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Smith S, Drummond K, Dowling A, Bennett I, Campbell D, Freilich R, Phillips C, Ahern E, Reeves S, Campbell R, Collins IM, Johns J, Dumas M, Hong W, Gibbs P, Gately L. Improving Clinical Registry Data Quality via Linkage With Survival Data From State-Based Population Registries. JCO Clin Cancer Inform 2024; 8:e2400025. [PMID: 38924710 DOI: 10.1200/cci.24.00025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/26/2024] [Accepted: 05/03/2024] [Indexed: 06/28/2024] Open
Abstract
PURPOSE Real-world data (RWD) collected on patients treated as part of routine clinical care form the basis of cancer clinical registries. Capturing accurate death data can be challenging, with inaccurate survival data potentially compromising the integrity of registry-based research. Here, we explore the utility of data linkage (DL) to state-based registries to enhance the capture of survival outcomes. METHODS We identified consecutive adult patients with brain tumors treated in the state of Victoria from the Brain Tumour Registry Australia: Innovation and Translation (BRAIN) database, who had no recorded date of death and no follow-up within the last 6 months. Full name and date of birth were used to match patients in the BRAIN registry with those in the Victorian Births, Deaths and Marriages (BDM) registry. Overall survival (OS) outcomes were compared pre- and post-DL. RESULTS Of the 7,346 clinical registry patients, 5,462 (74%) had no date of death and no follow-up recorded within the last 6 months. Of the 5,462 patients, 1,588 (29%) were matched with a date of death in BDM. Factors associated with an increased number of matches were poor prognosis tumors, older age, and social disadvantage. OS was significantly overestimated pre-DL compared with post-DL for the entire cohort (pre- v post-DL: hazard ratio, 1.43; P < .001; median, 29.9 months v 16.7 months) and for most individual tumor types. This finding was present independent of the tumor prognosis. CONCLUSION As revealed by linkage with BDM, a high proportion of patients in a brain cancer clinical registry had missing death data, contributed to by informative censoring, inflating OS calculations. DL to pertinent registries on an ongoing basis should be considered to ensure accurate reporting of survival data and interpretation of RWD outcomes.
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Affiliation(s)
- Samuel Smith
- Systems Biology and Personalised Medicine Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Medical Oncology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Kate Drummond
- University of Melbourne, Parkville, VIC, Australia
- Department of Neurosurgery, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Anthony Dowling
- Department of Medical Oncology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
- University of Melbourne, Parkville, VIC, Australia
| | - Iwan Bennett
- Department of Neurosurgery, Alfred Health, Prahran, VIC, Australia
| | - David Campbell
- Department of Medical Oncology, Barwon Health, Geelong, VIC, Australia
| | - Ronnie Freilich
- Department of Neurology, Cabrini Hospital, Malvern, VIC, Australia
| | - Claire Phillips
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Parkville, VIC, Australia
| | - Elizabeth Ahern
- Department of Medical Oncology, Monash Health, Clayton, VIC, Australia
| | - Simone Reeves
- Department of Radiation Oncology, Ballarat Austin Radiation Oncology Centre, Ballarat, VIC, Australia
| | - Robert Campbell
- Department of Medical Oncology, Bendigo Health, Bendigo, VIC, Australia
| | - Ian M Collins
- Department of Medical Oncology, South West Oncology, Warnambool, VIC, Australia
| | - Julie Johns
- Systems Biology and Personalised Medicine Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Megan Dumas
- Systems Biology and Personalised Medicine Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Wei Hong
- Systems Biology and Personalised Medicine Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Peter Gibbs
- Systems Biology and Personalised Medicine Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Lucy Gately
- Systems Biology and Personalised Medicine Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
- Department of Neurosurgery, Alfred Health, Prahran, VIC, Australia
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Kivuyo S, Birungi J, Okebe J, Wang D, Ramaiya K, Ainan S, Tumuhairwe F, Ouma S, Namakoola I, Garrib A, van Widenfelt E, Mutungi G, Jaoude GA, Batura N, Musinguzi J, Ssali MN, Etukoit BM, Mugisha K, Shimwela M, Ubuguyu OS, Makubi A, Jeffery C, Watiti S, Skordis J, Cuevas L, Sewankambo NK, Gill G, Katahoire A, Smith PG, Bachmann M, Lazarus JV, Mfinanga S, Nyirenda MJ, Jaffar S. Integrated management of HIV, diabetes, and hypertension in sub-Saharan Africa (INTE-AFRICA): a pragmatic cluster-randomised, controlled trial. Lancet 2023; 402:1241-1250. [PMID: 37805215 DOI: 10.1016/s0140-6736(23)01573-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND In sub-Saharan Africa, health-care provision for chronic conditions is fragmented. The aim of this study was to determine whether integrated management of HIV, diabetes, and hypertension led to improved rates of retention in care for people with diabetes or hypertension without adversely affecting rates of HIV viral suppression among people with HIV when compared to standard vertical care in medium and large health facilities in Uganda and Tanzania. METHODS In INTE-AFRICA, a pragmatic cluster-randomised, controlled trial, we randomly allocated primary health-care facilities in Uganda and Tanzania to provide either integrated care or standard care for HIV, diabetes, and hypertension. Random allocation (1:1) was stratified by location, infrastructure level, and by country, with a permuted block randomisation method. In the integrated care group, participants with HIV, diabetes, or hypertension were managed by the same health-care workers, used the same pharmacy, had similarly designed medical records, shared the same registration and waiting areas, and had an integrated laboratory service. In the standard care group, these services were delivered vertically for each condition. Patients were eligible to join the trial if they were living with confirmed HIV, diabetes, or hypertension, were aged 18 years or older, were living within the catchment population area of the health facility, and were likely to remain in the catchment population for 6 months. The coprimary outcomes, retention in care (attending a clinic within the last 6 months of study follow-up) for participants with either diabetes or hypertension (tested for superiority) and plasma viral load suppression for those with HIV (>1000 copies per mL; tested for non-inferiority, 10% margin), were analysed using generalised estimating equations in the intention-to-treat population. This trial is registered with ISCRTN 43896688. FINDINGS Between June 30, 2020, and April 1, 2021 we randomly allocated 32 health facilities (17 in Uganda and 15 in Tanzania) with 7028 eligible participants to the integrated care or the standard care groups. Among participants with diabetes, hypertension, or both, 2298 (75·8%) of 3032 were female and 734 (24·2%) of 3032 were male. Of participants with HIV alone, 2365 (70·3%) of 3365 were female and 1000 (29·7%) of 3365 were male. Follow-up lasted for 12 months. Among participants with diabetes, hypertension, or both, the proportion alive and retained in care at study end was 1254 (89·0%) of 1409 in integrated care and 1457 (89·8%) of 1623 in standard care. The risk differences were -0·65% (95% CI -5·76 to 4·46; p=0·80) unadjusted and -0·60% (-5·46 to 4·26; p=0·81) adjusted. Among participants with HIV, the proportion who had a plasma viral load of less than 1000 copies per mL was 1412 (97·0%) of 1456 in integrated care and 1451 (97·3%) of 1491 in standard care. The differences were -0·37% (one-sided 95% CI -1·99 to 1·26; pnon-inferiority<0·0001 unadjusted) and -0·36% (-1·99 to 1·28; pnon-inferiority<0·0001 adjusted). INTERPRETATION In sub-Saharan Africa, integrated chronic care services could achieve a high standard of care for people with diabetes or hypertension without adversely affecting outcomes for people with HIV. FUNDING European Union Horizon 2020 and Global Alliance for Chronic Diseases.
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Affiliation(s)
- Sokoine Kivuyo
- National Institutes for Medical Research, Dar es Salaam, Tanzania; Barcelona Institute for Global Health Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Josephine Birungi
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda; Medical Research Council/Uganda Virus Research Institute & London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda; School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Joseph Okebe
- Institute for Global Health, University College London, London, UK
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kaushik Ramaiya
- Tanzania NCDs Alliance, Dar es Salaam, Tanzania; Shree Hindu Mandal Hospital, Dar es Salaam, Tanzania
| | - Samafilan Ainan
- National Institutes for Medical Research, Dar es Salaam, Tanzania
| | - Faith Tumuhairwe
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
| | - Simple Ouma
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
| | - Ivan Namakoola
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Anupam Garrib
- Institute for Global Health, University College London, London, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Gerald Mutungi
- Non-Communicable Diseases Control Programme, Ministry of Health, Kampala, Uganda
| | | | - Neha Batura
- Institute for Global Health, University College London, London, UK
| | | | | | | | - Kenneth Mugisha
- The AIDS Support Organisation, Mulago Hospital Complex, Kampala, Uganda
| | | | | | | | - Caroline Jeffery
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Stephen Watiti
- The National Forum of People Living with HIV Networks in Uganda, Kampala, Uganda
| | - Jolene Skordis
- Institute for Global Health, University College London, London, UK
| | - Luis Cuevas
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Geoff Gill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anne Katahoire
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Peter G Smith
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Max Bachmann
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health Hospital Clinic, University of Barcelona, Barcelona, Spain; CUNY Graduate School of Public Health and Health Policy, New York, NY, USA
| | - Sayoki Mfinanga
- National Institutes for Medical Research, Dar es Salaam, Tanzania; Institute for Global Health, University College London, London, UK
| | - Moffat J Nyirenda
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Shabbar Jaffar
- Institute for Global Health, University College London, London, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
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Beres LK, Mody A, Sikombe K, Nicholas LH, Schwartz S, Eshun-Wilson I, Somwe P, Simbeza S, Pry JM, Kaumba P, McGready J, Holmes CB, Bolton-Moore C, Sikazwe I, Denison JA, Geng EH. The effect of tracer contact on return to care among adult, "lost to follow-up" patients living with HIV in Zambia: an instrumental variable analysis. J Int AIDS Soc 2021; 24:e25853. [PMID: 34921515 PMCID: PMC8683971 DOI: 10.1002/jia2.25853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 11/17/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Tracing patients lost to follow-up (LTFU) from HIV care is widely practiced, yet we have little knowledge of its causal effect on care engagement. In a prospective, Zambian cohort, we examined the effect of tracing on return to care within 2 years of LTFU. METHODS We traced a stratified, random sample of LTFU patients who had received HIV care between August 2013 and July 2015. LTFU was defined as a gap of >90 days from last scheduled appointment in the routine electronic medical record. Extracting 2 years of follow-up visit data through 2017, we identified patients who returned. Using random selection for tracing as an instrumental variable (IV), we used conditional two-stage least squares regression to estimate the local average treatment effect of tracer contact on return. We examined the observational association between tracer contact and return among patient sub-groups self-confirmed as disengaged from care. RESULTS Of the 24,164 LTFU patients enumerated, 4380 were randomly selected for tracing and 1158 were contacted by a tracer within a median of 14.8 months post-loss. IV analysis found that patients contacted by a tracer because they were randomized to tracing were no more likely to return than those not contacted (adjusted risk difference [aRD]: 3%, 95% CI: -2%, 8%, p = 0.23). Observational data showed that among contacted, disengaged patients, the rate of return was higher in the week following tracer contact (IR 5.74, 95% CI: 3.78-8.71) than in the 2 weeks to 1-month post-contact (IR 2.28, 95% CI: 1.40-3.72). There was a greater effect of tracing among patients lost for >6 months compared to those contacted within 3 months of loss. CONCLUSIONS Overall, tracer contact did not causally increase LTFU patient return to HIV care, demonstrating the limited impact of tracing in this program, where contact occurred months after patients were LTFU. However, observational data suggest that tracing may speed return among some LTFU patients genuinely out-of-care. Further studies may improve tracing effectiveness by examining the mechanisms underlying the impact of tracing on return to care, the effect of tracing at different times-since-loss and using more accurate identification of patients who are truly disengaged to target tracing.
