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Medina-Jaudes N, Adoa D, Williams A, Amulen C, Carmone A, Dowling S, Joseph J, Katureebe C, Nabitaka V, Musoke A, Namusoke Magongo E, Nabwire Chimulwa T. Predicting Lost to Follow-Up Status Using an Adolescent HIV Psychosocial Attrition Risk Assessment Tool: Results From a Mixed Methods Prospective Cohort Study in Uganda. J Acquir Immune Defic Syndr 2024; 95:439-446. [PMID: 38180899 DOI: 10.1097/qai.0000000000003381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/30/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Low retention in care for adolescents living with HIV (ALHIV) has been a key driver of suboptimal viral load suppression rates in Uganda. The objective of this study was to develop a psychosocial risk assessment tool and evaluate its ability to predict the risk of attrition of ALHIV between the ages 15 and 19 years. SETTING The study was conducted in 20 facilities in Central and Western Uganda from August 2021 through July 2022. METHODS A mixed methods prospective cohort study was conducted in two phases. In the first phase, the Adolescent Psychosocial Attrition Risk Assessment tool was developed and revised using feedback from focus group discussions and interviews. In the second phase, the ability of the Adolescent Psychosocial Attrition Risk Assessment tool to predict attrition among ALHIV was evaluated using diagnostic accuracy tests. RESULTS A total of 597 adolescents between the ages 15 and 19 years were enrolled, of which 6% were lost to follow-up at the end of the study period. A 20-question tool was developed, with 12 questions being responded to affirmatively by >50% of all participants. Using a cut-off score of 6 or more affirmative answers translated to an area under the curve of 0.58 (95% CI: 0.49 to 0.66), sensitivity of 55% (95% CI: 36% to 72%), and specificity of 61% (95% CI: 56% to 65%). CONCLUSION Although the Adolescent Psychosocial Attrition Risk Assessment tool was not effective at predicting lost to follow-up status among ALHIV, the tool was useful for identifying psychosocial issues experienced by ALHIV and may be appropriate to administer during routine care visits to guide action.
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Ruel T, Mwangwa F, Balzer LB, Ayieko J, Nyabuti M, Mugoma WE, Kabami J, Kamugisha B, Black D, Nzarubara B, Opel F, Schrom J, Agengo G, Nakigudde J, Atuhaire HN, Schwab J, Peng J, Camlin C, Shade SB, Bukusi E, Kapogiannis BG, Charlebois E, Kamya MR, Havlir D. A multilevel health system intervention for virological suppression in adolescents and young adults living with HIV in rural Kenya and Uganda (SEARCH-Youth): a cluster randomised trial. Lancet HIV 2023; 10:e518-e527. [PMID: 37541706 PMCID: PMC11158418 DOI: 10.1016/s2352-3018(23)00118-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 05/11/2023] [Accepted: 05/17/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Social and cognitive developmental events can disrupt care and medication adherence among adolescents and young adults living with HIV in sub-Saharan Africa. We hypothesised that a dynamic multilevel health system intervention helping adolescents and young adults and their providers navigate life-stage related events would increase virological suppression compared with standard care. METHODS We did a cluster randomised, open-label trial of young individuals aged 15-24 years with HIV and receiving care in eligible clinics (operated by the government and with ≥25 young people receiving care) in rural Kenya and Uganda. After clinic randomisation stratified by region, patient population, and previous participation in the SEARCH trial, participants in intervention clinics received life-stage-based assessment at routine visits, flexible clinic access, and rapid viral load feedback. Providers had a secure mobile platform for interprovider consultation. The control clinics followed standard practice. The primary, prespecified endpoint was virological suppression (HIV RNA <400 copies per mL) at 2 years of follow-up among participants who enrolled before Dec 1, 2019, and received care at the study clinics. This trial is registered with ClinicalTrials.gov, NCT03848728, and is closed to recruitment. FINDINGS 28 clinics were enrolled and randomly assigned (14 control, 14 intervention) in January, 2019. Between March 14, 2019, and Nov 26, 2020, we recruited 1988 participants at the clinics, of whom 1549 were included in the analysis (785 at intervention clinics and 764 at control clinics). The median participant age was 21 years (IQR 19-23) and 1248 (80·6%) of 1549 participants were female. The mean proportion of participants with virological suppression at 2 years was 88% (95% CI 85-92) for participants in intervention clinics and 80% (77-84) for participants in control clinics, equivalent to a 10% beneficial effect of the intervention (risk ratio [RR] 1·10, 95% CI 1·03-1·16; p=0·0019). The intervention resulted in increased virological suppression within all subgroups of sex, age, and care status at baseline, with greatest improvement among those re-engaging in care (RR 1·60, 95% CI 1·00-2·55; p=0·025). INTERPRETATION Routine and systematic life-stage-based assessment, prompt adherence support with rapid viral load testing, and patient-centred, flexible clinic access could help bring adolescents and young adults living with HIV closer towards a goal of universal virological suppression. FUNDING Eunice Kennedy Shriver National Institute of Child Health and Human Development, US National Institutes of Health.
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Affiliation(s)
- Theodore Ruel
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA.
| | | | - Laura B Balzer
- Division of Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | | | | | | | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Douglas Black
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Fred Opel
- Kenya Medical Research Institute, Kisumu, Kenya
| | - John Schrom
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Janet Nakigudde
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Josh Schwab
- Division of Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - James Peng
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Carol Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Starley B Shade
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | | | - Bill G Kapogiannis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Edwin Charlebois
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Moses R Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diane Havlir
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Nimwesiga C, Taremwa IM, Nakanjako D, Nasuuna E. Factors Associated with Retention in HIV Care Among HIV-Positive Adolescents in Public Antiretroviral Therapy Clinics in Ibanda District, Rural South Western Uganda. HIV AIDS (Auckl) 2023; 15:71-81. [PMID: 36910020 PMCID: PMC9994664 DOI: 10.2147/hiv.s401611] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/26/2023] [Indexed: 03/06/2023] Open
Abstract
Background Retention in antiretroviral therapy (ART) care is a key indicator of Human Immunodeficiency Virus (HIV) treatment success as it improves adherence, critical for better treatment outcomes and prevention of drug resistance. HIV treatment among adolescents living with HIV (ALHIV) is characterized by loss to follow-up, poor ART adherence, and eventual death. This study assessed retention in ART care and the associated factors among ALHIV in Ibanda district, rural South Western Uganda. Methods This was a retrospective cohort study using clinical data from ALHIV enrolled from 2019 to 2020 in eight health facilities in Ibanda district. Data from the Electronic Medical Record (EMR) system was extracted to assess the associated factors and participants' status two years after enrollment. Data were analyzed using EPIdata version 3.1 in which Univariate and multivariate cox proportional hazard regression analyses were determined. A hazard ratio (HR) at a 95% confidence interval was obtained, and a P-value <0.05 was considered statistically significant. Results Eighty-four ALHIV comprising 86.9% (N = 73) females were enrolled. The majority 63.1% (N = 53) resided in semi/peri-urban, and 44.0% (N = 37) stayed less than 5 km from the facility. Only 35.7% (N = 30) were active on ART, while 17 (20.2%) and 36 (42.9%) were lost to follow-up and transfer-outs, respectively. Factors associated with low retention were: ALHIV that moved 5-10Km (HR = 5.371; 95% CI: 1.227-23.5050, p = 0.026), used differential service delivery model was Facility-Based Group (FBG) (HR = 12.419; 95% CI: 4.034-38.236, p < 0.001) and those enrolled on the Young Adolescent Program Support (YAPs) (HR = 4.868; 95CI:1.851-12.803; p = 0.001). Retention reduced with increasing ART duration, ALHIV on (TDF/3TC/EFV) (p < 0.001), lived more than 10Km (p = 0.043) and did not benefit from any intervention (p < 0.001). Conclusion Results showed low retention in care and the urgent need to strengthen individual case management strategies for ALHIV, thus interventions focusing on peer support are desired.
