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Kay A, Lukhele B, Dlamini S, Seeger A, Dlamini P, Ndabezitha S, Mthethwa N, Steffy T, Komba L, Amuge P, Ketangenyi E, Elyanu P, Munthali A, Msekandiana A, Maldonado Y, Chiao E, Kekitiinwa A, Thahane L, Mwita L, Kirchner HL, Mandalakas AM. Predicting mortality within 1 year of ART initiation in children and adolescents living with HIV in sub-Saharan Africa: a retrospective observational cohort study. Lancet Glob Health 2024; 12:e929-e937. [PMID: 38762295 PMCID: PMC11149103 DOI: 10.1016/s2214-109x(24)00091-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/26/2024] [Accepted: 02/22/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Differentiated service delivery (DSD) for children and adolescents living with HIV can improve targeted resource use. We derived a mortality prediction score to guide clinical decision making for children and adolescents living with HIV. METHODS Data for this retrospective observational cohort study were evaluated for all children and adolescents living with HIV and initiating antiretroviral therapy (ART); aged 0-19 years; and enrolled at Baylor clinics in Eswatini, Malawi, Lesotho, Tanzania, and Uganda between 2005 and 2020. Data for clinical prediction, including anthropometric values, physical examination, ART, WHO stage, and laboratory tests were captured at ART initiation. Backward stepwise variable selection and logistic regression were performed to develop predictive models for mortality within 1 year of ART initiation. Probabilities of mortality were generated, compared with true outcomes, internally validated, and evaluated against WHO advanced HIV criteria. FINDINGS The study population included 16 958 children and adolescents living with HIV and initiated on ART between May 18, 2005, and Dec 18, 2020. Predictive variables for the most accurate model included: age, CD4 percentage, white blood cell count, haemoglobin concentration, platelet count, and BMI Z score as continuous variables, and WHO clinical stage and oedema, abnormal muscle tone and respiratory distress on examination as categorical variables. The area under the curve (AUC) of the predictive model was 0·851 (95% CI 0·839-0·863) in the training set and 0·822 (0·800-0·845) in the test set, compared with 0·606 (0·595-0·617) for the WHO advanced HIV criteria (p<0·0001). INTERPRETATION This study evaluated a large, multinational population to derive a mortality prediction tool for children and adolescents living with HIV. The model more accurately predicted clinical outcomes than the WHO advanced HIV criteria and has the potential to improve DSD for children and adolescents living with HIV in high-burden settings. FUNDING National Institute of Health Fogarty International Center.
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Affiliation(s)
- Alexander Kay
- Baylor College of Medicine, Houston, TX, USA; Baylor College of Medicine Children's Foundation-Eswatini, Mbabane, Eswatini.
| | - Bhekumusa Lukhele
- Department of Health Policy and Organization, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sandile Dlamini
- Baylor College of Medicine Children's Foundation-Eswatini, Mbabane, Eswatini
| | | | - Phumzile Dlamini
- Baylor College of Medicine Children's Foundation-Eswatini, Mbabane, Eswatini
| | - Sandile Ndabezitha
- Baylor College of Medicine Children's Foundation-Eswatini, Mbabane, Eswatini
| | | | - Teresa Steffy
- Baylor College of Medicine, Houston, TX, USA; Baylor College of Medicine Children's Foundation-Lesotho, Maseru, Lesotho
| | - Lilian Komba
- Baylor College of Medicine Children's Foundation-Tanzania, Mbeya and Mwanza, Tanzania
| | - Pauline Amuge
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Eunice Ketangenyi
- Baylor College of Medicine Children's Foundation-Tanzania, Mbeya and Mwanza, Tanzania
| | - Peter Elyanu
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Adamson Munthali
- Baylor College of Medicine Children's Foundation-Malawi, Lilongwe, Malawi
| | - Amos Msekandiana
- Baylor College of Medicine Children's Foundation-Malawi, Lilongwe, Malawi
| | - Yvonne Maldonado
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | | | - Adeodata Kekitiinwa
- Baylor College of Medicine, Houston, TX, USA; Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Lineo Thahane
- Baylor College of Medicine, Houston, TX, USA; Baylor College of Medicine Children's Foundation-Lesotho, Maseru, Lesotho
| | - Lumumba Mwita
- Baylor College of Medicine, Houston, TX, USA; Baylor College of Medicine Children's Foundation-Tanzania, Mbeya and Mwanza, Tanzania
| | - H Lester Kirchner
- Baylor College of Medicine, Houston, TX, USA; Department of Population Health Sciences, Geisinger Health, Danville, VA, USA
| | - Anna Maria Mandalakas
- Baylor College of Medicine, Houston, TX, USA; Research Center Borstel, Sülfeld, Germany
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Fentie DT, Kassa GM, Tiruneh SA, Muche AA. Development and validation of a risk prediction model for lost to follow-up among adults on active antiretroviral therapy in Ethiopia: a retrospective follow-up study. BMC Infect Dis 2022; 22:727. [PMID: 36071386 PMCID: PMC9449961 DOI: 10.1186/s12879-022-07691-x] [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: 11/30/2021] [Accepted: 08/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background Over 420,000 people have initiated life-saving antiretroviral therapy (ART) in Ethiopia; however, lost-to-follow-up (LTFU) rates continues to be high. A clinical decision tool is needed to identify patients at higher risk for LTFU to provide individualized risk prediction to intervention. Therefore, this study aimed to develop and validate a statistical risk prediction tool that predicts the probability of LTFU among adult clients on ART. Methods A retrospective follow-up study was conducted among 432 clients on ART in Gondar Town, northwest, Ethiopia. Prognostic determinates included in the analysis were determined by multivariable logistic regression. The area under the receiver operating characteristic (AUROC) and calibration plot were used to assess the model discriminative ability and predictive accuracy, respectively. Individual risk prediction for LTFU was determined using both regression formula and score chart rule. Youden index value was used to determine the cut-point for risk classification. The clinical utility of the model was evaluated using decision curve analysis (DCA). Results The incidence of LTFU was 11.19 (95% CI 8.95–13.99) per 100-persons years of observation. Potential prognostic determinants for LTFU were rural residence, not using prophylaxis (either cotrimoxazole or Isoniazid or both), patient on appointment spacing model (ASM), poor drug adherence level, normal Body mass index (BMI), and high viral load (viral copies > 1000 copies/ml). The AUROC was 85.9% (95% CI 82.0–89.6) for the prediction model and the risk score was 81.0% (95% CI 76.7–85.3) which was a good discrimination probability. The maximum sensitivity and specificity of the probability of LTFU using the prediction model were 72.07% and 83.49%, respectively. The calibration plot of the model was good (p-value = 0.350). The DCA indicated that the model provides a higher net benefit following patients based on the risk prediction tool. Conclusion The incidence of LTFU among clients on ART in Gondar town was high (> 3%). The risk prediction model presents an accurate and easily applicable prognostic prediction tool for clients on ART. A prospective follow-up study and external validation of the model is warranted before using the model. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07691-x.
