1
|
Nabukalu D, Yiannoutsos CT, Semeere A, Musick BS, Murungi T, Namulindwa JV, Waswa F, Nakigozi G, Sewankambo NK, Reynolds SJ, Lutalo T, Makumbi F, Kigozi G, Nalugoda F, Wools-Kaloustian K. Mortality Among HIV-Infected Adults on Antiretroviral Therapy in Southern Uganda. J Acquir Immune Defic Syndr 2024; 95:268-274. [PMID: 38408217 PMCID: PMC10898547 DOI: 10.1097/qai.0000000000003330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/24/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Monitoring and evaluation of clinical programs requires assessing patient outcomes. Numerous challenges complicate these efforts, the most insidious of which is loss to follow-up (LTFU). LTFU is a composite outcome, including individuals out of care, undocumented transfers, and unreported deaths. Incorporation of vital status information from routine patient outreach may improve the mortality estimates for those LTFU. SETTINGS We analyzed routinely collected clinical and patient tracing data for individuals (15 years or older) initiating antiretroviral treatment between January 2014 and December 2018 at 2 public HIV care clinics in greater Rakai, Uganda. METHODS We derived unadjusted mortality estimates using Kaplan-Meier methods. Estimates, adjusted for unreported deaths, applied weighting through the Frangakis and Rubin method to represent outcomes among LTFU patients who were successfully traced and for whom vital status was ascertained. Confidence intervals were determined through bootstrap methods. RESULTS Of 1969 patients with median age at antiretroviral treatment initiation of 31 years (interquartile range: 25-38), 1126 (57.2%) were female patients and 808 (41%) were lost. Of the lost patients, 640 patient files (79.2%) were found and reviewed, of which 204 (31.8%) had a tracing attempt. Within the electronic health records of the program, 28 deaths were identified with an estimated unadjusted mortality 1 year after antiretroviral treatment initiation of 2.5% (95% CI: 1.8% to 3.3%). Using chart review and patient tracing data, an additional 24 deaths (total 52) were discovered with an adjusted 1-year mortality of 3.8% (95% CI: 2.6% to 5.0%). CONCLUSIONS Data from routine outreach efforts by HIV care and treatment programs can be used to support plausible adjustments to estimates of client mortality. Mortality estimates without active ascertainment of vital status of LTFU patients may significantly underestimate program mortality.
Collapse
Affiliation(s)
| | | | - Aggrey Semeere
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | | | | | | | - Nelson K. Sewankambo
- Makerere University College of Health Sciences, School of Medicine, Kampala, Uganda
| | - Steven J. Reynolds
- Division of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
- Johns Hopkins University School of Medicine, Baltimore, MD; and
| | - Tom Lutalo
- Rakai Health Sciences Program, Rakai, Uganda
| | | | | | | | | |
Collapse
|
2
|
Yiannoutsos CT, Wools-Kaloustian K, Musick BS, Kosgei R, Kimaiyo S, Siika A. Assessing HIV-infected patient retention in a program of differentiated care in sub-Saharan Africa: a G-estimation approach. Int J Biostat 2023; 0:ijb-2023-0031. [PMID: 37713538 DOI: 10.1515/ijb-2023-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/20/2023] [Indexed: 09/17/2023]
Abstract
Differentiated care delivery aims to simplify care of people living with HIV, reflect their preferences, reduce burdens on the healthcare system, maintain care quality and preserve resources. However, assessing program effectiveness using observational data is difficult due to confounding by indication and randomized trials may be infeasible. Also, benefits can reach patients directly, through enrollment in the program, and indirectly, by increasing quality of and accessibility to care. Low-risk express care (LREC), the program under evaluation, is a nurse-centered model which assigns patients stable on ART to a nurse every two months and a clinician every third visit, reducing annual clinician visits by two thirds. Study population is comprised of 16,832 subjects from 15 clinics in Kenya. We focus on patient retention in care based on whether the LREC program is available at a clinic and whether the patient is enrolled in LREC. We use G-estimation to assess the effect on retention of two "strategies": (i) program availability but no enrollment; (ii) enrollment at an available program; versus no program availability. Compared to no availability, LREC results in a non-significant increase in patient retention, among patients not enrolled in the program (indirect effect), while enrollment in LREC is associated with a significant extension of the time retained in care (direct effect). G-estimation provides an analytical framework useful to the assessment of similar programs using observational data.
Collapse
Affiliation(s)
- Constantin T Yiannoutsos
- Department of Biostatistics and Health Data Science, Indiana University Fairbanks School of Public Health, Indianapolis, IN, USA
| | - Kara Wools-Kaloustian
- Indiana University School of Medicine, Division of Infectious Diseases, Indianapolis, IN, USA
| | - Beverly S Musick
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rose Kosgei
- University of Nairobi, Nairobi, Kenya
- Kenyatta National Hospital, Nairobi, Kenya
| | - Sylvester Kimaiyo
- Moi University College of Health Sciences & Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Abraham Siika
- Moi University College of Health Sciences & Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| |
Collapse
|
3
|
Thomadakis C, Yiannoutsos CT, Pantazis N, Diero L, Mwangi A, Musick BS, Wools-Kaloustian K, Touloumi G. The Effect of HIV Treatment Interruption on Subsequent Immunological Response. Am J Epidemiol 2023; 192:1181-1191. [PMID: 37045803 PMCID: PMC10326612 DOI: 10.1093/aje/kwad076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 11/03/2022] [Accepted: 03/27/2023] [Indexed: 04/14/2023] Open
Abstract
Recovery of CD4-positive T lymphocyte count after initiation of antiretroviral therapy (ART) has been thoroughly examined among people with human immunodeficiency virus infection. However, immunological response after restart of ART following care interruption is less well studied. We compared CD4 cell-count trends before disengagement from care and after ART reinitiation. Data were obtained from the East Africa International Epidemiology Databases to Evaluate AIDS (IeDEA) Collaboration (2001-2011; n = 62,534). CD4 cell-count trends before disengagement, during disengagement, and after ART reinitiation were simultaneously estimated through a linear mixed model with 2 subject-specific knots placed at the times of disengagement and treatment reinitiation. We also estimated CD4 trends conditional on the baseline CD4 value. A total of 10,961 patients returned to care after disengagement from care, with the median gap in care being 2.7 (interquartile range, 2.1-5.4) months. Our model showed that CD4 cell-count increases after ART reinitiation were much slower than those before disengagement. Assuming that disengagement from care occurred 12 months after ART initiation and a 3-month treatment gap, CD4 counts measured at 3 years since ART initiation would be lower by 36.5 cells/μL than those obtained under no disengagement. Given that poorer CD4 restoration is associated with increased mortality/morbidity, specific interventions targeted at better retention in care are urgently required.