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Affiliation(s)
- Christine Nimwesiga
- Uganda Nurses and Midwives Council, Ministry of Health, Kampala, Uganda.,Infectious Diseases Institute, Kampala, Uganda.,Institute of Allied Health Sciences, Clarke International University, Kampala, Uganda
| | - Ivan Mugisha Taremwa
- Institute of Allied Health Sciences, Clarke International University, Kampala, Uganda
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Leshargie CT, Demant D, Burrowes S, Frawley J. The proportion of loss to follow-up from antiretroviral therapy (ART) and its association with age among adolescents living with HIV in sub-Saharan Africa: A systematic review and meta-analysis. PLoS One 2022; 17:e0272906. [PMID: 35951621 PMCID: PMC9371308 DOI: 10.1371/journal.pone.0272906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/29/2022] [Indexed: 11/25/2022] Open
Abstract
Background Human immunodeficiency virus (HIV) remains a global health threat, especially in developing countries. The successful scale-up of antiretroviral therapy (ART) programs to address this threat is hindered by a high proportion of patient loss to follow-up (LTFU). LTFU is associated with poor viral suppression and increased mortality. It is particularly acute among adolescents, who face unique adherence challenges. Although LTFU is a critical obstacle on the continuum of care for adolescents, few regional-level studies report the proportion of LTFU among adolescents receiving ART. Therefore, a systematic review and meta-analysis were conducted to estimate the pooled LTFU in ART programs among adolescents living with HIV in sub-Saharan Africa (SSA). Methods We searched five databases (PubMed, Embase (Elsevier), PsycINFO, CINAHL, and Scopus) for articles published between 2005 and 2020 and reference lists of included articles. The PRISMA guidelines for systematic reviews were followed. A standardised checklist to extract data was used. Descriptive summaries were presented using narrative tables and figures. Heterogeneity within the included studies was examined using the Cochrane Q test statistics and I2 test. Random effect models were used to estimate the pooled prevalence of LTFU among ALHIV. We used Stata version 16 statistical software for our analysis. Results Twenty-nine eligible studies (n = 285,564) were included. An estimated 15.07% (95% CI: 11.07, 19.07) of ALHIV were LTFU. Older adolescents (15–19 years old) were 43% (AOR = 0.57, 95% CI: 0.37, 0.87) more likely to be LTFU than younger (10–14 years old) adolescents. We find an insignificant relationship between gender and LTFU (AOR = 0.95, 95% CI: 0.87, 1.03). A subgroup analysis found that regional differences in the proportion of adolescent LTFU were not statistically significant. The trend analysis indicates an increasing proportion of adolescent LTFU over time. Conclusions and recommendations The proportion of LTFU among HIV-positive adolescents in SSA seems higher than those reported in other regions. Older adolescents in the region are at an increased risk for LTFU than younger adolescents. These findings may help policymakers develop appropriate strategies to retain ALHIV in ART services. Such strategies could include community ART distribution points, appointment spacing, adherence clubs, continuous free access to ART, and community-based adherence support.
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Affiliation(s)
- Cheru Tesema Leshargie
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, Australia
- * E-mail:
| | - Daniel Demant
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, Australia
- School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Sahai Burrowes
- Public Health Program, College of Education and Health Sciences, Touro University California, Vallejo, CA, United States of America
| | - Jane Frawley
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, Australia
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Muwanguzi M, Lugobe HM, Ssemwanga E, Lule AP, Atwiine E, Kirabira V, Stella AK, Ashaba S, Rukundo GZ. Retention in HIV care and associated factors among youths aged 15-24 years in rural southwestern Uganda. BMC Public Health 2021; 21:1489. [PMID: 34332556 PMCID: PMC8325848 DOI: 10.1186/s12889-021-11547-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 07/23/2021] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Retention in HIV care contributes to antiretroviral therapy adherence, which is a key factor for improved treatment outcomes and prevention of drug resistance. However, HIV treatment among the youths is characterized by loss to follow up, poor adherence to ART, risk of treatment failure and high mortality rates compared to young children and adults. There is limited information about factors associated with retention of youths in HIV care in rural settings in Uganda. We aimed to determine retention in HIV care and associated factors among youths aged 15-24 years in rural southwestern Uganda. METHODS A cross-sectional study was conducted among youths aged 15-24 years who were receiving care at the HIV clinic at Kabuyanda HC IV who had been in care for at least 1 year before the study. We used an interviewer-administered questionnaire to collect socio-demographic information. Participant chart abstraction was used to collect information on HIV clinic attendance. We collected information on HIV related stigma using the 40-item Berger Stigma Scale. Chi-square test and multivariable logistic regression analysis were used to determine the factors associated with retention in HIV care with a significance level of < 0.05. Retention in HIV care was, defined as having sought care at least once per quarter in the 12 months prior to the study. RESULTS We enrolled 102 participants with a mean age of 20.95 (SD ± 3.07) years. Two thirds (65.7%) of the youths had been retained in HIV care in the previous 12 months. In adjusted analyses, being male, married and had perinatally acquired HIV were independently associated with retention in HIV care. The association between HIV related stigma and retention in HIV care was not statistically significant. CONCLUSION Retaining adolescents and young adults in HIV care in rural southwestern Uganda is still much lower than the WHO target of 90%. Being male, having perinatally acquired HIV and married or in a relationship are associated with retention in HIV care. Interventions targeting adolescents and young adults living with HIV are necessary to improve retention in HIV care to the WHO target of 90%.
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Affiliation(s)
- Moses Muwanguzi
- Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
| | - Henry Mark Lugobe
- Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda.,Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elastus Ssemwanga
- Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
| | - Allan Phillip Lule
- Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
| | - Elizabeth Atwiine
- Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
| | - Vincent Kirabira
- Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
| | - Ann K Stella
- Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
| | - Scholastic Ashaba
- Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda.,Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Godfrey Zari Rukundo
- Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda. .,Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda.
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Cluver L, Shenderovich Y, Toska E, Rudgard WE, Zhou S, Orkin M, Haghighat R, Chetty AN, Kuo C, Armstrong A, Sherr L. Clinic and care: associations with adolescent antiretroviral therapy adherence in a prospective cohort in South Africa. AIDS 2021; 35:1263-1271. [PMID: 33730747 PMCID: PMC8183481 DOI: 10.1097/qad.0000000000002882] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/02/2021] [Accepted: 03/08/2021] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Adolescent antiretroviral treatment (ART) adherence remains critically low. We lack research testing protective factors across both clinic and care environments. DESIGN A prospective cohort of adolescents living with HIV (sample n = 969, 55% girls, baseline mean age 13.6) in the Eastern Cape Province in South Africa were interviewed at baseline and 18-month follow-up (2014-2015, 2015-2016). We traced all adolescents ever initiated on treatment in 52 government health facilities (90% uptake, 93% 18-month retention, 1.2% mortality). METHODS Clinical records were collected; standardized questionnaires were administered by trained data collectors in adolescents' language of choice. Probit within-between regressions and average adjusted probability calculations were used to examine associations of caregiving and clinic factors with adherence, controlling for household structure, socioeconomic and HIV factors. RESULTS Past-week ART adherence was 66% (baseline), 65% (follow-up), validated against viral load in subsample. Within-individual changes in three factors were associated with improved adherence: no physical and emotional violence (12.1 percentage points increase in adjusted probability of adherence, P < 0.001), improvement in perceived healthcare confidentiality (7.1 percentage points, P < 0.04) and shorter travel time to the clinic (13.7 percentage points, P < 0.02). In combination, improvement in violence prevention, travel time and confidentiality were associated with 81% probability of ART adherence, compared with 47% with a worsening in all three. CONCLUSION Adolescents living with HIV need to be safe at home and feel safe from stigma in an accessible clinic. This will require active collaboration between health and child protection systems, and utilization of effective violence prevention interventions.
