Delayed Antiretroviral Therapy (ART) Initiation among Hospitalized Adults in a Resource-Limited Settings: A Challenge to the Global Target of ART for 90% of HIV-Infected Individuals

HIV test-and-treat policy improves clinical outcomes in Zambian adults from Southern Province: a multicenter retrospective cohort study

Background

Globally, most countries have implemented a test-and-treat policy to reduce morbidity and mortality associated with HIV infection. However, the impact of this strategy has not been critically appraised in many settings, including Zambia. We evaluated the retention and clinical outcomes of adults enrolled in antiretroviral therapy (ART) and assessed the impact of the test-and-treat policy.

Methods

We conducted a retrospective cohort study among 6,640 individuals who initiated ART between January 1, 2014 and July 31, 2016 [before test-and-treat cohort (BTT), n = 2,991] and between August 1, 2016 and October 1, 2020 [after test-and-treat cohort (ATT), n = 3,649] in 12 districts of the Southern province. To assess factors associated with retention, we used logistic regression (xtlogit model).

Results

The median age [interquartile range (IQR)] was 34.8 years (28.0, 42.1), and 60.2% (n = 3,995) were women. The overall retention was 83.4% [95% confidence interval (CI) 82.6, 84.4], and it was significantly higher among the ATT cohort, 90.6 vs. 74.8%, p < 0.001. The reasons for attrition were higher in the BTT compared to the ATT cohorts: stopped treatment (0.3 vs. 0.1%), transferred out (9.3 vs. 3.2%), lost to follow-up (13.5 vs. 5.9%), and death (1.4 vs. 0.2%). Retention in care was significantly associated with the ATT cohort, increasing age and baseline body mass index (BMI), rural residence, and WHO stage 2, while non-retention was associated with never being married, divorced, and being in WHO stage 3.

Conclusion

The retention rate and attrition factors improved in the ATT compared to the BTT cohorts. Drivers of retention were test-and-treat policy, older age, high BMI, rural residence, marital status, and WHO stage 1. Therefore, there is need for interventions targeting young people, urban residents, non-married people, and those in the symptomatic WHO stages and with low BMI. Our findings highlight improved ART retention after the implementation of the test-and-treat policy.

Predictors of Opportunistic Infections among HIV-infected Patients on Antiretroviral Therapy: A Cross-Sectional Study

Opportunistic infections (OIs) are diseases that cause infections in people whose immune systems are compromised. The purpose of this study was to assess the prevalence of OIs and associated factors among HIV-infected patients. Institutional-based cross-sectional study was done in Eastern Zone, Tigray, Ethiopia. A structured questionnaire was used to collect the data from 394 study participants through an interview method. The required sample size was determined using a single population proportion formula. Participants were selected using a systematic random sampling method. Data was entered and analyzed using SPSS version 22. Multivariable logistic regression analysis was used to find factors at p < .05. The prevalence of OIs was found to be 52% (95% CI [47.5, 57.1]). Occupation, CD4+ count, adherence to antiretroviral therapy (ART), and functional status were independently associated with OIs. Intervention measures such as improving adherence to ART should be strengthened to further reduce the burden of OIs.

Perspectives of people living with HIV on barriers to timely ART initiation following referral for antiretroviral therapy: A qualitative study at an urban HIV clinic in Kampala, Uganda

Early initiation of antiretroviral therapy (ART) after HIV diagnosis prevents HIV transmission, progression of HIV to AIDS and improves quality of life. However, little is known about the barriers to timely ART initiation among patients who test HIV positive in settings different from where they will receive HIV treatment, hence are referred in the routine setting. Therefore, we explored the perspectives of people living with HIV on barriers faced to initiate ART following HIV testing and referral for treatment. In this qualitative study, we purposively sampled and enrolled 17 patients attending the Mulago ISS clinic. We selected patients (≥18 years) who previously were received as referrals for HIV treatment and had delayed ART initiation, as ascertained from their records. We conducted in-depth interviews, which were audio recorded, transcribed and translated. We used Atlas.ti version 9 software for data management. Data analysis followed thematic and framework analysis techniques and we adopted the socio-ecological model to categorize final themes. Key themes were found at organizational level including; negative experiences at the place of HIV diagnosis attributed to inadequate counselling and support, unclear communication of HIV-positive results and ambiguous referral procedures; and, long waiting time when patients reached the HIV clinic. At individual level, the themes identified were; immediate denial with late acceptance of HIV-positive results attributed to severe emotional and psychological distress at receiving results, fear of perceived side effects and long duration on ART. At interpersonal level, we found that anticipated and enacted stigma after HIV diagnosis resulted in non-disclosure, discrimination and lack of social support. We found that challenges at entry (during HIV test) and navigation of the HIV care system in addition to individual and interpersonal factors contributed to delayed ART initiation. Interventions during HIV testing would facilitate early ART initiation among patients referred for HIV care.