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Affiliation(s)
- Dawit Tefera Fentie
- Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Gondar, Ethiopia.
| | - Getahun Molla Kassa
- Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Sofonyas Abebaw Tiruneh
- Department of Public Health, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Achenef Asmamaw Muche
- Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Gondar, Ethiopia
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Murnane PM, Ayieko J, Vittinghoff E, Gandhi M, Katumbi C, Milala B, Nakaye C, Kanda P, Moodley D, Nyati ME, Loftis AJ, Fowler MG, Flynn P, Currier JS, Cohen CR. Machine Learning Algorithms Using Routinely Collected Data Do Not Adequately Predict Viremia to Inform Targeted Services in Postpartum Women Living With HIV. J Acquir Immune Defic Syndr 2021; 88:439-447. [PMID: 34520443 PMCID: PMC8585692 DOI: 10.1097/qai.0000000000002800] [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] [Received: 05/05/2021] [Accepted: 08/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adherence to antiretroviral treatment (ART) among postpartum women with HIV is essential for optimal health and prevention of perinatal transmission. However, suboptimal adherence with subsequent viremia is common, and adherence challenges are often underreported. We aimed to predict viremia to facilitate targeted adherence support in sub-Saharan Africa during this critical period. METHODS Data are from PROMISE 1077BF/FF, which enrolled perinatal women between 2011 and 2014. This analysis includes postpartum women receiving ART per study randomization or country-specific criteria to continue from pregnancy. We aimed to predict viremia (single and confirmed events) after 3 months on ART at >50, >400, and >1000 copies/mL within 6-month intervals through 24 months. We built models with routine clinical and demographic data using the least absolute shrinkage and selection operator and SuperLearner (which incorporates multiple algorithms). RESULTS Among 1321 women included, the median age was 26 years and 96% were in WHO stage 1. Between 0 and 24 months postpartum, 42%, 31%, and 28% of women experienced viremia >50, >400, and >1000 copies/mL, respectively, at least once. Across models, the cross-validated area under the receiver operating curve ranged from 0.74 [95% confidence interval (CI): 0.72 to 0.76] to 0.78 (95% CI: 0.76 to 0.80). To achieve 90% sensitivity predicting confirmed viremia >50 copies/mL, 64% of women would be classified as high risk. CONCLUSIONS Using routinely collected data to predict viremia in >1300 postpartum women with HIV, we achieved moderate model discrimination, but insufficient to inform targeted adherence support. Psychosocial characteristics or objective adherence metrics may be required for improved prediction of viremia in this population.
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Affiliation(s)
- Pamela M. Murnane
- Department of Epidemiology & Biostatistics, University of California, San Francisco, USA
- Institute for Global Health Sciences, University of California, San Francisco, USA
| | - James Ayieko
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Eric Vittinghoff
- Department of Epidemiology & Biostatistics, University of California, San Francisco, USA
| | - Monica Gandhi
- Department of Medicine, University of California, San Francisco, USA
| | | | - Beteniko Milala
- University of North Carolina-Project Malawi, Lilongwe, Malawi
| | - Catherine Nakaye
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Peter Kanda
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Dhayendre Moodley
- Centre for the AIDS Programme of Research in South Africa and Department of Obstetrics and Gynaecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Mandisa E Nyati
- Perinatal HIV Research Unit, University of the Witwatersrand, Soweto, South Africa
| | - Amy James Loftis
- Institute for Global Health and Infectious Diseases, University of North Carolina Chapel Hill, USA
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Pat Flynn
- Department of Infectious Diseases, St. Jude Children’s Research Hospital Memphis, USA
| | - Judith S. Currier
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, CA USA
| | - Craig R. Cohen
- Institute for Global Health Sciences, University of California, San Francisco, USA
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA USA
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Derivation and external validation of a risk score for predicting HIV-associated tuberculosis to support case finding and preventive therapy scale-up: A cohort study. PLoS Med 2021; 18:e1003739. [PMID: 34491987 PMCID: PMC8454974 DOI: 10.1371/journal.pmed.1003739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 09/21/2021] [Accepted: 07/21/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Among people living with HIV (PLHIV), more flexible and sensitive tuberculosis (TB) screening tools capable of detecting both symptomatic and subclinical active TB are needed to (1) reduce morbidity and mortality from undiagnosed TB; (2) facilitate scale-up of tuberculosis preventive therapy (TPT) while reducing inappropriate prescription of TPT to PLHIV with subclinical active TB; and (3) allow for differentiated HIV-TB care. METHODS AND FINDINGS We used Botswana XPRES trial data for adult HIV clinic enrollees collected during 2012 to 2015 to develop a parsimonious multivariable prognostic model for active prevalent TB using both logistic regression and random forest machine learning approaches. A clinical score was derived by rescaling