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Nyakato P, Schomaker M, Boulle A, Euvrard J, Wood R, Eley B, Prozesky H, Christ B, Anderegg N, Ayakaka I, Rafael I, Kunzekwenyika C, Moore CB, van Lettow M, Chimbetete C, Mbewe S, Ballif M, Egger M, Yiannoutsos CT, Cornell M, Davies MA. Correcting mortality estimates among children and youth on antiretroviral therapy in southern Africa: A comparative analysis between a multi-country tracing study and linkage to a health information exchange. Trop Med Int Health 2024; 29:739-751. [PMID: 38961819 DOI: 10.1111/tmi.14030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES The objective of this study is to assess the outcomes of children, adolescents and young adults with HIV reported as lost to follow-up, correct mortality estimates for children, adolescents and young adults with HIV for unascertained outcomes in those loss to follow-up (LTFU) based on tracing and linkage data separately using data from the International epidemiology Databases to Evaluate AIDS in Southern Africa. METHODS We included data from two different populations of children, adolescents and young adults with HIV; (1) clinical data from children, adolescents and young adults with HIV aged ≤24 years from Lesotho, Malawi, Mozambique, Zambia and Zimbabwe; (2) clinical data from children, adolescents and young adults with HIV aged ≤14 years from the Western Cape (WC) in South Africa. Outcomes of patients lost to follow-up were available from (1) a tracing study and (2) linkage to a health information exchange. For both populations, we compared six methods for correcting mortality estimates for all children, adolescents and young adults with HIV. RESULTS We found substantial variations of mortality estimates among children, adolescents and young adults with HIV reported as lost to follow-up versus those retained in care. Ascertained mortality was higher among lost and traceable children, adolescents and young adults with HIV and lower among lost and linkable than those retained in care (mortality: 13.4% [traced] vs. 12.6% [retained-other Southern Africa countries]; 3.4% [linked] vs. 9.4% [retained-WC]). A high proportion of lost to follow-up children, adolescents and young adults with HIV had self-transferred (21.0% and 47.0%) in the traced and linked samples, respectively. The uncorrected method of non-informative censoring yielded the lowest mortality estimates among all methods for both tracing (6.0%) and linkage (4.0%) approaches at 2 years from ART start. Among corrected methods using ascertained data, multiple imputation, incorporating ascertained data (MI(asc.)) and inverse probability weighting with logistic weights were most robust for the tracing approach. In contrast, for the linkage approach, MI(asc.) was the most robust. CONCLUSIONS Our findings emphasise that lost to follow-up is non-ignorable and both tracing and linkage improved outcome ascertainment: tracing identified substantial mortality in those reported as lost to follow-up, whereas linkage did not identify out-of-facility deaths, but showed that a large proportion of those reported as lost to follow-up were self-transfers.
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Affiliation(s)
- Patience Nyakato
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Michael Schomaker
- Department of Statistics, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Khayelitsha ART Programme, Cape Town, South Africa
- Western Cape Government: Health and Wellness, Cape Town, South Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Khayelitsha ART Programme, Cape Town, South Africa
| | - Robin Wood
- Gugulethu HIV Programme and Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Brian Eley
- Red Cross War Memorial Children's Hospital and Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Hans Prozesky
- Division of Infectious Diseases, Department of Medicine, University of Stellenbosch and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Benedikt Christ
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nanina Anderegg
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | | | | | - Carolyn B Moore
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Monique van Lettow
- Dignitas International, Zomba, Malawi
- Madiro, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | | | - Marie Ballif
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Constantin T Yiannoutsos
- R.M Fairbanks, School of Public Health, Department of Biostatistics, Indiana University, Indianapolis, Indiana, USA
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Western Cape Government: Health and Wellness, Cape Town, South Africa
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Bankere AW, Daba SG, Ami B, Gedefa LK, Lencha B. Loss to follow-up and its predictors among children living with HIV on antiretroviral therapy, southern Oromia, Ethiopia: a 5-year retrospective cohort study. BMJ Open 2024; 14:e078370. [PMID: 39089715 PMCID: PMC11293378 DOI: 10.1136/bmjopen-2023-078370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 06/21/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Loss to follow-up (LTFU) among paediatric patients living with HIV presents a significant challenge to the global scale-up of life-saving antiretroviral therapy (ART). OBJECTIVES This study aims to estimate LTFU incidence and its determinants among children with HIV on ART in Shashemene town public health institutions, Oromia, Ethiopia. DESIGN A retrospective cohort study from 1 January 2015 to 30 December 2020. SETTING This study was conducted in Shashemene town, Oromia, Ethiopia. PARTICIPANTS Medical records of 269 children receiving ART at health facilities in Shashemene town were included. METHODS Data from patients' medical records were collected using a standardised checklist. EpiData V.3.1 was employed for data entry, while Statistical Package for the Social Sciences (SPSS) V.25 facilitated analysis. The Kaplan-Meier survival curve was used for estimation of survival time. To measure association, adjusted HRs (AHRs) with 95% CIs were calculated. Both bivariable and multivariable Cox proportional hazards regression models were employed to identify predictors of LTFU. RESULTS Of the 269 children living with HIV included in the final analysis, 43 (16%) were lost to follow-up. The overall incidence rate of LTFU was 3.3 (95% CI 2.4 to 4.4) per 100 child-years of observation. Age less than 5 years (AHR 0.03, 95% CI 0.00 to 0.36), non-orphan status of the child (AHR 0.13, 95% CI 0.05 to 0.34), < 30 min distance to health facility (AHR 0.24, 95% CI 0.08 to 0.73), disclosed HIV status (AHR 0. 32, 95% CI 0.13 to 0.80), history of opportunistic infection (AHR 3.54, 95% CI 1.15 to 10.87) and low CD4 count (AHR 5.17, 95% CI 2.08 to 12.85) were significant predictors of LTFU. CONCLUSION The incidence rate of LTFU was lower compared with other studies in Ethiopia. This result indicated that age less than 5 years, non-orphans, low CD4, disclosed HIV status and distance from health facility were predictors of LTFU.
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Affiliation(s)
- Assefa Washo Bankere
- Department of Public Health, Hawassa College of Health Science, Hawassa, Ethiopia
| | - Sintayehu Gabisa Daba
- Department of Disease Prevention and Control, Oromia Regional Health Bureau, Bishoftu, Addis Ababa, Ethiopia
| | - Bonso Ami
- Department of Public Health, Madda Walabu University, Robe, Ethiopia
| | | | - Bikila Lencha
- Department of Public Health, Madda Walabu University, Robe, Ethiopia
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Girma D, Abita Z, Lemu LG, Asmelash D, Bambo GM, Alie MS, Abebe GF. Incidence of lost to follow up among HIV-positive children on antiretroviral therapy in Ethiopia: Systematic review and meta-analysis. PLoS One 2024; 19:e0304239. [PMID: 38776343 PMCID: PMC11111029 DOI: 10.1371/journal.pone.0304239] [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: 12/03/2023] [Accepted: 05/08/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND At the end of 2022, globally, only 46% of children (aged 0-14 years) on ART had suppressed viral loads. Viral load suppression is crucial to reduce HIV-related deaths. To suppress the viral load at the expected level, children must be retained in ART treatment. Nevertheless, lost to follow-up from ART treatment continues to be a global challenge, particularly, in developing countries. Previously, primary studies were conducted in Ethiopia to assess the incidence of lost to follow-up among HIV-positive children on ART treatment. However, variations have been seen among the studies. Therefore, this systematic review and meta-analysis aimed to estimate the pooled incidence of lost to follow-up among HIV-positive children on ART and identify its associated factors in Ethiopia. METHODS We searched PubMed, HINARI, Science Direct, Google Scholar, and African Journals Online to obtain articles published up to November 20, 2023. Critical appraisal was done using the Joanna Briggs Institute checklist. Heterogeneity was identified using I-square statistics. Funnel plot and Egger's tests were used to identify publication bias. Data was presented using forest plots and tables. Random and fixed-effect models were used to compute the pooled estimate. RESULTS Twenty-four studies were included in the final analysis. The pooled incidence of lost to follow-up among HIV-positive children on ART was 2.79 (95% CI: 1.99, 3.91) per 100-child-year observations. Advanced HIV disease (HR: 2.20, 95% CI: 1.71, 2.73), having opportunistic infection (HR: 2.59, 95% CI: 1.39; 4.78), fair or poor ART treatment adherence (HR: 2.92, 95% CI: 1.31; 6.54) and children aged between 1-5 years (HR: 2.1,95% CI: 1.44; 2.95) were factors associated with lost to follow up among HIV positive children on ART. CONCLUSIONS The overall pooled incidence of lost to follow-up among HIV-positive children on ART is low in Ethiopia. Therefore, counseling on ART drug adherence should be strengthened. Moreover, emphasis has to be given to children with advanced HIV stage and opportunistic infection to reduce the rate of lost to follow up among HIV-positive children on ART. TRIAL REGISTRATION Registered in PROSPERO with ID: CRD42024501071.
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Affiliation(s)
- Desalegn Girma
- Department of Midwifery, College of Health Science, Mizan-Tepi University, Mizan-Teferi, Ethiopia
| | - Zinie Abita
- Department of Public Health, College of Health Science, Mizan-Tepi University, Mizan-Teferi, Ethiopia
| | - Lidya Gutema Lemu
- Department of Midwifery, College of Health Science, Mizan-Tepi University, Mizan-Teferi, Ethiopia
| | - Daniel Asmelash
- Department of Medical Laboratory, College of Health Science, Mizan Tepi University, Mizan-Teferi, Ethiopia
| | - Getachew Mesfin Bambo
- Department of Medical Laboratory, College of Health Science, Mizan Tepi University, Mizan-Teferi, Ethiopia
| | - Melesew Setegn Alie
- Department of Public Health, College of Health Science, Mizan-Tepi University, Mizan-Teferi, Ethiopia
| | - Gossa Fetene Abebe
- Department of Midwifery, College of Health Science, Mizan-Tepi University, Mizan-Teferi, Ethiopia
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Nyakato P, Boulle A, Wood R, Eley B, Rabie H, Egger M, Yiannoutsos CT, Davies MA, Cornell M. Self-transfers, Hospital Admissions and Mortality Among Children and Adolescents Lost to Follow-up From Antiretroviral Therapy Programs in the Western Cape, South Africa Between 2004 and 2019: Linkage to Provincial Records. Pediatr Infect Dis J 2024; 43:430-436. [PMID: 38451913 DOI: 10.1097/inf.0000000000004281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Pediatric programs face a high rate of loss to follow-up (LTFU) among children and adolescents living with HIV (CAHIV). We assessed true outcomes and predictors of these among CAHIV who were LTFU using linkage to the Western Cape Provincial Health Data Centre at Western Cape sites of the International epidemiology Databases to Evaluate AIDS-Southern Africa collaboration. METHODS We examined factors associated with self-transfer, hospital admission and mortality using competing risks regression in a retrospective cohort of CAHIV initiating antiretroviral therapy <15 years old between 2004 and 2019 and deemed LTFU (no recorded visit at the original facility for ≥180 days from the last visit date before database closure and not known to have officially transferred out or deceased). RESULTS Of the 1720 CAHIV deemed LTFU, 802 (46.6%) had self-transferred and were receiving care elsewhere within the Western Cape, 463 (26.9%) had been hospitalized and 45 (2.6%) CAHIV had died. The overall rates of self-transfer, hospitalization, mortality and LTFU were 9.4 [95% confidence interval (CI): 8.8-10.1], 5.4 (95% CI: 5.0-6.0), 0.5 (95% CI: 0.4-0.7) and 4.8 (95% CI: 4.4-5.3) per 100 person-years respectively. Increasing duration on antiretroviral therapy before LTFU was associated with self-transfers while male sex, older age at last visit (≥10 years vs. younger) were associated with hospital admission and immune suppression at last visit was associated with 5 times higher mortality. CONCLUSIONS Nearly half of CAHIV classified as LTFU had self-transferred to another health facility, a quarter had been hospitalized and a small proportion had died.