Trends in HIV/AIDS incidence rate in Mississippi, 2008-2019

Background and objectives: Despite the decline in new HIV infection across the United States, Mississippi is still experiencing high rates of new HIV infections. Reports highlighted significant variations by geographical locations and socio-demographic factors. This study examined trends of HIV/AIDS incidence rates in Mississippi from 2008 to 2019. Materials and methods: Data on HIV/AIDS diagnosis were extracted from Mississippi Enhanced HIV/AIDS Reporting System database. Data were cleaned and de-identified using Microsoft Excel and SAS 9.4. Overall and annual age-adjusted HIV and AIDS incidence rates were calculated by sex, race, and age using 2000 US population. Annual Percentage Change (APC) and Average Annual Percentage Change (AAPC) were analyzed using Joinpoint regression models. Results: Overall, HIV incidence rate declined from 25.0 in 2008 to 18.79 per 100,000 population in 2019 (24.8% decrease) while AIDS incidence increased from 6.4 in 2008 to 8.2 per 100,000 population in 2019 (28.1% increase). Comparison between sexes of all age groups showed a downward trend of new HIV infection (AAPC: Male:-1.50, Female:-5.17) and an upward trend of AIDS incidence (AAPC: Male: 1.90, Female: 3.70). Age adjusted HIV incidence declined by 26.8% and 12.4% among blacks and whites respectively (AAPC: Blacks: -2.8, Whites:-1.0) but there was no significant change in age-adjusted AIDS incidence among both races from 2008-2019. Conclusion: This study indicated that age-adjusted HIV incidence rate is declining in Mississippi but trends differ by race, gender, and age. More interventions aimed at ensuring early diagnosis, proper linkage to care and preventing the progression of HIV to AIDS particularly among at-risk population are needed in Mississippi. IMC J Med Sci. 2023; 17(2):002. DOI: https://doi.org/10.55010/imcjms.17.012 *Correspondence: Adetoun F. Asala, Department of Epidemiology and Biostatistics, School of Public Health, 350 W Woodrow Wilson Dr, Jackson, MS 39213. Email: adetoun.f.asala@students.jsums.edu

HIV and hepatitis C risk among Tajik migrant workers who inject drugs in Moscow

Background . The HIV epidemic in Eastern Europe and Central Asia continues to grow with most infections occurring in high-risk groups including people who inject drugs and their sexual partners. Labor migrants from this region who inject drugs while in Russia are at especially high HIV risk. Methods . We recruited 420 male Tajik migrant workers who inject drugs in Moscow for a peer-education HIV prevention intervention trial. Participants were interviewed about their sex and drug use behavior and tested for HIV and hepatitis C prior to the intervention. Results . Over half of the men reported injecting with a previously used syringe in the past month. Many men reported condomless sex (42%), multiple sex partners (30%), and sex with sex workers (42%). Only 17% had ever been tested for HIV. Despite substantial risk behavior, prevalence rates of HIV (6.8%) and HCV (2.9%) although elevated were lower than expected when compared to estimates of prevalence among PWID at the national level in Tajikistan. Risk behavior in diaspora varied across the men’s regional area of origin in Tajikistan and occupation in Moscow with HIV prevalence rates highest among those working at the bazaars. Conclusion . Tajik male migrants who inject drugs in Moscow are at heightened risk for HIV and hepatitis C. Evidence-based prevention approaches and messaging that specifically address the drug- and sex-related risk behavior of migrants from different parts of Tajikistan, employment sectors within the destination city, and socio-demographic background are needed.

Predictors of delayed Anti-Retroviral Therapy initiation among adults referred for HIV treatment in Uganda: a cross-sectional study

BACKGROUND

Uganda's current guidelines recommend immediate initiation of Anti-Retroviral Therapy (ART) for persons living with HIV in order to reduce HIV/AIDS related morbidity and mortality. However, not all eligible PLHIV initiate ART within the recommended time following HIV diagnosis. We assessed the prevalence and factors associated with delayed ART initiation among PLHIV referred for ART initiation, five years since rolling out the test and treat guidelines.

