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Nabukalu D, Yiannoutsos CT, Semeere A, Musick BS, Murungi T, Namulindwa JV, Waswa F, Nakigozi G, Sewankambo NK, Reynolds SJ, Lutalo T, Makumbi F, Kigozi G, Nalugoda F, Wools-Kaloustian K. Mortality Among HIV-Infected Adults on Antiretroviral Therapy in Southern Uganda. J Acquir Immune Defic Syndr 2024; 95:268-274. [PMID: 38408217 PMCID: PMC10898547 DOI: 10.1097/qai.0000000000003330] [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] [Received: 04/10/2023] [Accepted: 07/24/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Monitoring and evaluation of clinical programs requires assessing patient outcomes. Numerous challenges complicate these efforts, the most insidious of which is loss to follow-up (LTFU). LTFU is a composite outcome, including individuals out of care, undocumented transfers, and unreported deaths. Incorporation of vital status information from routine patient outreach may improve the mortality estimates for those LTFU. SETTINGS We analyzed routinely collected clinical and patient tracing data for individuals (15 years or older) initiating antiretroviral treatment between January 2014 and December 2018 at 2 public HIV care clinics in greater Rakai, Uganda. METHODS We derived unadjusted mortality estimates using Kaplan-Meier methods. Estimates, adjusted for unreported deaths, applied weighting through the Frangakis and Rubin method to represent outcomes among LTFU patients who were successfully traced and for whom vital status was ascertained. Confidence intervals were determined through bootstrap methods. RESULTS Of 1969 patients with median age at antiretroviral treatment initiation of 31 years (interquartile range: 25-38), 1126 (57.2%) were female patients and 808 (41%) were lost. Of the lost patients, 640 patient files (79.2%) were found and reviewed, of which 204 (31.8%) had a tracing attempt. Within the electronic health records of the program, 28 deaths were identified with an estimated unadjusted mortality 1 year after antiretroviral treatment initiation of 2.5% (95% CI: 1.8% to 3.3%). Using chart review and patient tracing data, an additional 24 deaths (total 52) were discovered with an adjusted 1-year mortality of 3.8% (95% CI: 2.6% to 5.0%). CONCLUSIONS Data from routine outreach efforts by HIV care and treatment programs can be used to support plausible adjustments to estimates of client mortality. Mortality estimates without active ascertainment of vital status of LTFU patients may significantly underestimate program mortality.
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Affiliation(s)
| | | | - Aggrey Semeere
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | | | | | | | - Nelson K. Sewankambo
- Makerere University College of Health Sciences, School of Medicine, Kampala, Uganda
| | - Steven J. Reynolds
- Division of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
- Johns Hopkins University School of Medicine, Baltimore, MD; and
| | - Tom Lutalo
- Rakai Health Sciences Program, Rakai, Uganda
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Bekolo CE, Ndeso SA, Moifo LL, Mangala N, Yimdjo TD, Ateudjieu J, Kouanfack C, Djam A, Tabah EN, Whegang S, Mapa-Tassou C, Tendongfor N, Nsagha DS, Choukem SP. Universal test and treat in Cameroon: a comparative retrospective analysis of mortality and loss to follow-up before and after a strategic change in approach to HIV care. Pan Afr Med J 2023; 45:191. [PMID: 38020352 PMCID: PMC10656581 DOI: 10.11604/pamj.2023.45.191.40448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/09/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction an increasing number of persons living with HIV (PLHIV) are accessing antiretroviral therapy (ART) since the adoption of the universal test and treat (UTT) policy by Cameroon in 2016. We sought to evaluate the effectiveness of the UTT approach to keep this growing number of PLHIV on a lifelong treatment. Methods a retrospective cohort analysis was conducted at the Nkongsamba Regional Hospital between 2002 and 2020, using routine data to compare the cumulative incidence of loss to follow-up (LTFU) and mortality between PLHIV initiated on ART under UTT guidelines and those initiated under the standard deferred approach. Chi-squared test was used to compare the risk of attrition between the guideline periods while multiple logistic regression modelling was used to adjust for confounders. Results of 1627 PLHIV included for analysis, 756 (46.47%) were enrolled during the era of UTT with 545 (33.54%) initiated on ART on the same day of HIV diagnosis. The transition to the UTT era was associated with an overall reduction in the risk of LTFU by 73% (aOR = 0.27, 95%CI: 0.17 - 0.45). There was modest evidence that the odds of mortality had increased under the UTT policy by about 3-fold (aOR = 2.86, 95%CI: 0.91-8.94). Same-day initiation had no overall effect on LTFU or mortality. LTFU was lower among the same-day initiators in the first 24 months but increased thereafter above the rate among late initiators. Conclusion overall ART programme implementation under the UTT has led to a significant decline in LTFU though mortality appeared to have increased. Ongoing efforts to keep patients on long-term treatment should be sustained while other innovative schemes are sought.
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Affiliation(s)
- Cavin Epie Bekolo
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Sylvester Atanga Ndeso
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Linda Lucienne Moifo
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Nkwele Mangala
- Department of Gynaecology and Obstetrics, University of Douala, Douala, Cameroon
| | | | - Jerome Ateudjieu
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Charles Kouanfack
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Alain Djam
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Earnest Njih Tabah
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Solange Whegang
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Clarisse Mapa-Tassou
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Nicolas Tendongfor
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Dickson Shey Nsagha
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Siméon-Pierre Choukem
- Department of Internal Medicine and Specialities, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
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Leno NN, Guilavogui F, Camara A, Kadio KJJO, Guilavogui T, Diallo TS, Diallo MA, Leno DWA, Ricarte B, Koita Y, Kaba L, Ahiatsi A, Touré N, Traoré P, Chaloub S, Kamano A, Vicente CA, Delamou A, Cissé M. Retention and Predictors of Attrition Among People Living With HIV on Antiretroviral Therapy in Guinea: A 13-Year Historical Cohort Study in Nine Large-Volume Sites. Int J Public Health 2023; 68:1605929. [PMID: 37519433 PMCID: PMC10372218 DOI: 10.3389/ijph.2023.1605929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 05/22/2023] [Indexed: 08/01/2023] Open
Abstract
Objectives: The objective of this study was to estimate the retention rate of patients in an ART program and identify the predictors of attrition. Methods: This was a historical cohort study of HIV patients who started ART between September 2007 and April 2020, and were followed up on for at least 6 months in nine large-volume sites. Kaplan Meier techniques were used to estimate cumulative retention and attrition probabilities. Cox proportional hazards models were used to identify predictors of attrition. Results: The cumulative probability of retention at 12 and 24 months was 76.2% and 70.2%, respectively. The attrition rate after a median follow-up time of 3.1 years was 35.2%, or an incidence of 11.4 per 100 person-years. Having initiated ART between 2012 and 2015; unmarried status; having initiated ART with CD4 count <100 cells/μL; and having initiated ART at an advanced clinical stage were factors significantly associated with attrition. Conclusion: The retention rate in our study is much lower than the proposed national target (90%). Studies to understand the reasons for loss to follow-up are needed.
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Affiliation(s)
- Niouma Nestor Leno
- African Center of Excellence for Prevention and Control of Communicable Diseases (CEA-PCMT), Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University, Conakry, Guinea
- Department of Public Health, Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University Conakry, Conakry, Guinea
- Ministry of Health, Conakry, Guinea
| | - Foromo Guilavogui
- Department of Public Health, Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University Conakry, Conakry, Guinea
- Ministry of Health, Conakry, Guinea
- National AIDS and Hepatitis Control Program, Conakry, Guinea
| | - Alioune Camara
- African Center of Excellence for Prevention and Control of Communicable Diseases (CEA-PCMT), Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University, Conakry, Guinea
- Department of Public Health, Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University Conakry, Conakry, Guinea
- National Malaria Control Program, Conakry, Guinea
| | | | - Timothé Guilavogui
- Department of Public Health, Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University Conakry, Conakry, Guinea
- Ministry of Health, Conakry, Guinea
| | | | | | | | | | - Youssouf Koita
- National AIDS and Hepatitis Control Program, Conakry, Guinea
| | - Laye Kaba
- National AIDS and Hepatitis Control Program, Conakry, Guinea
| | - Arnold Ahiatsi
- National AIDS and Hepatitis Control Program, Conakry, Guinea
| | - Nagnouman Touré
- National AIDS and Hepatitis Control Program, Conakry, Guinea
| | - Pascal Traoré
- Department of Public Health, Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University Conakry, Conakry, Guinea
| | | | - André Kamano
- NGO “Doctors Without Borders Belgium”, Conakry, Guinea
| | | | - Alexandre Delamou
- African Center of Excellence for Prevention and Control of Communicable Diseases (CEA-PCMT), Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University, Conakry, Guinea
- Department of Public Health, Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University Conakry, Conakry, Guinea
- National Center for Education and Research in Rural Health Maférinyah, Forécariah, Guinea
| | - Mohamed Cissé
- Department of Dermatology and Sexually Transmitted Infections, Gamal Abdel Nasser University of Conakry Faculty of Health Sciences and Techniques, Conakry, Guinea
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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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Predictors of loss to follow-up from HIV antiretroviral therapy in Namibia. PLoS One 2022; 17:e0266438. [PMID: 35421126 PMCID: PMC9009635 DOI: 10.1371/journal.pone.0266438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/21/2022] [Indexed: 11/24/2022] Open
Abstract
Despite progress on population-level HIV viral suppression, unknown outcomes amongst people who have initiated antiretroviral therapy (ART) in low- and middle-income countries, commonly referred to as loss to follow-up (LTFU), remains a barrier. The mean global estimate of LTFU is 20%, exceeding the World Health Organization target of <15%. Pervasive predictors associated with LTFU include younger age, low body mass index, low CD4 count, advanced HIV clinical stage and certain ART regimens. In Namibia, ART use by eligible individuals exceeds 85%, surpassing the global average. Nonetheless, LTFU remains a barrier to achieving viral suppression and requires research to elucidate context-specific factors. An observational cohort study was conducted in Namibia in 2012 by administering surveys to individuals who presented for HIV care and initiated ART for the first time. Additional data were collected from routine medical data monitoring systems. Participants classified as LTFU at 12 months were traced to confirm their status. Predictors of LTFU were analyzed using multivariable logistic regression. Of those who presented consecutively to initiate ART, 524 were identified as eligible to enroll in the study, 497 enrolled, and 474 completed the baseline questionnaire. The cohort had mean age 36 years, 39% were male, mean CD4 cell count 222 cells/mm3, 17% were WHO HIV clinical stage III-IV, and 14% started efavirenz-based regimens. Tracing participants classified as LTFU yielded a re-categorization from 27.8% (n = 132) to 14.3% (n = 68) LTFU. In the final multivariable model, factors associated with confirmed LTFU status were: younger age (OR 0.97, 95% CI 1.00–1.06, p = 0.02); male sex (OR 2.34, CI 1.34–4.06, p = 0.003); difficulty leaving work or home to attend clinic (OR 2.55, CI 1.40–4.65, p = 0.002); and baseline efavirenz-based regimen (OR 2.35, CI 1.22–4.51, p = 0.01). Interventions to reduce LTFU should therefore target young men, particularly those who report difficulty leaving work or home to attend clinic and are on an efavirenz-based regimen.
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Yohannes NT, Jenkins CA, Clouse K, Cortés CP, Mejía Cordero F, Padgett D, Rouzier V, Friedman RK, McGowan CC, Shepherd BE, Rebeiro PF. Timing of HIV diagnosis relative to pregnancy and postpartum HIV care continuum outcomes among Latin American women, 2000 to 2017. J Int AIDS Soc 2021; 24:e25740. [PMID: 34021715 PMCID: PMC8140191 DOI: 10.1002/jia2.25740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 04/05/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND HIV incidence among women of reproductive age and vertical HIV transmission rates remain high in Latin America. We, therefore, quantified HIV care continuum barriers and outcomes among pregnant women living with HIV (WLWH) in Latin America. METHODS WLWH (aged ≥16 years) enrolling at Caribbean, Central and South America network for HIV epidemiology (CCASAnet) sites from 2000 to 2017 who had HIV diagnosis, pregnancy and delivery dates contributed. Logistic regression produced adjusted odds ratios (aOR) and 95% confidence intervals (CI) for retention in care (≥2 visits ≥3 months apart) and virological suppression (viral load <200 copies/mL) 12 months after pregnancy outcome. Cumulative incidences of loss to follow-up (LTFU) postpartum were estimated using Cox regression. Evidence of HIV status at pregnancy confirmation was the exposure. Covariates included pregnancy outcome (born alive vs. others); AIDS diagnosis prior to delivery; CD4, age, HIV-1 RNA and cART regimen at first delivery and CCASAnet country. RESULTS Among 579 WLWH, median postpartum follow-up was 4.34 years (IQR 1.91, 7.35); 459 (79%) were HIV-diagnosed before pregnancy confirmation, 445 (77%) retained in care and 259 (45%) virologically suppressed at 12 months of postpartum. Cumulative incidence of LTFU was 21% by 12 months and 40% by five years postpartum. Those HIV-diagnosed during pregnancy had lower odds of retention (aOR = 0.58, 95% CI: 0.35 to 0.97) and virological suppression (aOR = 0.50, 95% CI: 0.31 to 0.82) versus those HIV-diagnosed before. CONCLUSION HIV diagnosis during pregnancy was associated with poorer 12-month retention and virological suppression. Young women should be tested and linked to HIV care earlier to narrow these disparities.
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Affiliation(s)
| | - Cathy A Jenkins
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | - Kate Clouse
- Division of Infectious DiseasesDepartment of MedicineVanderbilt University Medical CenterNashvilleTNUSA
- Vanderbilt University School of NursingNashvilleTNUSA
| | | | - Fernando Mejía Cordero
- Instituto de Medicina Tropical Alexander von HumboldtUniversidad Peruana Cayetano HerediaLimaPeru
| | - Denis Padgett
- Instituto Hondureño de Seguridad Social & Hospital Escuela UniversitarioTegucigalpaHonduras
| | - Vanessa Rouzier
- Groupe Haitien d'Etudes du Sarcome de Kaposi et des Infections OpportunistesPort‐au‐PrinceHaiti
| | - Ruth K Friedman
- Instituto Nacional de Infectologia Evandro Chagas (INI)Fundação Oswaldo CruzRio de JaneiroBrazil
| | - Catherine C McGowan
- Division of Infectious DiseasesDepartment of MedicineVanderbilt University Medical CenterNashvilleTNUSA
| | - Bryan E Shepherd
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | - Peter F Rebeiro
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
- Division of Infectious DiseasesDepartment of MedicineVanderbilt University Medical CenterNashvilleTNUSA
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Katz IT, Musinguzi N, Bell K, Cross A, Bwana MB, Amanyire G, Asiimwe S, Orrell C, Bangsberg DR, Haberer JE. Brief Report: The Impact of Disease Stage on Early Gaps in ART in the "Treatment for All" Era-A Multisite Cohort Study. J Acquir Immune Defic Syndr 2021; 86:562-567. [PMID: 33351529 PMCID: PMC7938906 DOI: 10.1097/qai.0000000000002605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/09/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Adoption of "Treat All" policies has increased antiretroviral therapy (ART) initiation in sub-Saharan Africa; however, unexplained early losses continue to occur. More information is needed to understand why treatment discontinuation continues at this vulnerable stage in care. METHODS The Monitoring Early Treatment Adherence Study involved a prospective observational cohort of individuals initiating ART at early-stage versus late-stage disease in South Africa and Uganda. Surveys and HIV-1 RNA levels were performed at baseline, 6, and 12 months, with adherence monitored electronically. This analysis included nonpregnant participants in the first 6 months of follow-up; demographic and clinical factors were compared across groups with χ2, univariable, and multivariable models. RESULTS Of 669 eligible participants, 91 (14%) showed early gaps of ≥30 days in ART use (22% in South Africa and 6% in Uganda) with the median time to gap of 77 days (interquartile range: 43-101) and 87 days (74, 105), respectively. Although 71 (78%) ultimately resumed care, having an early gap was still significantly associated with detectable viremia at 6 months (P ≤ 0.01). Multivariable modeling, restricted to South Africa, found secondary education and higher physical health score protected against early gaps [adjusted odds ratio (aOR) 0.4, 95% confidence interval (CI): 0.2 to 0.8 and (aOR 0.93, 95% CI: 0.9 to 1.0), respectively]. Participants reporting clinics as "too far" had double the odds of early gaps (aOR 2.2: 95% CI: 1.2 to 4.1). DISCUSSION Early gaps in ART persist, resulting in higher odds of detectable viremia, particularly in South Africa. Interventions targeting health management and access to care are critical to reducing early gaps.