Collapse
Affiliation(s)
- Christos Thomadakis
- Correspondence to Dr. Christos Thomadakis, Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece (e-mail: )
| | | | | | | | | | | | | | | |
Collapse
|
4
|
Edmonds A, Brazier E, Musick BS, Yotebieng M, Humphrey J, Abuogi LL, Adedimeji A, Keiser O, Msukwa M, Carlucci JG, Maia M, Pinto JA, Leroy V, Davies MA, Wools-Kaloustian KK. Clinical and programmatic outcomes of HIV-exposed infants enrolled in care at geographically diverse clinics, 1997-2021: A cohort study. PLoS Med 2022; 19:e1004089. [PMID: 36107857 PMCID: PMC9477260 DOI: 10.1371/journal.pmed.1004089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/11/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Although 1·3 million women with HIV give birth annually, care and outcomes for HIV-exposed infants remain incompletely understood. We analyzed programmatic and health indicators in a large, multidecade global dataset of linked mother-infant records from clinics and programs associated with the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. METHODS AND FINDINGS HIV-exposed infants were eligible for this retrospective cohort analysis if enrolled at <18 months at 198 clinics in 10 countries across 5 IeDEA regions: East Africa (EA), Central Africa (CA), West Africa (WA), Southern Africa (SA), and the Caribbean, Central, and South America network (CCASAnet). We estimated cumulative incidences of DNA PCR testing, loss to follow-up (LTFU), HIV diagnosis, and death through 24 months of age using proportional subdistribution hazard models accounting for competing risks. Competing risks were transfer, care withdrawal, and confirmation of negative HIV status, along with LTFU and death, when not the outcome of interest. In CA and EA, we quantified associations between maternal/infant characteristics and each outcome. A total of 82,067 infants (47,300 EA, 10,699 CA, 6,503 WA, 15,770 SA, 1,795 CCASAnet) born from 1997 to 2021 were included. Maternal antiretroviral therapy (ART) use during pregnancy ranged from 65·6% (CCASAnet) to 89·5% (EA), with improvements in all regions over time. Twenty-four-month cumulative incidences varied widely across regions, ranging from 12·3% (95% confidence limit [CL], 11·2%,13·5%) in WA to 94·8% (95% CL, 94·6%,95·1%) in EA for DNA PCR testing; 56·2% (95% CL, 55·2%,57·1%) in EA to 98·5% (95% CL, 98·3%,98·7%) in WA for LTFU; 1·9% (95% CL, 1·6%,2·3%) in WA to 10·3% (95% CL, 9·7%,10·9%) in EA for HIV diagnosis; and 0·5% (95% CL, 0·2%,1·0%) in CCASAnet to 4·7% (95% CL, 4·4%,5·0%) in EA for death. Although infant retention did not improve, HIV diagnosis and death decreased over time, and in EA, the cumulative incidence of HIV diagnosis decreased substantially, declining to 2·9% (95% CL, 1·5%,5·4%) in 2020. Maternal ART was associated with decreased infant mortality (subdistribution hazard ratio [sdHR], 0·65; 95% CL, 0·47,0·91 in EA, and sdHR, 0·51; 95% CL, 0·36,0·74 in CA) and HIV diagnosis (sdHR, 0·40; 95% CL, 0·31,0·50 in EA, and sdHR, 0·41; 95% CL, 0·31,0·54 in CA). Study limitations include potential misclassification of outcomes in real-world service delivery data and possible nonrepresentativeness of IeDEA sites and the population of HIV-exposed infants they serve. CONCLUSIONS While there was marked regional and temporal heterogeneity in clinical and programmatic outcomes, infant LTFU was high across all regions and time periods. Further efforts are needed to keep HIV-exposed infants in care to receive essential services to reduce HIV infection and mortality.
