Predictors of CD4 count over time among HIV patients initiated ART in Felege Hiwot Referral Hospital, northwest Ethiopia: multilevel analysis

Spatial distribution and geographical heterogeneity factors associated with households' enrollment level in community-based health insurance

Background

Healthcare service utilization is unequal among different subpopulations in low-income countries. For healthcare access and utilization of healthcare services with partial or full support, households are recommended to be enrolled in a community-based health insurance system (CBHIS). However, many households in low-income countries incur catastrophic health expenditure. This study aimed to assess the spatial distribution and factors associated with households' enrollment level in CBHIS in Ethiopia.

Methods

A cross-sectional study design with two-stage sampling techniques was used. The 2019 Ethiopian Mini Demographic and Health Survey (EMDHS) data were used. STATA 15 software and Microsoft Office Excel were used for data management. ArcMap 10.7 and SaTScan 9.5 software were used for geographically weighted regression analysis and mapping the results. A multilevel fixed-effect regression was used to assess the association of variables. A variable with a p < 0.05 was considered significant with a 95% confidence interval.

Results

Nearly three out of 10 (28.6%) households were enrolled in a CBHIS. The spatial distribution of households' enrollment in the health insurance system was not random, and households in the Amhara and Tigray regions had good enrollment in community-based health insurance. A total of 126 significant clusters were detected, and households in the primary clusters were more likely to be enrolled in CBHIS. Primary education (AOR: 1.21, 95% CI: 1.05, 1.31), age of the head of the household >35 years (AOR: 2.47, 95% CI: 2.04, 3.02), poor wealth status (AOR: 0.31, 95% CI: 0.21, 1.31), media exposure (AOR: 1.35, 95% CI: 1.02, 2.27), and residing in Afar (AOR: 0.01, 95% CI: 0.003, 0.03), Gambela (AOR: 0.03, 95% CI: 0.01, 0.08), Harari (AOR: 0.06, 95% CI: 0.02, 0.18), and Dire Dawa (AOR: 0.02, 95% CI: 0.01, 0.06) regions were significant factors for households' enrollment in CBHIS. The secondary education status of household heads, poor wealth status, and media exposure had stationary significant positive and negative effects on the enrollment of households in CBHIS across the geographical areas of the country.

Conclusion

The majority of households did not enroll in the CBHIS. Effective CBHIS frameworks and packages are required to improve the households' enrollment level. Financial support and subsidizing the premiums are also critical to enhancing households' enrollment in CBHIS.

Birth preparedness and pregnancy complication readiness and associated factors among pregnant women in Ethiopia: A multilevel analysis

Maternal and child deaths occur during pregnancy and delivery. Timely information on signs of pregnancy complications and ways to plan for normal birth is a strategy to reduce maternal and child deaths. The purpose of this study was to assess birth preparedness, and pregnancy complications readiness and identify associated factors in Ethiopia. A cross-sectional study design was used. A total of 1635 weighted samples of pregnant women were included for analysis from the 2016 Ethiopian demographic and health survey data set. Multilevel mixed-effect logistic regression was used to estimate the effects of potential variables on birth preparedness and complication readiness. STATA version 15 software was used for data processing and analysis. A variable with a p-value < 0.05 with a 95% confidence interval was considered a significant factor. Pregnant women were informed about convulsions (8.02%), fever (35.95%), abdominal pain (28.92%), leaking fluid from the vagina (28.21%), and blurred vision (17.98%). Pregnant women prepared for supplies needed for birth (38.70%), transportation (20.04%), money (18.97%), people's support for birth (5.03%), and blood donors (3.11%). Only 56% and 44.91% of pregnant women had good birth preparedness and were informed about pregnancy complications respectively. Educational status, antenatal care visits, and region were significant factors associated with birth preparedness and complication readiness. Distance to health facility and residency were significantly associated with birth and complication readiness, respectively. Birth preparedness and complication readiness among pregnant women were low in Ethiopia. Empowering women with education, installing safe roads, building accessible health facilities, and emphasizing pregnancy complications and birth preparedness plans during antenatal care visits are important interventions to enhance birth preparedness and pregnancy complication readiness.

Predictors associated with CD4 cell count changes over time among HIV-infected children on anti-retroviral therapy follow-up in Mekelle General Hospital, Northern Ethiopia, 2019: a retrospective longitudinal study

INTRODUCTION

AIDS continues to be a serious global public health issue. It targets CD4 cells and immunological cells, which are in charge of the body's resistance against pathogenic pathogens. In situations with limited resources, CD4 cell measurement is essential for assessing treatment responses and clinical judgments in HIV-infected children receiving Anti-Retroviral Therapy (ART). The volatility of CD4 cells during ART follow-up is still largely uncharacterized, and there are few new datasets on CD4 cell changes over time. Therefore, the purpose of this analysis was to identify the factors that were predictive of CD4 cell count changes over time in children who started ART at Mekelle General Hospital in northern Ethiopia.

METHODS

A retrospective follow-up study was done. 437 patients in Mekelle general hospital, northern Ethiopia, from 2014-2016 were involved. All patients who have started anti-retrieval treatment (ART) and measured their CD4 cell count at least twice, including the baseline and those who initiated ART treatment, were included in the study population. An exploratory data analysis and linear mixed model analysis were used to explore the predictors of CD4 cell count change in patients and consider variability within and between patients.

RESULTS

This study found the correlation variation explained in cells accounted for between patients was 61.3%, and the remaining 38.7% variation existed within. This indicates that there is a substantial change in random slope and intercept between and within patients. WHO clinical stage IV (β = -1.30, 95% CI: -2.37, -0.23), co-infection HIV/TB (β = -1.78, 95% CI: -2.58, -0.98), children aged 2-5 (β = -0.43; 95% CI: -0.82, -0.04), and 6-14 years (β = -1.02; 95% CI: -1.47, -0.56), non-opportunistic infection (β = 1.33, 95% CI: 0.51, 2.14), and bedridden functional status (β = -1.74, 95% CI: -2.81, -0.68) were predictors of cell changes over time.

CONCLUSIONS

This study found that patients receiving ART experienced a significant change in CD4 cells over time. Because 61.3% of the variation in CD4 cells explained between patients and the remaining 38.7% within patients, such nested data structures are often strong correlation evidence. Co-infection of HIV/TB, functional status, age category of children, WHO clinical stage, and opportunistic infections are potential predictors of CD4 cells count change. Hence, special guidance and attention is also required, especially for those patients who have an opportunistic infections, higher WHO clinical stages, co-infections with HIV and TB, and bedridden functional status.