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Affiliation(s)
- Patience Nyakato
- From the Centre for Infectious Disease Epidemiology and Research, School of Public Health, Faculty of Health Sciences, University of Cape Town
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine
| | - Andrew Boulle
- From the Centre for Infectious Disease Epidemiology and Research, School of Public Health, Faculty of Health Sciences, University of Cape Town
- Department of Health, Khayelitsha ART Programme
- Department of Health, Western Cape Government: Health
| | - Robin Wood
- Gugulethu HIV Programme and Desmond Tutu HIV Centre, University of Cape Town
| | - Brian Eley
- Red Cross War Memorial Children's Hospital and Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Helena Rabie
- Department of Paediatrics and Child Health, Tygerberg Academic Hospital, University of Stellenbosch, Stellenbosch, South Africa
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Constantin T Yiannoutsos
- Department of Biostatistics, R.M Fairbanks, School of Public Health, Indiana University, Indianapolis, Indiana
| | - Mary-Ann Davies
- From the Centre for Infectious Disease Epidemiology and Research, School of Public Health, Faculty of Health Sciences, University of Cape Town
- Department of Health, Western Cape Government: Health
| | - Morna Cornell
- From the Centre for Infectious Disease Epidemiology and Research, School of Public Health, Faculty of Health Sciences, University of Cape Town
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Nyandiko W, Enjema NA, Mugo R, Apondi E, Sang E, Mwangi A. Predictors of Mortality Among Children and Adolescents Living With HIV on Antiretroviral Therapy in Western Kenya. J Acquir Immune Defic Syndr 2024; 95:383-390. [PMID: 38133591 PMCID: PMC10896189 DOI: 10.1097/qai.0000000000003361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/14/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Antiretroviral therapy (ART) has decreased HIV-attributable deaths; however, children and adolescents continue to have high HIV-associated mortality. SETTING We determined the predictors of death among children and young adolescents living with HIV (CALWH) who died while in care in Western Kenya. METHODS This retrospective case-control study used electronically abstracted data of 6234 CALWH who received care in Academic Model Providing Access to Healthcare HIV clinics in Western Kenya between January 2002 and November 2022. The cases comprised CALWH who were reported dead by November 2022, while the controls constituted of matched CALWH who were alive and in care. Independent predictors of mortality were determined using univariable and multivariable Cox proportional hazard regression models. Kaplan-Meier analysis ascertained survival. RESULTS Of the 6234 participants enrolled, slightly more than half were male (51.7%). The mean (SD) age at the start of ART was significantly lower in cases than in controls at 6.01 (4.37) and 6.62 (4.11) ( P < 0.001), respectively. An age of 11 years or older at start of ART (adjusted Hazard Ratio [aHR]: 8.36 [3.60-19.40]), both parents being alive (aHR: 3.06 [1.67-5.60]), underweight (aHR: 1.82 [1.14-2.92]), and World Health Organization stages 3 (aHR: 2.63 [1.12-6.18]) and 4 (aHR: 2.20 [0.94-5.18]) increased mortality; while school attendance (aHR: 0.12 [0.06-0.21]), high CD4 + counts >350 cells/mm 3 (aHR: 0.79 [0.48-1.29]), and low first viral load <1000 copies/mL (aHR: 0.24 [0.14-0.40]) were protective. CONCLUSION Independent predictors of mortality were age 11 years or older at the start of ART, orphan status, underweight, and advanced HIV disease. Beyond the provision of universal ART, care accorded to CALWH necessitates optimization through tackling individual predictors of mortality.
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Affiliation(s)
- Winstone Nyandiko
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Njie Albertine Enjema
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Richard Mugo
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Edith Apondi
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Directorate of Paediatrics, Moi Teaching and Referral Hospital Eldoret, Kenya; and
| | - Edwin Sang
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Ann Mwangi
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Mathematics, Physics and Computing, Moi University Eldoret, Kenya
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Christie MJ, du Plessis NM. Retention in care of infants diagnosed with HIV at birth: Beyond the diagnostic strategy. S Afr J Infect Dis 2024; 39:589. [PMID: 38628425 PMCID: PMC11019047 DOI: 10.4102/sajid.v39i1.589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/17/2024] [Indexed: 04/19/2024] Open
Abstract
Background Birth HIV point-of-care (POC) tests curtail analytical testing issues and expedite diagnosis, potentially allowing for earlier mother-infant pair engagement and improved outcomes. Many children are lost post antiretroviral therapy (ART) initiation within the first 6 months of follow-up. Objectives We compared 6-month retention in care, HIV viral load (VL) suppression and mortality among infants diagnosed with HIV at birth, using laboratory-based versus POC HIV PCR testing. Method From 2018 to 2019, infants exposed to HIV underwent birth HIV PCR POC testing at Kalafong Provincial Tertiary Hospital in Tshwane District. Their outcomes were compared to a historical control born between 2014 and 2016, who exclusively underwent laboratory-based HIV PCR testing. Both groups received comparable HIV care following national guidelines. Results Fifty-seven infants were studied (POC: 27; Control: 30). The POC turnaround time was significantly shorter (POC: 15.5 h [IQR: 4.3-24.7], Control: 68.3 h [IQR 46.0-93.9]; p = < 0.0001). Both populations had the same elapsed time from HIV diagnosis to ART initiation (median: 13 days, POC: IQR 8-21 days; Control: IQR 9-36 days). Six infants were never initiated (POC: 2 [7%]; Control: 4 [13%]). At 6 months, overall care retention was 72% (41/57), higher among the Control group (Control 23/30, 77%; POC: 18/27, 67%). HIV viral suppression at 6 months was higher among the POC group (POC: 14/18, 78%; Control: 9/19, 47%, p = 0.09). No deaths were reported. Conclusion Poor care retention at 6 months post ART initiation is concerning. Initial mother-infant visits should be effectively utilised to assess and manage potential risk factors for loss of follow-up. Contribution This study highlights the ongoing need to find workable solutions to improve retention in care, thereby ensuring the benefits of expedited HIV diagnosis and ART initiation.
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Affiliation(s)
- Michael J Christie
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Nicolette M du Plessis
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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Zemariam AB, Abebe GK, Alamaw AW. Incidence and predictors of attrition among human immunodeficiency virus infected children on antiretroviral therapy in Amhara comprehensive specialized hospitals, Northwest Ethiopia, 2022: a retrospective cohort study. Sci Rep 2024; 14:4366. [PMID: 38388643 PMCID: PMC10883953 DOI: 10.1038/s41598-024-54229-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
Attrition rate is higher in developing nations and it leftovers a major obstacle to enhance the benefits of therapy and achieve the 90-90-90 plan targets. Despite this fact, data on the incidence and its predictors of attrition among human immune deficiency virus infected children on antiretroviral therapy are limited in developing countries including Ethiopia especially after the test and treat strategy implemented. This study aimed to assess the incidence and predictors of attrition among human immune deficiency virus infected children on antiretroviral therapy in Amhara Comprehensive Specialized Hospitals, Northwest Ethiopia. A retrospective follow-up study was conducted among 359 children on ART from June 14, 2014, to June 14, 2022. Study participants were selected using simple random sampling method and the data were collected using Kobo Toolbox software and analysis was done by STATA version 14. Both bi-variable and multivariable Cox regression models were fitted to ascertain predictors. Lastly, an AHR with a 95% CI was computed and variables with a p-value of < 0.05 were took an account statistically key predictors of attrition. The overall incidence of attrition rate was 9.8 (95% CI 7.9, 11.9) per 100 PYO. Children having baseline hemoglobin < 10 mg/dl (AHR 3.94; 95% CI 2.32, 6.7), suboptimal adherence (AHR 1.96; 95% CI 1.23, 3.13), baseline opportunistic infection (AHR 1.8; 95% CI 1.17, 2.96), and children who had experienced drug side effects (AHR 8.3; 95% CI 4.93, 13.84) were established to be a significant predictors of attrition. The attrition rate was relatively high. Decreased hemoglobin, suboptimal adherence, presence of drug side effects and baseline opportunistic infection were predictors of attrition. Therefore, it is crucial to detect and give special emphasis to those identified predictors promptly.
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Affiliation(s)
- Alemu Birara Zemariam
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, Woldia University, Woldia, Ethiopia.
| | - Gebremeskel Kibret Abebe
- Department of Emergency and Critical Care Nursing, School of Nursing, College of Medicine and Health Sciences, Woldia University, Woldia, Ethiopia
| | - Addis Wondmagegn Alamaw
- Department of Emergency and Critical Care Nursing, School of Nursing, College of Medicine and Health Sciences, Woldia University, Woldia, Ethiopia
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Yumo H, Ndenkeh JJ, Beissner M. The Positive Impact of Foods Support on Loss to Follow Up Among Children and Adolescents on HIV Antiretroviral Therapy in a District Hospital in East Cameroon. HIV AIDS (Auckl) 2023; 15:663-670. [PMID: 38028191 PMCID: PMC10644811 DOI: 10.2147/hiv.s417852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/04/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction The pediatric HIV treatment coverage in Cameroon remains low at 35%. The high loss to follow up (LTFU) remains a major factor to this dismal performance which is related to the lack of implementation of effective interventions to improve retention in care. This study assessed the impact of foods support (FS) on LTFU among children and adolescents in a rural district hospital in eastern Cameroon. Methods This was a retro-prospective study conducted in Abong Mbang District Hospital (ADH) in the East Region of Cameroon. We provided foods kits to children and adolescents initiated on antiretroviral therapy (ART) in this facility during the study and followed them up prospectively (prospective phase). On the other hand, using medical records, we collected retrospectively data for children and adolescents who enrolled on ART in the hospital prior to the study (retrospective phase). We then compared the proportions of children and adolescents LTFU before (no FS) and after (with FS) the study, using the Fisher's exact test, logistic regression, Kaplan-Meier survival curves and Cox proportional-hazards model at 5% significant level. Results We found that with FS, the proportion of children and adolescents LTFU was 11 times lower (2.4% vs 26.7%, p=0.014), the mean time of retention in care was 30% higher (17 months vs 12 months, p<0.001) and children and adolescents who did not receive FS were 10 times more likely to be LTFU [aHR=10.3 (4.0-26.2), p<0.001)]. Conclusion Foods support is an effective intervention in reducing LTFU among children and adolescents on ART. This intervention should be adequately funded to enable a large-scale implementation in the field. This could help to improve the outcome of pediatric ART coverage in resource-limited settings.
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Affiliation(s)
- Habakkuk Yumo
- R4D International Foundation, Yaounde, Cameroon
- Center for International Health, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Jackson Jr Ndenkeh
- R4D International Foundation, Yaounde, Cameroon
- Center for International Health, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Marcus Beissner
- Center for International Health, Ludwig-Maximilians-University of Munich, Munich, Germany
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Guyo TG, Toma TM, Haftu D, Kote M, Merid F, Kulayta K, Makisha M, Temesgen K. Proportion of Attrition and Associated Factors Among Children Receiving Antiretroviral Therapy in Public Health Facilities, Southern Ethiopia. HIV AIDS (Auckl) 2023; 15:491-502. [PMID: 37600485 PMCID: PMC10439800 DOI: 10.2147/hiv.s422173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 08/11/2023] [Indexed: 08/22/2023] Open
Abstract
Purpose Acquired immunodeficiency syndrome (AIDS) is a major global public health concern. Despite the improved access and utilization of antiretroviral therapy (ART), attrition from care among children continues to be a major obstacle to the effectiveness of ART programs. Hence, this study aimed to assess the proportion of attrition and associated factors among children receiving ART in public health facilities of Gamo and South Omo Zones, Southern Ethiopia. Patients and Methods A retrospective follow-up study was conducted in public health facilities of Gamo and South Omo Zones in Southern Ethiopia from April 12, 2022, to May 10, 2022. The proportion of attrition was determined by dividing the number of attrition by the total number of participants. Descriptive statistics were calculated. A binary logistic regression model was used to identify factors associated with attrition. Statistical significance was set at p-value <0.05. Results The median age of the participants was 5.5 (IQR: 2-9) years. The proportion of attrition from ART care was 32.4% (95% confidence interval (CI): 27.57% to 37.69%). Death of either of the parents (adjusted odds ratio (AOR) = 2.19; 95% CI:1.14, 4.18), or both parents (AOR = 3.19; 95% CI: 1.20, 8.52), hemoglobin level <10mg/dL (AOR = 2.39, 95% CI: 1.21, 4.70), a cluster of differentiation (CD)4 count ≤200 cells/mm3 (AOR = 6.78, 95% CI: 3.16, 14.53), CD4 count 200-350 cells/mm3 (AOR = 2.65, 95% CI: 1.16, 6.03), suboptimal adherence (AOR = 6.38; 95% CI: 3.36, 12.19), and unchanged initial regimen (AOR = 6.88; 95% CI: 3.58, 13.19) were factors associated with attrition. Conclusion Attrition from care is identified to be a substantial public health problem. Therefore, designing interventions to improve the timely tracing of missed follow-up schedules and adherence support is needed, especially for children with either/both parents died, unchanged initial regimen, low CD4, and/or low hemoglobin level.
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Affiliation(s)
- Tamirat Gezahegn Guyo
- Department of Public Health, Arba Minch College of Health Sciences, Arba Minch, Ethiopia
| | - Temesgen Mohammed Toma
- Department of Public Health, Arba Minch College of Health Sciences, Arba Minch, Ethiopia
| | - Desta Haftu
- School of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Mesfin Kote
- School of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Fasika Merid
- Department of Public Health, Arba Minch College of Health Sciences, Arba Minch, Ethiopia
| | - Kebede Kulayta
- Department of Medical Laboratory Technology, Arba Minch College of Health Sciences, Arba Minch, Ethiopia
| | - Markos Makisha
- Department of Midwifery, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Kidus Temesgen
- School of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
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High Unreported Mortality in Children and Youth (<25 Years) Living With HIV Who Were Lost to Care From Antiretroviral Therapy Programs in Southern Africa: Results From a Multicountry Tracing Study. J Acquir Immune Defic Syndr 2022; 91:429-433. [PMID: 36099024 PMCID: PMC9646412 DOI: 10.1097/qai.0000000000003090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/29/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Antiretroviral therapy program mortality maybe underestimated if deceased patients are misclassified as lost. METHODS We used two-stage inverse probability weighting to account for probability of being: sampled for tracing and found by the tracer. RESULTS Among 680 children and youth aged <25 years on antiretroviral therapy who were lost and traced in Southern Africa between October 2017 and November 2019, estimated mortality was high at 9.1% (62/680). After adjusting for measured covariates and within-site clustering, mortality remained lower for young adults aged 20-24 years compared with infants aged <2 years [adjusted hazard ratio: 0.40 (95% confidence interval: 0.31 to 0.51)]. CONCLUSIONS Our study confirms high unreported mortality in children and youth who are lost and the need for tracing to assess vital status among those who are lost to accurately report on program mortality.
