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Saura-Lázaro A, Augusto O, Fernández-Luis S, López-Varela E, Fuente-Soro L, Bila D, Tovela M, Macuacua N, Vaz P, Couto A, Bruno C, Naniche D. HIV care retention in three multi-month ART dispensing: a retrospective cohort study in Mozambique. AIDS 2024; 38:1402-1411. [PMID: 38652496 PMCID: PMC11216376 DOI: 10.1097/qad.0000000000003913] [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: 12/06/2023] [Revised: 03/14/2024] [Accepted: 03/21/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Evaluate the effect of three multimonth dispensing (3MMD) of antiretroviral therapy (ART) on HIV care retention in southern Mozambique. DESIGN Retrospective cohort study. METHODS We analyzed routine health data from people with HIV (PWH) aged 10 years old and older who started ART between January 2018 and March 2021. Individuals were followed until December 2021. Cox proportional-hazards models were used to compare attrition (lost to follow-up, death, and transfer out) between 3MMD and monthly ART dispensing. Results were stratified by time on ART before 3MMD enrolment: 'early enrollers' (<6 months on ART) and 'established enrollers' (≥6 months on ART), and age groups: adolescents and youth (AYLHIV) (10-24 years) and adults (≥25 years). RESULTS We included 7378 PWH (25% AYLHIV, 75% adults), with 59% and 62% enrolled in 3MMD, respectively. Median follow-up time was 11.3 [interquartile range (IQR): 5.7-21.6] months for AYLHIV and 10.2 (IQR: 4.8-20.9) for adults. Attrition was lower in PWH enrolled in 3MMD compared with monthly ART dispensing, in both established (aHR AYLHIV = 0.65; 95% CI: 0.54-0.78 and aHR adults = 0.50; 95% confidence interval (CI): 0.44-0.56) and early enrollers (aHR AYLHIV = 0.70; 95% CI: 0.58-0.85 and aHR adults = 0.63; 95% CI: 0.57-0.70). Among individuals in 3MMD, male gender (aHR = 1.30; 95% CI: 1.18-1.44) and receiving care in a medium-volume/low-volume healthcare facility (aHR = 1.18; 95% CI: 1.03-1.34) increased attrition risk. Conversely, longer ART time before 3MMD enrolment (aHR = 0.93; 95% CI: 0.92-0.94 per 1 month increase) and age at least 45 years (aHR = 0.77, 95% CI: 0.67-0.89) reduced risk of attrition. CONCLUSION 3MMD improves retention in care compared with monthly dispensing among established and early enrollers, although to a lesser extent among the latter.
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Affiliation(s)
- Anna Saura-Lázaro
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Orvalho Augusto
- Centro de Investigação em Saúde de Manhiça (CISM)
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Sheila Fernández-Luis
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM)
| | - Elisa López-Varela
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM)
| | - Laura Fuente-Soro
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM)
| | - Dulce Bila
- Fundação Ariel Glaser Contra o SIDA Pediatrico
| | | | | | - Paula Vaz
- Fundação Ariel Glaser Contra o SIDA Pediatrico
| | - Aleny Couto
- Programa Nacional de Controle de HIV/SIDA, Ministério da Saúde
| | - Carmen Bruno
- Direcção Provincial de Saúde, Maputo, Mozambique
| | - Denise Naniche
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM)
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Rosen JG, Ndyanabo A, Nakawooya H, Galiwango RM, Ssekubugu R, Ssekasanvu J, Kim S, Rucinski KB, Nakigozi G, Nalugoda F, Kigozi G, Quinn TC, Chang LW, Kennedy CE, Reynolds SJ, Kagaayi J, Grabowski MK. Incidence of Health Facility Switching and Associations With HIV Viral Rebound Among Persons on Antiretroviral Therapy in Uganda: A Population-based Study. Clin Infect Dis 2024; 78:1591-1600. [PMID: 38114162 PMCID: PMC11175689 DOI: 10.1093/cid/ciad773] [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: 09/12/2023] [Revised: 12/02/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND A substantial proportion of persons on antiretroviral therapy (ART) considered lost to follow-up have actually transferred their human immunodeficiency virus (HIV) care to other facilities. However, the relationship between facility switching and virologic outcomes, including viral rebound, is poorly understood. METHODS We used data from 40 communities (2015-2020) in the Rakai Community Cohort Study to estimate incidence of facility switching and viral rebound. Persons aged 15-49 years with serologically confirmed HIV who self-reported ART use and contributed ≥1 follow-up visit were included. Facility switching and virologic outcomes were assessed between 2 consecutive study visits (ie, index and follow-up visits, interval of approximately 18 months). Those who reported different HIV treatment facilities between index and follow-up study visits were classified as having switched facilities. Virologic outcomes included viral rebound among individuals initially suppressed (<200 copies/mL). Multivariable Poisson regression was used to estimate associations between facility switching and viral rebound. RESULTS Overall, 2257 persons who self-reported ART use (median age, 35 years; 65% female, 92% initially suppressed) contributed 3335 visit-pairs and 5959 person-years to the analysis. Facility switching was common (4.8 per 100 person-years; 95% confidence interval [CI], 4.2-5.5) and most pronounced in persons aged <30 years and fishing community residents. Among persons suppressed at their index visit (n = 2076), incidence of viral rebound was more than twice as high in persons who switched facilities (adjusted incidence rate ratio = 2.27; 95% CI, 1.16-4.45). CONCLUSIONS Facility switching was common and associated with viral rebound among persons initially suppressed. Investments in more agile, person-centered models for mobile clients are needed to address system inefficiencies and bottlenecks that can disrupt HIV care continuity.
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Affiliation(s)
- Joseph G Rosen
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | | | | | - Seungwon Kim
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Katherine B Rucinski
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | - Thomas C Quinn
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Larry W Chang
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Caitlin E Kennedy
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Steven J Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - M Kate Grabowski
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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3
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Odayar J, Rusch J, Dave JA, Van Der Westhuizen DJ, Mukonda E, Lesosky M, Myer L. Transfers between health facilities of people living with diabetes attending primary health care services in the Western Cape Province of South Africa: A retrospective cohort study. Trop Med Int Health 2024; 29:489-498. [PMID: 38514897 PMCID: PMC11147718 DOI: 10.1111/tmi.13990] [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] [Indexed: 03/23/2024]
Abstract
OBJECTIVES Transfers between health facilities of people living with HIV attending primary health care (PHC) including hospital to PHC facility, PHC facility to hospital and PHC facility to PHC facility transfers occur frequently, affect health service planning, and are associated with disengagement from care and viraemia. Data on transfers among people living with diabetes attending PHC, particularly transfers between PHC facilities, are few. We assessed the transfer incidence rate of people living with diabetes attending PHC, and the association between transfers between PHC facilities and subsequent HbA1c values. METHODS We analysed data on HbA1c tests at public sector facilities in the Western Cape Province (2016-March 2020). Individuals with an HbA1c in 2016-2017 were followed-up for 27 months and included in the analysis if ≥18 years at first included HbA1c, ≥2 HbA1cs during follow-up and ≥1 HbA1c at a PHC facility. A visit interval was the duration between two consecutive HbA1cs. Successive HbA1cs at different facilities of any type indicated any transfer, and HbA1cs at different PHC facilities indicated a transfer between PHC facilities. Mixed effects logistic regression adjusted for sex, age, rural/urban facility attended at the start of the visit interval, disengagement (visit interval >14 months) and a hospital visit during follow-up assessed the association between transfers between PHC facilities and HbA1c >8%. RESULTS Among 102,813 participants, 22.6% had ≥1 transfer of any type. Including repeat transfers, there were 29,994 transfers (14.4 transfers per 100 person-years, 95% confidence interval [CI] 14.3-14.6). A total of 6996 (30.1%) of those who transferred had a transfer between PHC facilities. Visit intervals with a transfer between PHC facilities were longer (349 days, interquartile range [IQR] 211-503) than those without any transfer (330 days, IQR 182-422). The adjusted relative odds of an HbA1c ≥8% after a transfer between PHC facilities versus no transfer were 1.20 (95% CI 1.05-1.37). CONCLUSION The volume of transfers involving PHC facilities requires consideration when planning services. Individuals who transfer between PHC facilities require additional monitoring and support.
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Affiliation(s)
- Jasantha Odayar
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Jody Rusch
- Division of Chemical Pathology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Joel A Dave
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Diederick J Van Der Westhuizen
- Division of Chemical Pathology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Elton Mukonda
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Maia Lesosky
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
- Department of Clinical Medicine, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
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Lujintanon S, Hausler H, Comins C, Mcingana M, Shipp L, Phetlhu DR, Makama S, Guddera V, Mishra S, Baral S, Schwartz S. Estimating the mortality risk correcting for high loss to follow-up among female sex workers with HIV in Durban, South Africa, 2018-2021. Ann Epidemiol 2024; 92:8-16. [PMID: 38382770 PMCID: PMC10981924 DOI: 10.1016/j.annepidem.2024.02.006] [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: 10/02/2023] [Revised: 02/13/2024] [Accepted: 02/17/2024] [Indexed: 02/23/2024]
Abstract
PURPOSE This study assesses risk factors of loss to follow-up (LTFU) and estimates mortality risk among female sex workers (FSW) with HIV in Durban, South Africa, in 2018-2021. METHODS We used data from the Siyaphambili trial, which evaluated strategies for improved viral suppression. FSW with HIV aged ≥ 18 years with viral load ≥ 50 copies/mL were followed up for 18 months. LTFU was defined as absence from study or intervention visits for 6 months. We traced LTFU participants by calling/in-person visit attempts to ascertain their vital status. We used Cox regression to determine risk factors of LTFU and inverse probability of tracing weights to correct mortality risk. RESULTS Of 777 participants, 10 (1.3%) had died and 578 (74.4%) were initially LTFU. Among those LTFU, 36.3% (210/578) were traced successfully, with 6 additional deaths ascertained. Recent physical and sexual violence, and non-viral suppression were associated with increased LTFU. The unweighted and weighted 18-month mortality risks were 2.4% (95% CI: 0.8%-3.9%) and 3.7% (95% CI: 1.8%-5.9%), respectively. CONCLUSIONS LTFU is common among FSW with HIV in South Africa with additional investigation of vital status demonstrating under-ascertained mortality. These data suggest the need for comprehensively addressing risks for mortality among FSW.
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Affiliation(s)
- Sita Lujintanon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, United States.
| | - Harry Hausler
- TB HIV Care, 7th Floor, 11 Adderley St, Cape Town City Centre, Cape Town 8001, South Africa; Department of Family Medicine, School of Medicine, University of Pretoria, 7th Floor, HW Snyman North building, Prinshof Campus, 31 Bophelo Rd, Gezina, Pretoria 0084, South Africa
| | - Carly Comins
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, United States
| | - Mfezi Mcingana
- TB HIV Care, Suit No. 2, Sutton Square, 306/310 Mathews Meyiwa Rd, Morningside, Durban 4001, South Africa
| | - Lillian Shipp
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, United States
| | - Deliwe Rene Phetlhu
- Department of Nursing, Sefako Makgatho Health Sciences University, Molotlegi St, Ga-Rankuwa, Pretoria, Gauteng 0208, South Africa
| | - Siyanda Makama
- TB HIV Care, Suit No. 2, Sutton Square, 306/310 Mathews Meyiwa Rd, Morningside, Durban 4001, South Africa
| | - Vijayanand Guddera
- TB HIV Care, Suit No. 2, Sutton Square, 306/310 Mathews Meyiwa Rd, Morningside, Durban 4001, South Africa
| | - Sharmistha Mishra
- St. Michael's Hospital, Li Ka Shing Knowledge Institute, University of Toronto, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, United States
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, United States
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Secor AM, Célestin K, Jasmin M, Honoré JG, Wagner AD, Beima-Sofie K, Pintye J, Puttkammer N. Electronic Medical Record Data Missingness and Interruption in Antiretroviral Therapy Among Adults and Children Living With HIV in Haiti: Retrospective Longitudinal Study. JMIR Pediatr Parent 2024; 7:e51574. [PMID: 38488632 PMCID: PMC10986334 DOI: 10.2196/51574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 04/04/2024] Open
Abstract
Background Children (aged 0-14 years) living with HIV often experience lower rates of HIV diagnosis, treatment, and viral load suppression. In Haiti, only 63% of children living with HIV know their HIV status (compared to 85% overall), 63% are on treatment (compared to 85% overall), and 48% are virally suppressed (compared to 73% overall). Electronic medical records (EMRs) can improve HIV care and patient outcomes, but these benefits are largely dependent on providers having access to quality and nonmissing data. Objective We sought to understand the associations between EMR data missingness and interruption in antiretroviral therapy treatment by age group (pediatric vs adult). Methods We assessed associations between patient intake record data missingness and interruption in treatment (IIT) status at 6 and 12 months post antiretroviral therapy initiation using patient-level data drawn from iSanté, the most widely used EMR in Haiti. Missingness was assessed for tuberculosis diagnosis, World Health Organization HIV stage, and weight using a composite score indicator (ie, the number of indicators of interest missing). Risk ratios were estimated using marginal parameters from multilevel modified Poisson models with robust error variances and random intercepts for the facility to account for clustering. Results Data were drawn from 50 facilities and comprised 31,457 patient records from people living with HIV, of which 1306 (4.2%) were pediatric cases. Pediatric patients were more likely than adult patients to experience IIT (n=431, 33% vs n=7477, 23.4% at 6 months; P<.001). Additionally, pediatric patient records had higher data missingness, with 581 (44.5%) pediatric records missing at least 1 indicator of interest, compared to 7812 (25.9%) adult records (P<.001). Among pediatric patients, each additional indicator missing was associated with a 1.34 times greater likelihood of experiencing IIT at 6 months (95% CI 1.08-1.66; P=.008) and 1.24 times greater likelihood of experiencing IIT at 12 months (95% CI 1.05-1.46; P=.01). These relationships were not statistically significant for adult patients. Compared to pediatric patients with 0 missing indicators, pediatric patients with 1, 2, or 3 missing indicators were 1.59 (95% CI 1.26-2.01; P<.001), 1.74 (95% CI 1.02-2.97; P=.04), and 2.25 (95% CI 1.43-3.56; P=.001) times more likely to experience IIT at 6 months, respectively. Among adult patients, compared to patients with 0 indicators missing, having all 3 indicators missing was associated with being 1.32 times more likely to experience IIT at 6 months (95% CI 1.03-1.70; P=.03), while there was no association with IIT status for other levels of missingness. Conclusions These findings suggest that both EMR data quality and quality of care are lower for children living with HIV in Haiti. This underscores the need for further research into the mechanisms by which EMR data quality impacts the quality of care and patient outcomes among this population. Efforts to improve both EMR data quality and quality of care should consider prioritizing pediatric patients.
