1
|
Rosen JG, Ndyanabo A, Nakawooya H, Galiwango RM, Ssekubugu R, Ssekasanvu J, Kim S, Rucinski KB, Nakigozi G, Nalugoda F, Kigozi G, Quinn TC, Chang LW, Kennedy CE, Reynolds SJ, Kagaayi J, Grabowski MK. Incidence of Health Facility Switching and Associations With HIV Viral Rebound Among Persons on Antiretroviral Therapy in Uganda: A Population-based Study. Clin Infect Dis 2024; 78:1591-1600. [PMID: 38114162 PMCID: PMC11175689 DOI: 10.1093/cid/ciad773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/02/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND A substantial proportion of persons on antiretroviral therapy (ART) considered lost to follow-up have actually transferred their human immunodeficiency virus (HIV) care to other facilities. However, the relationship between facility switching and virologic outcomes, including viral rebound, is poorly understood. METHODS We used data from 40 communities (2015-2020) in the Rakai Community Cohort Study to estimate incidence of facility switching and viral rebound. Persons aged 15-49 years with serologically confirmed HIV who self-reported ART use and contributed ≥1 follow-up visit were included. Facility switching and virologic outcomes were assessed between 2 consecutive study visits (ie, index and follow-up visits, interval of approximately 18 months). Those who reported different HIV treatment facilities between index and follow-up study visits were classified as having switched facilities. Virologic outcomes included viral rebound among individuals initially suppressed (<200 copies/mL). Multivariable Poisson regression was used to estimate associations between facility switching and viral rebound. RESULTS Overall, 2257 persons who self-reported ART use (median age, 35 years; 65% female, 92% initially suppressed) contributed 3335 visit-pairs and 5959 person-years to the analysis. Facility switching was common (4.8 per 100 person-years; 95% confidence interval [CI], 4.2-5.5) and most pronounced in persons aged <30 years and fishing community residents. Among persons suppressed at their index visit (n = 2076), incidence of viral rebound was more than twice as high in persons who switched facilities (adjusted incidence rate ratio = 2.27; 95% CI, 1.16-4.45). CONCLUSIONS Facility switching was common and associated with viral rebound among persons initially suppressed. Investments in more agile, person-centered models for mobile clients are needed to address system inefficiencies and bottlenecks that can disrupt HIV care continuity.
Collapse
Affiliation(s)
- Joseph G Rosen
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | | | | | - Seungwon Kim
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Katherine B Rucinski
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | - Thomas C Quinn
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Larry W Chang
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Caitlin E Kennedy
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Steven J Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - M Kate Grabowski
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| |
Collapse
|
2
|
Rosen JG, Nakyanjo N, Ddaaki WG, Zhao T, Van Vo A, Nakubulwa R, Ssekyewa C, Isabirye D, Katono RL, Nabakka P, Ssemwanga RJ, Kigozi G, Odiya S, Nakigozi G, Nalugoda F, Kigozi G, Kagaayi J, Grabowski MK, Kennedy CE. Identifying longitudinal patterns of HIV treatment (dis)engagement and re-engagement from oral histories of virologically unsuppressed persons in Uganda: A thematic trajectory analysis. Soc Sci Med 2023; 339:116386. [PMID: 37984182 PMCID: PMC10841599 DOI: 10.1016/j.socscimed.2023.116386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 10/01/2023] [Accepted: 10/28/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND There is limited study of persons deemed "harder to reach" by HIV treatment services, including those discontinuing or never initiating antiretroviral therapy (ART). We conducted narrative research in southern Uganda with virologically unsuppressed persons identified through population-based sampling to discern longitudinal patterns in HIV service engagement and identify factors shaping treatment persistence. METHODS In mid-2022, we sampled adult participants with high-level HIV viremia (≥1000 RNA copies/mL) from the prospective, population-based Rakai Community Cohort Study. Using life history calendars, we conducted initial and follow-up in-depth interviews to elicit oral histories of participants' journeys in HIV care, from diagnosis to the present. We then used thematic trajectory analysis to