Factors associated with CD4 + cell count recovery among males and females with advanced HIV disease

OBJECTIVE

HIV/AIDS mortality remains significantly high in sub-Saharan Africa, mostly driven by opportunistic infections and advanced HIV disease (AHD). This study aimed to assess CD4 + cell count recovery following ART initiation and factors associated with immune reconstitution.

METHODS

We conducted a prospective cohort study between 2015 and 2016. HIV-infected adults (≥18 years) with AHD (CD4 + cell count ≤100 cells/μl) receiving care at 20 outpatient HIV treatment facilities in Harare, Zimbabwe were enrolled. CD4 + cell count recovery (CD4 + cell count >200 cells/μl) was assessed following 12-month ART initiation and factors associated with immune reconstitution were investigated using logistic regression analysis. All statistical analyses were performed on Statistical Package for the Social Sciences (SPSS) version 23.

RESULTS

1320 participants were enrolled and 56.4% were males. The median (interquartile range, IQR) age was 37 (32-43) years. Tuberculosis was seen in 16.0%. Of the 739 participants that had CD4 + cell count at 12 months, CD4 + cell count recovery above 200 cells/μl was observed in 163 (22.1%) participants. Median (IQR) CD4 + cell count at 12-months increased to 127 (75-190) cells/μl from 31 (14-55) at baseline. Factors associated with CD4 + cell count recovery were younger age at baseline [odds ratio (OR) ≥40/<40  = 0.58, 95% confidence interval (CI): 0.40-0.85, P  = 0.005), sex (OR female/male  = 2.07, 95% CI: 1.44-2.99, P  < 0.0001) and baseline CD4 + cell count (OR ≥50/<50  = 1.60, 95% CI: 1.10-2.33, P  = 0.013).

CONCLUSION

A significant proportion (77.9%) of patients seeking care with AHD in a resource limited setting failed to recover a CD4 + cell count >200 cells/μl. Male sex, older age and low CD4 + cell count at ART initiation were factors associated with poor immune reconstitution. Better differentiated care deliveries targeting this vulnerable population are critical for improving clinical outcomes and quality of life of the patients.

Clinico-demographic and survival profile of people living with HIV on antiretroviral treatment

Objective

To assess the demographic, clinical, and survival profile of people living with HIV.

Methods

A retrospective cohort study was conducted among patients enrolled at a single antiretroviral therapy center in North Karnataka. A total of 11,099 were recruited from April 2007 to January 2020, out of which 3,676 were excluded and the final 7,423 entries were subjected to analysis. The outcome of interest was the time to death in months of people living with HIV on antiretroviral therapy (ART). The clinical and demographic characteristics were examined as potential risk factors for survival analysis. To investigate the factors that influence the mortality of patients using ART, univariate and multivariate Cox regression were performed. Hazard ratio (HR), 95% confidence interval (CI), and p-values were presented to show the significance. The log-rank test was used to determine the significance of the Kaplan-Meier survival curve.

Results

Out of 7,423 HIV-positive people, majority were female (51.4%), heterosexual typology (89.2%), and in the age group 31-45 years (45.5%). The risk of death in male patients was 1.24 times higher (95% CI: 1.14-1.35) than female patients. Patients with age >45 were 1.67 times more likely to die than patients ≤30 (95% CI: 1.50-1.91). In the multivariable analysis, the hazards of mortality increased by 3.11 times (95% CI: 2.09-2.79) in patients with baseline CD4 count ≤50 as compared to those who had baseline CD4 count >200. The risk of death in patients who were diagnosed with TB was 1.30 times more (95% CI: 1.19-1.42) than in those who did not have TB. The survival probabilities at 3 and 90 months were more in female patients (93%, 70%) compared with male patients (89, 54%), respectively.

Conclusion

This study proved that age, sex, baseline CD4 count, and tuberculosis (TB) status act as risk factors for mortality among people with HIV. Prevention strategies, control measures, and program planning should be done based on the sociodemographic determinants of mortality.

Effects of Gender and Baseline CD4 Count on Post Treatment CD4 Count Recovery and Outcomes in Patients with Advanced HIV Disease: a Retrospective Cohort Study

Presentation to care with advanced HIV disease (AHD) is a significant problem in Sub-Saharan Africa. We evaluated factors associated with immune recovery among individuals presenting to care with AHD in Zimbabwe. We conducted a retrospective evaluation of outcomes among adult (>18 years old) individuals with AHD (CD4 count ≤ 200 cells/mm3) receiving care at 18 outpatient primary care clinics in Harare, Zimbabwe. Baseline and 12-month CD4 count data were extracted from medical records. CD4 count recovery (defined as CD4 count > 200 cells/mm3) after 12 months on NNRTI-based antiretroviral therapy (ART) regimen was determined and factors associated with CD4 count recovery were established using logistic regression. All statistical analysis was performed on SPSS v23. A total of 1338 participant records were included in the analysis. The median interquartile range (IQR) age was 37 (30-43) years and 52% were females. The baseline median (IQR) CD4 count was 50 (28-75) cells/mm3 and was significantly lower among patients with history of cryptococcal meningitis compared to those without (25(10-52) vs 52(32-77), respectively; p=0.0009). The median (IQR) CD4 count at 12 months after ART initiation increased from 50 (28-75) at baseline to 180 (92-290) cells/mm3. Immune recovery with a CD4 count > 200 cells/mm3, was observed in 181/417 (43%). Male gender and low baseline CD4 count were strong predictors of poor immunological recovery on ART. Immunological recovery following ART initiation was 43% among individuals with AHD. Male patients are most vulnerable to persistent immunological failure.

Survival rate and predictors of mortality among TB/HIV co-infected adult patients: retrospective cohort study

Nowadays, Tuberculosis remains the major cause of HIV-associated mortality, which accounts for 1 out of every 5 HIV-related mortality worldwide. This study aimed to determine the survival rate and predictors of mortality among TB/HIV co-infected patients. An institution-based retrospective cohort study was undertaken on adult TB/HIV co-infected individuals between 1st February 2014 and 30th January 2022 at Mettu Karl Referral Hospital. A Cox regression model was used to identify predictors of survival time to death among TB/HIV co-infected patients. This study comprised 402 TB and HIV co-infected adult patients. Among these, 84 (20.9%) died, and 318 (79.1%) were censored. The study subjects have been followed up for 6920 person-months with an overall median survival time of 17.6 months. The overall incidence rate was 12.1 per 1000 person months [95% CI: 9.77-14.98]. The results of a multivariable Cox regression analysis showed that being at an older age, urban residence, WHO clinical stage II & IV, CD4 count of ≥ 200 cells/mm³, bedridden functional status, using INH, and using CPT were associated with the survival time of TB and HIV co-infected patients at a significance level of alpha = 0.05. This retrospective study found that high mortality of TB/HIV co-infected patients occurred in the earlier months of treatment initiation. Close monitoring of patients with low CD4, who do not utilize CPT, who are in advanced WHO stages, and who have poor functional levels can help them improve their health and live longer.