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Marca LM, Dias FA, Schultz DB, Höfelmann DA, Rattmann YD. Perfil sociodemográfico e farmacoepidemiológico de crianças infectadas pelo HIV. SAÚDE EM DEBATE 2022. [DOI: 10.1590/0103-11042022e514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
RESUMO A terapia antirretroviral interfere na replicação do vírus HIV, impede a progressão da infecção para a Aids e previne a mortalidade precoce das crianças infectadas. Esta pesquisa investigou o perfil sociodemográfico e os parâmetros relacionados com o tratamento antirretroviral das crianças HIV positivas residentes no estado do Paraná. Trata-se de um estudo observacional descritivo e analítico realizado com dados secundários do ano de 2020 referentes às crianças com até 12 anos de idade. Foram investigados: perfil, prevalência, medicamentos em uso, abandono da terapia, resistência e supressão viral. Foram identificadas 148 crianças, com uma prevalência igual a 8,1/100 mil no Paraná. Apesar de todas as crianças diagnosticadas com HIV terem iniciado o tratamento, 17,2% encontravam-se em abandono da terapia antirretroviral. Entre as crianças que permaneciam em tratamento, 9,8% não atingiram a supressão viral e suas cargas virais comumente ultrapassavam mil cópias virais/mL. Houve um predomínio de esquemas medicamentosos provavelmente prescritos após falhas terapêuticas. Os resultados indicam que o Paraná apresenta bons resultados quanto ao início rápido da terapia e à supressão viral das crianças. Entretanto, existe um número considerável de abandonos da terapia e de falhas terapêuticas, indicando a necessidade de reforçar a vinculação desta população aos serviços de saúde.
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Patel F, Fairlie L. HIV treatment success in children and adolescents with HIV. THE LANCET HIV 2022; 9:e526-e527. [DOI: 10.1016/s2352-3018(22)00196-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 11/15/2022]
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Temporal changes in paediatric and adolescent HIV outcomes across the care continuum in Zambia: an interrupted time-series analysis. THE LANCET HIV 2022; 9:e563-e573. [PMID: 35905754 PMCID: PMC9394542 DOI: 10.1016/s2352-3018(22)00127-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 04/13/2022] [Accepted: 04/22/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Paediatric and adolescent HIV treatment programmes in sub-Saharan Africa have rapidly expanded and evolved over the past decade. Real-world evidence of how the implementation of new policies over time has affected treatment outcomes is inadequate, but is crucial for guiding the implementation of the next phases of the HIV treatment response for children. We examined how treatment outcomes in Zambia's national paediatric and adolescent HIV treatment programmes have changed over time as new policies were implemented. METHODS We used data from Zambia's routine electronic health record to analyse children and adolescents living with HIV who were antiretroviral therapy (ART) naive between the ages of 0 and 19 years who were newly enrolled in care between Jan 1, 2011, and March 31, 2019, at 102 health facilities in Lusaka and Western provinces supported by the Centre for Infectious Disease Research in Zambia. Sociodemographic factors, clinical data, facility-level data, and visit history were obtained from the national electronic health record and laboratory systems used in routine HIV care in Zambia. We aimed to characterise the changes in the distribution of the age and sex of new enrolees over time. We used an interrupted time-series design to examine the rates of ART initiation, retention in care, time to ART initiation, and first-line ART regimens among new enrolees across different age strata as they changed over time with the adoption of new ART guidelines in 2014 and 2017. FINDINGS Between Jan 1, 2011, and March 31, 2019, 26 214 children and adolescents living with HIV who were ART naïve were newly enrolled at one of 102 ART facilities in two provinces in Zambia. Rates of new enrolees increased by 25-35% among children younger than 15 years over time, but by 92·3% between 2011 and 2017 among adolescents, with the largest absolute increase among adolescent girls. Rates of ART initiation increased steadily and in parallel across all age groups from before the implementation of the 2014 guidelines to after the implementation of the 2017 guidelines (<2 years, 42·4% for 2014 and 81·6% for 2017; 2 to <5 years, 39·3% for 2014 and 82·8% for 2017; 5 to <15 years, 49·2% for 2014 and 86·6% for 2017; 15 to 19 years, 52·4% for 2014 and 86·2% for 2017); median time to ART initiation went from 2-3 months to same-day initiation during this same time period. Rates of retention on ART 6 months after linkage saw much smaller improvements over time (<2 years, 35·4% for 2014 and 52·0% for 2017; 2 to <5 years, 40·2% for 2014 and 54·4% for 2017; 5 to <15 years, 46·7% for 2014 and 63·4% for 2017; 15 to 19 years, 40·1% for 2014 and 52·7% for 2017). INTERPRETATION Improvements in ART initiation occurred largely in parallel across age groups over time, despite universal treatment being implemented at different timepoints for different ages. Although the rates of ART initiation reach high levels, retention on ART was low. This analysis provides a comprehensive examination of how paediatric and adolescent outcomes have evolved over the past decade in Zambia and identifies where more targeted efforts will be needed over the next decade. FUNDING National Institutes of Health.
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Tesha ED, Kishimba R, Njau P, Revocutus B, Mmbaga E. Predictors of loss to follow up from antiretroviral therapy among adolescents with HIV/AIDS in Tanzania. PLoS One 2022; 17:e0268825. [PMID: 35857796 PMCID: PMC9299289 DOI: 10.1371/journal.pone.0268825] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 05/09/2022] [Indexed: 11/30/2022] Open
Abstract
Access to Antiretroviral Therapy (ART) is threatened by the increased rate of loss to follow-up (LTFU) among adolescents on ART care. We investigated the rate of LTFU from HIV care and associated predictors among adolescents living with HIV/AIDS in Tanzania. A retrospective cohort analysis of adolescents on ART from January 2014 to December 2016 was performed. Kaplan-Meier method was used to determine failure probabilities and the Cox proportion hazard regression model was used to determine predictors of loss to follow up. A total of 25,484 adolescents were on ART between 2014 and 2016, of whom 78.4% were female and 42% of adolescents were lost to follow-up. Predictors associated with LTFU included; adolescents aged 15–19 years (adjusted hazard ratio (aHR): 1.57; 95% Confidence Interval (CI); 1.47–1.69), having HIV/TB co-infection (aHR: 1.58; 95% CI, 1.32–1.89), attending care at dispensaries (aHR: 1.12; 95% CI, 1.07–1.18) or health center (aHR: 1.10; 95% CI, 1.04–1.15), and being malnourished (aHR: 2.27; 95% CI,1.56–3.23). Moreover, residing in the Lake Zone and having advanced HIV disease were associated with LTFU. These findings highlight the high rate of LTFU and the need for intervention targeting older adolescents with advanced diseases and strengthening primary public facilities to achieve the 2030 goal of ending HIV as a public health threat.
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Affiliation(s)
- Esther-Dorice Tesha
- Department of Epidemiology and Biostatistics at Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Tanzania Field of Epidemiology and Laboratory Training Program, Dar es Salaam, Tanzania
- * E-mail:
| | - Rogath Kishimba
- Tanzania Field of Epidemiology and Laboratory Training Program, Dar es Salaam, Tanzania
| | - Prosper Njau
- National AIDS Control Program, Ministry of Health, Community Development, Gender, Elderly, and Children, Dodoma, Tanzania
| | - Baraka Revocutus
- National AIDS Control Program, Ministry of Health, Community Development, Gender, Elderly, and Children, Dodoma, Tanzania
| | - Elia Mmbaga
- Department of Epidemiology and Biostatistics at Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Community Medicine and Global Health, University of Oslo, Oslo, Norway
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Jiménez-Osorio AS, Jaen-Vega S, Fernández-Martínez E, Ortíz-Rodríguez MA, Martínez-Salazar MF, Jiménez-Sánchez RC, Flores-Chávez OR, Ramírez-Moreno E, Arias-Rico J, Arteaga-García F, Estrada-Luna D. Antiretroviral Therapy-Induced Dysregulation of Gene Expression and Lipid Metabolism in HIV+ Patients: Beneficial Role of Antioxidant Phytochemicals. Int J Mol Sci 2022; 23:5592. [PMID: 35628408 PMCID: PMC9146859 DOI: 10.3390/ijms23105592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 12/02/2022] Open
Abstract
Human immunodeficiency virus (HIV) infection has continued to be the subject of study since its discovery nearly 40 years ago. Significant advances in research and intake of antiretroviral therapy (ART) have slowed the progression and appearance of the disease symptoms and the incidence of concomitant diseases, which are the leading cause of death in HIV+ persons. However, the prolongation of ART is closely related to chronic degenerative diseases and pathologies caused by oxidative stress (OS) and alterations in lipid metabolism (increased cholesterol levels), both of which are conditions of ART. Therefore, recent research focuses on using natural therapies to diminish the effects of ART and HIV infection: regulating lipid metabolism and reducing OS status. The present review summarizes current information on OS and cholesterol metabolism in HIV+ persons and how the consumption of certain phytochemicals can modulate these. For this purpose, MEDLINE and SCOPUS databases were consulted to identify publications investigating HIV disease and natural therapies and their associated effects.
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Affiliation(s)
- Angélica Saraí Jiménez-Osorio
- Área Académica de Enfermería, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado Hidalgo, Circuito Ex Hacienda La Concepción S/N, Carretera Pachuca-Actopan, San Agustín Tlaxiaca 42160, Mexico; (A.S.J.-O.); (S.J.-V.); (R.C.J.-S.); (O.R.F.-C.); (J.A.-R.)
| | - Sinaí Jaen-Vega
- Área Académica de Enfermería, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado Hidalgo, Circuito Ex Hacienda La Concepción S/N, Carretera Pachuca-Actopan, San Agustín Tlaxiaca 42160, Mexico; (A.S.J.-O.); (S.J.-V.); (R.C.J.-S.); (O.R.F.-C.); (J.A.-R.)
| | - Eduardo Fernández-Martínez
- Laboratorio de Química Medicinal y Farmacología, Centro de Investigación en Biología de la Reproducción, Área Académica de Medicina, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado de Hidalgo, Calle Dr. Eliseo Ramírez Ulloa no. 400, Col. Doctores, Pachuca Hidalgo 42090, Mexico;
| | - María Araceli Ortíz-Rodríguez
- Facultad de Nutrición, Universidad Autónoma del Estado de Morelos, Iztaccíhuatl 100 Col. Los Volcanes, Cuernavaca 62350, Mexico;
| | - María Fernanda Martínez-Salazar
- Facultad de Ciencias del Deporte, Facultad de Farmacia Universidad Autónoma del Estado de Morelos, Av. Universidad No. 1001 Col. Chamilpa, Cuernavaca 62209, Mexico;
| | - Reyna Cristina Jiménez-Sánchez
- Área Académica de Enfermería, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado Hidalgo, Circuito Ex Hacienda La Concepción S/N, Carretera Pachuca-Actopan, San Agustín Tlaxiaca 42160, Mexico; (A.S.J.-O.); (S.J.-V.); (R.C.J.-S.); (O.R.F.-C.); (J.A.-R.)
| | - Olga Rocío Flores-Chávez
- Área Académica de Enfermería, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado Hidalgo, Circuito Ex Hacienda La Concepción S/N, Carretera Pachuca-Actopan, San Agustín Tlaxiaca 42160, Mexico; (A.S.J.-O.); (S.J.-V.); (R.C.J.-S.); (O.R.F.-C.); (J.A.-R.)
| | - Esther Ramírez-Moreno
- Área Académica de Nutrición, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado Hidalgo, Circuito Ex Hacienda La Concepción S/N, Carretera Pachuca-Actopan, San Agustín Tlaxiaca 42160, Mexico;
| | - José Arias-Rico
- Área Académica de Enfermería, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado Hidalgo, Circuito Ex Hacienda La Concepción S/N, Carretera Pachuca-Actopan, San Agustín Tlaxiaca 42160, Mexico; (A.S.J.-O.); (S.J.-V.); (R.C.J.-S.); (O.R.F.-C.); (J.A.-R.)
| | - Felipe Arteaga-García
- Coordinación de Enseñanza e Investigación, Hospital del Niño DIF Hidalgo, Carretera México-Pachuca km 82, Pachuca de Soto 42080, Mexico;
| | - Diego Estrada-Luna
- Área Académica de Enfermería, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado Hidalgo, Circuito Ex Hacienda La Concepción S/N, Carretera Pachuca-Actopan, San Agustín Tlaxiaca 42160, Mexico; (A.S.J.-O.); (S.J.-V.); (R.C.J.-S.); (O.R.F.-C.); (J.A.-R.)
