Factors associated with late antiretroviral therapy initiation among adults in Mozambique

HIV Services Uptake Among People Living with HIV in Jiangsu Province, China: A Cross-Sectional Study

Healthcare disparities are common among people living with HIV (PLWH) in China and likely impact access to HIV services. This study aimed to assess the current status of access to HIV services among PLWH and explore the correlates of service uptake using baseline data from a prospective cohort study among PLWH in Jiangsu Province. Guided by Andersen's behavioral model, univariable and multivariable logistic regressions were conducted to identify factors associated with access to HIV services. Out of 8989 eligible PLWH included in this study, 46.4% perceived difficulty in seeing a healthcare professional for HIV treatment services in 2021-2022. PLWH aged 18-34 years (adjusted odds ratio [AOR] = 1.69, 95% CI 1.32-2.15), 35-39 years (AOR = 1.33, 95% CI 1.08-1.65), identified as a bisexual/other (AOR = 1.14, 95% CI 1.01-1.29), had a college and above education (AOR = 1.32, 95% CI 1.07-1.63), and perceived moderate (AOR = 1.70, 95% CI 1.51-1.91) and severe (AOR = 2.20, 95% CI 1.94-2.49) levels of HIV stigma were more likely to perceive difficulty in seeing healthcare professionals for HIV treatment in 2021-2022. Living in northern Jiangsu was also associated with increased odds of perceiving difficulty in seeing healthcare professionals for HIV treatment (AOR = 1.12, 95% CI 1.00-1.26). These findings underscore the need for innovative solutions to eliminate the practical barriers to HIV services utilization among PLWH who are bisexual, well-educated, and effective HIV-related stigma reduction interventions.

Trends and the associated factors of optimal immunological response and virological response in late anti-retroviral therapy initiation HIV cases in Taiwan from 2009 to 2020

BACKGROUND

Late cART initiation (CD4 count ≤200 cells/μL or AIDS-defining opportunistic illnesses [AOIs] at cART initiation) impedes CD4 count recovery and virologic suppression after cART initiation. However, studies to evaluate trends of and modifiable factors for optimal immunological response (IR) and virological response (VR) in people living with HIV (PLWH) with late cART initiation with the current HIV treatment strategies are limited.

METHODS

We retrospectively identified 475 PLWH with late cART initiation in 2009-2020. Patients were grouped based on the presence of IR (CD4 count ≥200 cells/μL) or VR (plasma viral load [PVL] ≤ 50 copies/mL) within 18 months after cART initiation (403 [84.8%] IR(+) and 72 [15.2%] IR(-); 422 [88.8%] VR(+) and 53 [11.2%] VR(-)). We used Joinpoint regression to identify IR (+) and VR(+) proportion changes.

RESULTS

From 2009 to 2020, the proportion of IR(+) patients remained unchanged (75% to 90%, P = 0.102), whereas that of VR(+) patients increased significantly (75% to 95%, P = 0.007). No join point was identified for either IR(+) or VR(+), and the annual percentage change was 0.56% (nonsignificant) and 1.35% (significant) for IR(+) and VR(+), respectively. Compared to IR(-) patients, IR(+) patients were more likely to have a higher pre-cART PVL, to start with a first-line INSTI-based regimen, or to start cART within 14 days of HIV diagnosis but were less likely to have chronic kidney disease, composite AOIs, or a lower pre-cART CD4 count. Compared to VR(-) patients, VR(+) patients were more likely to start a single-tablet regimen but were less likely to have a higher pre-cART PVL.

CONCLUSIONS

Our study identified several modifiable factors for optimal IR (rapid cART initiation and INSTI-based regimen initiation) and for optimal VR (STR initiation) among late initiators, which may guide early treatment modifications to reduce their AIDS-defining event incidence and mortality.

Factors associated with late initiation of antiretroviral therapy in Iran's HIV/AIDS surveillance data

Early initiation of Antiretroviral Treatment (ART) in HIV patients is essential for effectively suppressing the viral load and prognosis. This study utilized National HIV/AIDS Surveillance Data in Iran to identify factors associated factors with the duration to initiate ART. This hybrid cross-sectional historical cohort study was conducted on Iran's National HIV/AIDS Surveillance Data from 2001 to 2019. Sociodemographic characteristics, route of transmission, HIV diagnosis date, and ART initiation date were collected. Multivariable linear and quantile regression models were employed to analyze the duration to initiate ART by considering predictor variables. This study included 17,062 patients (mean age 34.14 ± 10.77 years, 69.49% males). Multivariate quantile regression coefficients varied across different distributions of the dependent variable (i.e., duration to initiate ART) for several independent variables. Generally, male gender, injecting drug use (IDU), and having an HIV-positive spouse were significantly associated with an increased duration to initiate ART (p < 0.05). However, a significant decrease was observed in older patients, those with a university level education, men who had sex with men (MSM), and patients diagnosed after 2016 (p < 0.05). Despite improvements in the duration to initiate ART after implementing the WHO's 2016 program in Iran, various sociodemographic groups were still vulnerable to delayed ART initiation in the region. Therefore, programs including early testing, early ART initiation, active care, educational and cultural interventions, and appropriate incentives are required for these groups.

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.

Burden of HIV, HBV and syphilis among children in urban Ethiopia: Community-based cross-sectional study

BACKGROUND

Children have largely been ignored in the fight against sexually transmitted infection (STI). Among children, STI is reported to be a globally emerging public health challenge. We evaluated the burden of HIV, hepatitis B virus (HBV) and syphilis among children (< 15 years old) and its determinants in urban Ethiopia.

METHODS

For this study, we used data from the Ethiopian Population-based HIV Impact Assessment (EPHIA), collected through a nationally representative, community-based study conducted in Ethiopia from October 2017 to April 2018. We used plasma samples from 4729 children. Moreover, we linked the data and analysed them alongside their respective mothers. Child and maternal HIV status was determined using the national testing algorithm. Plasma samples from children were also tested for syphilis and HBV surface antigen. A descriptive analysis was done followed by bivariable analysis with 95% confidence interval (CI) at a significance level of p < 0.05. We finally evaluated predictors of STIs using regression analysis.

RESULTS

HIV, HBV and syphilis prevalence rates among urban children in Ethiopia were 0.36%, 1.48% and 0.28%, respectively. Children living in Gambella and Addis Ababa had a 6.41-fold (95% CI: 3.20-9.88) and 4.20-fold (95% CI: 3.24-5.46) higher risk of HIV infection compared with those in Dire Dawa. Children of HIV-positive mothers had a 10.31-fold (95% CI: 3.20-18.19) higher risk of HIV infection, and if those mothers were not taking highly active antiretroviral therapy (HAART), the risk was 7.27 times higher (95% CI: 2.57-12.64). Those who were from HIV-positive mothers with viral load ≥ 1000 copies/mL had a 18.64-fold (95% CI: 6.36-31.24) higher risk of HIV infection and those with a history of breastfeeding had a 3.27-fold (95% CI: 1.11-5.67) higher risk. Children from Addis Ababa had a 3.26-fold (95% CI: 1.64-6.66) higher risk of HBV infection compared with those from Dire Dawa. Moreover, for those from HIV-positive mothers and whose mother was not taking HAART, the risk of HBV transmission was 6.37 (95% CI: 2.20-19.96) and 3.62 (95% CI: 1.27-11.29), respectively. Children living in Gambella, Somali, Afar and Tigray had a 7.21-fold (95% CI: 2.30-18.68), 3.10-fold (95% CI: 1.28-3.74) and 1.32-fold (95% CI: 1.11-3.38) higher risk of acquiring active syphilis compared with those living in Dire Dawa, respectively. Those from HIV-positive mothers also had a 4.22-fold (95% CI: 1.16-8.39) higher risk of acquiring active syphilis.

CONCLUSION

The burden of HIV, HBV and syphilis was high among children in urban Ethiopia. The key determinants for the high burden of HIV, syphilis and HBV were maternal factors including maternal HIV status and breastfeeding. This might be due to the challenges associated with mother-to-child transmission. Hence, the programme shall focus on the elimination of the triple infections of HIV, syphilis and HBV.

Universal HIV testing and the impact of late diagnosis on disease stage among adults in urban Ethiopia

BACKGROUND

Treatment as prevention evolved into the universal HIV test-and-treat (UTT) strategy, which entails testing to the general population and treatment to every people living with HIV. We investigated universal testing (UT) performance and its determinants in urban Ethiopia and explore magnitude of late diagnosis and its impact on disease stages.

METHOD

We used data from the Ethiopia Population Based HIV Impact assessment (EPHIA), conducted in 2017/2018 which was a cross-sectional and household-based study. For current analysis, we considered self-report first diagnosis to estimate universal testing irrespective of their serostatus and also consider HIV LAg avidity vs viral load vs plasma antiretroviral drug level algorithm to categorize the late diagnosis. We finally evaluate disease stages using CD4 count and viral load. A 2-level multilevel mixed-effect logistic regression model was employed. The effects of individual-level predictors were quantified by the estimates from the fixed-effect part of the model with p-value < 0.05.

RESULT

Data were collected from 18,926 adults among those 29.4% of people living in Urban Ethiopia were never tested for HIV. Never tested females was 26.4% (95% CI = 25.3; 27.5). Never tested among divorced and widowed were 19.4% (95% CI: 17.3; 21.8) and 28.3% (95% CI: 24.6; 32.2), respectively. Never tested among elderly and youth were high (28.3% among 45-54 years old) to (41.2% among 55-64 years old) to 47.8% among 15-24 years old. Overall, late HIV diagnosis among adults in urban Ethiopia was 25.9% (95% CI: 21.7, 30.2). Late diagnosis varies by region ranged from 38.1% in the Gambella to 5.8% in Benishangul Gumuz. Advanced immune suppression (CD4 count < 350 cells/µl) among newly diagnosed long-term infection were significantly higher compared to those who were recently infected which accounted 47.8% (95%CI = 33.2-52.1) and 30.9% (95%CI = 21.3-32.2), respectively. Moreover, Viral load suppression were significantly lower among those who were late diagnosed 26.1% (95%CI = 13.6-33.8) compared to those of newly infected 89.6% (95%CI = 76.2; 93.4).

CONCLUSION

With the aim of UT for high risk and priority population, the low rate of HIV testing among widowed, elderly, young adolescent and women in urban Ethiopia calls for enhanced HIV testing. Moreover, the low HIV testing and high late diagnosis among the high-burden regions calls for region-specific intervention. Advanced disease stages as a result of the high proportion of late diagnosis may impact on fueling community transmission and hinder treatment outcome among PLHIV.