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Affiliation(s)
- Ingrid T. Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Harvard Global Health Institute, Cambridge, MA
| | | | - Kathleen Bell
- Massachusetts General Hospital Center for Global Health, Boston, MA
| | - Anna Cross
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | | | - Gideon Amanyire
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Stephen Asiimwe
- Mbarara University of Science and Technology, Mbarara, Uganda
- Kabwohe Clinical Research Center, Kabwohe, Uganda; and
| | - Catherine Orrell
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - David R. Bangsberg
- Oregon Health and Science University-Portland State University School of Public Health, Portland, OR
| | - Jessica E. Haberer
- Harvard Medical School, Boston, MA
- Massachusetts General Hospital Center for Global Health, Boston, MA
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Outcomes After Being Lost to Follow-up Differ for Pregnant and Postpartum Women When Compared With the General HIV Treatment Population in Rural South Africa. J Acquir Immune Defic Syndr 2021; 85:127-137. [PMID: 32520907 PMCID: PMC7495979 DOI: 10.1097/qai.0000000000002413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is Available in the Text. Undetermined attrition prohibits full understanding of the coverage and effectiveness of HIV programs. Outcomes following loss to follow-up (LTFU) among antiretroviral therapy (ART) patients may differ according to their reasons for ART initiation.
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Fisiha Kassa S, Zemene Worku W, Atalell KA, Agegnehu CD. Incidence of Loss to Follow-Up and Its Predictors Among Children with HIV on Antiretroviral Therapy at the University of Gondar Comprehensive Specialized Referral Hospital: A Retrospective Data Analysis. HIV AIDS (Auckl) 2020; 12:525-533. [PMID: 33116915 PMCID: PMC7547131 DOI: 10.2147/hiv.s269580] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/09/2020] [Indexed: 11/23/2022] Open
Abstract
Background The magnitude of loss to follow-up is high and remains a major public health problem in developing countries. Therefore, the aim of this study determines the incidence rate and predictors of loss to follow-up among children with HIV on ART at the University of Gondar comprehensive specialized referral hospital. Methods An institution-based retrospective data analysis was conducted on 361 children with HIV. The simple random sampling technique was used, and data were entered into Epi-info version 7.1 and were exported to Stata version 14 for analysis. The proportional hazard assumption was checked, and Cox regression was fitted. Finally, an adjusted hazard ratio with a 95% CI was computed, and variables with P-value <0.05 in the multivariable analysis were taken as significant predictors of loss to follow-up. Results The overall incidence rate of lost to follow-up was 6.2 events per 100 child-years observations (95% CI: 4.9–7.7). Children who have got care from their biological parents (AHR 2.6, 95% CI: 1.2–5.5), WHO clinical stage III/IV (AHR 2.0, 95% CI: 1.1–3.8), history of regimen substitutions (AHR 1.7, 95% CI: 1.1–2.9), poor/fair medication adherence (AHR 2.5, 95% CI 1.4–4.2) and history of TB treatment (AHR 2.7, 95% CI: 1.6–4.4) were the significant predictors of lost to follow-up. Conclusion The incidence rate of loss to follow-up among children was found to be high. Children who have got care from their biological parent, WHO clinical stage III/IV, history of regimen substitution, poor/fair medication adherence, and history of TB treatment were the independent predictors of loss to follow-up. Therefore, strengthening HIV care intervention and addressing these significant predictors is highly recommended in the study setting.
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Affiliation(s)
- Selam Fisiha Kassa
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Workie Zemene Worku
- Department of Community Health Nursing, School of Nursing, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Kendalem Asmare Atalell
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Chilot Desta Agegnehu
- School of Nursing College of Medicine and Health Sciences and Comprehensive Specialized Hospital, University of Gondar, Gondar, Ethiopia
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The impact of user fees on uptake of HIV services and adherence to HIV treatment: Findings from a large HIV program in Nigeria. PLoS One 2020; 15:e0238720. [PMID: 33031440 PMCID: PMC7544141 DOI: 10.1371/journal.pone.0238720] [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: 03/13/2020] [Accepted: 08/21/2020] [Indexed: 11/30/2022] Open
Abstract
Background Global HIV funding cutbacks have been accompanied by the adoption of user fees to address funding gaps in treatment programs. Our objective was to assess the impact of user fees on HIV care utilization and medication adherence in Nigeria. Methods We conducted a retrospective analysis of patients enrolled in care before (October 2012-September 2013) and after (October 2014-September 2015) the introduction of user fees in a Nigerian clinic. We assessed pre- vs. post-user fee patient characteristics and enrollment trends, and determined risk of care interruption, loss to follow-up, and optimal medication adherence. Results After fees were instituted, there was a 66% decline in patient enrollment and 75% decline in number of ART doses dispensed. There was no difference in the proportion of female clients (64% vs 63%, p = 0.46), average age (36 vs. 37 years, p = 0.15), or median baseline CD4 (220/ul vs. 222/uL, p = 0.24) in pre- and post-fee cohorts. There was an increase in clients employed and/or had tertiary education (24% vs. 32%, p<0.001). Compared to pre-fee patients, the post-fee period had a 48% decreased risk of care interruption (aRR = 0.52, 95%CI:0.39–0.69), 22% decreased LTFU risk (aRR = 0.64, 95%CI:0.96), and 27% decreased odds of optimal medication adherence (aOR = 0.7, 3 95%CI 0.59–0.89). Conclusions Patients enrolled in care after introduction of user fees in Nigeria were more likely to be educated or employed, and effectively retained in care after starting ART. However, fees were accompanied by a drastic reduction in new patient enrollment, suggesting that many patients may have been marginalized from HIV care.
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11
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Differentiated Antiretroviral Therapy Distribution Models: Enablers and Barriers to Universal HIV Treatment in South Africa, Uganda, and Zimbabwe. J Assoc Nurses AIDS Care 2020; 30:e132-e143. [PMID: 31135515 DOI: 10.1097/jnc.0000000000000097] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Emerging HIV treatment distribution models across sub-Saharan Africa seek to overcome barriers to attaining antiretroviral therapy and to strengthen adherence in people living with HIV. We describe enablers, barriers, and benefits of differentiated treatment distribution models in South Africa, Uganda, and Zimbabwe. Data collection included semistructured interviews and focus group discussions with 163 stakeholders from policy, program, and patient levels. Four types of facility-based and 3 types of community-based models were identified. Enablers included policy, leadership, and guidance; functional information systems; strong care linkages; steady drug supply; patient education; and peer support. Barriers included insufficient drug supply, stigma, discrimination, and poor care linkages. Benefits included perceived improved adherence, peer support, reduced stigma and discrimination, increased time for providers to spend with complex patients, and travel and cost savings for patients. Differentiated treatment distribution models can enhance treatment access for patients who are clinically stable.
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12
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Tun NN, McLean A, Wilkins E, Hlaing M, Aung YY, Linn T, Ashley EA, Smithuis FM. Integration of HIV services with primary care in Yangon, Myanmar: a retrospective cohort analysis. HIV Med 2020; 21:547-556. [PMID: 32687684 DOI: 10.1111/hiv.12886] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Integration of HIV care with general healthcare may improve patient engagement. We assessed patient outcomes in four clinics offering HIV care integrated into primary care clinics in Yangon, Myanmar. METHODS We carried out a retrospective cohort analysis of 4551 patients who started antiretroviral therapy between 2009 and 2017. Mortality and disengagement from care were assessed using Cox regression. RESULTS People living with HIV presented late with low CD4 counts [median (25th , 75th percentile) = 178 (65, 308) from 4216 patients] and advanced HIV (69% with stage 3 or 4). Survival was 0.95 at 1 year and 0.90 at 5 years. Males were at a higher risk of mortality than females [unadjusted hazard ratio (uHR) = 1.6 (95% CI: 1.3-2.0). Patients linked to HIV care via antenatal care or partner/parent notification were at reduced risk of mortality [uHR = 0.4 (95% CI: 0.1-1.0) and uHR = 0.5 (95% CI: 0.3-0.7)] relative to patients who presented for HIV testing. The cumulative incidence of disengagement was 0.06 at 1 year and 0.15 at 5 years. Young adults had a higher risk of disengagement than did children and older patients. Women linked to HIV care via antenatal care services were at increased risk of disengagement relative to patients who came for HIV testing (uHR = 2.4; 95% CI: 1.7-3.4). Mortality and disengagement remained steady over calendar time as the programme scaled up. CONCLUSIONS HIV care within a primary care model is effective to attain early linkage to care, with high survival. However, close attention should be given to disengagement from care, in particular for pregnant women.
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Affiliation(s)
- N N Tun
- Medical Action Myanmar, Yangon, Myanmar.,Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - Ard McLean
- Medical Action Myanmar, Yangon, Myanmar.,Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - E Wilkins
- Medical Action Myanmar, Yangon, Myanmar
| | | | - Y Y Aung
- Medical Action Myanmar, Yangon, Myanmar
| | - T Linn
- Medical Action Myanmar, Yangon, Myanmar
| | - E A Ashley
- Medical Action Myanmar, Yangon, Myanmar.,Myanmar Oxford Clinical Research Unit, Yangon, Myanmar.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - F M Smithuis
- Medical Action Myanmar, Yangon, Myanmar.,Myanmar Oxford Clinical Research Unit, Yangon, Myanmar.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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13
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Teshale AB, Tsegaye AT, Wolde HF. Incidence and predictors of loss to follow up among adult HIV patients on antiretroviral therapy in University of Gondar Comprehensive Specialized Hospital: A competing risk regression modeling. PLoS One 2020; 15:e0227473. [PMID: 31978137 PMCID: PMC6980595 DOI: 10.1371/journal.pone.0227473] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/19/2019] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Loss to follow up after the initiation of antiretroviral therapy (ART) is common in Africa, particularly in Ethiopia and it is a considerable obstacle for the effectiveness of the ART program. Mortality is a competing risk of loss to follow up but it is often overlooked and there is limited evidence about the incidence and predictors of loss to follow up in the presence of competing events. OBJECTIVE To assess the Incidence and predictors of loss to follow up among adult HIV patients on ART in University of Gondar Comprehensive Specialized Hospital between January 1, 2015, and December 31, 2018. METHODS Institution based retrospective follow up study was conducted in University of Gondar Comprehensive Specialized Hospital. A Gray's test and cumulative incidence curve were used to compare the cumulative incidence function of loss to follow up. Bivariable and multivariable competing risk regression models were fitted to identify the predictors of lost to follow up and those variables with p-value <0.05 in the multivariable analysis was considered as significant predictors of lost to follow up. RESULT A total of 531 adult HIV patients on ART were included in the analysis. The incidence rate of loss to follow up in this study was 10.90 (95% CI: 8.9-13.2) per 100 person years. Being age group 15-30 years (aSHR = 2.01; 95%CI;1.11-3.63), being daily laborer(aSHR = 2.60; 95%CI;1.45-4.66), not receiving cotrimoxazole preventive therapy (aSHR = 2.66; 95%CI;1.68-4.21), not receiving isoniazid preventive therapy(aSHR = 4.57; 95% CI;1.60-13.08), ambulatory functional status (aSHR = 1.61; 95% CI; 1.02-2.51) and taking AZT-3TC-NVP medication at start of ART(aSHR = 2.01; 95% CI; 1.16-3.78) were significant predictors of lost to follow up. CONCLUSION In this study the incidence of lost to follow up was high. Young people, daily laborer, ambulatory patients and those taking AZT-3TC-NVP as well as those who did not take opportunistic prophylaxis were at higher risk of loss to follow up. Therefore, giving special attention to the high-risk groups for lost to follow up highlighted in this study could decrease the rate of LTFU.
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Affiliation(s)
- Achamyeleh Birhanu Teshale
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Adino Tesfahun Tsegaye
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Haileab Fekadu Wolde
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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14
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Kaplan S, Nteso KS, Ford N, Boulle A, Meintjes G. Loss to follow-up from antiretroviral therapy clinics: A systematic review and meta-analysis of published studies in South Africa from 2011 to 2015. South Afr J HIV Med 2019; 20:984. [PMID: 31956435 PMCID: PMC6956684 DOI: 10.4102/sajhivmed.v20i1.984] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/20/2019] [Indexed: 11/05/2022] Open
Abstract
Background South Africa has the largest antiretroviral therapy (ART) programme in the world. To optimise programme outcomes, it is critical that patients are retained in care and that retention is accurately measured. Objectives To identify all studies published in South Africa from 2011 to 2015 that used loss to follow-up (LTFU) as an indicator or outcome to describe the variation in definitions and to estimate the proportion of patients lost to care across studies. Method All studies published between 01 January 2011 and October 2015 that included loss to follow-up or default from ART care in a South African cohort were included by use of a broad search strategy across multiple databases. To be included, the cohort had to include any patient ART data, including follow-up time, from 01 January 2010. Two authors, working independently, extracted data and assessed risk of bias from all manuscripts. Meta-analysis was performed for studies stratified by the same loss to follow-up definition. Results Forty-eight adult, 15 paediatric and 4 pregnant cohorts were included. Median cohort size was 3737; follow-up time ranged from 9 weeks to 5 years. Meta-analysis did not reveal an important difference in LTFU estimates in adult cohorts at 1 year between loss to follow-up defined as 3 months (11.0%, n = 4; 95% CI 10.7% – 11.2%) compared with 6 months (12.0%, n = 4; 95% CI 11.8% – 12.2%). Only two cohorts reported reliable LTFU estimates at 5 years: this was 25.1% (95% CI 24.8% – 25.4%). Conclusion South Africa should standardise a LTFU definition. This would aid in monitoring and evaluation of ART programmes, with the broader goal of improving patient outcomes.
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Affiliation(s)
- Samantha Kaplan
- Department of Internal Medicine, University of Washington, Seattle, United States
| | - Katleho S Nteso
- Medical Care Development International, Maseru, Lesotho, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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15
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Theilgaard ZP, Chiduo MG, Flamholc L, Gerstoft J, Bygbjerg IC, Lemnge MM, Katzenstein TL. Retired Nurses Can Improve Retention in Prevention of Mother-to-Child Transmission Programmes. East Afr Health Res J 2019; 3:88-95. [PMID: 34308201 PMCID: PMC8279289 DOI: 10.24248/eahrj-d-19-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 09/06/2019] [Indexed: 12/03/2022] Open
Abstract
Background: The success of prevention of mother-to-child transmission (PMTCT) programmes depends on retention of mothers throughout the PMTCT cascade. Methods: In a clinical trial of short-course combination antiretroviral therapy (cART) for PMTCT in Tanzania, senior nurses were employed to reduce the substantial loss-to-follow up (LTFU) rate. Results: Following intervention, the relative risk (RR) of receiving a CD4 count result and antiretroviral therapy was 1.16 (95% confidence interval [CI], 1.05 to 1.27), the RR of delivery at clinic was 2.51 (95% CI, 2.06 to 3.06), the RR for reporting for follow-up at 6 to 8 weeks postpartum was 4.63 (95% CI, 3.41 to 6.27), and the RR for being retained until 9 months postpartum was 28.19 (95% CI, 11.81 to 67.28). No significant impact on transmission was found. Conclusion: Significantly higher retention was found after senior nurses were employed. No impact on transmission was found. Relatively low transmission was found in both study arms.