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Affiliation(s)
- Andrew M Secor
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kemar Célestin
- Centre Haïtien pour le Renforcement du Système de Santé, Port-au-Prince, Haiti
| | - Margareth Jasmin
- Centre Haïtien pour le Renforcement du Système de Santé, Port-au-Prince, Haiti
| | - Jean Guy Honoré
- Centre Haïtien pour le Renforcement du Système de Santé, Port-au-Prince, Haiti
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kristin Beima-Sofie
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Jillian Pintye
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Nancy Puttkammer
- International Training and Education Center for Health, Seattle, WA, United States
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Brazier E, Tymejczyk O, Wools-Kaloustian K, Jiamsakul A, Torres MTL, Lee JS, Abuogi L, Khol V, Mejía Cordero F, Althoff KN, Law MG, Nash D. Long-term HIV care outcomes under universal HIV treatment guidelines: A retrospective cohort study in 25 countries. PLoS Med 2024; 21:e1004367. [PMID: 38498589 PMCID: PMC10962811 DOI: 10.1371/journal.pmed.1004367] [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] [Received: 07/28/2023] [Revised: 03/25/2024] [Accepted: 02/22/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND While national adoption of universal HIV treatment guidelines has led to improved, timely uptake of antiretroviral therapy (ART), longer-term care outcomes are understudied. There is little data from real-world service delivery settings on patient attrition, viral load (VL) monitoring, and viral suppression (VS) at 24 and 36 months after HIV treatment initiation. METHODS AND FINDINGS For this retrospective cohort analysis, we used observational data from 25 countries in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium's Asia-Pacific, Central Africa, East Africa, Central/South America, and North America regions for patients who were ART naïve and aged ≥15 years at care enrollment between 24 months before and 12 months after national adoption of universal treatment guidelines, occurring 2012 to 2018. We estimated crude cumulative incidence of loss-to-clinic (CI-LTC) at 12, 24, and 36 months after enrollment among patients enrolling in care before and after guideline adoption using competing risks regression. Guideline change-associated hazard ratios of LTC at each time point after enrollment were estimated via cause-specific Cox proportional hazards regression models. Modified Poisson regression was used to estimate relative risks of retention, VL monitoring, and VS at 12, 24, and 36 months after ART initiation. There were 66,963 patients enrolling in HIV care at 109 clinics with ≥12 months of follow-up time after enrollment (46,484 [69.4%] enrolling before guideline adoption and 20,479 [30.6%] enrolling afterwards). More than half (54.9%) were females, and median age was 34 years (interquartile range [IQR]: 27 to 43). Mean follow-up time was 51 months (standard deviation: 17 months; range: 12, 110 months). Among patients enrolling before guideline adoption, crude CI-LTC was 23.8% (95% confidence interval [95% CI] 23.4, 24.2) at 12 months, 31.0% (95% CI [30.6, 31.5]) at 24 months, and 37.2% (95% [CI 36.8, 37.7]) at 36 months after enrollment. Adjusting for sex, age group, enrollment CD4, clinic location and type, and country income level, enrolling in care and initiating ART after guideline adoption was associated with increased hazard of LTC at 12 months (adjusted hazard ratio [aHR] 1.25 [95% CI 1.08, 1.44]; p = 0.003); 24 months (aHR 1.38 [95% CI 1.19, 1.59]; p < .001); and 36 months (aHR 1.34 [95% CI 1.18, 1.53], p < .001) compared with enrollment before guideline adoption, with no before-after differences among patients with no record of ART initiation by end of follow-up. Among patients retained after ART initiation, VL monitoring was low, with marginal improvements associated with guideline adoption only at 12 months after ART initiation. Among those with VL monitoring, VS was high at each time point among patients enrolling before guideline adoption (86.0% to 88.8%) and afterwards (86.2% to 90.3%), with no substantive difference associated with guideline adoption. Study limitations include lags in and potential underascertainment of care outcomes in real-world service delivery data and potential lack of generalizability beyond IeDEA sites and regions included in this analysis. CONCLUSIONS In this study, adoption of universal HIV treatment guidelines was associated with lower retention after ART initiation out to 36 months of follow-up, with little change in VL monitoring or VS among retained patients. Monitoring long-term HIV care outcomes remains critical to identify and address causes of attrition and gaps in HIV care quality.
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Affiliation(s)
- Ellen Brazier
- City University of New York, Institute for Implementation Science in Population Health (ISPH), New York, New York, United States of America
- City University of New York, Graduate School of Public Health and Health Policy, New York, New York, United States of America
| | - Olga Tymejczyk
- City University of New York, Institute for Implementation Science in Population Health (ISPH), New York, New York, United States of America
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | | | - Marco Tulio Luque Torres
- Department of Pediatrics, Instituto Hondureño de Seguridad Social and Hospital Escuela Universitario, Tegucigalpa, Honduras
| | - Jennifer S. Lee
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Lisa Abuogi
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado, United States of America
| | - Vohith Khol
- National Center for HIV/AIDS, Dermatology and STDs, Phnom Penh, Cambodia
| | - Fernando Mejía Cordero
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Keri N. Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Matthew G. Law
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Denis Nash
- City University of New York, Institute for Implementation Science in Population Health (ISPH), New York, New York, United States of America
- City University of New York, Graduate School of Public Health and Health Policy, New York, New York, United States of America
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7
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Raberahona M, Rakotomalala R, Andriananja V, Andriamamonjisoa J, Rakotomijoro E, Andrianasolo RL, Rakotoarivelo RA, Randria MJDD. A retrospective cohort analysis of people living with HIV/AIDS enrolled in HIV care at a reference center in Antananarivo, Madagascar. Front Public Health 2024; 11:1329194. [PMID: 38288430 PMCID: PMC10822960 DOI: 10.3389/fpubh.2023.1329194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 12/22/2023] [Indexed: 01/31/2024] Open
Abstract
Background The impact of the "Treat all" policy on the individual and in terms of public health is closely related to early diagnosis and retention in care. Patient-level data are scarce in Madagascar. In this study, we aimed to describe the profile of a cohort of newly diagnosed people living with HIV/AIDS (PLHIV), identify their outcomes, and assess factors associated with attrition from care and advanced HIV disease (AHD) at presentation. Methods We conducted a retrospective cohort study of PLHIV aged ≥15 years newly diagnosed at the University Hospital Joseph Raseta Befelatanana Antananarivo from 1 January 2010 to 31 December 2016. Results A total of 490 PLHIV were included in the cohort analysis. In total, 67.1% were male. The median age (interquartile range) at enrollment in care was 29 years (24-38). Overall, 36.1% of PLHIV were diagnosed with AHD at baseline. The proportion of patients with WHO stage IV at baseline increased significantly from 3.3% in 2010 to 31% in 2016 (p = 0.001 for trend). The probability of retention in care after the diagnosis at 12 months, 24 months, and 36 months was 71.8%, 65.5%, and 61.3%, respectively. Age ≥ 40 years (aHR: 1.55; 95% CI: 1.05-2.29; p = 0.026), low level of education (aHR:1.62; 95% CI: 1.11-2.36; p = 0,013), unspecified level of education (aHR:2.18; 95% CI: 1.37-3.47; p = 0.001) and unemployment (aHR:1.52; 95% CI: 1.07-2.16; p = 0.019) were independently associated with attrition from care. Factors associated with AHD at baseline were age ≥ 40 (aOR: 2.77; 95% CI: 1.38-5.57, p = 0.004), unspecified level of education (aOR: 3.80; 95% CI: 1.58-9.16, p = 0.003) and presence of clinical symptoms at baseline (aOR: 23.81; 95% CI: 10.7-52.98; p < 0.001). Sex workers were independently less likely to have an AHD at presentation (aOR: 0.23; 95% CI: 0.05-0.96, p = 0.044). Conclusion Sociodemographic determinants influenced retention in care more than clinical factors. The presence of clinical symptoms and sociodemographic determinants were the main factors associated with AHD at baseline.
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Affiliation(s)
- Mihaja Raberahona
- Department of Infectious Diseases, University Hospital Joseph Raseta Befelatanana Antananarivo, Antananarivo, Madagascar
- Faculty of Medicine, University of Antananarivo, Antananarivo, Madagascar
| | - Rado Rakotomalala
- Department of Infectious Diseases, University Hospital Joseph Raseta Befelatanana Antananarivo, Antananarivo, Madagascar
| | - Volatiana Andriananja
- Department of Infectious Diseases, University Hospital Joseph Raseta Befelatanana Antananarivo, Antananarivo, Madagascar
| | - Johary Andriamamonjisoa
- Department of Infectious Diseases, University Hospital Joseph Raseta Befelatanana Antananarivo, Antananarivo, Madagascar
| | - Etienne Rakotomijoro
- Department of Infectious Diseases, University Hospital Joseph Raseta Befelatanana Antananarivo, Antananarivo, Madagascar
| | | | - Rivonirina Andry Rakotoarivelo
- Department of Infectious Diseases, Faculty of Medicine, University Hospital Tambohobe Fianarantsoa, University of Fianarantsoa, Fianarantsoa, Madagascar
| | - Mamy Jean de Dieu Randria
- Department of Infectious Diseases, University Hospital Joseph Raseta Befelatanana Antananarivo, Antananarivo, Madagascar
- Faculty of Medicine, University of Antananarivo, Antananarivo, Madagascar
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8
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Odayar J, Myer L, Kabanda S, Knight L. Experiences of transfer of care among postpartum women living with HIV attending primary healthcare services in South Africa. Glob Public Health 2024; 19:2356624. [PMID: 38820565 DOI: 10.1080/17441692.2024.2356624] [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: 11/20/2023] [Accepted: 05/13/2024] [Indexed: 06/02/2024]
Abstract
Transfers between health facilities for postpartum women living with HIV are associated with disengagement from care. In South Africa, women must transfer from integrated antenatal/HIV care to general HIV services post-delivery. Thereafter, women transfer frequently e.g. due to geographic mobility. To explore barriers to transfer, we conducted in-depth interviews >2 years post-delivery in 28 participants in a trial comparing postpartum HIV care at primary health care (PHC) antiretroviral therapy (ART) facilities versus a differentiated service delivery model, the adherence clubs, which are the predominant model implemented in South Africa. Data were thematically analysed using inductive and deductive approaches. Women lacked information including where they could transfer to and transfer processes. Continuity mechanisms were affected when women transferred silently i.e. without informing facilities or obtaining referral letters. Silent transfers often occurred due to poor relationships with healthcare workers and were managed inconsistently. Fear of disclosure to family and community stigma led to transfers from local PHC ART facilities to facilities further away affecting accessibility. Mobility and the postpartum period presented unique challenges requiring specific attention. Information regarding long-term care options and transfer processes, ongoing counselling regarding disclosure and social support, and increased health system flexibility are required.
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Affiliation(s)
- Jasantha Odayar
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Siti Kabanda
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Lucia Knight
- Division of Social and Behavioural Sciences, School of Public Health, University of Cape Town, Cape Town, South Africa
- School of Public Health, University of the Western Cape, Bellville, South Africa
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Amanya I, Muhoozi M, Aruhomukama D, Ssebagereka A, Mugambe R. Isoniazid preventive therapy completion and factors associated with non-completion among patients on antiretroviral therapy at Kisenyi Health Centre IV, Kampala, Uganda. PLoS One 2023; 18:e0277739. [PMID: 37607176 PMCID: PMC10443854 DOI: 10.1371/journal.pone.0277739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 08/02/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Isoniazid preventive therapy (IPT) is given to HIV patients to reduce the risk of active tuberculosis (TB). However, treatment completion remains suboptimal among those that are initiated. This study aimed to determine the completion level of IPT and the factors associated with non-completion among patients on antiretroviral therapy (ART) at Kisenyi Health Center IV in Kampala, Uganda. METHODS A mixed-methods facility-based retrospective cohort study utilizing routinely collected data from 341 randomly selected HIV patients initiated on IPT was conducted. Data extracted from the registers was used to determine IPT completion. Robust Poisson regression was conducted to determine the associated factors of IPT non-completion, while in-depth interviews were conducted to explore barriers to IPT completion from the patient's perspective. RESULTS A total of 341 patients who started on isoniazid (INH) were retrospectively followed up, with 69% (236/341) being female. Overall IPT completion was 83%. Multivariate analysis revealed the prevalence of IPT non-completion among males was 2.24 times the prevalence among females (aPR 2.24, 95% CI: 1.40-3.58, p = 0.001). The prevalence of IPT non-completion among patients with a non-suppressed HIV viral load was 3.00 times the prevalence among those with a suppressed HIV viral load (aPR 3.00, 95% CI: 1.44-6.65, p = 0.007). The prevalence of IPT non-completion among patients who were married, or cohabiting was 0.31 times the prevalence among those who were single (aPR 0.31, 95% CI: 0.17-0.55, p<0.000). Lack of IPT-related health education, pill burden, distance to the health facility, and patient relocation were reported as barriers to IPT completion. CONCLUSION IPT completion was found to be 83% among the cohort studied. However, lower completion levels persist among males and HIV-virally non-suppressed patients. Lack of IPT-related health education, pill burden, distance to the health facility, and patient relocation were reported as barriers to IPT completion. Interventions that target these groups of people need to be intensified.
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Affiliation(s)
- Ian Amanya
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Brainmann Analytics, Kampala, Uganda
| | - Michael Muhoozi
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Dickson Aruhomukama
- Brainmann Analytics, Kampala, Uganda
- Department of Medical Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Immunology and Molecular Biology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Anthony Ssebagereka
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Richard Mugambe
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Pry JM, Mwila C, Kapesa H, Mulabe M, Frimpong C, Moono M, Savory T, Bolton-Moore C, Herce ME, Iyer S. Estimating potential silent transfer using baseline viral load measures among people presenting as new to HIV care in Lusaka, Zambia: a cross-sectional study. BMJ Open 2023; 13:e070384. [PMID: 37230517 DOI: 10.1136/bmjopen-2022-070384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVES To estimate potential silent transfer using baseline viral load measures among individuals presenting as new to HIV care in routine HIV clinical settings in Lusaka, Zambia. DESIGN Cross-sectional study. SETTING Two large, urban government-operated health facilities supported by the Centre for Infectious Disease Research in Zambia. PARTICIPANTS A total of 248 participants with an incident positive HIV rapid test. OUTCOME MEASURES The primary outcome measure was HIV viral suppression at baseline (i.e., potential silent transfer), defined as having a viral load ≤1000 RNA copies(c)/mL at the time of initiating HIV care. We also examined viral suppression at ≤60 c/mL. METHODS We surveyed and measured baseline HIV viral load as part of the national recent infection testing algorithm among people living with HIV (PLWH) presenting as new to care. Using mixed effects Poisson regression, we identified characteristics among PLWH associated with potential silent transfer. RESULTS Among the 248 PLWH included, 63% were women with median age of 30, and 66 (27% (66/248)) had viral suppression at ≤1000 c/mL and 53 (21% (53/248)) at ≤60 c/mL thresholds, respectively. Participants aged 40+ years had a significantly higher adjusted prevalence of potential silent transfer (adjusted prevalence ratio (aPR): 2.10; 95% CI: 2.08, 2.13) compared with participants aged 18-24 years. Participants reporting no formal education had a significantly higher adjusted prevalence of potential silent transfer (aPR: 1.63; 95% CI: 1.52, 1.75) compared with those completing primary education. Among 57 potential silent transfers who completed a survey, 44 (77%) indicated having tested positive previously at ≥1 of 38 clinics in Zambia. CONCLUSIONS The high proportion of PLWH with potential silent transfer points to clinic shopping and/or co-enrolment at multiple care sites simultaneously, suggesting an opportunity to improve care continuity at the time of HIV care entry.