Family APGAR and treatment outcomes among HIV patients at two ART Centres in Kumasi, Ghana

OBJECTIVES

This study aimed to examine the association between Family Adaptability, Partnership, Growth, Affection and Resolve (Family APGAR) and HIV treatment outcomes.

DESIGN

A cross-sectional study using the Family APGAR questionnaire.

SETTING

The study was conducted in Kumasi, Ghana, at the Komfo Anokye Teaching Hospital and the Kwame Nkrumah University of Science and Technology Hospital.

PARTICIPANTS

Consenting HIV-positive patients who had been on treatment for at least 12 months were recruited.

MAIN OUTCOME MEASURES

The Family APGAR questionnaire was administered, and relevant data were extracted from hospital records and analysed using STATA® software. The relationship between Family APGAR and treatment outcomes was determined using Chi-squared tests or Fisher's exact test.

RESULTS

Approximately 70.1% of 304 participants were females with a mean age of 41.8 years (±9.9). At treatment initiation, 47.4% of the patients presented at World Health Organisation (WHO) clinical stages I and II and had a CD4 count ≥ 200 cells/mm3. Females were less likely (Odds Ratio= 0.52; 95% CI=0.31 - 0.90, p = 0.018) to report late for treatment compared with the males. After 12 months of treatment, approximately 70% recorded undetectable viral load. Patients with functional families constituted 70.4%, which had a statistically significant relationship with viral load (p = 0.041).

CONCLUSION

HIV care providers should incorporate family functionality evaluation into clinical practice and provide early essential support to enhance treatment outcomes.

FUNDING

None declared.

Immuno-virological status and its associated factors among HIV-positive patients receiving highly active antiretroviral therapy at delgi primary hospital, northwest Ethiopia, 2020/2021: A cross-sectional study

Background

Highly active antiretroviral therapy (HAART) improves clinical outcomes by suppressing viral replication and allowing immune reconstitution. It also reduces HIV-related complications including morbidity, mortality, and extended hospitalizations for HIV-positive individuals. Regular assessment for antiretroviral treatment response is fundamentally important to address the factors associated with the poor clinical outcome including immunologic failures among HIV-positive patients on HAART. Therefore, this study aimed to investigate the immuno-virological status and describe its determinants among HIV-positive patients receiving HAART at Delgi primary hospital, Northwest Ethiopia.

Methods

A hospital-based cross-sectional study was conducted at Delgi primary hospital from October 25th through June 19th 2021 among a total of 442 study participants. A systematic random sampling technique was employed to enrol participants in the study. Socio-demographic and clinically related data were collected using a semi-structured questionnaire. About 3–5 ml of venous blood was collected aseptically for CD4⁺ T cell count and viral load test. SPSS version 20 software was used for statistical analysis. Bivariate and multivariate logistic regression analyses were conducted to determine the factors associated with immuno-virologic status among HIV-positive patients on HAART. The odds ratio with 95% CI was computed to determine the strength of association. Then, a p-value < 0.05 was considered a statistically significant association. For this study, the results were presented by using frequency summary tables, and texts.

Results

Among the total study participants, 283 (64%) were males and the mean age of the study participants was 37 ± 11.5. The overall immunological and virological failure among highly active antiretroviral therapy (HAART) receiving participants was found to be 9.5% (42/442, 95%CI:3.23–15.09) and 12.2% (54/442, 95% CI: 2.81–23.04) respectively. In the multivariate analysis, study participants with age ≥50 years old [AOR = 1.97, p = 0.01, 95%CI (0.02–4.03)], participants having current viral load count greater ≥1000 copies/ml [AOR = 3.97, p = 0.03, 95%CI (1.09–5.01)] and having TB-co-infection [AOR = 2.51, p = 0.05, 95%CI (1.02–7.51)] were statistically associated with increased risk of immunological failure. Similarly, TB-coinfected participants were 1.88 (95%CI = 0.89–10.02) times at greater risk for virological failure.

Conclusion

In this study, the magnitude of immuno-virological failure is alarming. This may be shown the need for integrated and substantial commitment to enhancing patient antiretroviral treatment adherence in the study area. Also, regular assessment for antiretroviral treatment response is fundamentally important to address the determinants associated with virological and immunologic failures among HIV-positive patients taking HAART. Furthermore, early initiation of HAART may be imperative to achieve favourable virological suppression and immunological reconstitution.

Modeling Survival Time to Death Among TB and HIV Co-infected Adult Patients: an Institution-Based Retrospective Cohort Study

BACKGROUND

Tuberculosis is a serious health threat, particularly for people living with human immunodeficiency virus (HIV), and HIV-positive people are more likely than others to contract the disease. Globally, tuberculosis (TB) is one of the leading causes of death among people living with HIV. The purpose of the current study was to identify factors associated with survival rates of TB/HIV co-infected patients using survival models.

METHODS

A retrospective study was conducted on TB/HIV co-infected adult patients registered and under follow-up at Tepi General Hospital (TGH) and Mizan-Tepi University Teaching Hospital (MTUTH), southwest Ethiopia. All TB/HIV co-infection patients who were registered and under follow-up from 1st January 2015 through 1st January 2020 were considered. The global Schoenfeld test was used to test the proportional hazard (PH) assumption. Various accelerated failure time (AFT) models were compared to determine the best model for the time to death of TB/HIV co-infected patients' data set. Among the most commonly used accelerated failure time models (AFT models), the study used exponential, Weibull, log-logistic, and log-lognormal AFT models. AIC and BIC were used to compare the performance of fitted models. The data were analyzed with the statistical software R.

RESULTS

Of 363 TB/HIV co-infected patients followed for 60 months, 79 (21.8%) died, while the remaining 284 (78.2%) were censored. The overall median survival time was 15.6 months. The proportional hazard assumption was checked and it was violated. In comparison to other models, the lognormal AFT model performed better. The results of the multivariable lognormal AFT model showed that age, residence, substance use, educational status, clinical stages of the disease, cluster of differentiation 4 (CD4 count/mm³), functional status, cotrimoxazole prophylactic therapy use (CPT use), and INH were all found to be significant factors, while gender, illness other than TB, and disclosure of status were insignificant variables at 5% level of significance.