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Affiliation(s)
- Zahra Persson Theilgaard
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mercy G Chiduo
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Leo Flamholc
- Department of Infectious Diseases, University Hospital of Malmö, Malmö, Sweden
| | - Jan Gerstoft
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ib C Bygbjerg
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Terese L Katzenstein
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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16
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Chammartin F, Zürcher K, Keiser O, Weigel R, Chu K, Kiragga AN, Ardura-Garcia C, Anderegg N, Laurent C, Cornell M, Tweya H, Haas AD, Rice BD, Geng EH, Fox MP, Hargreaves JR, Egger M. Outcomes of Patients Lost to Follow-up in African Antiretroviral Therapy Programs: Individual Patient Data Meta-analysis. Clin Infect Dis 2019; 67:1643-1652. [PMID: 29889240 PMCID: PMC6233676 DOI: 10.1093/cid/ciy347] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 05/17/2018] [Indexed: 11/14/2022] Open
Abstract
Background Low retention on combination antiretroviral therapy (cART) has emerged as a threat to the Joint United Nations Programme on human immunodeficiency virus (HIV)/AIDS (UNAIDS) 90-90-90 targets. We examined outcomes of patients who started cART but were subsequently lost to follow-up (LTFU) in African treatment programs. Methods This was a systematic review and individual patient data meta-analysis of studies that traced patients who were LTFU. Outcomes were analyzed using cumulative incidence functions and proportional hazards models for the competing risks of (i) death, (ii) alive but stopped cART, (iii) silent transfer to other clinics, and (iv) retention on cART. Results Nine studies contributed data on 7377 patients who started cART and were subsequently LTFU in sub-Saharan Africa. The median CD4 count at the start of cART was 129 cells/μL. At 4 years after the last clinic visit, 21.8% (95% confidence interval [CI], 20.8%-22.7%) were known to have died, 22.6% (95% CI, 21.6%-23.6%) were alive but had stopped cART, 14.8% (95% CI, 14.0%-15.6%) had transferred to another clinic, 9.2% (95% CI, 8.5%-9.8%) were retained on cART, and 31.6% (95% CI, 30.6%-32.7%) could not been found. Mortality was associated with male sex, more advanced disease, and shorter cART duration; stopping cART with less advanced disease andlonger cART duration; and silent transfer with female sex and less advanced disease. Conclusions Mortality in patients LTFU must be considered for unbiased assessments of program outcomes and UNAIDS targets in sub-Saharan Africa. Immediate start of cART and early tracing of patients LTFU should be priorities.
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Affiliation(s)
| | - Kathrin Zürcher
- Institute of Social and Preventive Medicine, University of Bern
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Switzerland
| | - Ralf Weigel
- Faculty of Health, Witten/Herdecke University, Witten, Germany.,Lighthouse Trust, Lilongwe, Malawi
| | - Kathryn Chu
- Department of Surgery, University of Cape Town, South Africa
| | - Agnes N Kiragga
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Nanina Anderegg
- Institute of Social and Preventive Medicine, University of Bern
| | - Christian Laurent
- Institut de Recherche pour le Développement, Inserm, Univ Montpellier, Recherches Translationnelles sur le VIH et les Maladies Infectieuses, Montpellier, France
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | | | - Andreas D Haas
- Institute of Social and Preventive Medicine, University of Bern
| | - Brian D Rice
- Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Elvin H Geng
- Division of Infectious Diseases, HIV and Global Medicine, Department of Medicine, University of California, San Francisco
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Departments of Epidemiology and Global Health, Boston University School of Public Health, Massachusetts
| | - James R Hargreaves
- Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
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17
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Banigbe B, Audet CM, Okonkwo P, Arije OO, Bassi E, Clouse K, Simmons M, Aliyu MH, Freedberg KA, Ahonkhai AA. Effect of PEPFAR funding policy change on HIV service delivery in a large HIV care and treatment network in Nigeria. PLoS One 2019; 14:e0221809. [PMID: 31553735 PMCID: PMC6760763 DOI: 10.1371/journal.pone.0221809] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 08/15/2019] [Indexed: 01/10/2023] Open
Abstract
The transition to PEPFAR 2.0 with its focus on country ownership was accompanied by substantial funding cuts. We describe the impact of this transition on HIV care in a large network of HIV clinics in Nigeria. We surveyed 30 comprehensive HIV treatment clinics to assess services supported before (October 2013-September 2014) and after (October 2014-September 2015) the PEPFAR funding policy change, the impact of these policy changes on service delivery areas, and response of clinics to the change. We compared differences in support for staffing, laboratory services, and clinical operations pre- and post-policy change using paired t-tests. We used framework analysis to assess answers to open ended questions describing responses to the policy change. Most sites (83%, n = 25) completed the survey. The majority were public (60%, n = 15) and secondary (68%, n = 17) facilities. Clinics had a median of 989 patients in care (IQR: 543-3326). All clinics continued to receive support for first and second line antiretrovirals and CD4 testing after the policy change, while no clinics received support for other routine drug monitoring labs. We found statistically significant reductions in support for viral load testing, staff employment, defaulter tracking, and prevention services (92% vs. 64%, p = 0.02; 80% vs. 20%, 100% vs. 44%, 84% vs. 16%, respectively, p<0.01 for all) after the policy change. Service delivery was hampered by interrupted laboratory services and reduced wages and staff positions leading to reduced provider morale, and compromised quality of care. Almost all sites (96%) introduced user fees to address funding shortages. Clinics in Nigeria are experiencing major challenges in providing routine HIV services as a result of PEPFAR's policy changes. Funding cutbacks have been associated with compromised quality of care, staff shortages, and reliance on fee-based care for historically free services. Sustainable HIV services funding models are urgently needed.
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Affiliation(s)
| | - Carolyn M. Audet
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Friends in Global Health, Maputo, Mozambique
| | | | - Olujide O. Arije
- Institute of Public Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | | | - Kate Clouse
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Melynda Simmons
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Muktar H. Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Kenneth A. Freedberg
- Division of Infectious Disease and General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Aima A. Ahonkhai
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Division of Infectious Disease and General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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18
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Mee P, Rice B, Lemsalu L, Hargreaves J, Sambu V, Harklerode R, Todd J, Somi G. Changes in patterns of retention in HIV care and antiretroviral treatment in Tanzania between 2008 and 2016: an analysis of routinely collected national programme data. J Glob Health 2019; 9:010424. [PMID: 30992984 PMCID: PMC6445500 DOI: 10.7189/jogh.09.010424] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Tanzania is a high HIV burden country in Sub-Saharan Africa with 1.5 million people infected. Unless monitored and responded to, low levels of retention in care may lead to poor HIV associated clinical outcomes and an increased likelihood of onward viral transmission. Using routine data, we assessed changes in retention in care and on treatment for HIV over time in Tanzanian facilities, using the national care and treatment programme (CTC) database. METHODS Data were extracted from the CTC database and analysed using two approaches: a series of cross-sectional analyses for each calendar year between 2008 and 2016 to assess the changing characteristics of the population in care and on treatment, and, a longitudinal analysis using survival analysis methods for a series of cohorts representing i) all engaging in care and ii) all initiating treatment in each calendar year from 2008 to 2015. Multivariate analyses were carried out to explore the independent effect of calendar year when controlling for other factors. RESULTS The total number of individuals enrolled in care increased from 160 268 in 2008 to 548 296 in 2016. The percentage of the in-care population enrolled for more than 3 years increased from 9.9% in 2008 to 54.5% in 2016. The overall rates of retention in care were 80.9%, 57.3% and 45.4% at 12, 24 and 36 months respectively. The rates of retention on antiretroviral therapy (ART) ART at 12, 24 and 36 months after treatment-initiation were 83.9%, 64.0% and 53.5%. There were small but statistically significant differences in the retention rates between cohorts and evidence for a significant decrease in the rates of retention in the most recent years analysed. CONCLUSIONS Data from Tanzania show that while the number of People Living with HIV (PLHIV) who were in care and monitored through the routine data system increased over time, the retention rates in care and treatment remained relatively stable. These rates were similar to other regional estimates. Systematic reviews of tracing studies indicate that mortality among those lost to follow up has decreased over time, partly underpinned by an increase in the numbers transferring between clinics. True retention rates may therefore be higher than we report here, and this underpins the need for data systems that can track patients between clinics.
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Affiliation(s)
- Paul Mee
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Brian Rice
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Liis Lemsalu
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
- Department of Drug and Infectious Diseases Epidemiology, National Institute for Health Development, Tallinn, Estonia
| | - James Hargreaves
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Veryeh Sambu
- Strategic Information Unit, National AIDS Control Programme, Dodoma Tanzania
| | - Richelle Harklerode
- University of California San Francisco, Global Health Sciences, San Francisco, California, USA
| | - Jim Todd
- The MeSH Consortium, London School of Hygiene and Tropical Medicine, London, UK
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Geoffrey Somi
- Strategic Information Unit, National AIDS Control Programme, Dodoma Tanzania
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19
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Haas AD, Zaniewski E, Anderegg N, Ford N, Fox MP, Vinikoor M, Dabis F, Nash D, Sinayobye JD, Niyongabo T, Tanon A, Poda A, Adedimeji AA, Edmonds A, Davies MA, Egger M. Retention and mortality on antiretroviral therapy in sub-Saharan Africa: collaborative analyses of HIV treatment programmes. J Int AIDS Soc 2019; 21. [PMID: 29479867 PMCID: PMC5897849 DOI: 10.1002/jia2.25084] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 01/29/2018] [Indexed: 01/17/2023] Open
Abstract
Introduction By 2020, 90% of all people diagnosed with HIV should receive long‐term combination antiretroviral therapy (ART). In sub‐Saharan Africa, this target is threatened by loss to follow‐up in ART programmes. The proportion of people retained on ART long‐term cannot be easily determined, because individuals classified as lost to follow‐up, may have self‐transferred to another HIV treatment programme, or may have died. We describe retention on ART in sub‐Saharan Africa, first based on observed data as recorded in the clinic databases, and second adjusted for undocumented deaths and self‐transfers. Methods We analysed data from HIV‐infected adults and children initiating ART between 2009 and 2014 at a sub‐Saharan African HIV treatment programme participating in the International epidemiology Databases to Evaluate AIDS (IeDEA). We used the Kaplan–Meier method to calculate the cumulative incidence of retention on ART and the Aalen–Johansen method to calculate the cumulative incidences of death, loss to follow‐up, and stopping ART. We used inverse probability weighting to adjust clinic data for undocumented mortality and self‐transfer, based on estimates from a recent systematic review and meta‐analysis. Results We included 505,634 patients: 12,848 (2.5%) from Central Africa, 109,233 (21.6%) from East Africa, 347,343 (68.7%) from Southern Africa and 36,210 (7.2%) from West Africa. In crude analyses of observed clinic data, 52.1% of patients were retained on ART, 41.8% were lost to follow‐up and 6.0% had died 5 years after ART initiation. After accounting for undocumented deaths and self‐transfers, we estimated that 66.6% of patients were retained on ART, 18.8% had stopped ART and 14.7% had died at 5 years. Conclusions Improving long‐term retention on ART will be crucial to attaining the 90% on ART target. Naïve analyses of HIV cohort studies, which do not account for undocumented mortality and self‐transfer of patients, may severely underestimate both mortality and retention on ART.
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Affiliation(s)
- Andreas D Haas
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland
| | - Elizabeth Zaniewski
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nanina Anderegg
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nathan Ford
- World Health Organisation, Geneva, Switzerland
| | - Matthew P Fox
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Michael Vinikoor
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,School of Medicine, University of Zambia, Lusaka, Zambia
| | - François Dabis
- ISPED, Centre Inserm U1219-Bordeaux Population Health, Université de Bordeaux, Bordeaux, France
| | - Denis Nash
- Department of Epidemiology and Biostatistics, City University of New York, School of Public Health, New York, NY, USA.,Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA
| | | | - Thêodore Niyongabo
- Centre National de Reference en Matiere de VIH/SIDA (CNR), Bujumbura, Burundi
| | - Aristophane Tanon
- Service de Maladies Infectieuses et Tropicales (SMIT), CHU de Treichville, Abidjan, Cote d'Ivoire
| | - Armel Poda
- Institut Supérieur des Sciences de la santé, Université Polytechnique de Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso
| | - Adebola A Adedimeji
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Andrew Edmonds
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Matthias Egger
- Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland.,Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
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Saumu WM, Maleche-Obimbo E, Irimu G, Kumar R, Gichuhi C, Karau B. Predictors of loss to follow-up among children attending HIV clinic in a hospital in rural Kenya. Pan Afr Med J 2019; 32:216. [PMID: 31312327 PMCID: PMC6620067 DOI: 10.11604/pamj.2019.32.216.18310] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 03/27/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction African studies have reported high rates of loss to follow up (LTFU) among children in HIV care and treatment centres. Factors associated with LTFU may vary across populations. Few studies have been conducted among HIV infected children in care in rural areas of Kenya. Methods this involved children aged less than 15 years on follow up at Kangundo Level 4 Hospital HIV clinic from January 2010 to December 2015. We obtained sociodemographic and clinical information from patient files and electronic databases. Univariate and multivariate regression analyses were conducted to identify factors predictive of LTFU. Results a total of 261 HIV-infected children were followed up. The mean age was 10.0 years (IQR, 7-13) and median CD4 count of 582cells/ul (IQR 314-984). By December 2015, 171 children (65.5%) remained in active care, 32 (12.3%) transferred out, 13 (5%) died, while 45 (17.2%) were classified as LTFU. Out of the 45 children presumed as LTFU, we traced 44 out of the 45 children (98%) and found that their actual current status was as follows: 33 of the 44 children (75.0%) had dropped out of care (true LTFU). Factors strongly predictive of LTFU included low caregiver level of education (HR 2.3, 1.9-3.9, P = 0.001), WHO stage I and II at enrolment (HR 1.6, 1.4-2.1, P = 0.05). Conclusion LTFU of HIV infected children was common with an incidence of 32.9 per 1000 child years and occurred early in treatment and risk factors included poverty, low caregiver education, male child and early HIV disease stage.