Collapse
Affiliation(s)
- Andrew Edmonds
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Ellen Brazier
- Institute for Implementation Science in Population Health, Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
| | - Beverly S. Musick
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Marcel Yotebieng
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - John Humphrey
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Lisa L. Abuogi
- Department of Pediatrics, University of Colorado, Denver, Aurora, Colorado, United States of America
| | - Adebola Adedimeji
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Malango Msukwa
- Center for International Health, Education, and Biosecurity, University of Maryland, Lilongwe, Malawi
| | - James G. Carlucci
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Marcelle Maia
- Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Jorge A. Pinto
- Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Valériane Leroy
- Inserm, Université de Toulouse, CERPOP, Université Paul Sabatier, Toulouse, France
| | | | - Kara K. Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | | |
Collapse
|
5
|
Romo ML, Patel RC, Edwards JK, Humphrey JM, Musick BS, Bernard C, Maina MW, Brazier E, Castelnuovo B, Penner J, Wyka K, Cardoso SW, Ly PS, Kunzekwenyika C, Cortés CP, Panczak R, Kelvin EA, Wools-Kaloustian KK, Nash D. Disparities in Dolutegravir Uptake Affecting Females of Reproductive Age With HIV in Low- and Middle-Income Countries After Initial Concerns About Teratogenicity : An Observational Study. Ann Intern Med 2022; 175:84-94. [PMID: 34843382 PMCID: PMC8808594 DOI: 10.7326/m21-3037] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The transition to dolutegravir-containing antiretroviral therapy (ART) in low- and middle-income countries (LMICs) was complicated by an initial safety signal in May 2018 suggesting that exposure to dolutegravir at conception was possibly associated with infant neural tube defects. On the basis of additional evidence, in July 2019, the World Health Organization recommended dolutegravir for all adults and adolescents living with HIV. OBJECTIVE To describe dolutegravir uptake and disparities by sex and age group in LMICs. DESIGN Observational cohort study. SETTING 87 sites that began using dolutegravir in 11 LMICs in the Asia-Pacific; Caribbean, Central and South America network for HIV epidemiology (CCASAnet); and sub-Saharan African regions of the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. PATIENTS 134 672 patients aged 16 years or older who received HIV care from January 2017 through March 2020. MEASUREMENTS Sex, age group, and dolutegravir uptake (that is, newly initiating ART with dolutegravir or switching to dolutegravir from another regimen). RESULTS Differences in dolutegravir uptake among females of reproductive age (16 to 49 years) emerged after the safety signal. By the end of follow-up, the cumulative incidence of dolutegravir uptake among females 16 to 49 years old was 29.4% (95% CI, 29.0% to 29.7%) compared with 57.7% (CI, 57.2% to 58.3%) among males 16 to 49 years old. This disparity was greater in countries that began implementing dolutegravir before the safety signal and initially had highly restrictive policies versus countries with a later rollout. Dolutegravir uptake was similar among females and males aged 50 years or older. LIMITATION Follow-up was limited to 6 to 8 months after international guidelines recommended expanding access to dolutegravir. CONCLUSION Substantial disparities in dolutegravir uptake affecting females of reproductive age through early 2020 are documented. Although this disparity was anticipated because of country-level restrictions on access, the results highlight its extent and initial persistence. PRIMARY FUNDING SOURCE National Institutes of Health.
Collapse
Affiliation(s)
- Matthew L Romo
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, and CUNY Institute for Implementation Science in Population Health, New York, New York (M.L.R., E.B., E.A.K., D.N.)
| | - Rena C Patel
- Department of Medicine and Department of Global Health, University of Washington, Seattle, Washington (R.C.P.)
| | - Jessie K Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (J.K.E.)
| | - John M Humphrey
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana (J.M.H., K.K.W.)
| | - Beverly S Musick
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana (B.S.M.)
| | - Caitlin Bernard
- Department of Obstetrics & Gynecology, Indiana University School of Medicine, Indianapolis, Indiana (C.B.)
| | - Mercy W Maina
- Department of Pharmacy, Moi Teaching and Referral Hospital, Eldoret, Kenya (M.W.M.)
| | - Ellen Brazier
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, and CUNY Institute for Implementation Science in Population Health, New York, New York (M.L.R., E.B., E.A.K., D.N.)
| | - Barbara Castelnuovo
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda (B.C.)
| | - Jeremy Penner
- Family AIDS Care & Education Services, Kisumu, Kenya, and Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada (J.P.)
| | - Katarzyna Wyka
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, New York (K.W.)
| | - Sandra Wagner Cardoso
- Instituto Nacional de Infectologia, Laboratório de Pesquisa Clínica em HIV/AIDS, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil (S.W.C.)
| | - Penh Sun Ly
- National Center for HIV/AIDS, Dermatology and STDs, Ministry of Health, Phnom Penh, Cambodia (P.S.L.)
| | | | - Claudia P Cortés
- Departamento de Medicina, Universidad de Chile & Fundación Arriarán, Santiago, Chile (C.P.C.)
| | - Radoslaw Panczak
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (R.P.)
| | - Elizabeth A Kelvin
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, and CUNY Institute for Implementation Science in Population Health, New York, New York (M.L.R., E.B., E.A.K., D.N.)
| | - Kara K Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana (J.M.H., K.K.W.)
| | - Denis Nash
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, and CUNY Institute for Implementation Science in Population Health, New York, New York (M.L.R., E.B., E.A.K., D.N.)
| | | |
Collapse
|
6
|
Romo ML, Edwards JK, Semeere AS, Musick BS, Urassa M, Odhiambo F, Diero L, Kasozi C, Murenzi G, Lelo P, Wyka K, Kelvin EA, Sohn AH, Wools-Kaloustian KK, Nash D. Viral Load Status Before Switching to Dolutegravir-Containing Antiretroviral Therapy and Associations With Human Immunodeficiency Virus Treatment Outcomes in Sub-Saharan Africa. Clin Infect Dis 2021; 75:630-637. [PMID: 34893813 PMCID: PMC9464076 DOI: 10.1093/cid/ciab1006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Dolutegravir is being rolled out globally as part of preferred antiretroviral therapy (ART) regimens, including among treatment-experienced patients. The role of viral load (VL) testing before switching patients already on ART to a dolutegravir-containing regimen is less clear in real-world settings. METHODS We included patients from the International epidemiology Databases to Evaluate AIDS consortium who switched from a nevirapine- or efavirenz-containing regimen to one with dolutegravir. We used multivariable cause-specific hazards regression to estimate the association of the most recent VL test in the 12 months before switching with subsequent outcomes. RESULTS We included 36 393 patients at 37 sites in 5 countries (Democratic Republic of the Congo, Kenya, Rwanda, Tanzania, Uganda) who switched to dolutegravir from July 2017 through February 2020, with a median follow-up of approximately 11 months. Compared with those who switched with a VL <200 copies/mL, patients without a recent VL test or with a preswitch VL ≥1000 copies/mL had significantly increased hazards of an incident VL ≥1000 copies/mL (adjusted hazard ratio [aHR], 2.89; 95% confidence interval [CI], 1.99-4.19 and aHR, 6.60; 95% CI, 4.36-9.99, respectively) and pulmonary tuberculosis or a World Health Organization clinical stage 4 event (aHR, 4.78; 95% CI, 2.77-8.24 and aHR, 13.97; 95% CI, 6.62-29.50, respectively). CONCLUSIONS A VL test before switching to dolutegravir may help identify patients who need additional clinical monitoring and/or adherence support. Further surveillance of patients who switched to dolutegravir with an unknown or unsuppressed VL is needed.