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Chanie ES, Tesgera Beshah D, Ayele AD. Incidence and predictors of attrition among children on antiretroviral therapy at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2019: Retrospective follow-up study. SAGE Open Med 2022; 10:20503121221077843. [PMID: 35173969 PMCID: PMC8841924 DOI: 10.1177/20503121221077843] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/17/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives: Retaining on antiretroviral therapy is essential for reducing HIV-related morbidity and mortality. However, attrition in HIV-positive children remains a critical challenge in resource-limited settings, including Ethiopia. This study aims to determine the incidence and predictors of attrition among children on antiretroviral therapy at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. Methods: An institution-based retrospective follow-up study was conducted among 357 HIV-positive children at the University of Gondar Comprehensive Specialized Hospital from 1 January 2005 to 30 December 2018 (G.C.). Data were collected by chart review using a structured and pre-tested data abstraction checklist. SPSS 22 and STATA 14.0 were used for data entry and analysis, respectively. In the Cox proportional hazard model, bivariables had a 0.25 computed to multivariable, and variables with a p-value of 0.05 at a 95% confidence interval were considered statistically significant predictors of attrition incidence. Results: A total of 344 child records with a completeness rate of 96.4% were reviewed and included in the analysis. The median follow-up period was 4.3 (interquartile range = 4.3 ± 4.7) years, and the median survival time was 132 months. The incidence rate of attrition was 6.6 per 100 person year observation (PYO) (95% confidence interval = 5.5, 8.0). In all, 105 (30.5%) children were recorded as attrition in the follow-up period. Baseline WHO clinical staging 3 and 4 (adjusted hazard ratio = 2.3 (95% confidence interval = 1.3, 4.0)), baseline weight-for-age −2 Z-score (adjusted hazard ratio = 3.1 (95% confidence interval = 1.7, 5.3)), cotrimoxazole non-users (adjusted hazard ratio = 2.5 (95% confidence interval = 1.4, 4.3)), and baseline hemoglobin levels 10 mg/dL (adjusted hazard ratio = 2.7 (95% confidence interval = 1.5, 47)) were found to be a predictor of attrition. Conclusion: The overall incidence of the rate of attrition was high. Baseline WHO clinical staging 3/4, baseline hemoglobin 10 mg/dL, cotrimoxazole (cotrimoxazole preventive therapy) non-user, and underweight at baseline (weight-for-age 2 Z-score) were found to be the main predictors of attrition.
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Affiliation(s)
- Ermias Sisay Chanie
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Northwest Ethiopia
| | - Debrework Tesgera Beshah
- Department of Surgical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Northwest Ethiopia
| | - Amare Demsie Ayele
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Northwest Ethiopia
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Anukam O, Blanco N, Jumare J, Lo J, Babatunde E, Odafe S, Onotu D, Ene U, Fagbamigbe J, Carpenter D, Rivadeneira ED, Omoigberale AI, Charurat M, Swaminathan M, Stafford KA. Outcomes of HIV Positive Children and Adolescents Initiated on Antiretroviral Treatment in Nigeria (2007-2016). J Int Assoc Provid AIDS Care 2022; 21:23259582221117009. [PMID: 35929105 PMCID: PMC9358598 DOI: 10.1177/23259582221117009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: This manuscript aimed to examine treatment outcomes of HIV-positive children and adolescents. Methods: We retrospectively analyzed data of a sample of patients aged 0–19 years who initiated ART (October 2007–September 2016) in participating sites in 30 states and the Federal Capital Territory in Nigeria. Results: Among 4006 patients alive at the end of the follow up period, 138 (3.4%) were LTFU. Adolescents had a significantly higher risk of being LTFU than children aged 3–5 years (HR 2.47 [95% CI 1.40-4.34]). Patients with advanced disease had a significantly higher risk of being LTFU (Stage IV HR, 3.66 [95% CI: 2.00-6.68]). On average, optimal ART refill adherence was met by 67.3% of patients. Conclusion: Our findings suggest that focusing on preventing and managing advanced disease and interventions supporting adolescents when transferring to adult care is warranted.
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Affiliation(s)
| | | | | | - Julia Lo
- 12265University of Maryland, Baltimore, MD, USA
| | | | - Solomon Odafe
- Division of Global HIV & Tuberculosis, Center for Global Health, 1242Centers for Disease Control and Prevention, Abuja, Nigeria
| | - Dennis Onotu
- Division of Global HIV & Tuberculosis, Center for Global Health, 1242Centers for Disease Control and Prevention, Abuja, Nigeria
| | - Uzoma Ene
- Division of Global HIV & Tuberculosis, Center for Global Health, 1242Centers for Disease Control and Prevention, Abuja, Nigeria
| | - Johnson Fagbamigbe
- Division of Global HIV & Tuberculosis, Center for Global Health, 1242Centers for Disease Control and Prevention, Abuja, Nigeria
| | - Deborah Carpenter
- Division of Global HIV & Tuberculosis, Center for Global Health, 1242Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Emilia D Rivadeneira
- Division of Global HIV & Tuberculosis, Center for Global Health, 1242Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Austin I Omoigberale
- Paediatric Association of Nigeria, Abuja, Nigeria.,Department of Child Health, 251350University of Benin Teaching Hospital, Benin City, Nigeria
| | | | - Mahesh Swaminathan
- Division of Global HIV & Tuberculosis, Center for Global Health, 1242Centers for Disease Control and Prevention, Abuja, Nigeria
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Sifr Z, Ando T, Semeon W, Rike M, Ashami K. Level of Attrition from Antiretroviral Therapy Among Human Immune Deficiency Virus-Infected Children: The Cases of Sidama Zone, Southern Ethiopia. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2021; 13:813-822. [PMID: 34413684 PMCID: PMC8370599 DOI: 10.2147/hiv.s317117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/23/2021] [Indexed: 12/01/2022]
Abstract
Background Human immune deficiency virus (HIV) remains one of the leading causes of infectious disease mortality and morbidity in Sub-Saharan Africa. Although remarkable progress has been made in prevention and treatment of HIV, there is a higher rate of loss to follow-up in HIV-infected children than in adults, once they enter care. Objective To determine the incidence and identify predictors of loss to follow-up among HIV-infected children on anti-retroviral treatment in Sidama Zone, Ethiopia. Methods A retrospective cohort study was done among children that were enrolled in ART care in Sidama Zone from September 2014 to August 2018. A total of 143 eligible children were included in this study. A structured checklist was used to extract data from patients’ medical records such as patient intake forms, electronic database, and registers. Data were entered, cleaned, coded, and analyzed by STATA version 12. Cox proportional hazards models were fitted to investigate predictors of loss to follow-up. Results Of the 143 participants, 76 (53.15%) were female children with a median age of 7 years and interquartile range of 4–9. The incidence rate was 5 per 100 person-years and the cumulative incidence 12.59%. The median follow-up time was 2.46 years and the total time at risk was 356.06 person-years. Furthermore, 55.56% and 72.22% of those lost to follow-up were within the first and the second years of follow-up, respectively. In multivariable Cox proportional model, only the TB status of the children was significantly associated with loss to follow-up with hazard ratio 3.348 [1.174831, 9.543494] and p-value of 0.024. Conclusion In this study, TB status of children was the significant determinant of loss to follow-up. However, the overall retention was 87.4% and a substantially higher proportion of loss was observed within the first and second years of follow-up.
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Affiliation(s)
- Zemenu Sifr
- Department of Health Information Technology, Hawassa College of Health Sciences, Hawassa, Ethiopia
| | - Telto Ando
- Department of Health Information Technology, Hawassa College of Health Sciences, Hawassa, Ethiopia
| | - Wosenyeleh Semeon
- Department of Health Information Technology, Hawassa College of Health Sciences, Hawassa, Ethiopia
| | - Muse Rike
- Department of Health Information Technology, Hawassa College of Health Sciences, Hawassa, Ethiopia
| | - Kidist Ashami
- Harvard Graduate School of Arts and Science, Boston, MA, 02138, USA
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Harrison MJ, Brice N, Scott C. Clinical Features of HIV Arthropathy in Children: A Case Series and Literature Review. Front Immunol 2021; 12:677984. [PMID: 34354702 PMCID: PMC8329591 DOI: 10.3389/fimmu.2021.677984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/02/2021] [Indexed: 12/02/2022] Open
Abstract
Background HIV infection has been associated with a non-erosive inflammatory arthritis in children, although few published reports exist. This study describes the clinical, laboratory and imaging features of this noncommunicable disease in a series of HIV-infected children in South Africa. Methods A database search was conducted to identify HIV-infected children enrolled in a Paediatric Rheumatology service in Cape Town, South Africa between 1 January 2010 and 31 December 2020. Retrospective data were collected from individuals classified with HIV arthropathy, based on a predefined checklist. Demographic, clinical, laboratory, sonographic, therapeutic, and outcomes data were extracted by chart review. Descriptive statistical analysis was performed using R (v4.0.3). Results Eleven cases of HIV arthropathy were included in the analysis. Cases predominantly presented in older boys with low CD4+ counts. Median age at arthritis onset was 10.3 years (IQR 6.9 – 11.6) and the male-female ratio was 3.0. The median absolute CD4+ count was 389 cells/uL (IQR 322 – 449). The clinical presentation was variable, with both oligoarthritis and polyarthritis being common. Elevated acute phase reactants were the most consistent laboratory feature, with a median ESR of 126 mL/h (IQR 67 – 136) and median CRP of 36 mg/L (IQR 25 – 68). Ultrasonography demonstrated joint effusions and synovial hypertrophy. Response to therapy was slower than has generally been described in adults, with almost all cases requiring more than one immunosuppressive agent. Five children were discharged in established remission after discontinuing immunotherapy, however outcomes data were incomplete for the remaining six cases. Conclusions In this case series, HIV arthropathy was associated with advanced immunosuppression. Therapeutic modalities included immunomodulators and antiretroviral therapy, which consistently induced disease remission although data were limited by a high rate of attrition. Prospective studies are needed to define and understand this HIV-associated noncommunicable disease.
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Affiliation(s)
- Michael J Harrison
- Fort Beaufort Provincial Hospital, Amathole District, Eastern Cape, South Africa
| | - Nicola Brice
- Division of Paediatric Rheumatology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.,University of Cape Town, Rondebosch, Cape Town, South Africa
| | - Christiaan Scott
- Division of Paediatric Rheumatology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.,University of Cape Town, Rondebosch, Cape Town, South Africa
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Onubogu CU, Ugochukwu EF. A 17 year experience of attrition from care among HIV infected children in Nnewi South-East Nigeria. BMC Infect Dis 2021; 21:409. [PMID: 33941101 PMCID: PMC8091640 DOI: 10.1186/s12879-021-06099-3] [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: 01/16/2021] [Accepted: 04/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A large number of HIV-infected children continue to die despite reported scale-up of paediatric HIV services. AIM The trend in attrition among children enrolled in an anti-retroviral therapy (ART) programme was evaluated. METHODS This was a retrospective review of children enrolled into NAUTH ART programme between 2003 and 2019. RESULTS 1114 children < 15 years at enrolment were studied. The male: female ratio was 1:1 while median age at enrolment was 4.3 years. About two-thirds had WHO stage 3 or 4 disease at enrolment. The rate of loss to follow-up (LTFU) and death were 41.0 and 8.4%, respectively, with overall attrition incidence of 108/1000PY. Despite the downward trend, spikes occurred among those enrolled in 2008 to 2011 and in 2017. The trend in 6-, 12-, 24- and 36-months attrition varied similarly with overall rates being 20.4, 27.7, 34.3 and 37.3%, respectively. Among those on ART, > 50% of attrition was recorded within 6 months of care. Advanced WHO stage, young age, non-initiation on ART or period of enrolment (P < 0.001), and caregiver (p = 0.026) were associated with attrition in bivariate analysis. Apart from caregiver category, these factors remained significant in multivariate analysis. Most LTFU could not be reached on phone. Among those contacted, common reasons for being lost to follow-up were financial constraints, caregiver loss, claim to divine healing, family disharmony/child custody issues and relocation of family/child. CONCLUSION/RECOMMENDATION Attrition rate was high and was mostly due to LTFU. Predictors of attrition were late presentation, young age, delay in ART initiation and financial constraints. Efforts should be intensified at early diagnosis, linkage to care and implementation of "test and treat" strategy. Innovative child centered approaches should be adopted to enable the HIV-infected children remain in care despite challenges which can truncate treatment.