Attrition from Care Among Men Initiating ART in Male-Only Clinics Compared with Men in General Primary Healthcare Clinics in Khayelitsha, South Africa: A Matched Propensity Score Analysis

Men have higher rates of attrition from antiretroviral therapy (ART) programs than women. In Khayelitsha, a high HIV prevalence area in South Africa, two public sector primary healthcare clinics offer services, including HIV testing and treatment, exclusively to men. We compared attrition from ART care among men initiating ART at these clinics with male attrition in six general primary healthcare clinics in Khayelitsha. We described baseline characteristics of patients initiating ART at the male and general clinics from 1 January 2014 to 31 March 2018. We used exposure propensity scores (generated based on baseline health and age) to match male clinic patients 1:1 to males at other clinics. The association between attrition (death or loss to follow-up, defined as no visits for nine months) and clinic type was estimated using Cox proportional hazards regression. Follow-up time began at ART initiation and ended at attrition, clinic transfer, or dataset closure. Before matching, patients from male clinics (n = 784) were younger than males from general clinics (n = 2726), median age: 31.2 vs 35.5 years. Those initiating at male clinics had higher median CD4 counts at ART initiation [Male Clinic 1: 329 (IQR 210-431), Male Clinic 2: 364 (IQR 260-536), general clinics 258 (IQR 145-398), cells/mm³]. In the matched analysis (1451 person-years, 1568 patients) patients initiating ART at male clinics had lower attrition (HR 0.71; 95% CI 0.60-0.85). In separate analyses for each of the two male clinics, only the more established male clinic showed a protective effect. Male-only clinics reached younger, healthier men, and had lower ART attrition than general services. These findings support clinic-specific adaptations to create more male-friendly environments.

Factors Associated With Late Antiretroviral Therapy Initiation Among People Living With HIV in Southern Iran: A Historical Cohort Study

Objectives

Late initiation of antiretroviral therapy (ART) is associated with poor outcome among people living with HIV (PLHIV) and higher risk of transmission of infection. This study was conducted to identify the determinants of late ART initiation among PLHIV in Southern Iran.

Methods

A historical cohort study was conducted on 1,326 PLHIV of ≥15 years of age who were registered with the behavioral diseases counseling center (BDCC) in southern Iran from August 1997 to March 2021. Late ART initiation was defined as a CD4 cell count &lt;200 cells/mm3 or having a clinical AIDS diagnosis at the time of ART initiation. The required demographic and clinical data were collected from the patients' medical records. Multiple regression analysis was conducted to define late ART initiation associated factors.

Results

Late ART initiation was found among 81.9% of patients. Based on the results of the multivariate analysis, older age (odds ratio [OR] = 1.02, 95% CI = 1.00–1.04), being single (ORsingle/married = 1.80, 95% CI = 1.17–2.78), history of drug use (ORyes/no = 1.64, 95% CI = 1.02–2.62), year of ART initiation (OR2011−2013/2018−2021 = 3.65, 95% CI = 2.28–5.86), and possible route of transmission (ORdruginjection/sexual = 7.34, 95% CI = 1.16–46.21) were directly associated with the risk of late ART initiation.

Conclusions

The results show that the prevalence of late ART initiation was alarmingly high. For better infection control and better prognosis of infection, people at high risk need to be provided with timely services (e.g., diagnosis, treatment, training, and social support).

Individual and healthcare supply-related HIV transmission factors in HIV-positive patients enrolled in the antiretroviral treatment access program in the Centre and Littoral regions in Cameroon (ANRS-12288 EVOLCam survey)

Background

Despite great progress in antiretroviral treatment (ART) access in recent decades, HIV incidence remains high in sub-Saharan Africa. We investigated the role of individual and healthcare supply-related factors in HIV transmission risk in HIV-positive adults enrolled in 19 HIV services in the Centre and Littoral regions of Cameroon.

Methods

Factors associated with HIV transmission risk (defined as both unstable aviremia and inconsistent condom use with HIV-negative or unknown status partners) were identified using a multi-level logistic regression model. Besides socio-demographic and behavioral individual variables, the following four HIV-service profiles, identified using cluster analysis, were used in regression analyses as healthcare supply-related variables: 1) district services with large numbers of patients, almost all practicing task-shifting and not experiencing antiretroviral drugs (ARV) stock-outs (n = 4); 2) experienced and well-equipped national reference services, most practicing task-shifting and not experiencing ARV stock-outs (n = 5); 3) small district services with limited resources and activities, almost all experiencing ARV stock-outs (n = 6); 4) small district services with a wide range of activities and half not experiencing ARV stock-outs (n = 4).

Results

Of the 1372 patients (women 67%, median age [Interquartile]: 39 [33–44] years) reporting sexual activity in the previous 12 months, 39% [min-max across HIV services: 25%-63%] were at risk of transmitting HIV. The final model showed that being a woman (adjusted Odd Ratio [95% Confidence Interval], p-value: 2.13 [1.60–2.82], p<0.001), not having an economic activity (1.34 [1.05–1.72], p = 0.019), having at least two sexual partners (2.45 [1.83–3.29], p<0.001), reporting disease symptoms at HIV diagnosis (1.38 [1.08–1.75], p = 0.011), delayed ART initiation (1.32 [1.02–1.71], p = 0.034) and not being ART treated (2.28 [1.48–3.49], p<0.001) were all associated with HIV transmission risk. Conversely, longer time since HIV diagnosis was associated with a lower risk of transmitting HIV (0.96 [0.92–0.99] per one-year increase, p = 0.024). Patients followed in the third profile had a higher risk of transmitting HIV (1.71 [1.05–2.79], p = 0.031) than those in the first profile.

Conclusions

Healthcare supply constraints, including limited resources and ARV supply chain deficiency may impact HIV transmission risk. To reduce HIV incidence, HIV services need adequate resources to relieve healthcare supply-related barriers and provide suitable support activities throughout the continuum of care.

Baseline CD4 count and the time interval between the initial HIV infection and diagnosis among PLHIV in Bhutan

INTRODUCTION

CD4 count is an important predictor of disease progression, opportunities infection, deaths, and to understand the time interval between initial HIV infection to the first diagnosis. However, baseline CD4 count and the time period between initial infection and the diagnosis amongst PLHIV in Bhutan never been evaluated.

METHODS

This is a retrospective study of the diagnosed PLHIV from the existing data system from January 10 to 30, 2021. Out of 512 reported HIV cases, 488 of those who were more than or equal to 18 years old and had their CD4 count testing within 6 months before initiating ART were considered for analysis. Descriptive statistical analysis was used to analyze the characteristics of the study population and relationship were established using the χ 2 Test. We have sought ethics approval and waiver for informed consent as it is the retrospective study of the client's record. The client's confidentiality was ensured by removing all the identifiers.

RESULTS

The mean CD4 was 345 cells/ml for males and females. Twenty-five percent of the clients had CD4 counts below 200, 30%, between 200 and 349, 25% between 350 and 499, and 20% above 500 cells/ml. A larger number of males showed a CD4 count below 200 cells/ml while more females showed a CD4 count more than 500 cells/ml. The mean time interval between initial infection to the first diagnosis was 4 years in males and females. However, about one-fourth were found to have been infected between 5 and 8 years before diagnosis and less than 10% were diagnosed within less than 1 year of infection.

CONCLUSIONS

The study revealed a late diagnosis of HIV infection in Bhutan thereby risking the transmission to the community and risk of severe disease and mortality. The upscaling of voluntary counseling and testing, medical screening, and alternative methods like community-based testing including HIV Self Testing for early detection needs to be implemented in the country.

Understanding the Reasons for Deferring ART Among Patients Diagnosed Under the Same-Day-ART Policy in Johannesburg, South Africa

We aimed to examine the correlates of antiretroviral therapy (ART) deferral to inform ART demand creation and retention interventions for patients diagnosed with HIV during the Universal Test and Treat (UTT) policy in South Africa. We conducted a cohort study enrolling newly diagnosed HIV-positive adults (≥ 18 years), at four primary healthcare clinics in Johannesburg between October 2017 and August 2018. Patients were interviewed immediately after HIV diagnosis, and ART initiation was determined through medical record review up to six-months post-test. ART deferral was defined as not starting ART six months after HIV diagnosis. Participants who were not on ART six-months post-test were traced and interviewed telephonically to determine reasons for ART deferral. Modified Poisson regression was used to evaluate correlates of six-months ART deferral. We adjusted for baseline demographic and clinical factors. We present crude and adjusted risk ratios (aRR) associated with ART deferral. Overall, 99/652 (15.2%) had deferred ART by six months, 20.5% men and 12.2% women. Baseline predictors of ART deferral were older age at diagnosis (adjusted risk ratio (aRR) 1.5 for 30-39.9 vs 18-29.9 years, 95% confidence intervals (CI): 1.0-2.2), disclosure of intentions to test for HIV (aRR 2.2 non-disclosure vs disclosure to a partner/spouse, 95% CI: 1.4-3.6) and HIV testing history (aRR 1.7 for  > 12 months vs < 12 months/no prior test, 95% CI: 1.0-2.8). Additionally, having a primary house in another country (aRR 2.1 vs current house, 95% CI: 1.4-3.1) and testing alone (RR 4.6 vs partner/spouse support, 95% CI: 1.2-18.3) predicted ART deferral among men. Among the 43/99 six-months interviews, women (71.4%) were more likely to self-report ART initiation than men (RR 0.4, 95% CI: 0.2-0.8) and participants who relocated within SA (RR 2.1 vs not relocated, 95% CI: 1.2-3.5) were more likely to still not be on ART. Under the treat-all ART policy, nearly 15.2% of study participants deferred ART initiation up to six months after the HIV diagnosis. Our analysis highlighted the need to pay particular attention to patients who show little social preparation for HIV testing and mobile populations.

Individual and healthcare supply-related barriers to treatment initiation in HIV-positive patients enrolled in the Cameroonian antiretroviral treatment access programme

Increasing demand for antiretroviral treatment (ART) together with a reduction in international funding during the last decade may jeopardize access to ART. Using data from a cross-sectional survey conducted in 2014 in 19 HIV services in the Centre and Littoral regions in Cameroon, we investigated the role of healthcare supply-related factors in time to ART initiation in HIV-positive patients eligible for ART at HIV diagnosis. HIV service profiles were built using cluster analysis. Factors associated with time to ART initiation were identified using a multilevel Cox model. The study population included 847 HIV-positive patients (women 72%, median age: 39 years). Median (interquartile range) time to ART initiation was 1.6 (0.5-4.3) months. Four HIV service profiles were identified: (1) small services with a limited staff practising partial task-shifting (n = 4); (2) experienced and well-equipped services practising task-shifting and involving HIV community-based organizations (n = 5); (3) small services with limited resources and activities (n = 6); (4) small services providing a large range of activities using task-shifting and involving HIV community-based organizations (n = 4). The multivariable model showed that HIV-positive patients over 39 years old [hazard ratio: 1.26 (95% confidence interval) (1.09-1.45), P = 0.002], those with disease symptoms [1.21 (1.04-1.41), P = 0.015] and those with hepatitis B co-infection [2.31 (1.15-4.66), P = 0.019] were all more likely to initiate ART early. However, patients in the first profile were less likely to initiate ART early [0.80 (0.65-0.99), P = 0.049] than those in the second profile, as were patients in the third profile [association only significant at the 10% level; 0.86 (0.72-1.02), P = 0.090]. Our findings provide a better understanding of the role played by healthcare supply-related factors in ART initiation. In HIV services with limited capacity, task-shifting and support from community-based organizations may improve treatment access. Additional funding is required to relieve healthcare supply-related barriers and achieve the goal of universal ART access.