Collapse
Affiliation(s)
- Matthew L Romo
- Correspondence: M. Romo, 55 West 125th St., 6th Floor, New York, NY 10027 ()
| | - Jessie K Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Aggrey S Semeere
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Beverly S Musick
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mark Urassa
- National Institute for Medical Research, Mwanza, Tanzania
| | - Francesca Odhiambo
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Lameck Diero
- School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | | | | | - Patricia Lelo
- Kalembelembe Pediatric Hospital, Kinshasa, Democratic Republic of the Congo
| | - Katarzyna Wyka
- Department of Epidemiology and Biostatistics & Institute for Implementation Science in Population Health, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | - Elizabeth A Kelvin
- Department of Epidemiology and Biostatistics & Institute for Implementation Science in Population Health, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | - Annette H Sohn
- TREAT Asia, amfAR–The Foundation for AIDS Research, Bangkok, Thailandand
| | | | - Denis Nash
- Department of Epidemiology and Biostatistics & Institute for Implementation Science in Population Health, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, New York, USA
| | | |
Collapse
|
7
|
Millar HC, Keter AK, Musick BS, Apondi E, Wachira J, MacDonald KR, Spitzer RF, Braitstein P. Decreasing incidence of pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya between 2005 and 2017: a retrospective cohort study. Reprod Health 2020; 17:191. [PMID: 33267899 PMCID: PMC7709285 DOI: 10.1186/s12978-020-01031-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 10/29/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective of this study was to estimate the prevalence, incidence and risk factors for pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya. METHODS The Academic Model Providing Access to Healthcare (AMPATH) program is a partnership between Moi University, Moi Teaching and Referral Hospital and a consortium of 11 North American academic institutions. AMPATH currently provides care to 85,000 HIV-positive individuals in western Kenya. Included in this analysis were adolescents aged 10-19 enrolled in AMPATH between January 2005 and February 2017. Socio-demographic, behavioural, and clinical data at baseline and time-updated antiretroviral treatment (ART) data were extracted from the electronic medical records and summarized using descriptive statistics. Follow up time was defined as time of inclusion in the cohort until the date of first pregnancy or age 20, loss to follow up, death, or administrative censoring. Adolescent pregnancy rates and associated risk factors were determined. RESULTS There were 8565 adolescents eligible for analysis. Median age at enrolment in HIV care was 14.0 years. Only 17.7% had electricity at home and 14.4% had piped water, both indicators of a high level of poverty. 12.9% (1104) were pregnant at study inclusion. Of those not pregnant at enrolment, 5.6% (448) became pregnant at least once during follow-up. Another 1.0% (78) were pregnant at inclusion and became pregnant again during follow-up. The overall pregnancy incidence rate was 21.9 per 1000 woman years or 55.8 pregnancies per 1000 women. Between 2005 and 2017, pregnancy rates have decreased. Adolescents who became pregnant in follow-up were more likely to be older, to be married or living with a partner and to have at least one child already and less likely to be using family planning. CONCLUSIONS A considerable number of these HIV-positive adolescents presented at enrolment into HIV care as pregnant and many became pregnant as adolescents during follow-up. Pregnancy rates remain high but have decreased from 2005 to 2017. Adolescent-focused sexual and reproductive health and ante/postnatal care programs may have the potential to improve maternal and neonatal outcomes as well as further decrease pregnancy rates in this high-risk group.
Collapse
Affiliation(s)
- Heather C Millar
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya. .,Section of Gynaecology, Division of Endocrinology, SickKids Hospital, 555 University Avenue, 7th Floor, Black Wing, Toronto, ON, M5G 1X8, Canada. .,Department of Obstetrics and Gynaecology, University of Toronto Faculty of Medicine, 123 Edward Street, Suite 1200, Toronto, ON, M5G 1E2, Canada.
| | - Alfred K Keter
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya
| | - Beverly S Musick
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya.,Department of Biostatistics, Indiana University School of Medicine, 410 West 10th Street, Suite 3000, Indianapolis, IN, 46202, USA
| | - Edith Apondi
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya.,Moi Teaching and Referral Hospital, Nandi Road, Uasin Gishu County, PO Box 3-30100, Eldoret, Kenya
| | - Juddy Wachira
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya.,Department of Behavioral Sciences, Moi University, College of Health Sciences, PO Box 4606, Eldoret, 30100, Kenya
| | - Katherine R MacDonald
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya.,Department of Pediatrics, Indiana University School of Medicine, 705 Riley Hospital Drive, Riley Hospital 5900, Indianapolis, IN, 46202, USA
| | - Rachel F Spitzer
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya.,Section of Gynaecology, Division of Endocrinology, SickKids Hospital, 555 University Avenue, 7th Floor, Black Wing, Toronto, ON, M5G 1X8, Canada.,Department of Obstetrics and Gynaecology, University of Toronto Faculty of Medicine, 123 Edward Street, Suite 1200, Toronto, ON, M5G 1E2, Canada
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), PO Box 4606, Eldoret, 30100, Kenya.,Department of Epidemiology, University of Toronto Dalla Lana School of Public Health, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada.,Moi University, College of Health Sciences, School of Medicine, PO Box 4606, Eldoret, 30100, Kenya