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Affiliation(s)
- Winnie Mueni Saumu
- Department of Paediatrics and Child Health, Chuka County Referral Hospital, Tharaka Nithi KE, Kenya
| | | | - Grace Irimu
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Rashmi Kumar
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Christine Gichuhi
- Department of Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, Kenya
| | - Bundi Karau
- Department of Internal Medicine, Kenya Methodist University, Nairobi, Kenya
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Patrikar S, Kachroo K, Sharma J, Kotwal A, Basannar DR, Bhatti VK, Mukherji S, Nair V. A systematic review and cost-effectiveness analyses of the new World Health Organization guidelines for the treatment of HIV-positive adults in India. Med J Armed Forces India 2019; 75:31-40. [PMID: 30705476 DOI: 10.1016/j.mjafi.2018.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 08/30/2018] [Indexed: 11/17/2022] Open
Abstract
Background The World Health Organization (WHO) in 2013 has revised its guidelines on antiretroviral therapy (ART) treatment for human immunodeficiency virus (HIV)-positive adults and further updated it in 2016. Based on the WHO recommendations, in May 2017, National AIDS Control Organisation, India recommended initiation of ART treatment for all people living with HIV, regardless of CD4 count, clinical stage, age, or population. This systematic review aims to assess the clinical effectiveness and cost implication of the new guidelines for India. Methods A systematic and comprehensive literature search on PubMed, OvidSP, Cochrane Library, and Google Scholar was carried out. Studies reporting either acquired immunodeficiency syndrome (AIDS) or mortality or both as outcome variables were selected. A meta-analysis of the available studies was carried out. The risk ratio was calculated to assess the reduction in AIDS or mortality or both. Cost-effectiveness analysis using health technology principles evaluating the lives saved in terms of incremental cost-effectiveness ratio and cost per quality-adjusted life years gained was carried out. Results Nine eligible studies were included for the meta-analysis. For India, the pooled relative risk of AIDS or mortality or both being 0.84 (95% confidence interval [CI], 0.76-0.92) and 0.78 (95% CI, 0.68-0.89) for ART initiation at CD4 count of ≤350 vs CD4 count of ≤500 and at CD4 count of ≤500 vs CD4 count > 500 cells/mm3, respectively. The incremental cost for per additional life saved is US$ 2592 and US$ 2357 for ART initiation at ≤500 and > 500 CD4 count, respectively. Conclusion The adoption of the new WHO guidelines is beneficial with substantial reduction in AIDS or mortality or both. This study suggests that adopting new WHO guidelines is cost-effective for India.
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Affiliation(s)
- Seema Patrikar
- Statistician, Department of Community Medicine, Armed Forces Medical College, Pune 411040, India
| | - Kavita Kachroo
- Consultant, NHSRC, Ministry of Health and Family Welfare, India
| | - Jitendar Sharma
- Director, WHO Collaborating Centre for Priority Medical Devices & Health Technology Policy, NHSRC, Ministry of Health and Family Welfare, India
| | - Atul Kotwal
- Professor (Community Medicine), Army College of Medical Science, New Delhi 110010, India
| | - D R Basannar
- Scientist 'F', Department of Community Medicine, Armed Forces Medical College, Pune 411040, India
| | - V K Bhatti
- Director Health, Armed Forces Medical Services, O/o DGAFMS. Ministry of Defence, Delhi, India
| | | | - Velu Nair
- Senior Consultant, Haemato-Oncology & Bone Marrow Transplant, Comprehensive Blood & Cancer Center (CBCC), 632, C-1, Ansals Palam Vihar, Carterpuri, Gurgaon 122017, India
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22
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Bernard C, Balestre E, Coffie PA, Eholie SP, Messou E, Kwaghe V, Okwara B, Sawadogo A, Abo Y, Dabis F, de Rekeneire N. Aging with HIV: what effect on mortality and loss to follow-up in the course of antiretroviral therapy? The IeDEA West Africa Cohort Collaboration. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2018; 10:239-252. [PMID: 30532600 PMCID: PMC6247956 DOI: 10.2147/hiv.s172198] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Reporting mortality and lost to follow-up (LTFU) by age is essential as older HIV-positive patients might be at risk of long-term effects of living with HIV and/or taking antiretroviral therapy (ART). As age effects might not be linear and might impact HIV outcomes in the oldest more severely, people living with HIV (PLHIV) aged 50-59 years and PLHIV aged >60 years were considered separately. Setting Seventeen adult HIV/AIDS clinics spread over nine countries in West Africa. Methods Data were collected within the International Epidemiological Databases to Evaluate AIDS West Africa Collaboration. ART-naïve PLHIV-1 adults aged >16 years initiating ART and attending ≥2 clinic visits were included (N=73,525). Age was divided into five groups: 16-29/30-39/40-49/50-59/≥60 years. The age effect on mortality and LTFU was evaluated with Kaplan-Meier curves and multivariable Cox proportional hazard regressions. Results At month 36, 5.9% of the patients had died and 47.3% were LTFU. Patients aged ≥60 (N=1,736) and between 50-59 years old (N=6,792) had an increased risk of death in the first 36 months on ART (adjusted hazard ratio=1.66; 95% CI: 1.36-2.03 and adjusted hazard ratio=1.31; 95% CI: 1.15-1.49, respectively; reference: <30 years old). Patients ≥60 years old tend to be more often LTFU. Conclusion The oldest PLHIV presented the poorest outcomes, suggesting that the PLHIV aged >50 years old should not be considered as a unique group irrespective of their age. Tailored programs focusing on improving the care services for older PLHIV in Sub-Saharan Africa are clearly needed to improve basic program outcomes.
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Affiliation(s)
- Charlotte Bernard
- INSERM, Centre INSERM U1219-Epidémiologie-Biostatistique, Bordeaux, France, .,University of Bordeaux, School of Public Health (ISPED), Bordeaux, France,
| | - Eric Balestre
- INSERM, Centre INSERM U1219-Epidémiologie-Biostatistique, Bordeaux, France, .,University of Bordeaux, School of Public Health (ISPED), Bordeaux, France,
| | - Patrick A Coffie
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Côte d'Ivoire.,Unit of Infectious and Tropical Diseases, Treichville University Teaching Hospital, Abidjan, Côte d'Ivoire.,Programme PAC-CI, Treichville University Teaching Hospital, Abidjan, Ivory Coast
| | - Serge Paul Eholie
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Côte d'Ivoire.,Unit of Infectious and Tropical Diseases, Treichville University Teaching Hospital, Abidjan, Côte d'Ivoire
| | - Eugène Messou
- Département de Dermatologie et d'Infectiologie, UFR des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Côte d'Ivoire.,Unit of Infectious and Tropical Diseases, Treichville University Teaching Hospital, Abidjan, Côte d'Ivoire.,Programme PAC-CI, Treichville University Teaching Hospital, Abidjan, Ivory Coast.,Center of Care, Research and Training (CePReF), Yopougon-Attié Hospital, Abidjan, Ivory Coast
| | | | - Benson Okwara
- University of Benin City Teaching Hospital, Benin City, Nigeria
| | - Adrien Sawadogo
- Institut Supérieur des Sciences de la Santé (INSSA), Bobo-Dioulasso Polytechnic University, Bobo-Dioulasso, Burkina Faso
| | - Yao Abo
- National Blood Transfusion Center (CNTS), Abidjan, Ivory Coast
| | - François Dabis
- INSERM, Centre INSERM U1219-Epidémiologie-Biostatistique, Bordeaux, France, .,University of Bordeaux, School of Public Health (ISPED), Bordeaux, France,
| | - Nathalie de Rekeneire
- INSERM, Centre INSERM U1219-Epidémiologie-Biostatistique, Bordeaux, France, .,University of Bordeaux, School of Public Health (ISPED), Bordeaux, France,
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Telele NF, Kalu AW, Marrone G, Gebre-Selassie S, Fekade D, Tegbaru B, Sönnerborg A. Baseline predictors of antiretroviral treatment failure and lost to follow up in a multicenter countrywide HIV-1 cohort study in Ethiopia. PLoS One 2018; 13:e0200505. [PMID: 29995957 PMCID: PMC6040773 DOI: 10.1371/journal.pone.0200505] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 06/27/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) has been rapidly scaled up in Ethiopia since 2005, but factors influencing the outcome are poorly studied. We therefore analysed baseline predictors of first-line ART outcome after 6 and 12 months. MATERIAL AND METHODS 874 HIV-infected patients, who started first-line ART, were enrolled in a countrywide prospective cohort. Two outcomes were defined: i) treatment failure: detectable viremia or lost-to-follow-up (LTFU) (confirmed death, moved from study sites or similar reasons); ii) LTFU only. Using stepwise logistic regression, four multivariable models identified baseline predictors for odds of treatment failure and LTFU. RESULTS The treatment failure rates were 23.3% and 33.9% at 6 and 12 months, respectively. Opportunistic infections (OI), tuberculosis (TB), CD4 cells <50/μl, and viral load >5 log10 copies/ml increased the odds of treatment failure both at 6 and 12 months. The odds of LTFU at month 6 increased with baseline functional disabilities, WHO stage III/IV, and CD4 cells <50/μl. TB also increased the odds at month 12. Importantly, ART outcome differed across hospitals. Compared to the national hospital in Addis Ababa, patients from most regional sites had higher odds of treatment failure and/or LTFU at month 6 and/or 12, with the exception of one clinic (Jimma), which had lower odds of failure at month 6. CONCLUSIONS In this first countrywide Ethiopian HIV cohort, a high ART failure rate was identified, to the largest extent due to LTFU, including death. The geographical region where the patients were treated was a strong baseline predictor of ART failure. The difference in ART outcome across hospitals calls the need for provision of more national support at regional level.
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Affiliation(s)
- Nigus Fikrie Telele
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
- Department of Microbiology, Immunology and Parasitology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Amare Worku Kalu
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
- Department of Microbiology, Immunology and Parasitology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gaetano Marrone
- Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Solomon Gebre-Selassie
- Department of Microbiology, Immunology and Parasitology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Daniel Fekade
- Department of Infectious Diseases, Addis Ababa University, Addis Ababa, Ethiopia
| | - Belete Tegbaru
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Anders Sönnerborg
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
- Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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Tang H, Mao Y, Tang W, Han J, Xu J, Li J. "Late for testing, early for antiretroviral therapy, less likely to die": results from a large HIV cohort study in China, 2006-2014. BMC Infect Dis 2018; 18:272. [PMID: 29895275 PMCID: PMC5998580 DOI: 10.1186/s12879-018-3158-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 05/22/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Timely HIV testing and initiation of antiretroviral therapy are two major determinants of survival for HIV-infected individuals. Our study aimed to explore the trend of late HIV/AIDS diagnoses and to assess the factors associated with these late diagnoses in China between 2006 and 2014. METHODS We used data from the Chinese Comprehensive Response Information Management System of HIV/AIDS (CRIMS). All individuals who tested positive for HIV between 2006 and 2014 in China and were at least 15 years of age were included. A late diagnosis was defined as an instance in which an individual was diagnosed as having AIDS or WHO stage 3 or 4 HIV/AIDS, or had a CD4 cell count less than 200 cells/mm3 at the time of diagnosis. RESULTS Among the 528,234 individuals (≥15 years old) newly diagnosed with HIV between 2006 and 2014, 179,700 (34.0%) people were considered to have received late diagnoses. The late diagnosis rate decreased from 33.9% in 2006 to 29.7% in 2014 (P < 0.01). Late diagnoses were more likely to be found among those who were 45-54 years old (adjusted odds ratio [aOR]: 3.25, 95% confidence interval [CI]: 3.17-3.34) or 55+ years old (OR: 2.94, 95% CI: 2.86-3.02), male (aOR: 1.15, 95% CI: 1.13,1.17), employed as a farmer or rural laborer (aOR: 1.13, 95% CI: 1.11-1.14), infected through blood or plasma transfusion (aOR: 4.18, 95% CI: 4.02, 4.35), diagnosed at hospitals (OR: 1.17, 95% CI: 1.15, 1.19), of Han ethnicity (aOR: 1.30, 95% CI: 1.28, 1.32), and married (OR: 1.12, 95% CI: 1.11,1.13). Of those people living with HIV (PLHIV) who received late diagnoses, 7.4%(8637) and 46.1%(28,462) ultimately died with or without receiving antiretroviral therapy within a year of diagnosis, respectively. CONCLUSION A large proportion of individuals with HIV/AIDS receive late diagnoses, and this proportion has witnessed a slight decline in recent years. Expanded testing is needed to increase early HIV diagnosis and antiretroviral therapy should be recommended to all diagnosed individuals as early as possible to reduce AIDS-related death.
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Affiliation(s)
- Houlin Tang
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yurong Mao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
| | - Weiming Tang
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China.,School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Jing Han
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Juan Xu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jian Li
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
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Davis N, Kanagat N, Sharer M, Eagan S, Pearson J, Amanyeiwe UU. Review of differentiated approaches to antiretroviral therapy distribution. AIDS Care 2018; 30:1010-1016. [PMID: 29471667 DOI: 10.1080/09540121.2018.1441970] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In response to global trends of maximizing the number of patients receiving antiretroviral therapy (ART), this review summarizes literature describing differentiated models of ART distribution at facility and community levels in order to highlight promising strategies and identify evidence gaps. Databases and gray literature were searched, yielding thirteen final articles on differentiated ART distribution models supporting stable adult patients. Of these, seven articles focused on distribution at facility level and six at community level. Findings suggest that differentiated models of ART distribution contribute to higher retention, lower attrition, and less loss to follow-up (LTFU). These models also reduced patient wait time, travel costs, and time lost from work for drug pick-up. Facility- and community-level ART distribution models have the potential to extend treatment availability, enable improved access and adherence among people living with HIV (PLHIV), and facilitate retention in treatment and care. Gaps remain in understanding the desirability of these models for PLHIV, and the need for more information the negative and positive impacts of stigma, and identifying models to reach traditionally marginalized groups such as key populations and youth. Replicating differentiated care so efforts can reach more PLHIV will be critical to scaling these approaches across varying contexts.
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Affiliation(s)
- Nicole Davis
- a JSI Research & Training Institute, Inc , Boston , MA , Washington, DC
| | - Natasha Kanagat
- a JSI Research & Training Institute, Inc , Boston , MA , Washington, DC
| | - Melissa Sharer
- a JSI Research & Training Institute, Inc , Boston , MA , Washington, DC.,b Department of Public Health , St. Ambrose University , Iowa , USA
| | - Sabrina Eagan
- a JSI Research & Training Institute, Inc , Boston , MA , Washington, DC
| | - Jennifer Pearson
- a JSI Research & Training Institute, Inc , Boston , MA , Washington, DC
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Elul B, Saito S, Chung H, Hoos D, El-Sadr W. Attrition From Human Immunodeficiency Virus Treatment Programs in Africa: A Longitudinal Ecological Analysis Using Data From 307 144 Patients Initiating Antiretroviral Therapy Between 2005 and 2010. Clin Infect Dis 2018; 64:1309-1316. [PMID: 28329244 DOI: 10.1093/cid/cix162] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 02/15/2017] [Indexed: 11/14/2022] Open
Abstract
Background As access to antiretroviral therapy (ART) in Africa has increased dramatically, concerns have been raised regarding patient attrition, an important measure of program quality. Methods We examined aggregate data from 307144 patients initiating ART in 5638 successive cohorts at 638 facilities in 9 African countries from 2005 to 2010, a period characterized by massive treatment expansion. Poisson regression assessed trends in 6- and 12-month cohort attrition (ie, the proportion of patients in each cohort no longer receiving ART at their initiating facility) over calendar time and as ART services matured, and identified factors associated with attrition. Results Across all 9 countries, 6- and 12-month cohort attrition was 21% and 29%, respectively, with no decrease over calendar time (6-month P = .8735; 12-month P = .5717) or as ART services matured (6-month P = .3005; 12-month P = .2277). Additionally, attrition remained stable or decreased across both measures in nearly all countries. Initiating ART in facilities with more documented transfers and fewer women on ART, and in cohorts with poor CD4 count documentation and lower median CD4 count at ART initiation was associated with increased 6-month attrition. Increased 12-month attrition was observed in semiurban facilities and those with more documented transfers, and in cohorts with poor CD4 count documentation, whereas higher patient load was associated with decreased attrition. Conclusions Stable or decreasing trends in attrition for ART patients were observed in most countries, suggesting programs can be expanded without compromising quality. However, further reductions in attrition are needed to maximize individual and population benefits of ART.