final model coefficients. The clinical score was developed using southern Botswana XPRES data and its accuracy validated internally, using northern Botswana data, and externally using 3 diverse cohorts of antiretroviral therapy (ART)-naive and ART-experienced PLHIV enrolled in XPHACTOR, TB Fast Track (TBFT), and Gugulethu studies from South Africa (SA). Predictive accuracy of the clinical score was compared with the World Health Organization (WHO) 4-symptom TB screen. Among 5,418 XPRES enrollees, 2,771 were included in the derivation dataset; 67% were female, median age was 34 years, median CD4 was 240 cells/μL, 189 (7%) had undiagnosed prevalent TB, and characteristics were similar between internal derivation and validation datasets. Among XPHACTOR, TBFT, and Gugulethu cohorts, median CD4 was 400, 73, and 167 cells/μL, and prevalence of TB was 5%, 10%, and 18%, respectively. Factors predictive of TB in the derivation dataset and selected for the clinical score included male sex (1 point), ≥1 WHO TB symptom (7 points), smoking history (1 point), temperature >37.5°C (6 points), body mass index (BMI) <18.5kg/m2 (2 points), and severe anemia (hemoglobin <8g/dL) (3 points). Sensitivity using WHO 4-symptom TB screen was 73%, 80%, 94%, and 94% in XPRES, XPHACTOR, TBFT, and Gugulethu cohorts, respectively, but increased to 88%, 87%, 97%, and 97%, when a clinical score of ≥2 was used. Negative predictive value (NPV) also increased 1%, 0.3%, 1.6%, and 1.7% in XPRES, XPHACTOR, TBFT, and Gugulethu cohorts, respectively, when the clinical score of ≥2 replaced WHO 4-symptom TB screen. Categorizing risk scores into low (<2), moderate (2 to 10), and high-risk categories (>10) yielded TB prevalence of 1%, 1%, 2%, and 6% in the lowest risk group and 33%, 22%, 26%, and 32% in the highest risk group for XPRES, XPHACTOR, TBFT, and Gugulethu cohorts, respectively. At clinical score ≥2, the number needed to screen (NNS) ranged from 5.0 in Gugulethu to 11.0 in XPHACTOR. Limitations include that the risk score has not been validated in resource-rich settings and needs further evaluation and validation in contemporary cohorts in Africa and other resource-constrained settings. CONCLUSIONS The simple and feasible clinical score allowed for prioritization of sensitivity and NPV, which could facilitate reductions in mortality from undiagnosed TB and safer administration of TPT during proposed global scale-up efforts. Differentiation of risk by clinical score cutoff allows flexibility in designing differentiated HIV-TB care to maximize impact of available resources.
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Auld AF, Fielding K, Agizew T, Maida A, Mathoma A, Boyd R, Date A, Pals SL, Bicego G, Liu Y, Shiraishi RW, Ehrenkranz P, Serumola C, Mathebula U, Alexander H, Charalambous S, Emerson C, Rankgoane-Pono G, Pono P, Finlay A, Shepherd JC, Holmes C, Ellerbrock TV, Grant AD. Risk scores for predicting early antiretroviral therapy mortality in sub-Saharan Africa to inform who needs intensification of care: a derivation and external validation cohort study. BMC Med 2020; 18:311. [PMID: 33161899 PMCID: PMC7650165 DOI: 10.1186/s12916-020-01775-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/02/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Clinical scores to determine early (6-month) antiretroviral therapy (ART) mortality risk have not been developed for sub-Saharan Africa (SSA), home to 70% of people living with HIV. In the absence of validated scores, WHO eligibility criteria (EC) for ART care intensification are CD4 < 200/μL or WHO stage III/IV. METHODS We used Botswana XPRES trial data for adult ART enrollees to develop CD4-independent and CD4-dependent multivariable prognostic models for 6-month mortality. Scores were derived by rescaling coefficients. Scores were developed using the first 50% of XPRES ART enrollees, and their accuracy validated internally and externally using South African TB Fast Track (TBFT) trial data. Predictive accuracy was compared between scores and WHO EC. RESULTS Among 5553 XPRES enrollees, 2838 were included in the derivation dataset; 68% were female and 83 (3%) died by 6 months. Among 1077 TBFT ART enrollees, 55% were female and 6% died by 6 months. Factors predictive of 6-month mortality in the derivation dataset at p < 0.01 and selected for the CD4-independent score included male gender (2 points), ≥ 1 WHO tuberculosis symptom (2 points), WHO stage III/IV (2 points), severe anemia (hemoglobin < 8 g/dL) (3 points), and temperature > 37.5 °C (2 points). The same variables plus CD4 < 200/μL (1 point) were included in the CD4-dependent score. Among XPRES enrollees, a CD4-independent score of ≥ 4 would provide 86% sensitivity and 66% specificity, whereas WHO EC would provide 83% sensitivity and 58% specificity. If WHO stage alone was used, sensitivity was 48% and specificity 89%. Among TBFT enrollees, the CD4-independent score of ≥ 4 would provide 95% sensitivity and 27% specificity, whereas WHO EC would provide 100% sensitivity but 0% specificity. Accuracy was similar between CD4-independent and CD4-dependent scores. Categorizing CD4-independent scores into low (< 4), moderate (4-6), and high risk (≥ 7) gave 6-month mortality of 1%, 4%, and 17% for XPRES and 1%, 5%, and 30% for TBFT enrollees. CONCLUSIONS Sensitivity of the CD4-independent score was nearly twice that of WHO stage in predicting 6-month mortality and could be used in settings lacking CD4 testing to inform ART care intensification. The CD4-dependent score improved specificity versus WHO EC. Both scores should be considered for scale-up in SSA.