CONCLUSION

Current study results revealed that older age, substance use, advanced WHO clinical stages of the disease (stage IV), bedridden functional status, and CD4 less than 200 count/mm³ were significantly associated with shorter survival time to death of HIV/TB co-infected patients while having advanced educational status, being from urban residence, CPT use, and INH significantly increase the survival time to death of TB/HIV co-infected patients. Patients with TB/HIV co-infection should be given special attention based on these important factors to improve their health and prolong their lives. HIV-positive patients are more likely than others to contract the TB disease. The risk of death among TB/HIV co-infected patients was found to be high. Out of all patients, 79 (21.8%) died. Accelerated failure time models are good alternatives for scenario Cox proportional hazard assumptions not met.

Determinants of CD4 count and risk for death of HIV infected children under ART

The main objective of this study was to identify variables jointly affected for CD4 count and hazard time to death of HIV-infected children under ART at Felege Hiwot Referal and Specialized Hospital. A retrospective cohort study design was conducted on 202 HIV-infected children under ART whose follow-ups were from January 2014 up to December 2018. The descriptive statistics revealed that about 25.2% of HIV-infected children under ART in the study period(Jaunary 2014–December 2018) died and 74.8% were censored. The estimated association parameter in the joint model was − 0.8339 and statistically significant (p value = 0.025). There was a negative relationship between the two response variables namely CD4 count and the risk for death on HIV-positive children under treatment. The level of education of children's parents, level of disclosure of the disease, baseline CD4 count, functional status, and adherence level were statistically and significantly affected for the two response variables, CD4 count and risks for the death of children. Separate and joint models have been compared interims of standard error and the joint model had a small standard error as compared to the separate models. The small standard errors in joint models indicate that the joint model was better in detecting variables that affected the two responses in this regard. Health-related education should be conducted to parents of children for easy recovery of CD4 count and for reducing risks for the death of children.

CD4+ cell count recovery after initiation of antiretroviral therapy in HIV-infected Ethiopian adults

Background

CD4+ cell count recovery after effective antiretroviral therapy (ART) is an important determinant of both AIDS and non-AIDS morbidity and mortality. Data on CD4+ cell count recovery after initiation of ART are still limited in Sub-Saharan Africa. The aim of this study was to assess CD4+ cell count recovery among HIV-infected adults initiating ART in an Ethiopian setting.

Methods

A retrospective cohort study of HIV-infected adults initiating ART between September 2008 and June 2019 was carried out. CD4+ cell count recovery was defined as an increase in CD4+ cell count of >100 cells/mm³ from baseline or achievement of a CD4+ cell count >500 cells/mm³ at 12 months after ART initiation. Factors associated with CD4+ cell count recovery were evaluated using logistic regression analysis.

Results

Of the 566 patients included in this study, the median baseline CD4+ cell count was 264 cells/mm³ (IQR: 192–500). At 12 months after ART initiation, the median CD4+ cell count increased to 472 cells/mm³, and the proportion of patients with CD4+ cell count < 200 cells/mm³ declined from 28.3 to 15.0%. A total of 58.0% of patients had an increase in CD4+ cell count of >100 cells/mm³ from baseline and 48.6% achieved a CD4+ cell count >500 cells/mm³ at 12 months. Among patients with CD4+ cell counts < 200, 200–350 and >350 cells/mm³ at baseline, respectively, 30%, 43.9% and 61.7% achieved a CD4+ cell count >500 cells/mm³ at 12 months. In multivariable analysis, poor CD4+ cell count recovery (an increase of ≤100 cells/mm³ from baseline) was associated with older age, male sex, higher baseline CD4+ cell count and zidovudine-containing initial regimen. Factors associated with poor CD4+ cell count recovery to reach the level >500 cells/mm³ included older age, male sex and lower baseline CD4+ cell count.

Conclusions

CD4+ cell count failed to recover in a substantial proportion of adults initiating ART in this resource-limited setting. Older age, male sex and baseline CD4+ cell count are the dominant factors for poor CD4+ cell count recovery. Novel therapeutic approaches are needed focusing on high risk patients to maximize CD4+ cell count recovery and improve outcomes during therapy.

Determinants of first-line antiretroviral treatment failure among adult patients on treatment in Mettu Karl Specialized Hospital, South West Ethiopia; a case control study

Background

Antiretroviral therapy has dramatically reduced Human Immunodeficiency Virus related morbidity and mortality. It has also transformed HIV infection into a manageable chronic condition. However, first-line antiretroviral treatment failure continues to grow especially in resource limited settings. Despite this, determinants of first-line antiretroviral treatment failure are not well studied in Ethiopia.

Objective

To identify determinants of first-line antiretroviral treatment failure among adult patients on antiretroviral therapy in Mettu Karl Specialized Hospital, South West Ethiopia, in 2020.

Methods

A hospital based case-control study was conducted from October to November 2020. Simple random sampling technique was used to select participants. Interviewer administered questionnaire and record review were used for data collection. Data were entered into epi data version 3.1 and exported to SPSS version 20 for analysis. Bivariable and multivariable logistic regression analysis were used. At the end, variables with P-value < 0.05 at 95% confidence intervals for adjusted odds ratio were considered statistically significant determinants of first line treatment failure.

Result

A total of 113 cases and 339 controls were included in the study with response rate of 98.6%. Sixty-four (56.6%) of cases and 183 (54.0%) of controls were females. Baseline WHO clinical stage III and IV (AOR = 1.909, 95% CI: (1.103, 3.305), baseline body mass index<18.5kg/m²(AOR = 2.208,95% CI:(1.257,3.877),baseline CD4 cell count <100cells/mm³ (AOR = 3.016, 95% CI: (1.734, 5.246), having history of TB co-infection (AOR = 1.855, 95% CI: (1.027, 3.353), having history of lost to follow up (AOR = 3.235, 95% CI: (1.096, 9.551), poor adherence to medication (AOR = 7.597, 95% CI: (4.059, 14.219) and initiation of treatment after two years of diagnosis with HIV (AOR = 4.979, 95% CI: (2.039, 12.158) were determinants of first-line antiretroviral treatment failure.