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Affiliation(s)
- Chinyere Ukamaka Onubogu
- Department of Paediatrics, Faculty of Medicine, Nnamdi Azikiwe University, Awka, Nigeria. .,Paediatric Infectious Diseases Unit, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria.
| | - Ebelechuku Francesca Ugochukwu
- Department of Paediatrics, Faculty of Medicine, Nnamdi Azikiwe University, Awka, Nigeria.,Paediatric Infectious Diseases Unit, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
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Iyun V, Technau KG, Vinikoor M, Yotebieng M, Vreeman R, Abuogi L, Desmonde S, Edmonds A, Amorissani-Folquet M, Davies MA. Variations in the characteristics and outcomes of children living with HIV following universal ART in sub-Saharan Africa (2006-17): a retrospective cohort study. Lancet HIV 2021; 8:e353-e362. [PMID: 33932330 DOI: 10.1016/s2352-3018(21)00004-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 12/22/2020] [Accepted: 01/11/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The proportion of children living with HIV and receiving antiretroviral therapy (ART) in sub-Saharan Africa has increased greatly since 2006, yet the changes in their demographic characteristics and treatment outcomes have not been well described. We examine the trends in characteristics and outcomes of children living with HIV who were younger than 5 years at ART initiation, and compare outcomes over time and across country income groups. METHODS We conducted a retrospective cohort analysis of data from children living with HIV who were younger than 5 years at ART initiation from 45 paediatric sites in 16 low-income, lower-middle-income, and upper-middle-income countries in sub-Saharan Africa (Benin, Burundi, Côte d'Ivoire, Democratic Republic of the Congo, Ghana, Kenya, Lesotho, Malawi, Mali, Mozambique, Rwanda, South Africa, Togo, Uganda, Zambia, and Zimbabwe). Outcomes were trends in patient characteristics at ART initiation (age, weight, height, and CD4%), and comparisons of mortality and loss to follow-up during ART over time and in various economic settings. We identified risk factors for mortality using Cox proportional hazards models. Each participating region had relevant institutional ethics review board approvals to contribute data to the analysis. FINDINGS We included 32 221 children living with HIV and initiating ART younger than 5 years between Jan 1, 2006, and Dec 31, 2017. Median age at ART initiation was 20·4 months (IQR 9·4-36·0) in 2006-10, 19·2 months (8·3-33·6) in 2011-13, and 19·2 months (8·8-33·7) in 2014-17. Median age at ART initiation was 13·2 months (IQR 4·7-26·8) in upper-middle-income countries, 22·6 months (13·2-37·5) in lower-middle-income countries and 24·2 months (13·5-39·1) in low-income countries. The proportion of children initiating ART younger than 3 months increased from 770 (5·1%) of 14 943 children in 2006-10 to 728 (10·0%) of 7290 children in 2014-17. The proportion of children initiating ART with severe immunosuppression decreased from 5469 (74·7%) of 7314 children for whom CD4% data were available in 2006-10 to 2353 (55·2%) of 4269 children in 2014-17. Mortality at 24 months on ART decreased from 970 (6·5%) of 14 943 children in 2006-10 to 214 (2·9%) of 7290 children in 2014-17. Loss to follow-up was 20·5% (95% CI 20·1-21·0) overall, and was similar across time periods. In multivariable analysis, lower mortality was observed for more recent ART initiation cohorts (adjusted hazard ratio 0·70, 95% CI 0·63-0·79 for 2011-13; 0·53, 0·45-0·72 for 2014-17 vs 2006-10) and for those residing in an upper-middle-income country (0·42, 0·35-0·49 vs low-income countries). INTERPRETATION Mortality declined significantly after universal ART recommendations for children younger than 2 years in 2010 and children younger than 5 years in 2013. However, substantial variations persisted across country income groups, and one in five children continue to be lost to follow-up. Targeted interventions are required to improve outcomes of children living with HIV, especially in the poorest countries. FUNDING National Institute of Allergy and Infectious Disease.
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Affiliation(s)
- Victoria Iyun
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Karl-Gunter Technau
- Empilweni Service and Research Centre, Rahima Moosa Mother and Child Hospital, University of Witwatersrand, Johannesburg, South Africa
| | - Michael Vinikoor
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Marcel Yotebieng
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rachel Vreeman
- Department of Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lisa Abuogi
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Sophie Desmonde
- Inserm U1027, Université Paul Sabatier Toulouse 3, Toulouse, France
| | - Andrew Edmonds
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; Health Impact Assessment, Western Cape Department of Health, Cape Town, South Africa
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Bimer KB, Sebsibe GT, Desta KW, Zewde A, Sibhat MM. Incidence and predictors of attrition among children attending antiretroviral follow-up in public hospitals, Southern Ethiopia, 2020: a retrospective study. BMJ Paediatr Open 2021; 5:e001135. [PMID: 34514177 PMCID: PMC8386224 DOI: 10.1136/bmjpo-2021-001135] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/31/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND It is a global challenge to enrol and retain paediatric patients in HIV/AIDS care. Attrition causes preventable transmission, stoppable morbidity and death, undesirable treatment outcomes, increased cost of care and drug resistance. Thus, this study intended to investigate the incidence and predictors of attrition among children receiving antiretroviral treatment (ART). METHOD A retrospective follow-up study was conducted among children <15 years who had ART follow-up in Gedeo public hospitals. After collection, data were entered into Epi-data V.4.6, then exported to and analysed using STATA V.14. Data were described using the Kaplan-Meier statistics, life table and general descriptive statistics. The analysis was computed using the Cox proportional hazard regression model. Covariates having <0.25 p values in the univariate analysis (such as developmental stage, nutritional status, haemoglobin level, adherence, etc) were fitted to multivariable analysis. Finally, statistical significance was declared at a p value of <0.05. RESULTS An overall 254 child charts were analysed. At the end of follow-up, attrition from ART care was 36.2% (92 of 254), of which 70 (76.1%) were lost to follow-up, and 22 (23.9%) children died. About 8145.33 child-months of observations were recorded with an incidence attrition rate of 11.3 per 1000 child-months (95% CI: 9.2 to 13.9), whereas the median survival time was 68.73 months. Decreased haemoglobin level (<10 g/dl) (adjusted HR (AHR)=3.1; 95% CI: 1.4 to 6.9), delayed developmental milestones (AHR=3.6; 95% CI: 1.2 to 10.7), underweight at baseline (AHR=5.9; 95% CI: 1.6 to 21.7), baseline CD4 count ≤200 (AHR=4.4; 95% CI: 1.6 to 12.2), and poor or fair ART adherence (AHR=3.5; 95% CI: 1.5 to 7.9) were significantly associated with attrition. CONCLUSION AND RECOMMENDATION Retention to ART care is challenging in the paediatrics population, with such a high attrition rate. Immune suppression, anaemia, underweight, delayed developmental milestones and ART non-adherence were independent predictors of attrition to ART care. Hence, it is crucial to detect and control the identified predictors promptly. Serious adherence support and strengthened nutritional provision with monitoring strategies are also essential.
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Affiliation(s)
- Kirubel Biweta Bimer
- Pediatrics and Child Health Nursing, Dilla University College of Health Sciences, Dilla, Ethiopia
| | - Girum Teshome Sebsibe
- School of nursing and midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Kalkidan Wondwossen Desta
- School of nursing and midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ashenafi Zewde
- Pediatrics and Child Health Nursing, Dilla University College of Health Sciences, Dilla, Ethiopia
| | - Migbar Mekonnen Sibhat
- Pediatrics and Child Health Nursing, Dilla University College of Health Sciences, Dilla, Ethiopia
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Nearly one in every six HIV-infected children lost from ART follow-up at Debre Markos Referral Hospital, Northwest Ethiopia: A 14-year retrospective follow-up study. PLoS One 2020; 15:e0239013. [PMID: 32931502 PMCID: PMC7491726 DOI: 10.1371/journal.pone.0239013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/27/2020] [Indexed: 11/29/2022] Open
Abstract
Background Although antiretroviral therapy (ART) significantly improves the survival status and quality of life among human immunodeficiency virus (HIV)-infected children, loss to follow-up (LTFU) from HIV-care profoundly affecting the treatment outcomes of this vulnerable population. For better interventions, up-to-date information concerning LTFU among HIV-infected children on ART is vital. However, only a few studies have been conducted in Ethiopia to address this concern. Thus, this study aims to identify the predictors of LTFU among HIV-infected children receiving ART at Debre Markos Referral Hospital. Methods An institution-based retrospective follow-up study was done among 408 HIV-infected children receiving ART at Debre Markos Referral Hospital between 2005 and March 15, 2019. Data were abstracted from the medical records of HIV-infected children using a standardized data abstracted checklist. We used Epi-Data Version 3.1 for data entry and Stata Version 14 for statistical analysis. The Kaplan-Meier survival curve was used to estimate the survival time. A generalized log-rank test was used to compare the survival curves of different categorical variables. Finally, both bi-variable and multivariable Cox proportional hazard regression models were used to identify the predictors of LTFU. Results Of 408 HIV-infected children included in the final analysis, 70 (17.1%) children were LTFU at the end of the study. The overall incidence rate of LTFU among HIV-infected children was found to be 4.5 (95%CI: 3.5–5.7) per 100-child years of observation. HIV-infected children living in rural areas (AHR: 3.2, 95%CI: 2.0–5.3), having fair or poor ART drug adherence (AHR: 2.3, 95%CI: 1.4–3.7), children started ART through test and treat approach (AHR: 2.7, 95%CI: 1.4–5.5), and children started protease inhibiter (PI)-based ART regimens (AHR: 2.2, 95%CI: 1.1–4.4) were at higher risk of LTFU. Conclusion This study found that one in every six HIV-infected children lost form ART follow-up. HIV-infected children living in rural areas, having fair or poor ART drug adherence, started ART based on test and treat approach, and taking PI-based ART regimens were at higher risk of LTFU.
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Nhampossa T, Fernandez S, Augusto O, Fuente-Soro L, Maculuve S, Bernardo E, Saura A, Casellas A, Gonzalez R, Ruperez M, Karajeans E, Vaz P, Menendez C, Buck WC, Naniche D, Lopez-Varela E. Discordant retention of HIV-infected mothers and children: Evidence for a family-based approach from Southern Mozambique. Medicine (Baltimore) 2020; 99:e21410. [PMID: 32769871 PMCID: PMC7593016 DOI: 10.1097/md.0000000000021410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
It is often assumed that children and their caregivers either stay in care together or discontinue together, but data is lacking on caregiver-child retention concordance. We sought to describe the pattern of care among a cohort of human immunodeficiency virus (HIV) infected children and mothers enrolled in care at the Manhiça District Hospital (MDH).This was a retrospective review of routine HIV clinical data collected under a larger prospective HIV cohort study at MDH. Children enrolling HIV care from January 2013 to November 2016 were identified and matched to their mother's HIV clinical data. Retention in care for mothers and children was assessed at 24 months after the child's enrolment. Multinomial logistic regression was performed to evaluate variables associated with retention discordance.For the 351 mother-child pairs included in the study, only 39% of mothers had concordant care status at baseline (23% already active in care, 16% initiated care concurrently with their children). At 24-months follow up, a total of 108 (31%) mother-child pairs were concordantly retained in care, 88 (26%) pairs were concordantly lost to follow up (LTFU), and 149 (43%) had discordant retention. Pairs with concurrent registration had a higher probability of being concordantly retained in care. Children who presented with advanced clinical or immunological stage had increased probability of being concordantly LTFU.High rates of LTFU as well as high proportions of discordant retention among mother-child pairs were found. Prioritization of a family-based care model that has the potential to improve retention for children and caregivers is recommended.
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Affiliation(s)
- Tacilta Nhampossa
- Centro de Investigação em Saúde de Manhiça (CISM)
- Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique
| | - Sheila Fernandez
- Centro de Investigação em Saúde de Manhiça (CISM)
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | | | - Laura Fuente-Soro
- Centro de Investigação em Saúde de Manhiça (CISM)
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - S.ó.nia Maculuve
- Centro de Investigação em Saúde de Manhiça (CISM)
- Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique
| | - Edson Bernardo
- Centro de Investigação em Saúde de Manhiça (CISM)
- Serviço Distrital de Saúde, Mulher e Acção Social de Manhiça, Maputo, Mozambique
| | - Anna Saura
- Hospital Clinic de Barcelona, Barcelona, Spain
| | - Aina Casellas
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - Raquel Gonzalez
- Centro de Investigação em Saúde de Manhiça (CISM)
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - Maria Ruperez
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | | | - Paula Vaz
- Fundação Ariel Glaser, Maputo, Mozambique
| | - Clara Menendez
- Centro de Investigação em Saúde de Manhiça (CISM)
- Serviço Distrital de Saúde, Mulher e Acção Social de Manhiça, Maputo, Mozambique
| | - W. Chris Buck
- University of California Los Angeles David Geffen School of Medicine (UCLA), Los Angeles, CA
| | - Denise Naniche
- Centro de Investigação em Saúde de Manhiça (CISM)
- Serviço Distrital de Saúde, Mulher e Acção Social de Manhiça, Maputo, Mozambique
| | - Elisa Lopez-Varela
- Centro de Investigação em Saúde de Manhiça (CISM)
- Serviço Distrital de Saúde, Mulher e Acção Social de Manhiça, Maputo, Mozambique
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Abebe Moges N, Olubukola A, Micheal O, Berhane Y. HIV patients retention and attrition in care and their determinants in Ethiopia: a systematic review and meta-analysis. BMC Infect Dis 2020; 20:439. [PMID: 32571232 PMCID: PMC7310275 DOI: 10.1186/s12879-020-05168-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 06/17/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND There is paucity of evidence on the magnitude of HIV patients' retention and attrition in Ethiopia. Hence, the aim of this study was to determine the pooled magnitude of HIV patient clinical retention and attrition and to identify factors associated with retention and attrition in Ethiopia. METHODS Systematic review and meta-analysis were done among studies conducted in Ethiopia using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Both published and unpublished studies conducted from January 1, 2005 to June 6th, 2019 were included. Major databases and search engines such as Google Scholar, PUBMED, African Journals Online (AJOL) and unpublished sources were searched to retrieve relevant articles. Data were assessed for quality, heterogeneity and publication bias. Analysis was conducted using STATA version 14 software. RESULT From a total of 45 studies 546,250 study participants were included in this review. The pooled magnitude of retention in care among HIV patients was 70.65% (95% CI, 68.19, 73.11). The overall magnitude of loss to follow up 15.17% (95% CI, 11.86, 18.47), transfer out 11.17% (95% CI, 7.12, 15.21) and death rate were 6.75% (95% CI, 6.22, 7.27). Major determinants of attrition were being unmarried patient (OR 1.52, 95% CI: 1.15-2.01), non-disclosed HIV status (OR 6.36, 95% CI: 3.58-11.29), poor drug adherence (OR 6.60, 95% CI: 1.41-30.97), poor functional status (OR 2.11, 95% CI: 1.33-3.34), being underweight (OR 2.21, 95% CI: 1.45-3.39) and advanced clinical stage (OR 1.85, 95% CI: 1.36-2.51). Whereas absence of opportunistic infections (OR 0.52, 95% CI: 0.30-0.9), normal hemoglobin status (OR 0.29, 95% CI: 0.20-0.42) and non-substance use (OR 95% CI: 0.41, 0.17-0.98) were facilitators of HIV patient retention in clinical care. CONCLUSION The level of retention to the care among HIV patients was low in Ethiopia. Socio-economic, clinical, nutritional and behavioral, intervention is necessary to achieve adequate patient retention in clinical care.