identify discrete archetypes of HIV treatment engagement by "re-storying" participant narratives and visualizing HIV treatment timelines derived from interviews and abstracted clinical data. RESULTS Thirty-eight participants (median age: 34 years, 68% men) completed 75 interviews. We identified six HIV care engagement archetypes from narrative timelines: (1) delayed ART initiation, (2) early treatment discontinuation, (3) treatment cycling, (4) prolonged treatment interruption, (5) transfer-related care disruption, and (6) episodic viremia. Patterns of service (dis)engagement were highly gendered, occurred in the presence and absence of optimal ART adherence, and were shaped by various factors emerging at different time points, including: denial of HIV serostatus and disclosure concerns; worsening HIV-related symptoms; psychological distress and depression; social support; intimate partner violence; ART side effects; accessibility constraints during periods of mobility; incarceration; and inflexible ART dispensing regulations. CONCLUSIONS Identified trajectories uncovered heterogeneities in both the timing and drivers of ART (re-)initiation and (dis)continuity, demonstrating the distinct characteristics and needs of people with different patterns of HIV treatment engagement throughout the life course. Enhanced mental health service provision, expanded eligibility for differentiated service delivery models, and streamlined facility switching processes may facilitate timely (re-)engagement in HIV services.
Collapse
Affiliation(s)
- Joseph G Rosen
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | | | | | - Tongying Zhao
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Anh Van Vo
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | | | | | | | | - Silas Odiya
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | | | | | | | - M Kate Grabowski
- Rakai Health Sciences Program, Entebbe, Uganda; Division of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Caitlin E Kennedy
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Rakai Health Sciences Program, Entebbe, Uganda
| |
Collapse
|
3
|
Fomo MF, Newman J, Sibaya T, Ndlela N, Hussen S, Archary M, Zanoni BC. A qualitative assessment of the perceived acceptability and feasibility of eHARTS, a mobile application for transition readiness assessment for adolescents living with HIV in South Africa. PLOS DIGITAL HEALTH 2023; 2:e0000272. [PMID: 37327198 DOI: 10.1371/journal.pdig.0000272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 05/08/2023] [Indexed: 06/18/2023]
Abstract
South Africa has the highest burden of adolescents living with HIV (ALHIV) in the world. The transition from pediatric to adult centered HIV care is a vulnerable period during which many clinical outcomes of ALHIV suffer. Transition readiness assessments may help ALHIV transition from pediatric to adult care to improve their health outcomes. Here, we evaluated the perceived acceptability and feasibility of a mobile health (mHealth) application, eHARTS, to determine transition readiness for ALHIV in South Africa. We conducted in-depth interviews with adolescents (n = 15) and healthcare providers (n = 15) at three government-supported hospitals in KwaZulu-Natal, South Africa. We used a semi-structured interview guide comprising of open-ended questions based on the unified theory of acceptance and use of technology. We did a thematic analysis of the data using an iterative, team-based coding approach to develop themes that were representative of the participants' perspectives on the acceptability and feasibility of eHARTS. We found that most participants found eHARTS to be acceptable because of its simplicity and lack of stigma. Participants believed eHARTS was feasible as it could easily be administered within a hospital setting and integrated into regular clinic activity without disrupting patient care. Additionally, eHARTS was found to have great utility for adolescents and healthcare providers. Clinicians saw it as a valuable tool to engage adolescents and prepare them for transition. Despite concerns that eHARTS may give adolescents a wrong impression about immediate transition, participants suggested that eHARTS be framed in an empowering way as they prepare for transition to adult care. Our data showed that eHARTS is a simple, mobile transition assessment tool with perceived acceptability and feasibility for use in HIV clinics in South Africa for ALHIV. It is particularly useful for ALHIV and transitioning to adult care as it can help identify gaps in readiness for transition.