Ten-year attrition and antiretroviral therapy response among HIV-positive adults: a sex-based cohort analysis from eight West African countries

INTRODUCTION

Sex differences have already been reported in sub-Saharan Africa for attrition and immunological response after antiretroviral therapy (ART) initiation, but follow-up was usually limited to the first two to three years after ART initiation. We evaluated sex differences on the same outcomes in the 10 years following ART initiation in West African adults.

METHODS

We used cohort data of patients included in the IeDEA West Africa collaboration, who initiated ART between 2002 and 2014. We modelled no-follow-up and 10-year attrition risks, and immunological response by sex using logistic regression analysis, survival analysis with random effect and linear mixed models respectively.

RESULTS

A total of 71,283 patients (65.8% women) contributed to 310,007 person-years of follow-up in 16 clinics in eight West African countries. The cumulative attrition incidence at 10-year after ART initiation reached 75% and 68% for men and women respectively. Being male was associated with an increased risk of no follow-up after starting ART (5.1% vs. 4.0%, adjusted Odds Ratio: 1.25 [95% CI: 1.15 to 1.35]) and of 10-year attrition throughout the 10-year period following ART initiation: adjusted Hazard Ratios were 1.22 [95% CI: 1.17 to 1.27], 1.08 [95% CI: 1.04 to 1.12] and 1.04 [95% CI: 1.01 to 1.08] during year 1, years 2 to 4 and 5 to 10 respectively. A better immunological response was achieved by women than men: monthly CD4 gain was 30.2 and 28.3 cells/mL in the first four months and 2.6 and 1.9 cells/μL thereafter. Ultimately, women reached the average threshold of 500 CD4 cells/μL in their sixth year of follow-up, whereas men failed to reach it even at the end of the 10-year follow-up period. The proportion of patients reaching the threshold was much higher in women than in men after 10 years since ART initiation (65% vs. 44%).

CONCLUSIONS

In West Africa, attrition is unacceptably high in both sexes. Men are more vulnerable than women on both attrition and immunological response to ART in the 10 years following ART initiation. Innovative tracing strategies that are sex-adapted are needed for patients in care to monitor attrition, detect early high-risk groups so that they can stay in care with a durably controlled infection.

Quantifying the gender gap in the HIV care cascade in southern Mozambique: We are missing the men

BACKGROUND

HIV-infected men have higher rates of delayed diagnosis, reduced antiretroviral treatment (ART) retention and mortality than women. We aimed to assess, by gender, the first two UNAIDS 90 targets in rural southern Mozambique.

METHODS

This analysis was embedded in a larger prospective cohort enrolling individuals with new HIV diagnosis between May 2014-June 2015 from clinic and home-based testing (HBT). We assessed gender differences between steps of the HIV-cascade. Adjusted HIV-community prevalence was estimated using multiple imputation (MI).

RESULTS

Among 11,773 adults randomized in HBT (7084 female and 4689 male), the response rate before HIV testing was 48.7% among eligible men and 62.0% among women (p<0.001). MI did not significantly modify all-age HIV-prevalence for men but did decrease prevalence estimates in women from 36.4%to 33.0%. Estimated proportion of HIV-infected individuals aware of their status was 75.9% for men and 88.9% for women. In individuals <25 years, we observed up to 22.2% disparity in awareness of serostatus between genders. Among individuals eligible for ART, similar proportions of men and women initiated treatment (81.2% and 85.9%, respectively). Fourfold more men than womenwere in WHO stage III/IV AIDS at first clinical visit. Once on ART, men had a twofold higher 18-month loss to follow-up rate than women.

CONCLUSION

The contribution of missing HIV-serostatus data differentially impacted indicators of HIV prevalence and of achievement of UNAIDS targets by age and gender and men were missing long before the second 90. Increased efforts to characterize missing men and their needs will and their needs will allow us to urgently address the barriers to men accessing care and ensure men are not left behind in the UNAIDS 90-90-90 targets achievement.

Immunodeficiency at Antiretroviral Therapy Start: Five-Year Adult Data (2012-2017) Based on Evolving National Policies in Rural Mozambique

Before the 2015 implementation of "Test and Start," the initiation of combination antiretroviral therapy (ART) was guided by specific CD4 cell count thresholds. As scale-up efforts progress, the prevalence of advanced HIV disease at ART initiation is expected to decline. We analyzed the temporal trends in the median CD4 cell counts among adults initiating ART and described factors associated with initiating ART with severe immunodeficiency in Zambézia Province, Mozambique. We included all HIV-positive, treatment-naive adults (age ≥ 15 years) who initiated ART at a Friends in Global Health (FGH)-supported health facility between September 2012 and September 2017. Quantile regression and multivariable logistic regression models were applied to ascertain the median change in CD4 cell count and odds of initiating ART with severe immunodeficiency, respectively. A total of 68,332 patients were included in the analyses. The median change in CD4 cell count under "Test and Start" was higher at +68 cells/mm³ (95% CI: 57.5-78.4) compared with older policies. Younger age and female sex (particularly those pregnant/lactating) were associated with higher median CD4 cell counts at ART initiation. Male sex, advanced age, WHO Stage 4 disease, and referrals to the health facility through inpatient provider-initiated testing and counseling (PITC) were associated with higher odds of initiating ART with severe immunodeficiency. Although there were reassuring trends in increasing median CD4 cell counts with ART initiation, ongoing efforts are needed that target universal HIV testing to ensure the early initiation of ART in men and older patients.

Late ART Initiation among adult HIV patients at university of Gondar Hospital, NorthWest Ethiopia

Introduction

Late initiation of anti-retroviral therapy (ART) is associated with low immunologic response, increase morbidity, mortality and hospitalization. Therefore, this study aimed to assess the prevalence and factors associated with late ART initiation among adult HIV patients in NorthWest Ethiopia.

Methods

Retrospective cross-sectional study was conducted among 412 HIV patients who started ART between January/2009 and December/2014. Simple random sampling technique was used to select patient records. Data were collected by using pretested and structured extraction tool. Binary logistic regression model was fitted to identify factors associated with late ART initiation.

Result

A total of 410 participants were included for analysis after excluding 2 participants with incomplete data. The prevalence of late ART initiation was 67.3%. Age between 35–44 years(AOR=3.85; 95%CI:1.68–8.82), duration between testing and enrollment to care<1year (AOR=2.19;95%CI:1.30–3.69), secondary education (AOR=2.59; 95%CI 1.36–4.94), teritary education(AOR=3.28; 95%CI 1.25–8.64), being unmarried(AOR=1.88; 95%CI 1.13–3.03), bedridden and ambulatory patients (AOR=4.68 95%CI:1.49–14.68), other medication use before ART initiation(AOR=2.18; 95%CI 1.07–4.44), starting ART between 2009–2010 (AOR=5.94; 95%CI 2.74–12.87) and 2011–2012(AOR=2.80; 95%CI 1.31–5.96) were significantly associated with late ART initation at p-value <0.05.

Conclusion

The prevalence of late ART initiation was high. Strengthening the mechanisms of early HIV testing and linkage to care are recommended to initiate treatment earlier.

Late antiretroviral therapy initiation and associated factors among children on antiretroviral therapy at University of Gondar Comprehensive Specialized Hospital, Gondar, Northwest Ethiopia: a cross-sectional study

Objective

Highly active antiretroviral therapy reduces HIV related morbidity and mortality dramatically. Despite this fact, late ART initiation poses poor treatment outcome in pediatrics. However, the information is scarce in Ethiopia. Therefore, the study was aimed at determining the burden of late ART initiation and its associated factors among children on ART. Cross-sectional study was conducted among 422 children selected by simple random sampling. Patient charts were reviewed using pretested and structured data abstraction tool. Binary logistic regression model was fitted.

Results

A total of 402 child records with a completeness rate of 95.3% were included. The overall proportion of late antiretroviral therapy initiation among children on antiretroviral therapy was 53.2% (95% CI 48.5–58.4%). Under-5 years of age [AOR: 2.165 (95% CI 1.341, 3.495)], rural residence [AOR: 1.825 (95% CI 1.052, 3.166)], taking non-ART medication [AOR: 2.237 (95% CI 1.212, 4.130)], past opportunistic infection [AOR: 2.548 (95% CI 1.554, 4.178)], unmarried caregiver [AOR: 1.618 (95% CI 1.023, 2.559)], male caregiver [AOR: 1.903 (95% CI 1.026–3.527)] and null ANC visit [AOR: 1.721 (95% CI 1.077, 2.752)] were significantly associated factors. There is high burden of late ART initiation in children. Thus, focus should be started from pregnancy.

Is co-location of services with HIV care associated with improved HIV care outcomes? A systematic review

This systematic review identifies models of service co-location, a structural intervention strategy to remove barriers to HIV care and services, and examines their associations with HIV care outcomes. A cumulative database (e.g., MEDLINE, EMBASE) of HIV, AIDS, and STI literature was systematically searched and manual searches were conducted to identify relevant studies. Thirty-six studies were classified into six models of co-location: HIV care co-located with multiple ancillary services, tuberculosis (TB) care, non-HIV specific primary care, drug abuse treatment, prevention of mother to child transmission programs (PMTCT), and mental health care. More evidence of a positive association was seen for linkage to care and antiretroviral therapy (ART) uptake than for retention and viral suppression. Models of co-location that addressed HIV and non-HIV medical care issues (i.e., co-location with non-HIV specific primary care, PMTCT, and TB) had more positive associations, particularly for linkage to care and ART uptake, than other co-location models. While some findings are encouraging, more research with rigorous study designs is needed to strengthen the evaluation of, and evidence for, service co-location.

