, Malawi. PLoS One 2014; 9:e101875. [PMID: 25033285 PMCID: PMC4102478 DOI: 10.1371/journal.pone.0101875] [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: 08/09/2013] [Accepted: 06/12/2014] [Indexed: 11/19/2022] Open
Abstract
Background Identifying follow-up (FU) visit patterns, and exploring which factors influence them are likely to be useful in determining which patients on antiretroviral therapy (ART) may become Lost to Follow-Up (LTFU). Using an operation and implementation research approach, we sought 1) to describe the timing of FU visits amongst patients who have been on ART for shorter and longer periods of time; and 2) to determine the median time to late visits, and 3) to identify specific factors that may be associated with these patterns in Zomba, Malawi. Methods and Findings Using routinely collected programme monitoring data from Zomba District, we performed descriptive analyses on all ART visits among patients who initiated ART between Jan. 1, 2007–June 30, 2010. Based on an expected FU date, each FU visit was classified as early (≥4 day before an expected FU date), on time (3 days before an expected FU date/up to 6 days after an expected FU date), or late (≥7 days after an expected FU date). In total, 7,815 patients with 76417 FU visits were included. Ninety-two percent of patients had ≥2 FU visits. At the majority of visits, patients were either on time or late. The median time to a first late visit among those with 2 or more visits was 216 days (IQR: 128–359). Various patient- and visit-level factors differed significantly across Early, On Time, and Late visit groups including ART adherence and frequency of, and type of side effects. Discussion The majority of patients do not demonstrate consistent FU visit patterns. Individuals were generally on ART for at least 6 months before experiencing their first late visit. Our findings have implications for the development of effective interventions that meet patient needs when they present early and can reduce patient losses to follow-up when they are late. In particular, time-varying visit characteristics need further research.
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Grimsrud A, Kaplan R, Bekker LG, Myer L. Outcomes of a nurse-managed service for stable HIV-positive patients in a large South African public sector antiretroviral therapy programme. Trop Med Int Health 2014; 19:1029-39. [PMID: 25041716 DOI: 10.1111/tmi.12346] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Models of care utilizing task shifting and decentralization are needed to support growing ART programmes. We compared patient outcomes between a doctor-managed clinic and a nurse-managed down-referral site in Cape Town, South Africa. METHODS Analysis included all adults who initiated ART between 2002 and 2011 within a large public sector ART service. Stable patients were eligible for down-referral. Outcomes [mortality, loss to follow-up (LTFU), virologic failure] were compared under different models of care using proportional hazards models with time-dependent covariates. RESULTS Five thousand seven hundred and forty-six patients initiated ART and over 5 years 41% (n = 2341) were down-referred; the median time on ART before down-referral was 1.6 years (interquartile range, 0.9-2.6). The nurse-managed down-referral site reported lower crude rates of mortality, LTFU and virologic failure compared with the doctor-managed clinic. After adjustment, there was no difference in the risk of mortality or virologic failure by model of care. However, patients who were down-referred were more likely to be LTFU than those retained at the doctor-managed site (adjusted hazard ratio, 1.36; 95% CI, 1.09-1.69). Increased levels of LTFU in the nurse-managed vs. doctor-managed service were observed in subgroups of male patients, those with advanced disease at initiation and those who started ART in the early years of the programme. CONCLUSION Reorganization of ART maintenance by down-referral to nurse-managed services is associated with programme outcomes similar to those achieved using doctor-driven primary care services. Further research is necessary to identify optimal models of care to support long-term retention of patients on ART in resource-limited settings.