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Affiliation(s)
- Laura K Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Aaloke Mody
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Lauren Hersch Nicholas
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ingrid Eshun-Wilson
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Jake M Pry
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.,Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Paul Kaumba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - John McGready
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Charles B Holmes
- Center for Innovation in Global Health, Georgetown University, Washington, DC, USA.,Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Julie A Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elvin H Geng
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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4
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Outcomes After Being Lost to Follow-up Differ for Pregnant and Postpartum Women When Compared With the General HIV Treatment Population in Rural South Africa. J Acquir Immune Defic Syndr 2021; 85:127-137. [PMID: 32520907 PMCID: PMC7495979 DOI: 10.1097/qai.0000000000002413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is Available in the Text. Undetermined attrition prohibits full understanding of the coverage and effectiveness of HIV programs. Outcomes following loss to follow-up (LTFU) among antiretroviral therapy (ART) patients may differ according to their reasons for ART initiation.
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5
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Etoori D, Wringe A, Renju J, Kabudula CW, Gomez-Olive FX, Reniers G. Challenges with tracing patients on antiretroviral therapy who are late for clinic appointments in rural South Africa and recommendations for future practice. Glob Health Action 2021; 13:1755115. [PMID: 32340584 PMCID: PMC7241554 DOI: 10.1080/16549716.2020.1755115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: It is common practice for HIV programmes to routinely trace patients who are late for a scheduled clinic visit to ensure continued care engagement. In South Africa, patients who are late for a scheduled visit are identified from clinic registers, and called by telephone up to three times by designated clinic staff, with home visits conducted for those who are unreachable by phone. It is important to understand outcomes among late patients in order to have accurate mortality data, identify defaulters to attempt to re-engage them into care, and have accurate estimates of patients still in care for planning purposes. Objective: We conducted a study to assess whether tracing of HIV patients in clinics in rural north-eastern South Africa was implemented in line with national policies. Methods: Thirty-three person-day of observations took place during multiple visits to eight facilities between October 2017 and January 2018 during which clinic tracing processes were captured. The facility level implementation processes were compared to the intended tracing process and gaps and challenges were identified. Results: Challenges to implementing effective tracing procedures fell into three broad categories: i) facility-level barriers, ii) issues relating to data, documentation and record-keeping, and iii) challenges relating to the roles and responsibilities of the different actors in the tracing cascade. We recommend improving linkages between clinics, improving record-keeping systems, and regular training of community health workers involved in tracing activities. Improved links between clinics would reduce the chance of patients being lost between clinics. Record-keeping systems could be improved through motivating health workers to take ownership of their data and training them on the importance of complete data. Finally, training of community health workers may improve sustained motivation, and improve their ability to respond appropriately to their clients’ needs. Conclusions: Substantial investment in data infrastructure and healthcare staff training is needed to improve routine tracing.
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Affiliation(s)
- David Etoori
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Chodziwadziwa Whiteson Kabudula
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Francesc Xavier Gomez-Olive
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Georges Reniers
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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6
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Vanobberghen F, Weisser M, Kasuga B, Katende A, Battegay M, Tanner M, Glass on behalf of the KIULARCO Study Group TR. Mortality Rate in a Cohort of People Living With HIV in Rural Tanzania After Accounting for Unseen Deaths Among Those Lost to Follow-up. Am J Epidemiol 2021; 190:251-264. [PMID: 33524120 PMCID: PMC7850129 DOI: 10.1093/aje/kwaa176] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 08/06/2020] [Accepted: 08/13/2020] [Indexed: 11/12/2022] Open
Abstract
Mortality assessment in cohorts with high numbers of persons lost to follow-up (LTFU) is challenging in settings with limited civil registration systems. We aimed to assess mortality in a clinical cohort (the Kilombero and Ulanga Antiretroviral Cohort (KIULARCO)) of human immunodeficiency virus (HIV)-infected persons in rural Tanzania, accounting for unseen deaths among participants LTFU. We included adults enrolled in 2005-2015 and traced a nonrandom sample of those LTFU. We estimated mortality using Kaplan-Meier methods 1) with routinely captured data (method A), 2) crudely incorporating tracing data (method B), 3) weighting using tracing data to crudely correct for unobserved deaths among participants LTFU (method C), and 4) weighting using tracing data accounting for participant characteristics (method D). We investigated associated factors using proportional hazards models. Among 7,460 adults, 646 (9%) died, 883 (12%) transferred to other clinics, and 2,911 (39%) were LTFU. Of 2,010 (69%) traced participants, 325 (16%) were found: 131 (40%) had died and 130 (40%) had transferred. Five-year mortality estimates derived using the 4 methods were 13.1% (A), 16.2% (B), 36.8% (C), and 35.1% (D), respectively. Higher mortality was associated with male sex, referral as a hospital inpatient, living close to the index clinic, lower body mass index, more advanced World Health Organization HIV clinical stage, lower CD4 cell count, and less time since initiation of antiretroviral therapy. Adjusting for unseen deaths among participants LTFU approximately doubled the 5-year mortality estimates. Our approach is applicable to other cohort studies adopting targeted tracing.
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Affiliation(s)
- Fiona Vanobberghen
- Correspondence to Dr. Fiona Vanobberghen, Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Switzerland (e-mail: )
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7
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Paganoni S, Hendrix S, Dickson SP, Knowlton N, Macklin EA, Berry JD, Elliott MA, Maiser S, Karam C, Caress JB, Owegi MA, Quick A, Wymer J, Goutman SA, Heitzman D, Heiman-Patterson TD, Jackson CE, Quinn C, Rothstein JD, Kasarskis EJ, Katz J, Jenkins L, Ladha S, Miller TM, Scelsa SN, Vu TH, Fournier CN, Glass JD, Johnson KM, Swenson A, Goyal NA, Pattee GL, Andres PL, Babu S, Chase M, Dagostino D, Hall M, Kittle G, Eydinov M, McGovern M, Ostrow J, Pothier L, Randall R, Shefner JM, Sherman AV, St Pierre ME, Tustison E, Vigneswaran P, Walker J, Yu H, Chan J, Wittes J, Yu ZF, Cohen J, Klee J, Leslie K, Tanzi RE, Gilbert W, Yeramian PD, Schoenfeld D, Cudkowicz ME. Long-term survival of participants in the CENTAUR trial of sodium phenylbutyrate-taurursodiol in amyotrophic lateral sclerosis. Muscle Nerve 2020; 63:31-39. [PMID: 33063909 PMCID: PMC7820979 DOI: 10.1002/mus.27091] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/07/2020] [Accepted: 10/09/2020] [Indexed: 12/18/2022]
Abstract
An orally administered, fixed‐dose coformulation of sodium phenylbutyrate‐taurursodiol (PB‐TURSO) significantly slowed functional decline in a randomized, placebo‐controlled, phase 2 trial in ALS (CENTAUR). Herein we report results of a long‐term survival analysis of participants in CENTAUR. In CENTAUR, adults with ALS were randomized 2:1 to PB‐TURSO or placebo. Participants completing the 6‐month (24‐week) randomized phase were eligible to receive PB‐TURSO in the open‐label extension. An all‐cause mortality analysis (35‐month maximum follow‐up post‐randomization) incorporated all randomized participants. Participants and site investigators were blinded to treatment assignments through the duration of follow‐up of this analysis. Vital status was obtained for 135 of 137 participants originally randomized in CENTAUR. Median overall survival was 25.0 months among participants originally randomized to PB‐TURSO and 18.5 months among those originally randomized to placebo (hazard ratio, 0.56; 95% confidence interval, 0.34‐0.92; P = .023). Initiation of PB‐TURSO treatment at baseline resulted in a 6.5‐month longer median survival as compared with placebo. Combined with results from CENTAUR, these results suggest that PB‐TURSO has both functional and survival benefits in ALS.
