1
|
Kose J, Tiam A, Siamba S, Lenz C, Okoth E, Wolters T, van de Vijver D, Rakhmanina N. Clinical outcomes among adolescents living with HIV in Kenya following initiation on antiretroviral treatment. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000094. [PMID: 36962291 PMCID: PMC10022018 DOI: 10.1371/journal.pgph.0000094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 02/01/2022] [Indexed: 11/19/2022]
Abstract
In Kenya, HIV/AIDS remains a leading cause of morbidity and mortality among adolescents living with HIV (ALHIV). Our study evaluated associations between demographic and healthcare factors and HIV treatment outcomes among ALHIV in care in Kenya. This retrospective cohort study evaluated the clinical outcomes of newly diagnosed ALHIV enrolled in HIV care during January 2017-June 2018 at 32 healthcare facilities in Homabay and Kakamega Counties. Demographic and clinical data were abstracted from patient clinical records and registers during the follow up study period January 2017-through May 2019. ALHIV were stratified by age (10-14 versus 15-19 years). Categorical variables were summarized using descriptive statistics; continuous variables were analyzed using mean values. The latest available treatment and virological outcomes for ALHIV were assessed. 330 ALHIV were included in the study (mean age 15.9 years; 81.8% female, 63.0% receiving HIV care at lower-level healthcare facilities). Most (93.2%) were initiated on ART within 14 days of diagnosis; 91.4% initiated EFV-based regimens. Of those on ART, only 44.6% were active on care at the end of the study period. Of those eligible for viral load testing, 83.9% were tested with 84.4% viral suppression rate. Retention in care was higher at higher-level facilities (67.5%) compared to lower-level facilities (28.6%). Factors associated with higher retention in care were school attendance (aRR = 1.453), receipt of disclosure support (aRR = 13.315), and receiving care at a high-level health facility (aRR = 0.751). Factors associated with viral suppression included older age (15-19 years) (aRR = 1.249) and pre-ART clinical WHO stage I/II (RR = .668). Viral suppression was higher among older ALHIV. Studies are needed to evaluate effective interventions to improve outcomes among ALHIV in Kenya.
Collapse
Affiliation(s)
- Judith Kose
- Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
- Department of Medical and Scientific Affairs, Washington, DC, United States of America
- ErasmusMC, Department of Viroscience, Rotterdam University, Rotterdam, Netherlands
| | - Appolinaire Tiam
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
- Department of Medical and Scientific Affairs, Washington, DC, United States of America
- University of Bergen, Centre for International Health, Bergen, Norway
| | - Stephen Siamba
- Elizabeth Glaser Pediatric AIDS Foundation, Nairobi, Kenya
| | - Cosima Lenz
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
- Department of Medical and Scientific Affairs, Washington, DC, United States of America
| | | | - Theresa Wolters
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
- Department of Medical and Scientific Affairs, Washington, DC, United States of America
| | - David van de Vijver
- ErasmusMC, Department of Viroscience, Rotterdam University, Rotterdam, Netherlands
| | - Natella Rakhmanina
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
- Department of Medical and Scientific Affairs, Washington, DC, United States of America
- Department of Pediatrics, The George Washington University, School of Medicine and Health Sciences, Washington, DC, United States of America
- Children's National Hospital, Washington, DC, United States of America
| |
Collapse
|
2
|
Nacarapa E, Verdu ME, Nacarapa J, Macuacua A, Chongo B, Osorio D, Munyangaju I, Mugabe D, Paredes R, Chamarro A, Revollo B, Alexandre SS, Simango M, Torrus D, Ramos-Rincon JM. Predictors of attrition among adults in a rural HIV clinic in southern Mozambique: 18-year retrospective study. Sci Rep 2021; 11:17897. [PMID: 34504234 PMCID: PMC8429703 DOI: 10.1038/s41598-021-97466-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/18/2021] [Indexed: 11/09/2022] Open
Abstract
HIV remains a major cause of morbidity and mortality for people living in many low-income countries. With an HIV prevalence of 12.4% among people aged over 15 years, Mozambique was ranked in 2019 as one of eight countries with the highest HIV rates in the world. We analyzed routinely collected data from electronical medical records in HIV-infected patients aged 15 years or older and enrolled at Carmelo Hospital of Chokwe in Chokwe from 2002 to 2019. Attrition was defined as individuals who were either reported dead or lost to follow-up (LTFU) (≥ 90 days since the last clinic visit with missed medical pick-up after 3 days of failed calls). Kaplan–Meier survival curves and Cox regression analyses were used to model the incidence and predictors of time to attrition. From January 2002 to December 2019, 16,321 patients were enrolled on antiretroviral therapy (ART): 59.2% were women, and 37.9% were aged 25–34 years old. At the time of the analysis, 7279 (44.6%) were active and on ART. Overall, the 16,321 adults on ART contributed a total of 72,987 person-years of observation. The overall attrition rate was 9.46 per 100 person-years. Cox regression showed a higher risk of attrition in those following an inpatient regimen (hazard ratio [HR] 3.18, 95% confidence interval [CI] 2.89–3.50; p < 0.001), having CD4 counts under 50 cells/µL (HR 1.91, 95% CI 1.63–2.24, p < 0.001), receiving anti-TB treatment within 90 days of ART initiation (HR 6.53, 95% CI 5.72–7.45; p < 0.001), classified as WHO clinical stage III (HR 3.75, 95% CI 3.21–4.37; p < 0.001), and having Kaposi’s sarcoma (HR 1.99, 95% CI 1.65–2.39, p < 0.001). Kaplan–Meier analysis showed that patients with CD4 counts of less than 50 cells/µL on ART initiation had a 40% lower chance of survival at 18 years. Low CD4 cell counts, ART initiation as an inpatient, WHO clinical stage III, and anti-tuberculosis treatment within 90 days of ART initiation were strongly associated with attrition. Strengthening HIV testing and ART treatment, improving the diagnosis of tuberculosis before ART initiation, and guaranteed psychosocial support systems are the best tools to reduce patient attrition after starting ART.