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Affiliation(s)
- Batya Elul
- Department of Epidemiology, and.,ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York
| | - Suzue Saito
- Department of Epidemiology, and.,ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York
| | - Hannah Chung
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York
| | - David Hoos
- Department of Epidemiology, and.,ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York
| | - Wafaa El-Sadr
- Department of Epidemiology, and.,ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York
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Driving factors of retention in care among HIV-positive MSM and transwomen in Indonesia: A cross-sectional study. PLoS One 2018; 13:e0191255. [PMID: 29342172 PMCID: PMC5771583 DOI: 10.1371/journal.pone.0191255] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/02/2018] [Indexed: 11/19/2022] Open
Abstract
Little is known about the prevalence of and factors that influence retention in HIV-related care among Indonesian men who have sex with men (MSM) and transgender women (transwomen, or waria in Indonesian term). Therefore, we explored the driving factors of retention in care among HIV-positive MSM and waria in Indonesia. This cross-sectional study involved 298 self-reported HIV-positive MSM (n = 165) and waria (n = 133). Participants were recruited using targeted sampling and interviewed using a structured questionnaire. We applied a four-step model building process using multivariable logistic regression to examine how sociodemographic, predisposing, enabling, and reinforcing factors were associated with retention in care. Overall, 78.5% of participants were linked to HIV care within 3 months after diagnosis or earlier, and 66.4% were adequately retained in care (at least one health care visit every three months once a person is diagnosed with HIV). Being on antiretroviral therapy (adjusted odds ratio [AOR] = 6.00; 95% confidence interval [CI]: 2.93-12.3), using the Internet to find HIV-related information (AOR = 2.15; 95% CI: 1.00-4.59), and having medical insurance (AOR = 2.84; 95% CI: 1.27-6.34) were associated with adequate retention in care. Involvement with an HIV-related organization was associated negatively with retention in care (AOR = 0.47; 95% CI: 0.24-0.95). Future interventions should increase health insurance coverage and utilize the Internet to help MSM and waria to remain in HIV-related care, thereby assisting them in achieving viral suppression.
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Jiamsakul A, Kariminia A, Althoff KN, Cesar C, Cortes CP, Davies MA, Do VC, Eley B, Gill J, Kumarasamy N, Machado DM, Moore R, Prozesky H, Zaniewski E, Law M. HIV Viral Load Suppression in Adults and Children Receiving Antiretroviral Therapy-Results From the IeDEA Collaboration. J Acquir Immune Defic Syndr 2017; 76:319-329. [PMID: 28708808 PMCID: PMC5634924 DOI: 10.1097/qai.0000000000001499] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Having 90% of patients on antiretroviral therapy (ART) and achieving an undetectable viral load (VL) is 1 of the 90:90:90 by 2020 targets. In this global analysis, we investigated the proportions of adult and paediatric patients with VL suppression in the first 3 years after ART initiation. METHODS Patients from the IeDEA cohorts who initiated ART between 2010 and 2014 were included. Proportions with VL suppression (<1000 copies/mL) were estimated using (1) strict intention to treat (ITT)-loss to follow-up (LTFU) and dead patients counted as having detectable VL; and (2) modified ITT-LTFU and dead patients were excluded. Logistic regression was used to identify predictors of viral suppression at 1 year after ART initiation using modified ITT. RESULTS A total of 35,561 adults from 38 sites/16 countries and 2601 children from 18 sites/6 countries were included. When comparing strict with modified ITT methods, the proportion achieving VL suppression at 3 years from ART initiation changed from 45.1% to 90.2% in adults, and 60.6% to 80.4% in children. In adults, older age, higher CD4 count pre-ART, and homosexual/bisexual HIV exposure were associated with VL suppression. In children, older age and higher CD4 percentage pre-ART showed significant associations with VL suppression. CONCLUSIONS Large increases in the proportion of VL suppression in adults were observed when we excluded those who were LTFU or had died. The increases were less pronounced in children. Greater emphasis should be made to minimize LTFU and maximize patient retention in HIV-infected patients of all age groups.
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Affiliation(s)
| | | | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Claudia P Cortes
- University of Chile School of Medicine & Fundación Arriaran, Santiago, Chile
| | - Mary-Ann Davies
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Viet Chau Do
- Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Brian Eley
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - John Gill
- University of Calgary, Calgary, Alberta, Canada
| | | | - Daisy Maria Machado
- Pediatric Infectious Disease Division, Escola Paulista de Medicina-Universidade Federal de SãoPaulo, São Paulo, Brazil
| | - Richard Moore
- Johns Hopkins University, Department of Medicine, Division of Infectious Diseases, Baltimore MD, United States
| | - Hans Prozesky
- Division of Infectious Diseases, Department of Medicine, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa
| | - Elizabeth Zaniewski
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Kaplan SR, Oosthuizen C, Stinson K, Little F, Euvrard J, Schomaker M, Osler M, Hilderbrand K, Boulle A, Meintjes G. Contemporary disengagement from antiretroviral therapy in Khayelitsha, South Africa: A cohort study. PLoS Med 2017; 14:e1002407. [PMID: 29112692 PMCID: PMC5675399 DOI: 10.1371/journal.pmed.1002407] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 09/12/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Retention in care is an essential component of meeting the UNAIDS "90-90-90" HIV treatment targets. In Khayelitsha township (population ~500,000) in Cape Town, South Africa, more than 50,000 patients have received antiretroviral therapy (ART) since the inception of this public-sector program in 2001. Disengagement from care remains an important challenge. We sought to determine the incidence of and risk factors associated with disengagement from care during 2013-2014 and outcomes for those who disengaged. METHODS AND FINDINGS We conducted a retrospective cohort study of all patients ≥10 years of age who visited 1 of the 13 Khayelitsha ART clinics from 2013-2014 regardless of the date they initiated ART. We described the cumulative incidence of first disengagement (>180 days not attending clinic) between 1 January 2013 and 31 December 2014 using competing risks methods, enabling us to estimate disengagement incidence up to 10 years after ART initiation. We also described risk factors for disengagement based on a Cox proportional hazards model, using multiple imputation for missing data. We ascertained outcomes (death, return to care, hospital admission, other hospital contact, alive but not in care, no information) after disengagement until 30 June 2015 using province-wide health databases and the National Death Registry. Of 39,884 patients meeting our eligibility criteria, the median time on ART to 31 December 2014 was 33.6 months (IQR 12.4-63.2). Of the total study cohort, 592 (1.5%) died in the study period, 1,231 (3.1%) formally transferred out, 987 (2.5%) were silent transfers and visited another Western Cape province clinic within 180 days, 9,005 (22.6%) disengaged, and 28,069 (70.4%) remained in care. Cumulative incidence of disengagement from care was estimated to be 25.1% by 2 years and 50.3% by 5 years on ART. Key factors associated with disengagement (age, male sex, pregnancy at ART start [HR 1.58, 95% CI 1.47-1.69], most recent CD4 count) and retention (ART club membership, baseline CD4) after adjustment were similar to those found in previous studies; however, notably, the higher hazard of disengagement soon after starting ART was no longer present after adjusting for these risk factors. Of the 9,005 who disengaged, the 2 most common initial outcomes were return to ART care after 180 days (33%; n = 2,976) and being alive but not in care in the Western Cape (25%; n = 2,255). After disengagement, a total of 1,459 (16%) patients were hospitalized and 237 (3%) died. The median follow-up from date of disengagement to 30 June 2015 was 16.7 months (IQR 11-22.4). As we included only patient follow-up from 2013-2014 by design in order to maximize the generalizability of our findings to current programs, this limited our ability to more fully describe temporal trends in first disengagement. CONCLUSIONS Twenty-three percent of ART patients in the large cohort of Khayelitsha, one of the oldest public-sector ART programs in South Africa, disengaged from care at least once in a contemporary 2-year period. Fifty-eight percent of these patients either subsequently returned to care (some "silently") or remained alive without hospitalization, suggesting that many who are considered "lost" actually return to care, and that misclassification of "lost" patients is likely common in similar urban populations. A challenge to meeting ART retention targets is developing, testing, and implementing program designs to target mobile populations and retain them in lifelong care. This should be guided by risk factors for disengagement and improving interlinkage of routine information systems to better support patient care across complex care platforms.
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Affiliation(s)
- Samantha R. Kaplan
- Yale School of Medicine, New Haven, Connecticut, United States of America
- * E-mail:
| | - Christa Oosthuizen
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kathryn Stinson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Médecins Sans Frontières (Southern Africa Medical Unit), Johannesburg, South Africa
| | - Francesca Little
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Meg Osler
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Katherine Hilderbrand
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Médecins Sans Frontières (Southern Africa Medical Unit), Johannesburg, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Graeme Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
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Tsadik M, Berhane Y, Worku A, Terefe W. The magnitude of, and factors associated with, loss to follow-up among patients treated for sexually transmitted infections: a multilevel analysis. BMJ Open 2017; 7:e016864. [PMID: 28716795 PMCID: PMC5726144 DOI: 10.1136/bmjopen-2017-016864] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/12/2017] [Accepted: 06/13/2017] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES The loss to follow-up (LTFU) among patients attending care for sexually transmitted infections (STIs) in Sub-Saharan Africa is a major barrier to achieving the goals of the STI prevention and control programme. The objective of this study was to investigate individual- and facility-level factors associated with LTFU among patients treated for STIs in Ethiopia. METHODS A prospective cohort study was conducted among patients attending care for STIs in selected facilities from January to June 2015 in the Tigray region of Ethiopia. LTFU was ascertained if a patient did not present in person to the same facility within 7 days of the initial contact. Multilevel logistic regression was used to identify factors associated with LTFU. RESULTS Out of 1082 patients, 59.80% (647) were LTFU. The individual-level factors associated with LTFU included having multiple partners (adjusted OR (AOR) 2.89, 95% CI 1.74 to 4.80), being male (AOR 2.23, 95% CI 1.63 to 3.04), having poor knowledge about the means of STI transmission (AOR 2.08, 95% CI 1.53 to 2.82), having college level education (AOR 0.38, 95% CI 0.22 to 0.65), and low perceived stigma (AOR 0.60, 95% CI 0.43 to 0.82). High patient flow (AOR 3.06, 95% CI 1.30 to 7.18) and medium health index score (AOR 2.80, 95% CI 1.28 to 6.13) were facility-level factors associated with LTFU. CONCLUSIONS Improving patient retention in STI follow-up care requires focused interventions targeting those who are more likely to be LTFU, particularly patients with multiple partners, male index cases and patients attending facilities with high patient flow.
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Affiliation(s)
- Mache Tsadik
- College of Health Science, Mekelle University, Tigray, Ethiopia
| | - Yemane Berhane
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
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Implementation and Operational Research: Impact of Nurse-Targeted Care on HIV Outcomes Among Immunocompromised Persons: A Before-After Study in Uganda. J Acquir Immune Defic Syndr 2017; 72:e32-6. [PMID: 27003494 DOI: 10.1097/qai.0000000000001002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Improving HIV outcomes among severely immunocompromised HIV-infected persons who have increased morbidity and mortality remains an important issue in sub-Saharan Africa. We sought to evaluate the impact of targeted clinic-based nurse care on antiretroviral therapy (ART) initiation and retention among severely immunocompromised HIV-infected persons. METHODS The study included ART-naive patients with CD4 counts <100 cells per microliter registered in seven urban clinics in Kampala, Uganda. Data were retrospectively collected on patients enrolled from July to December 2011 (routine care cohort). Between July 2012 and September 2013, 1 additional nurse per clinic was hired (nurse counselor cohort) to identify new patients, expedite ART initiation, and trace those who were lost to follow-up. We compared time to ART initiation and 6-month retention in care between cohorts and used a generalized linear model to estimate the relative risk of retention. RESULTS The study included 258 patients in the routine care cohort and 593 in the nurse counselor cohort. The proportion of patients who initiated ART increased from 190 (73.6%) in the routine care cohort to 506 (85.3%) in the nurse counselor cohort (P < 0.001). At 6 months, 62% of the routine care cohort were retained in care versus 76% in the nurse counselor cohort (P = 0.001). A 21% increase in the likelihood of retention in the nurse counselor cohort (relative risk: 1.21, 95% CI: 1.09 to 1.34) compared with the routine care cohort was observed. CONCLUSIONS Implementation of targeted nurse-led care of severely immunocompromised HIV-infected patients in public outpatient health care facilities resulted in decreased time to ART initiation and increased retention.
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McNairy ML, Joseph P, Unterbrink M, Galbaud S, Mathon JE, Rivera V, Jannat-Khah D, Reif L, Koenig SP, Domercant JW, Johnson W, Fitzgerald DW, Pape JW. Outcomes after antiretroviral therapy during the expansion of HIV services in Haiti. PLoS One 2017; 12:e0175521. [PMID: 28437477 PMCID: PMC5402937 DOI: 10.1371/journal.pone.0175521] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 03/27/2017] [Indexed: 11/18/2022] Open
Abstract
Background We report patient outcomes after antiretroviral therapy (ART) initiation in a network of HIV facilities in Haiti, including temporal trends and differences across clinics, during the expansion of HIV services in the country. Methods We assessed outcomes at 12 months after ART initiation (baseline) using routinely collected data on adults (≥15 years) in 11 HIV facilities from July 2007-December 2013. Outcomes include death (ascertained from medical records), lost to follow-up (LTF) defined as no visit > 365 days from ART initiation, and retention defined as being alive and attending care ≥ 365 days from ART initiation. Outcomes were compared across calendar year of ART initiation and across facilities. Risk factors for death and LTF were assessed using Cox proportional hazards and competing risk regression models. Results Cumulatively, 9,718 adults initiated ART with median age 37 years (IQR 30–46). Median CD4 count was 254 cells/uL (IQR 139–350). Twelve months after ART initiation, 4.4% (95% CI 4.0–4.8) of patients died, 21.7% (95% CI 20.9–22.6) were LTF, and 73.9% (95% CI 73.0–74.8) were retained in care. Twelve-month mortality decreased from 13.8% among adults who started ART in 2007 to 4.4% in 2013 (p<0.001). Twelve-month LTF after ART start was 29.2% in 2007, 18.7% in 2008, and increased to 30.1% in 2013 (p<0.001). Overall, twelve-month retention after ART start did not change over time but varied widely across facilities from 61.1% to 86.5%. Conclusion Expansion of HIV services across Haiti has been successful with increasing numbers of patients initiating ART and decreasing twelve-month mortality rates. However, overall retention has not improved, despite differences across facilities, suggesting additional strategies to improve engagement in care are needed.