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Affiliation(s)
- Sabrina Paganoni
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Eric A Macklin
- Department of Medicine, Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - James D Berry
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Samuel Maiser
- Departments of Neurology and Medicine, Hennepin Healthcare, Minneapolis, Minnesota
| | - Chafic Karam
- Department of Neurology, Oregon Health & Science University, Portland, Oregon
| | - James B Caress
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Margaret Ayo Owegi
- Department of Neurology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | - Adam Quick
- Department of Neurology, The Ohio State University College of Medicine, Columbus, Ohio
| | - James Wymer
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida
| | - Stephen A Goutman
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | | | - Terry D Heiman-Patterson
- Department of Neurology, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Carlayne E Jackson
- Department of Neurology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Colin Quinn
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jeffrey D Rothstein
- Brain Science Institute and Department of Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Edward J Kasarskis
- Department of Neurology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Jonathan Katz
- California Pacific Medical Center Research Institute and Forbes Norris MDA/ALS Research and Treatment Center, San Francisco, California
| | - Liberty Jenkins
- California Pacific Medical Center Research Institute and Forbes Norris MDA/ALS Research and Treatment Center, San Francisco, California
| | - Shafeeq Ladha
- Department of Neurology, Gregory W. Fulton ALS Center, Barrow Neurological Institute, Phoenix, Arizona
| | - Timothy M Miller
- Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Stephen N Scelsa
- Department of Neurology, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tuan H Vu
- Department of Neurology, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Christina N Fournier
- Departments of Neurology and Pathology, Emory University School of Medicine, Atlanta, Georgia
| | - Jonathan D Glass
- Departments of Neurology and Pathology, Emory University School of Medicine, Atlanta, Georgia
| | - Kristin M Johnson
- Department of Neurology, Ochsner Health System, New Orleans, Louisiana
| | - Andrea Swenson
- Department of Neurology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Namita A Goyal
- Department of Neurology, University of California, Irvine School of Medicine, Irvine, California
| | | | | | - Suma Babu
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marianne Chase
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Derek Dagostino
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Meghan Hall
- Department of Neurology, Gregory W. Fulton ALS Center, Barrow Neurological Institute, Phoenix, Arizona
| | - Gale Kittle
- Department of Neurology, Gregory W. Fulton ALS Center, Barrow Neurological Institute, Phoenix, Arizona
| | - Matthew Eydinov
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michelle McGovern
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph Ostrow
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lindsay Pothier
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rebecca Randall
- Department of Neurology, Gregory W. Fulton ALS Center, Barrow Neurological Institute, Phoenix, Arizona
| | - Jeremy M Shefner
- Department of Neurology, Gregory W. Fulton ALS Center, Barrow Neurological Institute, Phoenix, Arizona
| | - Alexander V Sherman
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maria E St Pierre
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric Tustison
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Prasha Vigneswaran
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jason Walker
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hong Yu
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - James Chan
- Department of Medicine, Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Janet Wittes
- Statistics Collaborative, Inc., Washington, District of Columbia
| | - Zi-Fan Yu
- Statistics Collaborative, Inc., Washington, District of Columbia
| | - Joshua Cohen
- Amylyx Pharmaceuticals, Inc., Cambridge, Massachusetts
| | - Justin Klee
- Amylyx Pharmaceuticals, Inc., Cambridge, Massachusetts
| | - Kent Leslie
- Amylyx Pharmaceuticals, Inc., Cambridge, Massachusetts
| | - Rudolph E Tanzi
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - David Schoenfeld
- Department of Medicine, Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Merit E Cudkowicz
- Sean M. Healey & AMG Center for ALS & the Neurological Clinical Research Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Brief Report: Improving Early Infant Diagnosis Observations: Estimates of Timely HIV Testing and Mortality Among HIV-Exposed Infants. J Acquir Immune Defic Syndr 2020; 83:235-239. [PMID: 31913988 PMCID: PMC7012331 DOI: 10.1097/qai.0000000000002263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background: Improving efforts toward elimination of mother-to-child transmission of HIV requires timely early infant diagnosis (EID) among all HIV-exposed infants, but the occurrence of timely EID and infant survival may be underascertained in routine, facility-bound program data. Methods: From March 2015 to May 2015, we traced a random sample of HIV-positive mother and HIV-exposed infant pairs lost to follow-up for EID in facility registers in Zimbabwe. We incorporated updated information into weighted survival analyses to estimate incidence of EID and death. Reasons for no EID were surveyed from caregivers. Results: Among 2651 HIV-positive women attending antenatal care, 1823 (68.8%) infants had no documented EID by 3 months of age. Among a random sample of 643 (35.3%) HIV-exposed infants lost to follow-up for EID, vital status was ascertained among 371 (57.7%) and updated care status obtained from 256 (39.8%) mothers traced. Among all HIV-infected mother–HIV-exposed infant pairs, weighted estimates found cumulative incidence of infant death by 90 days of 3.9% (95% confidence interval: 3.4% to 4.4%). Cumulative incidence of timely EID with death as a competing risk was 60%. The most frequently cited reasons for failure to uptake EID were “my child died” and “I didn't know I should have my child tested.” Conclusions: Our findings indicate uptake of timely EID among HIV-exposed infants is underestimated in routine health information systems. High, early mortality among HIV-exposed infants underscores the need to more effectively identify HIV-positive mother–HIV exposed infant pairs at high risk of adverse outcomes and loss to follow-up for enhanced interventions.
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Etoori D, Wringe A, Kabudula CW, Renju J, Rice B, Gomez-Olive FX, Reniers G. Misreporting of Patient Outcomes in the South African National HIV Treatment Database: Consequences for Programme Planning, Monitoring, and Evaluation. Front Public Health 2020; 8:100. [PMID: 32318534 PMCID: PMC7154050 DOI: 10.3389/fpubh.2020.00100] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 03/12/2020] [Indexed: 01/20/2023] Open
Abstract
Background: Monitoring progress toward global treatment targets using HIV programme data in sub-Saharan Africa has proved challenging. Constraints in routine data collection and reporting can lead to biased estimates of treatment outcomes. In 2010, South Africa introduced an electronic patient monitoring system for HIV patient visits, TIER.Net. We compare treatment status and outcomes recorded in TIER.Net to outcomes ascertained through detailed record review and tracing in order to assess discrepancies and biases in retention and mortality rates. Methods: The Agincourt Health and Demographic Surveillance System (HDSS) in north-eastern South Africa is served by eight public primary healthcare facilities. Since 2014, HIV patient visits are logged electronically at these clinics, with patient records individually linked to their HDSS record. These data were used to generate a list of patients >90 days late for their last scheduled clinic visit and deemed lost to follow-up (LTFU). Patient outcomes were ascertained through a review of the TIER.Net database, physical patient files, registers kept by two non-government organizations that assist with patient tracing, cross-referencing with the HDSS records and supplementary physical tracing. Descriptive statistics were used to compare patient outcomes reported in TIER.Net to their outcome ascertained in the study. Results: Of 1,074 patients that were eligible for this analysis, TIER.Net classified 533 (49.6%) as LTFU, 80 (7.4%) as deceased, and 186 (17.3%) as transferred out. TIER.Net misclassified 36% of patient outcomes, overestimating LTFU and underestimating mortality and transfers out. TIER.Net missed 40% of deaths and 43% of transfers out. Patients categorized as LTFU in TIER.Net were more likely to be misclassified than patients classified as deceased or transferred out. Discussion: Misclassification of patient outcomes in TIER.Net has consequences for programme forecasting, monitoring and evaluation. Undocumented transfers accounted for the majority of misclassification, suggesting that the transfer process between clinics should be improved for more accurate reporting of patient outcomes. Processes that lead to correct classification of patient status including patient tracing should be strengthened. Clinics could cross-check all available data sources before classifying patients as LTFU. Programme evaluators and modelers could consider using correction factors to improve estimates of outcomes from TIER.Net.
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Affiliation(s)
- David Etoori
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chodziwadziwa Whiteson Kabudula
- MRC/WITS Rural Public Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Brian Rice
- MeSH Consortium, Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - F. Xavier Gomez-Olive
- MRC/WITS Rural Public Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Georges Reniers
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC/WITS Rural Public Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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Kamacooko O, Mayanja Y, Bagiire D, Namale G, Hansen CH, Seeley J. Predictors of lost to follow-up in a "test and treat" programme among adult women with high-risk sexual behavior in Kampala, Uganda. BMC Public Health 2020; 20:353. [PMID: 32183759 PMCID: PMC7079529 DOI: 10.1186/s12889-020-8439-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 03/02/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Immediate uptake of antiretroviral therapy (ART) after an HIV-positive diagnosis (Test and Treat) is now being implemented in Uganda. Data are limited on lost to follow-up (LTFU) in high-risk cohorts that have initiated 'Test and Treat'. We describe LTFU in a cohort of women of high-risk sexual behaviour who initiated ART under "Test and Treat". METHODS We performed a retrospective cohort study of participant records at the Good Health for Women Project (GHWP) clinic, a clinic in Kampala for women at high-risk of HIV-infection. We included HIV positive women ≥18 years who initiated ART at GHWP between August 2014 and March 2018. We defined LTFU as not taking an ART refill for ≥3 months from the last clinic appointment among those not registered as dead or transferred to another clinic. We used the Kaplan-Meier technique to estimate time to LTFU after ART initiation. Predictors of LTFU were assessed using a multivariable Cox proportional hazards model. RESULTS The mean (±SD) age of the 293 study participants was 30.3 (± 6.5) years, with 274 (94%) reporting paid sex while 38 (13%) had never tested for HIV before enrolment into GHWP. LTFU within the first year of ART initiation was 16% and the incidence of LTFU was estimated at 12.7 per 100 person-years (95%CI 9.90-16.3). In multivariable analysis, participants who reported sex work as their main job at ART initiation (Adjusted Hazards Ratio [aHR] =1.95, 95%CI 1.10-3.45), having baseline WHO clinical stage III or IV (aHR = 2.75, 95% CI 1.30-5.79) were more likely to be LTFU. CONCLUSION LTFU in this cohort is high. Follow up strategies are required to support women on Test and Treat to remain on treatment, especially those who engage in sex work and those who initiate ART at a later stage of disease.
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Affiliation(s)
- Onesmus Kamacooko
- MRC/UVRI & LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, P. O Box 49, Entebbe, Uganda.
| | - Yunia Mayanja
- MRC/UVRI & LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, P. O Box 49, Entebbe, Uganda
| | - Daniel Bagiire
- MRC/UVRI & LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, P. O Box 49, Entebbe, Uganda
| | - Gertrude Namale
- MRC/UVRI & LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, P. O Box 49, Entebbe, Uganda
| | - Christian Holm Hansen
- MRC/UVRI & LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, P. O Box 49, Entebbe, Uganda.,London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Janet Seeley
- MRC/UVRI & LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, P. O Box 49, Entebbe, Uganda.,London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Kaplan S, Nteso KS, Ford N, Boulle A, Meintjes G. Loss to follow-up from antiretroviral therapy clinics: A systematic review and meta-analysis of published studies in South Africa from 2011 to 2015. South Afr J HIV Med 2019; 20:984. [PMID: 31956435 PMCID: PMC6956684 DOI: 10.4102/sajhivmed.v20i1.984] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/20/2019] [Indexed: 11/05/2022] Open
Abstract
Background South Africa has the largest antiretroviral therapy (ART) programme in the world. To optimise programme outcomes, it is critical that patients are retained in care and that retention is accurately measured. Objectives To identify all studies published in South Africa from 2011 to 2015 that used loss to follow-up (LTFU) as an indicator or outcome to describe the variation in definitions and to estimate the proportion of patients lost to care across studies. Method All studies published between 01 January 2011 and October 2015 that included loss to follow-up or default from ART care in a South African cohort were included by use of a broad search strategy across multiple databases. To be included, the cohort had to include any patient ART data, including follow-up time, from 01 January 2010. Two authors, working independently, extracted data and assessed risk of bias from all manuscripts. Meta-analysis was performed for studies stratified by the same loss to follow-up definition. Results Forty-eight adult, 15 paediatric and 4 pregnant cohorts were included. Median cohort size was 3737; follow-up time ranged from 9 weeks to 5 years. Meta-analysis did not reveal an important difference in LTFU estimates in adult cohorts at 1 year between loss to follow-up defined as 3 months (11.0%, n = 4; 95% CI 10.7% – 11.2%) compared with 6 months (12.0%, n = 4; 95% CI 11.8% – 12.2%). Only two cohorts reported reliable LTFU estimates at 5 years: this was 25.1% (95% CI 24.8% – 25.4%). Conclusion South Africa should standardise a LTFU definition. This would aid in monitoring and evaluation of ART programmes, with the broader goal of improving patient outcomes.