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Affiliation(s)
- Jake M Pry
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Public Health Sciences, University of California Davis School of Medicine, Sacramento, California, USA
| | - Chilambwe Mwila
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Herbert Kapesa
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Musunge Mulabe
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Christiana Frimpong
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Misinzo Moono
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Theodora Savory
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Disease, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Michael E Herce
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Shilpa Iyer
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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Leslie HH, Mooney AC, Gilmore HJ, Agnew E, Grignon JS, deKadt J, Shade SB, Ratlhagana MJ, Sumitani J, Barnhart S, Steward WT, Lippman SA. Prevalence, motivation, and outcomes of clinic transfer in a clinical cohort of people living with HIV in North West Province, South Africa. BMC Health Serv Res 2022; 22:1584. [PMID: 36572869 PMCID: PMC9791728 DOI: 10.1186/s12913-022-08962-8] [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: 09/07/2022] [Accepted: 12/13/2022] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Continuity of care is an attribute of high-quality health systems and a necessary component of chronic disease management. Assessment of health information systems for HIV care in South Africa has identified substantial rates of clinic transfer, much of it undocumented. Understanding the reasons for changing sources of care and the implications for patient outcomes is important in informing policy responses. METHODS In this secondary analysis of the 2014 - 2016 I-Care trial, we examined self-reported changes in source of HIV care among a cohort of individuals living with HIV and in care in North West Province, South Africa. Individuals were enrolled in the study within 1 year of diagnosis; participants completed surveys at 6 and 12 months including items on sources of care. Clinical data were extracted from records at participants' original clinic for 12 months following enrollment. We assessed frequency and reason for changing clinics and compared the demographics and care outcomes of those changing and not changing source of care. RESULTS Six hundred seventy-five (89.8%) of 752 study participants completed follow-up surveys with information on sources of HIV care; 101 (15%) reported receiving care at a different facility by month 12 of follow-up. The primary reason for changing was mobility (N=78, 77%). Those who changed clinics were more likely to be young adults, non-citizens, and pregnant at time of diagnosis. Self-reported clinic attendance and ART adherence did not differ based on changing clinics. Those on ART not changing clinics reported 0.66 visits more on average than were documented in clinic records. CONCLUSION At least 1 in 6 participants in HIV care changed clinics within 2 years of diagnosis, mainly driven by mobility; while most appeared lost to follow-up based on records from the original clinic, self-reported visits and adherence were equivalent to those not changing clinics. Routine clinic visits could incorporate questions about care at other locations as well as potential relocation, particularly for younger, pregnant, and non-citizen patients, to support existing efforts to make HIV care records portable and facilitate continuity of care across clinics. TRIAL REGISTRATION The original trial was registered with ClinicalTrials.gov , NCT02417233, on 12 December 2014.
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Affiliation(s)
- Hannah H. Leslie
- grid.266102.10000 0001 2297 6811Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Alyssa C. Mooney
- grid.266102.10000 0001 2297 6811Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA USA
| | - Hailey J. Gilmore
- grid.266102.10000 0001 2297 6811Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Emily Agnew
- grid.266102.10000 0001 2297 6811Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Jessica S. Grignon
- grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA ,International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Julia deKadt
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Starley B. Shade
- grid.266102.10000 0001 2297 6811Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Mary Jane Ratlhagana
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Jeri Sumitani
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Scott Barnhart
- grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA
| | - Wayne T. Steward
- grid.266102.10000 0001 2297 6811Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Sheri A. Lippman
- grid.266102.10000 0001 2297 6811Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
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Jiamsakul A, Gani Y, Avihingsanon A, Azwa I, Chaiwarith R, Khusuwan S, Ross J, Law M, Kiertiburanakul S. Brief Report: Mortality After Loss to Follow-Up-A Linkage Study of People Living With HIV in Thailand and Malaysia. J Acquir Immune Defic Syndr 2022; 91:290-295. [PMID: 35969472 PMCID: PMC9588686 DOI: 10.1097/qai.0000000000003067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 07/15/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Linkage studies have reported high rates of previously unascertained mortality among people living with HIV (PLHIV) who have been lost to follow-up (LTFU). We assessed survival outcomes among PLHIV who were LTFU in Thailand and Malaysia, through linkages to a national death registry or HIV database. METHODS Data linkages with the national death registry or national HIV database were conducted in 2020 on all PLHIV who met LTFU criteria while enrolled in care at participating HIV clinical sites. LTFU was defined as having no documented clinical contact in the previous year, excluding transfers and deaths. Survival time was analyzed using the Cox regression, stratified by site. RESULTS Data linkages were performed for 489 PLHIV who had been LTFU at sites in Malaysia (n = 2) and Thailand (n = 4). There were 151 (31%) deaths after being LTFU; the mortality rate was 4.89 per 100 person-years. Risk factors for mortality after being LTFU were older age [41-50 years: hazard ratio (HR) = 1.99, 95% confidence interval (CI): 1.08 to 3.68; and older than 50 years: HR = 4.93, 95% CI: 2.63 to 9.22; vs. age 30 years or younger]; receiving NRTI + PI (HR = 1.87, 95% CI: 1.22 to 2.85 vs. NRTI + NNRTI); positive hepatitis C antibody (HR = 2.25, 95% CI: 1.40 to 3.62); and having previous AIDS illness (HR = 1.45, 95% CI: 1.03 to 2.05). An improved survival was seen with a higher CD4 count (CD4 351-500 cells/µL: HR = 0.40, 95%CI: 0.21-0.76; and CD4 >500 cells/µL: HR = 0.43, 95%CI: 0.25-0.75; vs. CD4 ≤200 cells/µL). CONCLUSIONS Almost one-third of PLHIV who were LTFU in this cohort had died while out of care, emphasizing the importance of efforts to reengage PLHIV after they have been LTFU and ensure they have access to ongoing ART.
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Affiliation(s)
| | - Yasmin Gani
- Hospital Sungai Buloh, Sungai Buloh, Malaysia
| | - Anchalee Avihingsanon
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Center of Excellence in Tuberculosis, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Iskandar Azwa
- University of Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Romanee Chaiwarith
- Chiang Mai University - Research Institute for Health Sciences, Chiang Mai, Thailand
| | | | - Jeremy Ross
- TREAT Asia, amfAR - The Foundation for AIDS Research, Bangkok, Thailand
| | - Matthew Law
- The Kirby Institute, UNSW Sydney, NSW, Australia
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Muhula SO, Gachohi J, Kombe Y, Karanja S. Six-Months Retention on Treatment and Attrition Risk Factors among People Living with HIV in Kibera Informal Settlement, Nairobi, Kenya. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12657. [PMID: 36231957 PMCID: PMC9565028 DOI: 10.3390/ijerph191912657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/22/2022] [Accepted: 09/27/2022] [Indexed: 06/16/2023]
Abstract
Early retention of patients on HIV treatment is vital in preventing new infections, reducing transmissions, preventing AIDS related deaths and achieving viral suppression. This study sought to determine the effectiveness of non-cash intervention (reminding HIV positive patients at every clinic visit that they stand to receive free T-shirts of their favorite football team or free Kiondos based on preference if they made it to the sixth month visit without missing a treatment appointment) and psychosocial support on retention during the first six months of HIV treatment. This unblinded randomized control trial was conducted at three health centers within the Kibera informal settlement in Nairobi, Kenya. Participants were randomly assigned to the intervention and control groups at a ratio of 1:1. Eligible participants were patients who newly tested HIV positive and enrolled for treatment at the study sites, were 18 years and older and were willing and able to provide informed consent to participate in the study. The primary outcome of interest was retention on treatment at six months. The overall retention on treatment at six months was 93%. Retention at six months among the intervention and control groups was 94% and 91%, respectively (aRR: 1.03; 95% CI: 0.98-1.09; p-value = 0.24). Attrition from treatment was significantly associated with being divorced, being single/never married, time to clinic, participant weight and being on other first line ART regimens other than TDF/3TC/DTG and TDF/3TC/EFV. Mortality and lost to follow-up rates were 1.6 and 13.5 per 100 person-years, respectively. The combination of non-cash incentives and psychosocial support did not improve retention during the first six months of HIV treatment. To reduce further attrition in the early stages of HIV treatment, innovative strategies are needed to reach divorced and not married/single patients earlier and support them to remain on treatment. Efforts should also be made to further decentralize ART treatment to reduce costs and time associated with travelling to and from hospitals.
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Affiliation(s)
- Samuel Opondo Muhula
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi P.O. Box 62000-00200, Kenya
- Amref Health Africa, Nairobi P.O. Box 30125-00100, Kenya
| | - John Gachohi
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi P.O. Box 62000-00200, Kenya
| | - Yeri Kombe
- Kenya Medical Research Institute, Nairobi P.O. Box 54840-00200, Kenya
| | - Simon Karanja
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi P.O. Box 62000-00200, Kenya
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Ssemwogerere A, Kamya JK, Nuwasasira L, Ahura C, Isooba DI, Wakida EK, Obua C, Migisha R. Self-transfers and factors associated with successful tracing among persons lost to follow-up from HIV care, Sheema District, Southwestern Uganda: retrospective medical records review, 2017-2021. AIDS Res Ther 2022; 19:44. [PMID: 36127692 PMCID: PMC9487036 DOI: 10.1186/s12981-022-00471-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Due to improved coverage and scale-up of antiretroviral therapy (ART), patients are increasingly transferring between ART-providing sites. Self-transfers may constitute a high proportion of patients considered lost to follow-up (LTFU), and if overlooked when reporting patients who have dropped out of HIV care, may result in an incorrect estimation of retention. We determined the prevalence of self-transfers, and successful tracing, and identified associated factors among people living with HIV (PLHIV) LTFU from care at public health facilities in Sheema District, Southwestern Uganda. METHODS We conducted a cross-sectional retrospective medical records review during February and March 2022. We included records of all PLHIV who were LTFU from 2017 to 2021, and who were registered at government-owned ART clinics in Sheema District. LTFU was considered for those who were not taking ART refills for a period of ≥ 3 months. We abstracted demographic and clinical data from medical records at the selected clinics. Participants were traced via phone calls or in-person to ascertain the outcomes of LTFU. We performed multivariate modified Poisson regression to identify factors associated with self-transfer, and successful tracing. RESULTS Overall, 740 patients were identified as LTFU from three ART-providing clinics; of these, 560 (76%) were self-transfers. The mean age was 30 (SD ± 10) years, and most (69%, n = 514) were female; the majority (87%, 641/740) were successfully traced. Age (adjusted prevalence ratio [aPR] = 1.13, 95% CI 1.01-1.25, P = 0.026 for those aged 18-30 years compared to > 30 years), female sex (aPR = 1.18, 95% CI 1.11-1.25, P < 0.001), and having WHO clinical stage 1-2 (aPR = 2.34, 95% CI 1.89-3.91, P < 0.001) were significantly associated with self-transfer. Presence of a phone contact in the patient's file (aPR = 1.10, 95% CI 1.01-1.90, P = 0.026) was associated with successful tracing of the patients considered LTFU. CONCLUSION Self-transfers accounted for the majority of patients recorded as LTFU, highlighting the need to account for self-transfers among patients considered LTFU, to accurately estimate retention in care. ART-providing facilities should regularly update contact information for PLHIV to enable successful tracing, in the event that the patients are LTFU. This calls for a health-tracking system that easily identifies self-transfers across ART-providing clinics using unique patient identifiers.
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Affiliation(s)
- Arnold Ssemwogerere
- Department of Pharmacy, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Javilla Kakooza Kamya
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lillian Nuwasasira
- Department of Pharmaceutical Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Claire Ahura
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Derrick Isaac Isooba
- Department of Medical Laboratory Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Edith K Wakida
- Department of Medical Education, California University of Science and Medicine, San Bernardino, USA.,Office of Research Administration, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Celestino Obua
- Office of Research Administration, Mbarara University of Science and Technology, Mbarara, Uganda.,Office of the Vice Chancellor, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Richard Migisha
- Department of Physiology, Mbarara University of Science and Technology, P.O BOX 1410, Mbarara, Uganda.
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15
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Beeman A, Bengtson AM, Swartz A, Colvin CJ, Lurie MN. Cyclical Engagement in HIV Care: A Qualitative Study of Clinic Transfers to Re-enter HIV Care in Cape Town, South Africa. AIDS Behav 2022; 26:2387-2396. [PMID: 35061116 PMCID: PMC9167245 DOI: 10.1007/s10461-022-03582-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2022] [Indexed: 01/25/2023]
Abstract
Long-term patient engagement and retention in HIV care is an ongoing challenge in South Africa's strained health system. However, some patients thought to be "lost to follow-up" (LTFU) may have "transferred" clinics to receive care elsewhere. Through semi-structured interviews, we explored the relationship between clinic transfer and long-term patient engagement among 19 treatment-experienced people living with HIV (PLWH) who self-identified as having engaged in a clinic transfer at least once since starting antiretroviral therapy (ART) in Gugulethu, Cape Town. Our findings suggest that patient engagement is often fluid, as PLWH cycle in and out of care multiple times during their lifetime. The linear nature of the HIV care cascade model poorly describes the lived realities of PLWH on established treatment. Further research is needed to explore strategies for reducing unplanned clinic transfers and offer more supportive care to new and returning patients.
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Affiliation(s)
- Aly Beeman
- Brown University School of Public Health, Providence, RI, USA
| | - Angela M Bengtson
- Department of Epidemiology, Brown University School of Public Health, Box GS-121-2, Room 221, 121 South Main Street, Providence, RI, 02912, USA
| | - Alison Swartz
- Department of Epidemiology, Brown University School of Public Health, Box GS-121-2, Room 221, 121 South Main Street, Providence, RI, 02912, USA
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Christopher J Colvin
- Department of Epidemiology, Brown University School of Public Health, Box GS-121-2, Room 221, 121 South Main Street, Providence, RI, 02912, USA
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Mark N Lurie
- Department of Epidemiology, Brown University School of Public Health, Box GS-121-2, Room 221, 121 South Main Street, Providence, RI, 02912, USA.