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Affiliation(s)
- Lucie Cluver
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Yulia Shenderovich
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), School of Social Sciences, Cardiff University Cardiff, UK
| | - Elona Toska
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Centre for Social Science Research
- Department of Sociology, University of Cape Town, Cape Town
| | - William E. Rudgard
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | | | - Mark Orkin
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Medical Research Council Development Pathways to Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Roxanna Haghighat
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - Angelique N. Chetty
- Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK
- Centre for Social Science Research
| | - Caroline Kuo
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Alice Armstrong
- UNICEF Eastern and Southern Africa Regional Office, Nairobi, Kenya
| | - Lorraine Sherr
- Health Psychology Unit, Institute of Global Health, University College London, London, UK
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Limbada M, Zijlstra G, Macleod D, Ayles H, Fidler S. A systematic review of the effectiveness of non- health facility based care delivery of antiretroviral therapy for people living with HIV in sub-Saharan Africa measured by viral suppression, mortality and retention on ART. BMC Public Health 2021; 21:1110. [PMID: 34112135 PMCID: PMC8194040 DOI: 10.1186/s12889-021-11053-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 05/12/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Alternative models for sustainable antiretroviral treatment (ART) delivery are necessary to meet the increasing demand to maintain population-wide ART for all people living with HIV (PLHIV) in sub-Saharan Africa. We undertook a review of published literature comparing health facility-based care (HFBC) with non-health facility based care (nHFBC) models of ART delivery in terms of health outcomes; viral suppression, loss to follow-up, retention and mortality. METHODS We conducted a systematic search of Medline, Embase and Global Health databases from 2010 onwards. UNAIDS reports, WHO guidelines and abstracts from conferences were reviewed. All studies measuring at least one of the following outcomes, viral load suppression, loss-to-follow-up (LTFU) and mortality were included. Data were extracted, and a descriptive analysis was performed. Risk of bias assessment was done for all studies. Pooled estimates of the risk difference (for viral suppression) and hazard ratio (for mortality) were made using random-effects meta-analysis. RESULTS Of 3082 non-duplicate records, 193 were eligible for full text screening of which 21 published papers met the criteria for inclusion. The pooled risk difference of viral load suppression amongst 4 RCTs showed no evidence of a difference in viral suppression (VS) between nHFBC and HFBC with an overall estimated risk difference of 1% [95% CI -1, 4%]. The pooled hazard ratio of mortality amongst 2 RCTs and 4 observational cohort studies showed no evidence of a difference in mortality between nHFBC and HFBC with an overall estimated hazard ratio of 1.01 [95% CI 0.88, 1.16]. Fifteen studies contained data on LTFU and 13 studies on retention. Although no formal quantitative analysis was performed on these outcomes due to the very different definitions between papers, it was observed that the outcomes appeared similar between HFBC and nHFBC. CONCLUSIONS Review of current literature demonstrates comparable outcomes for nHFBC compared to HFBC ART delivery programmes in terms of viral suppression, retention and mortality. PROSPERO NUMBER CRD42018088194 .
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Affiliation(s)
- Mohammed Limbada
- Zambart House, PO Box 50697, UNZA-Ridgeway Campus, Lusaka, Zambia.
| | | | - David Macleod
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen Ayles
- Zambart House, PO Box 50697, UNZA-Ridgeway Campus, Lusaka, Zambia
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Imperial College and Imperial college NIHR BRC, London, UK
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Aarons GA, Reeder K, Sam-Agudu NA, Vorkoper S, Sturke R. Implementation determinants and mechanisms for the prevention and treatment of adolescent HIV in sub-Saharan Africa: concept mapping of the NIH Fogarty International Center Adolescent HIV Implementation Science Alliance (AHISA) initiative. Implement Sci Commun 2021; 2:53. [PMID: 34022956 PMCID: PMC8141156 DOI: 10.1186/s43058-021-00156-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 05/04/2021] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Adolescent HIV prevention and treatment is a high priority for youth healthcare in sub-Saharan Africa. METHODS This study employed concept mapping to identify factors that impact the implementation of HIV prevention and intervention programs for adolescents in sub-Saharan Africa. Key stakeholders including researchers, policymakers, and non-governmental organization (NGO) personnel constituting membership of the NIH-sponsored Adolescent HIV Prevention and Treatment Implementation Science Alliance responded to the question: "In your experience, what factors have facilitated or hindered implementation of evidence-based HIV prevention or treatment for adolescents in sub-Saharan Africa?" Participants generated statements in response to the focus question, sorted them into thematically relevant groups, and rated each statement on its importance and changeability. RESULTS Through data analyses and participant feedback, 15 distinct themes were derived. "Workforce/Workflow" and "HIV Stigma and Adolescent Development" were rated highest for importance, and "Threshold Conditions for Treatment" and "Structure of Implementation Efforts" were rated most changeable. CONCLUSIONS Understanding implementation science determinants and mechanisms can facilitate the uptake of successful implementation and sustainment strategies for the prevention and treatment of HIV in a given context. We placed determinants and mechanisms within the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to provide greater contextual integration with broader theories in implementation science. Implementers across multiple disciplines can use these findings to improve the scale-up of evidence-based practices for adolescent HIV prevention and treatment in sub-Saharan Africa. Implementation approaches that consider the determinants and mechanisms identified in this study and integrated in implementation frameworks will likely have utility for other health conditions and contexts.
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Affiliation(s)
- Gregory A. Aarons
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive (0812), La Jolla, CA 92093-0812 USA
- UC San Diego Dissemination and Implementation Science Center (UC San Diego ACTRI DISC), Altman Clinical and Translational Research Institute, La Jolla, CA 92093 USA
- Child and Adolescent Services Research Center, 3665 Kearny Villa Rd., Suite 200N, San Diego, CA 92123 USA
| | - Kendal Reeder
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive (0812), La Jolla, CA 92093-0812 USA
- UC San Diego Dissemination and Implementation Science Center (UC San Diego ACTRI DISC), Altman Clinical and Translational Research Institute, La Jolla, CA 92093 USA
- Child and Adolescent Services Research Center, 3665 Kearny Villa Rd., Suite 200N, San Diego, CA 92123 USA
| | - Nadia A. Sam-Agudu
- Institute of Human Virology and Department of Pediatrics, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201 USA
- International Research Center of Excellence, Institute of Human Virology Nigeria, Plot 252 Herbert Macaulay Way, Abuja, Nigeria
| | - Susan Vorkoper
- NIH Fogarty International Center, Center for Global Health Studies, Bethesda, MD USA
| | - Rachel Sturke
- NIH Fogarty International Center, Center for Global Health Studies, Bethesda, MD USA
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9
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Adrawa N, Alege JB, Izudi J. Alcohol consumption increases non-adherence to ART among people living with HIV enrolled to the community-based care model in rural northern Uganda. PLoS One 2020; 15:e0242801. [PMID: 33232369 PMCID: PMC7685449 DOI: 10.1371/journal.pone.0242801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 11/10/2020] [Indexed: 11/19/2022] Open
Abstract
Background Non-adherence to anti-retroviral therapy (ART) is associated with considerable morbidity and mortality among people living with Human Immunodeficiency Virus (PLHIV). Community-based ART delivery model offers a decentralized and patient-centered approach to care for PLHIV, with the advantage of improved adherence to ART hence good treatment outcomes. However, data are limited on the magnitude of non-adherence to ART among PLHIV enrolled to the community-based ART model of care. In this study, we determined the frequency of non-adherence to ART and the associated factors among PLHIV enrolled to the community-based ART delivery model in a large health facility in rural northern Uganda. Methods This analytic cross-sectional study randomly sampled participants from 21 community drug distribution points at the AIDS Support Organization (TASO) in Gulu district, northern Uganda. Data were collected using a standardized and pre-tested questionnaire, entered in Epi-Data and analyzed in Stata at univariate, bivariate, and multivariate analyses levels. Binary logistic regression analysis was used to determine factors independently associated with non-adherence to ART, reported using odds ratio (OR) and 95% confidence level (CI). The level of statistical significance was 5%. Results Of 381 participants, 25 (6.6%) were non-adherent to ART and this was significantly associated with alcohol consumption (Adjusted (aOR), 3.24; 95% CI, 1.24–8.34). Other factors namely being single/or never married (aOR, 1.97; 95% CI, 0.62–6.25), monthly income exceeding 27 dollars (aOR, 1.36; 95% CI, 0.52–3.55), being on ART for more than 5 years (aOR, 0.60; 95% CI, 0.23–1.59), receipt of health education on ART side effects (aOR, 0.36; 95% CI, 0.12–1.05), and disclosure of HIV status (aOR, 0.37; 95% CI, 0.04–3.20) were not associated with non-adherence in this setting. Conclusion Non-adherence to ART was low among PLHIV enrolled to community-based ART delivery model but increases with alcohol consumption. Accordingly, psychosocial support programs should focus on alcohol consumption.