Collapse
Affiliation(s)
- Edy Nacarapa
- Carmelo Hospital of Chókwè - The Daughters of Charity, Saint Vicente of Paul, TB/HIV Division, Avenida Trabalho, Chokwé, Gaza Province, Mozambique.,Tinpswalo Association, Vincentian Association to Fight AIDS and TB, Research Unit, Chókwè, Gaza Province, Mozambique
| | - M Elisa Verdu
- Carmelo Hospital of Chókwè - The Daughters of Charity, Saint Vicente of Paul, TB/HIV Division, Avenida Trabalho, Chokwé, Gaza Province, Mozambique
| | - Joana Nacarapa
- Carmelo Hospital of Chókwè - The Daughters of Charity, Saint Vicente of Paul, TB/HIV Division, Avenida Trabalho, Chokwé, Gaza Province, Mozambique.,Tinpswalo Association, Vincentian Association to Fight AIDS and TB, Research Unit, Chókwè, Gaza Province, Mozambique
| | - Artur Macuacua
- Carmelo Hospital of Chókwè - The Daughters of Charity, Saint Vicente of Paul, TB/HIV Division, Avenida Trabalho, Chokwé, Gaza Province, Mozambique
| | - Bartolomeu Chongo
- Carmelo Hospital of Chókwè - The Daughters of Charity, Saint Vicente of Paul, TB/HIV Division, Avenida Trabalho, Chokwé, Gaza Province, Mozambique
| | | | - Isabelle Munyangaju
- Tinpswalo Association, Vincentian Association to Fight AIDS and TB, Research Unit, Chókwè, Gaza Province, Mozambique
| | | | - Roger Paredes
- IrsiCaixa - Institute of AIDS Research, Barcelona, Spain.,FLS Foundation - Fight AIDS Foundation, Barcelona, Spain
| | - Ana Chamarro
- FLS Foundation - Fight AIDS Foundation, Barcelona, Spain
| | - Boris Revollo
- FLS Foundation - Fight AIDS Foundation, Barcelona, Spain
| | | | | | - Diego Torrus
- Department of Internal Medicine, University General Hospital of Alicante and Miguel Hernandez University, Elche, Spain
| | - Jose-Manuel Ramos-Rincon
- Department of Internal Medicine, University General Hospital of Alicante and Miguel Hernandez University, Elche, Spain.
| |
Collapse
|
3
|
Izco S, Murias‐Closas A, Jordan AM, Greene G, Catorze N, Chiconela H, Garcia JI, Blanco‐Arevalo A, Febrer A, Casellas A, Saavedra B, Chiller T, Nhampossa T, Garcia‐Basteiro A, Letang E. Improved detection and management of advanced HIV disease through a community adult TB-contact tracing intervention with same-day provision of the WHO-recommended package of care including ART initiation in a rural district of Mozambique. J Int AIDS Soc 2021; 24:e25775. [PMID: 34347366 PMCID: PMC8336616 DOI: 10.1002/jia2.25775] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 06/02/2021] [Accepted: 07/05/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION AIDS-mortality remains unacceptably high in sub-Saharan Africa, largely driven by advanced HIV disease (AHD). We nested a study in an existing tuberculosis (TB) contact-tracing intervention (Xpatial-TB). The aim was to assess the burden of AHD among high-risk people living with HIV (PLHIV) identified and to evaluate the provision of the WHO-recommended package of care to this population. METHODS All PLHIV ≥14 years old identified between June and December 2018 in Manhiça District by Xpatial-TB were offered to participate in the study if ART naïve or had suboptimal ART adherence. Consenting individuals were screened for AHD. Patients with AHD (CD4 < 200 cells/μL or WHO stage 3 or 4) were offered a package of interventions in a single visit, including testing for cryptococcal antigen (CrAg) and TB-lipoarabinomannan (TB-LAM), prophylaxis and treatment for opportunistic infections, adherence support or accelerated ART initiation. We collected information on follow-up visits carried out under routine programmatic conditions for six months. RESULTS A total of 2881 adults were identified in the Xpatial TB-contact intervention. Overall, 23% (673/2881) were HIV positive, including 351 TB index (64.2%) and 322 TB contacts (13.8%). Overall, 159/673 PLHIV (24%) were ART naïve or had suboptimal ART adherence, of whom 155 (97%, 124 TB index and 31 TB-contacts) consented to the study and were screened for AHD. Seventy percent of TB index-patients (87/124) and 16% of TB contacts (5/31) had CD4 < 200 cells/µL. Four (13%) of the TB contacts had TB, giving an overall AHD prevalence among TB contacts of 29% (9/31). Serum-CrAg was positive in 4.6% (4/87) of TB-index patients and in zero TB contacts. All ART naïve TB contacts without TB initiated ART within 48 hours of HIV diagnosis. Among TB cases, ART timing was tailored to the presence of TB and cryptococcosis. Six-month mortality was 21% among TB-index cases and zero in TB contacts. CONCLUSIONS A TB contact-tracing outreach intervention identified undiagnosed HIV and AHD in TB patients and their contacts, undiagnosed cryptococcosis among TB patients, and resulted in an adequate provision of the WHO-recommended package of care in this rural Mozambican population. Same-day and accelerated ART initiation was feasible and safe in this population including among those with AHD.