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Affiliation(s)
- Nurilign Abebe Moges
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
- Pan African University, Life and Earth Sciences Including Health and Agriculture Institute (PAULESI), University of Ibadan, Ibadan, Nigeria
| | - Adesina Olubukola
- Department of Obstetrics and Gynecology, University College Hospital, University of Ibadan, Ibadan, Nigeria
| | - Okunlola Micheal
- Department of Obstetrics and Gynecology, University College Hospital, University of Ibadan, Ibadan, Nigeria
| | - Yemane Berhane
- Department of Epidemiology, Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
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Mboweni SH, Makhado L. Conceptual framework for strengthening nurse-initiated management of antiretroviral therapy training and implementation in North West province. Health SA 2020; 25:1285. [PMID: 32161674 PMCID: PMC7059635 DOI: 10.4102/hsag.v25i0.1285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 10/15/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The implementation of nurse-initiated management of antiretroviral therapy (NIMART) management training is a challenge in the primary health care (PHC). It is evident from the literature reviewed and the data obtained from the North West province that gaps still exist. There is no conceptual framework providing guidance to NIMART training and implementation. AIM Therefore, the aim of this study was to develop a conceptual framework to strengthen NIMART training and implementation in the North West province to improve patients and human immunodeficiency virus (HIV) programme outcomes. SETTING The study was conducted in the North West Province, South Africa. METHODS A pragmatic, explanatory, sequential, mixed-methods research design was followed. A descriptive and explorative programme evaluation design was used. Data were collected from two sources: antiretroviral therapy (ART) statistics from District Health Information System (DHIS) & Tier.net of 10 PHC facilities to evaluate and determine the impact of NIMART on the HIV programme and five focus group discussions conducted amongst 28 NIMART nurses and three HIV programme managers to describe challenges influencing NIMART training and implementation. RESULTS The study revealed that there was low ART initiation compared to the number of clients who tested HIV-positive. There was poor monitoring of patients on ART, which was evident in the low viral load collection and suppression, high loss to follow-up and deaths related to HIV. Challenges exist and this was confirmed by the qualitative findings, including human resource ratios, training and mentoring and the entire absence of a conceptual framework or model that guides training and implementation. CONCLUSION The study findings were conceptualised to describe and develop a framework needed to facilitate and influence NIMART training and implementation to improve the HIV programme and patient outcomes. Dickoff, James and Wiedenbach's practice-oriented theory and Donabedian's structure process outcomes model provided a starting point in the ultimate development of the framework. Although the study was limited to the North West province's PHC clinics and community health centres and did not include hospitals, it is of high significance as there is no such conceptual framework in the province or in even South Africa.
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Affiliation(s)
| | - Lufuno Makhado
- School of Health Science, University of Venda, Thohoyandou, South Africa
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Makurumidze R, Mutasa-Apollo T, Decroo T, Choto RC, Takarinda KC, Dzangare J, Lynen L, Van Damme W, Hakim J, Magure T, Mugurungi O, Rusakaniko S. Retention and predictors of attrition among patients who started antiretroviral therapy in Zimbabwe's national antiretroviral therapy programme between 2012 and 2015. PLoS One 2020; 15:e0222309. [PMID: 31910445 PMCID: PMC6946589 DOI: 10.1371/journal.pone.0222309] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/17/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The last evaluation to assess outcomes for patients receiving antiretroviral therapy (ART) through the Zimbabwe public sector was conducted in 2011, covering the 2007-2010 cohorts. The reported retention at 6, 12, 24 and 36 months were 90.7%, 78.1%, 68.8% and 64.4%, respectively. We report findings of a follow-up evaluation for the 2012-2015 cohorts to assess the implementation and impact of recommendations from this prior evaluation. METHODS A nationwide retrospective study was conducted in 2016. Multi-stage proportional sampling was used to select health facilities and study participants records. The data extracted from patient manual records included demographic, baseline clinical characteristics and patient outcomes (active on treatment, died, transferred out, stopped ART and lost to follow-up (LTFU)) at 6, 12, 24 and 36 months. The data were analysed using Stata/IC 14.2. Retention was estimated using survival analysis. The predictors associated with attrition were determined using a multivariate Cox regression model. RESULTS A total of 3,810 participants were recruited in the study. The median age in years was 35 (IQR: 28-42). Overall, retention increased to 92.4% (p-value = 0.060), 86.5% (p-value<0.001), 79.2% (p-value<0.001) and 74.4% (p-value<0.001) at 6, 12, 24 and 36 months respectively. LTFU accounted for 98% of attrition. Being an adolescent or a young adult (15-24 years) (vs adult;1.41; 95% CI:1.14-1.74), children (<15years) (vs adults; aHR 0.64; 95% CI:0.46-0.91), receiving care at primary health care facility (vs central and provincial facility; aHR 1.23; 95% CI:1.01-1.49), having initiated ART between 2014-2015 (vs 2012-2013; aHR1.45; 95%CI:1.24-1.69), having WHO Stage IV (vs Stage I-III; aHR2.06; 95%CI:1.51-2.81) and impaired functional status (vs normal status; aHR1.25; 95%CI:1.04-1.49) predicted attrition. CONCLUSION The overall retention was higher in comparison to the previous 2007-2010 evaluation. Further studies to understand why attrition was found to be higher at primary health care facilities are warranted. Implementation of strategies for managing patients with advanced HIV disease, differentiated care for adolescents and young adults and tracking of LTFU clients should be prioritised to further improve retention.
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Affiliation(s)
- Richard Makurumidze
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
- Institute of Tropical Medicine, Antwerp, Belgium
- Gerontology, Faculty of Medicine & Pharmacy, Free University of Brussels (VUB), Brussels, Belgium
| | | | - Tom Decroo
- Institute of Tropical Medicine, Antwerp, Belgium
- Research Foundation of Flanders, Brussels, Belgium
| | - Regis C. Choto
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
| | - Kudakwashe C. Takarinda
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Janet Dzangare
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
| | | | - Wim Van Damme
- Institute of Tropical Medicine, Antwerp, Belgium
- Gerontology, Faculty of Medicine & Pharmacy, Free University of Brussels (VUB), Brussels, Belgium
| | - James Hakim
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | - Owen Mugurungi
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
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Carlucci JG, Liu Y, Clouse K, Vermund SH. Attrition of HIV-positive children from HIV services in low and middle-income countries. AIDS 2019; 33:2375-2386. [PMID: 31764102 PMCID: PMC6905128 DOI: 10.1097/qad.0000000000002366] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Identification and retention of HIV-positive children in HIV services is essential to ensure optimal health outcomes. This systematic review and meta-analysis examines the magnitude of attrition [loss to follow-up (LTFU) and death) of HIV-positive children from HIV services in low and middle-income countries (LMICs). METHODS We performed a comprehensive multidatabase search of original studies reporting retention/attrition data for HIV-positive children in LMICs through April 2016. Outcomes included LTFU, death, and overall attrition (LTFU + death) at intervals up to 60 months of follow-up. At least two authors determined study eligibility, performed data extraction, and made quality assessments. We used random-effects meta-analytic methods to aggregate effect sizes and perform meta-regression analyses. RESULTS We identified 3040 unique studies; 91 met eligibility criteria and were included in the analysis. This represents 147 129 HIV-positive children; most were from Africa (83%). LTFU definitions varied widely, with significant variability in outcomes across studies. Most attrition occurred in the first 6 months of follow-up, increasing to 23% by 36 months. HIV-positive children receiving antiretroviral therapy (ART) had significantly better retention in care than those not on ART. Studies that performed case-finding/tracing for those LTFU had better retention in care up to 24 months of follow-up. CONCLUSIONS These findings underscore the high attrition of children from HIV services in LMICs. Early ART initiation and decentralized patient support services (e.g. tracing for those LTFU) have potential to improve retention in care. Implementation research and resources are urgently needed to improve retention among this vulnerable population.
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Affiliation(s)
- James G. Carlucci
- Vanderbilt Institute for Global Health, Vanderbilt
University Medical Center, Nashville, Tennessee, USA
- Division of Pediatric Infectious Diseases, Department of
Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yu Liu
- Department of Public Health Sciences, School of Medicine
and Dentistry, University of Rochester, Rochester, New York, USA
| | - Kate Clouse
- Vanderbilt Institute for Global Health, Vanderbilt
University Medical Center, Nashville, Tennessee, USA
- School of Nursing, Vanderbilt University, Nashville,
Tennessee, USA
| | - Sten H. Vermund
- Yale School of Public Health, Yale University, New Haven,
Connecticut, USA
- Department of Pediatrics, Yale School of Medicine, Yale
University, New Haven, Connecticut, USA
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Matsena Zingoni Z, Chirwa TF, Todd J, Musenge E. HIV Disease Progression Among Antiretroviral Therapy Patients in Zimbabwe: A Multistate Markov Model. Front Public Health 2019; 7:326. [PMID: 31803702 PMCID: PMC6873884 DOI: 10.3389/fpubh.2019.00326] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 10/23/2019] [Indexed: 12/21/2022] Open
Abstract
Background: Antiretroviral therapy (ART) impact has prolonged survival of people living with HIV. We evaluated HIV disease progression among ART patients using routinely collected patient-level data between 2004 and 2017 in Zimbabwe. Methods: We partitioned HIV disease progression into four transient CD4 cell counts states: state 1 (CD4 ≥ 500 cells/μl), state 2 (350 cells/μl ≤ CD4 < 500 cells/μl), state 3 (200 cells/μl ≤ CD4 < 350 cells/μl), state 4 (CD4 < 200 cells/μl), and the absorbing state death (state 5). We proposed a semiparametric time-homogenous multistate Markov model to estimate bidirectional transition rates. Covariate effects (age, gender, ART initiation period, and health facility level) on the transition rates were assessed. Results: We analyzed 204,289 clinic visits by 63,422 patients. There were 24,325 (38.4%) patients in state 4 (CD4 < 200) at ART initiation, and 7,995 (12.6%) deaths occurred by December 2017. The overall mortality rate was 3.9 per 100 person-years. The highest mortality rate of 5.7 per 100 person-years (4,541 deaths) was from state 4 (CD4 < 200) compared to other states. Mortality rates decreased with increase in time since ART initiation. Health facility type was the strongest predictor for immune recovery. Provincial or central hospital patients showed a diminishing dose-response effect on immune recovery by state from a hazard ratio (HR) of 8.30 [95% confidence interval (95% CI), 6.64-10.36] (state 4 to 3) to HR of 3.12 (95% CI, 2.54-4.36) (state 2 to 1) compared to primary healthcare facilities. Immune system for male patients was more likely to deteriorate, and they had a 32% increased mortality risk (HR, 1.32; 95% CI, 1.23-1.42) compared to female patients. Elderly patients (45+ years) were more likely to immune deteriorate compared to 25-34 years age group: HR, 1.35; 95% CI, 1.18-1.54; HR, 1.56; 95% CI, 1.34-1.81 and HR, 1.53; 95% CI, 1.32-1.79 for states 1 to 2, state 2 to 3, and states 3 to 4, respectively. Conclusion: Immune recovery was pronounced among provincial or central hospitals. Male patients with lower CD4 cell counts were at a higher risk of immune deterioration and mortality, while elderly patients were more likely to immune deteriorate. Early therapeutic interventions when the immune system is relatively stable across gender and age may contain mortality and increase survival outcomes. Interventions which strengthen ART services in primary healthcare facilities are essential.
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Affiliation(s)
- Zvifadzo Matsena Zingoni
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Ministry of Health and Child Care, National Institute of Health Research, Harare, Zimbabwe
| | - Tobias F Chirwa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jim Todd
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Eustasius Musenge
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Zvandiri-Bringing a Differentiated Service Delivery Program to Scale for Children, Adolescents, and Young People in Zimbabwe. J Acquir Immune Defic Syndr 2019; 78 Suppl 2:S115-S123. [PMID: 29994833 DOI: 10.1097/qai.0000000000001737] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Since 2004, there has been a dramatic shift in the HIV response for children, adolescents, and young people in low resource settings. Previous programs and services were largely orientated to adults. This is now changing, but there is limited evidence on how to take services for children, adolescents, and young people living with HIV (CAYPLHIV) to scale. Zvandiri is a theoretically grounded, multicomponent-differentiated service delivery model for children, adolescents, and young people in Zimbabwe that integrates peer-led, community interventions within government health services. Africaid analyzed routine program and other data from November 2004 to October 2017 to document Zvandiri scale-up, framed by the World Health Organization framework for scaling up interventions. Since 2004, Zvandiri has evolved from one support group in Harare into a comprehensive model, combining community- and clinic-based health services and psychosocial support for CAYPLHIV. Zvandiri was scaled up across Zimbabwe through phased expansion into 51 of 63 districts, reaching 40,213 CAYPLHIV. Evidence indicates that this approach improved uptake of HIV testing services, adherence, and retention in care. The environment and strategic choices were critical when taking the model to scale, particularly nesting the program within existing services, and capacity strengthening of service providers working jointly with trained, mentored CAYPLHIV. The results provide a firm foundation for programming and from which to build evidence of sustainable impact. Formal impact evaluation is needed and underway. These program data contribute to the essential evidence base on strategic approaches to assist in planning services for this relatively neglected group.