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Affiliation(s)
- Andrew F Auld
- Division of Global HIV & TB, United States Centers for Disease Control and Prevention (CDC), Nico House, City Centre, P.O. Box 30016, Lilongwe 3, Malawi.
| | - Katherine Fielding
- TB Centre, London Sch. of Hygiene & Tropical Med, London, UK.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Tefera Agizew
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Alice Maida
- Division of Global HIV & TB, United States Centers for Disease Control and Prevention (CDC), Nico House, City Centre, P.O. Box 30016, Lilongwe 3, Malawi
| | - Anikie Mathoma
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Rosanna Boyd
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Anand Date
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sherri L Pals
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - George Bicego
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Yuliang Liu
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ray W Shiraishi
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Christopher Serumola
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Unami Mathebula
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Heather Alexander
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Courtney Emerson
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Pontsho Pono
- Ministry of Health and Wellness, Gaborone, Botswana
| | - Alyssa Finlay
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - James C Shepherd
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana.,Yale University School of Medicine, New Haven, CT, USA
| | - Charles Holmes
- Center for Global Health Practice and Impact, Georgetown University Medical Center, Washington D.C, USA
| | - Tedd V Ellerbrock
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alison D Grant
- TB Centre, London Sch. of Hygiene & Tropical Med, London, UK.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Africa Health Research Institute, School of Nursing and Public Heath, University of KwaZulu-Natal, Durban, South Africa
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Gupta-Wright A, Fielding K, van Oosterhout JJ, Alufandika M, Grint DJ, Chimbayo E, Heaney J, Byott M, Nastouli E, Mwandumba HC, Corbett EL, Gupta RK. Virological failure, HIV-1 drug resistance, and early mortality in adults admitted to hospital in Malawi: an observational cohort study. Lancet HIV 2020; 7:e620-e628. [PMID: 32890497 PMCID: PMC7487765 DOI: 10.1016/s2352-3018(20)30172-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/03/2020] [Accepted: 06/12/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Antiretroviral therapy (ART) scale-up in sub-Saharan Africa combined with weak routine virological monitoring has driven increasing HIV drug resistance. We investigated ART failure, drug resistance, and early mortality among patients with HIV admitted to hospital in Malawi. METHODS This observational cohort study was nested within the rapid urine-based screening for tuberculosis to reduce AIDS-related mortality in hospitalised patients in Africa (STAMP) trial, which recruited unselected (ie, irrespective of clinical presentation) adult (aged ≥18 years) patients with HIV-1 at admission to medical wards. Patients were included in our observational cohort study if they were enrolled at the Malawi site (Zomba Central Hospital) and were taking ART for at least 6 months at admission. Patients who met inclusion criteria had frozen plasma samples tested for HIV-1 viral load. Those with HIV-1 RNA of at least 1000 copies per mL had drug resistance testing by ultra-deep sequencing, with drug resistance defined as intermediate or high-level resistance using the Stanford HIVDR program. Mortality risk was calculated 56 days from enrolment. Patients were censored at death, at 56 days, or at last contact if lost to follow-up. The modelling strategy addressed the causal association between HIV multidrug resistance and mortality, excluding factors on the causal pathway (most notably, CD4 cell count, clinical signs of advanced HIV, and poor functional and nutritional status). FINDINGS Of 1316 patients with HIV enrolled in the STAMP trial at the Malawi site between Oct 26, 2015, and Sept 19, 2017, 786 had taken ART for at least 6 months. 252 (32%) of 786 patients had virological failure (viral load ≥1000 copies per mL). Mean age was 41·5 years (SD 11·4) and 528 (67%) of 786 were women. Of 237 patients with HIV drug resistance results available, 195 (82%) had resistance to lamivudine, 128 (54%) to tenofovir, and 219 (92%) to efavirenz. Resistance to at least two drugs was common (196, 83%), and this was associated with increased mortality (adjusted hazard ratio 1·7, 95% CI 1·2-2·4; p=0·0042). INTERPRETATION Interventions are urgently needed and should target ART clinic, hospital, and post-hospital care, including differentiated care focusing on patients with advanced HIV, rapid viral load testing, and routine access to drug resistance testing. Prompt diagnosis and switching to alternative ART could reduce early mortality among inpatients with HIV. FUNDING Joint Global Health Trials Scheme of the Medical Research Council, UK Department for International Development, and Wellcome Trust.
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Affiliation(s)
- Ankur Gupta-Wright
- Department of Infection and Immunity, University College London, London UK; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Joep J van Oosterhout
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi; Dignitas International, Zomba, Malawi
| | - Melanie Alufandika
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Dignitas International, Zomba, Malawi
| | - Daniel J Grint
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth Chimbayo
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Judith Heaney
- Advanced Pathogen Diagnostics Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Matthew Byott
- Advanced Pathogen Diagnostics Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Eleni Nastouli
- Advanced Pathogen Diagnostics Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Henry C Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Elizabeth L Corbett
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Ravindra K Gupta
- Department of Medicine, University of Cambridge, Cambridge, UK; Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
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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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Gebrezgi MT, Fennie KP, Sheehan DM, Ibrahimou B, Jones SG, Brock P, Ladner RA, Trepka MJ. Development and Validation of a Risk Prediction Tool to Identify People with HIV Infection Likely Not to Achieve Viral Suppression. AIDS Patient Care STDS 2020; 34:157-165. [PMID: 32324484 DOI: 10.1089/apc.2019.0224] [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] [Indexed: 12/23/2022] Open
Abstract
Identifying people with HIV infection (PHIV), who are at risk of not achieving viral suppression, is important for designing targeted intervention. The aim of this study was to develop and test a risk prediction tool for PHIV who are at risk of not achieving viral suppression after a year of being in care. We used retrospective data to develop an integer-based scoring method using backward stepwise logistic regression. We also developed risk score categories based on the quartiles of the total risk score. The risk prediction tool was internally validated by bootstrapping. We found that nonviral suppression after a year of being in care among PHIV can be predicted using seven variables, namely, age group, race, federal poverty level, current AIDS status, current homelessness status, problematic alcohol/drug use, and current viral suppression status. Those in the high-risk category had about a 23 increase in the odds of nonviral suppression compared with the low-risk group. The risk prediction tool has good discriminative performance and calibration. Our findings suggest that nonviral suppression after a year of being in care can be predicted using easily available variables. In settings with similar demographics, the risk prediction tool can assist health care providers in identifying high-risk individuals to target for intervention. Follow-up studies are required to externally validate this risk prediction tool.