Collapse
Affiliation(s)
- Santiago Izco
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | | | - Alexander M Jordan
- Mycotic Diseases BranchUnited States Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | - Gregory Greene
- Mycotic Diseases BranchUnited States Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | - Nteruma Catorze
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | | | - Juan Ignacio Garcia
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
- PhD Program in Methodology of Biomedical ResearchFaculty of MedicineUniversity of BarcelonaBarcelonaSpain
| | | | - Anna Febrer
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
| | - Aina Casellas
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
| | - Belén Saavedra
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | - Tom Chiller
- Mycotic Diseases BranchUnited States Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | | | - Alberto Garcia‐Basteiro
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | - Emilio Letang
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Department of Infectious Diseases Hospital del MarHospital del Mar Research Institute (IMIM)BarcelonaSpain
| |
Collapse
|
4
|
Mortality and Attrition Rates within the First Year of Antiretroviral Therapy Initiation among People Living with HIV in Guangxi, China: An Observational Cohort Study. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6657112. [PMID: 33628803 PMCID: PMC7892219 DOI: 10.1155/2021/6657112] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/14/2021] [Accepted: 01/21/2021] [Indexed: 02/06/2023]
Abstract
Objective To assess the mortality and attrition rates within the first year of antiretroviral therapy (ART) initiation among people living with human immunodeficiency virus (PLHIV) in rural Guangxi, China. Design Observational cohort study. Setting. The core treatment indicators and data were collected with standard and essential procedures as per the Free ART Manual guidelines across all the rural health care centers of Guangxi. Participants. 58,115 PLHIV who were under ART were included in the study. Interventions. The data collected included sociodemographic characteristics that consist of age, sex, marital status, route of HIV transmission, CD4 cell count before ART, initial ART regimen, level of ART site, and year of ART initiation. Primary and Secondary Outcome Measures. Mortality and attrition rate following ART initiation. Results The average mortality rate was 5.94 deaths, and 17.52 attritions per 100 person-years within the first year of ART initiation among PLHIV. The mortality rate was higher among intravenous drug users (Adjusted Hazard Ratio (AHR) 1.27, 95% Confidence Interval (CI) 1.14-1.43), prefecture as a level of ART site (AHR 1.14, 95% CI 1.02-1.28), and county as the level of ART site (AHR 2.12, 95% CI 1.90-2.37). Attrition was higher among intravenous drug users (AHR 1.87, 95% CI 1.75-2.00), the first-line ART containing AZT (AHR 1.09, 95% CI 1.03-1.16), and first-line ART containing LVP/r (AHR 1.34, 95% CI 1.23-1.46). Conclusion The mortality and attrition rates were both at the highest level in the first year of post-ART; continued improvement in the quality of HIV treatment and care is needed.
Collapse
|
5
|
Effects of undernutrition on mortality and morbidity among adults living with HIV in sub-Saharan Africa: a systematic review and meta-analysis. BMC Infect Dis 2021; 21:1. [PMID: 33390160 PMCID: PMC7780691 DOI: 10.1186/s12879-020-05706-z] [Citation(s) in RCA: 195] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 12/11/2020] [Indexed: 01/04/2023] Open
Abstract
Background Undernutrition is one of the most common problems among people living with HIV, contributing to premature death and the development of comorbidities within this population. In Sub-Saharan Africa (SSA), the impacts of these often inter-related conditions appear in a series of fragmented and inconclusive studies. Thus, this review examines the pooled effects of undernutrition on mortality and morbidities among adults living with HIV in SSA. Methods A systematic literature search was conducted from PubMed, EMBASE, CINAHL, and Scopus databases. All observational studies reporting the effects of undernutrition on mortality and morbidity among adults living with HIV in SSA were included. Heterogeneity between the included studies was assessed using the Cochrane Q-test and I2 statistics. Publication bias was assessed using Egger’s and Begg’s tests at a 5% significance level. Finally, a random-effects meta-analysis model was employed to estimate the overall adjusted hazard ratio. Results Of 4309 identified studies, 53 articles met the inclusion criteria and were included in this review. Of these, 40 studies were available for the meta-analysis. A meta-analysis of 23 cohort studies indicated that undernutrition significantly (AHR: 2.1, 95% CI: 1.8, 2.4) increased the risk of mortality among adults living with HIV, while severely undernourished adults living with HIV were at higher risk of death (AHR: 2.3, 95% CI: 1.9, 2.8) as compared to mildly undernourished adults living with HIV. Furthermore, the pooled estimates of ten cohort studies revealed that undernutrition significantly increased the risk of developing tuberculosis (AHR: 2.1, 95% CI: 1.6, 2.7) among adults living with HIV. Conclusion This review found that undernutrition has significant effects on mortality and morbidity among adults living with HIV. As the degree of undernutrition became more severe, mortality rate also increased. Therefore, findings from this review may be used to update the nutritional guidelines used for the management of PLHIV by different stakeholders, especially in limited-resource settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-020-05706-z.