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
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16
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Odayar J, Chi BH, Phillips TK, Mukonda E, Hsiao NY, Lesosky M, Myer L. Transfer of Patients on Antiretroviral Therapy Attending Primary Health Care Services in South Africa. J Acquir Immune Defic Syndr 2022; 90:309-315. [PMID: 35298449 DOI: 10.1097/qai.0000000000002950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/22/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients stable on antiretroviral therapy (ART) may require transfer between health care facilities to maintain continuous care, yet data on the frequency, predictors, and virologic outcomes of transfers are limited. METHODS Data for all viral load (VL) testing at public sector health facilities in the Western Cape Province (2011-2018) were obtained. Participant inclusion criteria were a first VL between 2011 and 2013, age >15 years at ART initiation, and >1 VL within 5 years of ART initiation, of which ≥1 was at a primary health care facility. Two successive VLs taken at different facilities indicated a transfer. We assessed predictors of transfer using generalized estimating equations with Poisson regression and the association between transfer and subsequent VL> 1000 copies/mL using generalized mixed effects. RESULTS Overall 84,814 participants (median age at ART initiation 34 years and 68% female) were followed up for up to 4.5 years after their first VL: 34% (n = 29,056) transferred at least once, and among these, 26% transferred twice and 11% transferred thrice or more. Female sex, age <30 years, and first VL > 1000 copies/mL were independently associated with an increased rate of transfer [adjusted rate ratio 1.24, 95% confidence interval (CI): 1.21 to 1.26; 1.34, 95% CI: 1.31 to 1.36; and 1.42, 95% CI: 1.38 to 1.45, respectively]. Adjusting for age, sex, and disengagement, transfer was associated with an increased relative odds of VL > 1000 copies/mL (odds ratio 1.35, 95% CI: 1.29 to 1.42). CONCLUSIONS Approximately one-third of participants transferred and virologic outcomes were poor post-transfer. Stable patients who transfer may require additional support to maintain adherence.
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Affiliation(s)
- Jasantha Odayar
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; and
| | - Tamsin K Phillips
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elton Mukonda
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nei-Yuan Hsiao
- Division of Medical Virology, National Health Laboratory Service, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Maia Lesosky
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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17
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Samba BO, Lewis-Kulzer J, Odhiambo F, Juma E, Mulwa E, Kadima J, Bukusi EA, Cohen CR. Exploring Estimates and Reasons for Lost to Follow-Up Among People Living With HIV on Antiretroviral Therapy in Kisumu County, Kenya. J Acquir Immune Defic Syndr 2022; 90:146-153. [PMID: 35213856 PMCID: PMC9203903 DOI: 10.1097/qai.0000000000002942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 02/11/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND A better understanding why people living with HIV (PLHIV) become lost to follow-up (LTFU) and determining who is LTFU in a program setting is needed to attain HIV epidemic control. SETTING This retrospective cross-sectional study used an evidence-sampling approach to select health facilities and LTFU patients from a large HIV program supporting 61 health facilities in Kisumu County, Kenya. METHODS Eligible PLHIV included adults 18 years and older with at least 1 clinic visit between September 1, 2016, and August 31, 2018, and were LTFU (no clinical contact for ≥90 days after their last expected clinic visit). From March to June 2019, demographic and clinical variables were collected from a sample of LTFU patient files at 12 health facilities. Patient care status and retention outcomes were determined through program tracing. RESULTS Of 787 LTFU patients selected and traced, 36% were male, median age was 30.5 years (interquartile range: 24.6-38.0), and 78% had their vital status confirmed with 560 (92%) alive and 52 (8%) deceased. Among 499 (89.0%) with a retention outcome, 233 (46.7%) had stopped care while 266 (53.3%) had self-transferred to another facility. Among those who had stopped care, psychosocial reasons were most common {65.2% [95% confidence interval (CI): 58.9 to 71.1]} followed by structural reasons [29.6% (95% CI: 24.1 to 35.8)] and clinic-based reasons [3.0% (95% CI: 1.4 to 6.2)]. CONCLUSION We found that more than half of patients LTFU were receiving HIV care elsewhere, leading to a higher overall patient retention rate than routinely reported. Similar strategies could be considered to improve the accuracy of reporting retention in HIV care.
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Affiliation(s)
- Benard O Samba
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Jayne Lewis-Kulzer
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA; and
| | - Francesca Odhiambo
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Eric Juma
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Edwin Mulwa
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Julie Kadima
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Elizabeth A Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA; and
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18
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Nshimirimana C, Ndayizeye A, Smekens T, Vuylsteke B. Loss to follow-up of patients in HIV care in Burundi: A retrospective cohort study. Trop Med Int Health 2022; 27:574-582. [PMID: 35411666 DOI: 10.1111/tmi.13753] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective was to assess the loss to follow-up (LTFU) rates and associated factors amongst patients in HIV care in Burundi. METHODS We conducted a retrospective cohort study in HIV-positive patients aged ≥15 years who started antiretroviral therapy (ART) between January 2015 and July 2020, with 31 December 2020 as the end point. The outcome of LTFU was defined as failure of a patient to report for drug refill within 90 days from the last appointment. Study data were extracted from the national AIDS Info database. The LTFU proportion was determined using the Kaplan-Meier method with the log-rank test, whereas LTFU risk factors were explored using the Cox regression model. RESULTS A total of 29,829 patients on ART were included in the analysis. Cumulative incidence of LTFU was 2.3% at 12 months, 6.5% at 24 months, 12.7% at 36 months, 19.0% at 48 months, 24.1% at 60 months and 25.3% at 72 months. The overall LTFU incidence rate was 11.2 per 100 person-years of observation. The risk of LTFU was higher amongst patients who started ART after 2016 (adjusted hazard ratio [aHR] 1.75, 95% confidence interval [CI] 1.65-1.85) or within 7 days after diagnosis (aHR 1.27, 95% CI 1.21-1.35). CONCLUSION Our findings demonstrate the relatively high incidence of LTFU in the Burundi HIV programme. Interventions targeting patients with risk factors for LTFU are particularly necessary.
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Affiliation(s)
| | - Aimé Ndayizeye
- HIV/STIs Burundi National Program, Ministry of Public Health, Bujumbura, Burundi
| | - Tom Smekens
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bea Vuylsteke
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Stockman J, Friedman J, Sundberg J, Harris E, Bailey L. Predictive Analytics Using Machine Learning to Identify ART Clients at Health System Level at Greatest Risk of Treatment Interruption in Mozambique and Nigeria. J Acquir Immune Defic Syndr 2022; 90:154-160. [PMID: 35262514 DOI: 10.1097/qai.0000000000002947] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 02/23/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND A core objective of HIV/AIDS programming is keeping clients on treatment to improve their health outcomes and to limit spread. Machine learning and artificial intelligence can combine client, temporal, and locational attributes to identify which clients are at greatest risk of loss to follow-up (LTFU) and enable health providers to direct support interventions accordingly. SETTING The analysis was part of a project funded by U.S. President's Emergency Plan for AIDS Relief and United States Agency for International Development, Data for Implementation, and applied to data from publicly available sources (health facility data, geospatial data, and satellite imagery) and de-identified electronic medical record data on antiretroviral therapy clients in Nigeria and Mozambique. METHODS The project applied binary classification techniques using temporal cross-validation to predict the risk that patients would be LTFU. Classifiers included logistic regression, neural networks, and tree-based models. RESULTS Models showed strong predictive power in both settings. In Mozambique, the best-performing model, a Random Forest, achieved an area under the precision-recall curve of 0.65 compared against an underlying LTFU rate of 23%. In Nigeria, the best-performing model, a boosted tree, achieved an area under the precision-recall curve of 0.52 compared against an underlying LTFU rate of 27%. CONCLUSIONS Machine-learned models outperformed current classification techniques and showed potential to better direct health worker resources toward patients at greatest risk of LTFU. Moreover, models performed equally across sex and age groups, supporting the model's generalizability and wider application.
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Affiliation(s)
- Jeni Stockman
- Data for Implementation (Data.FI) Project, Macro-Eyes, Washington, DC
| | | | - Johnna Sundberg
- Data for Implementation (Data.FI) Project, Macro-Eyes, Washington, DC
| | - Emily Harris
- United States Agency for International Development (USAID), Office of HIV/AIDS, Washington, DC
| | - Lauren Bailey
- United States Agency for International Development (USAID), Office of HIV/AIDS, Washington, DC
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20
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Long-term HIV treatment outcomes and associated factors in sub-Saharan Africa: multi-country longitudinal cohort analysis. AIDS 2022; 36:1437-1447. [PMID: 35608116 DOI: 10.1097/qad.0000000000003270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In a multicountry prospective cohort of persons with HIV from six countries between 2007 and 2015, we evaluated long-term outcomes of first-line non-nucleoside reverse-transcriptase inhibitor-based antiretroviral therapy (ART), and risk factors for loss-to-follow-up, mortality, virological failure, and incomplete CD4+ T-cell recovery. METHODS We calculated cumulative incidence of lost-to-follow-up, death, virological failure (VL ≥ 1000 cps/ml) and incomplete CD4+ T-cell recovery (<500 cells/μl) at successive years, using Kaplan-Meier and Cox regression. RESULTS Of 2735 participants, 58.0% were female, median age was 37 (interquartile range [IQR] 32-43) years, and median pre-ART CD4+ T-cell count was 135 (IQR 63-205)/μl. Total follow-up time was 7208 person-years (median 24.3 months, IQR 18.7-58.3). Deaths by any cause and loss to follow-up occurred mostly during the first year of ART (84%, 201/240 and 56%, 199/353, respectively). During their first 6 years of ART, 71% (95% confidence interval [CI] 69.0-73.7) were retained on first-line, and among those 90-93% sustained viral suppression (<1000 cps/ml); CD4+ T-cell recovery was incomplete in 60% (220/363) of participants. The risk factors associated with poor outcomes during long-term ART were: for loss-to-follow-up, recent VL ≥1000 cps/ml, recent CD4+ T-cell count ≤50 cells/μl, age <30 years, being underweight; for mortality, recent CD4+ T-cell count ≤50 cells/μl; and, for virological failure, age <40 years, recent CD4+ T-cell count ≤200 cells/μl, poor adherence, male sex, and low-level viremia. CONCLUSION To achieve long-term ART success towards the UNAIDS targets, early ART initiation is crucial, coupled with careful monitoring and retention support, particularly in the first year of ART. Male and youth-centred care delivery models are needed to improve outcomes for those vulnerable groups.
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21
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Sasse SA, Harrington BJ, DiPrete BL, Chagomerana MB, Klyn LL, Wallie SD, Maliwichi M, Jumbe AN, Hoffman IF, Rosenberg NE, Tang JH, Hosseinipour MC. Factors associated with a history of treatment interruption among pregnant women living with HIV in Malawi: A cross-sectional study. PLoS One 2022; 17:e0267085. [PMID: 35439264 PMCID: PMC9017884 DOI: 10.1371/journal.pone.0267085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/02/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction
Long-term care engagement of women on antiretroviral therapy (ART) is essential to effective HIV public health measures. We sought to explore factors associated with a history of HIV treatment interruption among pregnant women living with HIV presenting to an antenatal clinic in Lilongwe, Malawi.
Methods
We performed a cross-sectional study of pregnant women living with HIV who had a history of ART interruption presenting for antenatal care. Women were categorized as either retained in HIV treatment or reinitiating care after loss-to-follow up (LTFU). To understand factors associated with treatment interruption, we surveyed socio-demographic and partner relationship characteristics. Crude and adjusted prevalence ratios (aPR) for factors associated with ART interruption were estimated using modified Poisson regression with robust variance. We additionally present patients’ reasons for ART interruption.
Results
We enrolled 541 pregnant women living with HIV (391 retained and 150 reinitiating). The median age was 30 years (interquartile range (IQR): 25–34). Factors associated with a history of LTFU were age <30 years (aPR 1.46; 95% CI: 1.33–1.63), less than a primary school education (aPR 1.25; CI: 1.08–1.46), initiation of ART during pregnancy or breastfeeding (aPR 1.49, CI: 1.37–1.65), nondisclosure of HIV serostatus to their partner (aPR 1.39, CI: 1.24–1.58), lack of awareness of partner’s HIV status (aPR 1.41, CI: 1.27–1.60), and no contraception use at conception (aPR 1.60, CI 1.40–1.98). Access to care challenges were the most common reasons reported by women for treatment interruption (e.g., relocation, transport costs, or misplacing health documentation).
Conclusions
Interventions that simplify the ART clinic transfer process, facilitate partner disclosure, and provide counseling about the importance of lifelong ART beyond pregnancy and breastfeeding should be further evaluated for improving retention in ART treatment of women living with HIV in Malawi.
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Affiliation(s)
- Simone A. Sasse
- Department of Obstetrics and Gynecology, New York University, New York, New York, United States of America
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
- * E-mail:
| | - Bryna J. Harrington
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Bethany L. DiPrete
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, United States of America
| | | | - Laura Limarzi Klyn
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Shaphil D. Wallie
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Madalitso Maliwichi
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Allan N. Jumbe
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Irving F. Hoffman
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
- Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, United States of America
| | - Nora E. Rosenberg
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
- Department of Health Behavior, The University of North Carolina at Chapel Hill, Chapel Hill, United States of America
| | - Jennifer H. Tang
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
- Department of Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, United States of America
| | - Mina C. Hosseinipour
- University of North Carolina Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
- Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, United States of America
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22
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Interventions to improve early retention of patients in antiretroviral therapy programmes in sub-Saharan Africa: A systematic review. PLoS One 2022; 17:e0263663. [PMID: 35139118 PMCID: PMC8827476 DOI: 10.1371/journal.pone.0263663] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 01/24/2022] [Indexed: 11/24/2022] Open
Abstract
Background Several interventions to improve long term retention (12 months and above) on treatment have been rigorously evaluated in Sub-Saharan Africa (SSA). However, research on interventions to improve retention of patients in the early stages of treatment (6 months) during this era of Universal Test and Treat has only recently emerged. The aim of this study is to systematically map evidence of interventions used to improve early retention of patients in antiretroviral therapy (ART) programmes in SSA. Methods We searched PubMed, EMBASE and Cochrane electronic databases to identify studies describing interventions aimed at improving early retention in ART treatment. We applied the methodological frameworks by Arksey and O’Malley (2005) and Levac et al. (2010). We also followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Interventions were categorized according to key broad areas in the existing literature. Results A total of 2,241 articles were identified of which 19 met the inclusion criteria and were eligible for this review, with the majority either being randomized control trials 32% (n = 6) or cohort studies 32% (n = 6). The studies reviewed were conducted in 11 SSA countries. The most common interventions described under key broad areas included: Health system interventions such as Universal Test-and-Treat, integration of ART initiation, HIV Testing and Counselling and Antenatal Care services and reduction of ART drug costs; Patient centered approaches such as fast track ART initiation, Differentiated Drug Delivery models and point of care HIV birth testing; Behavioral interventions and support through lay counselors, mentor mothers, nurse counselors and application of quality improvement interventions and financial incentives. Majority of the studies targeted the HIV positive adults and pregnant women. Conclusion With the introduction of Universal Test-and-Treat and same-day initiation of ART, findings suggest that adoption of policies that expand ART uptake with the goal of reducing HIV transmission at the population level, promoting patient centered approaches such as fast track ART initiation, Differentiated Service Delivery models and providing adequate support through Mentor Mothers, lay and nurse counselors may improve early retention in HIV care in SSA. However, these interventions have only been tested in few countries in the region which points to how hard evidence based HIV programming is. Further research investigating the impact of individual and a combination of interventions to improve early retention in HIV care, including for various groups at high risk of attrition, is warranted across SSA countries to fast track the achievement of 95-95-95 Joint United Nations Programme on HIV/AIDS (UNAIDS) targets by 2030.