| |
Collapse
|
8
|
Patsis I, Goodrich S, Yiannoutsos CT, Brown SA, Musick BS, Diero L, Kulzer JL, Bwana MB, Oyaro P, Wools-Kaloustian KK. Lower rates of ART initiation and decreased retention among ART-naïve patients who consume alcohol enrolling in HIV care and treatment programs in Kenya and Uganda. PLoS One 2020; 15:e0240654. [PMID: 33095784 PMCID: PMC7584184 DOI: 10.1371/journal.pone.0240654] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 10/01/2020] [Indexed: 12/21/2022] Open
Abstract
Objectives Almost 13 million people are estimated to be on antiretroviral therapy in Eastern and Southern Africa, and their disease course and program effectiveness could be significantly affected by the concurrent use of alcohol. Screening for alcohol use may be important to assess the prevalence of alcohol consumption and its impact on patient and programmatic outcomes. Methods As part of this observational study, data on patient characteristics and alcohol consumption were collected on a cohort of 765 adult patients enrolling in HIV care in East Africa. Alcohol consumption was assessed with the AUDIT questionnaire at enrollment. Subjects were classified as consuming any alcohol (AUDIT score >0), hazardous drinkers (AUDIT score ≥8) and hyper drinkers (AUDIT score ≥16). The effects of alcohol consumption on retention in care, death and delays in antiretroviral therapy (ART) initiation were assessed through competing risk (Fine & Gray) models. Results Of all study participants, 41.6% consumed alcohol, 26.7% were classified as hazardous drinkers, and 16.0% as hyper drinkers. Depending on alcohol consumption classification, men were 3–4 times more likely to consume alcohol compared to women. Hazardous drinkers (median age 32.8 years) and hyper drinkers (32.7 years) were slightly older compared to non-hazardous drinkers (30.7 years) and non-hyper drinkers (30.8 years), (p-values = 0.014 and 0.053 respectively). Median CD4 at enrollment was 330 cells/μl and 16% were classified World Health Organization (WHO) stage 3 or 4. There was no association between alcohol consumption and CD4 count or WHO stage at enrollment. Alcohol consumption was associated with significantly lower probability of ART initiation (adjusted sub-distribution hazard ratio aSHR = 0.77 between alcohol consumers versus non-consumers; p-value = 0.008), and higher patient non-retention in care (aSHR = 1.77, p-value = 0.023). Discussion Alcohol consumption is associated with significant delays in ART initiation and reduced retention in care for patients enrolling in HIV care and treatment programs in East Africa. Consequently, interventions that target alcohol consumption may have a significant impact on the HIV care cascade.
Collapse
Affiliation(s)
- Ioannis Patsis
- Department of Hygiene and Epidemiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Suzanne Goodrich
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Constantin T. Yiannoutsos
- Department of Biostatistics, Indiana University Fairbanks School of Public Health, Indianapolis, Indiana, United States of America
- * E-mail:
| | - Steven A. Brown
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Beverly S. Musick
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Lameck Diero
- School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Jayne L. Kulzer
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Mwembesa Bosco Bwana
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Patrick Oyaro
- Centre for Microbiology Research, Kenya Medical Research (KEMRI), Nairobi, Kenya
| | - Kara K. Wools-Kaloustian
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| |
Collapse
|
9
|
Ferretti F, Bestetti A, Yiannoutsos CT, Musick BS, Gerevini S, Passeri L, Bossolasco S, Boschini A, Franciotta D, Lazzarin A, Cinque P. Diagnostic and Prognostic Value of JC Virus DNA in Plasma in Progressive Multifocal Leukoencephalopathy. Clin Infect Dis 2019; 67:65-72. [PMID: 29346632 DOI: 10.1093/cid/ciy030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/13/2018] [Indexed: 12/23/2022] Open
Abstract
Background Progressive multifocal leukoencephalopathy (PML) is a severe demyelinating disease caused by the polyomavirus JC (John Cunningham; JCV) that affects patients with impaired immune systems. While JCV-DNA detection in cerebrospinal fluid (CSF) is diagnostic of PML, the clinical significance of plasma JCV-DNA is uncertain. Methods We retrospectively analyzed plasma samples from PML patients that were drawn close to disease onset and from controls without PML. In PML patients, we compared plasma JCV-DNA detection and levels to clinical and laboratory parameters, and patient survival. Results JCV-DNA was detected in plasma of 49/103 (48%) patients with PML (20/24, 83%, human immunodeficiency virus [HIV] negative; 29/79, 37%, HIV-positive) and of 4/144 (3%) controls without PML (0/95 HIV-negative; 4/49, 8%, HIV-positive), yielding a diagnostic sensitivity and specificity of 48% and 97% (83% and 100% in HIV-negative; 37% and 92% in HIV-positive), respectively. Among 16 PML patients with undetectable CSF JCV-DNA, 4 (25%) had detectable plasma JCV-DNA. Plasma JCV-DNA levels were independently associated with CSF levels (P < .0001) and previous corticosteroid treatment (P = .012). Higher plasma JCV-DNA levels were associated with disease progression in HIV-negative patients (P = .005); in HIV-positive patients, there was an increased risk of progression only in those treated with combination antiretroviral therapy (cART; P < .0001). Conclusions Testing JCV-DNA in plasma might complement PML diagnosis, especially when CSF is unavailable or JCV-DNA not detectable in CSF. In addition, JCV-DNA plasma levels could be useful as a marker of disease progression in both HIV-negative and cART-treated, HIV-positive PML patients.