Collapse
|
6
|
Matsena Zingoni Z, Chirwa T, Todd J, Musenge E. Competing risk of mortality on loss to follow-up outcome among patients with HIV on ART: a retrospective cohort study from the Zimbabwe national ART programme. BMJ Open 2020; 10:e036136. [PMID: 33028546 PMCID: PMC7539573 DOI: 10.1136/bmjopen-2019-036136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 08/24/2020] [Accepted: 09/01/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine the loss to follow-up (LTFU) rates at different healthcare levels after antiretroviral therapy (ART) services decentralisation among ART patients who initiated ART between 2004 and 2017 using the competing risk model in addition to the Kaplan-Meier and Cox regressions analysis. DESIGN A retrospective cohort study. SETTING The study was done in Zimbabwe using a nationwide routinely collected HIV patient-level data from various health levels of care facilities compiled through the electronic patient management system (ePMS). PARTICIPANTS We analysed 390 771 participants aged 15 years and above from 538 health facilities. OUTCOMES The primary endpoint was LTFU defined as a failure of a patient to report for drug refill for at least 90 days from last appointment date or if the patient missed the next scheduled visit date and never showed up again. Mortality was considered a secondary outcome if a patient was reported to have died. RESULTS The total exposure time contributed was 1 544 468 person-years. LTFU rate was 5.75 (95% CI 5.71 to 5.78) per 100 person-years. Adjustment for the competing event independently increased LTFU rate ratio in provincial and referral (adjusted sub-HRs (AsHR) 1.22; 95% CI 1.18 to 1.26) and district and mission (AsHR 1.47; 95% CI 1.45 to 1.50) hospitals (reference: primary healthcare); in urban sites (AsHR 1.61; 95% CI 1.59 to 1.63) (reference: rural); and among adolescence and young adults (15-24 years) group (AsHR 1.19; 95% CI 1.16 to 1.21) (reference: 35-44 years). We also detected overwhelming association between LTFU and tuberculosis-infected patients (AsHR 1.53; 95% CI 1.45 to 1.62) (reference: no tuberculosis). CONCLUSIONS We have observed considerable findings that 'leakages' (LTFU) within the ART treatment cascade persist even after the decentralisation of health services. Risk factors for LTFU reflect those found in sub-Saharan African studies. Interventions that retain patients in care by minimising any 'leakages' along the treatment cascade are essential in attaining the 90-90-90 UNAIDS fast-track targets.
Collapse
Affiliation(s)
- Zvifadzo Matsena Zingoni
- Division of Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- National Institute of Health Research, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Tobias Chirwa
- Division of Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jim Todd
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Eustasius Musenge
- Division of Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
7
|
Wekesa P, McLigeyo A, Owuor K, Mwangi J, Nganga E, Masamaro K. Factors associated with 36-month loss to follow-up and mortality outcomes among HIV-infected adults on antiretroviral therapy in Central Kenya. BMC Public Health 2020; 20:328. [PMID: 32171279 PMCID: PMC7071670 DOI: 10.1186/s12889-020-8426-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 02/28/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The scale-up of HIV treatment programs has resulted in a reduction in HIV-related morbidity and mortality. However, retention of patients in these programs remains a challenge in sub-Saharan Africa. Understanding factors associated with loss to follow-up (LTFU) and mortality outcomes is therefore important to inform targeted program interventions. METHODS A retrospective multi-cohort analysis of 23,890 adult patients on ART over 36 months of follow-up in Kenya was done. Multivariate logistic regression analysis was done to assess for factors associated with LTFU and mortality at 6, 12, 24, and 36 months of follow-up. RESULTS Majority, 67.7%, were female. At 36 months, 27.2% were LTFU and 13.5% had died. Factors associated with mortality at 36 months included older age (51 years and above) using 20-35 years as reference [(adjusted odds ratio [aOR], 1.51, 95% confidence interval (CI) 1.23-1.86, p < 0.001], being male (aOR, 1.59, 95% CI 1.39-1.83, p < 0.001), divorced using married as reference (aOR, 1.86, 95% CI 1.56-2.22, p < 0.001), having a body mass index (BMI) score of less than 18.5 kg/m2 using 18.5-24.9 kg/m2 as reference (aOR = 1.79, 95% CI 1.52-2.11, p < 0.001), and, World Health Organization stage III and IV using stage I as the reference (aOR, 1.94, 95% CI 1.43-2.63 and aOR, 4.24, 95% CI 3.06-5.87, p < 0.001 respectively). Factors associated with LTFU at 36 months included being young between 20 and 35 years (aOR, 1.49, 95% CI 1.40-1.59, p < 0.001) using 36-50 years as reference, being male (aOR, 1.19, 95% CI 1.12-1.27, p < 0.001), and being single or divorced using married as reference (aOR, 1.34, 95% CI 1.23-1.45 and aOR, 1.25, 95% CI 1.15-1.36, p < 0.001 respectively). Patients with baseline BMI of less than 18.5 kg/m2 using normal BMI as reference (aOR, 1.68, 95% CI 1.39-2.02, p < 0.001) were also likely to be LTFU. CONCLUSIONS Factors associated with LTFU and mortality were generally similar over time. Implementation of programs in similar settings should be tailored to gender, age profiles, nutritional, and, marital status of patients to address LTFU. In addition, programs should focus on the care of older patients to reduce the risk of mortality.