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Affiliation(s)
- Norbert Adrawa
- The AIDS Support Organization, Center of Clinical Excellence, Gulu, Uganda
- Department of Business Studies, Faculty of Management Studies, Islamic University in Uganda, Mbale, Uganda
- Institute of Public Health and Management, Clarke International University, Kampala, Uganda
| | - John Bosco Alege
- Institute of Public Health and Management, Clarke International University, Kampala, Uganda
| | - Jonathan Izudi
- Institute of Public Health and Management, Clarke International University, Kampala, Uganda
- Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
- * E-mail:
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van Wyk B, Kriel E, Mukumbang F. Retention in care for adolescents who were newly initiated on antiretroviral therapy in the Cape Metropole in South Africa. South Afr J HIV Med 2020. [DOI: 10.4102/sajhivmed.v21i1.1077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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11
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van Wyk B, Kriel E, Mukumbang F. Retention in care for adolescents who were newly initiated on antiretroviral therapy in the Cape Metropole in South Africa. South Afr J HIV Med 2020; 21:1077. [PMID: 32832112 PMCID: PMC7433256 DOI: 10.4102/hivmed.v21i1.1077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 05/23/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Long-term retention of adolescents aged 10 -19 years on antiretroviral therapy (ART) is crucial to achieve viral load suppression. However, it is reported globally that adolescents have lower retention in care (RiC) on ART, compared with children and adults. OBJECTIVES To determine the prevalence and predictors of RiC of adolescents over 2 years following initiation onto ART in public health facilities in the Metropole District Health Services of the Western Cape province in 2013. METHODS Data of 220 adolescent patients who were newly initiated on ART in 2013 were extracted from the provincial electronic database, and subjected to univariate and bivariate analyses using SPSS. RESULTS The rate of RiC post-initiation was low throughout the study period, that is, 68.6%, 50.5% and 36.4% at 4, 12 and 24 months, respectively. The corresponding post-initiation viral load suppression levels on ART of those remaining in care and who had viral loads monitored were 84.1%, 77.4% and 68.8% at 4, 12 and 24 months, respectively. Retention in care after initiation on ART was higher amongst younger adolescents (10-14 years), compared with older adolescents (15-19 years). Male adolescents were significantly more likely to be retained, compared with females. Pregnant adolescents were significantly less likely to be retained compared with those who were not pregnant. CONCLUSION Key interventions are needed to motivate adolescents to remain in care, and to adhere to their treatment regimen to achieve the target of 90% viral load suppression, with specific emphasis on older and pregnant adolescents.
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Affiliation(s)
- Brian van Wyk
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Ebrahim Kriel
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Ferdinand Mukumbang
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
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Haghighat R, Steinert J, Cluver L. The effects of decentralising antiretroviral therapy care delivery on health outcomes for adolescents and young adults in low- and middle-income countries: a systematic review. Glob Health Action 2020; 12:1668596. [PMID: 31558145 PMCID: PMC6781195 DOI: 10.1080/16549716.2019.1668596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Decentralisation of antiretroviral therapy has been implemented to scale up HIV care provision for patients in resource-limited countries. Youth living with HIV demonstrate the poorest care outcomes, compared to other age groups. Objectives: To systematically evaluate evidence on the effects of decentralising facility-based HIV care on care outcomes for youth living with HIV in low- and middle-income countries. Methods: A systematic review was conducted through 12 electronic databases of peer-reviewed articles, conference abstracts, and grey literature; contacting relevant experts; and hand-searching references. Records were included if they were published after 1 January 1996 (advent of triple-drug ART) and reported health outcomes for decentralised and centralised care, separately, or evaluated the effect of decentralised care on care outcomes. Two authors independently screened search results. When age-disaggregated data (10-24 years old) were required for inclusion, we contacted study authors for data abstraction. Implementation fidelity of decentralisation, study quality, and risk of bias was assessed using the TIDieR checklist, CASP checklists, and ROBINS-I tool, respectively. Results: Of 11 potentially eligible studies, two studies from sub-Saharan Africa met inclusion criteria after data disaggregation by age. The studies and abstracted data were insufficiently homogenous in implementation and study design to justify meta-analysis. However, evidence suggests the potential for decentralised care to result in at least equivalent attrition-related outcomes (retention in care and mortality) for youth within decentralised HIV care. Limited sample size and significant selection and allocation bias confound clear, generalisable conclusions for youth living with HIV in resource-limited settings. Conclusions: There is a paucity of evidence for the effects of decentralising HIV care for youth living in resource-limited settings, particularly recent evidence reflective of the current HIV care landscape. Further work is required to rigorously analyse the effects of decentralising HIV care to inform policymakers and care providers, particularly as demand for HIV care in this population grows.
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Affiliation(s)
- Roxanna Haghighat
- Department of Social Policy & Intervention, University of Oxford , Oxford , UK
| | - Janina Steinert
- Department of Social Policy & Intervention, University of Oxford , Oxford , UK
| | - Lucie Cluver
- Department of Social Policy & Intervention, University of Oxford , Oxford , UK.,Department of Psychiatry and Mental Health, University of Cape Town , Rondebosch , South Africa
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Seo G, Joseph JMB, Confident N, Jean E, Louis B, Bell T, Riche RC, Belizaire ME, Rouzier V, Apollon A, Reif L, Rivera V, Abrams E, Bang H, Schackman B, Fitzgerald D, Pape JW, McNairy ML. The FANMI ("my FAMILY" in Creole) study to evaluate community-based cohort care for adolescent and young women living with HIV in Haiti: protocol for a randomized controlled trial. BMC Public Health 2019; 19:1749. [PMID: 31888569 PMCID: PMC6937670 DOI: 10.1186/s12889-019-8065-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/11/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Adolescent girls and young women living with HIV in resource-limited settings have the poorest health outcomes of any age group, due in part to poor retention in care. Differentiated models of HIV care that target the specific challenges of young people living with HIV are urgently needed. METHODS The FANMI study is an unblinded randomized controlled trial designed to evaluate the efficacy of an adolescent-specific model of HIV care in Port-au-Prince, Haiti. The FANMI intervention places newly young women living with HIV who are not currently on ART or on ART ≤ 3 months, in cohorts of 5-10 peers to receive monthly group HIV care in a community location. In contrast, participants in the standard care arm receive routine HIV care and individual counseling each month in GHESKIO's Adolescent Clinic. A total of 160 participants ages 16-23 years old are being randomized on a 1:1 basis. The primary outcome is retention in HIV care defined as being alive and in care at 12 months after enrollment. Secondary outcomes include viral suppression at 12 months, sexual risk behaviors, acceptability of the FANMI intervention, and health care utilization and costs. DISCUSSION The FANMI study evaluates a novel community-based cohort model of HIV care aimed at improving retention in care and reducing risk behaviors for HIV transmission among adolescent girls and young women living with HIV. Specifically, the FANMI model of care addresses social isolation by placing participants in cohorts of 5-10 peers to provide intensified peer support and makes HIV health management a group norm; reduces stigma and improves convenience by providing care in a community setting; and integrates clinical care and social support by the same providers to streamline care and promote long-term patient-provider relationships. If shown to be effective, the FANMI intervention may serve as a model of HIV care for improving retention among hard-to-reach adolescents and young adults in Haiti and could be adapted for other high-risk groups globally. TRIAL REGISTRATION Identifier: NCT03286504, Registered September 18, 2017.
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Affiliation(s)
- Grace Seo
- Center for Global Health, Weill Cornell Medical College, New York, NY, USA.