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Affiliation(s)
- Samantha Kaplan
- Department of Internal Medicine, University of Washington, Seattle, United States
| | - Katleho S Nteso
- Medical Care Development International, Maseru, Lesotho, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Anne N, Dunbar MD, Abuna F, Simpson P, Macharia P, Betz B, Cherutich P, Bukusi D, Carey F. Feasibility and acceptability of an iris biometric system for unique patient identification in routine HIV services in Kenya. Int J Med Inform 2019; 133:104006. [PMID: 31706230 DOI: 10.1016/j.ijmedinf.2019.104006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 09/24/2019] [Accepted: 10/10/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Use of routine HIV programme data for surveillance is often limited due to inaccuracies associated with patient misclassification which can be addressed by unique patient identification.We assessed the feasibility and acceptability of integrating an iris recognition biometric identification system into routine HIV care services at 4 sites in Kenya. METHODS Patients who had recently tested HIV-positive or were engaged in care were enrolled. Images of the iris were captured using a dual-iris camera connected to a laptop. A prototype iris biometric identification system networked across the sites, analysed the iris patterns; created a template from those patterns; and generated a 12-digit ID number based on the template. During subsequent visits, the patients' irises were re-scanned, and the pattern was matched to stored templates to retrieve the ID number. RESULTS Over 55 weeks 8,614 (98%) of 8,794 new patients were assigned a unique ID on their first visit. Among 6,078 return visits, the system correctly re-identified patients' IDs 5,234 times (86%). The false match rate (a new patient given the ID of another patient) was 0·5% while the generalized false reject rate (re-scans assigned a new ID) was 4·7%. Overall, 9 (0·1%) agreed to enrol but declined to have an iris scan. The most common reasons cited for declining an iris scan were concerns about privacy and confidentiality. CONCLUSION Implementation of an iris recognition system in routine health information systems is feasible and highly acceptable as part of routine care in Kenya. Scale-up could improve unique patient identification and tracking, enhancing disease surveillance activities.
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Affiliation(s)
- Njoroge Anne
- University of Washington, Department of Global Health, Seattle, United States; Kenyatta National Hospital, Research & Programs, Nairobi, Kenya.
| | - Matthew D Dunbar
- University of Washington, Centre for Demography and Ecology, Seattle, United States.
| | - Felix Abuna
- Kenyatta National Hospital, Research & Programs, Nairobi, Kenya.
| | | | - Paul Macharia
- National AIDS & STI Control Program, MOH, Nairobi, Kenya.
| | - Bourke Betz
- University of Washington, Department of Global Health, Seattle, United States.
| | | | - David Bukusi
- Kenyatta National Hospital, VCT and HIV Prevention/ Youth Centre, Nairobi, Kenya.
| | - Farquhar Carey
- University of Washington, Department of Global Health, Seattle, United States; University of Washington, Department of Medicine, Seattle, United States; University of Washington, Department of Epidemiology, Seattle, United States.
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Balogun M, Meloni ST, Igwilo UU, Roberts A, Okafor I, Sekoni A, Ogunsola F, Kanki PJ, Akanmu S. Status of HIV-infected patients classified as lost to follow up from a large antiretroviral program in southwest Nigeria. PLoS One 2019; 14:e0219903. [PMID: 31344057 PMCID: PMC6657856 DOI: 10.1371/journal.pone.0219903] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 07/04/2019] [Indexed: 11/19/2022] Open
Abstract
Background Loss to follow-up (LTFU) is a term used to classify patients no longer being seen in a clinical care program, including HIV treatment programs. It is unclear if these patients have transferred their care services elsewhere, died, or if there are other reasons for their LTFU. To better understand the status of patients meeting the criteria of LTFU, we traced a sample of HIV-infected patients that were LTFU from the Lagos University Teaching Hospital (LUTH) antiretroviral program. Methods We conducted a cross-sectional study of HIV-infected adult patients who enrolled for care between 2010 and 2014 at LUTH and were considered LTFU. Patients with locator information were traced using phone calls. Face-to-face interviews were used to collect data from successfully traced and consenting participants. Predictors of LTFU from LUTH, disengagement from care and willingness to re-engage in care in LUTH were assessed. Results Of 6108 registered patients, 3397 (56%) were LTFU and being unmarried was a predictor of being LTFU from LUTH. Of 425 patients that were traced, 355 (84%) were alive and 70 (16%) were dead. Two hundred and sixty-eight patients consented to interviews; 96 (35.8%) of these had transferred to another clinic for care while 172 (64.2%) were disengaged from care. More than half (149/268; 55.6%) were not on antiretroviral therapy (ART). Some of the primary reasons for LTFU were; long distance to clinic (56%) and feeling healthy (6.7%). Predictor of disengagement from care within the interviewed cohort was not having started ART. The predictors of willingness to re-engage in care included, not having started ART, male sex and longer duration in HIV care prior to LTFU. Conclusion Most of the interviewed cohort that was LTFU were truly disengaged from care and not on ART. Interventions are required to address processes of re-engagement of patients that are LTFU.
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Affiliation(s)
- Mobolanle Balogun
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria
- * E-mail:
| | - Seema Thakore Meloni
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | | | - Alero Roberts
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Ifeoma Okafor
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Adekemi Sekoni
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Folasade Ogunsola
- Department of Medical Microbiology and Parasitology, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Phyllis J. Kanki
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | - Sulaimon Akanmu
- Department of Haematology and Blood Transfusion, College of Medicine of the University of Lagos, Lagos, Nigeria
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Kerschberger B, Schomaker M, Ciglenecki I, Pasipamire L, Mabhena E, Telnov A, Rusch B, Lukhele N, Teck R, Boulle A. Programmatic outcomes and impact of rapid public sector antiretroviral therapy expansion in adults prior to introduction of the WHO treat-all approach in rural Eswatini. Trop Med Int Health 2019; 24:701-714. [PMID: 30938037 PMCID: PMC6849841 DOI: 10.1111/tmi.13234] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES To assess long-term antiretroviral therapy (ART) outcomes during rapid HIV programme expansion in the public sector of Eswatini (formerly Swaziland). METHODS This is a retrospectively established cohort of HIV-positive adults (≥16 years) who started first-line ART in 25 health facilities in Shiselweni (Eswatini) between 01/2006 and 12/2014. Temporal trends in ART attrition, treatment expansion and ART coverage were described over 9 years. We used flexible parametric survival models to assess the relationship between time to ART attrition and covariates. RESULTS Of 24 772 ART initiations, 6% (n = 1488) occurred in 2006, vs. 13% (n = 3192) in 2014. Between these years, median CD4 cell count at ART initiation increased (113-265 cells/mm3 ). The active treatment cohort expanded 8.4-fold, ART coverage increased 8.0-fold (7.1% in 2006 vs. 56.8% in 2014) and 12-month crude ART retention improved from 71% to 86%. Compared with the pre-decentralisation period (2006-2007), attrition decreased by 5% (adjusted hazard ratio [aHR] 0.95, 95% confidence interval 0.88-1.02) during HIV-TB service decentralisation (2008-2010), by 17% (aHR 0.83, 0.75-0.92) during service consolidation (2011-2012), and by 20% (aHR 0.80, 0.71-0.90) during further treatment expansion (2013-2014). The risk of attrition was higher for young age, male sex, pathological baseline haemoglobin and biochemistry results, more toxic drug regimens, WHO III/IV staging and low CD4 cell count; access to a telephone was protective. CONCLUSIONS Programmatic outcomes improved during large expansion of the treatment cohort and increased ART coverage. Changes in ART programming may have contributed to better outcomes.
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Affiliation(s)
- Bernhard Kerschberger
- Médecins Sans Frontières (Operational Centre Geneva)MbabaneEswatini
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Iza Ciglenecki
- Médecins Sans Frontières (Operational Centre Geneva)GenevaSwitzerland
| | | | - Edwin Mabhena
- Médecins Sans Frontières (Operational Centre Geneva)MbabaneEswatini
| | - Alex Telnov
- Médecins Sans Frontières (Operational Centre Geneva)GenevaSwitzerland
| | - Barbara Rusch
- Médecins Sans Frontières (Operational Centre Geneva)GenevaSwitzerland
| | | | | | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
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Alizadeh F, Mfitumuhoza G, Stephens J, Habimaana C, Myles K, Baganizi M, Paccione G. Identifying and Reengaging Patients Lost to Follow-Up in Rural Africa: The "Horizontal" Hospital-Based Approach in Uganda. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:103-115. [PMID: 30926739 PMCID: PMC6538125 DOI: 10.9745/ghsp-d-18-00394] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 02/06/2019] [Indexed: 11/30/2022]
Abstract
Between 30% and 60% of hospital outpatient clinic patients were lost to follow-up. A defaulter-tracking service using performance-based remuneration for outreach workers, cutting across different clinical services, improved patient retention overall but varied by disease, with the poorest outcomes among patients with HIV. Among the many challenges facing health systems grappling with the explosive growth of chronic disease in Africa are continuity of care, particularly in poor, rural areas. We report the strategy, field experience, and results of an ongoing 6-year follow-up program operating in a rural district hospital in Kisoro, Uganda, that attempts to locate and reengage patients lost to follow-up (LTFU) from communities that are largely without phones, addresses, or paved roads. The program works with diverse hospital clinics, including chronic diseases, HIV, tuberculosis (TB), nutrition, and women's health, to identify patients who have not returned to care, employing a modest staff who spend about 20 days monthly making outreach visits by motorcycle in search of approximately 130 patients. We describe the organization of this unique “horizontal” program and report on follow-up outcomes between November 2015 to October 2016. Between 30% and 60% of patients were found to have lapses in care. The follow-up program was able to locate 64% of patients, with a reengagement rate of 54% to 92% (average, 69%) depending on the clinic. The program costs approximately US$5 per patient LTFU but about US$40 per patient maintained in care. The hospital-based follow-up program that cuts across diverse clinics and wards was novel and feasible in this rural sub-Saharan African setting.