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Affiliation(s)
- Margaret L. McNairy
- Center for Global Health, Weill Cornell Medical College, New York, New York, United States of America
- Division of General Medicine, Weill Cornell Medical College, New York, New York, United States of America
- * E-mail:
| | - Patrice Joseph
- Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Michelle Unterbrink
- Division of General Medicine, Weill Cornell Medical College, New York, New York, United States of America
| | - Stanislas Galbaud
- Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jean-Edouard Mathon
- Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Vanessa Rivera
- Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Deanna Jannat-Khah
- Division of General Medicine, Weill Cornell Medical College, New York, New York, United States of America
| | - Lindsey Reif
- Center for Global Health, Weill Cornell Medical College, New York, New York, United States of America
| | - Serena P. Koenig
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | | | - Warren Johnson
- Center for Global Health, Weill Cornell Medical College, New York, New York, United States of America
| | - Daniel W. Fitzgerald
- Center for Global Health, Weill Cornell Medical College, New York, New York, United States of America
| | - Jean W. Pape
- Center for Global Health, Weill Cornell Medical College, New York, New York, United States of America
- Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
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Agaba PA, Meloni ST, Sule HM, Agbaji OO, Sagay AS, Okonkwo P, Idoko JA, Kanki PJ. Treatment Outcomes Among Older Human Immunodeficiency Virus-Infected Adults in Nigeria. Open Forum Infect Dis 2017; 4:ofx031. [PMID: 29497627 PMCID: PMC5780650 DOI: 10.1093/ofid/ofx031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 02/09/2017] [Indexed: 02/07/2023] Open
Abstract
Background Older age at initiation of combination antiretroviral therapy (cART) has been associated with poorer clinical outcomes. Our objectives were to compare outcomes between older and younger patients in our clinical cohort in Jos, Nigeria. Methods This retrospective cohort study evaluated patients enrolled on cART at the Jos University Teaching Hospital, Nigeria between 2004 and 2012. We compared baseline and treatment differences between older (≥50 years) and younger (15–49 years) patients. Kaplan-Meier analysis and Cox proportional hazard models estimated survival and loss to follow-up (LTFU) and determined factors associated with these outcomes at 24 months. Results Of 8352 patients, 643 (7.7%) were aged ≥50 years. The median change in CD4 count from baseline was 151 vs 132 (P = .0005) at 12 months and 185 vs 151 cells/mm3 (P = .03) at 24 months for younger and older patients, respectively. A total of 68.9% vs 71.6% (P = .13) and 69.6% vs 74.8% (P = .005) of younger and older patients achieved viral suppression at 12 and 24 months, with similar incidence of mortality and LTFU. In adjusted hazard models, factors associated with increased risk of mortality were male sex, World Health Organization (WHO) stage III/IV, and having a gap in care, whereas being fully suppressed was protective. The risk of being LTFU was lower for older patients, those fully suppressed virologically and with adherence rates >95%. Male sex, lack of education, WHO stage III/IV, body mass index <18.5 kg/m2, and having a gap in care independently predicted LTFU. Conclusions Older patients achieved better viral suppression, and older age was not associated with increased mortality or LTFU in this study.
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Affiliation(s)
- Patricia A Agaba
- Departments of Family Medicine.,APIN Centre, Jos University Teaching Hospital, Nigeria
| | - Seema T Meloni
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; and
| | - Halima M Sule
- Departments of Family Medicine.,APIN Centre, Jos University Teaching Hospital, Nigeria
| | - Oche O Agbaji
- Medicine, and.,APIN Centre, Jos University Teaching Hospital, Nigeria
| | - Atiene S Sagay
- Obstetrics and Gynaecology, University of Jos/Jos University Teaching Hospital, Nigeria.,APIN Centre, Jos University Teaching Hospital, Nigeria
| | | | | | - Phyllis J Kanki
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; and
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Monroe A, Nakigozi G, Ddaaki W, Bazaale JM, Gray RH, Wawer MJ, Reynolds SJ, Kennedy CE, Chang LW. Qualitative insights into implementation, processes, and outcomes of a randomized trial on peer support and HIV care engagement in Rakai, Uganda. BMC Infect Dis 2017; 17:54. [PMID: 28068935 PMCID: PMC5223463 DOI: 10.1186/s12879-016-2156-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 12/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND People living with human immunodeficiency virus (HIV) who have not yet initiated antiretroviral therapy (ART) can benefit from being engaged in care and utilizing preventive interventions. Community-based peer support may be an effective approach to promote these important HIV services. METHODS After conducting a randomized trial of the impact of peer support on pre-ART outcomes, we conducted a qualitative evaluation to better understand trial implementation, processes, and results. Overall, 75 participants, including trial participants (clients), peer supporters, and clinic staff, participated in 41 in-depth interviews and 6 focus group discussions. A situated Information Motivation, and Behavioral skills model of behavior change was used to develop semi-structured interview and focus group guides. Transcripts were coded and thematically synthesized. RESULTS We found that participant narratives were generally consistent with the theoretical model, indicating that peer support improved information, motivation, and behavioral skills, leading to increased engagement in pre-ART care. Clients described how peer supporters reinforced health messages and helped them better understand complicated health information. Peer supporters also helped clients navigate the health system, develop support networks, and identify strategies for remembering medication and clinic appointments. Some peer supporters adopted roles beyond visiting patients, serving as a bridge between the client and his or her family, community, and health system. Qualitative results demonstrated plausible processes by which peer support improved client engagement in care, cotrimoxazole use, and safe water vessel use. Challenges identified included insufficient messaging surrounding ART initiation, lack of care continuity after ART initiation, rare breaches in confidentiality, and structural challenges. CONCLUSIONS The evaluation found largely positive perceptions of the peer intervention across stakeholders and provided valuable information to inform uptake and scalability of the intervention. Study findings also suggest several areas for improvement for future implementation of pre-ART peer support programs. TRIAL REGISTRATION NCT01366690 . Registered June 2, 2011.
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Affiliation(s)
- April Monroe
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | - Ronald H Gray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Maria J Wawer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Steven J Reynolds
- Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Laboratory of Immunoregulation, Bethesda, Maryland, USA.,Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Larry W Chang
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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High levels of retention in care with streamlined care and universal test and treat in East Africa. AIDS 2016; 30:2855-2864. [PMID: 27603290 DOI: 10.1097/qad.0000000000001250] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to measure retention in care and identify predictors of nonretention among patients receiving antiretroviral therapy (ART) with streamlined delivery during the first year of the ongoing Sustainable East Africa Research on Community Health (SEARCH) 'test-and-treat' trial (NCT 01864603) in rural Uganda and Kenya. DESIGN Prospective cohort of patients in the intervention arm of the SEARCH study. METHODS We measured retention in care at 12 months among HIV-infected adults who linked to care and were offered ART regardless of CD4 cell count, following community-wide HIV-testing. Kaplan-Meier estimates and Cox proportional hazards modeling were used to calculate the probability of retention at 1 year and identify predictors of nonretention. RESULTS Among 5683 adults (age ≥15) who linked to care, 95.5% [95% confidence interval (CI): 92.9-98.1%] were retained in care at 12 months. The overall probability of retention at 1 year was 89.3% (95% CI: 87.6-90.7%) among patients newly linking to care and 96.4% (95% CI: 95.8-97.0%) among patients previously in care. Younger age and pre-ART CD4 cell count below country treatment initiation guidelines were predictors of nonretention among all patients. Among those newly linking, taking more than 30 days to link to care after HIV diagnosis was additionally associated with nonretention at 1 year. HIV viral load suppression at 12 months was observed in 4227 of 4736 (89%) of patients retained with valid viral load results. CONCLUSION High retention in care and viral suppression after 1 year were achieved in a streamlined HIV care delivery system in the context of a universal test-and-treat intervention.
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Dalhatu I, Onotu D, Odafe S, Abiri O, Debem H, Agolory S, Shiraishi RW, Auld AF, Swaminathan M, Dokubo K, Ngige E, Asadu C, Abatta E, Ellerbrock TV. Outcomes of Nigeria's HIV/AIDS Treatment Program for Patients Initiated on Antiretroviral Treatment between 2004-2012. PLoS One 2016; 11:e0165528. [PMID: 27829033 PMCID: PMC5102414 DOI: 10.1371/journal.pone.0165528] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 10/13/2016] [Indexed: 12/20/2022] Open
Abstract
Background The Nigerian Antiretroviral therapy (ART) program started in 2004 and now ranks among the largest in Africa. However, nationally representative data on outcomes have not been reported. Methods We evaluated retrospective cohort data from a nationally representative sample of adults aged ≥15 years who initiated ART during 2004 to 2012. Data were abstracted from 3,496 patient records at 35 sites selected using probability-proportional-to-size (PPS) sampling. Analyses were weighted and controlled for the complex survey design. The main outcome measures were mortality, loss to follow-up (LTFU), and retention (the proportion alive and on ART). Potential predictors of attrition were assessed using competing risk regression models. Results At ART initiation, 66.4 percent (%) were females, median age was 33 years, median weight 56 kg, median CD4 count 161 cells/mm3, and 47.1% had stage III/IV disease. The percentage of patients retained at 12, 24, 36 and 48 months was 81.2%, 74.4%, 67.2%, and 61.7%, respectively. Over 10,088 person-years of ART, mortality, LTFU, and overall attrition (mortality, LTFU, and treatment stop) rates were 1.1 (95% confidence interval (CI): 0.7–1.8), 12.3 (95%CI: 8.9–17.0), and 13.9 (95% CI: 10.4–18.5) per 100 person-years (py) respectively. Highest attrition rates of 55.4/100py were witnessed in the first 3 months on ART. Predictors of LTFU included: lower-than-secondary level education (reference: Tertiary), care in North-East and South-South regions (reference: North-Central), presence of moderate/severe anemia, symptomatic functional status, and baseline weight <45kg. Predictor of mortality was WHO stage higher than stage I. Male sex, severe anemia, and care in a small clinic were associated with both mortality and LTFU. Conclusion Moderate/Advanced HIV disease was predictive of attrition; earlier ART initiation could improve program outcomes. Retention interventions targeting men and those with lower levels of education are needed. Further research to understand geographic and clinic size variations with outcome is warranted.
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Affiliation(s)
- Ibrahim Dalhatu
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
| | - Dennis Onotu
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
| | - Solomon Odafe
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
- * E-mail:
| | - Oseni Abiri
- School of Biomedical Informatics, University of Texas, Houston, Texas, United States of America
| | - Henry Debem
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
| | - Simon Agolory
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
| | - Ray W. Shiraishi
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
| | - Andrew F. Auld
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
| | - Mahesh Swaminathan
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
| | - Kainne Dokubo
- School of Biomedical Informatics, University of Texas, Houston, Texas, United States of America
| | - Evelyn Ngige
- National AIDS & STIs Control Program, Federal Ministry of Health, Abuja, Nigeria
| | - Chukwuemeka Asadu
- National AIDS & STIs Control Program, Federal Ministry of Health, Abuja, Nigeria
| | - Emmanuel Abatta
- National AIDS & STIs Control Program, Federal Ministry of Health, Abuja, Nigeria
| | - Tedd V. Ellerbrock
- Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
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Marked sex differences in all-cause mortality on antiretroviral therapy in low- and middle-income countries: a systematic review and meta-analysis. J Int AIDS Soc 2016; 19:21106. [PMID: 27834182 PMCID: PMC5103676 DOI: 10.7448/ias.19.1.21106] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 09/15/2016] [Accepted: 10/06/2016] [Indexed: 01/14/2023] Open
Abstract
Introduction While women and girls are disproportionately at risk of HIV acquisition, particularly in low- and middle-income countries (LMIC), globally men and women comprise similar proportions of people living with HIV who are eligible for antiretroviral therapy. However, men represent only approximately 41% of those receiving antiretroviral therapy globally. There has been limited study of men’s outcomes in treatment programmes, despite data suggesting that men living with HIV and engaged in treatment programmes have higher mortality rates. This systematic review (SR) and meta-analysis (MA) aims to assess differential all-cause mortality between men and women living with HIV and on antiretroviral therapy in LMIC. Methods A SR was conducted through searching PubMed, Ovid Global Health and EMBASE for peer-reviewed, published observational studies reporting differential outcomes by sex of adults (≥15 years) living with HIV, in treatment programmes and on antiretroviral medications in LMIC. For studies reporting hazard ratios (HRs) of mortality by sex, quality assessment using Newcastle–Ottawa Scale (cohort studies) and an MA using a random-effects model (Stata 14.0) were conducted. Results A total of 11,889 records were screened, and 6726 full-text articles were assessed for eligibility. There were 31 included studies in the final MA reporting 42 HRs, with a total sample size of 86,233 men and 117,719 women, and total time on antiretroviral therapy of 1555 months. The pooled hazard ratio (pHR) showed a 46% increased hazard of death for men while on antiretroviral treatment (1.35–1.59). Increased hazard was significant across geographic regions (sub-Saharan Africa: pHR 1.41 (1.28–1.56); Asia: 1.77 (1.42–2.21)) and persisted over time on treatment (≤12 months: 1.42 (1.21–1.67); 13–35 months: 1.48 (1.23–1.78); 36–59 months: 1.50 (1.18–1.91); 61 to 108 months: 1.49 (1.29–1.71)). Conclusions Men living with HIV have consistently and significantly greater hazards of all-cause mortality compared with women while on antiretroviral therapy in LMIC. This effect persists over time on treatment. The clinical and population-level prevention benefits of antiretroviral therapy will only be realized if programmes can improve male engagement, diagnosis, earlier initiation of therapy, clinical outcomes and can support long-term adherence and retention.
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Auld AF, Agizew T, Pals S, Finlay A, Ndwapi N, Boyd R, Alexander H, Mathoma A, Basotli J, Gwebe-Nyirenda S, Shepherd J, Ellerbrock TV, Date A. Implementation of a pragmatic, stepped-wedge cluster randomized trial to evaluate impact of Botswana's Xpert MTB/RIF diagnostic algorithm on TB diagnostic sensitivity and early antiretroviral therapy mortality. BMC Infect Dis 2016; 16:606. [PMID: 27782821 PMCID: PMC5080709 DOI: 10.1186/s12879-016-1905-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/08/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In 2012, as a pilot for Botswana's national Xpert MTB/RIF (Xpert) rollout plans, intensified tuberculosis (TB) case finding (ICF) activities were strengthened at 22 HIV treatment clinics prior to phased activation of 13 Xpert instruments. Together, the strengthened ICF intervention and Xpert activation are referred to as the "Xpert package". METHODS The evaluation, called the Xpert Package Rollout Evaluation using a Stepped-wedge design (XPRES), has two key objectives: (1) to compare sensitivity of microscopy-based and Xpert-based pulmonary TB diagnostic algorithms in diagnosing sputum culture-positive TB; and (2) to evaluate impact of the "Xpert package" on all-cause, 6-month, adult antiretroviral therapy (ART) mortality. A pragmatic, stepped-wedge cluster-randomized trial design was chosen. The design involves enrollment of three cohorts: (1) cohort R, a retrospective cohort of all study clinic ART enrollees in the 24 months before study initiation (July 31, 2012); (2) cohort A, a prospective cohort of all consenting patients presenting to study clinics after study initiation, who received the ICF intervention and the microscopy-based TB diagnostic algorithm; and (3) cohort B, a prospective cohort of all consenting patients presenting to study clinics after Xpert activation, who received the ICF intervention and the Xpert-based TB diagnostic algorithm. TB diagnostic sensitivity will be compared between TB culture-positive enrollees in cohorts A and B. All-cause, 6-month ART-mortality will be compared between cohorts R and B. With anticipated cohort R, A, and B sample sizes of about 10,131, 1,878, and 4,258, respectively, the study is estimated to have >80 % power to detect differences in pre-versus post-Xpert TB diagnostic sensitivity if pre-Xpert sensitivity is ≤52.5 % and post-Xpert sensitivity ≥82.5 %, and >80 % power to detect a 40 % reduction in all-cause, 6-month, ART mortality between cohorts R and B if cohort R mortality is ≥13/100 person-years. DISCUSSION Only one small previous trial (N = 424) among ART enrolees in Zimbabwe evaluated, in a secondary analysis, Xpert impact on all-cause 6-month ART mortality. No mortality impact was observed. This Botswana trial, with its larger sample size and powered specifically to detect differences in all-cause 6-month ART mortality, remains well-positioned to contribute understanding of Xpert impact. TRIAL REGISTRATION Retrospectively registered at ClinicalTrials.gov: NCT02538952 .