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti.
| | - Joseph Marie Bajo Joseph
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Nancy Confident
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Esther Jean
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Bianca Louis
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Tatiana Bell
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Rose Cardelle Riche
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Marie Elmase Belizaire
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Vanessa Rouzier
- Center for Global Health, Weill Cornell Medical College, New York, NY, USA
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Alexandra Apollon
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Lindsey Reif
- Center for Global Health, Weill Cornell Medical College, New York, NY, USA
| | - Vanessa Rivera
- Center for Global Health, Weill Cornell Medical College, New York, NY, USA
| | - Elaine Abrams
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Heejung Bang
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, CA, USA
| | - Bruce Schackman
- Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - Daniel Fitzgerald
- Center for Global Health, Weill Cornell Medical College, New York, NY, USA
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Jean W Pape
- Center for Global Health, Weill Cornell Medical College, New York, NY, USA
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Margaret L McNairy
- Center for Global Health, Weill Cornell Medical College, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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Mugglin C, Haas AD, van Oosterhout JJ, Msukwa M, Tenthani L, Estill J, Egger M, Keiser O. Long-term retention on antiretroviral therapy among infants, children, adolescents and adults in Malawi: A cohort study. PLoS One 2019; 14:e0224837. [PMID: 31725750 PMCID: PMC6855432 DOI: 10.1371/journal.pone.0224837] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 10/22/2019] [Indexed: 12/01/2022] Open
Abstract
Objectives We examine long-term retention of adults, adolescents and children on antiretroviral therapy under different HIV treatment guidelines in Malawi. Design Prospective cohort study. Setting and participants Adults and children starting ART between 2005 and 2015 in 21 health facilities in southern Malawi. Methods We used survival analysis to assess retention at clinic level, Cox regression to examine risk factors for loss to follow up, and competing risk analysis to assess long-term outcomes of people on antiretroviral therapy (ART). Results We included 132,274 individuals in our analysis, totalling 270,256 person years of follow up (PYFU; median per patient 1.3, interquartile range (IQR) 0.26–3.1), 62% were female and the median age was 32 years. Retention on ART was lower in the first year on ART compared to subsequent years for all guideline periods and age groups. Infants (0–3 years), adolescents and young adults (15–24 years) were at highest risk of LTFU. Comparing the different calendar periods of ART initiation we found that retention improved initially, but remained stable thereafter. Conclusion Even though the number of patients and the burden on health care system increased substantially during the study period of rapid ART expansion, retention on ART improved in the early years of ART provision, but gains in retention were not maintained over 5 years on ART. Reducing high attrition in the first year of ART should remain a priority for ART programs, and so should addressing poor retention among adolescents, young adults and men.
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Affiliation(s)
- Catrina Mugglin
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- * E-mail:
| | - Andreas D. Haas
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Joep J. van Oosterhout
- Dignitas International, Zomba, Malawi
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Malango Msukwa
- Baobab Health Trust, Lilongwe, Malawi
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Lyson Tenthani
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- I-TECH Malawi, Lilongwe, Malawi
| | - Janne Estill
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Olivia Keiser
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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15
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Adolescents living with HIV are at higher risk of death and loss to follow up from care: Analysis of cohort data from eight health facilities in Ethiopia. PLoS One 2019; 14:e0223655. [PMID: 31622391 PMCID: PMC6797201 DOI: 10.1371/journal.pone.0223655] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 09/25/2019] [Indexed: 11/23/2022] Open
Abstract
Background There are limited data on the treatment outcomes of adolescents living with HIV. Our objective was to compare mortality and loss to follow up (LTFU) rates between adolescent and younger age groups at enrollment in care. Methods This was a retrospective cohort study carried out in eight health facilities in two regions of Ethiopia. Adolescents (age 10–14 and 15–19 year) and children (age 0–9 year) enrolled in chronic HIV care between 2005 and 2013 constituted the study population. We reviewed the individual patient charts between March and June 2014 and updated the data on the status of each patient through December 2015. We used death and loss-to-follow up as primary endpoints and used the Cox-regression analysis where age, categorized as adolescent versus child, was the main predictor variable. Results Of 2058 participants studied, 52.1% were adolescents. The cohort contributed 2422 person-years of observation (PYO) during the pre-ART follow-up, whereas 1531 patients put on ART contributed 5984 PYO. Of those put on ART, 209 (13.7%) LTFU and 92 (6%) deaths were reported. Adolescents in age group 15–19 yr had the highest risk of LTFU [adjusted hazard ratio, aHR (95% CI) = 3.1 2.1, 5.0 ] followed by those in age group 10–14 yr (aHR = 1.5 [0.9, 2.3]) compared with children aged 0–9 yr. Mortality hazard was significantly higher among younger adolescents (aHR = 2.8 [1.4, 5.4]) and older adolescents (aHR = 2.3 [1.1, 4.9]) compared with children. Conclusions Adolescents are at higher risk of mortality and LTFU as compared to children ages 0–9. Younger adolescents and children had similar LTFU rates. Narrow age band disaggregated analysis can serve as useful guide for tailoring interventions to the specific needs of different age groups.
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Siwingwa M, Nzala SH, Sikateyo B, Mutale W. Perceptions on the feasibility of decentralizing phlebotomy services in community anti-retroviral therapy group model in Lusaka, Zambia. BMC Health Serv Res 2019; 19:570. [PMID: 31412849 PMCID: PMC6694622 DOI: 10.1186/s12913-019-4386-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 07/31/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The focus of the community anti-retroviral therapy Group model is on drug refill, adherence and support groups. However, laboratory services are completely neglected in this model, and stable patient still have to go to the clinic for blood draws after drugs refills from the community. Due to the introduction of new ART drugs, the guidelines now recommend the use of viral loads to guide decision in switching all patients from NNRTI to dolutegravir based first line ART regimens. But the national viral load testing coverage stands at 37% and and falls short of meeting the global UNAIDS and phlebotomy delivery system is congested. The purpose of this study was to identify the perceptions in decentralizing phlebotomy services into the community anti-retroviral therapy Group model. METHOD A qualitative case study design was used. Data were collected through ten Focused group discussions among community anti-retroviral therapy Group members, community and health care workers at anti-retroviral therapy clinics and in-depth interviews with five key informants. Data were managed with the help of Nvivo version 10 and analyzed using thematic method. RESULTS Positive perceptions were identified as those which contributed to decongesting phlebotomy rooms, reduced missing phlebotomy appointments, work Load, and lost results. Improved quality of phlebotomy service delivery and testing coverage, innovative access to laboratory services and encouraged patient's accountability. The negative perceptions were compromised sample integrity, inability to perform prevention control and patients less contact with clinicians. CONCLUSION The study has demonstrated that decentralizing phlebotomy services within the CAG model has greater potential to improve the quality of services delivery for patients. In addition, it has perceived threats on the quality of specimen collected, patient's safety, and health care.
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Affiliation(s)
- Mpanji Siwingwa
- Department of health policy and management, University of Zambia, School of public health, P.O BOX 50110 Lusaka, Zambia
| | - Selestine H. Nzala
- Department of medical education development, University of Zambia, School of Medicine, P.O BOX 50110 Lusaka, Zambia
| | - Bornwell Sikateyo
- Department of bioethics, University of Zambia, School of medicine, P.O BOX 50110 Lusaka, Zambia
| | - Wilbroad Mutale
- Department of health policy and management, University of Zambia, School of public health, P.O BOX 50110 Lusaka, Zambia
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Carbone NB, Njala J, Jackson DJ, Eliya MT, Chilangwa C, Tseka J, Zulu T, Chinkonde JR, Sherman J, Zimba C, Mofolo IA, Herce ME. "I would love if there was a young woman to encourage us, to ease our anxiety which we would have if we were alone": Adapting the Mothers2Mothers Mentor Mother Model for adolescent mothers living with HIV in Malawi. PLoS One 2019; 14:e0217693. [PMID: 31173601 PMCID: PMC6555548 DOI: 10.1371/journal.pone.0217693] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 05/12/2019] [Indexed: 12/03/2022] Open
Abstract
Background Pregnant and post-partum adolescent girls and young women (AGYW) living with HIV in sub-Saharan Africa experience inferior outcomes along the prevention of mother-to-child transmission of HIV (PMTCT) cascade compared to their adult counterparts. Yet, despite this inequality in outcomes, scarce data from the region describe AGYW perspectives to inform adolescent-sensitive PMTCT programming. In this paper, we report findings from formative implementation research examining barriers to, and facilitators of, PMTCT care for HIV-infected AGYW in Malawi, and explore strategies for adapting the mothers2mothers (m2m) Mentor Mother Model to better meet AGYW service delivery-related needs and preferences. Methods Qualitative researchers conducted 16 focus group discussions (FGDs) in 4 Malawi districts with HIV-infected adolescent mothers ages 15–19 years categorized into two groups: 1) those who had experience with m2m programming (8 FGDs, n = 38); and 2) those who did not (8 FGDs, n = 34). FGD data were analyzed using thematic analysis to assess major and minor themes and to compare findings between groups. Results Median participant age was 17 years (interquartile range: 2 years). Poverty, stigma, food insecurity, lack of transport, and absence of psychosocial support were crosscutting barriers to PMTCT engagement. While most participants highlighted resilience and self-efficacy as motivating factors to remain in care to protect their own health and that of their children, they also indicated a desire for tailored, age-appropriate services. FGD participants indicated preference for support services delivered by adolescent HIV-infected mentor mothers who have successfully navigated the PMTCT cascade themselves. Conclusions HIV-infected adolescent mothers expressed a preference for peer-led, non-judgmental PMTCT support services that bridge communities and facilities to pragmatically address barriers of stigma, poverty, health system complexity, and food insecurity. Future research should evaluate implementation and health outcomes for adolescent mentor mother services featuring these and other client-centered attributes, such as provision of livelihood assistance and peer-led psychosocial support.