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23
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Etoori D, Kabudula CW, Wringe A, Rice B, Renju J, Gomez-Olive FX, Reniers G. Investigating clinic transfers among HIV patients considered lost to follow-up to improve understanding of the HIV care cascade: Findings from a cohort study in rural north-eastern South Africa. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000296. [PMID: 36962304 PMCID: PMC10022370 DOI: 10.1371/journal.pgph.0000296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 05/02/2022] [Indexed: 11/18/2022]
Abstract
Investigating clinical transfers of HIV patients is important for accurate estimates of retention and informing interventions to support patients. We investigate transfers for adults reported as lost to follow-up (LTFU) from eight HIV care facilities in the Agincourt health and demographic surveillance system (HDSS), South Africa. Using linked clinic and HDSS records, outcomes of adults more than 90 days late for their last scheduled clinic visit were determined through clinic and routine tracing record reviews, HDSS data, and supplementary tracing. Factors associated with transferring to another clinic were determined through Cox regression models. Transfers were graphically and geospatially visualised. Transfers were more common for women, patients living further from the clinic, and patients with higher baseline CD4 cell counts. Transfers to clinics within the HDSS were more likely to be undocumented and were significantly more likely for women pregnant at ART initiation. Transfers outside the HDSS clustered around economic hubs. Patients transferring to health facilities within the HDSS may be shopping for better care, whereas those who transfer out of the HDSS may be migrating for work. Treatment programmes should facilitate transfer processes for patients, ensure continuity of care among those migrating, and improve tracking of undocumented transfers.
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Affiliation(s)
- David Etoori
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chodziwadziwa Whiteson Kabudula
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Alison Wringe
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Brian Rice
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jenny Renju
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Francesc Xavier Gomez-Olive
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Georges Reniers
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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24
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Espinosa Dice AL, Bengtson AM, Mwenda KM, Colvin CJ, Lurie MN. Quantifying clinic transfers among people living with HIV in the Western Cape, South Africa: a retrospective spatial analysis. BMJ Open 2021; 11:e055712. [PMID: 34857581 PMCID: PMC8640660 DOI: 10.1136/bmjopen-2021-055712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/03/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES For persons living with HIV (PLWH) in long-term care, clinic transfers are common and influence sustained engagement in HIV care, as they are associated with significant time out-of-care, low CD4 count, and unsuppressed viral load on re-entry. Despite the geospatial nature of clinic transfers, there exist limited data on the geospatial trends of clinic transfers to guide intervention development. In this study, we investigate the geospatial characteristics and trends of clinic transfers among PLWH on antiretroviral therapy (ART) in the Western Cape Province of South Africa. DESIGN Retrospective spatial analysis. SETTING PLWH who initiated ART treatment between 2012 and 2016 in South Africa's Western Cape Province were followed from ART initiation to their last visit prior to 2017. Deidentified electronic medical records from all public clinical, pharmacy, and laboratory visits in the Western Cape were linked across space and time using a unique patient identifier number. PARTICIPANTS 4176 ART initiators in South Africa (68% women). METHODS We defined a clinic transfer as any switch between health facilities that occurred on different days and measured the distance between facilities using geodesic distance. We constructed network flow maps to evaluate geospatial trends in clinic transfers over time, both for individuals' first transfer and overall. RESULTS Two-thirds of ART initiators transferred health facilities at least once during follow-up. Median distance between all clinic transfer origins and destinations among participants was 8.6 km. Participant transfers were heavily clustered around Cape Town. There was a positive association between time on ART and clinic transfer distance, both among participants' first transfers and overall. CONCLUSION This study is among the first to examine geospatial trends in clinic transfers over time among PLWH. Our results make clear that clinic transfers are common and can cluster in urban areas, necessitating better integrated health information systems and HIV care.
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Affiliation(s)
- Ana Lucia Espinosa Dice
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Angela M Bengtson
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Kevin M Mwenda
- Spatial Structures in the Social Sciences (S4), Population Studies and Training Center (PSTC), Brown University, Providence, Rhode Island, USA
| | - Christopher J Colvin
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Observatory, Western Cape, South Africa
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Mark N Lurie
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
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25
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Han WM, Law MG, Egger M, Wools-Kaloustian K, Moore R, McGowan C, Kumarasamy N, Desmonde S, Edmonds A, Davies MA, Yiannoutsos C, Althoff KN, Cortes CP, Mohamed TJ, Jaquet A, Anastos K, Euvrard J, Castelnuovo B, Salters K, Coelho LE, Ekouevi DK, Eley B, Diero L, Zaniewski E, Ford N, Sohn AH, Kariminia A. Global estimates of viral suppression in children and adolescents and adults on antiretroviral therapy adjusted for missing viral load measurements: a multiregional, retrospective cohort study in 31 countries. Lancet HIV 2021; 8:e766-e775. [PMID: 34856180 PMCID: PMC8782625 DOI: 10.1016/s2352-3018(21)00265-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/12/2021] [Accepted: 09/16/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND As countries move towards the UNAIDS's 95-95-95 targets and with strong evidence that undetectable equals untransmittable, it is increasingly important to assess whether those with HIV who are receiving antiretroviral therapy (ART) achieve viral suppression. We estimated the proportions of children and adolescents and adults with viral suppression at 1, 2, and 3 years after initiating ART. METHODS In this retrospective cohort study, seven regional cohorts from the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium contributed data from individuals initiating ART between Jan 1, 2010, and Dec 31, 2019, at 148 sites in 31 countries with annual viral load monitoring. Only people with HIV who started ART after the time a site started routine viral load monitoring were included. Data up to March 31, 2020, were analysed. We estimated the proportions of children and adolescents (aged <18 years at ART initiation) and adults (aged ≥18 years at ART initiation) with viral suppression (viral load <1000 copies per mL) at 1, 2, and 3 years after ART initiation using an intention-to-treat approach and an adjusted approach that accounted for missing viral load measurements. FINDINGS 21 594 children and adolescents (11 812 [55%] female, 9782 [45%] male) from 106 sites in 22 countries and 255 662 adults (163 831 [64%] female, 91 831 [36%] male) from 143 sites in 30 countries were included. Using the intention-to-treat approach, the proportion of children and adolescents with viral suppression was 7303 (36%) of 20 478 at 1 year, 5709 (30%) of 19 135 at 2 years, and 4287 (24%) of 17 589 at 3 years after ART initiation; the proportion of adults with viral suppression was 106 541 (44%) of 240 600 at 1 year, 79 141 (36%) of 220 925 at 2 years, and 57 970 (29%) of 201 124 at 3 years after ART initiation. After adjusting for missing viral load measurements among those who transferred, were lost to follow-up, or who were in follow-up without viral load testing, the proportion of children and adolescents with viral suppression was 12 048 (64% [plausible range 43-81]) of 18 835 at 1 year, 10 796 (62% [41-77]) of 17 553 at 2 years, and 9177 (59% [38-91]) of 15 667 at 3 years after ART initiation; the proportion of adults with viral suppression was 176 964 (79% [53-80]) of 225 418 at 1 year, 145 552 (72% [48-79]) of 201 238 at 2 years, and 115 260 (65% [43-69]) of 178 458 at 3 years after ART initiation. INTERPRETATION Although adults with HIV are approaching the global target of 95% viral suppression, progress among children and adolescents is much slower. Substantial efforts are still needed to reach the viral suppression target for children and adolescents. FUNDING US National Institutes of Health.
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Affiliation(s)
- Win Min Han
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand.
| | - Matthew G Law
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Richard Moore
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Catherine McGowan
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nagalingesawaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site, The Voluntary Health Services, Chennai, India
| | | | - Andrew Edmonds
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mary-Ann Davies
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Keri N Althoff
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Claudia P Cortes
- Fundación Arriaran-Facultad de Medicina Universidad de Chile, Santiago, Chile
| | | | - Antoine Jaquet
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development, UMR 1219, Bordeaux, France
| | - Kathryn Anastos
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jonathan Euvrard
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Kate Salters
- British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada
| | - Lara Esteves Coelho
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Didier K Ekouevi
- Program PAC-CI, Abidjan, Côte d'Ivoire; Bordeaux Population Health (UMR1219), Bordeaux, France
| | - Brian Eley
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Lameck Diero
- Department of Medicine, Moi University School of Medicine and Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Elizabeth Zaniewski
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nathan Ford
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; HIV/AIDS Department and Global Hepatitis Program, WHO, Geneva, Switzerland
| | - Annette H Sohn
- TREAT Asia/amfAR, The Foundation for AIDS Research, Bangkok, Thailand
| | - Azar Kariminia
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
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Ford N, Crawford KW, Ameyan W. Rapidly starting antiretroviral therapy to improve outcomes among disadvantaged groups. AIDS 2021; 35:2217-2219. [PMID: 34602591 PMCID: PMC8505146 DOI: 10.1097/qad.0000000000003052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 08/10/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Nathan Ford
- Global HIV, Hepatitis and Sexually Transmitted Infections Programme, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Keith W. Crawford
- Therapeutic Research Program, Division of AIDS, National Institute of Allergy and Infectious Disease, National Institutes of Health, Rockville, MD, USA
| | - Wole Ameyan
- Global HIV, Hepatitis and Sexually Transmitted Infections Programme, World Health Organization, Geneva, Switzerland
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27
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Low A, Sachathep K, Rutherford G, Nitschke AM, Wolkon A, Banda K, Miller LA, Solmo C, Jackson K, Patel H, McCracken S, Findley S, Mutenda N. Migration in Namibia and its association with HIV acquisition and treatment outcomes. PLoS One 2021; 16:e0256865. [PMID: 34473757 PMCID: PMC8412347 DOI: 10.1371/journal.pone.0256865] [Citation(s) in RCA: 6] [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: 01/12/2021] [Accepted: 08/17/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In the 21st century, understanding how population migration impacts human health is critical. Namibia has high migration rates and HIV prevalence, but little is known about how these intersect. We examined the association between migration and HIV-related outcomes using data from the 2017 Namibia Population-based HIV Impact Assessment (NAMPHIA). METHODS AND FINDINGS The NAMPHIA survey selected a nationally representative sample of adults in 2017. All adults aged 15-64 years were invited to complete an interview and home-based HIV test. Recent infection (<130 days) was measured using HIV-1 LAg avidity combined with viral load (>1000 copies/mL) and antiretroviral analyte data. Awareness of HIV status and antiretroviral use were based on self-report and/or detectable antiretrovirals in blood. Viremia was defined as having a viral load ≥1000 copies/mL, including all participants in the denominator regardless of serostatus. We generated community viremia values as a weighted proportion at the EA level, excluding those classified as recently infected. Significant migrants were those who had lived outside their current region or away from home >one month in the past three years. Recent cross-community in-migrants were those who had moved to the community <two years ago. Separate analyses were done to compare significant migrants to non-migrants and recent cross-community in-migrants to those who in-migrated >two years ago to determine the association of migration and timing with recent infection or viral load suppression (VLS). All proportions are weighted. Of eligible adults, we had HIV results and migration data on 9,625 (83.9%) of 11,474 women and 7,291 (73.0%) of 9,990 men. Most respondents (62.5%) reported significant migration. Of cross-community in-migrants, 15.3% were recent. HIV prevalence was 12.6% and did not differ by migration status. Population VLS was 77.4%. Recent cross-community in-migration was associated with recent HIV infection (aOR: 4.01, 95% CI 0.99-16.22) after adjusting for community viremia. Significant migration (aOR 0.73, 95% CI: 0.55-0.97) and recent cross-community in-migration (aOR 0.57, 95% CI: 0.35-0.92) were associated with lower VLS, primarily due to lack of awareness of HIV infection. The study was limited by lack of precise data on trajectory of migration. CONCLUSIONS Despite a high population-level VLS, Namibia still has migrant populations that are not accessing effective treatment for HIV. Targeting migrants with effective prevention and testing programs in communities with viremia could enable further epidemic control.