Collapse
Affiliation(s)
- Francesca Ferretti
- Department of Infectious Diseases, San Raffaele Scientific Institute, Milano, Italy
| | - Arabella Bestetti
- Department of Infectious Diseases, San Raffaele Scientific Institute, Milano, Italy
| | | | - Beverly S Musick
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | | | - Laura Passeri
- Department of Infectious Diseases, San Raffaele Scientific Institute, Milano, Italy
| | - Simona Bossolasco
- Department of Infectious Diseases, San Raffaele Scientific Institute, Milano, Italy
| | | | - Diego Franciotta
- Laboratory of Neuroimmunology, 'C. Mondino' National Neurological Institute, Pavia, Italy
| | - Adriano Lazzarin
- Department of Infectious Diseases, San Raffaele Scientific Institute, Milano, Italy
| | - Paola Cinque
- Department of Infectious Diseases, San Raffaele Scientific Institute, Milano, Italy
| |
Collapse
|
10
|
Brazier E, Maruri F, Duda SN, Tymejczyk O, Wester CW, Somi G, Ross J, Freeman A, Cornell M, Poda A, Musick BS, Zhang F, Althoff KN, Mugglin C, Kimmel AD, Yotebieng M, Nash D. Implementation of "Treat-all" at adult HIV care and treatment sites in the Global IeDEA Consortium: results from the Site Assessment Survey. J Int AIDS Soc 2019; 22:e25331. [PMID: 31623428 PMCID: PMC6625339 DOI: 10.1002/jia2.25331] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 05/29/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Since 2015, the World Health Organization (WHO) has recommended that all people living with HIV (PLHIV) initiate antiretroviral treatment (ART), irrespective of CD4+ count or clinical stage. National adoption of universal treatment has accelerated since WHO's 2015 "Treat All" recommendation; however, little is known about the translation of this guidance into practice. This study aimed to assess the status of Treat All implementation across regions, countries, and levels of the health care delivery system. METHODS Between June and December 2017, 201/221 (91%) adult HIV treatment sites that participate in the global IeDEA research consortium completed a survey on capacity and practices related to HIV care. Located in 41 countries across seven geographic regions, sites provided information on the status and timing of site-level introduction of Treat All, as well as site-level practices related to ART initiation. RESULTS Almost all sites (93%) reported that they had begun implementing Treat All, and there were no statistically significant differences in site-level Treat All introduction by health facility type, urban/rural location, sector (public/private) or country income level. The median time between national policy adoption and site-level introduction was one month. In countries where Treat All was not yet adopted in national guidelines, 69% of sites reported initiating all patients on ART, regardless of clinical criteria, and these sites had been implementing Treat All for a median period of seven months at the time of the survey. The majority of sites (77%) reported typically initiating patients on ART within 14 days of confirming diagnosis, with 60% to 62% of sites implementing Treat All in East, Southern and West Africa reporting same-day ART initiation for most patients. CONCLUSIONS By mid- to late-2017, the Treat All strategy was the standard of care at almost all IeDEA sites, including rural, primary-level health facilities in low-resource settings. While further assessments of site-level capacity to provide high-quality HIV care under Treat All and to support sustained viral suppression after ART initiation are needed, the widespread introduction of Treat All at the service delivery level is a critical step towards global targets for ending the HIV epidemic as a public health threat.
Collapse
Affiliation(s)
- Ellen Brazier
- Institute for Implementation Science in Population HealthCity University of New YorkNew YorkNYUSA
- Graduate School of Public Health and Health Policy (GSPHHP)City University of New YorkNew YorkNYUSA
| | - Fernanda Maruri
- Department of MedicineDivision of Infectious DiseasesVanderbilt University Medical CenterNashvilleTNUSA
| | - Stephany N Duda
- Department of Biomedical InformaticsVanderbilt University School of MedicineNashvilleTNUSA
| | - Olga Tymejczyk
- Institute for Implementation Science in Population HealthCity University of New YorkNew YorkNYUSA
- Graduate School of Public Health and Health Policy (GSPHHP)City University of New YorkNew YorkNYUSA
| | - C William Wester
- Department of MedicineDivision of Infectious DiseasesVanderbilt University Medical CenterNashvilleTNUSA
- Vanderbilt Institute for Global Health (VIGH)NashvilleTNUSA
| | - Geoffrey Somi
- National AIDS Control ProgrammeDar es SalaamTanzania
| | - Jeremy Ross
- TREAT Asia, amfARThe Foundation for AIDS ResearchBangkokThailand
| | - Aimee Freeman
- Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMDUSA
| | - Morna Cornell
- School of Public Health and Family MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Armel Poda
- Hôpital de Jour, Service des Maladies Infectieuses, CHU Souro SanouBobo‐DioulassoBurkina Faso
- Institut Supérieur des Sciences de la Santé (INSSA)Université Nazi BoniBobo‐DioulassoBurkina Faso
| | | | - Fujie Zhang
- Clinical and Research Center of Infectious DiseasesBeijing Ditan HospitalCapital Medical UniversityBeijingChina
| | - Keri N Althoff
- Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMDUSA
| | - Catrina Mugglin
- Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
| | - April D Kimmel
- School of MedicineVirginia Commonwealth UniversityRichmondVAUSA
| | | | - Denis Nash
- Institute for Implementation Science in Population HealthCity University of New YorkNew YorkNYUSA
- Graduate School of Public Health and Health Policy (GSPHHP)City University of New YorkNew YorkNYUSA
| |
Collapse
|
11
|
Nuwagaba‐Biribonwoha H, Kiragga AN, Yiannoutsos CT, Musick BS, Wools‐Kaloustian KK, Ayaya S, Wolf H, Lugina E, Ssali J, Abrams EJ, Elul B. Adolescent pregnancy at antiretroviral therapy (ART) initiation: a critical barrier to retention on ART. J Int AIDS Soc 2018; 21:e25178. [PMID: 30225908 PMCID: PMC6141900 DOI: 10.1002/jia2.25178] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 07/13/2018] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Adolescence and pregnancy are potential risk factors for loss to follow-up (LTFU) while on antiretroviral therapy (ART). We compared adolescent and adult LTFU after ART initiation to quantify the impact of age, pregnancy, and site-level factors on LTFU. METHODS We used routine clinical data for patients initiating ART as young adolescents (YA; 10 to 14 years), older adolescents (OA; 15 to 19 years) and adults (≥20 years) from 2000 to 2014 at 52 health facilities affiliated with the International epidemiology Databases to Evaluate AIDS (IeDEA) East Africa collaboration. We estimated cumulative incidence (95% confidence interval, CI) of LTFU (no clinic visit for ≥6 months after ART initiation) and identified patient and site-level correlates of LTFU, using multivariable Cox proportional hazards models for all patients as well as individual age groups. RESULTS A total of 138,387 patients initiated ART, including 2496 YA, 2955 OA and 132,936 adults. Of these, 55%, 78% and 66%, respectively, were female and 0.7% of YA, 22.3% of OA and 8.3% of adults were pregnant at ART initiation. Cumulative incidence of LTFU at five years was 26.6% (24.6 to 28.6) among YA, 44.1% (41.8 to 46.3) among OA and 29.3% (29.1 to 29.6) among adults. Overall, compared to adults, the adjusted hazard ratio, aHR, (95% CI) of LTFU for OA was 1.54 (1.41 to 1.68) and 0.77 (0.69 to 0.86) for YA. Compared to males, pregnant females had higher hazard of LTFU, aHR 1.20 (1.14 to 1.27), and nonpregnant women had lower hazard aHR 0.90 (0.88 to 0.93). LTFU hazard among the OA was primarily driven by both pregnant and nonpregnant females, aHR 2.42 (1.98 to 2.95) and 1.51 (1.27 to 1.80), respectively, compared to men. The LTFU hazard ratio varied by IeDEA program. Site-level factors associated with overall lower LTFU hazard included receiving care in tertiary versus primary-care clinics aHR 0.61 (0.56 to 0.67), integrated adult and adolescent services and food ration provision aHR 0.93 (0.89 to 0.97) versus nonintegrated clinics with food ration provision, having patient support groups aHR 0.77 (0.66 to 0.90) and group adherence counselling aHR 0.61 (0.57 to 0.67). CONCLUSIONS Older adolescents experienced higher risk of LTFU compared to YA and adults. Interventions to prevent LTFU among older adolescents are critically needed, particularly for female and/or pregnant adolescents.