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Affiliation(s)
- Anna Grimsrud
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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Auld AF, Ekra KA, Shiraishi RW, Tuho MZ, Kouakou JS, Mohamed F, Ettiègne-Traoré V, Sabatier J, Essombo J, Adjorlolo-Johnson G, Marlink R, Ellerbrock TV. Temporal trends in treatment outcomes for HIV-1 and HIV-2-infected adults enrolled in Côte d'Ivoire's national antiretroviral therapy program. PLoS One 2014; 9:e98183. [PMID: 24866468 PMCID: PMC4035349 DOI: 10.1371/journal.pone.0098183] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 04/25/2014] [Indexed: 12/13/2022] Open
Abstract
Background In Côte d'Ivoire during 2004–2007, numbers of ART enrollees increased from <5,000 to 36,943. Trends in nationally representative ART program outcomes have not yet been reported. Methodology/Principal Findings We conducted a retrospective chart review to assess trends in patient characteristics and attrition [death or loss to follow-up (LTFU)] over time, among a nationally representative sample of 3,682 adults (≥15 years) initiating ART during 2004–2007 at 34 health facilities. Among ART enrollees during 2004–2007, median age was 36, the proportion female was 67%, the proportion HIV-2-infected or dually HIV-1&2 reactive was 5%, and median baseline CD4+ T-cell (CD4) count was 135 cells/µL. Comparing cohorts initiating ART in 2004 with cohorts initiating ART in 2007, median baseline weight declined from 55 kg to 52 kg (p = 0.008) and the proportion weighing <45 kg increased from 17% to 22% (p = 0.014). During 2004–2007, pharmacy-based estimates of the percentage of new ART enrollees ≥95% adherent to ART declined from 74% to 60% (p = 0.026), and twelve-month retention declined from 86% to 69%, due to increases in 12-month mortality from 2%–4% and LTFU from 12%–28%. In univariate analysis, year of ART initiation was associated with increasing rates of both LTFU and mortality. Controlling for baseline CD4, weight, adherence, and other risk factors, year of ART initiation was still strongly associated with LTFU but not mortality. In multivariate analysis, weight <45 kg and adherence <95% remained strong predictors of LTFU and mortality. Conclusions During 2004–2007, increasing prevalence among ART enrollees of measured mortality risk factors, including weight <45 kg and ART adherence <95%, might explain increases in mortality over time. However, the association between later calendar year and increasing LTFU is not explained by risk factors evaluated in this analysis. Undocumented transfers, political instability, and patient dissatisfaction with crowded facilities might explain increasing LTFU.
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Affiliation(s)
- Andrew F. Auld
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
| | - Kunomboa A. Ekra
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Abidjan, Côte d'Ivoire
| | - Ray W. Shiraishi
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Moise Z. Tuho
- National Program for Medical Care of Persons Living with HIV/AIDS, Ministry of Health, Abidjan, Côte d'Ivoire
| | | | - Fayama Mohamed
- Elizabeth Glaser Pediatric AIDS Foundation, Abidjan, Côte d'Ivoire
- Department of Economy and Finance, Directorate General of Budget and Finance, Abidjan, Côte d'Ivoire
| | - Virginie Ettiègne-Traoré
- National Program for Medical Care of Persons Living with HIV/AIDS, Ministry of Health, Abidjan, Côte d'Ivoire
| | - Jennifer Sabatier
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Joseph Essombo
- Elizabeth Glaser Pediatric AIDS Foundation, Abidjan, Côte d'Ivoire
| | | | - Richard Marlink
- Elizabeth Glaser Pediatric AIDS Foundation, Los Angeles, California, United States of America
| | - Tedd V. Ellerbrock
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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"I don't want financial support but verbal support." How do caregivers manage children's access to and retention in HIV care in urban Zimbabwe? J Int AIDS Soc 2014; 17:18839. [PMID: 24815595 PMCID: PMC4017591 DOI: 10.7448/ias.17.1.18839] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 03/21/2014] [Accepted: 04/07/2014] [Indexed: 11/08/2022] Open
Abstract