Conclusion

In this study several variables were found to be determinants of first-line antiretroviral treatment failure. Concerned bodies should give more attention to early diagnosis of HIV, early enrollment in chronic HIV care and early initiation of ART before patients develop advanced WHO clinical stages. In addition, focus has to be given for patients with low CD4 count. Regular screening for TB, counseling on optimal adherence to medication and enhancing nutritional status of patients with low body mass index are also crucial to prevent first-line antiretroviral treatment failure.

Statistical Analysis on Determinant Factors Associated with Time to Death of HIV/TB Co-Infected Patients Under HAART at Debre Tabor Referral Hospital: An Application of Accelerated Failure Time-Shared Frailty Models

Background

Human immune virus/tuberculosis co-infection in one's immune system potentiates each other and hastening the weakening of the host's immunological capabilities while growing active TB, which will increase susceptibility to primary contamination, re-contamination, and/or reactivation for sufferers with latent TB. The goal of this study was to identify determinant factors associated with the survival time to death of HIV/TB co-infected adult patients under HAART at Debre Tabor referral hospital.

Methods

A retrospective follow-up analysis was undertaken for 243 HIV/TB co-infected patients who were receiving ART treatment and had follow-ups between January 2014 and December 2019. To compare the survival experiences of different patient groups, the Log rank test was performed. The Weibull accelerated failure time gamma shared frailty model was used to find determinants of HIV/TB co-infected patients' survival time.

Results

Among HIV/TB co-infected patients, 87 (35.39%) died of whom 77 (88.5%) patients were females. The Weibull AFT gamma shared frailty model showed that sex, baseline age, adherence status, educational status of respondents, functional status, WHO clinical stage, baseline hemoglobin and type of TB were among the potential determinants of survival time of HIV/TB co-infected patients. Furthermore, the findings of this study demonstrated that there is a clustering impact on patient time to death that results from the residency of HIV/TB co-infected patients' survival time.

Conclusion and Recommendation

The majority of patients reside in rural area, have poor adherence to treatment, and have low CD4 cell counts. Educational status, WHO clinical stages, adherence status, and hemoglobin levels of patients are all important determinants of HIV/TB co-infected patients' survival. As a result, to improve the survival of HIV/TB co-infected patients at the start of and during some stages of anti-TB treatment, the concerned body, FMOH, in collaboration with Regional Health Bureau, should emphasize the importance of following treatment for HIV/TB co-infected patients with poor adherence status, advanced WHO clinical stages, and a low CD4+ count.

Socio-Demographic, Economic and Clinical Predictors for HAART Adherence Competence in HIV-Positive Adults at Felege Hiwot Teaching and Specialized Hospital, North West Ethiopia

Background

Currently, around 36.7 million people in the world are living with HIV. Among these, 52% are living in sub-Saharan Africa. The main objective of this study was to identify socio-demographic economic and clinical factors associated with HAART adherence competence in successive visits among adult HIV patients after commencement of their treatment.

Methods

A retrospective cohort study design was conducted on a random sample of 792 treatment attendants. The samples were selected using stratified random samples technique considering their residence area as strata. Secondary data were used in this study. Structural equation modeling (SEM) was applied to identify predictors of HAART adherence competence over time.

Results

In this longitudinal study, factors affecting long-term HAART adherence competence in successive visits were identified. Among the predictors, marital status (mean = 3.97, variance = 0.6, p = 0.021), level of disclosure of the disease (mean = 6.24, variance = 0.29, p = 0.012), residence area (mean = 3.97, variance = 0.6, p = 0.021), level of education (mean = 2.04, variance= 0.81, p = 0.012), ownership of cell phone (mean = 2.99, variance = 0.68, p = 0.034), household income (mean = 6.37, variance = 0.53, p = 0.002), age of patients (mean = –2.78, variance = 56.64, p = 0.023), sex of patients (mean = –1.25, variance = 0.88, p = 0.036), weight (mean = –2.89, 42.36, p = 0.001), initial CD4 cell count (mean = 2.57, variance = 158.48, p = 0.015) and WHO stages (mean = 2.37, variance = 0.78, p = 0.026) were directly associated with retention of medication care. On the other hand, medication care was significantly and independently associated with longitudinal adherence competence.

Conclusion

The outcome variable in successive visits increased with the number of follow-up visits, but the rate of increase was different for different groups, such as urban and rural, and for those patients disclosing and not disclosing the disease to family members. An integrated health-related education should be given for non-adherent patients like rural residents, patients living without partners, patients with no cell phone and aged patients.

Predictors of Current CD4+ T-Cell Count Among Women of Reproductive Age on Antiretroviral Therapy in Public Hospitals, Southwest Ethiopia

Background

HIV/AIDS is one of the major global public health problems. CD4 is a glycoprotein found on the surface of different immune cells. CD4 cell counts determine the need for screening and prophylactic interventions against common opportunistic infections in those with advanced HIV disease. Thus, this study aimed to assess the predictors of current CD4⁺ T-cell count among women of reproductive age on antiretroviral therapy in public hospitals, southwest Ethiopia.

Methods

A cross-sectional study was conducted from February to April 2018. A total of 422 participants in the three public hospitals were selected using a systematic random sampling method. Linear regression analyses were used to determine the important predictors of current CD4⁺ T-cell count at p-values of <0.05.

Results

A total of 422 women with a median age of 37.00 years participated in this study. More than one in ten (12.8%) respondents experienced immunological failure. An increased current CD4⁺ T-cell count was observed among patients with a tertiary level of education [β = 56.45, 95% CI (3.5, 109.4)], baseline WHO clinical stage II [β = 44.06, 95% CI (5.3, 82.9)], initial regimen of AZT+3TC+EFV [β = 167.23, 95% CI (100.4, 234.1)], with increased baseline CD4⁺ T-cell count [β = 0.35, 95% CI (0.2, 0.5)], and with increased time duration on ART [β = 14.36, 95% CI (6.304, 22.4)]. On the other hand, the current CD4⁺ T-cell count was lowered among patients with poor baseline adherence, opportunistic infection, and viral load of ≥1000 by 181.06 cells/mm³, 101.62 cells/mm³, and 137.53 cells/mm³ compared to good baseline adherence, no opportunistic infection and undetectable viral load, respectively.

Conclusion

The immunological failure was relatively low. Maintaining adherence, early identification and treatment of opportunistic infections, and minimizing viral load to undetectable levels may further decrease immunological failure.

Spatial distribution of iron rich foods consumption and its associated factors among children aged 6-23 months in Ethiopia: spatial and multilevel analysis of 2016 Ethiopian demographic and health survey

BACKGROUND

Micronutrient deficiencies are the most prevalent nutritional deficiencies that cause serious developmental problems in the globe. The aim of this study was to assess the spatial distribution of iron rich foods consumption and its associated factors among children aged 6-23 months in Ethiopia.