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Affiliation(s)
- Andrea Low
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
- * E-mail:
| | - Karam Sachathep
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - George Rutherford
- Institute for Global Health Sciences, University of California, San Francisco, CA, United States of America
| | | | - Adam Wolkon
- Centers for Disease Control and Prevention, Windhoek, Namibia
| | - Karen Banda
- Institute for Global Health Sciences, University of California, San Francisco, CA, United States of America
| | | | - Chelsea Solmo
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Keisha Jackson
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Center for Global Health, Atlanta, GA, United States of America
| | - Hetal Patel
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Center for Global Health, Atlanta, GA, United States of America
| | - Stephen McCracken
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Center for Global Health, Atlanta, GA, United States of America
| | - Sally Findley
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, United States of America
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Mody A, Tram KH, Glidden DV, Eshun-Wilson I, Sikombe K, Mehrotra M, Pry JM, Geng EH. Novel Longitudinal Methods for Assessing Retention in Care: a Synthetic Review. Curr HIV/AIDS Rep 2021; 18:299-308. [PMID: 33948789 DOI: 10.1007/s11904-021-00561-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW Retention in care is both dynamic and longitudinal in nature, but current approaches to retention often reduce these complex histories into cross-sectional metrics that obscure the nuanced experiences of patients receiving HIV care. In this review, we discuss contemporary approaches to assessing retention in care that captures its dynamic nature and the methodological and data considerations to do so. RECENT FINDINGS Enhancing retention measurements either through patient tracing or "big data" approaches (including probabilistic matching) to link databases from different sources can be used to assess longitudinal retention from the perspective of the patient when they transition in and out of care and access care at different facilities. Novel longitudinal analytic approaches such as multi-state and group-based trajectory analyses are designed specifically for assessing metrics that can change over time such as retention in care. Multi-state analyses capture the transitions individuals make in between different retention states over time and provide a comprehensive depiction of longitudinal population-level outcomes. Group-based trajectory analyses can identify patient subgroups that follow distinctive retention trajectories over time and highlight the heterogeneity of retention patterns across the population. Emerging approaches to longitudinally measure retention in care provide nuanced assessments that reveal unique insights into different care gaps at different time points over an individuals' treatment. These methods help meet the needs of the current scientific agenda for retention and reveal important opportunities for developing more tailored interventions that target the varied care challenges patients may face over the course of lifelong treatment.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA.
| | - Khai Hoan Tram
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
| | - Kombatende Sikombe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
- Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Megha Mehrotra
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Jake M Pry
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
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29
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Kerschberger B, Boulle A, Kuwengwa R, Ciglenecki I, Schomaker M. The Impact of Same-Day Antiretroviral Therapy Initiation Under the World Health Organization Treat-All Policy. Am J Epidemiol 2021; 190:1519-1532. [PMID: 33576383 PMCID: PMC8327202 DOI: 10.1093/aje/kwab032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 01/27/2021] [Accepted: 02/09/2021] [Indexed: 12/18/2022] Open
Abstract
Rapid initiation of antiretroviral therapy (ART) is recommended for people living with human immunodeficiency virus (HIV), with the option to start treatment on the day of diagnosis (same-day ART). However, the effect of same-day ART remains unknown in realistic public sector settings. We established a cohort of ≥16-year-old patients who initiated first-line ART under a treat-all policy in Nhlangano (Eswatini) during 2014-2016, either on the day of HIV care enrollment (same-day ART) or 1-14 days thereafter (early ART). Directed acyclic graphs, flexible parametric survival analysis, and targeted maximum likelihood estimation (TMLE) were used to estimate the effect of same-day-ART initiation on a composite unfavorable treatment outcome (loss to follow-up, death, viral failure, treatment switch). Of 1,328 patients, 839 (63.2%) initiated same-day ART. The adjusted hazard ratio of the unfavorable outcome was higher, 1.48 (95% confidence interval: 1.16, 1.89), for same-day ART compared with early ART. TMLE suggested that after 1 year, 28.9% of patients would experience the unfavorable outcome under same-day ART compared with 21.2% under early ART (difference: 7.7%; 1.3%-14.1%). This estimate was driven by loss to follow-up and varied over time, with a higher hazard during the first year after HIV care enrollment and a similar hazard thereafter. We found an increased risk with same-day ART. A limitation was that possible silent transfers that were not captured.
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Affiliation(s)
- Bernhard Kerschberger
- Correspondence to Dr. Bernhard Kerschberger, Médecins Sans Frontières, Mantsholo Road 325, Mbabane, Eswatini (e-mail: )
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30
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Outcomes of retained and disengaged pregnant women living with HIV in Uganda. PLoS One 2021; 16:e0251413. [PMID: 34019568 PMCID: PMC8139492 DOI: 10.1371/journal.pone.0251413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/26/2021] [Indexed: 02/03/2023] Open
Abstract
Introduction Loss-to-follow-up among women living with HIV (WLWHIV) may lead to unfavorable outcomes for both mother and exposed infant. This study traced WLWHIV disengaged from care and their infants and compared their outcomes with those retained in care. Methods The study included WLWHIV who initiated ART during pregnancy at six public clinics in Uganda. A woman was defined as disengaged (DW) if she had not attended her 6-week post-partum visit by 10 weeks after her estimated date of delivery. DW were matched with retained women (RW) by age and duration on ART. Nurse counselors traced all selected DW via telephone and community visits to assess vital status, infant HIV sero-status and maternal HIV viral load through blood draws. Results Between July 2017 and July 2018, 734 women (359 DW and 375 RW) were identified for the study. Tracing was attempted on 349 DW and 160 (44.6%) were successfully located and enrolled in the study. They were matched with 162 RW. Among DW, 52 (32.5%) transferred to another health facility. Very few DW, 39.0% were HIV virally suppressed (<1000 copies/ml) compared to RW 89.5%, P<0.001). Among 138 babies born to DW, 4.3% tested positive for HIV compared to 1.4% among babies born to RW (P = 0.163). Conclusion Pregnant and breastfeeding WLWHIV who disengage from care are difficult to find in urban environments. Many have detectable viral loads, leading to the potential for an increased risk of MTCT. Efforts to reduce disengagement from care are critical for the successful elimination of MTCT in resource-limited settings.
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Ballif M, Christ B, Anderegg N, Chammartin F, Muhairwe J, Jefferys L, Hector J, van Dijk J, Vinikoor MJ, van Lettow M, Chimbetete C, Phiri SJ, Onoya D, Fox MP, Egger M. Tracing people living with HIV who are lost to follow-up at ART programs in Southern Africa: A sampling-based cohort study in six countries. Clin Infect Dis 2021; 74:171-179. [PMID: 33993219 DOI: 10.1093/cid/ciab428] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Attrition threatens the success of antiretroviral therapy (ART). In this cohort study, we examined outcomes of people living with HIV (PLHIV) lost to follow-up (LTFU) 2014-2017 at ART programs in Southern Africa. METHODS We confirmed LTFU (missed appointment for ≥60 or ≥90 days, according to local guidelines) by checking medical records and used a standardized protocol to trace a weighted random sample of PLHIV who were LTFU in eight ART programs in Lesotho, Malawi, Mozambique, South Africa, Zambia and Zimbabwe, 2017-2019. We ascertained vital status and identified predictors of mortality using logistic regression, adjusted for sex, age, time on ART, time since LTFU, travel time, and urban or rural setting. RESULTS Among 3,256 PLHIV, 385 (12%) were wrongly categorized as LTFU and 577 (17%) had missing contact details. We traced 2,294 PLHIV (71%) by phone calls, home visits or both: 768 (34% of 2,294) were alive and in care, including 385 (17%) silent transfers to another clinic; 528 (23%) were alive without care or unknown care; 252 (11%) had died. Overall, the status of 1,323 (41% of 3,256) PLHIV remained unknown. Mortality was higher in men than women, higher in children than in young people or adults, higher in PLHIV who had been on ART <1 year or lost >1 year, living further from the clinic or in rural areas. Results were heterogeneous across sites. CONCLUSIONS Our study highlights the urgent need for better medical record systems at HIV clinics and rapid tracing of PLHIV who are LTFU.
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Affiliation(s)
- Marie Ballif
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Benedikt Christ
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nanina Anderegg
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | | | | | | | | | | | | | | | | | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa.,Department of Epidemiology and Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Centre for Infectious Disease Research and Epidemiology, University of Cape Town, Cape Town, South Africa.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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32
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Outcomes After Being Lost to Follow-up Differ for Pregnant and Postpartum Women When Compared With the General HIV Treatment Population in Rural South Africa. J Acquir Immune Defic Syndr 2021; 85:127-137. [PMID: 32520907 PMCID: PMC7495979 DOI: 10.1097/qai.0000000000002413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is Available in the Text. Undetermined attrition prohibits full understanding of the coverage and effectiveness of HIV programs. Outcomes following loss to follow-up (LTFU) among antiretroviral therapy (ART) patients may differ according to their reasons for ART initiation.
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Stockton MA, Gaynes BN, Hosseinipour MC, Pettifor AE, Maselko J, Mphonda SM, Kulisewa K, Udedi M, Pence BW. Association Between Depression and HIV Care Engagement Outcomes Among Patients Newly Initiating ART in Lilongwe, Malawi. AIDS Behav 2021; 25:826-835. [PMID: 32970274 PMCID: PMC7886828 DOI: 10.1007/s10461-020-03041-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 12/13/2022]
Abstract
As in other sub-Saharan countries, the burden of depression is high among people living with HIV in Malawi. However, the association between depression at ART initiation and two critical outcomes-retention in HIV care and viral suppression-is not well understood. Prior to the launch of an integrated depression treatment program, adult patients were screened for depression at ART initiation at two clinics in Lilongwe, Malawi. We compared retention in HIV care and viral suppression at 6 months between patients with and without depression at ART initiation using tabular comparison and regression models. The prevalence of depression among this population of adults newly initiating ART was 27%. Those with depression had similar HIV care outcomes at 6 months to those without depression. Retention metrics were generally poor for those with and without depression. However, among those completing viral load testing, nearly all achieved viral suppression. Depression at ART initiation was not associated with either retention or viral suppression. Further investigation of the relationship between depression and HIV is needed to understand the ways depression impacts the different aspects of HIV care engagement.
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Affiliation(s)
- Melissa A Stockton
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA.
| | - Bradley N Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC, 27516, USA
| | - Mina C Hosseinipour
- University of North Carolina Project-Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
- Division of Infectious Disease, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC, 27516, USA
| | - Audrey E Pettifor
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
| | - Joanna Maselko
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
| | - Steven M Mphonda
- University of North Carolina Project-Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Kazione Kulisewa
- College of Medicine, Department of Mental Health, University of Malawi, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Michael Udedi
- NCDs & Mental Health Unit, Ministry of Health, P. O. Box 30377, Capital City, Lilongwe 3, Malawi
- College of Medicine, Department of Mental Health, University of Malawi, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Brian W Pence
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
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34
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Etoori D, Wringe A, Renju J, Kabudula CW, Gomez-Olive FX, Reniers G. Challenges with tracing patients on antiretroviral therapy who are late for clinic appointments in rural South Africa and recommendations for future practice. Glob Health Action 2021; 13:1755115. [PMID: 32340584 PMCID: PMC7241554 DOI: 10.1080/16549716.2020.1755115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: It is common practice for HIV programmes to routinely trace patients who are late for a scheduled clinic visit to ensure continued care engagement. In South Africa, patients who are late for a scheduled visit are identified from clinic registers, and called by telephone up to three times by designated clinic staff, with home visits conducted for those who are unreachable by phone. It is important to understand outcomes among late patients in order to have accurate mortality data, identify defaulters to attempt to re-engage them into care, and have accurate estimates of patients still in care for planning purposes. Objective: We conducted a study to assess whether tracing of HIV patients in clinics in rural north-eastern South Africa was implemented in line with national policies. Methods: Thirty-three person-day of observations took place during multiple visits to eight facilities between October 2017 and January 2018 during which clinic tracing processes were captured. The facility level implementation processes were compared to the intended tracing process and gaps and challenges were identified. Results: Challenges to implementing effective tracing procedures fell into three broad categories: i) facility-level barriers, ii) issues relating to data, documentation and record-keeping, and iii) challenges relating to the roles and responsibilities of the different actors in the tracing cascade. We recommend improving linkages between clinics, improving record-keeping systems, and regular training of community health workers involved in tracing activities. Improved links between clinics would reduce the chance of patients being lost between clinics. Record-keeping systems could be improved through motivating health workers to take ownership of their data and training them on the importance of complete data. Finally, training of community health workers may improve sustained motivation, and improve their ability to respond appropriately to their clients’ needs. Conclusions: Substantial investment in data infrastructure and healthcare staff training is needed to improve routine tracing.
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Affiliation(s)
- David Etoori
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Chodziwadziwa Whiteson Kabudula
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Francesc Xavier Gomez-Olive
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Georges Reniers
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Sikombe K, Mody A, Kadota J, Pry J“J, Simbeza S, Eshun-Wilson I, Situmbeko SR, Bukankala C, Beres L, Mukamba N, Wa Mwanza M, Bolton- Moore C, Holmes CB, Geng EH, Sikazwe I. Understanding patient transfers across multiple clinics in Zambia among HIV infected adults. PLoS One 2020; 15:e0241477. [PMID: 33147250 PMCID: PMC7641414 DOI: 10.1371/journal.pone.0241477] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/15/2020] [Indexed: 12/30/2022] Open
Abstract
Many patients in HIV care in Africa considered lost to follow up (LTFU) at one facility are reportedly accessing care in another. The success of these unofficial transfers as measured by time to re-entry at the new-facility, prevalence of treatment interruptions, speed of ART-initiation, and overall continuity of care is not well characterized but may reveal opportunities for improvement. We traced a random sample of LTFU HIV-infected patients in Zambia. Among those found alive and reported in care at a new-facility, we reviewed records at the receiving facility to verify transfer; and when verified, documented the transfer experience. We used Kaplan-Meier methods to examine incidence of ART-initiation after transfer to new clinic. We assessed demographic and clinical characteristics, official and cross-provincial transfer for associations with HIV treatment re-engagement using Poisson regression models and associations between official-transfer and same-day ART initiation at the new-facility. Among 350 LTFU-patients, 178 (51%) were successfully verified through chart review at the new-facility. 132 (74.2%) were female, 72 (40.4%) aged 25-35, and 51% were ever recorded as previously being on ART. 110 patients (61.8%) were registered under new ART-IDs and 97 (54.5%) received a new HIV test. 54% of those previously on ART-initiated on the same-day. Using the same ART-ID was associated with same-day initiation compared to those receiving a new ART-ID (p = 0.07). 80% (n = 91) of those ever on ART had evidence of medication initiation at new clinic. Among these, initiation reached 66% (95% CI: 56-75) by 30 days, 77.5% (95% CI: 68-86) by 90 days after new-facility presentation. Many patients use new identifiers at new facilities, indicative of inefficiencies. Re-entry into new facilities among the unofficial-transfer population is often delayed and timely treatment initiation is inconsistent, suggesting interruptions in treatment. Health systems innovations to ensure smooth and safe transfers are needed to maintain quality HIV care.
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Affiliation(s)
- Kombatende Sikombe
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Jillian Kadota
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
| | - Jesse “Jake” Pry
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Sandra Simbeza
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | | | - Chama Bukankala
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Laura Beres
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Njekwa Mukamba
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Mwanza Wa Mwanza
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton- Moore
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, University of Alabama, Birmingham, Alabama, United States of America
| | - Charles B. Holmes
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Center for Global Health and Quality, Georgetown University, Washington, District of Columbia, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Izukanji Sikazwe
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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Hannaford A, Moll AP, Madondo T, Khoza B, Shenoi SV. Mobility and structural barriers in rural South Africa contribute to loss to follow up from HIV care. AIDS Care 2020; 33:1436-1444. [PMID: 32856470 DOI: 10.1080/09540121.2020.1808567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Retention in HIV care is crucial to sustaining viral load suppression, and reducing HIV transmission, yet loss to follow-up (LTFU) in South Africa remains substantial. We conducted a mixed methods evaluation in rural South Africa to characterize ART disengagement in neglected rural settings. Using convenience sampling, surveys were completed by 102 PLWH who disengaged from ART (minimum 90 days) and subsequently resumed care. A subset (n = 60) completed individual in-depth interviews. Median duration of ART discontinuation was 9 months (IQR 4-22). Participants had HIV knowledge gaps regarding HIV transmission and increased risk of tuberculosis. The major contributors to LTFU were mobility and structural barriers. PLWH traveled for an urgent family need or employment, and were not able to collect ART while away. Structural barriers included inability to access care, due to lack of financial resources to reach distant clinics. Other factors included dissatisfaction with care, pill fatigue, lack of social support, and stigma. Illness was the major precipitant of returning to care. Mobility and structural barriers impede longitudinal HIV care in rural South Africa, threatening the gains made from expanded ART access. To achieve 90-90-90, future interventions, including emphasis on patient centered care, must address barriers relevant to rural settings.