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Affiliation(s)
- Faraz Alizadeh
- Boston Children's Hospital, Boston Medical Center, and Doctors for Global Health, Boston, MA, USA.
| | | | - Joseph Stephens
- Montefiore Medical Center, Albert Einstein College of Medicine, and Doctors for Global Health, Boston, MA, USA
| | | | - Kwiringira Myles
- Kisoro District Hospital and Doctors for Global Health, Kisoro, Uganda
| | - Michael Baganizi
- Kisoro District Hospital and Doctors for Global Health, Kisoro, Uganda
| | - Gerald Paccione
- Montefiore Medical Center, Albert Einstein College of Medicine, and Doctors for Global Health, Boston, MA, USA
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Kiwanuka G, Kiwanuka N, Muneza F, Nabirye J, Oporia F, Odikro MA, Castelnuovo B, Wanyenze RK. Retention of HIV infected pregnant and breastfeeding women on option B+ in Gomba District, Uganda: a retrospective cohort study. BMC Infect Dis 2018; 18:533. [PMID: 30355356 PMCID: PMC6201534 DOI: 10.1186/s12879-018-3450-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 10/16/2018] [Indexed: 12/12/2022] Open
Abstract
Background Lifelong antiretroviral therapy for HIV infected pregnant and lactating women (Option B+) has been rapidly scaled up but there are concerns about poor retention of women initiating treatment. However, facility-based data could underestimate retention in the absence of measures to account for self-transfers to other facilities. We assessed retention-in-care among women on Option B+ in Uganda, using facility data and follow-up to ascertain transfers to other facilities. Methods In a 25-month retrospective cohort analysis of routine program data, women who initiated Option B+ between March 2013 and March 2015 were tracked and interviewed quantitatively and qualitatively (in-depth interviews). Kaplan Meier survival analysis was used to estimate time to loss-to-follow-up (LTFU) while multivariable Cox proportional hazards regression was applied to estimate the adjusted predictors of LTFU, based on facility data. Thematic analysis was done for qualitative data, using MAXQDA 12. Quantitative data were analyzed with STATA® 13. Results A total of 518 records were reviewed. The mean (SD) age was 26.4 (5.5) years, 289 women (55.6%) attended primary school, and 53% (276/518) had not disclosed their HIV status to their partners. At 25 months post-ART initiation, 278 (53.7%) were LTFU based on routine facility data, with mean time to LTFU of 15.6 months. Retention was 60.2 per 1000 months of observation (pmo) (95% CI: 55.9–64.3) at 12, and 46.3/1000pmo (95% CI: 42.0–50.5) at 25 months. Overall, 237 (55%) women were successfully tracked and interviewed and 43/118 (36.4%) of those who were classified as LTFU at facility level had self-transferred to another facility. The true 25 months post-ART initiation retention after tracking was 71.3% (169/237). Women < 25 years, aHR = 1.71 (95% CI: 1.28–2.30); those with no education, aHR = 5.55 (95% CI: 3.11–9.92), and those who had not disclosed their status to their partners, aHR = 1.59 (95% CI: 1.16–2.19) were more likely to be LTFU. Facilitators for Option B+ retention based on qualitative findings were adequate counselling, disclosure, and the desire to stay alive and raise HIV-free children. Drug side effects, inadequate counselling, stigma, and unsupportive spouses, were barriers to retention in care. Conclusions Retention under Option B+ is suboptimal and is under-estimated at health facility level. There is need to institute mechanisms for tracking of women across facilities. Retention could be enhanced through strategies to enhance disclosure to partners, targeting the uneducated, and those < 25 years.
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Affiliation(s)
- George Kiwanuka
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O Box 7072, Kampala, Uganda.
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Fiston Muneza
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Juliet Nabirye
- Department of Health Policy Planning and Management, Makerere University School of Public Health, P.O Box 7072, Kampala, Uganda
| | - Frederick Oporia
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - Magdalene A Odikro
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Barbara Castelnuovo
- Department of Research, Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
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17
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Estill J, Kerr CC, Blaser N, Salazar-Vizcaya L, Tenthani L, Wilson DP, Keiser O. The Effect of Monitoring Viral Load and Tracing Patients Lost to Follow-up on the Course of the HIV Epidemic in Malawi: A Mathematical Model. Open Forum Infect Dis 2018; 5:ofy092. [PMID: 29977952 PMCID: PMC6007424 DOI: 10.1093/ofid/ofy092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 04/24/2018] [Indexed: 12/01/2022] Open
Abstract
Background Antiretroviral therapy (ART) reduces HIV transmission, but treated patients may again become infectious. We used a mathematical model to determine whether ART as prevention is more effective if viral load (VL) is routinely monitored and patients lost to follow-up (LTFU) traced. Methods We simulated ART cohorts to parameterize a deterministic transmission model calibrated to Malawi. We investigated the following strategies for improving treatment and retention: monitoring VL every 12 or 24 months, tracing patients LTFU, or a generic strategy leading to uninterrupted treatment. We tested 3 scenarios, where ART scale-up continues at current (Universal ART), reduced (Failed scale-up), or accelerated speed (Test&Treat). Results In the Universal ART scenario, between 2017 and 2020 (2050), monitoring VL every 24 months prevented 0.5% (0.9%), monitoring every 12 months prevented 0.8% (1.4%), tracing prevented 0.3% (0.5%), and uninterrupted treatment prevented 5.5% (9.9%) of HIV infections. Failed scale-up resulted in 25% more infections than the Universal ART scenarios, whereas Test&Treat resulted in 7%–8% less. Conclusions Test&Treat reduces transmission of HIV, despite individual cases of treatment failure and ART interruption. Whereas viral load monitoring and tracing have only a minor impact on transmission, interventions that aim to minimize treatment interruptions can further increase the preventive effect of ART.
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Affiliation(s)
- Janne Estill
- Institute of Global Health, University of Geneva, Geneva, Switzerland.,Institute of Mathematical Statistics and Actuarial Science (IMSV).,Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Cliff C Kerr
- Burnet Institute, Melbourne, Australia.,School of Physics, University of Sydney, Sydney, Australia
| | - Nello Blaser
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.,Department of Mathematics, University of Bergen, Bergen, Norway
| | - Luisa Salazar-Vizcaya
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.,Department of Infectious Diseases, University Hospital Bern, Bern, Switzerland
| | - Lyson Tenthani
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.,Supporting Operational AIDS Research (Project SOAR), Population Council, Blantyre, Malawi
| | | | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland.,Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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18
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Etoori D, Kerschberger B, Staderini N, Ndlangamandla M, Nhlabatsi B, Jobanputra K, Mthethwa-Hleza S, Parker LA, Sibanda S, Mabhena E, Pasipamire M, Kabore SM, Rusch B, Jamet C, Ciglenecki I, Teck R. Challenges and successes in the implementation of option B+ to prevent mother-to-child transmission of HIV in southern Swaziland. BMC Public Health 2018; 18:374. [PMID: 29558896 PMCID: PMC5859825 DOI: 10.1186/s12889-018-5258-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 03/06/2018] [Indexed: 01/09/2023] Open
Abstract
Background Universal antiretroviral therapy (ART) for all pregnant/ breastfeeding women living with Human Immunodeficiency Virus (HIV), known as Prevention of mother-to child transmission of HIV (PMTCT) Option B+ (PMTCTB+), is being scaled up in most countries in Sub-Saharan Africa. In the transition to PMTCTB+, many countries face challenges with proper implementation of the HIV care cascade. We aimed to describe the feasibility of a PMTCTB+ approach in the public health sector in Swaziland. Methods Lifelong ART was offered to a cohort of HIV+ pregnant women aged ≥16 years at the first antenatal care (ANC1) visit in 9 public sector facilities, between 01/2013 and 06/2014. The study enrolment period was divided into 3 phases (early: 01–06/2013, mid: 07–12/2013 and late: 01–06/2014) to account for temporal trends. Kaplan-Meier estimates and Cox proportional-hazards regression models were applied for ART initiation and attrition analyses. Results Of 665 HIV+ pregnant women, 496 (74.6%) initiated ART. ART initiation increased in later study enrolment phases (mid: aHR: 1.41; later: aHR: 2.36), and decreased at CD4 ≥ 500 (aHR: 0.69). 52.9% were retained in care at 24 months. Attrition was associated with ANC1 in the third trimester (aHR: 2.37), attending a secondary care facility (aHR: 1.98) and ART initiation during later enrolment phases (mid aHR: 1.48; late aHR: 1.67). Of 373 women eligible, 67.3% received a first VL. 223/251 (88.8%) were virologically suppressed (< 1000 copies/mL). Of 670 infants, 53.6% received an EID test, 320/359 had a test result recorded and of whom 7 (2.2%) were HIV+. Conclusions PMTCTB+ was found to be feasible in this setting, with high rates of maternal viral suppression and low transmission to the infant. High treatment attrition, poor follow-up of mother-baby pairs and under-utilisation of VL and EID testing are important programmatic challenges.
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Affiliation(s)
- David Etoori
- Médecins Sans Frontières, Mbabane, Swaziland. .,London School of Hygiene and Tropical Medicine, London, UK.
| | | | | | | | - Bonisile Nhlabatsi
- Sexual and Reproductive Health Unit, Ministry of Health, Mbabane, Swaziland
| | | | | | - Lucy Anne Parker
- Médecins Sans Frontières, Geneva, Switzerland.,CIBER Epidemiología y Salud Pública, Universidad Miguel Hernández, Alicante, Spain
| | | | | | | | | | | | | | | | - Roger Teck
- Médecins Sans Frontières, Geneva, Switzerland.,South African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
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19
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Bershetyn A, Odeny TA, Lyamuya R, Nakiwogga-Muwanga A, Diero L, Bwana M, Braitstein P, Somi G, Kambugu A, Bukusi E, Hartogensis W, Glidden DV, Wools-Kaloustian K, Yiannoutsos C, Martin J, Geng EH. The Causal Effect of Tracing by Peer Health Workers on Return to Clinic Among Patients Who Were Lost to Follow-up From Antiretroviral Therapy in Eastern Africa: A "Natural Experiment" Arising From Surveillance of Lost Patients. Clin Infect Dis 2018; 64:1547-1554. [PMID: 28329184 DOI: 10.1093/cid/cix191] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 03/12/2017] [Indexed: 11/12/2022] Open
Abstract
Background. The effect of tracing human immunodeficiency virus (HIV)-infected patients who are lost to follow-up (LTFU) on reengagement has not been rigorously assessed. We carried out an ex post analysis of a surveillance study in which LTFU patients were randomly selected for tracing to identify the effect of tracing on reengagement. Methods. We evaluated HIV-infected adults on antiretroviral therapy who were LTFU (>90 days late for last visit) at 14 clinics in Uganda, Kenya, and Tanzania. A random sample of LTFU patients was selected for tracing by peer health workers. We assessed the effect of selection for tracing using Kaplan-Meier estimates of reengagement among all patients as well as the subset of LTFU patients who were alive, contacted in person by the tracer, and out of care. Results. Of 5781 eligible patients, 991 (17%) were randomly selected for tracing. One year after selection for tracing, 13.3% (95% confidence interval [CI], 11.1%-15.3%) of those selected for tracing returned compared with 10.0% (95% CI, 9.1%-10.8%) of those not randomly selected, an adjusted risk difference of 3.0% (95% CI, .7%-5.3%). Among patients found to be alive, personally contacted, and out of care, tracing increased the absolute probability of return at 1 year by 22% (95% CI, 7.1%-36.2%). The effect of tracing on rate of return to clinic decayed with a half-life of 7.0 days after tracing (95% CI, 2.6 %-12.9%). Conclusions. Tracing interventions increase reengagement, but developing methods for targeting LTFU patients most likely to benefit can make this practice more efficient.
