Delayed initiation of anti-retroviral therapy in TB/HIV co-infected patients, Sanyati District, Zimbabwe, 2011-2012

Risk factors for late linkage to care and delayed antiretroviral therapy initiation amongst HIV infected adults in sub-Saharan Africa: a systematic review and meta-analyses

BACKGROUND

Late treatment initiation threatens the clinical and public health benefits of antiretroviral therapy (ART). Quantitative synthesises of the existing evidence related to this is lacking in sub-Saharan Africa (SSA), which would help ascertain the best evidence-based interventions. This review aimed to systematically synthesise the available literature on factors affecting linkage to care and ART initiation amongst HIV-infected adults in SSA.

METHODS

Systematic searches were undertaken on four databases to identify observational studies investigating factors affecting both HIV care outcomes amongst adults (age ≥19 years) in SSA, and were published between January 1, 2015 and June 1, 2021. RevMan-5 software was used to conduct meta-analyses and Mantel-Haenszel statistics to pool outcomes with 95% confidence interval and <0.05 level of significance.

RESULTS

Forty-six studies were included in the systematic review, of which 18 fulfilled requirements for meta-analysis. In both narrative review and meta-analyses, factors related to health care delivery, individual perception and sociodemographic circumstances were associated with late linkage to care and delays in ART initiation.

CONCLUSION

This review identified a range of risk factors for late linkage to care and delayed ART initiation amongst HIV-infected adults in SSA. We recommend implementation of patient-centred intervention approaches to alleviate these barriers.

Delayed HIV treatment, barriers in access to care and mortality in tuberculosis/HIV co-infected patients in Cali, Colombia

OBJECTIVE

To determine factors associated with mortality in tuberculosis/HIV co-infected patients in Cali, Colombia.

METHODS

This retrospective cohort design included tuberculosis/HIV co-infected persons. Kaplan-Meier and Cox regression were used to estimate survival and risk factors associated with mortality.

RESULTS

Of the 279 tuberculosis/HIV co-infected participants, 27.2% died during the study. Participants mainly were adults and males. CD4 count information was available for 41.6% (the median count was 83 cells/mm³), and half were subject to tuberculosis susceptibility testing. The median time between HIV diagnosis and antiretroviral therapy initiation was 372 days. HIV was identified prior to tuberculosis in 53% and concurrent HIV-tuberculosis were diagnosed in 37% of patients. 44.8% had tuberculosis treatment success. Body mass index above 18 kg/m², initiation of tuberculosis treatment within two weeks, having any health insurance coverage and CD4 count information conferred a survival advantage.

CONCLUSIONS

Delays in treatment initiation and factors associated with limited health care access or utilization were associated with mortality. As HIV and tuberculosis are both reportable conditions in Colombia, strategies should be focused on optimizing treatment outcomes within both tuberculosis and HIV programs, particularly improving early HIV diagnosis, early antiretroviral therapy treatment initiation, and adherence to tuberculosis treatment.

Markov modelling of viral load adjusting for CD4 orthogonal variable and multivariate conditional autoregressive mapping of the HIV immunological outcomes among ART patients in Zimbabwe

BACKGROUND

This study aimed to jointly model HIV disease progression patterns based on viral load (VL) among adult ART patients adjusting for the time-varying "incremental transients states" variable, and the CD4 cell counts orthogonal variable in a single 5-stage time-homogenous multistate Markov model. We further jointly mapped the relative risks of HIV disease progression outcomes (detectable VL (VL ≥ 50copies/uL) and immune deterioration (CD4 < 350cells/uL) at the last observed visit) conditional not to have died or become loss to follow-up (LTFU).

METHODS

Secondary data analysis of individual-level patients on ART was performed. Adjusted transition intensities, hazard ratios (HR) and regression coefficients were estimated from the joint multistate model of VL and CD4 cell counts. The mortality and LTFU transition rates defined the extent of patients' retention in care. Joint mapping of HIV disease progression outcomes after ART initiation was done using the Bayesian intrinsic Multivariate Conditional Autoregressive prior model.

RESULTS

The viral rebound from the undetectable state was 1.78times more likely compared to viral suppression among patients with VL ranging from 50-1000copies/uL. Patients with CD4 cell counts lower than expected had a higher risk of viral increase above 1000copies/uL and death if their VL was above 1000copies/uL (state 2 to 3 (λ₂₃): HR = 1.83 and (λ₃₄): HR = 1.42 respectively). Regarding the time-varying effects of CD4 cell counts on the VL transition rates, as the VL increased, (λ₁₂ and λ₂₃) the transition rates increased with a decrease in the CD4 cell counts over time. Regardless of the individual's VL, the transition rates to become LTFU decreased with a decrease in CD4 cell counts. We observed a strong shared geographical pattern of 66% spatial correlation between the relative risks of detectable VL and immune deterioration after ART initiation, mainly in Matabeleland North.

CONCLUSION

With high rates of viral rebound, interventions which encourage ART adherence and continual educational support on the barriers to ART uptake are crucial to achieve and sustain viral suppression to undetectable levels. Area-specific interventions which focus on early ART screening through self-testing, behavioural change campaigns and social support strategies should be strengthened in heavily burdened regions to sustain the undetectable VL. Sustaining undetectable VL lowers HIV transmission in the general population and this is a step towards achieving zero HIV incidences by 2030.