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Affiliation(s)
- Alisse Hannaford
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anthony P Moll
- Church of Scotland Hospital, Tugela Ferry, South Africa.,Philanjalo NGO, Tugela Ferry, South Africa
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Anderegg N, Hector J, Jefferys LF, Burgos-Soto J, Hobbins MA, Ehmer J, Meier L, Maathuis MH, Egger M. Loss to follow-up correction increased mortality estimates in HIV-positive people on antiretroviral therapy in Mozambique. J Clin Epidemiol 2020; 128:83-92. [PMID: 32828836 DOI: 10.1016/j.jclinepi.2020.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 08/03/2020] [Accepted: 08/18/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES People living with human immunodeficiency virus (HIV) on antiretroviral therapy (ART) may be lost to follow-up (LTFU), which hampers the assessment of outcomes. We estimated mortality for patients starting ART in a rural region in sub-Saharan Africa and examined risk factors for death, correcting for LTFU. STUDY DESIGN AND SETTING We analyzed data from Ancuabe, Mozambique, where patients LTFU are traced by phone and home visits. We used cumulative incidence functions to estimate mortality and LTFU. To correct for LTFU, we revised outcomes based on tracing data using different inverse probability weights (maximum likelihood, Ridge regression, or Bayesian model averaging). We fitted competing risk models to identify risk factors for death and LTFU. RESULTS The analyses included 4,492 patients; during 8,152 person-years of follow-up, 486 patients died, 2,375 were LTFU, 752 were traced, and 603 were found. At 4 years after starting ART, observed mortality was 11.9% (95% confidence interval [CI]: 10.9-13.0), but 23.5% (95% CI: 19.8-28.0), 21.6% (95% CI: 18.7-25.0), and 23.3% (95% CI: 19.7-27.6) after correction with maximum likelihood, Ridge regression, and Bayesian model averaging weights, respectively. The risk factors for death included male sex, lower CD4 cell counts, and more advanced clinical stage. CONCLUSION In ART programs with substantial LTFU, mortality estimates need to take LTFU into account.
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Affiliation(s)
- Nanina Anderegg
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
| | | | | | | | | | | | - Lukas Meier
- Seminar for Statistics, ETH Zürich, Zürich, Switzerland
| | | | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Centre for Infectious Disease Epidemiology & Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Risk factors for loss to follow-up from antiretroviral therapy programmes in low-income and middle-income countries. AIDS 2020; 34:1261-1288. [PMID: 32287056 DOI: 10.1097/qad.0000000000002523] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Loss to follow-up (LTFU) rates from antiretroviral treatment (ART) programmes in low- and middle-income countries (LMIC) are high, leading to poor treatment outcomes and onward transmission of HIV. Knowledge of risk factors is required to address LTFU. In this systematic review, risk factors for LTFU are identified and meta-analyses performed. METHODS PubMed, Embase, Psycinfo and Cochrane were searched for studies that report on potential risk factors for LTFU in adults who initiated ART in LMICs. Meta-analysis was performed for risk factors evaluated by at least five studies. Pooled effect estimates and their 95% confidence intervals (95% CI) were calculated using random effect models with inverse variance weights. Risk of bias was assessed and sensitivity analyses performed. RESULTS Eighty studies were included describing a total of 1 605 320 patients of which 87.4% from sub-Saharan Africa. The following determinants were significantly associated with an increased risk of LTFU in meta-analysis: male sex, older age, being single, unemployment, lower educational status, advanced WHO stage, low weight, worse functional status, poor adherence, nondisclosure, not receiving cotrimoxazole prophylactic therapy when indicated, receiving care at secondary level and more recent year of initiation. No association was seen for CD4 cell count, tuberculosis at baseline, regimen, and geographical setting. CONCLUSION There are several sociodemographic, clinical, patient behaviour, treatment-related and system level risk factors for LTFU from ART programs. Knowledge of risk factors should be used to better target retention interventions and develop tools to identify high-risk patients.
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Etoori D, Wringe A, Kabudula CW, Renju J, Rice B, Gomez-Olive FX, Reniers G. Misreporting of Patient Outcomes in the South African National HIV Treatment Database: Consequences for Programme Planning, Monitoring, and Evaluation. Front Public Health 2020; 8:100. [PMID: 32318534 PMCID: PMC7154050 DOI: 10.3389/fpubh.2020.00100] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 03/12/2020] [Indexed: 01/20/2023] Open
Abstract
Background: Monitoring progress toward global treatment targets using HIV programme data in sub-Saharan Africa has proved challenging. Constraints in routine data collection and reporting can lead to biased estimates of treatment outcomes. In 2010, South Africa introduced an electronic patient monitoring system for HIV patient visits, TIER.Net. We compare treatment status and outcomes recorded in TIER.Net to outcomes ascertained through detailed record review and tracing in order to assess discrepancies and biases in retention and mortality rates. Methods: The Agincourt Health and Demographic Surveillance System (HDSS) in north-eastern South Africa is served by eight public primary healthcare facilities. Since 2014, HIV patient visits are logged electronically at these clinics, with patient records individually linked to their HDSS record. These data were used to generate a list of patients >90 days late for their last scheduled clinic visit and deemed lost to follow-up (LTFU). Patient outcomes were ascertained through a review of the TIER.Net database, physical patient files, registers kept by two non-government organizations that assist with patient tracing, cross-referencing with the HDSS records and supplementary physical tracing. Descriptive statistics were used to compare patient outcomes reported in TIER.Net to their outcome ascertained in the study. Results: Of 1,074 patients that were eligible for this analysis, TIER.Net classified 533 (49.6%) as LTFU, 80 (7.4%) as deceased, and 186 (17.3%) as transferred out. TIER.Net misclassified 36% of patient outcomes, overestimating LTFU and underestimating mortality and transfers out. TIER.Net missed 40% of deaths and 43% of transfers out. Patients categorized as LTFU in TIER.Net were more likely to be misclassified than patients classified as deceased or transferred out. Discussion: Misclassification of patient outcomes in TIER.Net has consequences for programme forecasting, monitoring and evaluation. Undocumented transfers accounted for the majority of misclassification, suggesting that the transfer process between clinics should be improved for more accurate reporting of patient outcomes. Processes that lead to correct classification of patient status including patient tracing should be strengthened. Clinics could cross-check all available data sources before classifying patients as LTFU. Programme evaluators and modelers could consider using correction factors to improve estimates of outcomes from TIER.Net.
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Affiliation(s)
- David Etoori
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chodziwadziwa Whiteson Kabudula
- MRC/WITS Rural Public Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Brian Rice
- MeSH Consortium, Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - F. Xavier Gomez-Olive
- MRC/WITS Rural Public Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Georges Reniers
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC/WITS Rural Public Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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Odayar J, Myer L. Transfer of primary care patients receiving chronic care: the next step in the continuum of care. Int Health 2020; 11:432-439. [PMID: 31081907 DOI: 10.1093/inthealth/ihz014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/11/2019] [Indexed: 12/26/2022] Open
Abstract
The burden of chronic conditions is increasing rapidly in low- and middle-income countries. Chronic conditions require long-term and continuous care, including for patients transferring between facilities. Patient transfer is particularly important in the context of health service decentralization, which has led to increasing numbers of primary care facilities at which patients can access care, and high levels of migration, which suggest that patients might require care at multiple facilities. This article provides a critical review of existing evidence regarding transfer of stable patients receiving primary care for chronic conditions. Patient transfer has received limited consideration in people living with HIV, with growing concern that patients who transfer are at risk of poor outcomes; this appears similar for people with TB, although studies are few. There are minimal data on transfer of patients with non-communicable diseases, including diabetes. Patient transfer for chronic conditions has thus received surprisingly little attention from researchers; considering the potential risks, more research is urgently required regarding reasons for and outcomes of transfers, transfer processes and interventions to optimize transfers, for different chronic conditions. Ultimately, it is the responsibility of health systems to facilitate successful transfers, and this issue requires increased attention from researchers and policy-makers.
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Affiliation(s)
- Jasantha Odayar
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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Teshale AB, Tsegaye AT, Wolde HF. Incidence and predictors of loss to follow up among adult HIV patients on antiretroviral therapy in University of Gondar Comprehensive Specialized Hospital: A competing risk regression modeling. PLoS One 2020; 15:e0227473. [PMID: 31978137 PMCID: PMC6980595 DOI: 10.1371/journal.pone.0227473] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/19/2019] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Loss to follow up after the initiation of antiretroviral therapy (ART) is common in Africa, particularly in Ethiopia and it is a considerable obstacle for the effectiveness of the ART program. Mortality is a competing risk of loss to follow up but it is often overlooked and there is limited evidence about the incidence and predictors of loss to follow up in the presence of competing events. OBJECTIVE To assess the Incidence and predictors of loss to follow up among adult HIV patients on ART in University of Gondar Comprehensive Specialized Hospital between January 1, 2015, and December 31, 2018. METHODS Institution based retrospective follow up study was conducted in University of Gondar Comprehensive Specialized Hospital. A Gray's test and cumulative incidence curve were used to compare the cumulative incidence function of loss to follow up. Bivariable and multivariable competing risk regression models were fitted to identify the predictors of lost to follow up and those variables with p-value <0.05 in the multivariable analysis was considered as significant predictors of lost to follow up. RESULT A total of 531 adult HIV patients on ART were included in the analysis. The incidence rate of loss to follow up in this study was 10.90 (95% CI: 8.9-13.2) per 100 person years. Being age group 15-30 years (aSHR = 2.01; 95%CI;1.11-3.63), being daily laborer(aSHR = 2.60; 95%CI;1.45-4.66), not receiving cotrimoxazole preventive therapy (aSHR = 2.66; 95%CI;1.68-4.21), not receiving isoniazid preventive therapy(aSHR = 4.57; 95% CI;1.60-13.08), ambulatory functional status (aSHR = 1.61; 95% CI; 1.02-2.51) and taking AZT-3TC-NVP medication at start of ART(aSHR = 2.01; 95% CI; 1.16-3.78) were significant predictors of lost to follow up. CONCLUSION In this study the incidence of lost to follow up was high. Young people, daily laborer, ambulatory patients and those taking AZT-3TC-NVP as well as those who did not take opportunistic prophylaxis were at higher risk of loss to follow up. Therefore, giving special attention to the high-risk groups for lost to follow up highlighted in this study could decrease the rate of LTFU.
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Affiliation(s)
- Achamyeleh Birhanu Teshale
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Adino Tesfahun Tsegaye
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Haileab Fekadu Wolde
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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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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Kaplan S, Nteso KS, Ford N, Boulle A, Meintjes G. Loss to follow-up from antiretroviral therapy clinics: A systematic review and meta-analysis of published studies in South Africa from 2011 to 2015. South Afr J HIV Med 2019; 20:984. [PMID: 31956435 PMCID: PMC6956684 DOI: 10.4102/sajhivmed.v20i1.984] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/20/2019] [Indexed: 11/05/2022] Open
Abstract
Background South Africa has the largest antiretroviral therapy (ART) programme in the world. To optimise programme outcomes, it is critical that patients are retained in care and that retention is accurately measured. Objectives To identify all studies published in South Africa from 2011 to 2015 that used loss to follow-up (LTFU) as an indicator or outcome to describe the variation in definitions and to estimate the proportion of patients lost to care across studies. Method All studies published between 01 January 2011 and October 2015 that included loss to follow-up or default from ART care in a South African cohort were included by use of a broad search strategy across multiple databases. To be included, the cohort had to include any patient ART data, including follow-up time, from 01 January 2010. Two authors, working independently, extracted data and assessed risk of bias from all manuscripts. Meta-analysis was performed for studies stratified by the same loss to follow-up definition. Results Forty-eight adult, 15 paediatric and 4 pregnant cohorts were included. Median cohort size was 3737; follow-up time ranged from 9 weeks to 5 years. Meta-analysis did not reveal an important difference in LTFU estimates in adult cohorts at 1 year between loss to follow-up defined as 3 months (11.0%, n = 4; 95% CI 10.7% – 11.2%) compared with 6 months (12.0%, n = 4; 95% CI 11.8% – 12.2%). Only two cohorts reported reliable LTFU estimates at 5 years: this was 25.1% (95% CI 24.8% – 25.4%). Conclusion South Africa should standardise a LTFU definition. This would aid in monitoring and evaluation of ART programmes, with the broader goal of improving patient outcomes.
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Affiliation(s)
- Samantha Kaplan
- Department of Internal Medicine, University of Washington, Seattle, United States
| | - Katleho S Nteso
- Medical Care Development International, Maseru, Lesotho, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Retention in Care Trajectories of HIV-Positive Individuals Participating in a Universal Test-and-Treat Program in Rural South Africa (ANRS 12249 TasP Trial). J Acquir Immune Defic Syndr 2019; 80:375-385. [PMID: 30570525 PMCID: PMC6410969 DOI: 10.1097/qai.0000000000001938] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Supplemental Digital Content is Available in the Text. Objective: To study retention in care (RIC) trajectories and associated factors in
patients eligible for antiretroviral therapy (ART) in a universal
test-and-treat setting (TasP trial, South Africa, 2012–2016). Design: A cluster-randomized trial whereby individuals identified HIV positive after
home-based testing were invited to initiate ART immediately (intervention)
or following national guidelines (control). Methods: Exiting care was defined as ≥3 months late for a clinic appointment,
transferring elsewhere, or death. Group-based trajectory modeling was
performed to estimate RIC trajectories over 18 months and associated factors
in 777 ART-eligible patients. Results: Four RIC trajectory groups were identified: (1) group 1
“remained” in care (reference, n = 554, 71.3%), (2) group
2 exited care then “returned” after [median (interquartile
range)] 4 (3–9) months (n = 40, 5.2%), (3) group 3
“exited care rapidly” [after 4 (4–6) months, n =
98, 12.6%], and (4) group 4 “exited care later” [after 11
(9–13) months, n = 85, 10.9%]. Group 2 patients were less likely
to have initiated ART within 1 month and more likely to be male, young
(<29 years), without a regular partner, and to have a CD4 count
>350 cells/mm3. Group 3 patients were more likely to be
women without social support, newly diagnosed, young, and less likely to
have initiated ART within 1 month. Group 4 patients were more likely to be
newly diagnosed and aged 39 years or younger. Conclusions: High CD4 counts at care initiation were not associated with a higher risk of
exiting care. Prompt ART initiation and special support for young and newly
diagnosed patients with HIV are needed to maximize RIC.