Collapse
Affiliation(s)
- Paul Wekesa
- Centre for Health Solutions, Nairobi, Kenya.
| | | | | | - Jonathan Mwangi
- Division of Global HIV & TB, Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | | | - Kenneth Masamaro
- Division of Global HIV & TB, Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| |
Collapse
|
8
|
Matsena Zingoni Z, Chirwa TF, Todd J, Musenge E. HIV Disease Progression Among Antiretroviral Therapy Patients in Zimbabwe: A Multistate Markov Model. Front Public Health 2019; 7:326. [PMID: 31803702 PMCID: PMC6873884 DOI: 10.3389/fpubh.2019.00326] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 10/23/2019] [Indexed: 12/21/2022] Open
Abstract
Background: Antiretroviral therapy (ART) impact has prolonged survival of people living with HIV. We evaluated HIV disease progression among ART patients using routinely collected patient-level data between 2004 and 2017 in Zimbabwe. Methods: We partitioned HIV disease progression into four transient CD4 cell counts states: state 1 (CD4 ≥ 500 cells/μl), state 2 (350 cells/μl ≤ CD4 < 500 cells/μl), state 3 (200 cells/μl ≤ CD4 < 350 cells/μl), state 4 (CD4 < 200 cells/μl), and the absorbing state death (state 5). We proposed a semiparametric time-homogenous multistate Markov model to estimate bidirectional transition rates. Covariate effects (age, gender, ART initiation period, and health facility level) on the transition rates were assessed. Results: We analyzed 204,289 clinic visits by 63,422 patients. There were 24,325 (38.4%) patients in state 4 (CD4 < 200) at ART initiation, and 7,995 (12.6%) deaths occurred by December 2017. The overall mortality rate was 3.9 per 100 person-years. The highest mortality rate of 5.7 per 100 person-years (4,541 deaths) was from state 4 (CD4 < 200) compared to other states. Mortality rates decreased with increase in time since ART initiation. Health facility type was the strongest predictor for immune recovery. Provincial or central hospital patients showed a diminishing dose-response effect on immune recovery by state from a hazard ratio (HR) of 8.30 [95% confidence interval (95% CI), 6.64-10.36] (state 4 to 3) to HR of 3.12 (95% CI, 2.54-4.36) (state 2 to 1) compared to primary healthcare facilities. Immune system for male patients was more likely to deteriorate, and they had a 32% increased mortality risk (HR, 1.32; 95% CI, 1.23-1.42) compared to female patients. Elderly patients (45+ years) were more likely to immune deteriorate compared to 25-34 years age group: HR, 1.35; 95% CI, 1.18-1.54; HR, 1.56; 95% CI, 1.34-1.81 and HR, 1.53; 95% CI, 1.32-1.79 for states 1 to 2, state 2 to 3, and states 3 to 4, respectively. Conclusion: Immune recovery was pronounced among provincial or central hospitals. Male patients with lower CD4 cell counts were at a higher risk of immune deterioration and mortality, while elderly patients were more likely to immune deteriorate. Early therapeutic interventions when the immune system is relatively stable across gender and age may contain mortality and increase survival outcomes. Interventions which strengthen ART services in primary healthcare facilities are essential.
Collapse
Affiliation(s)
- Zvifadzo Matsena Zingoni
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Ministry of Health and Child Care, National Institute of Health Research, Harare, Zimbabwe
| | - Tobias F Chirwa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jim Todd
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Eustasius Musenge
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
9
|
Floridia M, Ciccacci F, Andreotti M, Hassane A, Sidumo Z, Magid NA, Sotomane H, David M, Mutemba E, Cebola J, Mugunhe RJ, Riccardi F, Marazzi MC, Giuliano M, Palombi L, Mancinelli S. Tuberculosis Case Finding With Combined Rapid Point-of-Care Assays (Xpert MTB/RIF and Determine TB LAM) in HIV-Positive Individuals Starting Antiretroviral Therapy in Mozambique. Clin Infect Dis 2018; 65:1878-1883. [PMID: 29020319 DOI: 10.1093/cid/cix641] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 07/20/2017] [Indexed: 12/12/2022] Open
Abstract
Background Tuberculosis is a major health concern in several countries, and effective diagnostic algorithms for use in human immunodeficiency virus (HIV)-positive patients are urgently needed. Methods At prescription of antiretroviral therapy, all patients in 3 Mozambican health centers were screened for tuberculosis, with a combined approach: World Health Organization (WHO) 4-symptom screening (fever, cough, night sweats, and weight loss), a rapid test detecting mycobacterial lipoarabinomannan in urine (Determine TB LAM), and a molecular assay performed on a sputum sample (Xpert MTB/RIF; repeated if first result was negative). Patients with positive LAM or Xpert MTB/RIF results were referred for tuberculosis treatment. Results Among 972 patients with a complete diagnostic algorithm (58.5% female; median CD4 cell count, 278/μL; WHO HIV stage I, 66.8%), 98 (10.1%) tested positive with Xpert (90, 9.3%) or LAM (34, 3.5%) assays. Compared with a single-test Xpert strategy, dual Xpert tests improved case finding by 21.6%, LAM testing alone improved it by 13.5%, and dual Xpert tests plus LAM testing improved it by 32.4%. Rifampicin resistance in Xpert-positive patients was infrequent (2.5%). Among patients with positive results, 22 of 98 (22.4%) had no symptoms at WHO 4-symptom screening. Patients with tuberculosis diagnosed had significantly lower CD4 cell counts and hemoglobin levels, more advanced WHO stage, and higher HIV RNA levels. Fifteen (15.3%) did not start tuberculosis treatment, mostly owing to rapidly deteriorating clinical conditions or logistical constraints. The median interval between start of the diagnostic algorithm and start of tuberculosis treatment was 7 days. Conclusions The prevalence of tuberculosis among Mozambican HIV-positive patients starting antiretroviral therapy was 10%, with limited rifampicin resistance. Use of combined point-of-care tests increased case finding, with a short time to treatment. Interventions are needed to remove logistical barriers and prevent presentation in very advanced HIV/tuberculosis disease.