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Affiliation(s)
- Merhawi T. Gebrezgi
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, Florida, USA
| | | | - Diana M. Sheehan
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, Florida, USA
- Center for Research on US Latino HIV/AIDS and Drug Abuse (CRUSADA), Florida International University, Miami, Florida, USA
- Research Centers in Minority Institutions (RCMI), Florida International University, Miami, Florida, USA
| | - Boubakari Ibrahimou
- Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, Florida, USA
| | - Sandra G. Jones
- Nicole Wertheim College of Nursing & Health Sciences, Florida International University, Miami, Florida, USA
| | - Petra Brock
- Behavioral Science Research Corporation, Miami, Florida, USA
| | | | - Mary Jo Trepka
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, Florida, USA
- Research Centers in Minority Institutions (RCMI), Florida International University, Miami, Florida, USA
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9
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Mukosha M, Chiyesu G, Vwalika B. Adherence to antiretroviral therapy among HIV infected pregnant women in public health sectors: a pilot of Chilenje level one Hospital Lusaka, Zambia. Pan Afr Med J 2020; 35:49. [PMID: 32537054 PMCID: PMC7250199 DOI: 10.11604/pamj.2020.35.49.20078] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 08/24/2019] [Indexed: 12/22/2022] Open
Abstract
Introduction regular use of Antiretroviral Therapy (ART) in pregnancy and breastfeeding reduces the odds of Mother-to-Child HIV Transmission (MTCT). However, adherence to ART is critical for MTCT to be successful. The present study investigated factors that influence adherence to ART among HIV infected pregnant women in Zambia. Methods a cross-sectional study design was conducted involving 71 HIV infected pregnant women who were advised to join the Prevention of Mother-to-Child HIV Transmission (PMTCT) program during their routine Antenatal clinic (ANC) visit and were on ART for more than six months. We used the Medication Possession Ratio (MPR) to quantify adherence levels. We used logistic regression to establish factors that influence adherence to ART. Results a total of 71 HIV infected pregnant women with a median age of 27years (IQR, 25-30) were enrolled in the study. There was evidence of a difference in adherence levels between pregnant women above 30 years and ones between 15 years and 30 years (P<0.001). Median adherence levels in this group were found to be at 96%(IQR 89-97). The main predictor of adherence in this population was marital status (being on separation) and age. The women who were on separation were 0.14 times less likely to adhere to option B+ compared to married women. Conclusion adherence to option B+ among pregnant women is low. Adherence was significantly influenced by marital status (being on separation) and age. Efforts to improve adherence should be directed towards women on separation and young adults (< 30 years of age).
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Affiliation(s)
- Moses Mukosha
- Department of Pharmacy, University of Zambia, Lusaka, Zambia.,Mosi-o-Tunya University of Science and Technology, Lusaka, Zambia
| | - Grace Chiyesu
- Faculty of Pharmacy Nutrition and Dietetics, Apex Medical University, Lusaka, Zambia
| | - Bellington Vwalika
- Department of Obstetrics and Gynecology, University of Zambia, Lusaka, Zambia
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10
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Mutanga JN, Mutembo S, Ezeamama AE, Song X, Fubisha RC, Mutesu-Kapembwa K, Sialondwe D, Simuchembu B, Chinyonga J, Thuma PE, Whalen CC. Predictors of loss to follow-up among children on long-term antiretroviral therapy in Zambia (2003-2015). BMC Public Health 2019; 19:1120. [PMID: 31416432 PMCID: PMC6694674 DOI: 10.1186/s12889-019-7374-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 07/26/2019] [Indexed: 11/28/2022] Open
Abstract
Background Retention in care is critical for children living with HIV taking antiretroviral therapy (ART). Loss to follow-up (LTFU) is high in HIV treatment programs in resource limited settings. We estimated the cumulative incidence of LTFU and identified associated risk factors among children on ART at Livingstone Central Hospital (LCH), Zambia. Methods Using a retrospective cohort study design, we abstracted data from medical records of children who received ART between 2003 and 2015. Loss to follow-up was defined as no clinical and pharmacy contact for at least 90 days after the child missed their last scheduled clinical visit. Non-parametric competing risks models were used to estimate the cumulative incidence of death, LTFU and transfer. Cause-specific Cox regression was used to estimate the hazard ratios of the risk factors of LTFU. Results A total of 1039 children aged 0–15 years commenced ART at LCH between 2003 and 2015. Median duration of follow-up was 3.8 years (95% CI: 1.2–6.5), median age at ART initiation was 3.6 years (IQR: 1.3–8.6), 179 (17%) started treatment during their first year of life. At least 167 (16%) were LTFU and we traced 151 (90%). Of those we traced, 39 (26%) had died, 71 (47%) defaulted, 20 (13%) continued ART at other clinics and 21 (14%) continued treatment with gaps. The cumulative incidence of LTFU for the entire cohort was 2.7% (95% CI: 1.9–3.9) at 3 months, 4.1% (95% CI: 2.9–5.4) at 6 months and 14.1% (95% CI: 12.4–16.9) after 5 years on ART. Associated risk factors were: 1) non-disclosure of HIV status at baseline, aHR = 1.9 (1.2–2.9), 2) No phone ownership, aHR = 2.1 (1.6–2.9), 3) starting treatment between 2013 to 2015, aHR = 5.6 (2.2–14.1). Conclusion Among the children LTFU mortality and default were substantially high. Children who started treatment in recent years (2013–2015) had the highest hazard of LTFU. Lack of access to a phone and non-disclosure of HIV-status to the index child was associated with higher hazards of LTFU. We recommend re-enforcement of client counselling and focused follow-up strategies using modern technology such as mobile phones as adjunct to current approaches.