Barriers and facilitators to the uptake of Test and Treat in Mozambique: A qualitative study on patient and provider perceptions

Background

In mid-2016, Mozambique began phased implementation of the ‘Test-and-Treat’ policy, which enrolls HIV positive clients into antiretroviral treatment (ART) immediately regardless of CD4 cell count or disease stage. Novel insights into barriers and facilitators to ART initiation among healthy clients are needed to improve implementation of Test and Treat.

Methods and findings

A cross-sectional qualitative study was conducted across 10 health facilities in Mozambique. In-depth interviews (IDIs) were conducted with HIV-positive clients (60 who initiated/20 who did not initiate ART within Test and Treat) and 9 focus group discussion (FGDs) were conducted with health care workers (HCWs; n = 53). Data were analyzed using deductive and inductive analysis strategies. Barriers to ART initiation included: (1) feeling ‘healthy’; (2) not prepared to start ART for life; (3) concerns about ART side effects; (4) fear of HIV disclosure and discrimination; (5) poor interactions with HCWs; (6) limited privacy at health facilities; and (7) perceptions of long wait times. Facilitators included the motivation to stay healthy and to take care of dependents, as well as new models of ART services such as adaptation of counseling to clients’ specific needs, efficient patient flow, and integrated HIV/primary care services.

Conclusions

ART initiation may be difficult for healthy clients in the context of Test-and-Treat. Specific strategies to engage this population are needed. Strategies could include targeted support for clients, community sensitization on the benefits of early ART initiation, client-centered approaches to patient care, and improved efficiency through multi-month scripting and increased workforce.

Effective linkage from point of HIV testing to care and treatment in Tanga region, Tanzania

Background

Linkage to care and treatment is an important part of efforts to accelerate HIV prevention, treatment, care, and support. It offers an opportunity for PLHIV to receive information and services in a timely manner. Clients who present late for HIV care and treatment may miss out on timely initiation of prophylaxis and ART, which may accelerate disease progression and lead to an increased rate of HIV transmission within the community. The objective of this study was to determine the factors influencing effective linkages of newly diagnosed PLHIV from the point of testing to entry in care and treatment centres (CTCs) in Tanga Region, Tanzania.

Methods

This cross-sectional study examined five clinics with a high volume of clients in each of the three districts in Tanga Region. All adults ages 18 years and above at the time of CTC enrolment, between 2010 and 2014, were eligible to participate in the study.

The study engaged both secondary and primary data. To complement the secondary data, mixed methods were applied in primary data collection. Using a structured questionnaire, interviews with the sampled CTC clients while focus group discussions with healthcare providers and in-depth interviews with CTC clients.

The qualitative data were analysed using a thematic analysis framework. The outcome of interest was whether a client enrolled in a CTC within three months of his or her first positive HIV test. A logistic regression model was used to determine factors associated with effective linkage of newly diagnosed HIV clients to CTC.

Results

A total of 16,041 adults from the three study districts were enrolled at a CTC from 2010 to 2014. A total of 1,096 clients from the sampled CTCs were recruited into the study for interview. The characteristics of these clients were representative of the larger group (16,041). The majority (72.4%) were female. More than half (52.1%) were married, and almost a quarter (21.2%) were single. The majority (59.6%) of participants completed primary education and almost half (45.1%) were subsistence farmers. The median CD4 count at enrolment was 218 (87–397) cells/mL with more than half (56.3%) having CD4 counts of less than 350 cells per millilitre (mL). Nearly all (91%) of the clients presented at a CTC within three months of receiving a positive HIV test. In a multivariate analysis, factors that remained significantly associated with early entry in CTC were level of education, CD4 count, and point of diagnosis. Participants’ responses were consistent with many of the factors explained by participants to be barriers to effective linkages and referrals repeated in the FGDs and IDIs across the study sites. For instance, FGD respondent expressed that clients were worried about stigma from their relatives, which creates a delay in seeking treatment.

Conclusion

Although the rate of early entry in care and treatment services is high, surprisingly was a marked increase in those who waited more than three months to seek treatment. To meet the target, issues such as disclosure and stigma need to be addressed.

Trends, treatment outcomes, and determinants for attrition among adult patients in care at a large tertiary HIV clinic in Nairobi, Kenya: a 2004-2015 retrospective cohort study

Background

Understanding trends in patient profiles and identifying predictors for adverse outcomes are key to improving the effectiveness of HIV care and treatment programs. Previous work in Kenya has documented findings from a rural setting. This paper describes trends in demographic and clinical characteristics of antiretroviral therapy (ART) treatment cohorts at a large urban, referral HIV clinic and explores treatment outcomes and factors associated with attrition during 12 years of follow-up.

Methods

This was a retrospective cohort analysis of HIV-infected adults who started ART between January 1, 2004, and September 30, 2015. ART-experienced patients and those with missing data were excluded. The Cochran–Armitage test was used to determine trends in baseline characteristics over time. Cox proportional hazards models were used to determine the effect of baseline characteristics on attrition.

Results

ART uptake among older adolescents (15–19 years), youth, and young adults increased over time (p=0.0001). Independent predictors for attrition included (adjusted hazard ratio [95% CI]) male sex: 1.30 (1.16–1.45), p=0.0001; age: 15–19 years: 1.83 (1.26–2.66), p=0.0014; 20–24 years: 1.93 (1.52–2.44), p=0.0001; and 25–29 years: 1.31 (1.11–1.54), p=0.0012; marital status – single: 1.27 (1.11–1.44), p=0.0005; and divorced/separated: 1.56 (1.30–1.87), p=0.0001; urban residence: 1.40 (1.20–1.64), p=0.0001; entry into HIV care following hospitalization: 1.31 (1.10–1.57), p=0.0026, or transfer from another facility: 1.60 (1.26–2.04), p=0.0001; initiation of ART more than 12 months after the date of HIV diagnosis: 1.36 (1.19–1.55), p=0.0001, and history of a current or past opportunistic infection (OI): 1.15 (1.02–1.30), p=0.0284.

Conclusion

Although ART uptake among adolescents and young people increased over time, this group was at increased risk for attrition. Single marital status, urban residence, history of hospitalization or OI, and delayed initiation of ART also predicted attrition. This calls for focused evidence-informed strategies to address attrition and improve outcomes.

'Test and Treat' Among Women at High Risk for HIV-infection in Kampala, Uganda: Antiretroviral Therapy Initiation and Associated Factors

Data on implementation of 'Test and Treat' among key populations in sub-Saharan Africa are still limited. We examined factors associated with prompt antiretroviral therapy/ART (within 1 month of HIV-positive diagnosis or 1 week if pregnant) among 343 women at high risk for HIV infection in Kampala-Uganda, of whom 28% initiated prompt ART. Most (95%) reported paid sex within 3 months prior to enrolment. Multivariable logistic regression was used to determine baseline characteristics associated with prompt ART. Sex work as main job, younger age and being widowed/separated were associated with lower odds of prompt ART; being enrolled after 12 months of implementing the intervention was associated with higher odds of prompt ART. Younger women, widowed/separated and those reporting sex work as their main job need targeted interventions to start ART promptly after testing. Staff supervision and mentoring may need strengthening during the first year of implementing 'test and treat' interventions.

Failure to initiate HIV treatment in patients with high CD4 counts: evidence from demographic surveillance in rural South Africa

OBJECTIVES

To assess the relationship between CD4 count at presentation and ART uptake and assess predictors of timely treatment initiation in rural KwaZulu-Natal, South Africa.

METHODS

We used Kaplan-Meier and Cox proportional hazards models to assess the association between first CD4 count and time from first CD4 to ART initiation among all adults presenting to the Hlabisa HIV Treatment and Care Programme between August 2011 and December 2012 with treatment-eligible CD4 counts (≤ 350 cells/mm3 ). For a subset of healthier patients (200 < CD4 ≤ 350 cells) residing within the population surveillance of the Africa Health Research Institute, we assessed sociodemographic, economic and geographic predictors hypothesised to influence ART uptake.

RESULTS

A total of 4739 patients presented for care with eligible CD4 counts. The proportion initiating ART within six months of diagnosis was 67% (95% CI 63, 71) in patients with CD4 ≤ 50, 59% (0.55, 0.63) in patients with CD4 151-200 and 48% (95% CI 44, 51) in patients with CD4 301-350. The hazard of starting ART fell by 17% (95% CI 14, 20) for every 100-cell increase in baseline CD4 count. Among healthier patients under demographic surveillance (n = 193), observable sociodemographic, economic and geographic predictors did not add discriminatory power beyond CD4 count, age and sex to identify patients at high risk of non-initiation.

CONCLUSIONS

Individuals presenting for HIV care at higher CD4 counts were less likely to initiate ART than patients presenting at low CD4 counts. Overall, ART uptake was low. Under new guidelines that establish ART eligibility regardless of CD4 count, patients with high CD4 counts may require additional interventions to encourage treatment initiation.

Using multilevel models to evaluate the influence of contextual factors on HIV/AIDS, sexually transmitted infections, and risky sexual behavior in sub-Saharan Africa: a systematic review

PURPOSE

To describe the use of multilevel models (MLMs) in evaluating the influence of contextual factors on HIV/AIDS, sexually transmitted infections (STIs), and risky sexual behavior (RSB) in sub-Saharan Africa.

METHODS

Ten databases were searched through May 29, 2016. Two reviewers completed screening and full-text review. Studies examining the influence of contextual factors on HIV/AIDS, STIs, and RSB and using MLMs for analysis were included. The Quality Assessment Tool for Quantitative Studies was used to evaluate study quality.

RESULTS

A total of 118 studies met inclusion criteria. Seventy-four studies focused on HIV/AIDS-related topics; 46 focused on RSB. No studies related to STIs other than HIV/AIDS met the eligibility criteria. Of five studies examining HIV serostatus and community socioeconomic factors, three found an association between poverty and measures of inequality and increased HIV prevalence. Among studies examining RSB, associations were found with numerous contextual factors, including poverty, education, and gender norms.

CONCLUSIONS

Studies using MLMs indicate that several contextual factors, including community measures of socioeconomic status and educational attainment, are associated with a number of outcomes related to HIV/AIDS and RSB. Future studies using MLMs should focus on contextual-level interventions to strengthen the evidence base for causality.

Advanced Human Immunodeficiency Virus Disease at Diagnosis in Mozambique and Swaziland

Background

Early diagnosis of human immunodeficiency virus (HIV) is a prerequisite to maximizing individual and societal benefits of antiretroviral therapy.

Methods

Adults ≥18 years of age testing HIV positive at 10 health facilities in Mozambique and Swaziland received point-of-care CD4⁺ cell count testing immediately after diagnosis. We examined median CD4⁺ cell count at diagnosis, the proportion diagnosed with advanced HIV disease (CD4⁺ cell count ≤350 cells/μL) and severe immunosuppression (CD4⁺ cell count ≤100 cells/μL), and determinants of the latter 2 measures.