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Making Implementation Science Work for Children and Adolescents Living With HIV. J Acquir Immune Defic Syndr 2019; 78 Suppl 1:S58-S62. [PMID: 29994921 PMCID: PMC6044463 DOI: 10.1097/qai.0000000000001750] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The global HIV response is leaving children and adolescents behind. Because of a paucity of studies on treatment and care models for these age groups, there are gaps in our understanding of how best to implement services to improve their health outcomes. Without this evidence, policymakers are left to extrapolate from adult studies, which may not be appropriate, and can lead to inefficiencies in service delivery, hampered uptake, and ineffective mechanisms to support optimal outcomes. Implementation science research seeks to investigate how interventions known to be efficacious in study settings are, or are not, routinely implemented within real-world programmes. Effective implementation science research must be a collaborative effort between government, funding agencies, investigators, and implementers, each playing a key role. Successful implementation science research in children and adolescents requires clearer policies about age of consent for services and research that conform to ethical standards but allow for rational modifications. Implementation research in these age groups also necessitates age-appropriate consultation and engagement of children, adolescents, and their caregivers. Finally, resource, systems, technology, and training must be prioritized to improve the availability and quality of age-/sex-disaggregated data. Implementation science has a clear role to play in facilitating understanding of how the multiple complex barriers to HIV services for children and adolescents prevent effective interventions from reaching more children and adolescents living with HIV, and is well positioned to redress gaps in the HIV response for these age groups. This is truer now more than ever, with urgent and ambitious 2020 global targets on the horizon and insufficient progress in these age groups to date.
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Fernández-Luis S, Fuente-Soro L, Augusto O, Bernardo E, Nhampossa T, Maculuve S, Manning Hernández T, Naniche D, López-Varela E. Reengagement of HIV-infected children lost to follow-up after active mobile phone tracing in a rural area of Mozambique. J Trop Pediatr 2019; 65:240-248. [PMID: 30101345 DOI: 10.1093/tropej/fmy041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Retention in care and reengagement of lost to follow-up (LTFU) patients are priority challenges in pediatric HIV care. We aimed to assess whether a telephone-call active tracing program facilitated reengagement in care (RIC) in the Manhiça District Hospital, Mozambique. METHODS Telephone tracing of LTFU children was performed from July 2016 to March 2017. Both ART (antiretroviral treatment) and preART patients were included in this study. LTFU was defined as not attending the clinic for ≥120 days after last attended visit. Reengagement was determined 3 months after an attempt to contact. RESULTS A total of 144 children initially identified as LTFU entered the active tracing program and 37 were reached by means of telephone tracing. RIC was 57% (95% CI, 39-72%) among children who could be reached versus 18% (95% CI, 11-26%) of those who could not be reached (p = 0.001). CONCLUSION Telephone tracing could be an effective tool for facilitating reengagement in pediatric HIV care. However, the difficulty of reaching patients is an obstacle that can undermine the program.
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Affiliation(s)
- Sheila Fernández-Luis
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Laura Fuente-Soro
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Orvalho Augusto
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Edson Bernardo
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,Serviços Distritais de Saude, Ministerio de Saude, Mozambique
| | - Tacilta Nhampossa
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Sonia Maculuve
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | | | - Denise Naniche
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Elisa López-Varela
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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Minn AC, Kyaw NTT, Aung TK, Mon OM, Htun T, Oo MM, Moe J, Mon AA, Satyanarayana S, Oo HN. Attrition among HIV positive children enrolled under integrated HIV care programme in Myanmar: 12 years cohort analysis. Glob Health Action 2019; 11:1510593. [PMID: 30191749 PMCID: PMC6136349 DOI: 10.1080/16549716.2018.1510593] [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] [Indexed: 11/16/2022] Open
Abstract
Background: In Myanmar, HIV seropositive children are being enrolled in an integrated HIV care (IHC) Program for HIV treatment and care since 2005. Objectives: To assess the: (a) attrition (death or loss-to-follow-up) rates among children (aged ≥ 18 months to < 15 years) enrolled into the programme before and after initiation of anti-retroviral therapy (ART) (pre-ART and ART periods); (b) demographic and clinical factors associated with attrition during these two periods. Methods: Children enrolled in IHC Programme and their status (death, lost to follow-up, regular follow-up or transferred out) was assessed as on 30 June 2017. Attrition rates (per 100 person-years) at pre – ART and ART periods were calculated and the association between demographic and clinical characteristics with attrition was assessed using Cox proportional hazards model. Results: Among 2,736 children enrolled, pre-ART attrition rate was 19 per 100 person-years of follow-up (95% CI: 17–21) and ART attrition rate was 4 per 100 person-years of follow-up (95% CI: 3–4) with higher levels during the initial few months of enrolment. The 36-month retention rates during pre-ART period was 75% (95% CI: 72–78) and during ART period was 87% (95% CI: 86–88). The children ‘at enrolment’ with relatively lower levels of haemoglobin, immune deficiency, underweight for age, higher WHO clinical stages, presence of hepatitis B infection had higher hazards of attrition in both periods. Conclusion: The attrition rates are high particularly among children with relatively poorer clinical, nutritional profiles at enrolment. The study suggests the urgent need for improving adherence counselling especially during the initial few months of enrolment and early ART initiation.
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Affiliation(s)
- Aung Chan Minn
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Nang Thu Thu Kyaw
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Thet Ko Aung
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Ohn Mar Mon
- b Ministry of Health and Sports (MOHS) , 550 bedded Children Hospital , Mandalay , Myanmar
| | - Thurain Htun
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Myo Minn Oo
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - July Moe
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Aye Aye Mon
- a International Union Against Tuberculosis and Lung Disease , Myanmar country office , Mandalay , Myanmar
| | - Srinath Satyanarayana
- c Center for Operational Research , International Union Against Tuberculosis and Lung Diseases , Paris , France
| | - Htun Nyunt Oo
- d National AIDS Program, Department of Public Health , Ministry of Health and Sports , Nay Pyi Taw , Myanmar
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Ahmed I, Lemma S. Mortality among pediatric patients on HIV treatment in sub-Saharan African countries: a systematic review and meta-analysis. BMC Public Health 2019; 19:149. [PMID: 30717720 PMCID: PMC6360742 DOI: 10.1186/s12889-019-6482-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/25/2019] [Indexed: 12/29/2022] Open
Abstract
Background Despite substantial improvements in accessibility of Anti-Retroviral Treatment (ART), death of children on ART remains a prevailing challenge in sub-Saharan African (SSA) countries. However, the pooled magnitude of mortality at different ART follow-up periods remains unknown for the region. We estimated the pooled proportion of all-cause mortality for pediatric patients receiving first-line ART at 3, 6, 12, and 24 months follow-up period in SSA. Methods We searched for relevant articles published between January 2014 and June 2018 on PubMed, Hinari and Google scholar databases. We searched for additional articles from reference lists and 2014–2018 abstracts archived by the Conference on Retroviruses and Opportunistic Infections (CROI) and the International AIDS Society Conference on HIV Science (IAS). Results We reviewed 29 articles reporting mortality among pediatric ART patients at different follow-up periods in countries from 2001 to 2016. Among the 51,619 pediatric ART patients in these cohorts, studies reported 4061 (7.9%) all-cause cumulative death. The cumulative pooled proportion of mortality at 3, 6, 12 and 24 months of ART were 3% (95% CI: 3.0–4.0), 5% (95% CI: 4.0–6.0), 6% (95% CI: 5.0–7.0) and 7% (95% CI: 6.0–8.0), respectively. Conclusions In SSA, significant proportion of mortality among children occurs in the first 3–6 months of ART initiation. Western Africa has a little higher estimate of mortality among pediatric ART patients at 6 and 12 months of follow-up. Strategies to prevent early mortality including thorough screening and management of opportunistic infections before ART initiation are needed. Electronic supplementary material The online version of this article (10.1186/s12889-019-6482-1) contains supplementary material, which is available to authorized users.
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Boeke CE, Nabitaka V, Rowan A, Guerra K, Nawaggi P, Mulema V, Bigira V, Magongo E, Mucheri P, Musoke A, Katureebe C. Results from a proactive follow-up intervention to improve linkage and retention among people living with HIV in Uganda: a pre-/post- study. BMC Health Serv Res 2018; 18:949. [PMID: 30522484 PMCID: PMC6282267 DOI: 10.1186/s12913-018-3735-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 11/19/2018] [Indexed: 11/12/2022] Open
Abstract
Background Despite gains in HIV testing and treatment access in sub-Saharan Africa, patient attrition from care remains a problem. Evidence is needed of real-world implementation of low-cost, scalable, and sustainable solutions to reduce attrition. We hypothesized that more proactive patient follow-up and enhanced counseling by health facilities would improve patient linkage and retention. Methods At 20 health facilities in Central Uganda, we implemented a quality of care improvement intervention package that included training lay health workers in best practices for patient follow-up and counseling, including improved appointment recordkeeping, phone calls and home visits to lost patients, and enhanced adherence counseling strategies; and strengthening oversight of these processes. We compared patient linkage to and retention in HIV care in the 9 months before implementation of the intervention to the 9 months after implementation. Data were obtained from facility-based registers and files and analysed using multivariable logistic regression. Results Among 1900 patients testing HIV-positive during the study period, there was not a statistically significant increase in linkage to care after implementing the intervention (52.9% versus 54.9%, p = 0.63). However, among 1356 patients initiating antiretroviral therapy during the follow-up period, there were statistically significant increases in patient adherence to appointment schedules (44.5% versus 55.2%, p = 0.01) after the intervention. There was a small increase in Ministry of Health-defined retention in care (71.7% versus 75.7%, p = 0.12); when data from the period of intervention ramp-up was dropped, this increase became statistically significant (71.7% versus 77.6%, p = 0.01). The increase in retention was more dramatic for patients under age 19 years (N = 84; 64.0% versus 83.9%, p = 0.01). The cost per additional patient retained in care was $47. Conclusions Improving patient tracking and counseling practices was relatively low cost and enhanced patient retention in care, particularly for pediatric and adolescent patients. This approach should be considered for scale-up in Uganda and elsewhere. However, no impact was seen in improved patient linkage to care with this proactive follow-up intervention. Trial registration Pan African Clinical Trial Registry #PACTR201611001756166. Registered August 31, 2016.
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Affiliation(s)
- Caroline E Boeke
- Clinton Health Access Initiative (CHAI), 383 Dorchester Road, Suite 400, Boston, MA, 02127, USA.
| | | | | | - Katherine Guerra
- Clinton Health Access Initiative (CHAI), 383 Dorchester Road, Suite 400, Boston, MA, 02127, USA
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Pilgrim NA, Okal J, Matheka J, Mukui I, Kalibala S. Challenges to and opportunities for the adoption and routine use of early warning indicators to monitor pediatric HIV drug resistance in Kenya. BMC Pediatr 2018; 18:243. [PMID: 30045700 PMCID: PMC6060498 DOI: 10.1186/s12887-018-1209-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 07/03/2018] [Indexed: 11/11/2022] Open
Abstract
Background Pediatric non-adherence to antiretroviral therapy (ART), loss to follow-up, and HIV drug resistance (HIVDR) are challenges to achieving UNAIDS’ targets of 90% of those diagnosed HIV-positive receiving treatment, and 90% of those receiving treatment achieving viral suppression. In Kenya, the pediatric population represents 8% of total HIV infections and pediatric virological failure is estimated at 33%. The monitoring of early warning indicators (EWIs) for HIVDR can help to identify and correct gaps in ART program functioning to improve HIV care and treatment outcomes. However, EWIs have not been integrated into health systems. We assessed challenges to the use of EWIs and solutions to challenges identified by frontline health administrators. Methods We conducted key informant interviews with health administrators who were fully knowledgeable of the ART program at 23 pediatric ART sites in 18 counties across Kenya from May to June 2015. Thematic content analysis identified themes for three EWIs: on-time pill pick-up, retention in care, and virological suppression. Results Nine themes—six at the facility level and three at the patient level—emerged as major challenges to EWI monitoring. At the facility level, themes centered on system issues (e.g., slow return of viral load results), staff shortages and inadequate adherence counseling skills, lack of effective patient tracking and linkage systems, and lack of support for health personnel. At the patient level, themes focused on stigma, non-disclosure of HIV status to children who are age eligible, and little engagement of guardians in the children’s care. Practical solutions identified included the use of lay health workers (e.g., peer educators, community health workers) to implement a variety of care and treatment tasks, whole facility approaches to adherence counseling, adolescent peer support groups, and working with children directly as soon as they are age eligible. Discussion The monitoring of EWIs has not been routine in health facilities in Kenya due to several challenges. However, facilities have implemented novel strategies to address some of these barriers. Future work is needed to assess whether scale-up of some of these approaches can aid in the effective use of EWIs and improving HIV care outcomes among the pediatric population.