Collapse
Affiliation(s)
- Marco Floridia
- National Center for Global Health, Istituto Superiore di Sanità
| | | | - Mauro Andreotti
- National Center for Global Health, Istituto Superiore di Sanità
| | | | - Zita Sidumo
- DREAM Program, Community of S. Egidio, Maputo
| | | | | | | | - Elsa Mutemba
- DREAM Program, Community of S. Egidio, Beira, Mozambique
| | - Junia Cebola
- DREAM Program, Community of S. Egidio, Beira, Mozambique
| | | | - Fabio Riccardi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata
| | | | - Marina Giuliano
- National Center for Global Health, Istituto Superiore di Sanità
| | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata
| | - Sandro Mancinelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata
| |
Collapse
|
10
|
Agaba PA, Genberg BL, Sagay AS, Agbaji OO, Meloni ST, Dadem NY, Kolawole GO, Okonkwo P, Kanki PJ, Ware NC. Retention in Differentiated Care: Multiple Measures Analysis for a Decentralized HIV Care and Treatment Program in North Central Nigeria. ACTA ACUST UNITED AC 2018; 9. [PMID: 29682399 PMCID: PMC5909978 DOI: 10.4172/2155-6113.1000756] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective Differentiated care refers collectively to flexible service models designed to meet the differing needs of HIV-infected persons in resource-scarce settings. Decentralization is one such service model. Retention is a key indicator for monitoring the success of HIV treatment and care programs. We used multiple measures to compare retention in a cohort of patients receiving HIV care at “hub” (central) and “spoke” (decentralized) sites in a large public HIV treatment program in north central Nigeria. Methods This retrospective cohort study utilized longitudinal program data representing central and decentralized levels of care in the Plateau State Decentralization Initiative, north central Nigeria. We examined retention with patient- level (retention at fixed times, loss-to-follow-up [LTFU]) and visit-level (gaps-in-care, visit constancy) measures. Regression models with generalized estimating equations (GEE) were used to estimate the effect of decentralization on visit-level measures. Patient-level measures were examined using survival methods with Cox regression models, controlling for baseline variables. Results Of 15,650 patients, 43% were enrolled at the hub. Median time in care was 3.1 years. Hub patients were less likely to be LTFU (adjusted hazard ratio (AHR)=0.91, 95% CI: 0.85-0.97), compared to spoke patients. Visit constancy was lower at the hub (−4.5%, 95% CI: −3.5, −5.5), where gaps in care were also more likely to occur (adjusted odds ratio=1.95, 95% CI: 1.83-2.08). Conclusion Decentralized sites demonstrated better retention outcomes using visit-level measures, while the hub achieved better retention outcomes using patient-level measures. Retention estimates produced by incorporating multiple measures showed substantial variation, confirming the influence of measurement strategies on the results of retention research. Future studies of retention in HIV care in sub-Saharan Africa will be well-served by including multiple measures.
Collapse
Affiliation(s)
| | - Becky L Genberg
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Oche O Agbaji
- Faculty of Medical Sciences, University of Jos, Nigeria
| | | | - Nancin Y Dadem
- APIN Centre, Jos University Teaching Hospital, Jos, Nigeria
| | | | | | | | - Norma C Ware
- Harvard Medical School, Boston MA, USA.,Brigham & Women's Hospital, Boston, MA, USA
| |
Collapse
|
11
|
KHUMALO PG, CHOU YJ, PU C. Antiretroviral treatment attrition in Swaziland: a population-based study. Epidemiol Infect 2016; 144:3474-3482. [PMID: 27545693 PMCID: PMC9150204 DOI: 10.1017/s0950268816001813] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 07/18/2016] [Accepted: 07/20/2016] [Indexed: 11/07/2022] Open
Abstract
Swaziland has the highest prevalence of human immunodeficiency virus (HIV) in the world. Attrition (loss to follow-up and mortality) in people living with HIV/AIDS (PLWHA) already on treatment is a major challenge, undermining achievements of the antiretroviral treatment (ART) programme in Swaziland. The contributing factors to attrition in the Swazi context are unclear. This study aims to (1) estimate attrition from the ART programme 12 months after ART initiation in Swaziland, and (2) determine the predictors of attrition in PLWHA treated with ART in Swaziland. A retrospective cohort study using national baseline data was conducted. A competing-risk Cox proportional hazard regression was used to determine the predictors of attrition. We estimated 10·3% (95% confidence interval 10·1-10·6) attrition in 16 423 participants that initiated ART in 2012. Attrition was significantly associated with sex, age, district, treatment supporter at initiation, co-infection of HIV and TB, functional status, WHO clinical stage, and ownership of facility. Our study can form a base of policies, plans, and service delivery strategies for preventing and controlling attrition in Swaziland.