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Affiliation(s)
- Jane N Mutanga
- Department of Pediatrics and Child Health, Livingstone Central Hospital, Akapelwa Street, Livingstone, Zambia.
| | - Simon Mutembo
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA.,Southern Province Medical Office, Ministry of Health, Choma, Zambia
| | - Amara E Ezeamama
- Department of Psychiatry, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Xiao Song
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - Robert C Fubisha
- Department of Pediatrics and Child Health, Livingstone Central Hospital, Akapelwa Street, Livingstone, Zambia
| | - Kunda Mutesu-Kapembwa
- Department of Pediatrics and Child Health, Livingstone Central Hospital, Akapelwa Street, Livingstone, Zambia
| | - Derrick Sialondwe
- Department of Pediatrics and Child Health, Livingstone Central Hospital, Akapelwa Street, Livingstone, Zambia
| | - Brenda Simuchembu
- Department of Pediatrics and Child Health, Livingstone Central Hospital, Akapelwa Street, Livingstone, Zambia
| | - Jelita Chinyonga
- Southern Province Medical Office, Ministry of Health, Choma, Zambia
| | | | - Christopher C Whalen
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
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11
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Kave S, Khuzwayo NF, Hatcher A, Sikweyiya Y. The role of support groups in linking and retaining newly diagnosed clients in HIV care in a peri-urban location in South Africa. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2019; 18:9-17. [PMID: 30880579 DOI: 10.2989/16085906.2018.1551233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Although South Africa has the largest number of people on antiretroviral therapy (ART) in the world, many HIV clients drop out of care immediately after HIV diagnosis. This qualitative study explored the perceptions and experiences of newly diagnosed clients on the role support groups play in linking and retaining newly diagnosed clients in HIV care in Mbandazayo peri-urban location. The data were analysed using the thematic content analysis approach. Data revealed four mechanisms through which support groups appeared to link and retain newly diagnosed clients in the HIV care continuum. First, support groups were a formal link between newly diagnosed clients and health facilities. Second, support groups mitigated the effects of both felt and enacted stigma, thereby facilitating acceptance of HIV diagnosis among newly diagnosed clients. Third, support groups were an advocacy and networking tool for newly diagnosed clients to make their health related needs, challenges, and concerns known to local health clinics, thereby forging and maintaining a close relationship with their local health facilities. Last, support groups were spaces within the community where practical needs of newly diagnosed clients are met, which in turn help in retaining them within support groups, and facilitate their linkage and retention in the HIV continuum of care in Mbandazayo. Our findings suggest that HIV support groups are critical in enhancing linkages and retention of newly diagnosed clients in HIV care. With the introduction of universal test and treat (UTT) in South Africa, our findings suggest that support groups can play a significant role in retaining HIV care clients who are diagnosed and immediately enrolled on ART.
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Affiliation(s)
- Siyabonga Kave
- a Department of Rural Health , University of KwaZulu-Natal , Durban , South Africa
| | - Nelisiwe F Khuzwayo
- a Department of Rural Health , University of KwaZulu-Natal , Durban , South Africa
| | - Abigail Hatcher
- b School of Public Health , University of the Witwatersrand , Johannesburg , South Africa
| | - Yandisa Sikweyiya
- c Gender & Health Research Unit, School of Public Health , University of the Witwatersrand , Johannesburg , South Africa
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12
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Risk score for predicting mortality including urine lipoarabinomannan detection in hospital inpatients with HIV-associated tuberculosis in sub-Saharan Africa: Derivation and external validation cohort study. PLoS Med 2019; 16:e1002776. [PMID: 30951533 PMCID: PMC6450614 DOI: 10.1371/journal.pmed.1002776] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 03/06/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The prevalence of and mortality from HIV-associated tuberculosis (HIV/TB) in hospital inpatients in Africa remains unacceptably high. Currently, there is a lack of tools to identify those at high risk of early mortality who may benefit from adjunctive interventions. We therefore aimed to develop and validate a simple clinical risk score to predict mortality in high-burden, low-resource settings. METHODS AND FINDINGS A cohort of HIV-positive adults with laboratory-confirmed TB from the STAMP TB screening trial (Malawi and South Africa) was used to derive a clinical risk score using multivariable predictive modelling, considering factors at hospital admission (including urine lipoarabinomannan [LAM] detection) thought to be associated with 2-month mortality. Performance was evaluated internally and then externally validated using independent cohorts from 2 other studies (LAM-RCT and a Médecins Sans Frontières [MSF] cohort) from South Africa, Zambia, Zimbabwe, Tanzania, and Kenya. The derivation cohort included 315 patients enrolled from October 2015 and September 2017. Their median age was 36 years (IQR 30-43), 45.4% were female, median CD4 cell count at admission was 76 cells/μl (IQR 23-206), and 80.2% (210/262) of those who knew they were HIV-positive at hospital admission were taking antiretroviral therapy (ART). Two-month mortality was 30% (94/315), and mortality was associated with the following factors included in the score: age 55 years or older, male sex, being ART experienced, having severe anaemia (haemoglobin < 80 g/l), being unable to walk unaided, and having a positive urinary Determine TB LAM Ag test (Alere). The score identified patients with a 46.4% (95% CI 37.8%-55.2%) mortality risk in the high-risk group compared to 12.5% (95% CI 5.7%-25.4%) in the low-risk group (p < 0.001). The odds ratio (OR) for mortality was 6.1 (95% CI 2.4-15.2) in high-risk patients compared to low-risk patients (p < 0.001). Discrimination (c-statistic 0.70, 95% CI 0.63-0.76) and calibration (Hosmer-Lemeshow statistic, p = 0.78) were good in the derivation cohort, and similar in the external validation cohort (complete cases n = 372, c-statistic 0.68 [95% CI 0.61-0.74]). The validation cohort included 644 patients between January 2013 and August 2015. Median age was 36 years, 48.9% were female, and median CD4 count at admission was 61 (IQR 21-145). OR for mortality was 5.3 (95% CI 2.2-9.5) for high compared to low-risk patients (complete cases n = 372, p < 0.001). The score also predicted patients at higher risk of death both pre- and post-discharge. A simplified score (any 3 or more of the predictors) performed equally well. The main limitations of the scores were their imperfect accuracy, the need for access to urine LAM testing, modest study size, and not measuring all potential predictors of mortality (e.g., tuberculosis drug resistance). CONCLUSIONS This risk score is capable of identifying patients who could benefit from enhanced clinical care, follow-up, and/or adjunctive interventions, although further prospective validation studies are necessary. Given the scale of HIV/TB morbidity and mortality in African hospitals, better prognostic tools along with interventions could contribute towards global targets to reduce tuberculosis mortality.