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Affiliation(s)
| | - Joseph Njala
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | - Debra J. Jackson
- UNICEF/New York, New York, New York, United States of America
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Michael T. Eliya
- Department of HIV and AIDS, Ministry of Health, Government of the Republic of Malawi, Lilongwe, Malawi
| | | | - Jennifer Tseka
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | - Tasila Zulu
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | | | | | - Chifundo Zimba
- University of North Carolina Project/Malawi, Lilongwe, Malawi
| | | | - Michael E. Herce
- University of North Carolina Project/Malawi, Lilongwe, Malawi
- Institute for Global Health & Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
- * E-mail:
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Kwena ZA, Njuguna SW, Ssetala A, Seeley J, Nielsen L, De Bont J, Bukusi EA. HIV prevalence, spatial distribution and risk factors for HIV infection in the Kenyan fishing communities of Lake Victoria. PLoS One 2019; 14:e0214360. [PMID: 30908555 PMCID: PMC6433243 DOI: 10.1371/journal.pone.0214360] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/12/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Global efforts to end HIV by 2030 focus on reducing and eventually eliminating new infections in priority populations. Identifying these populations and characterizing their vulnerability factors helps in guiding investment of scarce HIV prevention resources to achieve maximum impact. We sought to establish HIV prevalence, spatial distribution and risk factors for HIV infection in the Kenyan fishing communities of Lake Victoria. METHODS We conducted a cross-sectional survey of 2637 people from all the 308 fish-landing beaches on the Kenyan shore of Lake Victoria. The number of participants enrolled at each beach were weighted based on the size of the beach, determined by the number of functional registered boats. We used simple random sampling to select those to be approached for study participation. Consenting participants were privately interviewed about their socio-economic and demographic characteristics and sexual behavior, and were invited for HIV test using the Kenya rapid HIV testing protocol. We used descriptive statistics and multivariate logistic and linear regression for analysis. RESULTS We found high HIV prevalence of 32% with significant differences between men (29%) and women (38%). Among men, having an HIV negative sexual partner, being circumcised, increasing number of condom protected sex acts in the preceding month, being younger and being a resident of Homa Bay, Kisumu, Siaya and Busia counties compared to Migori County reduced the risk of HIV infection. For women, being married, having more children with the current spouse, having an HIV negative sexual partner and being a resident of Busia compared to Migori County reduced the risk of HIV infection. We also found that longer distance from the beaches to the nearest public health facilities was associated with increasing cumulative HIV prevalence at the beaches. CONCLUSION Fishing communities have high HIV prevalence and may greatly benefit from interventions such as wider ART coverage, couple HIV risk reduction counseling, PrEP use for HIV negative partner at substantial continuous risk, alongside other HIV prevention services that the Kenyan government is currently rolling out. This will additionally require adequate plans to synchronize the provision of these services with the population's routine schedules for all these options to be reasonably accessible to them.
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Affiliation(s)
| | | | - Ali Ssetala
- UVRI-IAVI HIV Vaccine Program, Entebbe, Uganda
| | | | - Leslie Nielsen
- International AIDS Vaccine Initiative, New York, United States of America
| | - Jan De Bont
- International AIDS Vaccine Initiative, New York, United States of America
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Enane LA, Davies MA, Leroy V, Edmonds A, Apondi E, Adedimeji A, Vreeman RC. Traversing the cascade: urgent research priorities for implementing the 'treat all' strategy for children and adolescents living with HIV in sub-Saharan Africa. J Virus Erad 2018; 4:40-46. [PMID: 30515313 PMCID: PMC6248846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Children and adolescents living with HIV (CALHIV) in sub-Saharan Africa experience significant morbidity and alarmingly high mortality rates due to critical gaps in the HIV care cascade, including late diagnosis and initiation of treatment, as well as poor retention in care and adherence to treatment. Interventions to strengthen the adult HIV care cascade may not be as effective in improving the cascade for CALHIV, for whom specific strategies are needed. Particular attention needs to be paid to the contexts of sub-Saharan Africa, where more than 85% of the world's CALHIV live. Implementing the 'treat all' strategy in sub-Saharan Africa requires dedicated efforts to address the unique diagnosis and care needs of CALHIV, in order to improve paediatric and adolescent outcomes, prevent viral resistance and reduce the number of new HIV infections. We consider the UNAIDS 90-90-90 targets from the perspective of infants, children and adolescents, and discuss the key challenges, knowledge gaps and urgent research priorities for CALHIV in implementation of the 'treat all' strategy in sub-Saharan Africa.
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Affiliation(s)
- Leslie A Enane
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine,
Indianapolis, IN,
USA,Corresponding author:
Leslie Enane, 1044 W Walnut Street, Room 402A,
Indianapolis,
Indiana,
46202,
USA
| | - Mary-Ann Davies
- Center for Infectious Disease Epidemiology and Research, University of Cape Town,
South Africa
| | - Valériane Leroy
- Inserm (French Institute of Health and Medical Research), UMR 1027, Université Toulouse 3,
France
| | - Andrew Edmonds
- Department of Epidemiology, University of North Carolina at Chapel Hill,
NC,
USA
| | - Edith Apondi
- Moi Teaching and Referral Hospital,
Eldoret,
Kenya
| | - Adebola Adedimeji
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine,
Bronx, NY,
USA
| | - Rachel C Vreeman
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine,
Indianapolis, IN,
USA
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Enane LA, Davies MA, Leroy V, Edmonds A, Apondi E, Adedimeji A, Vreeman RC. Traversing the cascade: urgent research priorities for implementing the ‘treat all’ strategy for children and adolescents living with HIV in sub-Saharan Africa. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30344-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Berheto TM, Hinderaker SG, Senkoro M, Tweya H, Deressa T, Getaneh Y, Gezahegn G. Body and mind: retention in antiretroviral treatment care is improved by mental health training of care providers in Ethiopia. BMC Public Health 2018; 18:896. [PMID: 30029598 PMCID: PMC6053784 DOI: 10.1186/s12889-018-5821-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 07/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ethiopia has achieved a high coverage of antiretroviral treatment (ART), but maintaining lifelong care is still a great challenge. Mental illnesses often co-exist with HIV/AIDS and may compromise the retention on ART. In order to improve prolonged retention in ART care, basic training in mental health care was introduced for ART providers, but this hasn't been evaluated yet. The aim of this study was to examine if this training has improved patient retention in care. METHOD A retrospective cohort study was employed to compare attrition from ART between clients attended by care provider trained with basic mental health service (exposed) and those in the standard ART follow-up care (unexposed) in public health facilities. A routine patient follow-up electronic database enrolled for ART between 2005 and 2017 was abstracted for the study. The Kaplan-Meier plot was used to compare the attrition rates between the two groups. The log-rank test was used to assess differences in the groups. The Cox proportional hazards regression model was used to determine predictors of attrition. We used estimated effect size of hazard ratios (HR) with 95% confidence intervals (CI). RESULT During the 12 years of observation, 8009 study participants under ART were followed for 33,498 person-years. The incidence of attrition was 6.5 per 100 person-years and 21% higher in the unexposed group (HR 1.21; 95% CI 1.1, 1.3), and retention in care was significantly higher in the mental health exposed group throughout the study period. WHO clinical staging III/IV, tuberculosis coinfection, the male gender, and poor functional status were independent risk factors for attrition. CONCLUSION We found that clients in the group exposed to mental health care training tended to have better retention in ART care with some variation according to gender, WHO Clinical stage and functional status. Training of ART providers in mental health may be considered in order to strengthen ART retention in low resource settings.