Collapse
Affiliation(s)
- Messaline F Fomo
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - John Newman
- Department of Medicine and Pediatric Infectious Diseases, Emory University, Georgia, United States of America
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Thobekile Sibaya
- Department of Pediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, KwaZulu Natal, South Africa
| | - Nompumelelo Ndlela
- Department of Pediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, KwaZulu Natal, South Africa
| | - Sophia Hussen
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- Department of Medicine and Pediatric Infectious Diseases, Emory University, Georgia, United States of America
| | - Moherndran Archary
- Department of Pediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, KwaZulu Natal, South Africa
| | - Brian C Zanoni
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- Department of Medicine and Pediatric Infectious Diseases, Emory University, Georgia, United States of America
- Children's Healthcare of Atlanta, Atlanta, Georgia, United States of America
| |
Collapse
|
4
|
Yang N, Chen C, He J, Li J, Zhong Y. Treatment outcome and its associated factors among HIV-MTB co-infected patients in Sichuan, China: A retrospective study. Medicine (Baltimore) 2022; 101:e32006. [PMID: 36482608 PMCID: PMC9726276 DOI: 10.1097/md.0000000000032006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/03/2022] [Indexed: 12/13/2022] Open
Abstract
Human immunodeficiency virus (HIV)-Mycobacterium tuberculosis (MTB) co-infection has become a pressing global public health problem. Although tuberculosis (TB) is both treatable and curable, it has been exacerbated by the HIV/acquired immune deficiency syndrome (AIDS) epidemic. HIV-MTB co-infected patients have a variety of disease-specific, and treatment-related factors that can adversely affect their treatment outcomes. This study was conducted to assess the outcomes of TB treatment and its associated factors among HIV-MTB co-infected patients in Sichuan, Southwest China. A retrospective study was performed on HIV-MTB co-infected patients who were diagnosed and registered in TB designated hospitals in Sichuan from January 1, 2016, to December 31, 2020. Data were collected from patients' electronic medical records regarding their demographic, clinical, and social support information, and categorical data, such as sex, were reported using numbers and percentages. χ2 and t-tests were conducted to compare groups in relation to different levels of medical institutions. A binary logistic regression model was used to identify the factors associated with unsuccessful TB treatment outcomes. For logistic regression analysis performed using an α of 0.05, odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated for various risk factors. A total of 3677 registered HIV-MTB co-infected patients were enrolled. After adjusting for other variables, male, advanced age, receiving TB treatment at the municipal medical institution, being diagnosed with external pulmonary TB, referral or tracing, being sputum smear positive, not initiating antiretroviral therapy (ART) and not using fixed-dose combinations were the main risk factors for treatment failure of HIV-MTB co-infected patients in Sichuan province. Sex, age, hospital level, patient source, other diagnostic factors (e.g., sputum smear results, anatomical site of TB), and factors of therapeutic schemes (e.g., antiretroviral therapy, fixed-dose combinations) may serve as risk factors to estimate the likely treatment outcome of HIV-TB co-infection.
Collapse
Affiliation(s)
- Ni Yang
- Sichuan Center for Disease Control and Prevention, Chengdu, Sichuan, China
| | - Chuang Chen
- Sichuan Center for Disease Control and Prevention, Chengdu, Sichuan, China
| | - Jinge He
- Sichuan Center for Disease Control and Prevention, Chengdu, Sichuan, China
| | - Jing Li
- Sichuan Center for Disease Control and Prevention, Chengdu, Sichuan, China
| | - Yin Zhong
- Sichuan Center for Disease Control and Prevention, Chengdu, Sichuan, China
| |
Collapse
|
5
|
Development of a transition readiness score for adolescents living with perinatally-acquired HIV and transitioning to adult care. AIDS Behav 2022; 26:3131-3138. [PMID: 35362907 PMCID: PMC9372012 DOI: 10.1007/s10461-022-03650-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2022] [Indexed: 11/01/2022]
Abstract
We created a transition readiness score for adolescents with perinatally-acquired HIV as they transition from pediatric to adult care. Of the 199 adolescents who transitioned to adult care, 84 (42%) had viral suppression (< 200 copies/ml) one year after transition. Adolescents on first-line ART, with documented HIV status disclosure, and higher rating on the HIV Adolescent Readiness to Transition Scale had significantly higher odds of viral suppression after transition. Conversely, females, those with older age at ART initiation, and those with prior alcohol use had significantly lower odds of viral suppression after transition. Using these data, we created a transition readiness score organized into low, intermediate, and high levels of transition readiness. This transition readiness score can be used to identify adolescents who are likely ready to transition to adult care and identify additional areas for intervention to improve the likelihood of successful transition for those with lower transition readiness scores.