METHODS

The data retrieved from the standard Ethiopian Demographic and Health Survey 2016 dataset with a total sample size of 3055 children aged 6-23 months. Spatial scan statistics done using Kuldorff's SaTScan version 9.6 software. ArcGIS version 10.7 software used to visualize spatial distribution for poor consumption of iron rich foods. Multilevel mixed-effects logistic regression analysis employed to identify the associated factors for good consumption of iron-rich foods. Level of statistical significance was declared at a two-sided P-value < 0.05.

RESULTS

Overall, 21.41% (95% CI: 19.9-22.9) of children aged 6-23 months had good consumption of iron rich foods in Ethiopia. Poor consumption of iron rich foods highly clustered at Southern Afar, Southeastern Amhara and Tigray, and the Northern part of Somali Regional States of Ethiopia. In spatial scan statistics, children aged 6-23 months living in the most likely cluster were 21% more likely vulnerable to poor consumption of iron rich foods than those living outside the window (RR = 1.21, P-value < 0.001). Child aged 12-17 months (AOR = 1.90, 95% CI: 1.45-2.49) and 18-23 months (AOR = 2.05, 95% CI: 1.55-2.73), primary (AOR = 1.42, 95% CI:1.06-1.87) and secondary and above (AOR = 2.26, 95% CI: 1.47-3.46) mother's education level, rich (AOR = 1.49, 95% CI: 1.04-2.13) and middle (AOR = 1.83, 95% CI: 1.31-2.57) household wealth status, Amhara (AOR = 0.24, 95% CI: 0.09-0.60), Afar (AOR = 0.38, 95% CI: 0.17-0.84), and Harari (AOR = 2.11, 95% CI: 1.02-4.39) regional states of Ethiopia were statistically significant factors for good consumption of iron rich foods.

CONCLUSION

Overall, the consumption of iron rich foods was low and spatially non-random in Ethiopia. Federal Ministry of Health and other stakeholders should give prior attention to the identified hot spot areas to enhance the consumption of iron rich foods among children aged 6-23 months.

Determinants of immunological recovery following HAART among severely immunosuppressed patients at enrolment to care in Northern Ethiopia: a retrospective study

OBJECTIVE

This study aimed to identify determinants of immunological recovery following highly active antiretroviral therapy (HAART) among severely immunosuppressed patients at enrolment to care in Northern Ethiopia.

METHODS

A retrospective study.

SETTING

The study was done in Tigray Region, Northern Ethiopia.

PARTICIPANTS

The study was done among severely immunosuppressed (<200 CD4 cells/mm³) individuals at initial enrolment to care and whose samples were sent for viral load determination from April 2015 to March 2019 in Tigray Health Research Institute.

MAIN OUTCOMES

The main outcome variable was immunological recovery, modelled using binary logistic regression.

RESULTS

Among the 9687 patients with severe immunosuppression at enrolment, 2746 (28.35%, 95% CI 27.45% to 29.26%) had immunological recovery following HAART for at least 6 months. Male gender (adjusted OR (AOR)=0.50, p<0.001), age 20-34 years old (AOR=0.33, p<0.001), age ≥50 years old (AOR=0.26, p<0.001), WHO clinical stage III (OR=0.68, p=0.036) and viral non-suppression (AOR=0.38, p<0.001) were strong predictors of immunological failure.

CONCLUSIONS

Immunological recovery following HAART was low among severely immunosuppressed individuals at enrolment to care. Gender, age, WHO stage III and viral non-suppression were determinants of immunological recovery. Male patients, adolescents and virally non-suppressed patients should be identified as groups at higher risk for immunological failure. Therefore, greater support and intensive counselling should be prioritised among adolescents, men and virally non-suppressed patients for better immunological recovery.

Immunological Response During HAART and Determinants of Current CD4+ T-Cell Count Among HIV/AIDS Patients Attending University of Gondar Referral Hospital, Northwest Ethiopia

PURPOSE

After the initiation of highly active antiretroviral therapy (HAART), successful HAART is characterized by an increase in the CD4+ count. Several factors affect the CD4+ T-cell count. This study aimed to assess the immunological response during HAART and determinants of the current CD4+ T-cell count among HIV/AIDS patients on HAART.

PATIENTS AND METHODS

A hospital-based cross-sectional study was conducted from February 1 to April 1, 2017. A total of 423 HIV/AIDS patients on HAART were enrolled using simple random sampling. Descriptive statistics, and bivariate and multiple regression analyses were conducted. Variables with p-value <0.2 in the bivariate analysis were entered in the multiple regression models. p-Values <0.05 and 95% confidence intervals were used to identify determinants of the current CD4+ T-cell count.

RESULTS

The mean CD4+ T-cell count gradually increased until 8 years on HAART but declined thereafter. An increased current CD4+ T-cell count was observed among patients with an initial regimen of pediatric d4T-3TC-NVP [β=185.5, 95% CI (8.8, 362.2)] (p=0.040), with increased baseline CD4+ T-cell count [β=0.468, 95% CI (0.342, 0.594)] (p<0.0001), and with long duration on HAART [β=18.0, 95% CI (9.9, 26.1)] (p<0.0001), whereas a decreased level of current CD4+ T-cell count was observed among males [β=-72.7, 95% CI (-114.5, -30.9)]) (p<0.0001) and those with poor baseline adherence [β=-108.9, 95% CI (-210.9, -7.0)] (p=0.036) and viral load >1000 copies [β=-189.2, 95% CI (-243.5, -134.9)] (p<0.0001).

CONCLUSION

The trend in immunological response was not increased linearly throughout the HAART duration. Sex, type of initial regimen, baseline adherence, baseline CD4+ count, viral load, and duration on HAART were independent determinants of current CD4+ count. These determinants could be addressed by regular monitoring of HIV patients on HAART, and special attention should be paid to male patients.

Multilevel ordinal model for CD4 count trends in seroconversion among South Africa women

BACKGROUND

Ordinal health longitudinal response variables have distributions that make them unsuitable for many popular statistical models that assume normality. We present a multilevel growth model that may be more suitable for medical ordinal longitudinal outcomes than are statistical models that assume normality and continuous measurements.

METHODS

The data is from an ongoing prospective cohort study conducted amongst adult women who are HIV-infected patients in Kwazulu-Natal, South Africa. Participants were enrolled into the acute infection, then into early infection subsequently into established infection and afterward on cART. Generalized linear multilevel models were applied.