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Affiliation(s)
- Tezera Moshago Berheto
- Ethiopian Public Health Institute, HIV/AIDS and TB Research Directorate, P.o.box 138, Wolaita Sodo Addis Ababa, Ethiopia
| | | | - Mbazi Senkoro
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dare Selam, Tanzania
| | - Hannock Tweya
- Medecins Sans Frontieres, Medical Department (Operational Research) Brussels Operational Center, Luxembourg, Luxembourg
| | - Tekalign Deressa
- Ethiopian Public Health Institute, HIV/AIDS and TB Research Directorate, P.o.box 138, Wolaita Sodo Addis Ababa, Ethiopia
| | - Yimam Getaneh
- Ethiopian Public Health Institute, HIV/AIDS and TB Research Directorate, P.o.box 138, Wolaita Sodo Addis Ababa, Ethiopia
| | - Gulilat Gezahegn
- Guraghe Zonal Health Department, Disease Prevention and Control Unit, Wolkite, Ethiopia
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Pediatric to adult healthcare transitioning for adolescents living with HIV in Nigeria: A national survey. PLoS One 2018; 13:e0198802. [PMID: 29894519 PMCID: PMC5997346 DOI: 10.1371/journal.pone.0198802] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 05/27/2018] [Indexed: 02/06/2023] Open
Abstract
Introduction The period of transition from pediatric to adult care has been associated with poor health outcomes among 10–19 year old adolescents living with HIV (ALHIV). This has prompted a focus on the quality of transition services, especially in high ALHIV-burden countries. Due to lack of guidelines, there are no healthcare transition standards for Nigeria’s estimated 240,000 ALHIV. We conducted a nationwide survey to characterize routine transition procedures for Nigerian ALHIV. Materials and methods This cross-sectional survey was conducted at public healthcare facilities supported by five local HIV service implementing partners. Comprehensive HIV treatment facilities with ≥1 year of HIV service provision and ≥20 ALHIVs enrolled were selected. A structured questionnaire assessed availability of treatment, care and transition services for ALHIV. Transition was defined as a preparatory process catering to the medical, psychosocial, and educational needs of adolescents moving from pediatric to adult care. Comprehensive transition services were defined by 6 core elements: policy, tracking and monitoring, readiness evaluation, planning, transfer of care, and follow-up. Results All 152 eligible facilities were surveyed and comprised 106 (69.7%) secondary and 46 (30.3%) tertiary centers at which 17,662 ALHIV were enrolled. The majority (73, 48.3%) of the 151 facilities responding to the “clinic type” question were family-centered and saw all clients together regardless of age. Only 42 (27.8%) facilities had an adolescent-specific HIV clinic; 53 (35.1%) had separate pediatric/adolescent and adult HIV clinics, of which 39 (73.6%) reported having a transfer/transition policy. Only 6 (15.4%) of these 39 facilities reported having a written protocol. There was a bimodal peak at 15 and 18 years for age of ALHIV transfer to adult care. No surveyed facility met the study definition for comprehensive transition services. Conclusions Facilities surveyed were more likely to have non-specialized HIV treatment services and had loosely-defined, abrupt transfer versus transition practices, which lacked the core transition elements. Evidence-based standards of transitional care tailored to non-specialized HIV treatment programs need to be established to optimize transition outcomes among ALHIV in Nigeria and in similar settings.
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Retention of HIV-Positive Adolescents in Care: A Quality Improvement Intervention in Mid-Western Uganda. BIOMED RESEARCH INTERNATIONAL 2018; 2018:1524016. [PMID: 29854727 PMCID: PMC5960514 DOI: 10.1155/2018/1524016] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 03/22/2018] [Indexed: 11/18/2022]
Abstract
Background Low retention of HIV-positive adolescents in care is a major problem across HIV programs. Approximately 70% of adolescents were nonretained in care at Katooke Health Center, Mid-Western Uganda. Consequently, a quality improvement (QI) project was started to increase retention from 29.3% in May 2016 to 90% in May 2017. Methods In May 2016, we analyzed data for retention, prioritized gaps with theme-matrix selection, analyzed root causes with fishbone diagram, developed site-specific improvement changes and prioritized with countermeasures matrix, and implemented improvement changes with Plan-Do-Study-Act (PDSA). Identified root causes were missing follow-up strategy, stigma and discrimination, difficult health facility access, and missing scheduled appointments. Interventions tested included generating list of adolescents who missed scheduled appointments, use of mobile phone technology, and linkage of adolescents to nearest health facilities (PDSA 1), Adolescent Only Clinic (PDSA 2), and monthly meetings to address care and treatment challenges (PDSA 3). Results Retention increased from 17 (29.3%) in May 2016 to 60 (96.7%) in August 2016 and was maintained above 90% until May 2017 (with exception of February and May 2017 recording 100% retention levels). Conclusion Context specific, integrated, adolescent-centered interventions implemented using QI significantly improved retention in Mid-Western Uganda.
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Bock P, Fatti G, Ford N, Jennings K, Kruger J, Gunst C, Louis F, Grobbelaar N, Shanaube K, Floyd S, Grimwood A, Hayes R, Ayles H, Fidler S, Beyers N. Attrition when providing antiretroviral treatment at CD4 counts >500cells/μL at three government clinics included in the HPTN 071 (PopART) trial in South Africa. PLoS One 2018; 13:e0195127. [PMID: 29672542 PMCID: PMC5909512 DOI: 10.1371/journal.pone.0195127] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 03/16/2018] [Indexed: 12/02/2022] Open
Abstract
Introduction WHO recommends antiretroviral treatment (ART) for all HIV-positive individuals. This study evaluated the association between baseline CD4 count and attrition in a cohort of HIV positive adults initiating ART at three department of health (DOH) clinics routinely providing ART at baseline CD4 counts >500cells/μL for the HPTN 071 (PopART) trial. Methods All clients attending the DOH clinics were managed according to standard care guidelines with the exception that those starting ART outside of pertinent local guidelines signed research informed consent. DOH data on all HIV-positive adult clients recorded as having initiated ART between January 2014 and November 2015 at the three study clinics was analysed. Attrition, included clients lost to follow up or died, and was defined as ‘being three or more months late for an antiretroviral pharmacy pick-up appointment’. All clients were followed until attrition, transfer out or end May 2016. Results A total of 2423 clients with a median baseline CD4 count of 328 cells/μL (IQR 195–468) were included of whom 631 (26.0%) experienced attrition and 140 (5.8%) were TFO. Attrition was highest during the first six months of ART (IR 38.3/100 PY; 95% CI 34.8–42.1). Higher attrition was found amongst those with baseline CD4 counts > 500 cells/μL compared to those with baseline CD4 counts of 0–500 cells/μL (aHR 1.26, 95%CI 1.05 to 1.52) This finding was confirmed on subset analyses when restricted to individuals non-pregnant at baseline and when restricted to individuals with follow up of > 12months. Conclusions Attrition in this study was high, particularly during the first six months of treatment. Attrition was highest amongst clients starting ART at baseline CD4 counts > 500 cells/μL. Strategies to improve retention amongst ART clients, particularly those starting ART at baseline CD4 counts >500cells/μL, need strengthening. Improved monitoring of clients moving in and out of ART care and between clinics will assist in better understanding attrition and ART coverage in high burden countries.