Introduction Children living with HIV experience particular challenges in accessing HIV care. Children usually rely on adult caregivers for access to care, including timely diagnosis, initiation of treatment and sustained engagement with HIV services. The aim of this study was to inform the design of a community-based intervention to support caregivers of HIV-positive children to increase children's retention in care as part of a programme introducing decentralized HIV care in primary health facilities. Methods Using an existing conceptual framework, we conducted formative research to identify key local contextual factors affecting children's linkages to HIV care in Harare, Zimbabwe. We conducted semi-structured interviews with 15 primary caregivers of HIV-positive children aged 6–15 years enrolled at a hospital clinic for at least six months, followed by interviews with nine key informants from five community-based organizations providing adherence support or related services. Results We identified a range of facilitators and barriers that caregivers experience. Distance to the hospital, cost of transportation, fear of disclosing HIV status to the child or others, unstable family structure and institutional factors such as drug stock-outs, healthcare worker absenteeism and unsympathetic school environments proved the most salient limiting factors. Facilitators included openness within the family, availability of practical assistance and psychosocial support from community members. Conclusions The proposed decentralization of HIV care will mitigate concerns about distance and transport costs but is likely to be insufficient to ensure children's sustained retention. Following this study, we developed a package of structured home visits by voluntary lay workers to proactively address other determinants such as disclosure within families, access to available services and support through caregivers’ social networks. A randomized controlled trial is underway to assess impact on children's retention in care over two years.
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Rasschaert F, Decroo T, Remartinez D, Telfer B, Lessitala F, Biot M, Candrinho B, Van Damme W. Adapting a community-based ART delivery model to the patients' needs: a mixed methods research in Tete, Mozambique. BMC Public Health 2014; 14:364. [PMID: 24735550 PMCID: PMC3990026 DOI: 10.1186/1471-2458-14-364] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 04/07/2014] [Indexed: 11/10/2022] Open
Abstract
Background To improve retention in antiretroviral therapy (ART), lessons learned from chronic disease care were applied to HIV care, providing more responsibilities to patients in the care of their chronic disease. In Tete - Mozambique, patients stable on ART participate in the ART provision and peer support through Community ART Groups (CAG). This article analyses the evolution of the CAG-model during its implementation process. Methods A mixed method approach was used, triangulating qualitative and quantitative findings. The qualitative data were collected through semi-structured focus groups discussions and in-depth interviews. An inductive qualitative content analysis was applied to condense and categorise the data in broader themes. Health outcomes, patients’ and groups’ characteristics were calculated using routine collected data. We applied an ‘input – process – output’ pathway to compare the initial planned activities with the current findings. Results Input wise, the counsellors were considered key to form and monitor the groups. In the process, the main modifications found were the progressive adaptations of the daily CAG functioning and the eligibility criteria according to the patients’ needs. Beside the anticipated outputs, i.e. cost and time saving benefits and improved treatment outcomes, the model offered a mutual adherence support and protective environment to the members. The active patient involvement in several health activities in the clinics and the community resulted in a better HIV awareness, decreased stigma, improved health seeking behaviour and better quality of care. Conclusions Over the past four years, the modifications in the CAG-model contributed to a patient empowerment and better treatment outcomes. One of the main outstanding questions is how this model will evolve in the future. Close monitoring is essential to ensure quality of care and to maintain the core objective of the CAG-model ‘facilitating access to ART care’ in a cost and time saving manner.
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Affiliation(s)
- Freya Rasschaert
- Departement of Public Health, Institute of Tropical Medicine, Nationale straat 155, Antwerp 2000, Belgium.