RESULTS

Multilevel ordinal non-proportional and proportional-odds growth models were presented and compared. We observed that the effects of covariates can't be assumed identical across the three cumulative logits. Our analyses also revealed that the rate of change of immune recovery of patients increased as the follow-up time increases. Patients with stable sexual partners, middle-aged, cART initiation, and higher educational levels were more likely to have better immunological stages with time. Similarly, patients having high electrolytes component scores, higher red blood cell indices scores, higher physical health scores, higher psychological well-being scores, a higher level of independence scores, and lower viral load more likely to have better immunological stages through the follow-up time.

CONCLUSION

It can be concluded that the multilevel non-proportional-odds method provides a flexible modeling alternative when the proportional-odds assumption of equal effects of the predictor variables at every stage of the response variable is violated. Having higher clinical parameter scores, higher QoL scores, higher educational levels, and stable sexual partners were found to be the significant factors for trends of CD4 count recovery.

Predictors of CD4 count changes over time among children who initiated highly active antiretroviral therapy in Ethiopia

Introduction

Human immunodeficiency virus (HIV) infection results in a gradual depletion of immune function, particularly CD4 cells. The CD4 assessment plays a significant role in assessing treatment responses and clinical decision-making for patients on combination antiretroviral therapy (ART) in resource-limited settings. However, new data on CD4 count changes are scarce; the volatility of CD4 counts after initiation of ART over time remains largely uncharacterized. This study aimed to identify the predictors of CD4 changes over time among HIV-infected children who began ART in Amhara, Ethiopia.

Methods

A retrospective follow-up study was performed. A total of 983 HIV-infected children who initiated ART in government hospitals in the Amhara region between 2010 and 2016 were included using a simple random sampling technique. Data were extracted using a structured checklist. An exploratory data analysis was carried out to explain individual and average profile plots. The linear mixed model was used to identify the CD4 change count predictors over time. Variables with p value < 0.05 were considered statistically significant in a multivariable linear mixed regression analysis.

Results

The mean CD4 count of the participants was 465.1 cells/mm³ with an average CD4 count increase of 30.06 cells/mm³ over 6 months from baseline CD4 count and ART initiation. Childhood age (β = − 0.015; 95% Cl − 0.021, − 0.009), opportunistic infection at ART initiation (β = − 0.044, 95% CI − 0.085, − 0.004), hemoglobin level (β = 0.013; 95% CI 0.004, 0.022), and baseline WHO clinical stage II (β = − 0.046, 95% CI − 0.091, − 0.0003) were significant predictors of CD4 changes over time.

Conclusions

The average CD4 count increase was sufficient in HIV patients who began combined antiretroviral therapy over time. The younger age of the infant, the higher baseline level of hemoglobin, the baseline WHO clinical stage II, and opportunistic infections led to changes in CD4 counts. As a result, timely diagnosis and treatment of opportunistic infections will reduce the risk of opportunistic infections.

Immunological recovery, failure and factors associated with CD-4 T-cells progression over time, among adolescents and adults living with HIV on Antiretroviral Therapy in Northern Ethiopia: A retrospective cross sectional study

Background

This study was aimed to assess immunological recovery, failure, and factors associated with CD-4 T-cells progression over time, among adolescents and adults living with HIV on Antiretroviral Therapy in Northern Ethiopia.

Methods

A retrospective cross sectional study was done on 19,525 HIV patients on ART. Data were collected using a data retrieval checklist from a database. All eligible data in the database were exported to Microsoft excel 2010 and then data verification and filtration were done before exporting to STATA 14.0 for analysis. Factors associated with recent CD-4 count were modeled by using Generalized Linear Model poison family.

Results

Among the patients with advanced HIV infection (< 200 CD-4 T-cell/ mm³) at baseline, only 28.35%, 95% CI (27.45–29.26) of them had immunological recovery (≥ 500 T-cells/mm³). Only 2.14%, 95%CI (1.94%- 2.35%) of the patients had immunological failure. Baseline CD-4 count (Incidence Rate Ratio (IRR) = 1.0007, 95%CI = 1.00069–1.00078), patients from military health care facility (IRR = 1.11, 95%CI = 1.06–1.16), good adherence (IRR = 1.12, 95%CI = 1.04–1.21) and viral load suppression (IRR = 1.31, 95%CI = 1.28–1.33) were positively associated with recent CD-4 count in the full model. Whereas, being male (IRR = 0.85, 95%CI = 0.83–0.86), patients with on Anti-Retroviral Therapy (ART) regimen of 1e (TDF-3TC-EFV), 2f (AZT-3TC-ATV/r), and 2h (TDF-3TC-ATV/r) (IRR = 0.92, 95%CI = 0.91–0.94), (IRR = 0.65, 95%CI = 0.55–0.76) and (IRR = 0.71, 95%CI = 0.63–0.81) respectively were negatively associated with the recent CD-4 count in the full model.

Conclusions

Immunological recovery was achieved by 1/3 of the patients despite being on highly active ART (HAART). Therefore, intensive adherence counseling, follow-up and support should be focused on patients with viral non suppression to enhance immunological recovery.

Health outcomes of asymptomatic HIV-infected pregnant women initiating antiretroviral therapy at different baseline CD4 counts in Ethiopia

OBJECTIVE

To compare health outcomes following initiation of antiretroviral therapy (ART) for asymptomatic HIV-infected pregnant women at different CD4 levels.

METHODS

We analyzed data from 706 asymptomatic HIV-infected Ethiopian women initiating ART during pregnancy between February 2012 and October 2016. The outcomes evaluated were CD4 gain, CD4 normalization (CD4 count ≥750cells/mm3) and occurrence of HIV-related clinical events after twelve months of treatment.

RESULT

On average, CD4 count (cells/mm3) increased from 391 (95% CI: 372-409) at baseline to 523 (95% CI: 495-551) after twelve months of treatment. Rate of CD4 gain was higher among women with baseline CD4 between 350 and 499 compared to CD4 ≥500 (207 versus 6, p<0.001). But women with baseline CD4 between 350 and 499 could not catch up with women with CD4 ≥500. Women with baseline CD4 ≥500 had significantly higher likelihood of achieving CD4 normalization as compared to those with CD4 between 350 and 499 (AOR=0.32, 95% CI: 0.13-0.76). No strong evidence of differential risk in the occurrence of HIV-related clinical events.