Collapse
Affiliation(s)
- Harriet Nuwagaba‐Biribonwoha
- Mailman School of Public HealthICAP at Columbia UniversityNew YorkNY
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNY
| | - Agnes N Kiragga
- Research DepartmentInfectious Diseases InstituteCollege of Health SciencesMakerere UniversityKampalaUganda
| | | | | | | | - Samuel Ayaya
- Academic Model Providing Access to Healthcare (AMPATH)Moi UniversityEldoretKenya
| | - Hilary Wolf
- Department of PediatricsUniversity of Maryland School of MedicineBaltimoreMD
| | | | - John Ssali
- Masaka Regional Referral HospitalMasakaUganda
| | - Elaine J Abrams
- Mailman School of Public HealthICAP at Columbia UniversityNew YorkNY
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNY
- Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNY
| | - Batya Elul
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNY
| | | |
Collapse
|
12
|
Vreeman RC, Ayaya SO, Musick BS, Yiannoutsos CT, Cohen CR, Nash D, Wabwire D, Wools-Kaloustian K, Wiehe SE. Adherence to antiretroviral therapy in a clinical cohort of HIV-infected children in East Africa. PLoS One 2018; 13:e0191848. [PMID: 29466385 PMCID: PMC5842873 DOI: 10.1371/journal.pone.0191848] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 01/08/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To describe antiretroviral therapy (ART) adherence and associated factors for a large HIV-infected pediatric cohort followed by sites of the East Africa International Epidemiologic Databases to Evaluate AIDS (IeDEA) consortium. METHODS This study utilized prospectively collected clinical data from HIV-infected children less than 13 years of age who initiated ART within 4 clinical care programs (with 26 clinical sites) in Kenya, Uganda, and Tanzania and were followed for up to 6 years. Programs used one of 3 adherence measures, including 7-day quantitative recall, 7-day categorical recall, and clinician pill assessments. We fit a hierarchical, three-level, logistic-regression model to examine adherence, with observations nested within patient, and patients within the 26 sites providing pediatric HIV data to this analysis. RESULTS In East Africa, 3,304 children, 52.0% male, were enrolled in care and were subsequently observed for a median of 92 weeks (inter-quartile range [IQR] 50.3-145.0 weeks). Median age at ART initiation was 5.5 years ([IQR] 3.0-8.5 years). "Good" adherence, as reported by each clinic's measures, was extremely high, remaining on average above 90% throughout all years of follow-up. Longer time on ART was associated with higher adherence (adjusted Odds Ratio-aOR-per log-transformed week on ART: 1.095, 95% Confidence Interval-CI-[1.052-1.150].) Patients enrolled in higher-volume programs exhibited higher rates of clinician-assessed adherence (aOR per log-500 patients: 1.174, 95% CI [1.108-1.245]). Significant site-level variability in reported adherence was observed (0.28), with even higher variability among patients (0.71). In a sub-analysis, being an orphan at the start of ART was strongly associated with lower ART adherence rates (aOR: 0.919, 95% CI [0.864-0.976]). CONCLUSIONS Self-reported adherence remained high over a median of 1.8 years in HIV care, but varied according to patient-level and site-level factors. Consistent adherence monitoring with validated measures and attention to vulnerable groups is recommended.