Collapse
Affiliation(s)
- P. G. KHUMALO
- Antiretroviral Treatment Unit, Mbabane Government Hospital, Mbabane, Swaziland
| | - Y. J. CHOU
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - C. PU
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| |
Collapse
|
12
|
Oo MM, Gupta V, Aung TK, Kyaw NTT, Oo HN, Kumar AM. Alarming attrition rates among HIV-infected individuals in pre-antiretroviral therapy care in Myanmar, 2011-2014. Glob Health Action 2016; 9:31280. [PMID: 27562473 PMCID: PMC4999509 DOI: 10.3402/gha.v9.31280] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 07/26/2016] [Accepted: 07/26/2016] [Indexed: 12/17/2022] Open
Abstract
Background High retention rates have been documented among patients receiving antiretroviral therapy (ART) in Myanmar. However, there is no information on human immunodeficiency virus (HIV)-infected individuals in care before initiation of ART (pre-ART care). We assessed attrition (loss-to-follow-up [LTFU] and death) rates among HIV-infected individuals in pre-ART care and their associated factors over a 4-year period. Design In this retrospective cohort study, we extracted routinely collected data of HIV-infected adults (>15 years old) entering pre-ART care (June 2011–June 2014) as part of an Integrated HIV Care (IHC) programme, Myanmar. Attrition rates per 100 person-years and cumulative incidence of attrition were calculated. Factors associated with attrition were examined by calculating hazard ratios (HRs). Results Of 18,037 HIV-infected adults enrolled in the IHC programme, 11,464 (63%) entered pre-ART care (60% men, mean age 37 years, median cluster of differentiation 4 (CD4) cell count 160 cells/µL). Of the 11,464 eligible participants, 3,712 (32%) underwent attrition of which 43% were due to deaths and 57% were due to LTFU. The attrition rate was 78 per 100 person-years (95% CI, 75–80). The cumulative incidence of attrition was 70% at the end of a 4-year follow-up, of which nearly 90% occurred in the first 6 months. Male sex (HR 1.5, 95% CI 1.4–1.6), WHO clinical Stage 3 and 4, CD4 count <200 cells/µL, abnormal BMI, and anaemia were statistically significant predictors of attrition. Conclusions Pre-ART care attrition among persons living with HIV in Myanmar was alarmingly high – with most attrition occurring within the first 6 months. Strategies aimed at improving early HIV diagnosis and initiation of ART are needed. Suggestions include comprehensive nutrition support and intensified monitoring to prevent pre-ART care attrition by tracking patients who do not return for pre-ART care appointments. It is high time that Myanmar moves towards a ‘test and treat’ approach and ultimately eliminates the need for pre-ART care.
Collapse
Affiliation(s)
- Myo Minn Oo
- International Union Against Tuberculosis and Lung Disease, Mandalay, Myanmar;
| | - Vivek Gupta
- International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office, New Delhi, India.,International Union Against Tuberculosis and Lung Disease, Paris, France.,Community Ophthalmology, Dr. RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Thet Ko Aung
- International Union Against Tuberculosis and Lung Disease, Mandalay, Myanmar
| | - Nang Thu Thu Kyaw
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | | | - Ajay Mv Kumar
- International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office, New Delhi, India.,International Union Against Tuberculosis and Lung Disease, Paris, France
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
Mekuria LA, Prins JM, Yalew AW, Sprangers MAG, Nieuwkerk PT. Retention in HIV Care and Predictors of Attrition from Care among HIV-Infected Adults Receiving Combination Anti-Retroviral Therapy in Addis Ababa. PLoS One 2015; 10:e0130649. [PMID: 26114436 PMCID: PMC4482764 DOI: 10.1371/journal.pone.0130649] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 05/22/2015] [Indexed: 02/07/2023] Open
Abstract
Background Patient retention in chronic HIV care is a major challenge following the rapid expansion of combination antiretroviral therapy (cART) in Ethiopia. Objective To describe the proportion of patients who are retained in HIV care and characterize predictors of attrition among HIV-infected adults receiving cART in Addis Ababa. Method A retrospective analysis was conducted among 836 treatment naïve patients, who started cART between May 2009 and April 2012. Patients were randomly selected from ten health-care facilities, and their current status in HIV care was determined based on routinely available data in the medical records. Patients lost to follow-up (LTFU) were traced by telephone. Kaplan-Meier technique was used to estimate survival probabilities of retention and Cox proportional hazards regression was performed to identify the predictors of attrition. Results Based on individual patient data from the medical records, nearly 80% (95%CI: 76.7, 82.1) of the patients were retained in care in the first 3 and half years of antiretroviral therapy. After successfully tracing more than half of the LTFU patients, the updated one year retention in care estimate became 86% (95% CI: 83.41%, 88.17%). In the multivariate Cox regression analyses, severe immune deficiency at enrolment in care/or at cART initiation and ‘bed-ridden’ or ‘ambulatory’ functional status at the start of cART predicted attrition. Conclusion Retention in HIV care in Addis Ababa is comparable with or even better than previous findings from other resource-limited as well as EU/USA settings. However, measures to detect and enroll patients in HIV care as early as possible are still necessary.