Collapse
|
6
|
DAVIES C, JOHNSON L, SAWRY S, CHIMBETETE C, ELEY B, VINIKOOR M, TECHNAU KG, EHMER J, RABIE H, PHIRI S, TANSER F, MALISITA K, FATTI G, OSLER M, WOOD R, NEWTON S, HAAS A, DAVIES MA. Effect of antiretroviral therapy care interruptions on mortality in children living with HIV. AIDS 2022; 36:729-737. [PMID: 35152225 PMCID: PMC10002475 DOI: 10.1097/qad.0000000000003194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the characteristics and outcomes of HIV-infected children that have care interruptions, during which the child's health status and use of medication is unknown. DESIGN We included data on children initiating ART between 2004 and 2016 at less than 16 years old at 16 International Epidemiologic Databases to Evaluate AIDS Southern Africa cohorts. Children were classified as loss to follow up (LTFU) if they had not attended clinic for more than 180 days. Children had a care interruption if they were classified as LTFU, and subsequently returned to care. Children who died within 180 days of ART start were excluded. METHODS The main outcome was all cause mortality. Two exposed groups were considered: those with a first care interruption within the first 6 months on ART, and those with a first care interruption after 6 months on ART. Adjusted hazard ratios were determined using a Cox regression model. RESULTS Among 53 674 children included, 23 437 (44%) had a care interruption, of which 10 629 (20%) had a first care interruption within 6 months on ART and 12 808 (24%) had a first care interruption after 6 months on ART. Increased mortality was associated with a care interruption within 6 months on ART [adjusted hazard ratio (AHR) = 1.52, 95% CI 1.12-2.04] but not with a care interruption after 6 months on ART (AHR = 1.05, 95% CI 0.77-1.44). CONCLUSION The findings suggest that strengthening retention of children in care in the early period after ART initiation is critical to improving paediatric ART outcomes.
Collapse
Affiliation(s)
- Claire DAVIES
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Leigh JOHNSON
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Shobna SAWRY
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Harriet Shezi Children’s Clinic, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa
| | | | - Brian ELEY
- Red Cross War Memorial Children’s Hospital and Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Michael VINIKOOR
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Karl-Günter TECHNAU
- Empilweni Services and Research Unit, Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Helena RABIE
- Department of Paediatrics and Child Health, Tygerberg Academic Hospital, University of Stellenbosch, Stellenbosch, South Africa
| | - Sam PHIRI
- Lighthouse Trust Clinic, Kamuzu Central Hospital, Lilongwe, Malaysia
| | - Frank TANSER
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
| | | | - Geoffrey FATTI
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Meg OSLER
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Robin WOOD
- Gugulethu HIV Programme and Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Sam NEWTON
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Andreas HAAS
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | - Mary-Ann DAVIES
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
7
|
Zanoni BC, Archary M, Sibaya T, Musinguzi N, Kelley ME, McManus S, Haberer JE. Development and validation of the HIV adolescent readiness for transition scale (HARTS) in South Africa. J Int AIDS Soc 2021; 24:e25767. [PMID: 34235876 PMCID: PMC8264413 DOI: 10.1002/jia2.25767] [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: 10/16/2020] [Revised: 04/30/2021] [Accepted: 06/11/2021] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Adolescents living with perinatally acquired HIV have low rates of retention in care and viral suppression after the transition from paediatric to adult care. In this study, we developed and validated a tool to identify adolescent transition readiness. METHODS We developed the HIV Adolescent Readiness for Transition Scale (HARTS) from June 2016 to May 2019 by iteratively adapting existing transition readiness scales for other chronic illnesses by conducting focus groups with 11 healthcare providers and 20 adolescents in South Africa. We administered a preliminary questionnaire to 131 adolescents to determine psychometric properties and assess test-retest variability. We used confirmatory factor analysis to verify the proposed scale structure using the underlying variable