METHODS

In this cross-sectional study, we enrolled adult patients referred to Mulago Immune Suppressive Syndrome (Mulago ISS) clinic for ART initiation from January 2017 to May 2021. We collected data on socio-demographics, HIV diagnosis and referral circumstances, and time to ART initiation using a questionnaire. The outcome of interest was proportion of patients that delayed ART, defined as spending more than 30 days from HIV diagnosis to ART initiation. We performed multivariable logistic regression and identified significant factors.

RESULTS

A total of 312 patients were enrolled of which 62.2% were female. The median (inter-quartile range [IQR]) age and baseline CD4 count of the patients were 35 (28-42) years and 315 (118.8-580.5) cells/μL respectively. Forty-eight (15.4%) patients delayed ART initiation and had a median (IQR) time to ART of 92 (49.0-273.5) days. The factors associated with delayed ART initiation were; 1) having had the HIV diagnosis made from a private health facility versus public, (adjusted odds ratio [aOR] = 2.4 (95% confidence interval [CI] 1.1-5.5); 2) initial denial of positive HIV test results, aOR = 5.4 (95% CI: 2.0-15.0); and, 3) having not received a follow up phone call from the place of HIV diagnosis, aOR = 2.8 (95% CI: 1.2-6.8).

CONCLUSION

There was significant delay of ART initiation among referred PLHIV within 5 years after the rollout of test and treat guidelines in Uganda. Health system challenges in the continuity of HIV care services negatively affects timely ART initiation among referred PLHIV in Uganda.

"I am alive because of her": factors affecting adherence to combination antiretroviral therapy among people living with HIV in KwaZulu-Natal, South Africa

BACKGROUND

People living with HIV need to take lifelong, combination antiretroviral therapy (cART), but there have been only limited explorations of how factors affecting adherence can change over the course of an individual's lifetime.

METHODS

We carried out a qualitative study of men and women living with HIV in KwaZulu, Natal, South Africa who were prescribed cART and who had periods of higher and lower adherence.

RESULTS

18 individuals participated in open-ended interviews. Using a dynamic theory of adherence, we identified factual, relational, and experiential factors that were associated with adherence and non-adherence to cART. Periods of non-adherence were commonly reported. Participants described relationships and experiences as being important influences on their ability to adhere to cART throughout their treatment journeys.

CONCLUSIONS

Periods of non-adherence to cART are common. While many cART counseling models are based on conveying facts to people prescribed cART, providing opportunities for supportive relationship where people can process their varied experiences is likely important to maintaining health for people living with HIV.

Time to Antiretroviral Therapy Initiation and Its Predictors Among Newly Diagnosed HIV-Positive People in Nekemte Town, Western Ethiopia: Claim of Universal Test and Treat

Background

HIV continuum of care demands early ART initiation for all HIV-infected individuals. Early ART initiation reduces onward HIV transmission facilitating rapid viral suppression. Despite this, delayed ART use is a challenge among newly diagnosed HIV-positive individuals, and there is limited evidence on time to ART initiation among this group in Ethiopia. Thus, this study aimed to assess time to ART initiation and its predictors among newly diagnosed HIV-positive individuals in Nekemte town, Western Ethiopia.

Methods

An institution-based retrospective follow-up study was conducted on 518 newly diagnosed HIV-positive people from September 5, 2016 to December 20, 2020 at Nekemte town, Western Ethiopia. Data were collected from ART intake forms, registration log books and patient charts. The collected data were entered into Epi Data version 3.1 and STATA version 14.0 was used for analysis. Survival probability was checked graphically by Kaplan–Meier curve and statistically by Log rank test. Both bivariable and multivariable Cox Proportional hazards regression models were conducted to identify the predictors of ART initiation. Hazard ratio with 95% CI and p-value of <0.05 was used to declare a statistical significance.

Results

By the end of the follow-up, 371 (71.6%) individuals had initiated ART with an overall incidence rate of 51.9 per 1000 [95% CI: 54.07–66.32] person days; median time to ART initiation was 4 [IQR: 1–9] days. Being female (AHR = 1.33, 95% CI: 1.06–1.67), urban dwellers (AHR = 2.02, 95% CI: 1.37–2.97), having baseline OIs (AHR = 1.62, 95% CI: 1.60–4.30); being tested via VCT (AHR = 1.33, 95% CI: 1.02–1.74); linked from OPD (AHR = 0.64, 95% CI: 0.47–0.85); disclosing HIV sero-status (AHR = 2.07, 95% CI: 1.17–3.68); and college and above education level (AHR = 1.43, 95% CI: 1.00–2.0) were identified as significant predictors of early initiation of ART.