Collapse
Affiliation(s)
- Legese A. Mekuria
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Epidemiology, Netherlands Institute for Health Sciences/Erasmus University Medical Center, Rotterdam, The Netherlands
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
- * E-mail:
| | - Jan M. Prins
- Department of Internal Medicine, Division of Infectious Diseases, Trop Med & AIDS, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Mirjam A. G. Sprangers
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Pythia T. Nieuwkerk
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
15
|
Shaweno T, Shaweno D. When are patients lost to follow-up in pre-antiretroviral therapy care? a retrospective assessment of patients in an Ethiopian rural hospital. Infect Dis Poverty 2015; 4:27. [PMID: 26034602 PMCID: PMC4450642 DOI: 10.1186/s40249-015-0056-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 04/20/2015] [Indexed: 11/18/2022] Open
Abstract
Background There is concern about the increasing rates of loss to follow-up (LTFU) among pre-antiretroviral therapy (pre-ART) patients in Ethiopia. Little information is available regarding the time when pre-ART patients are lost to follow-up in the country. This study assessed the time when LTFU occurs as well as the associated factors among adults enrolled in pre-ART care in an Ethiopian rural hospital. Methods Data of all adult pre-ART patients enrolled at the Sheka Zonal Hospital between 2010 and 2013 were reviewed. Patients were considered lost to follow-up if they failed to keep scheduled appointments for more than 90 days. The Cox proportional hazards regression model was used to assess factors associated with time until LTFU. The Kaplan-Meier survival table was used to compare the LTFU experiences of patients, segregated by significant predictors. Results A total of 626 pre-ART patients were followed for 319.92 person-years of observation (PYOs) from enrolment to pre-ART outcomes, with an overall LTFU rate of 55.8 per 100 PYOs. A total of 178 (28.4%) pre-ART patients were lost to follow-up, 93% of which occurred within the first six months. The median follow-up time was 6.13 months. The independent predictors included: not having been started on co-trimoxazole prophylaxis (adjusted hazard ratio [AHR] = 1.77, 95% confidence interval [CI], 1.12–2.79), a baseline CD4 count of or above 350 cells/mm3 (AHR = 1.87, 95%CI, 1.02–3.45), and an undisclosed HIV status (AHR = 3.04, 95%CI, 2.07–4.45). Conclusion A significant proportion of pre-ART patients is lost to follow-up. Not having been started on co-trimoxazole prophylaxis, presenting to care with a baseline CD4 cell count ≥350 cells/mm3, and an undisclosed HIV status were significant predictors of LTFU among pre-ART patients. Thus, close monitoring and tracking of patients during this period is highly recommended. Those patients with identified risk factors deserve special attention. Electronic supplementary material The online version of this article (doi:10.1186/s40249-015-0056-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Tamrat Shaweno
- Public Health Emergency Response Epidemiologist, African Union, Addis Ababa, Ethiopia
| | - Debebe Shaweno
- School of Public and Environmental Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| |
Collapse
|
16
|
Aliyu MH, Blevins M, Megazzini KM, Parrish DD, Audet CM, Chan N, Odoh C, Gebi UI, Muhammad MY, Shepherd BE, Wester CW, Vermund SH. Pregnant women with HIV in rural Nigeria have higher rates of antiretroviral treatment initiation, but similar loss to follow-up as non-pregnant women and men. Int Health 2015; 7:405-11. [PMID: 26012740 DOI: 10.1093/inthealth/ihv032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 04/01/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We examined antiretroviral therapy (ART) initiation and retention by sex and pregnancy status in rural Nigeria. METHODS We studied HIV-infected ART-naïve patients aged ≥15 years entering care from June 2009 to September 2013. We calculated the probability of early ART initiation and cumulative incidence of loss to follow-up (LTFU) during the first year of ART, and examined the association between LTFU and sex/pregnancy using Cox regression. RESULTS The cohort included 3813 ART-naïve HIV-infected adults (2594 women [68.0%], 273 [11.8%] of them pregnant). The proportion of pregnant clients initiating ART within 90 days of enrollment (78.0%, 213/273) was higher than among non-pregnant women (54.3%,1261/2321) or men (53.0%, 650/1219), both p<0.001. Pregnant women initiated ART sooner than non-pregnant women and men (median [IQR] days from enrollment to ART initiation for pregnant women=7 days [0-21] vs 14 days [7-49] for non-pregnant women and 14 days [7-42] for men; p<0.001). Cumulative incidence of LTFU during the first year post-ART initiation was high and did not differ by sex and pregnancy status. Persons who were unemployed, bedridden, had higher CD4+ counts, and/or in earlier WHO clinical stages were more likely to be LTFU. CONCLUSIONS Pregnant women with HIV in rural Nigeria were more likely to initiate ART but were no more likely to be retained in care. Our findings underscore the importance of effective retention strategies across all patient groups, regardless of sex and pregnancy status.
Collapse
Affiliation(s)
- Muktar H Aliyu
- Vanderbilt Institute for Global Health Departments of Health Policy
| | - Meridith Blevins
- Vanderbilt Institute for Global Health Department of Biostatistics
| | | | - Deidra D Parrish
- Vanderbilt Institute for Global Health Departments of Health Policy
| | - Carolyn M Audet
- Vanderbilt Institute for Global Health Departments of Health Policy
| | - Naomi Chan
- Vanderbilt Institute for Global Health Department of Human and Organizational Development
| | - Chisom Odoh
- Department of Health Administration and Health Sciences, Tennessee State University, 330 10th Avenue North, Suite D-400, Nashville, TN 37203, USA
| | - Usman I Gebi
- Friends for Global Health Initiative, Abuja, Nigeria
| | | | - Bryan E Shepherd
- Vanderbilt Institute for Global Health Department of Biostatistics
| | | | - Sten H Vermund
- Vanderbilt Institute for Global Health Department of Pediatrics, Vanderbilt University, 2525 West End Avenue, Suite 750, Nashville, TN 37203, USA
| |
Collapse
|