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Affiliation(s)
- Andrew F Auld
- Division of Global HIV & TB, Center for Global Health, United States Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, USA.
| | - Tefera Agizew
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana
| | - Sherri Pals
- Division of Global HIV & TB, Center for Global Health, United States Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Alyssa Finlay
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana.,Division of TB Elimination, National Center for HIV, Hepatitis and STD Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Ndwapi Ndwapi
- Ministerial Strategy Office, Ministry of Health, 24 Amos Street, Gaborone, Botswana
| | - Rosanna Boyd
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana.,Division of TB Elimination, National Center for HIV, Hepatitis and STD Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Heather Alexander
- Division of Global HIV & TB, Center for Global Health, United States Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Anikie Mathoma
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana
| | - Joyce Basotli
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana
| | - Sambayawo Gwebe-Nyirenda
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana
| | - James Shepherd
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana.,Yale University School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA
| | - Tedd V Ellerbrock
- Division of Global HIV & TB, Center for Global Health, United States Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Anand Date
- Division of Global HIV & TB, Center for Global Health, United States Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, USA
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Nordentoft PB, Engell-Sørensen T, Jespersen S, Correia FG, Medina C, da Silva Té D, Østergaard L, Laursen AL, Wejse C, Hønge BL. Assessing factors for loss to follow-up of HIV infected patients in Guinea-Bissau. Infection 2016; 45:187-197. [PMID: 27743308 DOI: 10.1007/s15010-016-0949-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 09/25/2016] [Indexed: 01/18/2023]
Abstract
PURPOSE The objective of this study was to ascertain vital status of patients considered lost to follow-up at an HIV clinic in Guinea-Bissau, and describe reasons for loss to follow-up (LTFU). METHODS This study was a cross-sectional sample of a prospective cohort, carried out between May 15, 2013, and January 31, 2014. Patients lost to follow-up, who lived within the area of the Bandim Health Project, a demographic surveillance site (DSS), were eligible for inclusion. Active follow-up was attempted by telephone and tracing by a field assistant. Semi-structured interviews were done face to face or by phone by a field assistant and patients were asked why they had not shown up for the scheduled appointment. Patients were included by date of HIV testing and risk factors for LTFU were assessed using Cox proportional hazard model. RESULTS Among 561 patients (69.5 % HIV-1, 18.0 % HIV-2 and 12.6 % HIV-1/2) living within the DSS, 292 patients had been lost to follow-up and were, therefore, eligible for active follow-up. Vital status was ascertained in 65.9 % of eligible patients and 42.7 % were alive, while 23.2 % had died. Information on reasons for LTFU existed for 103 patients. Major reasons were moving (29.1 %), travelling (17.5 %), and transferring to other clinics (11.7 %). CONCLUSION A large proportion of the patients at the clinic were lost to follow-up. The main reason for this was found to be the geographic mobility of the population in Guinea-Bissau.
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Affiliation(s)
- Pernille Bejer Nordentoft
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau.,Department of Infectious Diseases, Aarhus University Hospital, 8200, Aarhus N, Denmark
| | - Thomas Engell-Sørensen
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau.,Department of Infectious Diseases, Aarhus University Hospital, 8200, Aarhus N, Denmark
| | - Sanne Jespersen
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau.,Department of Infectious Diseases, Aarhus University Hospital, 8200, Aarhus N, Denmark
| | | | - Candida Medina
- National HIV Programme, Ministry of Health, Bissau, Guinea-Bissau
| | | | - Lars Østergaard
- Department of Infectious Diseases, Aarhus University Hospital, 8200, Aarhus N, Denmark
| | - Alex Lund Laursen
- Department of Infectious Diseases, Aarhus University Hospital, 8200, Aarhus N, Denmark
| | - Christian Wejse
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau. .,Department of Infectious Diseases, Aarhus University Hospital, 8200, Aarhus N, Denmark. .,GloHAU, Center for Global Health, School of Public Health, Aarhus University, 8000, Aarhus C, Denmark.
| | - Bo Langhoff Hønge
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau.,Department of Infectious Diseases, Aarhus University Hospital, 8200, Aarhus N, Denmark.,Department of Clinical Immunology, Aarhus University Hospital, 8200, Aarhus N, Denmark
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Kemp C, Gerth-Guyette E, Dube L, Andrasik M, Rao D. Mixed-Methods Evaluation of a Novel, Structured, Community-Based Support and Education Intervention for Individuals with HIV/AIDS in KwaZulu-Natal, South Africa. AIDS Behav 2016; 20:1937-50. [PMID: 27553008 DOI: 10.1007/s10461-016-1386-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
People living with HIV in Sub-Saharan Africa face significant challenges accessing care. Community-based peer support groups can increase linkage to treatment, though the effectiveness of structured, scalable groups has not been demonstrated. This study aimed to measure the impact of the structured Integrated Access to Care and Treatment intervention on clients' knowledge, attitudes, and practice regarding HIV/AIDS, including their experiences of stigma, in KwaZulu-Natal, South Africa. Data collection involved pre-/post-tests and client interviews. Pre-/post-test data from 66 clients were collected. 17 participants were interviewed. Paired t-tests did not detect significant changes in the main outcomes. Qualitative results suggested a psychosocial benefit as participants connected with their peers, expressed themselves openly, and re-engaged with their communities. Unfortunately, this study did not quantitatively measure psychosocial changes, and the results have limited generalizability to men. I ACT may be an effective complement to clinic-based support services, though further study should quantify the psychosocial benefit.
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Affiliation(s)
- Christopher Kemp
- Department of Global Health, University of Washington, Ninth and Jefferson Building, 13th Floor, 908 Jefferson Street, Box 359932, Seattle, WA, 98104, USA.
| | | | - Lungile Dube
- SaveAct, 123 Jabu Ndlovu St, Pietermaritzburg, 3201, South Africa
| | - Michele Andrasik
- Department of Global Health, University of Washington, Ninth and Jefferson Building, 13th Floor, 908 Jefferson Street, Box 359932, Seattle, WA, 98104, USA
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N, E3-300, Seattle, WA, 98109, USA
| | - Deepa Rao
- Department of Global Health, University of Washington, Ninth and Jefferson Building, 13th Floor, 908 Jefferson Street, Box 359932, Seattle, WA, 98104, USA
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French N, Gordon SB, Mwalukomo T, White SA, Mwafulirwa G, Longwe H, Mwaiponya M, Zijlstra EE, Molyneux ME, Gilks CF. A trial of a 7-valent pneumococcal conjugate vaccine in HIV-infected adults. Malawi Med J 2016; 28:115-122. [PMID: 27895845 PMCID: PMC5117001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Streptococcus pneumoniae is a leading and serious coinfection in adults with human immunodeficiency virus (HIV) infection, particularly in Africa. Prevention of this disease by vaccination with the current 23-valent polysaccharide vaccine is suboptimal. Protein conjugate vaccines offer a further option for protection, but data on their clinical efficacy in adults are needed. METHODS In this double-blind, randomized, placebo-controlled clinical efficacy trial, we studied the efficacy of a 7-valent conjugate pneumococcal vaccine in predominantly HIV-infected Malawian adolescents and adults who had recovered from documented invasive pneumococcal disease. Two doses of vaccine were given 4 weeks apart. The primary end point was a further episode of pneumococcal infection caused by vaccine serotypes or serotype 6A. RESULTS From February 2003 through October 2007, we followed 496 patients (of whom 44% were male and 88% were HIV-seropositive) for 798 person-years of observation. There were 67 episodes of pneumococcal disease in 52 patients, all in the HIV-infected subgroup. In 24 patients, there were 19 episodes that were caused by vaccine serotypes and 5 episodes that were caused by the 6A serotype. Of these episodes, 5 occurred in the vaccine group and 19 in the placebo group, for a vaccine efficacy of 74% (95% confidence interval [CI], 30 to 90). There were 73 deaths from any cause in the vaccine group and 63 in the placebo group (hazard ratio in the vaccine group, 1.18; 95% CI, 0.84 to 1.66). The number of serious adverse events within 14 days after vaccination was significantly lower in the vaccine group than in the placebo group (3 vs. 17, P = 0.002), and the number of minor adverse events was significantly higher in the vaccine group (41 vs. 13, P = 0.003). CONCLUSIONS The 7-valent pneumococcal conjugate vaccine protected HIV-infected adults from recurrent pneumococcal infection caused by vaccine serotypes or serotype 6A. (Current Controlled Trials number, ISRCTN54494731.).
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Affiliation(s)
- Neil French
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Karonga Prevention Study, London School of Hygiene and Tropical Medicine, Karonga, Malawi
| | - Stephen B Gordon
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Thandie Mwalukomo
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Sarah A White
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Gershom Mwafulirwa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Herbert Longwe
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Martin Mwaiponya
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Eduard E Zijlstra
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Malcolm E Molyneux
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Rachlis B, Bakoyannis G, Easterbrook P, Genberg B, Braithwaite RS, Cohen CR, Bukusi EA, Kambugu A, Bwana MB, Somi GR, Geng EH, Musick B, Yiannoutsos CT, Wools-Kaloustian K, Braitstein P. Facility-Level Factors Influencing Retention of Patients in HIV Care in East Africa. PLoS One 2016; 11:e0159994. [PMID: 27509182 PMCID: PMC4980048 DOI: 10.1371/journal.pone.0159994] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/12/2016] [Indexed: 12/25/2022] Open
Abstract
Losses to follow-up (LTFU) remain an important programmatic challenge. While numerous patient-level factors have been associated with LTFU, less is known about facility-level factors. Data from the East African International epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium was used to identify facility-level factors associated with LTFU in Kenya, Tanzania and Uganda. Patients were defined as LTFU if they had no visit within 12 months of the study endpoint for pre-ART patients or 6 months for patients on ART. Adjusting for patient factors, shared frailty proportional hazard models were used to identify the facility-level factors associated with LTFU for the pre- and post-ART periods. Data from 77,362 patients and 29 facilities were analyzed. Median age at enrolment was 36.0 years (Interquartile Range: 30.1, 43.1), 63.9% were women and 58.3% initiated ART. Rates (95% Confidence Interval) of LTFU were 25.1 (24.7–25.6) and 16.7 (16.3–17.2) per 100 person-years in the pre-ART and post-ART periods, respectively. Facility-level factors associated with increased LTFU included secondary-level care, HIV RNA PCR turnaround time >14 days, and no onsite availability of CD4 testing. Increased LTFU was also observed when no nutritional supplements were provided (pre-ART only), when TB patients were treated within the HIV program (pre-ART only), and when the facility was open ≤4 mornings per week (ART only). Our findings suggest that facility-based strategies such as point of care laboratory testing and separate clinic spaces for TB patients may improve retention.
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Affiliation(s)
- Beth Rachlis
- The Ontario HIV Treatment Network, Toronto, Canada.,Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Giorgos Bakoyannis
- Department of Biostatistics, Richard Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, United States of America
| | | | - Becky Genberg
- Department of Health Services, Brown University, Providence, Rhode Island, United States of America
| | - Ronald Scott Braithwaite
- Department of Population Health, School of Medicine, New York University, New York, New York, United States of America
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Mwebesa Bosco Bwana
- Department of Internal Medicine, Mbarara University of Science & Technology, Mbarara, Uganda
| | | | - Elvin H Geng
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Beverly Musick
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Constantin T Yiannoutsos
- Department of Biostatistics, Richard Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, United States of America
| | - Kara Wools-Kaloustian
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Paula Braitstein
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya.,Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya.,Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Yende-Zuma N, Naidoo K. The Effect of Timing of Initiation of Antiretroviral Therapy on Loss to Follow-up in HIV-Tuberculosis Coinfected Patients in South Africa: An Open-Label, Randomized, Controlled Trial. J Acquir Immune Defic Syndr 2016; 72:430-6. [PMID: 26990824 PMCID: PMC4927384 DOI: 10.1097/qai.0000000000000995] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the effect of early integrated, late-integrated, and delayed antiretroviral therapy (ART) initiation during tuberculosis (TB) treatment on the incidence rates of loss to follow-up (LTFU) and to evaluate the effect of ART initiation on LTFU rates within trial arms in patients coinfected with TB and HIV. METHODS A substudy within a 3-armed, open label, randomized, controlled trial. Patients were randomized to initiate ART either early or late during TB treatment or after the TB treatment completion. We reported the incidence and predictors of LTFU from TB treatment initiation during the 24 months of follow-up. LTFU was defined as having missed 4 consecutive monthly visits with the inability to make contact. RESULTS Of the 642 patients randomized, a total of 96 (15.0%) were LTFU at a median of 6.0 [interquartile range (IQR), 1.1-11.3] months after TB treatment initiation. Incidence rates of LTFU were 7.5 per 100 person-years (PY) [95% confidence interval (CI): 4.9 to 11], 10.9 per 100 PY (95% CI: 7.6 to 15.1), and 11.0 per 100 PY (95% CI: 7.6 to 15.4) in the early integrated, late-integrated, and delayed treatment arms (P = 0.313). Incidence rate of LTFU before and after ART initiation was 31.7 per 100 PY (95% CI: 11.6 to 69.0) vs. 6.1 per 100 PY (95% CI: 3.7 to 9.4); incidence rate ratio (IRR) was 5.2 (95% CI: 2.1 to 13.0; P < 0.001) in the early integrated arm; 31.9 per 100 PY (95% CI: 20.4 to 47.5) vs. 4.7 per 10 PY (95% CI: 2.4 to 8.2) and IRR was 6.8 (95% CI: 3.4 to 13.6; P < 0.0001) in the late-integrated arm; and 21.9 per 100 PY (95% CI: 14.6 to 31.5) vs. 2.8 per 100 PY (95% CI: 0.9 to 6.6) and IRR was 7.7 (95% CI: 3.0 to 19.9; P < 0.0001) in the sequential arm. CONCLUSION LTFU rates were not significantly different between the 3 trials arms. However, ART initiation within each trial arm resulted in a significant reduction in LTFU rates among TB patients.
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Affiliation(s)
- Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council (SAMRC) - CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council (SAMRC) - CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
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Tiruneh YM, Galárraga O, Genberg B, Wilson IB. Retention in Care among HIV-Infected Adults in Ethiopia, 2005- 2011: A Mixed-Methods Study. PLoS One 2016; 11:e0156619. [PMID: 27272890 PMCID: PMC4896473 DOI: 10.1371/journal.pone.0156619] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 05/17/2016] [Indexed: 11/19/2022] Open
Abstract
Background Poor retention in HIV care challenges the success of antiretroviral therapy (ART). This study assessed how well patients stay in care and explored factors associated with retention in the context of an initial ART rollout in Sub-Saharan Africa. Methods We conducted a mixed-methods study at a teaching hospital in Addis Ababa, Ethiopia. A cohort of 385 patients was followed for a median of 4.6 years from ART initiation to lost-to-follow-up (LTFU—missing appointments for more than three months after last scheduled visit or administrative censoring). We used Kaplan-Meier plots to describe LTFU over time and Cox-regression models to identify factors associated with being LTFU. We held six focus group discussions, each with 6–11 patients enrolled in care; we analyzed data inductively informed by grounded theory. Results Patients in the cohort were predominantly female (64%) and the median age was 34 years. Thirty percent were LTFU by study’s end; the median time to LTFU was 1,675 days. Higher risk of LTFU was associated with baseline CD4 counts <100 and >200 cells/μL (HR = 1.62; 95% CI:1.03–2.55; and HR = 2.06; 95% CI:1.15–3.70, respectively), compared with patients with baseline CD4 counts of 100–200 cells/μL. Bedridden participants at ART initiation (HR = 2.05; 95% CIs [1.11–3.80]) and those with no or only primary education (HR = 1.50; 95% CIs [1.00–2.24]) were more likely to be LTFU. Our qualitative data revealed that fear of stigma, care dissatisfaction, use of holy water, and economic constraints discouraged retention in care. Social support and restored health and functional ability motivated retention. Conclusion Complex socio-cultural, economic, and health-system factors inhibit optimum patient retention. Better tracking, enhanced social support, and regular adherence counseling addressing stigma and alternative healing options are needed. Intervention strategies aimed at changing clinic routines and improving patient–provider communication could address many of the identified barriers.