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Carlucci JG, Liu Y, Clouse K, Vermund SH. Attrition of HIV-positive children from HIV services in low and middle-income countries. AIDS 2019; 33:2375-2386. [PMID: 31764102 PMCID: PMC6905128 DOI: 10.1097/qad.0000000000002366] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Identification and retention of HIV-positive children in HIV services is essential to ensure optimal health outcomes. This systematic review and meta-analysis examines the magnitude of attrition [loss to follow-up (LTFU) and death) of HIV-positive children from HIV services in low and middle-income countries (LMICs). METHODS We performed a comprehensive multidatabase search of original studies reporting retention/attrition data for HIV-positive children in LMICs through April 2016. Outcomes included LTFU, death, and overall attrition (LTFU + death) at intervals up to 60 months of follow-up. At least two authors determined study eligibility, performed data extraction, and made quality assessments. We used random-effects meta-analytic methods to aggregate effect sizes and perform meta-regression analyses. RESULTS We identified 3040 unique studies; 91 met eligibility criteria and were included in the analysis. This represents 147 129 HIV-positive children; most were from Africa (83%). LTFU definitions varied widely, with significant variability in outcomes across studies. Most attrition occurred in the first 6 months of follow-up, increasing to 23% by 36 months. HIV-positive children receiving antiretroviral therapy (ART) had significantly better retention in care than those not on ART. Studies that performed case-finding/tracing for those LTFU had better retention in care up to 24 months of follow-up. CONCLUSIONS These findings underscore the high attrition of children from HIV services in LMICs. Early ART initiation and decentralized patient support services (e.g. tracing for those LTFU) have potential to improve retention in care. Implementation research and resources are urgently needed to improve retention among this vulnerable population.
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Affiliation(s)
- James G. Carlucci
- Vanderbilt Institute for Global Health, Vanderbilt
University Medical Center, Nashville, Tennessee, USA
- Division of Pediatric Infectious Diseases, Department of
Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yu Liu
- Department of Public Health Sciences, School of Medicine
and Dentistry, University of Rochester, Rochester, New York, USA
| | - Kate Clouse
- Vanderbilt Institute for Global Health, Vanderbilt
University Medical Center, Nashville, Tennessee, USA
- School of Nursing, Vanderbilt University, Nashville,
Tennessee, USA
| | - Sten H. Vermund
- Yale School of Public Health, Yale University, New Haven,
Connecticut, USA
- Department of Pediatrics, Yale School of Medicine, Yale
University, New Haven, Connecticut, USA
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Belus JM, Cholera R, Miller WC, Bassett J, Gaynes BN. Psychiatric Comorbidity of Unipolar Mood, Anxiety, and Trauma Disorders Prior to HIV Testing and the Effect on Linkage to Care Among HIV-Infected Adults in South Africa. AIDS Behav 2019; 23:3444-3451. [PMID: 31297682 PMCID: PMC8781612 DOI: 10.1007/s10461-019-02586-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Psychiatric comorbidity, the presence of two or more psychiatric disorders, leads to worse HIV outcomes in the United States; this relationship has not been studied in sub-Saharan Africa. We conducted a preliminary study to describe the prevalence of psychiatric comorbidity (unipolar mood, anxiety, and trauma disorders) among 363 adults prior to HIV testing at Witkoppen Health and Welfare Centre, a primary care clinic in Johannesburg, South Africa. We also examined whether psychiatric comorbidity predicted subsequent linkage to HIV care 3 months later. Prevalence of psychiatric comorbidity prior to HIV testing was approximately 5.5%. In the final HIV-positive subsample (n = 76), psychiatric comorbidity of unipolar mood, anxiety, and trauma disorders did not predict linkage to care [adjusted relative risk = 1.01 (0.59, 1.71)] or number of follow-up appointments (adjusted relative risk = 0.86 (0.40, 1.82)]. A similar psychiatric profile emerged for HIV-positive and HIV-negative individuals before becoming aware of their HIV status. The psychiatric burden typically seen in HIV-positive individuals may manifest over time.
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Affiliation(s)
- Jennifer M Belus
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Rushina Cholera
- Department of Pediatrics, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - William C Miller
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Jean Bassett
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | - Bradley N Gaynes
- Department of Psychiatry, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Assemie MA, Leshargie CT, Petrucka P. Outcomes and factors affecting mortality and successful tracing among patients lost to follow-up from antiretroviral therapy in Pawi Hospital, Northwest Ethiopia. Trop Med Health 2019; 47:52. [PMID: 31719791 PMCID: PMC6836319 DOI: 10.1186/s41182-019-0181-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/26/2019] [Indexed: 11/10/2022] Open
Abstract
Background Loss to follow-up (LTFU) is a major public health problem to antiretroviral therapy (ART) programs in sub-Saharan Africa. Failure to account for patients' LTFU outcomes (self-transfers and restarts) can result in inaccurate reporting of retention in care. In Ethiopia, specifically in the Benishangule Gumuz region, high LTFU reported patients, who were not assessed for their outcomes, are identified as a gap. Therefore, our objective was to determine the outcomes (alive or dead) of patients lost to follow-up (LTFU) from ART and identify factors associated with successful tracing and mortality of these patients. Results The proportion of successful tracing was 75.5% (249 of 330). Among the traced patients (n = 249), 22.9% were deceased, 47.8% were on ART, and 29.3% had discontinued treatment. However, the remaining untraceable patients were not locatable due to wrong addresses (53.1%), change of residence (29.6%), and/or lack of functional phone contact (17.3%). Some (32.9%) of the patients discontinued because of negative test results, others (21.9%) for spiritual reasons or side effects (28.8%), and the remaining (16.4%) for other reasons. Tracing using phone numbers (AOR = 2.97, 95% CI 1.57-5.59) and existing long-term follow-up period for ART (AOR = 2.13, 95% CI 1.17-3.88) were strong predictors of successful tracing while not receiving cotrimoxazole preventive therapy (CPT) (AOR = 2.59, 95% CI 1.22-5.39) is a predictor for mortality of patients post-LTFU. Conclusion ART programs need to retain current contact information of patients or guardians/friends for tracing. Having phone contact numbers and prolonged lengths of compliance with ART are predictors of successful tracing, while lack of cotrimoxazole preventive therapy is a predictor of mortality. Early tracing of beginners (newly admitted recipients) and updating their detailed information at each follow-up visit is essential.
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Affiliation(s)
- Moges Agazhe Assemie
- 1Department of Public Health, College of Health Science, Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
| | - Cheru Tesema Leshargie
- 2Department of Environmental Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Pammla Petrucka
- 3College of Nursing, University of Saskatchewan, Saskatoon, Canada.,4School of Life Sciences and Bioengineering, Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
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Chammartin F, Zürcher K, Keiser O, Weigel R, Chu K, Kiragga AN, Ardura-Garcia C, Anderegg N, Laurent C, Cornell M, Tweya H, Haas AD, Rice BD, Geng EH, Fox MP, Hargreaves JR, Egger M. Outcomes of Patients Lost to Follow-up in African Antiretroviral Therapy Programs: Individual Patient Data Meta-analysis. Clin Infect Dis 2019; 67:1643-1652. [PMID: 29889240 PMCID: PMC6233676 DOI: 10.1093/cid/ciy347] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 05/17/2018] [Indexed: 11/14/2022] Open
Abstract
Background Low retention on combination antiretroviral therapy (cART) has emerged as a threat to the Joint United Nations Programme on human immunodeficiency virus (HIV)/AIDS (UNAIDS) 90-90-90 targets. We examined outcomes of patients who started cART but were subsequently lost to follow-up (LTFU) in African treatment programs. Methods This was a systematic review and individual patient data meta-analysis of studies that traced patients who were LTFU. Outcomes were analyzed using cumulative incidence functions and proportional hazards models for the competing risks of (i) death, (ii) alive but stopped cART, (iii) silent transfer to other clinics, and (iv) retention on cART. Results Nine studies contributed data on 7377 patients who started cART and were subsequently LTFU in sub-Saharan Africa. The median CD4 count at the start of cART was 129 cells/μL. At 4 years after the last clinic visit, 21.8% (95% confidence interval [CI], 20.8%-22.7%) were known to have died, 22.6% (95% CI, 21.6%-23.6%) were alive but had stopped cART, 14.8% (95% CI, 14.0%-15.6%) had transferred to another clinic, 9.2% (95% CI, 8.5%-9.8%) were retained on cART, and 31.6% (95% CI, 30.6%-32.7%) could not been found. Mortality was associated with male sex, more advanced disease, and shorter cART duration; stopping cART with less advanced disease andlonger cART duration; and silent transfer with female sex and less advanced disease. Conclusions Mortality in patients LTFU must be considered for unbiased assessments of program outcomes and UNAIDS targets in sub-Saharan Africa. Immediate start of cART and early tracing of patients LTFU should be priorities.
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Affiliation(s)
| | - Kathrin Zürcher
- Institute of Social and Preventive Medicine, University of Bern
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Switzerland
| | - Ralf Weigel
- Faculty of Health, Witten/Herdecke University, Witten, Germany.,Lighthouse Trust, Lilongwe, Malawi
| | - Kathryn Chu
- Department of Surgery, University of Cape Town, South Africa
| | - Agnes N Kiragga
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Nanina Anderegg
- Institute of Social and Preventive Medicine, University of Bern
| | - Christian Laurent
- Institut de Recherche pour le Développement, Inserm, Univ Montpellier, Recherches Translationnelles sur le VIH et les Maladies Infectieuses, Montpellier, France
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | | | - Andreas D Haas
- Institute of Social and Preventive Medicine, University of Bern
| | - Brian D Rice
- Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Elvin H Geng
- Division of Infectious Diseases, HIV and Global Medicine, Department of Medicine, University of California, San Francisco
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Departments of Epidemiology and Global Health, Boston University School of Public Health, Massachusetts
| | - James R Hargreaves
- Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
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Reidy W, Nuwagaba-Biribonwoha H, Shongwe S, Sahabo R, Hartsough K, Wu Y, Gachuhi A, Mthethwa-Hleta S, Abrams EJ. Engagement in care among women and their infants lost to follow-up under Option B+ in eSwatini. PLoS One 2019; 14:e0222959. [PMID: 31665137 PMCID: PMC6821080 DOI: 10.1371/journal.pone.0222959] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 09/10/2019] [Indexed: 11/18/2022] Open
Abstract
Background Universal antiretroviral treatment (ART) for pregnant women with HIV, Option B+, has been adopted widely for prevention of mother-to-child HIV transmission (PMTCT). Some evidence shows high loss to follow-up (LTF) under this model. However, gaps in data systems limit this evidence. We collected additional information for women and infants LTF from Option B+ in Eswatini to assess more accurate outcomes. Methods LTF at 6-months postpartum was assessed using facility data. Additional data was gathered from: 1) the national ART database and paper records; 2) patient tracing; and 3) interviews and abstraction from patient-held records. Engagement in care was defined as any clinic visit within 91 days before or after 6-months postpartum or completion of a documented transfer; or, for those traced but not completing study interviews, visits at 6-months postpartum or later (for infants), or visits within 3-months of tracing (for women). Multivariable loglinear models were used to identify correlates of engagement. Results One-hundred-ninety-four (44.7%) of 434 LTF women had outcomes ascertained, including 122 (62.9%) women engaged in care. Among 510 LTF infants, 265 (52.0%) had ascertained outcomes, including 143 (54.0%) engaged in care, 47 (17.7%) pregnancy losses, and 18 (6.8%) deaths. Seventy-two of 189 live infants (38.1%) with ascertained outcomes had a 6-week early infant diagnostic (EID) test. Among women with ascertained outcomes, gestational age of 20+ weeks (vs. fewer than 20 weeks, aRR 0.80; 95% CI 0.68–0.94) and age 25–29 years (vs. 15–24 years, aRR 0.81; 95% CI 0.67–0.97), were associated with lower engagement; initiating ART after first ANC visit was associated with higher engagement (vs. at first ANC visit, aRR 1.12; 95% CI 1.04–1.21). Among infants with ascertained outcomes, mother not initiating ART was associated with lower engagement (vs. ART at first ANC visit, aRR 0.71; 95% CI 0.54–0.91). Conclusion Substantial numbers of women and infants classified as LTF under Option B+ were engaged in care, though a suboptimal level of 6-week EID testing was observed. These findings highlight a need to improve coverage of routine EID testing, and improve data systems to better capture PMTCT patient outcomes.
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Affiliation(s)
- William Reidy
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, United States of America
- * E-mail:
| | - Harriet Nuwagaba-Biribonwoha
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, United States of America
| | - Siphesihle Shongwe
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Ruben Sahabo
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Kieran Hartsough
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Yingfeng Wu
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Averie Gachuhi
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | | | - Elaine J. Abrams
- ICAP at Columbia, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, New York, United States of America
- Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, United States of America
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Continuum of HIV Care in Rural Mozambique: The Implications of HIV Testing Modality on Linkage and Retention. J Acquir Immune Defic Syndr 2019; 78:527-535. [PMID: 29771786 PMCID: PMC6075879 DOI: 10.1097/qai.0000000000001720] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is Available in the Text. Introduction: Context-specific improvements in the continuum of HIV care are needed to achieve the UNAIDS target of 90-90-90. This study aimed to assess the linkage to and retention in HIV care according to different testing modalities in rural southern Mozambique. Methods: Adults newly diagnosed with HIV from voluntary counseling and testing, provider-initiated counseling and testing, and home-based HIV testing services were prospectively enrolled between 2014 and 2015 at the Manhiça District. Patients were passively followed up through chart examination. Tracing was performed at 12 months to ascertain causes of loss to follow-up. Fine and Gray competing risk analysis was performed to determine factors associated with the each step of the cascade. Results: Overall linkage to care as defined by having a CD4 count at 3 months was 43.7% [95% confidence interval (CI): 40.8 to 46.6] and 25.2% of all participants initiated antiretroviral therapy. Factors associated with increased linkage in multivariable analysis included testing at voluntary counseling and testing, older age, having been previously tested for HIV, owning a cell phone, presenting with WHO clinical stages III/IV, self-reported illness-associated disability in the previous month, and later calendar month of participant recruitment. Ascertaining deaths and transfers allowed for adjustment of the rate of 12-month retention in treatment from 75.6% (95% CI: 70.2 to 80.5) to 84.2% (95% CI: 79.2 to 88.5). Conclusions: Home-based HIV testing reached a sociodemographically distinct population from that of clinic-based testing modalities but low linkage to care points to a need for facilitated linkage interventions. Distinguishing between true treatment defaulting and other causes of loss to follow-up can significantly change indicators of retention in care.
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