Results

Among 2333 participants, the median CD4⁺ cell count at diagnosis was 313 cells/μL (interquartile range, 164–484), more than half (56.5%) had CD4⁺ ≤350 cells/μL, and 13.9% had CD4⁺ ≤100 cells/μL. The adjusted relative risk (aRR) of both advanced HIV disease and severe immunosuppression at diagnosis was higher in men versus women (advanced disease aRR = 1.31; 95% confidence interval [CI] = 1.16–1.48; severe immunosuppression aRR = 1.54, 95% CI = 1.17–2.02) and among those who sought HIV testing because they felt ill (advanced disease aRR = 1.30, 95% CI = 1.08–1.55; severe immunosuppression aRR = 2.10, 95% CI = 1.35–2.26). Age 18–24 versus 25–39 was associated with a lower risk of both outcomes (advanced disease aRR = 0.70, 95% CI = 0.59–0.84; severe immunosuppression aRR = 0.62, 95% CI = 0.41–0.95).

Conclusions

More than 10 years into the global scale up of comprehensive HIV services, the majority of adults diagnosed with HIV at health facilities in 2 high-prevalence countries presented with advanced disease and 1 in 7 had severe immunosuppression. Innovative strategies for early identification of HIV-positive individuals are urgently needed.

Trends and outcomes of late initiation of combination antiretroviral therapy driven by late presentation among HIV-positive Taiwanese patients in the era of treatment scale-up

OBJECTIVES

The international and national HIV treatment guidelines in 2016 have focused on scaling up access to combination antiretroviral therapy (cART). We aimed to assess the trends and treatment outcomes of late cART initiation in Taiwan.

METHODS

Between June 2012 and May 2016, we retrospectively included antiretroviral-naive HIV-positive adults who initiated cART. Late initiation was defined as when cART was initiated in patients with a CD4 count <200 cells/mm3 or having experienced AIDS-defining illnesses. The treatment outcomes were assessed up to 6 months after starting cART.

RESULTS

We included 3655 HIV-positive patients, and the majority of the patients were male (95.4%) with a median age of 31 years and initiated non-nucleoside reverse-transcriptase inhibitor-containing regimens (87.0%). The median CD4 count at cART initiation increased from 207 cells/mm3 in 2012 to 298 cells/mm3 in 2016, and the overall proportion of late cART initiation decreased from 49.1% in 2012 to 29.0% in 2016 (P for trend <0.001). Late cART initiation mainly resulted from late presentation for HIV care and was associated with older age (per 1-year increase, adjusted odds ratio [AOR], 1.05; 95% CI, 1.04-1.06), HBsAg seropositivity (AOR, 1.31; 95% CI, 1.04-1.64), HIV care in central and southern Taiwan, initiating cART in earlier year, non-intravenous drug users (AOR, 1.96; 95% CI, 1.33-2.86), and negative hepatitis C serostatus (AOR, 1.47; 95% CI, 1.04-2.08). Compared with non-late initiators, late initiators had a higher rate of all-cause mortality (1.7% vs. 0.3%) and regimen modification due to virological failure (7.1% vs. 2.6%). The predicting factors of all-cause mortality were late cART initiation (adjusted hazard ratio [AHR], 5.40; 95% CI, 2.14-13.65) and older age (AHR, 1.06; 95% CI, 1.03-1.10).

CONCLUSIONS

While the proportion of late cART initiation decreased over time in Taiwan, late initiation remained in a substantial proportion of HIV-positive patients. The late initiators had higher risk for poor outcomes. The need for strategies to earlier detection of HIV infection and expediting cART initiation should be highlighted, especially among the older population.

Trends in baseline CD4 cell counts and risk factors for late antiretroviral therapy initiation among HIV-positive patients in Shanghai, a retrospective cross-sectional study

BACKGROUNDS

There are few studies focus on the factors underlying the late initiation of ART in China. We analyzed the trends in the median CD4 cell counts among different patient groups over time and the risk factors for the late initiation of ART in Shanghai, China.

METHODS

A retrospective cross-sectional survey was made in the Department of Infectious Disease of Shanghai Public Health Clinical Center which is a designated diagnosis and treatment center for HIV-positive patients in Shanghai during the period of January 1st, 2008--June 30th, 2014. Late ART initiation was defined as a CD4 cell count <200 cells/mm³ or having a clinical AIDS diagnosis prior to ART initiation. Trends in the median CD4 cell count at ART initiation and the proportion of late ART initiation by year were evaluated using Spearman's correlations and Chi-squared methods, respectively. We used a logistic regression model to analyze the risk factors for late ART initiation. The related factors collected in the multivariate model were the patient's age, gender, infection routes and marital status.

RESULTS

A total of 3796 patients were analyzed in this study, with a median baseline CD4 cell count of 205 cells/mm³ [interquartile range: 75-287]. The median CD4 cell counts of patients initiating ART late increased from 76 cells/mm³ in 2008 to 103 cells/mm³ in 2014 (p < 0.001), and the proportion of late ART initiation decreased from 80% to 45% (p < 0.001). The risk factors for late ART initiation were male gender, heterosexual transmission and older age (>30 years) (p < 0.001).

CONCLUSIONS

Notable improvements were made in the median CD4 cell count at ART initiation and the proportion of late ART initiation from 2008 to 2014. However, persons with high risk of HIV exposure who are male, older even heterosexual orientation should be given more opportunities to receive frequently screening, earlier diagnoses and timely treatment.

Nonadherence to antiretroviral therapy among HIV-infected patients in Zambia is concentrated among a minority of patients and is highly variable across clinics

OBJECTIVES

The distribution of adherence to antiretroviral therapy (ART) can indicates whether barriers are concentrated or more distributed. We quantified the medication possession ratio (MPR) and characterized the distribution of medication nonpossession in a network of clinics in Zambia to identify 'hotspots' and predictors of poorer adherence.

METHODS

We analyzed a population of adults on ART for more than 3 months who made at least one clinic visit between 1 January 2013 and 28 February 2015. Pharmacy refill and clinical information were obtained through the electronic medical record system used in routine care. We constructed a Lorenz curve to visualize the distribution of poor adherence and used a multilevel logistic regression model to examine factors associated with MPR.

RESULTS

Among 131 767 patients in 56 clinics [64% women, median age 34 years (interquartile range (IQR) 29-41), median CD4 cell count at ART initiation 351 cells/μl (IQR 220-517)], the median MPR was 85.8% (IQR 70.8-96.8). During months 7-12 on ART, 45.6% of patients had 100% MPR and 10.5% accounted for 50% of medication nonpossession. Across clinics, median MPR ranged from 49.1 to 98.5, and clinic accounted for 12% of the variability in adherence after adjusting for individual and clinic-level characteristics.

CONCLUSION

A small fraction of patients account for the majority of days of medication nonpossession. Further characterization of these subpopulations is needed to target interventions. Clinic also accounted for much variability in MPR. Health systems interventions targeting clinic 'hot spots' may represent an efficient use of resources to improve ART adherence.

Exploratory Analysis of Time from HIV Diagnosis to ART Start, Factors and effect on survival: A longitudinal follow up study at seven teaching hospitals in Ethiopia

BACKGROUND

The HIV care in Ethiopia has reached 79% coverage. The timeliness of the care provided at the different levels in the course of the disease starting from knowing HIV positive status to ART initiation is not well known. This study intends to explore the timing of the care seeking, the care provision and associated factors.

METHODS

This is a longitudinal follow-up study at seven university hospitals. Patients enrolled in HIV care from September 2005 to December 2013 and aged ≥14 years were studied. Different times in the cascade of HIV care were examined including the duration from date HIV diagnosed to enrollment in HIV care, duration from enrollment to eligibility for ART and time from eligibility to initiation of ART. Ordinal logistic regression was used to investigate their determinants while the effect of these periods on survival of patients was determined using cox-proportional hazards regression.

RESULTS

4159 clients were studied. Time to enrollment after HIV test decreased from 39 days in 2005 to 1 day after 2008. It took longer if baseline CD4 was higher, and eligibility for ART was assessed late. Young adults, lower baseline CD4, HIV diagnosis<2008, late enrollment, and early eligibility assessment were associated with early ART initiation. Male gender, advanced disease stage and lower baseline CD4 were consistent risk factors for mortality.

CONCLUSION AND RECOMMENDATION

Time to enrollment and duration of ART eligibility assessment as well as ART initiation time after eligibility is improving. Further study is required to identify why mortality is slightly increasing after 2010.

Comprehensiveness of HIV care provided at global HIV treatment sites in the IeDEA consortium: 2009 and 2014

INTRODUCTION

An important determinant of the effectiveness of HIV treatment programs is the capacity of sites to implement recommended services and identify systematic changes needed to ensure that invested resources translate into improved patient outcomes. We conducted a survey in 2014 of HIV care and treatment sites in the seven regions of the International epidemiologic Database to Evaluate AIDS (IeDEA) Consortium to evaluate facility characteristics, HIV prevention, care and treatment services provided, laboratory capacity, and trends in the comprehensiveness of care compared to data obtained in the 2009 baseline survey.

METHODS

Clinical staff from 262 treatment sites in 45 countries in IeDEA completed a site survey from September 2014 to January 2015, including Asia-Pacific with Australia (n = 50), Latin America and the Caribbean (n = 11), North America (n = 45), Central Africa (n = 17), East Africa (n = 36), Southern Africa (n = 87), and West Africa (n = 16). For the 55 sites with complete data from both the 2009 and 2014 survey, we evaluated change in comprehensiveness of care.

RESULTS

The majority of the 262 sites (61%) offered seven essential services (ART adherence, nutritional support, PMTCT, CD4+ cell count testing, tuberculosis screening, HIV prevention, and outreach). Sites that were publicly funded (64%), cared for adults and children (68%), low or middle Human Development Index (HDI) rank (68%, 68%), and received PEPFAR support (71%) were most often fully comprehensive. CD4+ cell count testing was universally available (98%) but only 62% of clinics offered it onsite. Approximately two-thirds (69%) of sites reported routine viral load testing (44-100%), with 39% having it onsite. Laboratory capacity to monitor antiretroviral-related toxicity and diagnose opportunistic infections varied widely by testing modality and region. In the subgroup of 55 sites with two surveys, comprehensiveness of services provided significantly increased across all regions from 2009 to 2014 (5.7 to 6.5, p < 0.001).

CONCLUSION

The availability of viral load monitoring remains suboptimal and should be a focus for site capacity, particularly in East and Southern Africa, where the majority of those initiating on ART reside. However, the comprehensiveness of care provided increased over the past 5 years and was related to type of funding received (publicly funded and PEPFAR supported).