Effects of time of initiation of antiretroviral therapy in the treatment of patients with HIV/TB co-infection: A systemic review and meta-analysis

This systemic review and meta-analysis aimed to investigate the burden of tuberculosis immune reconstitution syndrome (TB-IRIS) and associated mortality to highlight the importance of future direction in preventing and treatment of TB-IRIS. Randomized clinical trials (RCTs) that compared early antiretroviral therapy (ART) versus late ART were included. PubMed, EMBASE, Science Direct and Cochrane Central Register of Controlled Trials electronic databases were searched. This meta-analysis included 8 RCTs with a total of 4, 425 participants. The result of analysis showed that early initiation of ART was associated with increase in TB-IRIS (RR = 1.83; 95% CI: 1.24-2.70, p = 0.002; I2 = 74%, p = 0.0007) and TB-IRIS associated mortality (RR = 6.05; 95% CI: 1.06-34.59, p = 0.04; I2 = 0%, p = 0.78). Early ART was associated with overall mortality compared with late ART initiation. Grade 3 or 4 adverse events, achieving lower viral load and development of new AIDS-defining illness were not associated with the time of ART initiation. Early ART in HIV/TB co-infected patients resulted conclusive evidence of increased TB-IRIS incidence and TB-IRIS associated mortality. Hence, the finding calls for clinical judgment as to the benefits of initiating ART earlier against the risk of TB-IRIS and associated mortality.

Effect of HIV infection on TB treatment outcomes and time to mortality in two urban hospitals in Ghana-a retrospective cohort study

Introduction

Tuberculosis (TB) is currently causing more deaths than Human Immunodeficiency Virus (HIV) globally. Ghana as one of the 30 high burden TB/HIV countries has a high annual TB case-fatality rate of 10%. The study sought to assess the effect of HIV infection on TB treatment outcomes and assess the time to mortality after treatment onset.

Methods

We conducted a review of treatment files of TB patients who were treated from January 2013 to December 2015 in two urban hospitals in the Accra Metropolis. Modified Poisson regression analysis was used to measure the association between HIV infection and TB treatment outcomes. Kaplan-Meier survival estimates were used to plot survival curves.

Results

Seventy-seven percent (83/107) of HIV infected individuals had successful treatment, compared to 91.2% (382/419) treatment success among HIV non-infected individuals. The proportion of HIV-positive individuals who died was 21.5% (23/107) whilst that of HIV-negative individuals was 5.5% (23/419). Being HIV-positive increased the risk of adverse outcome relative to successful outcome by a factor of 2.89(95% CI 1.76-4.74). The total number of deaths recorded within the treatment period was 46; of which 29(63%) occurred within the first two months of TB treatment. The highest mortality rate observed was among HIV infected persons (38.6/1000 person months). Of the 107 TB/HIV co-infected patients, 4(3.7%) initiated ART during TB treatment.

Conclusion

The uptake of ART in co-infected individuals in this study was very low. Measures should be put in place to improve ART coverage among persons with TB/HIV co-infection to help reduce mortality.

The prevalence and associated factors for delayed presentation for HIV care among tuberculosis/HIV co-infected patients in Southwest Ethiopia: a retrospective observational cohort

Background

A delay presentation for human immunodeficiency virus (HIV) patient’s care (that is late engagement to HIV care due to delayed HIV testing or delayed linkage for HIV care after the diagnosis of HIV positive) is a critical step in the series of HIV patient care continuum. In Ethiopia, delayed presentation (DP) for HIV care among vulnerable groups such as tuberculosis (Tb) /HIV co-infected patients has not been assessed. We aimed to assess the prevalence of and factors associated with DP (CD4 < 200 cells/μl at first visit) among Tb/HIV co-infected patients in southwest Ethiopia.

Methods

A retrospective observational cohort study collated Tb/HIV data from Jimma University Teaching Hospital for the period of September 2010 and August 2012. The data analysis used logistic regression model at P value of ≤ 0.05 in the final model.

Results

The prevalence of DP among Tb/HIV co-infected patients was 59.9 %. Tb/HIV co-infected patients who had a house with at least two rooms were less likely (AOR, 0.5; 95 % CI: 0.3–1.0) to present late than those having only single room. Tobacco non-users of Tb/HIV co-infected participants were also 50 % less likely (AOR, 0.5; 95 % CI: 0.3–0.8) to present late for HIV care compared to tobacco users. The relative odds of DP among Tb/HIV co-infected patients with ambulatory (AOR, 1.8; 95 % CI, 1.0–3.1) and bedridden (AOR, 8.3; 95 % CI, 2.8–25.1) functional status was higher than with working status.

Conclusions

Three out of five Tb/HIV co-infected patients presented late for HIV care. Higher proportions of DP were observed in bedridden patients, tobacco smokers, and those who had a single room residence. These findings have intervention implications and call for effective management strategies for Tb/HIV co-infection including early HIV diagnosis and early linkage to HIV care services.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0193-y) contains supplementary material, which is available to authorized users.