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Affiliation(s)
- Yordanos M. Tiruneh
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
- * E-mail:
| | - Omar Galárraga
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Becky Genberg
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Ira B. Wilson
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
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Mitiku I, Arefayne M, Mesfin Y, Gizaw M. Factors associated with loss to follow-up among women in Option B+ PMTCT programme in northeast Ethiopia: a retrospective cohort study. J Int AIDS Soc 2016; 19:20662. [PMID: 27005750 PMCID: PMC4803835 DOI: 10.7448/ias.19.1.20662] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 02/09/2016] [Accepted: 02/23/2016] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Ethiopia has recently adopted lifelong antiretroviral therapy (ART) for all HIV-positive pregnant and breastfeeding women (Option B+ strategy), regardless of CD4 count or clinical stage. However, the exact timing and predictors of loss to follow-up (LFU) are unknown. Thus, we examined the levels and determinants of LFU under Option B+ among pregnant and breastfeeding women initiated on lifelong ART for prevention of mother-to-child transmission (PMTCT) in Ethiopia. METHODS We conducted a retrospective cohort study among 346 pregnant and breastfeeding women who started ART at 14 public health facilities in northeast Ethiopia from March 2013 to April 2015. We defined LFU as 90 days since the last clinic visit among those not known to have died or transferred out. We used Kaplan-Meier and Cox proportional hazards regression to estimate cumulative LFU and identify the predictors of LFU, respectively. RESULTS Of the 346 women included, 88.4% were pregnant and the median follow-up was 13.7 months. Overall, 57 (16.5%) women were LFU. The cumulative proportions of LFU at 6, 12 and 24 months were 11.9, 15.7 and 22.6%, respectively. The risk of LFU was higher in younger women (adjusted hazard ratio (aHR) 18 to 24 years/30 to 40 years: 2.3; 95% confidence interval (CI): 1.2 to 4.5), in those attending hospitals compared to those attending health centres (aHR: 1.8; 95% CI: 1.1 to 3.2), in patients starting ART on the same day of diagnosis (aHR: 1.85; 95% CI: 1.1 to 3.2) and missing CD4 cell counts at ART initiation (aHR: 2.3; 95% CI: 1.2 to 4.4). CONCLUSIONS The level of LFU we found in this study is comparable with previous findings from other resource-limited settings. However, high early LFU shortly after ART initiation is still a major problem. LFU was high among younger women, those initiating ART on the day of HIV diagnosis, those missing baseline CD4 count and those attending hospitals. Thus, targeted HIV care and treatment programmes for these patients should be part of future interventions to improve retention in care under the Option B+ PMTCT programme.
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Affiliation(s)
- Israel Mitiku
- Department of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia;
| | - Mastewal Arefayne
- Department of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Yonatal Mesfin
- Department of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Muluken Gizaw
- Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Health outcomes among HIV-positive Latinos initiating antiretroviral therapy in North America versus Central and South America. J Int AIDS Soc 2016; 19:20684. [PMID: 26996992 PMCID: PMC4800379 DOI: 10.7448/ias.19.1.20684] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 01/28/2016] [Accepted: 02/22/2016] [Indexed: 11/08/2022] Open
Abstract
Introduction Latinos living with HIV in the Americas share a common ethnic and cultural heritage. In North America, Latinos have a relatively high rate of new HIV infections but lower rates of engagement at all stages of the care continuum, whereas in Latin America antiretroviral therapy (ART) services continue to expand to meet treatment needs. In this analysis, we compare HIV treatment outcomes between Latinos receiving ART in North America versus Latin America. Methods HIV-positive adults initiating ART at Caribbean, Central and South America Network for HIV (CCASAnet) sites were compared to Latino patients (based on country of origin or ethnic identity) starting treatment at North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) sites in the United States and Canada between 2000 and 2011. Cox proportional hazards models compared mortality, treatment interruption, antiretroviral regimen change, virologic failure and loss to follow-up between cohorts. Results The study included 8400 CCASAnet and 2786 NA-ACCORD patients initiating ART. CCASAnet patients were younger (median 35 vs. 37 years), more likely to be female (27% vs. 20%) and had lower nadir CD4 count (median 148 vs. 195 cells/µL, p<0.001 for all). In multivariable analyses, CCASAnet patients had a higher risk of mortality after ART initiation (adjusted hazard ratio (AHR) 1.61; 95% confidence interval (CI): 1.32 to 1.96), particularly during the first year, but a lower hazard of treatment interruption (AHR: 0.46; 95% CI: 0.42 to 0.50), change to second-line ART (AHR: 0.56; 95% CI: 0.51 to 0.62) and virologic failure (AHR: 0.52; 95% CI: 0.48 to 0.57). Conclusions HIV-positive Latinos initiating ART in Latin America have greater continuity of treatment but are at higher risk of death than Latinos in North America. Factors underlying these differences, such as HIV testing, linkage and access to care, warrant further investigation.
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Patient-reported factors associated with reengagement among HIV-infected patients disengaged from care in East Africa. AIDS 2016; 30:495-502. [PMID: 26765940 DOI: 10.1097/qad.0000000000000931] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Engagement in care is key to successful HIV treatment in resource-limited settings; yet little is known about the magnitude and determinants of reengagement among patients out of care. We assessed patient-reported reasons for not returning to clinic, identified latent variables underlying these reasons, and examined their influence on subsequent care reengagement. DESIGN We used data from the East Africa International Epidemiologic Databases to Evaluate AIDS to identify a cohort of patients disengaged from care (>3 months late for last appointment, reporting no HIV care in preceding 3 months) (n = 430) who were interviewed about reasons why they stopped care. Among the 399 patients for whom follow-up data were available, 104 returned to clinic within a median observation time of 273 days (interquartile range: 165-325). METHODS We conducted exploratory and confirmatory factor analyses (EFA, CFA) to identify latent variables underlying patient-reported reasons, then used these factors as predictors of time to clinic return in adjusted Cox regression models. RESULTS EFA and CFA findings suggested a six-factor structure that lent coherence to the range of barriers and motivations underlying care disengagement, including poverty, transport costs, and interference with work responsibilities; health system 'failures,' including poor treatment by providers; fearing disclosure of HIV status; feeling healthy; and treatment fatigue/seeking spiritual alternatives to medicine. Factors related to poverty and poor treatment predicted higher rate of return to clinic, whereas the treatment fatigue factor was suggestive of a reduced rate of return. CONCLUSION Certain barriers to reengagement appear easier to overcome than factors such as treatment fatigue. Further research will be needed to identify the easiest, least expensive interventions to reengage patients lost to HIV care systems. Interpersonal interventions may continue to play an important role in addressing psychological barriers to retention.
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Mehta KG, Baxi R, Patel S, Parmar M. Drug adherence rate and loss to follow-up among people living with HIV/AIDS attending an ART Centre in a Tertiary Government Hospital in Western India. J Family Med Prim Care 2016; 5:266-269. [PMID: 27843825 PMCID: PMC5084545 DOI: 10.4103/2249-4863.192325] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Introduction: National AIDS Control Organization (NACO) has expanded the reach of anti retroviral therapy (ART) to combat the epidemic of HIV/AIDS in India which has one of the largest populations of people living with HIV/AIDS (PLWHA) in the world. One of the major challenges related to ART is a lifelong commitment by patients to adhere diligently to daily medication dosing schedules and scheduled visits to the ART center. Hence, the current study is carried out to assess the drug adherence rate and loss to follow-up (LFU) among PLWHA attending ART centre of a tertiary care hospital in Western India. Materials and Methods: The current cross-sectional study was carried out using medical records of all patients registered at ART Center, Shree Sayaji General Hospital, Vadodara after taking Ethical Clearance from Local IRB. LFU was classified according to NACO guidelines. Data were collected using a standardized data extraction form as per NACO treatment card. Data entry and analysis were performed using Epi Info software. Results: Of 755 PLWHA registered at ART center, 534 (70.7%) subjects were alive on ART, 61 (8%) were transferred out, 68 (9%) died, and 92 (17%) were LFU. Nearly, 57% PLWHA have drug adherence rate of more than 95%. Education status of the participant showed independent and significant association with drug adherence. Conclusion: This study showed 57.3% were adherent to ART among PLWHA, whereas 17.22% were lost to follow-up. Hence, there is a need to emphasize on increasing drug adherence rate and on outreach activities to combat LFU.
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Affiliation(s)
- Kedar G Mehta
- Department of Community Medicine (PSM), GMERS Medical College, Vadodara, Gujarat, India
| | - Rajendra Baxi
- Department of Community Medicine (PSM), Baroda Medical College, Vadodara, Gujarat, India
| | - Sangita Patel
- Department of Community Medicine (PSM), Baroda Medical College, Vadodara, Gujarat, India
| | - Mahendra Parmar
- Department of Medicine, Baroda Medical College, Vadodara, Gujarat, India
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Grimsrud A, Cornell M, Schomaker M, Fox MP, Orrell C, Prozesky H, Stinson K, Tanser F, Egger M, Myer L. CD4 count at antiretroviral therapy initiation and the risk of loss to follow-up: results from a multicentre cohort study. J Epidemiol Community Health 2015; 70:549-55. [PMID: 26700300 DOI: 10.1136/jech-2015-206629] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/25/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND Antiretroviral therapy (ART) initiation is now recommended irrespective of CD4 count. However data on the relationship between CD4 count at ART initiation and loss to follow-up (LTFU) are limited and conflicting. METHODS We conducted a cohort analysis including all adults initiating ART (2008-2012) at three public sector sites in South Africa. LTFU was defined as no visit in the 6 months before database closure. The Kaplan-Meier estimator and Cox's proportional hazards models examined the relationship between CD4 count at ART initiation and 24-month LTFU. Final models were adjusted for demographics, year of ART initiation, programme expansion and corrected for unascertained mortality. RESULTS Among 17 038 patients, the median CD4 at initiation increased from 119 (IQR 54-180) in 2008 to 257 (IQR 175-318) in 2012. In unadjusted models, observed LTFU was associated with both CD4 counts <100 cells/μL and CD4 counts ≥300 cells/μL. After adjustment, patients with CD4 counts ≥300 cells/μL were 1.35 (95% CI 1.12 to 1.63) times as likely to be LTFU after 24 months compared to those with a CD4 150-199 cells/μL. This increased risk for patients with CD4 counts ≥300 cells/μL was largest in the first 3 months on treatment. Correction for unascertained deaths attenuated the association between CD4 counts <100 cells/μL and LTFU while the association between CD4 counts ≥300 cells/μL and LTFU persisted. CONCLUSIONS Patients initiating ART at higher CD4 counts may be at increased risk for LTFU. With programmes initiating patients at higher CD4 counts, models of ART delivery need to be reoriented to support long-term retention.
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Affiliation(s)
- Anna Grimsrud
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Morna Cornell
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Matthew P Fox
- Center for Global Health & Development, Boston University, Boston, Massachusetts, USA Department of Internal Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Catherine Orrell
- Faculty of Health Sciences, Desmond Tutu HIV Centre, Institute for Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Hans Prozesky
- Division of Infectious Diseases, Department of Medicine, University of Stellenbosch, Cape Town, South Africa Tygerberg Academic Hospital, Cape Town, South Africa
| | - Kathryn Stinson
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa Médecins Sans Frontières, Cape Town, South Africa
| | - Frank Tanser
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
| | - Matthias Egger
- Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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Geng EH, Odeny TA, Lyamuya R, Nakiwogga-Muwanga A, Diero L, Bwana M, Braitstein P, Somi G, Kambugu A, Bukusi E, Wenger M, Neilands TB, Glidden DV, Wools-Kaloustian K, Yiannoutsos C, Martin J. Retention in Care and Patient-Reported Reasons for Undocumented Transfer or Stopping Care Among HIV-Infected Patients on Antiretroviral Therapy in Eastern Africa: Application of a Sampling-Based Approach. Clin Infect Dis 2015; 62:935-944. [PMID: 26679625 DOI: 10.1093/cid/civ1004] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 12/01/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Improving the implementation of the global response to human immunodeficiency virus requires understanding retention after starting antiretroviral therapy (ART), but loss to follow-up undermines assessment of the magnitude of and reasons for stopping care. METHODS We evaluated adults starting ART over 2.5 years in 14 clinics in Uganda, Tanzania, and Kenya. We traced a random sample of patients lost to follow-up and incorporated updated information in weighted competing risks estimates of retention. Reasons for nonreturn were surveyed. RESULTS Among 18 081 patients, 3150 (18%) were lost to follow-up and 579 (18%) were traced. Of 497 (86%) with ascertained vital status, 340 (69%) were alive and, in 278 (82%) cases, updated care status was obtained. Among all patients initiating ART, weighted estimates incorporating tracing outcomes found that 2 years after ART, 69% were in care at their original clinic, 14% transferred (4% official and 10% unofficial), 6% were alive but out of care, 6% died in care (<60 days after last visit), and 6% died out of care (≥ 60 days after last visit). Among lost patients found in care elsewhere, structural barriers (eg, transportation) were most prevalent (65%), followed by clinic-based (eg, waiting times) (33%) and psychosocial (eg, stigma) (27%). Among patients not in care elsewhere, psychosocial barriers were most prevalent (76%), followed by structural (51%) and clinic based (15%). CONCLUSIONS Accounting for outcomes among those lost to follow-up yields a more informative assessment of retention. Structural barriers contribute most to silent transfers, whereas psychological and social barriers tend to result in longer-term care discontinuation.
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Affiliation(s)
- Elvin H Geng
- Departmentof Medicine, Division of HIV/AIDS, San Francisco General Hospital, California
| | - Thomas A Odeny
- Kenya Medical Research Institute and the Family AIDS Care and Education Services Program, Nairobi
| | - Rita Lyamuya
- National AIDS Control Program, Dar es Salaam, Tanzania
| | | | - Lameck Diero
- US Agencyfor International Development-Academic Model Providing Access to Healthcare Program, Eldoret, Kenya
| | - Mwebesa Bwana
- Mbarara University of Science and Technology, Uganda
| | - Paula Braitstein
- US Agencyfor International Development-Academic Model Providing Access to Healthcare Program, Eldoret, Kenya
| | - Geoffrey Somi
- National AIDS Control Program, Dar es Salaam, Tanzania
| | | | - Elizabeth Bukusi
- Kenya Medical Research Institute and the Family AIDS Care and Education Services Program, Nairobi
| | - Megan Wenger
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Torsten B Neilands
- Departmentof Medicine, Division of HIV/AIDS, San Francisco General Hospital, California
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | | | - Constantin Yiannoutsos
- Department of Biostatistics, Fairbanks School of Public Health, Indiana University, Indianapolis
| | - Jeffrey Martin
- Department of Medicine, Division of HIV/AIDS, San Francisco General Hospital, California.,Department of Epidemiology and Biostatistics, University of California, San Francisco
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