Tenofovir stock shortages have limited impact on clinic- and patient-level HIV treatment outcomes in public sector clinics in South Africa

OBJECTIVE

Using data from four public sector clinics in South Africa, we sought to investigate provider- and patient-level outcomes, to understand how the 2012 tenofovir stock shortage affected the HIV care and monitoring of ART patients.

METHODS

Prospective cohort analysis of ART-naïve, non-pregnant, HIV-infected patients >18 years initiating first-line ART between 1 July 2011-31 March 2013. Linear regression was used for all outcomes (number of ART initiates, days between pharmacy visits, transfers, single-drug substitutions, treatment interruptions, missed pharmacy visits, loss to follow-up and elevated viral load). We fit splines to smooth curves with knots at the beginning (1 February 2012) and end (31 August 2012) of the stock shortage and displayed results graphically by clinic. Difference-in-difference models were used to evaluate the effect of the stock shortage on outcomes.

RESULTS

Results suggest a potential shift in the management of patients during the shortage, mainly fewer average days between visits during the shortage vs. before or after at all four clinics, and a significant difference in the proportion of patients missing visits during vs. before (RD: 1.2%; 95% CI: 0.5%, 2.0%). No significant difference was seen in other outcomes.

CONCLUSION

While South Africa has made great strides to extend access to ART and increase the quality of the health services provided, patient care can be affected when stock shortages/outs occur. While our results show little effect on treatment outcomes, this most likely reflects the clinics' ability to mitigate the crisis by continuing to keep patient care and treatment as consistent as possible.

Insights into Adherence among a Cohort of Adolescents Aged 12-20 Years in South Africa: Reported Barriers to Antiretroviral Treatment

Adolescents experience disproportionately high rates of poor ART outcomes compared to adults despite prolonged use of antiretroviral therapy in Southern African treatment programs, presenting a significant challenge to national attempts to meet the UNAIDS 90-90-90 targets for 2020. This cohort study among adolescents aged 12-20 years accessing ART care at two urban public-sector clinics in Johannesburg between September and November 2013 aimed to identify factors potentially associated with poor attendance at clinic visits. Patients were followed up through routine medical records to identify missed visits (failing to attend clinic within 30 days of scheduled visit date) up to 2 years after enrolment. We enrolled 126 adolescents on ART for a median of 6.3 years (IQR: 2.7-8.4). A total of 47 (38%) adolescents missed a scheduled visit within 24 months of enrolment. Older adolescents (18-20 years) were more likely to miss a visit compared to adolescents aged 12-14 years (risk ratio (RR) = 1.72; 95% CI: 1.00-2.95). Those who were identified to have difficulty in taking medication (RR = 1.57; 95% CI: 1.13-2.18) as a barrier to care were more likely to miss a visit compared to adolescents who did not. Awareness of treatment fatigue, challenges to taking ART, and caregiver difficulties is important when considering interventions to improve treatment outcomes among adolescents.

The status of adolescent medicine: building a global adolescent workforce

Remarkable public health achievements to reduce infant and child mortality as well as improve the health and well-being of children worldwide have successfully resulted in increased survival and a growing population of young people aged 10-24 years. Population trends indicate that the current generation of 1.8 billion young people is the largest in history. However, there is a scarcity of dedicated resources available to effectively meet the health needs of adolescents and young adults worldwide. Growing recognition of the pivotal roles young people play in the cultures, societies, and countries in which they live has spurred an expanding global movement to address the needs of this special population. Building an effective global workforce of highly-skilled adolescent health professionals who understand the unique biological, psychological, behavioral, social, and environmental factors that affect the health of adolescents is a critical step in addressing the health needs of the growing cohort of young people. In this review, we aim to: 1) define a global assessment of the health needs for adolescents around the world; 2) describe examples of current training programs and requirements in adolescent medicine; 3) identify existing gaps and barriers to develop an effective adolescent health workforce; and 4) develop a call for targeted actions to build capacity of the adolescent health workforce, broaden culturally relevant research and evidence-based intervention strategies, and reinforce existing interdisciplinary global networks of youth advocates and adolescent health professionals to maximize the opportunities for training, research, and care delivery.

Late presentation for diagnosis of HIV infection among HIV positive patients in South Tigray Zone, Ethiopia

BACKGROUND

In spite of the availability and accessibility of HIV testing opportunities and efforts, people are being late to test in the course of HIV infection. Late diagnosis leads to late anti-retroviral therapy initiation which in turn results in poor treatment outcome and prognosis of the disease. The aim of this study was to determine the prevalence and predictors of late HIV diagnosis among HIV-infected patients in South Tigray Zone, Ethiopia.

METHODS

A facility based cross sectional study was conducted among HIV positive patients from February 1-30, 2014 in Southern Tigray, Ethiopia. Multistage sampling technique was employed to select the study participants. Data were collected by reviewing patient medical card and interviewing using structured questionnaire. Data were entered using Epi-Data version 3.1 and analyzed using SPSS version 20.0. Both bivariate and multivariate logistic regressions were modeled to evaluate the association of predictors with late diagnosis of HIV infection.

RESULTS

Out of 789 study participants, 68.8 % of them were late for HIV diagnosis. Feeling healthy (65.7 %), fear of stigma and discrimination (32.4 %) and using traditional treatment (1.5 %) were reported as the main reasons for late HIV diagnosis. Use of Khat [AOR = 3.27, 95 % CI (1.75, 6.13)], bed ridden functional status [AOR = 2.66, 95 % CI (1.60, 4.42)], ambulatory functional status [AOR = 1.56, 95 % CI (1.03, 2.35)] and Muslim religion [AOR = 2.26, 95 % CI (1.13, 4.49)] were significantly associated with late presentation for HIV diagnosis.

CONCLUSIONS

High prevalence of late HIV diagnosis was recorded in Southern Tigray Zone, Ethiopia. Public health educations and campaigns targeted at improving early diagnosis and prognosis of people living with HIV/AIDS in Southern Tigray, Northern Ethiopia should be underway.

CD4 Decay Rate as an Indicator of the Time Interval between Initial Infection and First Diagnosis among Drug-Naïve Human Immunodeficiency Virus Seropositive Individuals in Lagos, Nigeria

OBJECTIVE

The aim of this study was to determine the time interval between human immunodeficiency virus (HIV) infection and the first diagnosis among drug-naïve individuals in Badagry, Nigeria.

SUBJECTS AND METHODS

A sample of 213 subjects who tested HIV positive for the first time were enrolled in this study. The HIV diagnosis was performed using Startpak® and Determine® kits, and a CD4 count was carried out using a FACS Count® flow cytometer. The mean CD4 values were determined by gender and age groups. The time interval between initial HIV infection and first testing was calculated based on the average CD4 decay rate per calendar year, and data analysis was performed using SPSS software.

RESULTS

At diagnosis, the mean CD4 values showed that females recorded 270 cells/µl and males 244 cells/µl. By age range, individuals <25 years recorded 437 cells/µl, those between 25 and 40 years of age had 237 cells/µl, and those aged ≥41 years had 192 cells/µl. There was a significant difference between CD4 cell categorization and age range (p < 0.001). Subjects aged between 25 and 40 years recorded the highest distribution of all CD4 cell counts. The time interval between infection and testing for females was 8.1 years and for males 6.7 years. Within the age group <25 years the interval was 5.1 years, whilst it was 8.1 years for those aged ≥41 years.

CONCLUSION

Most of the population presented for testing during the advanced stages of infection. We suggest an upscaling of HIV voluntary counseling and testing to encourage early detection and better treatment outcomes.

Determinants of late presentation to HIV/AIDS care in Southern Tigray Zone, Northern Ethiopia: an institution based case-control study

BACKGROUND

Late diagnosis and presentation to human immune deficiency virus (HIV)/acquired immune deficiency syndrome care reduce the benefits of antiretroviral therapy and increase the risk of HIV transmission.

OBJECTIVES

This study was conducted to identify determinants of late presentation to HIV care among people living with HIV in Southern Tigray, Northern Ethiopia.

METHODS

An institution based un-matched case-control (1:2 ratios) supported with qualitative data was conducted in Southern Tigray Zone from March 1 to April 30, 2014. Individuals with HIV enrolled from six randomly selected health facilities were included in the study. Cases were people living with HIV who had cluster of differentiation four count <350 cells/μl or World Health Organization stages 3 or 4. A total of 442 study participants were included by systematic sampling techniques. Bivariable and multivariable binary logistic regression model was used to identify associated factors. Odds ratio with 95 % CI was computed to assess the strength of the associations.

RESULT

Age categories, 25-29 years [AOR 3, 95 % CI (1.2-8.1)] and 35-39 years [AOR 4.1, 95 % CI (1.4-12.5)], having two [AOR 6, 95 % CI (1.3-28)] and more [AOR 5.2, 95 % CI (1.1-24.8)] lifetime sexual partners, poor social support [AOR 2.3, 95 % CI (1.26-4.30)], second (next to lowest) wealth quintile [AOR 3.3, 95 % CI 91.3-8.5)], fear of stigma [AOR 4.4, 95 % CI (2.2-8.3)], fear of losing job [AOR 6.8, 95 % CI (1.8-24.5)], and reported severe illness [AOR 4.3, 95 % CI (2.26-8)] were identified to be the risk factors for late presentation.

CONCLUSION

Low socio-economic status and social support, fear of stigma were potential risk factors for late presentation. Efforts towards promoting early care seeking should target on these factors in the study area and other similar settings.

The clock is ticking: the rate and timeliness of antiretroviral therapy initiation from the time of treatment eligibility in Kenya

Introduction

Understanding the determinants of timely antiretroviral therapy (ART) initiation is useful for HIV programmes intent on developing models of care that reduce delays in treatment initiation while maintaining a high quality of care. We analysed patient- and facility-level determinants of time to ART initiation among patients who initiated ART in Kenya.

Methods

We collected facility-level information and conducted a retrospective chart review of adults initiating ART between 2007 and 2012 at 51 health facilities in Kenya. We evaluated the association between patient- and facility-level covariates at the time of ART eligibility and time to ART initiation. We also explored the determinants associated with timeliness of ART initiation.