approach. We correlated responses to self-described transition readiness and age using linear regression. We subsequently validated the scale by prospectively administering it to 199 adolescents in a second South African setting before their transition. We then used multivariable logistic regression to assess the effects of the HARTS and relevant socio-behavioural covariates on viral suppression one year after transition. RESULTS We identified four domains relevant to transition readiness: disclosure, health navigation, self-advocacy and health literacy. Fifteen questions with a significant factor loading of 0.3 to 0.9 were identified. No significant test-retest variability was seen among 10% of participants. Positive correlations with self-described transition readiness were significant with the overall HARTS and domains of health navigation, self-advocacy and health literacy. In the prospective analysis, for adolescents not using drugs, each 10-point increase in the HARTS was associated with 0.62 odds of viral failure (95% CI 0.45 to 0.86; p = 0.004). The individual domains of self-advocacy (AOR 0.56; 95% CI 0.33 to 0.94; p = 0.029), disclosure (AOR 0.02; 95% CI 0.01 to 0.25; p = 0.002), health navigation (AOR 0.51; 95%CI 0.25 to 1.02; p = 0.056) and health literacy (AOR 0.37; 95% CI 0.10 to 1.30; p = 0.121) were associated with viral failure adjusting for age at antiretroviral therapy initiation, ART regimen, sex, disclosure status, and alcohol use in both analyses. CONCLUSIONS The HARTS is a validated scale that can be used to identify which adolescents may require additional interventions prior to transitioning to adult care to improve viral suppression after transition.
Collapse
Affiliation(s)
- Brian C Zanoni
- Emory UniversityAtlantaGAUSA
- Children’s Healthcare of AtlantaAtlantaGAUSA
| | - Moherndran Archary
- University of KwaZulu‐Natal Nelson Mandela School of MedicineDurbanSouth Africa
- King Edward VIII HospitalDurbanSouth Africa
| | - Thobekile Sibaya
- University of KwaZulu‐Natal Nelson Mandela School of MedicineDurbanSouth Africa
| | - Nicholas Musinguzi
- Global Health CollaborativeUniversity of Science and TechnologyMbararaUganda
| | - Mary E Kelley
- Emory UniversityAtlantaGAUSA
- Rollins School of Public healthAtlantaGAUSA
| | - Shauna McManus
- Emory UniversityAtlantaGAUSA
- Rollins School of Public healthAtlantaGAUSA
| | - Jessica E Haberer
- Massachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| |
Collapse
|
8
|
Zanoni BC, Archary M, Sibaya T, Musinguzi N, Haberer JE. Transition from pediatric to adult care for adolescents living with HIV in South Africa: A natural experiment and survival analysis. PLoS One 2020; 15:e0240918. [PMID: 33108396 PMCID: PMC7591089 DOI: 10.1371/journal.pone.0240918] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 10/05/2020] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To determine rates of retention and viral suppression among adolescents living with perinatally-acquired HIV who remained in pediatric care compared to those who transitioned to adult care. METHODS We evaluated a natural experiment involving adolescents living with perinatally-acquired HIV who were attending a government-supported antiretroviral clinic in KwaZulu-Natal, South Africa. Prior to 2011, all adolescents transitioned to adult care at 12 years of age. Due to a policy change, all adolescents were retained in pediatric care after 2011. We analyzed adolescents two years before and two years after this policy change. Outcomes were retention in care and HIV viral suppression one year after transition to adult care or the 13th birthday if remaining in pediatric care. RESULTS In the natural experiment, 180 adolescents who turned 12 years old between 2011 and 2014 were evaluated; 35 (20%) transitioned to adult care under the old policy and 145 (80%) remained in pediatric care under the new policy. Adolescents who transitioned to the adult clinic had lower rates of retention in care (49%; 17/35) compared to adolescents remaining in the pediatric clinic (92%; 134/145; p<0.001). Retention in care was lower (ARR 0.59; 95%CI 0.43-0.82; p = 0.001) and viral suppression was similar (ARR = 1.06, 95%CI 0.89-1.26; p = 0.53) for adolescents who transitioned to adult care compared to adolescents remaining in pediatric care. CONCLUSION Adolescents living with perinatally-acquired HIV appear to have higher retention in care when cared for in pediatric clinics compared to adult clinics. Longer-term follow-up is needed to fully assess viral suppression.