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Affiliation(s)
| | | | - Rita Lyamuya
- National AIDS Control Program, Dar es Salaam, Tanzania
| | | | - Lameck Diero
- United States Agency for International Development-Academic Partnership Program, Eldoret, Kenya
| | - Mwebesa Bwana
- Department of Epidemiology and Biostatistics, University of California, San Francisco.,Mbarara University of Science and Technology, Uganda
| | - Paula Braitstein
- United States Agency for International Development-Academic Partnership Program, Eldoret, Kenya
| | - Geoffrey Somi
- National AIDS Control Program, Dar es Salaam, Tanzania
| | | | | | - Wendy Hartogensis
- Division of HIV/AIDS, Department of Medicine, San Francisco General Hospital, California
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | | | - Constantin Yiannoutsos
- Department of Biostatistics, Fairbanks School of Public Health, Indiana University, Indianapolis
| | - Jeffrey Martin
- Department of Epidemiology and Biostatistics, University of California, San Francisco.,Division of HIV/AIDS, Department of Medicine, San Francisco General Hospital, California
| | - Elvin H Geng
- Division of HIV/AIDS, Department of Medicine, San Francisco General Hospital, California
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20
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Rachlis B, Karwa R, Chema C, Pastakia S, Olsson S, Wools-Kaloustian K, Jakait B, Maina M, Yotebieng M, Kumarasamy N, Freeman A, de Rekeneire N, Duda SN, Davies MA, Braitstein P. Targeted Spontaneous Reporting: Assessing Opportunities to Conduct Routine Pharmacovigilance for Antiretroviral Treatment on an International Scale. Drug Saf 2017; 39:959-76. [PMID: 27282427 PMCID: PMC5018020 DOI: 10.1007/s40264-016-0434-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Introduction Targeted spontaneous reporting (TSR) is a pharmacovigilance method that can enhance reporting of adverse drug reactions related to antiretroviral therapy (ART). Minimal data exist on the needs or capacity of facilities to conduct TSR. Objectives Using data from the International epidemiologic Databases to Evaluate AIDS (IeDEA) Consortium, the present study had two objectives: (1) to develop a list of facility characteristics that could constitute key assets in the conduct of TSR; (2) to use this list as a starting point to describe the existing capacity of IeDEA-participating facilities to conduct pharmacovigilance through TSR. Methods We generated our facility characteristics list using an iterative approach, through a review of relevant World Health Organization (WHO) and Uppsala Monitoring Centre documents focused on pharmacovigilance activities related to HIV and ART and consultation with expert stakeholders. IeDEA facility data were drawn from a 2009/2010 IeDEA site assessment that included reported characteristics of adult and pediatric HIV care programs, including outreach, staffing, laboratory capacity, adverse event monitoring, and non-HIV care. Results A total of 137 facilities were included: East Africa (43); Asia–Pacific (28); West Africa (21); Southern Africa (19); Central Africa (12); Caribbean, Central, and South America (7); and North America (7). Key facility characteristics were grouped as follows: outcome ascertainment and follow-up; laboratory monitoring; documentation—sources and management of data; and human resources. Facility characteristics ranged by facility and region. The majority of facilities reported that patients were assigned a unique identification number (n = 114; 83.2 %) and most sites recorded adverse drug reactions (n = 101; 73.7 %), while 82 facilities (59.9 %) reported having an electronic database on site. Conclusion We found minimal information is available about facility characteristics that may contribute to pharmacovigilance activities. Our findings, therefore, are a first step that can potentially assist implementers and facility staff to identify opportunities and leverage their existing capacities to incorporate TSR into their routine clinical programs.
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Affiliation(s)
- Beth Rachlis
- Ontario HIV Treatment Network, Toronto, ON, Canada
| | - Rakhi Karwa
- College of Pharmacy, Purdue University, West Lafayette, IN, USA.,Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Celia Chema
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Sonak Pastakia
- College of Pharmacy, Purdue University, West Lafayette, IN, USA.,Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | | | - Kara Wools-Kaloustian
- Academic Model Providing Access to Healthcare, Eldoret, Kenya.,School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Beatrice Jakait
- Academic Model Providing Access to Healthcare, Eldoret, Kenya.,Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Mercy Maina
- Academic Model Providing Access to Healthcare, Eldoret, Kenya.,Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Marcel Yotebieng
- College of Public Health, Ohio State University, Columbus, OH, USA.,Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Nagalingeswaran Kumarasamy
- YRGCARE Medical Centre, Chennai Antiviral Research and Treatment Clinical Research Site (CART CRS), Voluntary Health Services, Chennai, India
| | - Aimee Freeman
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Stephany N Duda
- Department of Medical Informatics, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare, Eldoret, Kenya. .,Division of Epidemiology, University of Toronto, Dalla Lana School of Public Health, 155 College Street, Toronto, ON, M5T 3M7, Canada. .,Department of Medicine, School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya.
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21
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Zürcher K, Mooser A, Anderegg N, Tymejczyk O, Couvillon MJ, Nash D, Egger M. Outcomes of HIV-positive patients lost to follow-up in African treatment programmes. Trop Med Int Health 2017; 22:375-387. [PMID: 28102610 DOI: 10.1111/tmi.12843] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The retention of patients on antiretroviral therapy (ART) is key to achieving global targets in response to the HIV epidemic. Loss to follow-up (LTFU) can be substantial, with unknown outcomes for patients lost to ART programmes. We examined changes in outcomes of patients LTFU over calendar time, assessed associations with other study and programme characteristics and investigated the relative success of different tracing methods. METHODS We performed a systematic review and logistic random-effects meta-regression analysis of studies that traced adults or children who started ART and were LTFU in sub-Saharan African treatment programmes. The primary outcome was mortality, and secondary outcomes were undocumented transfer to another programme, treatment interruption and the success of tracing attempts. RESULTS We included 32 eligible studies from 12 countries in sub-Saharan Africa: 20 365 patients LTFU were traced, and 15 708 patients (77.1%) were found. Compared to telephone calls, tracing that included home visits increased the probability of success: the adjusted odds ratio (aOR) was 9.35 (95% confidence interval [CI] 1.85-47.31). The risk of death declined over calendar time (aOR per 1-year increase 0.86, 95% CI 0.78-0.95), whereas undocumented transfers (aOR 1.13, 95% CI 0.96-1.34) and treatment interruptions (aOR 1.31, 95% CI 1.18-1.45) tended to increase. Mortality was lower in urban than in rural areas (aOR 0.59, 95% CI 0.36-0.98), but there was no difference in mortality between adults and children. The CD4 cell count at the start of ART increased over time. CONCLUSIONS Mortality among HIV-positive patients who started ART in sub-Saharan Africa, were lost to programmes and were successfully traced has declined substantially during the scale-up of ART, probably driven by less severe immunodeficiency at the start of therapy.
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Affiliation(s)
- Kathrin Zürcher
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Anne Mooser
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nanina Anderegg
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Olga Tymejczyk
- Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA.,Department of Epidemiology and Biostatistics, City University of New York School of Public Health, New York, NY, USA
| | - Margaret J Couvillon
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA.,Department of Epidemiology and Biostatistics, City University of New York School of Public Health, New York, NY, USA
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
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22
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Ahonkhai AA, Adeola J, Banigbe B, Onwuatuelo I, Adegoke AB, Bassett IV, Losina E, Freedberg KA, Okonkwo P, Regan S. Impact of Unplanned Care Interruption on CD4 Response Early After ART Initiation in a Nigerian Cohort. J Int Assoc Provid AIDS Care 2016; 16:98-104. [PMID: 28084189 PMCID: PMC5289066 DOI: 10.1177/2325957416672010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The authors conducted a retrospective cohort study of unplanned care interruption (UCI) among adults initiating antiretroviral therapy (ART) from 2009 to 2011 in a Nigerian clinic. The authors used repeated measures regression to model the impact of UCI on CD4 count upon return to care and rate of CD4 change on ART. Among 2496 patients, 83% had 0, 15% had 1, and 2% had ≥2 UCIs. Mean baseline CD4 for those with 0, 1, or ≥2 UCIs was 228/cells/mm3, 355/cells/mm3, and 392/cells/mm3 ( P < .0001), respectively. The UCI was associated with a 62 CD4 cells/mm3 decrease (95% confidence interval [CI]: -78 to -45) at next measurement. In months 1 to 6 on ART, patients with 0 UCI gained 10 cells/µL/mo (95% CI: 7-4). Those with 1 and ≥2 UCIs lost 2 and 5 cells/µL/mo (95% CI: -18 to 13 and -26 to 16). Patients with UCI did not recover from early CD4 losses associated with UCI. Preventing UCI is critical to maximize benefits of ART.
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Affiliation(s)
- Aimalohi A. Ahonkhai
- Division of infectious Disease, Massachusetts General Hospital, Boston, MA, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Juliet Adeola
- AIDS Prevention Initiative in Nigeria (APIN), Abuja, Nigeria
| | - Bolanle Banigbe
- AIDS Prevention Initiative in Nigeria (APIN), Abuja, Nigeria
| | | | | | - Ingrid V. Bassett
- Division of infectious Disease, Massachusetts General Hospital, Boston, MA, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard University Center for AIDS Research (CFAR), Boston, MA, USA
| | - Elena Losina
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard University Center for AIDS Research (CFAR), Boston, MA, USA
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Kenneth A. Freedberg
- Division of infectious Disease, Massachusetts General Hospital, Boston, MA, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard University Center for AIDS Research (CFAR), Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Susan Regan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard University Center for AIDS Research (CFAR), Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
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23
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Kessler J, Nucifora K, Li L, Uhler L, Braithwaite S. Impact and Cost-Effectiveness of Hypothetical Strategies to Enhance Retention in Care within HIV Treatment Programs in East Africa. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:946-955. [PMID: 26686778 PMCID: PMC4696404 DOI: 10.1016/j.jval.2015.09.2940] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/21/2015] [Accepted: 09/18/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Attrition from care among HIV infected patients can lead to poor clinical outcomes. Our objective was to evaluate hypothetical interventions seeking to improve retention-in-care (RIC) for HIV-infected patients in East Africa, asking whether they could offer favorable value compared to earlier ART initiation. METHODS We used a micro-simulation model to analyze two RIC focused strategies within an East African HIV treatment program--"risk reduction," defined as intervention(s) that decrease the risk of attrition from care; and "outreach," defined as interventions that find patients and relink them with care. We compared this to earlier ART treatment as a measure of the potential health benefits forgone (e.g., opportunity cost). RESULTS Reducing attrition by 40% at an average cost of $10 per person remains a less efficient use of resources compared to ensuring full access to ART (cost- effectiveness ratio $1300 vs $3700) for ART eligible patients. An outreach intervention had limited clinical benefit in our simulation. If intervention costs are <$10 per person, however, an intervention able to achieve a 40% (or greater) reduction in attrition may be a cost-effective next implementation option following implementation of earlier ART treatment. CONCLUSIONS Our results suggest that programs should consider retention focused programs once they have already achieved high degrees of ART coverage among eligible patients. It is important that decision makers understand the epidemiology and associated outcomes of those patients who are classified as lost to follow up in their systems prior to implementation in order to achieve the highest value.