Results

The analysis included 11,942 patients. The median age at the time eligibility was first determined was 37 years (interquartile range [IQR] 31–45). Overall, 75% of patients initiated ART within two months of eligibility. The median CD4 cell count at the time eligibility was first determined rose from 132 (IQR 51–217) in 2007 to 195 (IQR 91–286) in 2011 to 2012 (p<0.001). The cumulative probability of ART initiation among treatment-eligible patients increased over time: 87.1% (95% confidence interval [CI] 85.1–89.0%) in 2007; 96.8% (96.0–97.5%) in 2008; 97.1% (96.3–97.7%) in 2009; 98.5% (98.0 −98.9%) in 2010; and 99.7% (95% CI 99.4 −99.8%) in 2011 to 2012 (p<0.0001). In multivariate analyses, attending a health facility with high ART patient volumes within two months of eligibility was considered the key facility-level determinant of ART initiation (adjusted odds ratio 0.57, 95% CI 0.45–0.72, p<0.001). Patient-level determinants included being eligible for ART in the years subsequent to 2007, advanced World Health Organization clinical stage and low CD4 cell count at the time eligibility was first determined.

Conclusions

Overall, the time between treatment eligibility and ART initiation decreased substantially in Kenya between 2007 and 2012, with uniform gains across different types of health facilities. Our findings highlight the slow increase in CD4 cell counts at the time of ART eligibility over time, indicating that a large number of patients are still beginning ART with advanced HIV disease. Our findings also support the decentralisation of ART services at all health facilities that have the capacity to initiate treatment. Continued evaluation of programme- and country-level data is needed to monitor timeliness of ART initiation as countries continue to expand treatment access.

ART Adherence as a Key Component of Prevention With Persons Living With HIV in Mozambique

Medication adherence is an effective approach to prevent HIV transmission. In Mozambique, a country with a generalized epidemic, the government has adopted Positive Prevention (PP) training for clinicians as part of its national strategy. Our study, conducted after trainings in five clinics, examined the understanding of trained health care staff and their patients about the importance of adherence to antiretroviral therapy (ART), a key element of PP. Interviews with trained clinicians (n = 31) and patients (n = 57) were conducted and analyzed. Clinicians and patients demonstrated an understanding that ART adherence could decrease HIV transmission. However, participants also highlighted the difficulties of adherence when patients had limited access to food. At the same time that treatment as prevention awareness was increasing, poverty and widespread food insecurity were barriers to taking medications. In Mozambique, the full benefits of treatment as prevention may not be realized without adequate access to food.

Implementation and Operational Research: Evaluation of Swaziland's Hub-and-Spoke Model for Decentralizing Access to Antiretroviral Therapy Services

BACKGROUND

In 2007, Swaziland initiated a hub-and-spoke model for decentralizing antiretroviral therapy (ART) access. Decentralization was facilitated through (1) down-referral of stable ART patients from overburdened central facilities (hubs) to primary health care clinics (spokes) and (2) ART initiation at spokes (spoke initiation).

METHODS

We conducted a nationally representative retrospective cohort study among adult ART enrollees during 2004-2010 to assess the effect of down-referral and spoke-initiation on rates of loss to follow-up (LTFU), death, and attrition (death or LTFU). Sixteen of 31 hubs were randomly selected using probability-proportional-to-size sampling. Seven selected facilities had initiated the hub-and-spoke model by study start. At these facilities, 1149 of 24,782 hub-initiated and maintained and 878 of 7722 down-referred or spoke-initiated patient records were randomly selected and analyzed. At the 9 hub-only facilities, 483 of 6638 records were randomly selected and analyzed. Multivariable proportional hazards regression was used to assess effect of down-referral (a time-varying covariate) and spoke-initiation on outcomes.

RESULTS

At ART initiation, median age was 35, 65% were female, and median CD4 count was 147 cells per microliter. Controlling for known confounders, down-referral was strongly protective against LTFU [adjusted hazard ratio (AHR) 0.38; 95% confidence interval (CI): 0.29 to 0.50] and attrition (AHR = 0.50; 95% CI: 0.34 to 0.76) but not mortality. Compared with hub-initiated and maintained patients, spoke-initiated patients had lower LTFU (AHR 0.59; 95% CI: 0.45 to 0.77) and attrition rates (AHR 0.60; 95% CI: 0.47 to 0.77), but not mortality.

CONCLUSIONS

Down-referral and spoke-initiation within a hub-and-spoke ART decentralization model were protective against LTFU and overall attrition and could facilitate future ART program expansion.

Implementation and operational research: Integrated pre-antiretroviral therapy screening and treatment for tuberculosis and cryptococcal antigenemia

OBJECTIVE

To demonstrate the feasibility of integrated screening for cryptococcal antigenemia and tuberculosis (TB) before antiretroviral therapy (ART) initiation and to assess disease specific and all-cause mortality in the first 6 months of follow-up.

METHODS

We enrolled a cohort of HIV-infected, ART-naive adults with CD4 counts ≤250 cells per microliter in rural Uganda who were followed for 6 months after ART initiation. All subjects underwent screening for TB; those with CD4 ≤100 cells per microliter also had cryptococcal antigen (CrAg) screening. For those who screened positive, standard treatment for TB or preemptive treatment for cryptococcal infection was initiated, followed by ART 2 weeks later.

RESULTS

Of 540 participants enrolled, pre-ART screening detected 10.6% (57/540) with prevalent TB and 6.8% (12/177 with CD4 count ≤100 cells/μL) with positive serum CrAg. After ART initiation, 13 (2.4%) patients were diagnosed with TB and 1 patient developed cryptococcal meningitis. Overall 7.2% of participants died (incidence rate 15.6 per 100 person-years at risk). Death rates were significantly higher among subjects with TB and cryptococcal antigenemia compared with subjects without these diagnoses. In multivariate analysis, significant risk factors for mortality were male sex, baseline anemia of hemoglobin ≤10 mg/dL, wasting defined as body mass index ≤15.5 kg/m, and opportunistic infections (TB, positive serum CrAg).

CONCLUSIONS

Pre-ART screening for opportunistic infections detects many prevalent cases of TB and cryptococcal infection. However, severely immunosuppressed and symptomatic HIV patients continue to experience high mortality after ART initiation.

Characteristics and outcomes of adult Ethiopian patients enrolled in HIV care and treatment: a multi-clinic observational study

Background

We describe trends in characteristics and outcomes among adults initiating HIV care and treatment in Ethiopia from 2006-2011.

Methods

We conducted a retrospective longitudinal analysis of HIV-positive adults (≥15 years) enrolling at 56 Ethiopian health facilities from 2006–2011. We investigated trends over time in the proportion enrolling through provider-initiated counseling and testing (PITC), baseline CD4+ cell counts and WHO stage. Additionally, we assessed outcomes (recorded death, loss to follow-up (LTF), transfer, and total attrition (recorded death plus LTF)) before and after ART initiation. Kaplan-Meier techniques estimated cumulative incidence of these outcomes through 36 months after ART initiation. Factors associated with LTF and death after ART initiation were estimated using Hazard Ratios accounting for within-clinic correlation.

Results

93,418 adults enrolled into HIV care; 53,300 (57%) initiated ART. The proportion enrolled through PITC increased from 27.6% (2006–2007) to 44.8% (2010–2011) (p < .0001). Concurrently, median enrollment CD4+ cell count increased from 158 to 208 cells/mm³ (p < .0001), and patients initiating ART with advanced WHO stage decreased from 56.6% (stage III) and 15.0% (IV) in 2006–2007 to 47.6% (stage III) and 8.5% (IV) in 2010–2011. Median CD4+ cell count at ART initiation remained stable over time. 24% of patients were LTF before ART initiation. Among those initiating ART, attrition was 30% after 36 months, with most occurring within the first 6 months. Recorded death after ART initiation was 6.4% and 9.2% at 6 and 36 months, respectively, and decreased over time. Younger age, male gender, never being married, no formal education, low CD4+ cell count, and advanced WHO stage were associated with increased LTF. Recorded death was lower among younger adults, females, married individuals, those with higher CD4+ cell counts and lower WHO stage at ART initiation.

Conclusions

Over time, enrollment in HIV care through outpatient PITC increased and patients enrolled into HIV care at earlier disease stages across all HIV testing points. However, median CD4+ cell count at ART initiation remained steady. Pre- and post-ART attrition (particularly in the first 6 months) have remained major challenges in ensuring prompt ART initiation and retention on ART.

Barriers to antiretroviral treatment initiation in rural KwaZulu-Natal, South Africa

OBJECTIVES

Although antiretroviral therapy (ART) has been freely available since 2004 in South Africa, not all those who are eligible initiate ART. We aimed to investigate individual and household characteristics as barriers to ART initiation in men and women in rural KwaZulu-Natal.

METHODS

Adults ≥ 16 years old living within a sociodemographic surveillance area (DSA) who accessed the local HIV programme between 2007 and 2011 were included in the study. Individual and household factors associated with ART initiation within 3 months of becoming eligible for ART were investigated using multivariable logistic regression stratified by sex and after exclusion of individuals who died before initiating ART.

RESULTS

Of the 797 men and 1598 women initially included, 8% and 5.5%, respectively, died before ART initiation and were excluded from further analysis. Of the remaining 733 men and 1510 women, 68.2% and 60.2%, respectively, initiated ART ≤ 3 months after becoming eligible (P = 0.34 after adjustment for CD4 cell count). In men, factors associated with a higher ART initiation rate were being a member of a household located < 2 km from the nearest HIV clinic and being resident in the DSA at the time of ART eligibility. In women, ART initiation was more likely in those who were not pregnant, in members of a household where at least one person was on ART and in those with a high wealth index.

CONCLUSIONS

In this rural South African setting, barriers to ART initiation differed for men and women. Supportive individual- and household-level interventions should be developed to guarantee rapid ART initiation taking account gender specificities.

Cotrimoxazole prophylaxis and antiretroviral therapy: an observational cohort study in China

Objective

To assess if cotrimoxazole prophylaxis administered early during antiretroviral therapy (ART) reduces mortality in Chinese adults who are infected with human immunodeficiency virus (HIV).

Methods

We did a retrospective observational cohort study using data from the Chinese national free antiretroviral database. Patients older than 14 years who started ART between 1 January 2010 and 31 December 2012 and had baseline CD4+ T-lymphocyte (CD4+ cell) count less than 200 cells/µL were followed until death, loss to follow-up or 31 December 2013. Hazard ratios (HRs) for several variables were calculated using multivariate analyses.

Findings

The analysis involved 23 816 HIV-infected patients, 2706 of whom died during the follow-up. Mortality in patients who did and did not start cotrimoxazole during the first 6 months of ART was 5.3 and 7.0 per 100 person–years, respectively. Cotrimoxazole was associated with a 37% reduction in mortality (hazard ratio, HR: 0.63; 95% confidence interval, CI: 0.56–0.70). Cotrimoxazole in addition to ART reduced mortality significantly over follow-up lasting 6 months (HR: 0.65; 95% CI: 0.59–0.73), 12 months (HR: 0.58; 95% CI: 0.49–0.70), 18 months (HR: 0.49; 95% CI: 0.38–0.63) and 24 months (HR: 0.66; 95% CI: 0.48–0.90). The mortality reduction was evident in patients with baseline CD4+ cell counts less than 50 cells/µL (HR: 0.60; 95% CI: 0.54–0.67), 50–99 cells/µL (HR: 0.66; 95% CI: 0.56–0.78) and 100–199 cells/µL (HR: 0.78; 95% CI: 0.62–0.98).