Collapse
Affiliation(s)
- Brian C. Zanoni
- Emory University, Atlanta, Georgia, United States of America
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Moherndran Archary
- University of KwaZulu-Natal Nelson Mandela School of Medicine, Durban, South Africa
| | - Thobekile Sibaya
- University of KwaZulu-Natal Nelson Mandela School of Medicine, Durban, South Africa
| | | | - Jessica E. Haberer
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| |
Collapse
|
9
|
Pediatric HIV Treatment Gaps in 7 East and Southern African Countries: Examination of Modeled, Survey, and Routine Program Data. J Acquir Immune Defic Syndr 2019; 78 Suppl 2:S134-S141. [PMID: 29994836 DOI: 10.1097/qai.0000000000001739] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Remarkable success in the prevention and treatment of pediatric HIV infection has been achieved in the past decade. Large differences remain between the estimated number of children living with HIV (CLHIV) and those identified through national HIV programs. We evaluated the number of CLHIV and those on treatment in Lesotho, Malawi, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe. METHODS We assessed the total number of CLHIV, CLHIV on antiretroviral treatment (ART), and national and regional ART coverage gaps using 3 data sources: (1) Joint United Nations Programme on HIV/AIDS model-based estimates and national program data used as input values in the models, (2) population-based HIV impact surveys (PHIA), and (3) program data from the President's Emergency Plan for AIDS Relief (PEPFAR)-supported clinics. RESULTS Across the 7 countries, HIV prevalence among children aged 0-14 years ranged from 0.4% (Uncertainty Bounds (UB) 0.2%-0.6%) to 2.8% (UB: 2.2%-3.4%) according to the PHIA surveys, resulting in estimates of 520,000 (UB: 460,000-580,000) CLHIV in 2016-2017 in the 7 countries. This compared with Spectrum estimates of pediatric HIV prevalence ranging from 0.5% (UB: 0.5%-0.6%) to 3.5% (UB: 3.0%-4.0%) representing 480,000 (UB: 390,000-550,000) CLHIV. CLHIV not on treatment according to the PEPFAR, PHIA, and Spectrum for the countries stood at 48% (UB: 25%-60%), 49% (UB: 37%-50%), and 38% (UB: 24%-47%), respectively. Of 78 regions examined across 7 countries, 33% of regions (PHIA data) or 41% of regions (PEPFAR data) had met the ART coverage target of 81%. CONCLUSIONS There are substantial gaps in the coverage of HIV treatment in CLHIV in the 7 countries studied according to all sources. There is continued need to identify, engage, and treat infants and children. Important inconsistencies in estimates across the 3 sources warrant in-depth investigation.
Collapse
|
10
|
Abstract
Observational data characterizing the pediatric and adolescent HIV epidemics in real-world settings are critical to informing clinical guidelines, governmental HIV programs, and donor prioritization. Global expertise in curating and analyzing these data has been expanding, with increasingly robust collaborations and the identification of gaps in existing surveillance capacity. In this commentary, we describe existing sources of observational data for children and youth living with HIV, focusing on larger regional and global research cohorts, and targeted surveillance studies and programs. Observational data are valuable resources to cross-validate other research and to monitor the impact of changing HIV program policies. Observational studies were among the first to highlight the growing population of children surviving perinatal HIV and transitioning to adolescence and young adulthood, and have raised serious concerns about high rates of treatment failure, loss to follow-up, and death among older perinatally infected youth. The use of observational data to inform modeling of the current global epidemic, predict future patterns of the youth cascade, and facilitate antiretroviral forecasting are critical priorities and key end products of observational HIV research. Greater investments into data infrastructure are needed at the local level to improve data quality and at the global level to faciliate reliable interpretation of the evolving patterns of the pediatric and youth epidemics. Although this includes harmonized data forms, use of unique patient identifiers to allow for data linkages across routine data sets and electronic medical record systems, and competent data managers and analysts are essential to make optimal use of the data collected.