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Affiliation(s)
- Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Campus, Western Cape, South Africa
- * E-mail:
| | | | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Karen Jennings
- City of Cape Town Health Services, Foreshore, Cape Town, South Africa
| | - James Kruger
- Western Cape Department of Health, HIV Treatment & PMTCT programme, Cape Town, South Africa
| | - Colette Gunst
- Western Cape Department of Health Cape Winelands District Brewelskloof Hospital, Worcester, South Africa
- Stellenbosch University Division of Family Medicine and Primary Health Care, Faculty of Medicine and Health Sciences,Tygerberg Campus, Western Cape, South Africa
| | | | | | - Kwame Shanaube
- Zambart, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen Ayles
- Zambart, University of Zambia, Ridgeway Campus, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sarah Fidler
- Department of Medicine, Imperial College London, St Mary’s Campus, London, United Kingdom
| | - Nulda Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Campus, Western Cape, South Africa
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Ross J, Edmonds A, Hoover DR, Shi Q, Anastos K, Lelo P, Behets F, Yotebieng M. Association between pregnancy at enrollment into HIV care and loss to care among women in the Democratic Republic of Congo, 2006-2013. PLoS One 2018; 13:e0195231. [PMID: 29608618 PMCID: PMC5880386 DOI: 10.1371/journal.pone.0195231] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 03/08/2018] [Indexed: 01/08/2023] Open
Abstract
Background Loss to care is high among asymptomatic HIV-infected women initiated on antiretroviral therapy (ART) during pregnancy or in the postpartum period. However, whether pregnancy itself plays a role in the high loss to care rate is uncertain. We compared loss to care over seven years between pregnant and non-pregnant women at enrollment into HIV care in the Democratic Republic of Congo (DRC). Methods We conducted a retrospective analysis of all ART-naive women aged 15–45 initiating HIV care at two large clinics in Kinshasa, DRC, from 2007–2013. Pregnancy status was recorded at care enrollment. Patients were classified as having no follow-up if they did not return to care after the initial enrollment visit. Among those with at least one follow-up visit after enrollment, we classified patients as lost to care if more than 365 days had passed since their last clinic visit. We used logistic regression to model the association between pregnancy status and no follow-up, and Cox proportional hazards regression to model the association between pregnancy status and time to loss to care. Results Of 2175 women included in the analysis, 1497 (68.8%) were pregnant at enrollment. Compared to non-pregnant women, pregnant women were less likely to be over 35 years of age (19.1% vs. 31.9%, p<0.0001) and less likely to be in WHO stage III or IV (9.0% vs. 26.3%, p<0.0001). Among pregnant women, 106 (7.1%) were not seen after enrollment, versus 25 (3.7%) non-pregnant women (adjusted odds ratio 2.01, 95% CI 1.24–3.24). Of the 2,044 women with at least one follow-up visit, 46.5% of pregnant women and 46.7% of non-pregnant women were lost to care by 5 years; hazards of loss to care were similar for pregnant and non-pregnant women (adjusted hazard ratio 1.08, 95% CI 0.93–1.26). Conclusions In this large cohort of HIV-infected women, patients pregnant at care enrollment were more likely to never return for follow-up. Among those who attended at least one follow-up visit, loss to care was not different between pregnant and non-pregnant women, suggesting that pregnancy itself may not be the main driver of the high attrition observed in this cohort.
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Affiliation(s)
- Jonathan Ross
- Department of Medicine, Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Bronx, NY, United States of America
- * E-mail:
| | - Andrew Edmonds
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Donald R. Hoover
- Department of Statistics and Biostatistics, Rutgers University, New Brunswick, NJ, United States of America
| | - Qiuhu Shi
- Department of Epidemiology and Community Health, New York Medical College, Valhalla, NY, United States of America
| | - Kathryn Anastos
- Department of Medicine, Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Bronx, NY, United States of America
| | - Patricia Lelo
- Kalembelembe Pediatric Hospital, Kinshasa, The Democratic Republic of Congo
| | - Frieda Behets
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Marcel Yotebieng
- College of Public Health, Division of Epidemiology, The Ohio State University, Columbus, OH, United States of America
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Ssebunya R, Wanyenze RK, Lukolyo H, Mutto M, Kisitu G, Amuge P, Maganda A, Kekitiinwa A. Antiretroviral therapy initiation within seven days of enrolment: outcomes and time to undetectable viral load among children at an urban HIV clinic in Uganda. BMC Infect Dis 2017. [PMID: 28629459 PMCID: PMC5477116 DOI: 10.1186/s12879-017-2550-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Viral suppression is a critical indicator of HIV treatment success. In the era of test-and-start, little is known about treatment outcomes and time to undetectable viral loads. This study compares treatment outcomes, median times to achieve undetectable viral loads and its predictors under different antiretroviral (ART) treatment initiation schedules (i.e. within seven days of enrolment or later). METHODS A retrospective cohort of 367 patients <18 years who enrolled in care between January 2010 and December 2015 with a baseline viral load of >5000 copies/ml were followed up for 60 months. Undetectable viral load measurements were based on both Roche (<20copies/ml) and Abbot (<75copies/ml). Clinical treatment outcomes were compared using chi-squared test. Survival experiences between the two cohorts were assessed through incidence rates and Kaplan Meier curves. A cox model with competing risks was used to assess predictors for time to undetectable viral load. RESULTS Of the 367 patients, 180 (49.1%) initiated ART within seven days from enrolment, 192 (52.3%) attained undetectable viral load of which 133 (69.3%) were children below six years and 101 (52.6%) were females. Among those who initiated ART within seven days 15 (8.3%) died and 6 (3.3%) were lost to follow-up compared to 27 (14.4%) and 16 (8.6%) respectively in the later initiators. The median time to undetectable viral load was 24.9 months (95% CI: 19.7, 28.5) among early ART initiators and 38.5 months (95% CI: 31.1, 44.5) among those initiating beyond seven days. There was a significant difference in failure estimates between those initiating within seven and those that deferred (log rank, p = 0.001). Significant predictors for time to undetectable viral load were; starting ART within seven days (SHR = 2.02, 95% CI: 1.24, 3.28), baseline WHO stage I or II (SHR = 1.59, 95% CI: 1.06, 2.28), inconsistent adherence on three consecutive clinic visits (SHR = 0.44, 95% CI: 0.28, 0.67), and baseline weight (SRH = 1.04, 95% CI: 1.01, 1.07). CONCLUSION Prompt initiation of ART within the first week of enrolment is associated with better treatment outcomes. Early timing, baseline WHO clinical stage and adherence rates should be major considerations while managing HIV among children.
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Affiliation(s)
- Rogers Ssebunya
- Baylor College of Medicine Children's Foundation, Mulago Hospital Complex, P.O. Box 72052, Kampala, Uganda.
| | - Rhoda K Wanyenze
- School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Heather Lukolyo
- Baylor College of Medicine Children's Foundation, Mulago Hospital Complex, P.O. Box 72052, Kampala, Uganda
| | - Milton Mutto
- School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Grace Kisitu
- Baylor College of Medicine Children's Foundation, Mulago Hospital Complex, P.O. Box 72052, Kampala, Uganda
| | - Pauline Amuge
- Baylor College of Medicine Children's Foundation, Mulago Hospital Complex, P.O. Box 72052, Kampala, Uganda
| | - Albert Maganda
- Baylor College of Medicine Children's Foundation, Mulago Hospital Complex, P.O. Box 72052, Kampala, Uganda
| | - Adeodata Kekitiinwa
- Baylor College of Medicine Children's Foundation, Mulago Hospital Complex, P.O. Box 72052, Kampala, Uganda
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Rutenberg N, Tun W, Borse NN. Lessons learned and study results from HIVCore: an HIV implementation science initiative. J Int AIDS Soc 2016; 19:21194. [PMID: 27443275 PMCID: PMC4956738 DOI: 10.7448/ias.19.5.21194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 05/13/2016] [Indexed: 11/08/2022] Open
Affiliation(s)
- Naomi Rutenberg
- HIV and AIDS Program, Population Council, Washington, DC, USA
| | - Waimar Tun
- HIV and AIDS Program, Population Council, Washington, DC, USA;
| | - Nagesh N Borse
- Research Division, Office of HIV and AIDS, US Agency for International Development (USAID), Washington, DC, USA
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Lessons learned and study results from HIVCore, an HIV implementation science initiative. J Int AIDS Soc 2016. [DOI: 10.7448/ias.19.5.21261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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