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Affiliation(s)
- Jason Kessler
- Department of Population Health, New York University School of Medicine, New York, NY, USA.
| | - Kimberly Nucifora
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Lingfeng Li
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Lauren Uhler
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Scott Braithwaite
- Department of Population Health, New York University School of Medicine, New York, NY, USA
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24
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Abstract
More than 75 million people worldwide have been infected with human immunodeficiency virus (HIV), and there are now approximately 37 million individuals living with the infection. Untreated HIV replication causes progressive CD4(+) T cell loss and a wide range of immunological abnormalities, leading to an increased risk of infectious and oncological complications. HIV infection also contributes to cardiovascular disease, bone disease, renal and hepatic dysfunction and several other common morbidities. Antiretroviral drugs are highly effective at inhibiting HIV replication, and for individuals who can access and adhere to these drugs, combination antiretroviral therapy leads to durable (and probably lifelong) suppression of viral replication. Viral suppression enables immune recovery and the near elimination of the risk for developing acquired immune deficiency syndrome (AIDS). Despite effective treatment, HIV-infected individuals have a higher than expected risk of heart, bone, liver, kidney and neurological disease. When used optimally by an infected (or by an uninfected) person, antiretroviral drugs can virtually eliminate the risk of HIV transmission. Despite major advances in prevention sciences, HIV transmission remains common in many vulnerable populations, including men who have sex with men, injection drug users and sex workers. Owing to a lack of widespread HIV testing and the costs and toxicities associated with antiretroviral drugs, the majority of the infected population is not on effective antiretroviral therapy. To reverse the pandemic, improved prevention, treatment and implementation approaches are necessary.
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Affiliation(s)
- Steven G Deeks
- University of California, San Francisco, Department of Medicine, 995 Potrero Avenue, San Francisco, California 94110, USA
| | - Julie Overbaugh
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Andrew Phillips
- Department of Infection and Population Health, University College London, London, UK
| | - Susan Buchbinder
- University of California, San Francisco, Department of Medicine, 995 Potrero Avenue, San Francisco, California 94110, USA.,San Francisco Department of Health, San Francisco, California, USA
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Ojeniran MA, Emokpae A, Mabogunje C, Akintan P, Hoshen M, Weiss R. How are children with HIV faring in Nigeria?--a 7 year retrospective study of children enrolled in HIV care. BMC Pediatr 2015. [PMID: 26198439 PMCID: PMC4510895 DOI: 10.1186/s12887-015-0405-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background To review the pediatric care and treatment program at Massey Street Children Hospital, in Lagos, Nigeria a retrospective analysis of medical records focusing on health services, survival and retention in care. Methods The analysis covered a cohort of children initiated on antiretroviral therapy (ART) from 2005 to 2011. In this population, pediatric HIV care was defined as initiating ART between ages 0 and 14 years. Treatment initiation and follow-up were according to the Nigerian national guidelines for pediatric ART, which are based on World Health Organization guidelines adapted to our local context. The primary endpoint was mortality measured as cumulative survival. Other outcomes of interest included “loss to follow-up”, “transferred out”, and “stopped treatment”. Results Mean (SD) age at ART initiation was 51 (39) months in female children and 52 (42) months in male children. After seven years of ART care, 64 % of the 660 study children were retained in care and on treatment, 16 % were lost to follow-up, 10 % were dead, and 9 % had discontinued HIV care at this facility for other reasons. World Health Organization disease stage, CD4 count, age, and year of ART initiation were highly predictive of mortality, while anemia at baseline was not statistically significantly associated. Conclusions Overall study results suggest a viable pediatric HIV program exists at the study facility. Retention rates were lowest for the earliest cohort of infected children, which implies long-term challenges. Mother-to-child transmission programs need to be dynamic to stem the scourge of pediatric HIV in Nigeria.
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Affiliation(s)
- Moyinoluwa A Ojeniran
- Lifescope Integrated Services, Lagos, Nigeria. .,School of Public Health, Hebrew University Hadassah, Jerusalem, Israel. .,Massey Street Children's Hospital, Lagos, Nigeria.
| | | | | | | | | | - Ram Weiss
- Massey Street Children's Hospital, Lagos, Nigeria.
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Teshome W, Belayneh M, Moges M, Mekonnen E, Endrias M, Ayele S, Misganaw T, Shiferaw M, Tesema T. Do loss to follow-up and death rates from ART care vary across primary health care facilities and hospitals in south Ethiopia? A retrospective follow-up study. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2015; 7:167-74. [PMID: 26064071 PMCID: PMC4455856 DOI: 10.2147/hiv.s85440] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Decentralization and task shifting has significantly improved access to antiretroviral therapy (ART). Many studies conducted to determine the attrition rate in Ethiopia have not compared attrition rates between hospitals and health centers in a relatively recent cohort of patients. This study compared death and loss to follow-up (LTFU) rates among ART patients in hospitals and health centers in south Ethiopia. Methods Data routinely collected from patients aged older than 15 years who started ART between July 2011 and August 2012 in 20 selected health facilities (12 being hospitals) were analyzed. The outcomes of interest were LTFU and death. The data were entered, cleaned, and analyzed using Statistical Package for the Social Sciences version 20.0 and Stata version 12.0. Competing-risk regression models were used. Results The service years of the facilities were similar (median 8 and 7.5 for hospitals and health centers, respectively). The mean patient age was 33.7±9.6 years. The median baseline CD4 count was 179 (interquartile range 93–263) cells/mm3. A total of 2,356 person-years of observation were made with a median follow-up duration of 28 (interquartile range 22–31) months; 24.6% were either dead or LTFU, resulting in a retention rate of 75.4%. The death rates were 3.0 and 1.5 and the LTFU rate were 9.0 and 10.9 per 100 person-years of observation in health centers and hospitals, respectively. The competing-risk regression model showed that the gap between testing and initiation of ART, body mass index, World Health Organization clinical stage, isoniazid prophylaxis, age, facility type, and educational status were independently associated with LTFU. Moreover, baseline tuberculous disease, poor functional status, and follow-up at a health center were associated with an elevated probability of death. Conclusion We observed a higher death rate and a lower LTFU rate in health centers than in hospitals. Most of the associated variables were also previously documented. Higher LTFU was noticed for patients with a smaller gap between testing and initiation of treatment.
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Affiliation(s)
- Wondu Teshome
- School of Public and Environmental Health, Hawassa University, Hawassa, Ethiopia
| | - Mehretu Belayneh
- School of Public and Environmental Health, Hawassa University, Hawassa, Ethiopia
| | - Mathewos Moges
- School of Public and Environmental Health, Hawassa University, Hawassa, Ethiopia
| | - Emebet Mekonnen
- Health Research and Technology Transfer Support Process, Southern Nations Nationalities and Peoples' Regional Health Bureau, Hawassa, Ethiopia
| | - Misganu Endrias
- Health Research and Technology Transfer Support Process, Southern Nations Nationalities and Peoples' Regional Health Bureau, Hawassa, Ethiopia
| | - Sinafiksh Ayele
- Health Research and Technology Transfer Support Process, Southern Nations Nationalities and Peoples' Regional Health Bureau, Hawassa, Ethiopia
| | - Tebeje Misganaw
- Health Research and Technology Transfer Support Process, Southern Nations Nationalities and Peoples' Regional Health Bureau, Hawassa, Ethiopia
| | - Mekonnen Shiferaw
- Health Research and Technology Transfer Support Process, Southern Nations Nationalities and Peoples' Regional Health Bureau, Hawassa, Ethiopia
| | - Tigist Tesema
- Health Research and Technology Transfer Support Process, Southern Nations Nationalities and Peoples' Regional Health Bureau, Hawassa, Ethiopia
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Rachlis B, Ochieng D, Geng E, Rotich E, Ochieng V, Maritim B, Ndege S, Naanyu V, Martin JN, Keter A, Ayuo P, Diero L, Nyambura M, Braitstein P. Implementation and operational research: evaluating outcomes of patients lost to follow-up in a large comprehensive care treatment program in western Kenya. J Acquir Immune Defic Syndr 2015; 68:e46-55. [PMID: 25692336 PMCID: PMC4348019 DOI: 10.1097/qai.0000000000000492] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Academic Model Providing Access To Healthcare (AMPATH) program provides comprehensive HIV care and treatment services. Approximately, 30% of patients have become lost to follow-up (LTFU). We sought to actively trace and identify outcomes for a sample of these patients. METHODS LTFU was defined as missing a scheduled visit by ≥3 months. A randomly selected sample of 17% of patients identified as LTFU between January 2009 and June 2011 was generated, with sample stratification on age, antiretroviral therapy (ART) status at last visit, and facility. Chart reviews were conducted followed by active tracing. Tracing was completed by trained HIV-positive outreach workers July 2011 to February 2012. Outcomes were compared between adults and children and by ART status. RESULTS Of 14,811 LTFU patients, 2540 were randomly selected for tracing (2179 adults, 1071 on ART). The chart reviews indicated that 326 (12.8%) patients were not actually LTFU. Outcomes for 71% of sampled patients were determined including 85% of those physically traced. Of those with known outcomes, 21% had died, whereas 29% had disengaged from care for various reasons. The remaining patients had moved away (n = 458, 25%) or were still receiving HIV care (n = 443 total, 25%). CONCLUSIONS Our findings demonstrate the feasibility of a large-scale sampling-based approach. A significant proportion of patients were found not to be LTFU, and further, high numbers of patients who were LTFU could not be located. Over a quarter of patients disengaged from care for various reasons including access challenges and familial influences.