Collapse
|
11
|
Ahmed I, Lemma S. Mortality among pediatric patients on HIV treatment in sub-Saharan African countries: a systematic review and meta-analysis. BMC Public Health 2019; 19:149. [PMID: 30717720 PMCID: PMC6360742 DOI: 10.1186/s12889-019-6482-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/25/2019] [Indexed: 12/29/2022] Open
Abstract
Background Despite substantial improvements in accessibility of Anti-Retroviral Treatment (ART), death of children on ART remains a prevailing challenge in sub-Saharan African (SSA) countries. However, the pooled magnitude of mortality at different ART follow-up periods remains unknown for the region. We estimated the pooled proportion of all-cause mortality for pediatric patients receiving first-line ART at 3, 6, 12, and 24 months follow-up period in SSA. Methods We searched for relevant articles published between January 2014 and June 2018 on PubMed, Hinari and Google scholar databases. We searched for additional articles from reference lists and 2014–2018 abstracts archived by the Conference on Retroviruses and Opportunistic Infections (CROI) and the International AIDS Society Conference on HIV Science (IAS). Results We reviewed 29 articles reporting mortality among pediatric ART patients at different follow-up periods in countries from 2001 to 2016. Among the 51,619 pediatric ART patients in these cohorts, studies reported 4061 (7.9%) all-cause cumulative death. The cumulative pooled proportion of mortality at 3, 6, 12 and 24 months of ART were 3% (95% CI: 3.0–4.0), 5% (95% CI: 4.0–6.0), 6% (95% CI: 5.0–7.0) and 7% (95% CI: 6.0–8.0), respectively. Conclusions In SSA, significant proportion of mortality among children occurs in the first 3–6 months of ART initiation. Western Africa has a little higher estimate of mortality among pediatric ART patients at 6 and 12 months of follow-up. Strategies to prevent early mortality including thorough screening and management of opportunistic infections before ART initiation are needed. Electronic supplementary material The online version of this article (10.1186/s12889-019-6482-1) contains supplementary material, which is available to authorized users.
Collapse
|
12
|
Judd A, Davies MA. Adolescent transition among young people with perinatal HIV in high-income and low-income settings. Curr Opin HIV AIDS 2018; 13:236-248. [PMID: 29528851 PMCID: PMC6424353 DOI: 10.1097/coh.0000000000000448] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW To summarize evidence for health outcomes among adolescents and young people living with HIV (AYLHIV) who have transitioned to adult care/adulthood, views of AYLHIV and providers on the transition process, and the effect of adolescent and youth friendly services (AYFS) on outcomes. RECENT FINDINGS A total of 43 studies were identified [n = 13 high-income countries (HICs), n = 30 low-/middle-income countries (LMICs)]. In HICs, around 75% of patients were retained in care at approximately 4 years posttransition. In LMICs, retention worsened from older adolescence into young adulthood. Across both contexts, comparisons of mortality, immunological, and virological outcomes were hampered by a limited number of studies and/or different definitions and study durations. AYLHIV and providers reported several factors that could aid transition and AYFS had generally positive outcomes. SUMMARY Overall, outcomes varied by study and context; direct comparison was severely hampered by the inclusion of different populations of AYLHIV (sometimes with small numbers and a lack of comparison groups), the use of different outcome definitions, varying follow-up duration, and the lack of a specific transition process in LMICs. Future studies need to consider harmonizing definitions and implementing unique patient identifiers, and data linkage techniques to improve the evidence base on long-term outcomes.
Collapse
Affiliation(s)
- Ali Judd
- MRC Clinical Trials Unit at UCL, University College London, London, UK
| | - Mary-Ann Davies
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
| |
Collapse
|