CONCLUSION

Starting ART for asymptomatic HIV-infected women with CD4 count ≥500cells/mm3 was beneficial to preserve or recover immunity after 12 months of treatment in a resource limited setting.

Immunologic and virological response to ART among HIV infected individuals at a tertiary hospital in Ghana

Background

The need to study the outcome of Antiretroviral Therapy (ART) among Human Immunodeficiency Virus (HIV) infected individuals in Ghana, a sub-Saharan African country crucial in the era of the “Treat All” policy. The aim of this study was to analyze selected determinants of immunological and virological response to ART among HIV infected individuals in a tertiary facility in Cape Coast, Ghana.

Methods

An analytical cross sectional study with a retrospective component was conducted in the Cape Coast Teaching Hospital (CCTH), Central Region. Clients aged 18 years and above attending the HIV Clinics for ART and who were on ART for 6 months or more were recruited. The viral loads, CD4 count and other socio-demographic data were analyzed using STATA version 13 (STATA Corp, Texas USA). Descriptive analysis was done and presented with appropriate measures of central tendencies. In addition, bivariate and multivariate analysis was carried out with p value of 0.05 interpreted as evidence of association between variables.

Results

A total of 440 participants were included in this study with a mean age of 45.5 (±11.6) years. The mean CD4 count at baseline, 6 months on ART and currently at study recruitment were 215.1 cells/mm³ (±152.6), 386.6 cells/mm³ (±178.5), and 579.6 cells/mm³ (±203.0) respectively. After 6 months and 12 months on ART, the number who had achieved viral copies < 1000/ml were 149 (47.0%) and 368 (89.6%) respectively. There was strong evidence of an association between having CD4 count < 350 cells/mm³ after 6 months on ART and having a diagnosis of tuberculosis since HIV diagnosis (aOR 8.5, 95% CI 1.1–73.0, p = 0.05) and clients having plasma viral load > 1000 copies/ml after 6 months on ART (aOR 2.0, 95% CI 1.2–3.2, p = 0.01).

Conclusion

There was good response to ART among clients, high virological suppression and immunological recovery hence low rates of change to second line ART regimen in this cohort studied. With strict adherence to the national policy on HIV testing, management of positive clients and full implementation of the “Treat All” policy, Ghana could achieve, if nothing at all, the third “90, 90, 90” target by 2020.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3142-5) contains supplementary material, which is available to authorized users.

Determinants of CD4 cell count change and time-to default from HAART; a comparison of separate and joint models

BACKGROUND

HIV has the most serious effects in Sub-Saharan African countries as compared to countries in other parts of the world. As part of these countries, Ethiopia has been affected significantly by the disease, and the burden of the disease has become worst in the Amhara Region, one of the eleven regions of the country. Being a defaulter or dropout of HIV patients from the treatment plays a significant role in treatment failure. The current research was conducted with the objective of comparing the performance of the joint and the separate modelling approaches in determining important factors that affect HIV patients' longitudinal CD4 cell count change and time to default from treatment.

METHODS

Longitudinal data was obtained from the records of 792 HIV adult patients at Felege-Hiwot Teaching and Specialized Hospital in Ethiopia. Two alternative approaches, namely separate and joint modeling data analyses, were conducted in the current study. Joint modeling was conducted for an analysis of the change of CD4 cell count and the time to default in the treatment. In the joint model, a generalized linear mixed effects model and Weibul survival sub-models were combined together for the repetitive measures of the CD4 cell count change and the number of follow-ups in which patients wait in the treatment. Finally, the two models were linked through their shared unobserved random effects using a shared parameter model.

RESULTS

Both separate and joint modeling approach revealed a consistent result. However, the joint modeling approach was more parsimonious and fitted the given data well as compared to the separate one. Age, baseline CD4 cell count, marital status, sex, ownership of cell phone, adherence to HAART, disclosure of the disease and the number of follow-ups were important predictors for both the fluctuation of CD4 cell count and the time-to default from treatment. The inclusion of patient-specific variations in the analyses of the two outcomes improved the model significantly.

CONCLUSION

Certain groups of patients were identified in the current investigation. The groups already identified had high fluctuation in the number of CD4 cell count and defaulted from HAART without any convincing reasons. Such patients need high intervention to adhere to the prescribed medication.

Joint longitudinal data analysis in detecting determinants of CD4 cell count change and adherence to highly active antiretroviral therapy at Felege Hiwot Teaching and Specialized Hospital, North-west Ethiopia (Amhara Region)

BACKGROUND

Adherence and CD4 cell count change measure the progression of the disease in HIV patients after the commencement of HAART. Lack of information about associated factors on adherence to HAART and CD4 cell count reduction is a challenge for the improvement of cells in HIV positive adults. The main objective of adopting joint modeling was to compare separate and joint models of longitudinal repeated measures in identifying long-term predictors of the two longitudinal outcomes: CD4 cell count and adherence to HAART.

METHODS

A longitudinal retrospective cohort study was conducted to examine the joint predictors of CD4 cell count change and adherence to HAART among HIV adult patients enrolled in the first 10 months of the year 2008 and followed-up to June 2012. Joint model was employed to determine joint predictors of two longitudinal response variables over time. Furthermore, the generalized linear mixed effect model had been used for specification of the marginal distribution, conditional to correlated random effect.

RESULTS

A total of 792 adult HIV patients were studied to analyze the longitudinal joint model study. The result from this investigation revealed that age, weight, baseline CD4 cell count, ownership of cell phone, visiting times, marital status, residence area and level of disclosure of the disease to family members had significantly affected both outcomes. From the two-way interactions, time * owner of cell phone, time * sex, age * sex, age * level of education as well as time * level of education were significant for CD4 cell count change in the longitudinal data analysis. The multivariate joint model with linear predictor indicates that CD4 cell count change was positively correlated (p ≤ 0.0001) with adherence to HAART. Hence, as adherence to HAART increased, CD4 cell count also increased; and those patients who had significant CD4 cell count change at each visiting time had been encouraged to be good adherents.

CONCLUSION

Joint model analysis was more parsimonious as compared to separate analysis, as it reduces type I error and subject-specific analysis improved its model fit. The joint model operates multivariate analysis simultaneously; and it has great power in parameter estimation. Developing joint model helps validate the observed correlation between the outcomes that have emerged from the association of intercepts. There should be a special attention and intervention for HIV positive adults, especially for those who had poor adherence and with low CD4 cell count change. The intervention may be important for pre-treatment counseling and awareness creation. The study also identified a group of patients who were with maximum risk of CD4 cell count change. It is suggested that this group of patients needs high intervention for counseling.