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Affiliation(s)
- Beth Rachlis
- *Academic Model Providing Access To Healthcare, Eldoret, Kenya; †Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; ‡Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA; §Moi University School of Public Health, Kenya; Departments of ‖Behavioral Sciences; and ¶Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
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Wilkinson LS, Skordis-Worrall J, Ajose O, Ford N. Self-transfer and mortality amongst adults lost to follow-up in ART programmes in low- and middle-income countries: systematic review and meta-analysis. Trop Med Int Health 2015; 20:365-79. [PMID: 25418366 DOI: 10.1111/tmi.12434] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To ascertain estimates of adult patients, recorded as lost to follow-up (LTFU) within antiretroviral treatment (ART) programmes, who have self-transferred care, died or truly stopped ART in low- and middle-income countries. METHODS PubMed, EMBASE, Web of Science, Science Direct, LILACS, IndMed and AIM databases (2003-2013) and IAS/AIDS conference abstracts (2011-2013) were searched for tracing studies reporting the proportion of traced patients found to have self-transferred, died or stopped ART. These estimates were then combined using random-effects meta-analysis. Risk of bias was assessed through subgroup and sensitivity analyses. RESULTS Twenty eight studies were eligible for inclusion, reporting true outcomes for 10,806 traced patients attending approximately 258 ART facilities. None were from outside sub-Saharan Africa. Twenty three studies reported 4.5-54.4% traced LTFU patients self-transferring care, providing a pooled estimate of 18.6% (95% CI 15.8-22.0%). A significant positive association was found between rates of self-transfer and LTFU in the ART cohort. The pooled estimates for unreported deaths were 38.8% (95% CI 30.8-46.8%; 27 studies) and 28.6% (95% CI 21.9-36.0%; 20 studies) for patients stopping ART. A significant decrease in unreported deaths from 50.0% (95% CI 41.5-58.4%) to 30.0% (95% CI 21.1-38.9%) was found comparing study periods before and after 31 December 2007. CONCLUSIONS Substantial unaccounted for transfers and deaths amongst patients LTFU confirms that retention and mortality is underestimated where the true outcomes of LTFU patients are not ascertained.
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Affiliation(s)
- Lynne S Wilkinson
- UCL Institute for Global Health, London, UK; Medecins Sans Frontieres, Khayelitsha, South Africa
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29
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Antiretroviral therapy uptake, attrition, adherence and outcomes among HIV-infected female sex workers: a systematic review and meta-analysis. PLoS One 2014; 9:e105645. [PMID: 25265158 PMCID: PMC4179256 DOI: 10.1371/journal.pone.0105645] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/16/2014] [Indexed: 11/19/2022] Open
Abstract
Purpose We aimed to characterize the antiretroviral therapy (ART) cascade among female sex workers (FSWs) globally. Methods We systematically searched PubMed, Embase and MEDLINE in March 2014 to identify studies reporting on ART uptake, attrition, adherence, and outcomes (viral suppression or CD4 count improvements) among HIV-infected FSWs globally. When possible, available estimates were pooled using random effects meta-analyses (with heterogeneity assessed using Cochran's Q test and I2 statistic). Results 39 studies, reporting on 21 different FSW study populations in Asia, Africa, North America, South America, and Central America and the Caribbean, were included. Current ART use among HIV-infected FSWs was 38% (95% CI: 29%–48%, I2 = 96%, 15 studies), and estimates were similar between high-, and low- and middle-income countries. Ever ART use among HIV-infected FSWs was greater in high-income countries (80%; 95% CI: 48%–94%, I2 = 70%, 2 studies) compared to low- and middle-income countries (36%; 95% CI: 7%–81%, I2 = 99%, 3 studies). Loss to follow-up after ART initiation was 6% (95% CI: 3%–11%, I2 = 0%, 3 studies) and death after ART initiation was 6% (95% CI: 3%–11%, I2 = 0%, 3 studies). The fraction adherent to ≥95% of prescribed pills was 76% (95% CI: 68%–83%, I2 = 36%, 4 studies), and 57% (95% CI: 46%–68%, I2 = 82%, 4 studies) of FSWs on ART were virally suppressed. Median gains in CD4 count after 6 to 36 months on ART, ranged between 103 and 241 cells/mm3 (4 studies). Conclusions Despite global increases in ART coverage, there is a concerning lack of published data on HIV treatment for FSWs. Available data suggest that FSWs can achieve levels of ART uptake, retention, adherence, and treatment response comparable to that seen among women in the general population, but these data are from only a few research settings. More routine programme data on HIV treatment among FSWs across settings should be collected and disseminated.
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30
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Mountain E, Pickles M, Mishra S, Vickerman P, Alary M, Boily MC. The HIV care cascade and antiretroviral therapy in female sex workers: implications for HIV prevention. Expert Rev Anti Infect Ther 2014; 12:1203-19. [PMID: 25174997 DOI: 10.1586/14787210.2014.948422] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
To achieve viral suppression and fully benefit from antiretroviral therapy (ART), it is important that individuals with HIV know that they are HIV infected, link to and remain in HIV care, start and remain on ART and adhere to treatment. In HIV epidemics where female sex workers (FSWs) are key drivers of HIV transmission, the extent to which FSWs use ART and engage in the HIV care cascade could have a considerable impact on HIV transmission from FSWs to the wider population. In this article we review the spectrum of FSW engagement in the HIV care cascade, look at the impact of the HIV care cascade and ART use among FSWs on population-level HIV transmission and discuss HIV prevention for FSWs in the context of ART and the HIV care cascade.
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Affiliation(s)
- Elisa Mountain
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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31
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Grimsrud A, Kaplan R, Bekker LG, Myer L. Outcomes of a nurse-managed service for stable HIV-positive patients in a large South African public sector antiretroviral therapy programme. Trop Med Int Health 2014; 19:1029-39. [PMID: 25041716 DOI: 10.1111/tmi.12346] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Models of care utilizing task shifting and decentralization are needed to support growing ART programmes. We compared patient outcomes between a doctor-managed clinic and a nurse-managed down-referral site in Cape Town, South Africa. METHODS Analysis included all adults who initiated ART between 2002 and 2011 within a large public sector ART service. Stable patients were eligible for down-referral. Outcomes [mortality, loss to follow-up (LTFU), virologic failure] were compared under different models of care using proportional hazards models with time-dependent covariates. RESULTS Five thousand seven hundred and forty-six patients initiated ART and over 5 years 41% (n = 2341) were down-referred; the median time on ART before down-referral was 1.6 years (interquartile range, 0.9-2.6). The nurse-managed down-referral site reported lower crude rates of mortality, LTFU and virologic failure compared with the doctor-managed clinic. After adjustment, there was no difference in the risk of mortality or virologic failure by model of care. However, patients who were down-referred were more likely to be LTFU than those retained at the doctor-managed site (adjusted hazard ratio, 1.36; 95% CI, 1.09-1.69). Increased levels of LTFU in the nurse-managed vs. doctor-managed service were observed in subgroups of male patients, those with advanced disease at initiation and those who started ART in the early years of the programme. CONCLUSION Reorganization of ART maintenance by down-referral to nurse-managed services is associated with programme outcomes similar to those achieved using doctor-driven primary care services. Further research is necessary to identify optimal models of care to support long-term retention of patients on ART in resource-limited settings.
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Affiliation(s)
- Anna Grimsrud
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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Nakiwogga-Muwanga A, Musaazi J, Katabira E, Worodria W, Talisuna SA, Colebunders R. Patients who return to care after tracking remain at high risk of attrition: experience from a large HIV clinic, Uganda. Int J STD AIDS 2014; 26:42-7. [PMID: 24648320 DOI: 10.1177/0956462414529098] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We determined the retention rate of patients infected with HIV who resumed care after being tracked at the Infectious Diseases Clinic (IDC) in Kampala, Uganda. Between April 2011 and September 2013, patients who missed their clinic appointment for 8-90 days were tracked, and those who returned to the clinic within 120 days were followed up. The proportion of patients retained among tracked patients, and those who resumed care before tracking started was compared. At 18 months of follow up, 33 (39%) of the tracked patients and 72 (61%) of those who had resumed care before tracking started were retained in care. The most important cause of attrition among the traceable was self-transfer to another clinic (38 [73%] patients), whereas among those who resumed care before tracking was loss to follow up (LTFU) (32 [71%] patients). Tracked patients who resume care following a missed appointment are at high risk of attrition. To increase retention, antiretroviral therapy clinics need to adopt a chronic care model which takes into consideration patients' changing needs and their preference for self-management.
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Affiliation(s)
- A Nakiwogga-Muwanga
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - J Musaazi
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - E Katabira
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - W Worodria
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - R Colebunders
- Department of Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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Evangeli M, Newell ML, Richter L, McGrath N. The association between self-reported stigma and loss-to-follow up in treatment eligible HIV positive adults in rural Kwazulu-Natal, South Africa. PLoS One 2014; 9:e88235. [PMID: 24586310 PMCID: PMC3930529 DOI: 10.1371/journal.pone.0088235] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 01/06/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The relationship between loss-to-follow-up (LTFU) in HIV treatment and care programmes and psychosocial factors, including self-reported stigma, is important to understand. This prospective cohort study explored stigma and LTFU in treatment eligible adults who had yet not started antiretroviral therapy (ART). METHODS Psychosocial, clinical and demographic data were collected at a baseline interview. Self-reported stigma was measured with a multi-item scale. LTFU was defined as not attending clinic in the 90 days since last appointment or before death. Data was collected between January 2009 and January 2013 and analysed using Cox Regression. RESULTS 380 individuals were recruited (median time in study 3.35 years, total time at risk 1065.81 person-years). 203 were retained (53.4%), 109 were LTFU (28.7%), 48 had died and were not LTFU at death (12.6%) and 20 had transferred out (5.3%). The LTFU rate was 10.65 per 100 person-years (95% CI: 8.48-12.34). 362 individuals (95.3%) started ART. Stigma total score (categorised in quartiles) was not significantly associated with LTFU in either univariable or multivariable analysis (adjusting for other variables in the final model): second quartile aHR 0.77 (95%CI: 0.41-1.46), third quartile aHR 1.20(95%CI: 0.721-2.04), fourth quartile aHR 0.62 (95%CI: 0.35-1.11). In the final multivariable model, higher LTFU rates were associated with male gender, increased openness with friends/family and believing that community problems would be solved at higher levels. Lower LTFU rates were independently associated with increased year of age, greater reliance on family/friends, and having children. CONCLUSIONS Demographic and other psychosocial factors were more closely related to LTFU than self-reported stigma. This may be consistent with high levels of social exposure to HIV and ART and with stigma affecting LTFU less than other stages of care. Research and clinical implications are discussed.
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Affiliation(s)
- Michael Evangeli
- Department of Psychology, Royal Holloway University of London, United Kingdom
| | - Marie-Louise Newell
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Linda Richter
- Human Sciences Research Council, Durban, South Africa
| | - Nuala McGrath
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
- Academic Unit of Primary Care and Population Sciences and Division of Social Statistics and Demography, University of Southampton, Southampton, United Kingdom
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