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Affiliation(s)
- Nanlesta A Pilgrim
- Population Council, 4301 Connecticut Avenue NW, Suite 280, Washington, DC, 20008, USA.
| | | | | | - Irene Mukui
- National AIDS & STI Control Programme, Nairobi, Kenya
| | - Samuel Kalibala
- Population Council, 4301 Connecticut Avenue NW, Suite 280, Washington, DC, 20008, USA
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Chandiwana N, Sawry S, Chersich M, Kachingwe E, Makhathini B, Fairlie L. High loss to follow-up of children on antiretroviral treatment in a primary care HIV clinic in Johannesburg, South Africa. Medicine (Baltimore) 2018; 97:e10901. [PMID: 30024494 PMCID: PMC6086461 DOI: 10.1097/md.0000000000010901] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Outcomes of HIV-infected children have improved dramatically over the past decade, but are undermined by patient loss to follow-up (LTFU). We assessed patterns of LTFU among HIV-infected children receiving antiretroviral treatment (ART) at a large inner-city HIV clinic in Johannesburg, South Africa between 2005 and 2014.Demographic and clinical data were extracted from clinic records of children under 12 years. Differences between characteristics of children retained in care and LTFU were assessed using Wilcoxon rank sum tests or Pearson χ tests. Cox proportional hazard models then identified characteristics associated with LTFU.Of 135 children, the median age at ART initiation was 21.5 months (IQR: 6.3-47.7) with a median follow-up time of 3.3 years (IQR: 1.4-5.0). The incidence rate of LTFU was 10.8 per 100 person-years (95% CI: 8.2-14.4); cumulatively 36% of children were LTFU. Almost a third (n = 39) of children missed a clinic visit, but then returned to care; 77% of these were eventually LTFU. In total, 18% of children had elevated viral loads after 6 or more months of ART. Older age at ART initiation (18-59 months: aHR 1.6, 95% CI: 3.9-14.2) and ever missing a clinic visit (aHR 7.4 95% CI: 3.9-14.2) were independent predictors of LTFU.High rates of LTFU were observed in this primary care clinic. Risks for LTFU included older age (>18 months old) and missed clinic visits. Identifying children who miss scheduled visits and developing strategies directed at retaining them in care is critical to improving long-term pediatric HIV outcomes.
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Affiliation(s)
- Nomathemba Chandiwana
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | - Shobna Sawry
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | - Matthew Chersich
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | - Elizabeth Kachingwe
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
| | | | - Lee Fairlie
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand
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Validity of reported retention in antiretroviral therapy after roll-out to peripheral facilities in Mozambique: Results of a retrospective national cohort analysis. PLoS One 2018; 13:e0198916. [PMID: 29927961 PMCID: PMC6013210 DOI: 10.1371/journal.pone.0198916] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 05/29/2018] [Indexed: 12/29/2022] Open
Abstract
Background Retention in anti-retroviral therapy (ART) presents a challenge in sub-Saharan Africa. In Mozambique, after roll-out to peripheral facilities, the 12-month retention rate was reported mostly from sites with an electronic patient tracking system (EPTS), representing only 65% of patients. We conducted a nationally representative study, compared 12-month retention at EPTS and non-EPTS sites, and its predictors. Methods Applying a proportionate to population size sampling strategy, we obtained a nationally representative sample of patients who initiated ART between January 2013 and June 2014. We calculated weighted proportions of the patients’ status at 12 months after ART initiation, and 12-month incidence of lost to follow-up (LTFU) and death. We assessed determinants of LTFU and death by calculating adjusted hazard ratios (AHR) through multivariate cox-proportional hazard models. Results Among 19,297 patients sampled, 54.3% were still active, 33.1% LTFU, 2.0% dead, 2.6% transferred-out and 8.0% had unknown status, 12 months after ART initiation. Total attrition rate (LTFU or dead) was 45.5/100PY, higher at facilities without EPTS (51.8/100PY) than with EPTS (37.7/100PY). Clinical stage IV (AHR = 1.7), CD4 count ≤150 (AHR = 1.3) and being pregnant (AHR = 1.6) were significantly associated with LTFU. Clinical stage III or IV (AHR = 2.1 and 3.8), CD4 count ≤150 (AHR = 3.0), not being pregnant (AHR = 3.0), and ART regimens with stavudine (AHR = 4.28) were significantly associated with deaths. Patients enrolled in adherence support groups were 4.6 times less likely to be LTFU, but the number (n = 174) was too small to be significant (p = 0.273). Conclusion Retention in ART was substantially lower at non-EPTS sites. EPTS should be expanded to all ART sites to facilitate comprehensive routine monitoring of retention in care. Retention in Mozambique is low and needs to be improved, especially among pregnant women and patients with advanced disease at ART initiation. The effect of ART adherence support groups needs to be further monitored.
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Rates and predictors of attrition among children on antiretroviral therapy in Ethiopia: A prospective cohort study. PLoS One 2018; 13:e0189777. [PMID: 29408897 PMCID: PMC5800538 DOI: 10.1371/journal.pone.0189777] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 11/12/2017] [Indexed: 12/03/2022] Open
Abstract
Introduction Attrition from antiretroviral therapy (ART) programmes is a critical challenge among children receiving care in resource-limited settings. Our objective was to determine the rates and predictors of attrition among children on ART in Ethiopia. Methods Between December 2014 and September 2016, we conducted a prospective cohort study in eight health facilities in Ethiopia. Eligibility criteria included age 3 months–14 years; being on ART for not more than a month. Outcome was attrition due to death and/or loss to follow-up. Predictor variables were child clinical and socio-demographic characteristics, and caregiver socio-demographic characteristics. We used Cox Regression analyses to examine the association between predictors and outcome. Results Of 309 children, 304 were included, 52% were male. Their median age was 9 years (Inter-quartile range, IQR, 6–12). At ART initiation, their median CD4 was 362 cells/mm3 (IQR 231–499); and 74.3% had WHO stage 1 or 2 disease. During 287.7 person-years of observation (PYO), 24 attritions were recorded, yielding an attrition rate of 8.3 per 100 PYO (95% CI 5.4–12.1). Of these, six children were reported dead, leading to a mortality rate of 2.1 per 100 PYO (95% CI 0.8–4.3). Eighteen were lost to follow-up (LTFU) leading to LTFU rate of 6.26 per 100 PYO (95% CI: 3.83–9.70). The majority, 14 (58%) of attrition occurred during the first six months of treatment. Age below three years [aHR] = 5.14 (95% CI: 2.07–12.96), rural residence (aHR = 3.97, 95% CI: 1.34–11.78) and baseline Hgb in g/dl < 10 g/dl [aHR] = 5.68 (95% CI: 2.03–6.23) predicted higher risk of attrition. Baseline Hgb < 10 g/dl (aHR = 16.63, 95% CI: 1.64–168.4) and WHO stage III or IV (aHR = 12.25, 95% CI: 1.26–119.05) predicted the death of the child. Higher attrition was documented among children of both biological parents alive and biologically related close family caregivers. Conclusion Younger children, those from rural areas, and children with anaemia were at higher risk of attrition, especially during the early months of treatment, and therefore should be prioritized during treatment follow-up. Further studies should examine underlying reasons for higher attrition.
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Sikhondze N, Mahomed OH. Retention of children under 18 months testing HIV positive in care in Swaziland: a retrospective study. Pan Afr Med J 2017; 28:316. [PMID: 29721146 PMCID: PMC5927566 DOI: 10.11604/pamj.2017.28.316.13857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 10/06/2017] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Significant progress has been made with respect to the initiation of children on antiretroviral therapy (ART) in Southern Africa including Swaziland, however retention of these children in care poses a major challenge. The aim of the study was to assess retention to care in children testing HIV positive taking into account the number of return child welfare care (CWC) visits the child made. METHODS A retrospective cross sectional study and was conducted at 4 facilities in Swaziland. All children who were HIV infected from 0 to 18 months were identified using the child welfare register (CWC). Infant characteristics were obtained from the child welfare register and early infant diagnosis logbooks. Proportion of patients retained in care were calculated at three, six, nine and twelve months. RESULTS Of the 32 HIV positive children identified tested between December 2014 up to July 2016, sixty eight percent (n = 22) of the children that tested HIV positive were retained at three months, 40.6% at six months, 18.8% at nine months and 12.5% at twelve months. Children that resided in urban areas, more male than female children, children from mothers who were on antiretroviral treatment, children initiated on antiretroviral treatment, mothers on antiretroviral treatment for more than one year and children who received Infant Nevirapine were more likely to be retained. CONCLUSION Facilities are performing well in terms of identifying HIV positive children within the first two months of life and linking them into care. However, as time progresses the retention of children in care declines. Innovative strategies need to be developed to enhance patient retention.
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Affiliation(s)
- Nomvuselelo Sikhondze
- Discipline of Public Health Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Ozayr Haroon Mahomed
- Discipline of Public Health Medicine, University of KwaZulu Natal, Durban, South Africa
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McHugh G, Simms V, Dauya E, Bandason T, Chonzi P, Metaxa D, Munyati S, Nathoo K, Mujuru H, Kranzer K, Ferrand RA. Clinical outcomes in children and adolescents initiating antiretroviral therapy in decentralized healthcare settings in Zimbabwe. J Int AIDS Soc 2017; 20:21843. [PMID: 28872269 PMCID: PMC5719665 DOI: 10.7448/ias.20.1.21843] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 09/01/2017] [Accepted: 08/18/2017] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Decentralized HIV care for adults does not appear to compromise clinical outcomes. HIV care for children poses additional clinical and social complexities. We conducted a prospective cohort study to investigate clinical outcomes in children aged 6-15 years who registered for HIV care at seven primary healthcare clinics (PHCs) in Harare, Zimbabwe. METHODS Participants were recruited between January 2013 and December 2014 and followed for 18 months. Rates of and reasons for mortality, hospitalization and unscheduled PHC attendances were ascertained. Cox proportional modelling was used to determine the hazard of death, unscheduled attendances and hospitalization. RESULTS We recruited 385 participants, median age 11 years (IQR: 9-13) and 52% were female. The median CD4 count was 375 cells/mm3 (IQR: 215-599) and 77% commenced ART over the study period, with 64% of those who had viral load measured achieving an HIV viral load <400 copies/ml. At 18 months, 4% of those who started ART vs. 24% of those who remained ART-naïve were lost-to-follow-up (p < 0.001). Hospitalization and mortality rates were low (8.14/100 person-years (pyrs) and 2.86/100 pyrs, respectively). There was a high rate of unscheduled PHC attendances (34.94/100 pyrs), but only 7% resulted in hospitalization. Respiratory disease was the major cause of hospitalization, unscheduled attendances and death. CD4 count <350cells/mm3 was a risk factor for hospitalization (aHR 3.6 (95%CI 1.6-8.2)). CONCLUSIONS Despite only 64% of participants achieving virological suppression, clinical outcomes were good and high rates of retention in care were observed. This demonstrates that in an era moving towards differentiated care in addition to implementation of universal treatment, decentralized HIV care for children is achievable. Interventions to improve adherence in this age-group are urgently needed.
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Affiliation(s)
- Grace McHugh
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Victoria Simms
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Ethel Dauya
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Tsitsi Bandason
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Prosper Chonzi
- Directorate of Health Services, Harare City Health, Harare, Zimbabwe
| | - Dafni Metaxa
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Shungu Munyati
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Kusum Nathoo
- Department of Paediatrics, University of Zimbabwe, Harare, Zimbabwe
| | - Hilda Mujuru
- Department of Paediatrics, University of Zimbabwe, Harare, Zimbabwe
| | - Katharina Kranzer
- Biomedical Research and Training Institute, Harare, Zimbabwe
- National and Supranational Reference Laboratory, Research Centre Borstel, Germany
| | - Rashida A. Ferrand
- Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Relationship Between Time to Initiation of Antiretroviral Therapy and Treatment Outcomes: A Cohort Analysis of ART Eligible Adolescents in Zimbabwe. J Acquir Immune Defic Syndr 2017; 74:390-398. [PMID: 28002183 PMCID: PMC5321111 DOI: 10.1097/qai.0000000000001274] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is Available in the Text. Background: Age-specific retention challenges make antiretroviral therapy (ART) initiation in adolescents difficult, often requiring a lengthy preparation process. This needs to be balanced against the benefits of starting treatment quickly. The optimal time to initiation duration in adolescents is currently unknown. Objective: To assess the effect of time to ART initiation on mortality and loss to follow-up (LTFU) among treatment eligible adolescents. Methods: We conducted a retrospective cohort analysis among 1499 ART eligible adolescents aged ≥10 to <19 years registered in a public sector HIV program in Bulawayo, Zimbabwe, between 2004 and 2011. Hazard ratios (HR) for mortality and LTFU were calculated for different time to ART durations using multivariate Cox regression models. Results: Median follow-up duration was 1.6 years. Mortality HRs of patients who initiated at 0 to ≤7 days, >14 days to ≤1 month, >1 to ≤2 months, >2 months, and before initiation were 1.59, 1.19, 1.56, 1.08, and 0.94, respectively, compared with the reference group of >7 to ≤14 days. LTFU HRs were 1.02, 1.07, 0.85, 0.97, and 3.96, respectively. Among patients not on ART, 88% of deaths and 85% of LTFU occurred during the first 3 months after becoming ART eligible, but only 37% and 29% among adolescents on ART, respectively. Conclusions: Neither mortality or LTFU was associated with varying time to ART. The initiation process can be tailored to the adolescents' needs and individual life situations without risking to increase poor treatment outcomes. Early mortality was high despite rapid ART initiation, calling for earlier rather than faster initiation through HIV testing scale-up.
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