Conclusion

Cotrimoxazole prophylaxis started early during ART reduced mortality and should be offered to HIV-infected patients in low- and middle-income countries.

Trends in and correlates of CD4+ cell count at antiretroviral therapy initiation after changes in national ART guidelines in Rwanda

BACKGROUND

Initiation of antiretroviral therapy (ART) in the advanced stages of HIV infection remains a major challenge in sub-Saharan Africa. This study was conducted to better understand barriers and enablers to timely ART initiation in Rwanda where ART coverage is high and national ART eligibility guidelines first expanded in 2007-2008.

METHODS

Using data on 6326 patients (≥15 years) at five Rwandan clinics, we assessed trends and correlates of CD4 cell count at ART initiation and the proportion initiating ART with advanced HIV disease (CD4 <200 cells/μl or WHO stage IV).

RESULTS

Out of 6326 patients, 4486 enrolling in HIV care initiated ART with median CD4 cell count of 211 cells/μl [interquartile range: 131-300]. Median CD4 cell counts at ART initiation increased from 183 cells/μl in 2007 to 293 cells/μl in 2011-2012, and the proportion with advanced HIV disease decreased from 66.2 to 29.4%. Factors associated with a higher odds of advanced HIV disease at ART initiation were male sex [adjusted odds ratios (AOR) = 1.7; 95% confidence interval (CI): 1.3-2.1] and older age (AOR46-55+vs.<25 = 2.3; 95% CI: 1.2-4.3). Among those initiating ART more than 1 year after enrollment in care, those who had a gap in care of 12 or more months prior to ART initiation had higher odds of advanced HIV disease (AOR = 5.2; 95% CI: 1.2-21.1).

CONCLUSION

Marked improvements in the median CD4 cell count at ART initiation and proportion initiating ART with advanced HIV disease were observed following the expansion of ART eligibility criteria in Rwanda. However, sex disparities in late treatment initiation persisted through 2011-2012, and appeared to be driven by later diagnosis and/or delayed linkage to care among men.

Characteristics and comprehensiveness of adult HIV care and treatment programmes in Asia-Pacific, sub-Saharan Africa and the Americas: results of a site assessment conducted by the International epidemiologic Databases to Evaluate AIDS (IeDEA) Collaboration

INTRODUCTION

HIV care and treatment programmes worldwide are transforming as they push to deliver universal access to essential prevention, care and treatment services to persons living with HIV and their communities. The characteristics and capacity of these HIV programmes affect patient outcomes and quality of care. Despite the importance of ensuring optimal outcomes, few studies have addressed the capacity of HIV programmes to deliver comprehensive care. We sought to describe such capacity in HIV programmes in seven regions worldwide.

METHODS

Staff from 128 sites in 41 countries participating in the International epidemiologic Databases to Evaluate AIDS completed a site survey from 2009 to 2010, including sites in the Asia-Pacific region (n=20), Latin America and the Caribbean (n=7), North America (n=7), Central Africa (n=12), East Africa (n=51), Southern Africa (n=16) and West Africa (n=15). We computed a measure of the comprehensiveness of care based on seven World Health Organization-recommended essential HIV services.

RESULTS

Most sites reported serving urban (61%; region range (rr): 33-100%) and both adult and paediatric populations (77%; rr: 29-96%). Only 45% of HIV clinics that reported treating children had paediatricians on staff. As for the seven essential services, survey respondents reported that CD4+ cell count testing was available to all but one site, while tuberculosis (TB) screening and community outreach services were available in 80 and 72%, respectively. The remaining four essential services - nutritional support (82%), combination antiretroviral therapy adherence support (88%), prevention of mother-to-child transmission (PMTCT) (94%) and other prevention and clinical management services (97%) - were uniformly available. Approximately half (46%) of sites reported offering all seven services. Newer sites and sites in settings with low rankings on the UN Human Development Index (HDI), especially those in the President's Emergency Plan for AIDS Relief focus countries, tended to offer a more comprehensive array of essential services. HIV care programme characteristics and comprehensiveness varied according to the number of years the site had been in operation and the HDI of the site setting, with more recently established clinics in low-HDI settings reporting a more comprehensive array of available services. Survey respondents frequently identified contact tracing of patients, patient outreach, nutritional counselling, onsite viral load testing, universal TB screening and the provision of isoniazid preventive therapy as unavailable services.

CONCLUSIONS

This study serves as a baseline for on-going monitoring of the evolution of care delivery over time and lays the groundwork for evaluating HIV treatment outcomes in relation to site capacity for comprehensive care.

Gender-related differences in outcomes and attrition on antiretroviral treatment among an HIV-infected patient cohort in Zimbabwe: 2007-2010

Objectives

To determine (1) gender-related differences in antiretroviral therapy (ART) outcomes, and (2) gender-specific characteristics associated with attrition.

Methods

This was a retrospective patient record review of 3919 HIV-infected patients aged ≥15 years who initiated ART between 2007 and 2009 in 40 randomly selected ART facilities countrywide.

Results

Compared to females, males had more documented active tuberculosis (12% vs. 9%; p < 0.02) and a lower median CD4 cell count (117 cells/μl vs. 143 cells/μl; p < 0.001) at ART initiation. Males had a higher risk of attrition (adjusted hazard ratio (AHR) 1.28, 95% confidence interval (CI) 1.10–1.49) and mortality (AHR 1.56, 95% CI 1.10–2.20). Factors associated with attrition for both sexes were lower baseline weight (<45 kg and 45–60 kg vs. >60 kg), initiating ART at an urban health facility, and care at central/provincial or district/mission hospitals vs. primary healthcare facilities.

Conclusions

Our findings show that males presented late for ART initiation compared to females. Similar to other studies, males had higher patient attrition and mortality compared to females and this may be attributed in part to late presentation for HIV treatment and care. These observations highlight the need to encourage early HIV testing and enrolment into HIV treatment and care, and eventually patient retention on ART, particularly amongst men.

Management of fever in ambulatory HIV-infected adults in resource-limited settings: prospective observational evaluation of a new Mozambican guideline

A new Mozambican guideline for management of fever in HIV-infected adults requires malaria testing and systematic consideration of specific alternative diagnoses (eg, tuberculosis and bacterial infections) in addition to malaria. We conducted a prospective observational study of the guideline's performance. Of 258 HIV-infected subjects with axillary temperature ≥37.5° C or history of fever, 76.0% improved, 13.6% died or were hospitalized, and 10.5% were lost to follow-up. In multivariate analyses, factors associated with adverse outcomes were bacterial blood stream infection, syndromically diagnosed tuberculosis, lower CD4 T-lymphocyte count, no antiretroviral therapy, lower body mass index, lower hemoglobin, and nonprescription of antibiotics.

Advanced disease at enrollment in HIV care in four sub-Saharan African countries: change from 2006 to 2011 and multilevel predictors in 2011

OBJECTIVES

To examine changes between 2006 and 2011 in the proportion of HIV-positive patients newly enrolled in HIV care with advanced disease and the median CD4 cell count at enrollment; and identify patient, facility, and contextual-level factors associated with late enrollment in care in 2011.

DESIGN

Cross-sectional over time.

METHODS

For time-trends analyses, routinely collected patient-level data (307 110 adults newly enrolled in 138 HIV clinical care facilities) in Kenya, Mozambique, Rwanda and Tanzania; and for analyses of correlates, patient-level data (46 201 in 195 facilities), and facility and population-level survey data were used. Late enrollment was defined as CD4 cell count 350 cells/μl or less and/or WHO clinical stage 3/4.

RESULTS

Late enrollment declined from 69.9 to 57.2% (P < 0.0001); median CD4 cell count increased from 242 to 292 cells/μl (Ptrend < 0.0001). In 2011, risk of late enrollment was significantly higher for men and nonpregnant women vs. pregnant women; patients aged above 25 vs. 15-25 years; nonmarried vs. married; and those entering from sites other than prevention of mother-to-child transmission. More extensive HIV testing coverage in the region of a facility was significantly associated with lower risk of late enrollment.

CONCLUSIONS

Despite improvement, in 2011, 57% of patients entered HIV care who were already antiretroviral therapy-eligible. The lower risk of late enrollment among those referred from prevention of mother-to-child transmission and in regions where HIV testing coverage was higher suggests that innovative approaches to rapidly increase testing uptake among people living with HIV prior to the development of symptoms have the potential to reduce late enrollment in care.

Poor clinical outcomes for HIV infected children on antiretroviral therapy in rural Mozambique: need for program quality improvement and community engagement

INTRODUCTION

Residents of Zambézia Province, Mozambique live from rural subsistence farming and fishing. The 2009 provincial HIV prevalence for adults 15-49 years was 12.6%, higher among women (15.3%) than men (8.9%). We reviewed clinical data to assess outcomes for HIV-infected children on combination antiretroviral therapy (cART) in a highly resource-limited setting.

METHODS

We studied rates of 2-year mortality and loss to follow-up (LTFU) for children <15 years of age initiating cART between June 2006-July 2011 in 10 rural districts. National guidelines define LTFU as >60 days following last-scheduled medication pickup. Kaplan-Meier estimates to compute mortality assumed non-informative censoring. Cumulative LTFU incidence calculations treated death as a competing risk.

RESULTS

Of 753 children, 29.0% (95% CI: 24.5, 33.2) were confirmed dead by 2 years and 39.0% (95% CI: 34.8, 42.9) were LTFU with unknown clinical outcomes. The cohort mortality rate was 8.4% (95% CI: 6.3, 10.4) after 90 days on cART and 19.2% (95% CI: 16.0, 22.3) after 365 days. Higher hemoglobin at cART initiation was associated with being alive and on cART at 2 years (alive: 9.3 g/dL vs. dead or LTFU: 8.3-8.4 g/dL, p<0.01). Cotrimoxazole use within 90 days of ART initiation was associated with improved 2-year outcomes Treatment was initiated late (WHO stage III/IV) among 48% of the children with WHO stage recorded in their records. Marked heterogeneity in outcomes by district was noted (p<0.001).

CONCLUSIONS

We found poor clinical and programmatic outcomes among children taking cART in rural Mozambique. Expanded testing, early infant diagnosis, counseling/support services, case finding, and outreach are insufficiently implemented. Our quality improvement efforts seek to better link pregnancy and HIV services, expand coverage and timeliness of infant diagnosis and treatment, and increase follow-up and adherence.