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13
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Humphrey JM, Genberg BL, Keter A, Musick B, Apondi E, Gardner A, Hogan JW, Wools‐Kaloustian K. Viral suppression among children and their caregivers living with HIV in western Kenya. J Int AIDS Soc 2019; 22:e25272. [PMID: 30983148 PMCID: PMC6462809 DOI: 10.1002/jia2.25272] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 03/12/2019] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Despite the central role of caregivers in managing HIV treatment for children living with HIV, viral suppression within caregiver-child dyads in which both members are living with HIV is not well described. METHODS We conducted a retrospective analysis of children living with HIV <15 years of age and their caregivers living with HIV attending HIV clinics affiliated with the Academic Model Providing Access to Healthcare (AMPATH) in Kenya between 2015 and 2017. To be included in the analysis, children and caregivers must have had ≥1 viral load (VL) during the study period while receiving antiretroviral therapy (ART) for ≥6 months, and the date of the caregiver's VL must have occurred ±90 days from the date of the child's VL. The characteristics of children, caregivers and dyads were descriptively summarized. Multivariable logistic regression was used to estimate the odds of viral non-suppression (≥ 1000 copies/mL) in children, adjusting for caregiver and child characteristics. RESULTS Of 7667 children who received care at AMPATH during the study period, 1698 were linked to a caregiver living with HIV and included as caregiver-child dyads. For caregivers, 94% were mothers, median age at ART initiation 32.8 years, median CD4 count at ART initiation 164 cells/mm3 and 23% were not virally suppressed. For children, 52% were female, median age at ART initiation 4.2 years, median CD4 values at ART initiation were 15% (age < 5 years) and 396 cells/mm3 (age ≥ 5 years), and 38% were not virally suppressed. In the multivariable model, children were found more likely to not be virally suppressed if their caregivers were not suppressed compared to children with suppressed caregivers (aOR = 2.40, 95% CI: 1.86 to 3.10). Other characteristics associated with child viral non-suppression included caregiver ART regimen change prior to the VL, caregiver receipt of a non-NNRTI-based regimen at the time of the VL, younger child age at ART initiation and child tuberculosis treatment at the time of the VL. CONCLUSIONS Children were at higher risk of viral non-suppression if their caregivers were not virally suppressed compared to children with suppressed caregivers. A child's viral suppression status should be closely monitored if his or her caregiver is not suppressed.
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Affiliation(s)
| | - Becky L Genberg
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Alfred Keter
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
| | - Beverly Musick
- Department of BiostatisticsIndiana UniversityIndianapolisINUSA
| | - Edith Apondi
- Department of PaediatricsMoi Teaching and Referral HospitalEldoretKenya
| | - Adrian Gardner
- Department of MedicineIndiana UniversityIndianapolisINUSA
| | - Joseph W Hogan
- Department of BiostatisticsBrown UniversityProvidenceRIUSA
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14
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Teasdale CA, Yuengling K, Preko P, Syowai M, Ndagije F, Rabkin M, Abrams EJ, El‐Sadr WM. Persons living with HIV with advanced HIV disease: need for novel care models. J Int AIDS Soc 2018; 21:e25210. [PMID: 30549245 PMCID: PMC6293147 DOI: 10.1002/jia2.25210] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 10/26/2018] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Despite increasing focus on test and treat strategies for people living with HIV (PLHIV), many continue to enrol late in care and initiate antiretroviral therapy (ART) when they have advanced HIV disease. METHODS We analyzed PLHIV ≥15 years of age starting ART in Ethiopia, Kenya, Mozambique and Tanzania from 2005 to 2015 based on CD4+ groups at ART initiation (≥200, 100 to 199, 50 to 99 and <50 cells/mm3 ) to examine attrition (loss to follow-up (LTF) and death) using Kaplan-Meier estimators and Cox proportional hazards models. LTF was defined as no clinic visit >6 months; deaths were ascertained from medical records. RESULTS AND DISCUSSION A total of 305,443 PLHIV were included in the analysis: 118,580 (38.8%) CD4+ ≥200, 91,788 (30.1%) CD4+ 100 to 199, 44,029 (14.4%) CD4+ 50 to 99 and 51,046 (16.7%) CD4+ <50 cells/mm3 . At 12 months after ART initiation, attrition for those with CD4+ ≥200, 100 to 199, 50 to 99 and <50 cells/mm3 was 21.3% (95% CI 21.1 to 21.6), 21.8% (95% CI 21.6 to 22.1), 27.3% (95% CI 26.9 to 27.7) and 33.6% (95% CI 33.2 to 34.0) respectively. In multivariable models, compared to PLHIV with CD4+ ≥200 cells/mm3 , those with CD4+ 50 to 99 cells/mm3 had 29% increased risk of attrition (adjusted hazard ratio (AHR) 1.29, 95% CI 1.27 to 1.32) and those with <50 cells/mm3 had 56% increased risk of attrition (AHR 1.56, 95% CI 1.53 to 1.58). Men had higher attrition compared to women across all CD4+ groups and overall were 28% more likely to experience attrition (AHR 1.28, 95% CI 1.26 to 1.29). Even after ART initiation, PLHIV with advanced disease had notably inferior outcomes with substantial gradient within the low CD4+ strata highlighting the need for targeted interventions for these populations. CONCLUSIONS Greater efforts, including the identification of effective differentiated service delivery models, are needed to ensure that all PLHIV starting treatment can garner the benefits from ART and achieve favourable outcomes.