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Massavon W, Barlow-Mosha L, Mugenyi L, McFarland W, Gray G, Lundin R, Costenaro P, Nannyonga MM, Penazzato M, Bagenda D, Namisi CP, Wabwire D, Mubiru M, Kironde S, Bilardi D, Mazza A, Fowler MG, Musoke P, Giaquinto C. Factors Determining Survival and Retention among HIV-Infected Children and Adolescents in a Community Home-Based Care and a Facility-Based Family-Centred Approach in Kampala, Uganda: A Cohort Study. ISRN AIDS 2014; 2014:852489. [PMID: 25006529 PMCID: PMC4003865 DOI: 10.1155/2014/852489] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 04/01/2014] [Indexed: 12/28/2022]
Abstract
We describe factors determining retention and survival among HIV-infected children and adolescents engaged in two health care delivery models in Kampala, Uganda: one is a community home-based care (CHBC) and the other is a facility-based family-centred approach (FBFCA). This retrospective cohort study reviewed records from children aged from 0 to 18 years engaged in the two models from 2003 to 2010 focussing on retention/loss to follow-up, mortality, use of antiretroviral therapy (ART), and clinical characteristics. Kaplan Meier survival curves with log rank tests were used to describe and compare retention and survival. Overall, 1,623 children were included, 90.0% (1460/1623) from the CHBC. Children completed an average of 4.2 years of follow-up (maximum 7.7 years). Median age was 53 (IQR: 11-109) months at enrolment. In the CHBC, retention differed significantly between patients on ART and those not (log-rank test, adjusted, P < 0.001). Comparing ART patients in both models, there was no significant difference in long-term survival (log-rank test, P = 0.308, adjusted, P = 0.489), while retention was higher in the CHBC: 94.8% versus 84.7% in the FBFCA (log-rank test, P < 0.001, adjusted P = 0.006). Irrespective of model of care, children receiving ART had better retention in care and survival.
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Affiliation(s)
- W. Massavon
- Department of Paediatrics, University of Padua, Via Giustiniani 3, 35128 Padua, Italy
- St. Raphael of St. Francis Hospital (Nsambya Hospital), Kampala, Uganda
| | - L. Barlow-Mosha
- Makerere University, Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - L. Mugenyi
- Infectious Diseases Research Collaboration, Mulago Hospital Complex, Kampala, Uganda
| | - W. McFarland
- Department of Global Health Sciences, University of California San Francisco, 50 Beale Street, 12th Floor, San Francisco, CA 94105, USA
| | - G. Gray
- University of Witwatersrand, 1 Jan Smuts Avenue, Braamfontein 2000, Johannesburg, South Africa
| | - R. Lundin
- Department of Paediatrics, University of Padua, Via Giustiniani 3, 35128 Padua, Italy
| | - P. Costenaro
- Department of Paediatrics, University of Padua, Via Giustiniani 3, 35128 Padua, Italy
| | - M. M. Nannyonga
- St. Raphael of St. Francis Hospital (Nsambya Hospital), Kampala, Uganda
| | - M. Penazzato
- Department of Paediatrics, University of Padua, Via Giustiniani 3, 35128 Padua, Italy
| | - D. Bagenda
- Makerere University, Johns Hopkins University Research Collaboration, Kampala, Uganda
- Department of Global Heath and Population, Harvard University School of Public Health, Boston, MA, USA
| | - C. P. Namisi
- St. Raphael of St. Francis Hospital (Nsambya Hospital), Kampala, Uganda
| | - D. Wabwire
- Makerere University, Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - M. Mubiru
- Makerere University, Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - S. Kironde
- St. Raphael of St. Francis Hospital (Nsambya Hospital), Kampala, Uganda
| | - D. Bilardi
- Department of Paediatrics, University of Padua, Via Giustiniani 3, 35128 Padua, Italy
| | - A. Mazza
- Santa Chiara Hospital, Via Largo Gold Medals 9, 38122 Trento, Italy
| | - M. G. Fowler
- Makerere University, Johns Hopkins University Research Collaboration, Kampala, Uganda
- Department of Pathology, Johns Hopkins School of Medicine 600 N. Wolfe Street/Carnegie 43 Baltimore, MD 21287, USA
| | - P. Musoke
- Makerere University, Johns Hopkins University Research Collaboration, Kampala, Uganda
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - C. Giaquinto
- Department of Paediatrics, University of Padua, Via Giustiniani 3, 35128 Padua, Italy
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