Conclusion

The proportion and incidence of ART initiation was high; a short median time to ART initiation was revealed in this study. Strictly screening OIs, encouraging HIV sero-status disclosure and voluntary HIV testing are recommended to increase early ART initiation.

Frequency and reasons for delayed treatment initiation after HIV diagnosis: cross-sectional study in Lahore, Pakistan

Background

Well-timed initiation of HIV therapy enhances life expectancy, decreases mortality and morbidity, and inhibits the transmission of HIV and complications related to it. The purpose of the present survey is to investigate the frequency and reasons for delayed initiation of anti-retroviral therapy (ART) and to determine its relationship with various socio-demographic variables and HIV-related characteristics.

Methods

The analysis is based on a cross-sectional study involving 355 people living with HIV (diagnosed by PCR) who were more than 18 years of age and not receiving HIV therapy before enrolment at the HIV clinics of two selected tertiary-care teaching hospitals in Lahore, Pakistan. In this study, delayed initiation of ART was defined as not attending the HIV management centre or a clinic for ART within 3 months of a confirmed diagnosis. The participants were selected using a systematic probability sampling technique. Bivariate logistic regression was performed using a backward stepwise technique to establish the variables related to delayed onset of HIV therapy. Factors significant at p ≤ 0.20 were considered for multivariate analysis, which was used to describe the association between independent factors and delayed initiation of treatment.

Results

Delayed onset of ART was observed in 28.5% of individuals. Factors such as no schooling (AOR = 5.92; 95% CI: 1.38–25.41; p = 0.017) and occasional household income (AOR = 3.88; 95% CI: 1.01–14.89; p = 0.048) were significantly associated with late onset of ART. Our research findings also indicated that the main reasons for late beginning of HIV therapy were: feeling healthy (45.5%), did not have time to go to the HIV treatment centre (42.6%), did not want to discuss HIV test result (37.6%), and fear of stigma and discrimination within their community (35.6%).

Conclusions

Late commencement of HIV therapy in Pakistan is common, and an improved connection is needed between identification of HIV and beginning of therapy. HIV management centres should counsel and monitor patients from the time of a positive HIV test result until they initiate therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11031-0.

Effect of the Test and Treat Strategy on Mortality Among HIV-Positive Adult Clients on Antiretroviral Treatment in Public Hospitals of Addis Ababa, Ethiopia

Background

The primary goal of antiretroviral therapy is to prevent human immune deficiency virus (HIV)-related morbidity and mortality. Deferring antiretroviral therapy (ART) until CD4 counts decline puts individuals with HIV at risk of HIV-related morbidity and mortality.

Objective

This study aims to assess the effect of the test and treat strategy on mortality among HIV-positive clients on ART in public hospitals in Addis Ababa.

Methods

A retrospective cohort study was conducted at five selected public hospitals in Addis Ababa. A cohort of 216 ART clients taken as an exposed group (test and treat" strategy) from 2017 to 2019 and 216 ART clients as an unexposed group taken from 2014 to 2017; totally, 432 clients were included in the study. Multivariate Cox regression was used to estimate the effect of the test and treat strategy on the survival of ART clients adjusting for other covariates.

Results

The 432 clients contributed to a total of 1025.17 person-years follow-up. Ninety-one (21.06%) of them died, 14.3% were unexposed and 6.7% were exposed (test and treat). The incidence of death was 92.4 and 81.8/1000 person-years in the unexposed group and exposed group, respectively, with an overall mortality rate of 88.8/1000 person-years. Besides, test and treat strategy (AHR: 0.31; 95% CI: 0.19, 0.52), baseline CD4 counts >350 cells/mm3 (AHR 0.40; 95%: CI: 0.20, 0.80), bedridden functional status (AHR 2.46; 95% CI: 1.41, 4.27), poor adherence (AHR 3.25; 95% CI: 1.410-7.51), moderate malnutrition on last visit (AHR 2.56; 95% CI: 1.30-5.04) and staying on original regimen (AHR 4.68; 95% CI 2.72, 8.07) were independent predictors of mortality.

Conclusion

Mortality among HIV patients on treatment decreased significantly since the start of the test and treat strategy. Therefore, test and treat strategy should be strengthened in all public and private facilities throughout the country.