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Affiliation(s)
- Chloe A Teasdale
- ICAP‐Columbia UniversityMailman School of Public HealthColumbia UniversityNew YorkNYUSA
- Department of EpidemiologyMailman School of Public Health Columbia UniversityNew YorkNYUSA
| | - Katharine Yuengling
- ICAP‐Columbia UniversityMailman School of Public HealthColumbia UniversityNew YorkNYUSA
| | - Peter Preko
- ICAP‐Columbia UniversityMailman School of Public HealthColumbia UniversityNew YorkNYUSA
| | - Maureen Syowai
- ICAP‐Columbia UniversityMailman School of Public HealthColumbia UniversityNew YorkNYUSA
| | - Felix Ndagije
- ICAP‐Columbia UniversityMailman School of Public HealthColumbia UniversityNew YorkNYUSA
| | - Miriam Rabkin
- ICAP‐Columbia UniversityMailman School of Public HealthColumbia UniversityNew YorkNYUSA
- Department of EpidemiologyMailman School of Public Health Columbia UniversityNew YorkNYUSA
- College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Elaine J Abrams
- ICAP‐Columbia UniversityMailman School of Public HealthColumbia UniversityNew YorkNYUSA
- Department of EpidemiologyMailman School of Public Health Columbia UniversityNew YorkNYUSA
- College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
| | - Wafaa M El‐Sadr
- ICAP‐Columbia UniversityMailman School of Public HealthColumbia UniversityNew YorkNYUSA
- Department of EpidemiologyMailman School of Public Health Columbia UniversityNew YorkNYUSA
- College of Physicians and SurgeonsColumbia UniversityNew YorkNYUSA
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15
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McNairy ML, Jannat-Khah D, Pape JW, Marcelin A, Joseph P, Mathon JE, Koenig S, Wells M, Fitzgerald DW, Evans A. Predicting death and lost to follow-up among adults initiating antiretroviral therapy in resource-limited settings: Derivation and external validation of a risk score in Haiti. PLoS One 2018; 13:e0201945. [PMID: 30157197 PMCID: PMC6114504 DOI: 10.1371/journal.pone.0201945] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 06/19/2018] [Indexed: 12/23/2022] Open
Abstract
Background Over 18 million adults have initiated life-saving antiretroviral therapy (ART) in resource-poor settings; however, mortality and lost-to-follow-up rates continue to be high among patients in their first year after treatment start. Clinical decision tools are needed to identify patients at high risk for poor outcomes in order to provide individualized risk assessment and intervention. This study aimed to develop and externally validate risk prediction tools that estimate the probability of dying or of being lost to follow-up (LTF) during the year after starting ART. Methods We used a derivation cohort of 7,031 adults age 15–70 years initiating ART from 2007 to 2013 at 6 clinics in Haiti; 242 (3.5%) had documented death and 1,521 (21.6%) were LTF at 1 year after starting ART. The following routinely collected data were used as predictors in two logistic regression models (one to predict death and another to predict LTF): age, gender, weight, CD4 count, WHO Stage, and diagnosis of tuberculosis (TB). The validation cohort consisted of 1,835 adults initiating ART at a different HIV clinic in Haiti during 2012. We assessed model discrimination by measuring the C-statistic, and measured model calibration by how closely the predicted probabilities approximated actual probabilities of the two outcomes. We derived a nomogram and a point-based risk score from the predictive models. Findings The model predicting death within the year after starting ART had a C-statistic of 0.75 (95% CI 0.74 to 0.81). There was no evidence for significant overfitting and the predictions were well calibrated. The strongest predictors of 1-year mortality were male gender, low weight, low CD4 count, advanced WHO stage, and the absence of TB. In the validation cohort, the C-statistic was 0.69 (95% CI 0.59 to 0.77). A point-based risk score for death had a C-statistic 0.73 (95% CI 0.69 to 0.76) and categorizes patients as low risk (<2% risk of death), average risk (3–4%), and high-risk (8–10%) and very high-risk (14–19%) with likelihood ratios to be used in settings where the baseline risk is different from our study population. The model predicting LTF did not discriminate well (C-statistic 0.59). Conclusions A simple risk-score using routinely collected data can predict 1-year mortality after ART initiation for HIV-positive adults in Haiti. However, predicting lost to follow-up using routinely collected data was not as successful. The next step is to assess whether use of this risk score can identify patients who need tailored services to reduce mortality in resource-poor settings such as Haiti.
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Affiliation(s)
- Margaret L. McNairy
- Division of General Internal Medicine, Weill Cornell Medicine, New York, United States of America
- Center for Global Health, Weill Cornell Medicine, New York, United States of America
- * E-mail:
| | - Deanna Jannat-Khah
- Division of General Internal Medicine, Weill Cornell Medicine, New York, United States of America
| | - Jean W. Pape
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince Haiti
| | - Adias Marcelin
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince Haiti
| | - Patrice Joseph
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince Haiti
| | - Jean Edward Mathon
- Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port au Prince Haiti
| | - Serena Koenig
- Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School, Boston MA, United States of America
| | - Martin Wells
- Department of Statistical Science, Cornell University, Ithaca, United States of America
| | - Daniel W. Fitzgerald
- Center for Global Health, Weill Cornell Medicine, New York, United States of America
| | - Arthur Evans
- Division of General Internal Medicine, Weill Cornell Medicine, New York, United States of America
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