Collapse
Affiliation(s)
- Rachel C. Vreeman
- Indiana University School of Medicine, Indianapolis, IN, United States of America
- Regenstrief Institute, Inc, Indianapolis, IN, United States of America
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- * E-mail:
| | - Samuel O. Ayaya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Beverly S. Musick
- Indiana University School of Medicine, Indianapolis, IN, United States of America
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Constantin T. Yiannoutsos
- Indiana University School of Medicine, Indianapolis, IN, United States of America
- R.M. Fairbanks School of Public Health, Indianapolis, IN, United States of America
| | - Craig R. Cohen
- University of California San Francisco, San Francisco, CA, United States of America
| | - Denis Nash
- City University of New York (CUNY) Graduate School of Public Health and Health Policy, New York, NY, United States of America
| | - Deo Wabwire
- Makerere University–Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Kara Wools-Kaloustian
- Indiana University School of Medicine, Indianapolis, IN, United States of America
- Regenstrief Institute, Inc, Indianapolis, IN, United States of America
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Sarah E. Wiehe
- Indiana University School of Medicine, Indianapolis, IN, United States of America
- Regenstrief Institute, Inc, Indianapolis, IN, United States of America
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| |
Collapse
|
13
|
Holmes CB, Yiannoutsos CT, Elul B, Bukusi E, Ssali J, Kambugu A, Musick BS, Cohen C, Williams C, Diero L, Padian N, Wools-Kaloustian KK. Increased prevalence of pregnancy and comparative risk of program attrition among individuals starting HIV treatment in East Africa. PLoS One 2018; 13:e0190828. [PMID: 29342180 PMCID: PMC5771608 DOI: 10.1371/journal.pone.0190828] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 12/20/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The World Health Organization now recommends initiating all pregnant women on life-long antiretroviral therapy (ART), yet there is limited information about the characteristics and program outcomes of pregnant women already on ART in Africa. Our hypothesis was that pregnant women comprised an increasing proportion of those starting ART, and that sub-groups of these women were at higher risk for program attrition. METHODS AND FINDINGS We used the International Epidemiology Databases to Evaluate AIDS- East Africa (IeDEA-EA) to conduct a retrospective cohort study including HIV care and treatment programs in Kenya, Uganda, and Tanzania. The cohort consecutively included HIV-infected individuals 13 years or older starting ART 2004-2014. We examined trends over time in the proportion pregnant, their characteristics and program attrition rates compared to others initiating and already receiving ART. 156,474 HIV-infected individuals (67.0% women) started ART. The proportion of individuals starting ART who were pregnant women rose from 5.3% in 2004 to 12.2% in 2014. Mean CD4 cell counts at ART initiation, weighted for annual program size, increased from 2004 to 2014, led by non-pregnant women (annual increase 20 cells/mm3) and men (17 cells/mm3 annually), with lower rates of change in pregnant women (10 cells/mm3 per year) (p<0.0001). There was no significant difference in the cumulative incidence of program attrition at 6 months among pregnant women starting ART and non-pregnant women. However, healthy pregnant women starting ART (WHO stage 1/2) had a higher rate of attrition rate (9.6%), compared with healthy non-pregnant women (6.5%); in contrast among women with WHO stage 3/4 disease, pregnant women had lower attrition (8.4%) than non-pregnant women (14.4%). Among women who initiated ART when healthy and remained in care for six months, subsequent six-month attrition was slightly higher among pregnant women at ART start (3.5%) compared to those who were not pregnant (2.4%), (absolute difference 1.1%, 95% CI 0.7%-1.5%). CONCLUSIONS Pregnant women comprise an increasing proportion of those initiating ART in Africa, and pregnant women starting ART while healthy are at higher risk for program attrition than non-pregnant women. As ART programs further expand access to healthier pregnant women, further studies are needed to better understand the drivers of loss among this high risk group of women to optimize retention.
Collapse
Affiliation(s)
- Charles B. Holmes
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Georgetown University School of Medicine, Washington, DC, United States of America
| | - Constantin T. Yiannoutsos
- Indiana University R.M. Fairbanks School of Public Health, Indianapolis, Indiana, United States of America
| | - Batya Elul
- Mailman School of Public Health, Columbia University, ICAP at Columbia University, New York, New York, United States of America
| | - Elizabeth Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - John Ssali
- Masaka Regional Hospital, Masaka, Uganda
| | | | - Beverly S. Musick
- Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Craig Cohen
- University of California San Francisco, San Francisco, California, United States of America
| | - Carolyn Williams
- National Institute of Allergies and Infectious Diseases, Bethesda, Maryland, United States of America
| | - Lameck Diero
- Academic Model Providing Access to Health Care (AMPATH), Eldoret, Kenya
| | - Nancy Padian
- University of California, Berkeley, California, United States of America
| | | |
Collapse
|
14
|
Lee H, Hogan JW, Genberg BL, Wu XK, Musick BS, Mwangi A, Braitstein P. A state transition framework for patient-level modeling of engagement and retention in HIV care using longitudinal cohort data. Stat Med 2017; 37:302-319. [PMID: 29164648 DOI: 10.1002/sim.7502] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 08/24/2017] [Accepted: 08/26/2017] [Indexed: 01/10/2023]
Abstract
The human immunodeficiency virus (HIV) care cascade is a conceptual model used to outline the benchmarks that reflects effectiveness of HIV care in the whole HIV care continuum. The models can be used to identify barriers contributing to poor outcomes along each benchmark in the cascade such as disengagement from care or death. Recently, the HIV care cascade has been widely applied to monitor progress towards HIV prevention and care goals in an attempt to develop strategies to improve health outcomes along the care continuum. Yet, there are challenges in quantifying successes and gaps in HIV care using the cascade models that are partly due to the lack of analytic approaches. The availability of large cohort data presents an opportunity to develop a coherent statistical framework for analysis of the HIV care cascade. Motivated by data from the Academic Model Providing Access to Healthcare, which has provided HIV care to nearly 200,000 individuals in Western Kenya since 2001, we developed a state transition framework that can characterize patient-level movements through the multiple stages of the HIV care cascade. We describe how to transform large observational data into an analyzable format. We then illustrate the state transition framework via multistate modeling to quantify dynamics in retention aspects of care. The proposed modeling approach identifies the transition probabilities of moving through each stage in the care cascade. In addition, this approach allows regression-based estimation to characterize effects of (time-varying) predictors of within and between state transitions such as retention, disengagement, re-entry into care, transfer-out, and mortality. Copyright © 2017 John Wiley & Sons, Ltd.
Collapse
Affiliation(s)
- Hana Lee
- Department of Biostatistics, Brown University, 121 S. Main Street, Providence, 02912, RI, USA
| | - Joseph W Hogan
- Department of Biostatistics, Brown University, 121 S. Main Street, Providence, 02912, RI, USA.,Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Becky L Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Maryland, U.S.A
| | - Xiaotian K Wu
- Department of Biostatistics, Brown University, 121 S. Main Street, Providence, 02912, RI, USA
| | - Beverly S Musick
- Division of Biostatistics, School of Medicine, Indiana University, Indiana, USA
| | - Ann Mwangi
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya.,Dalla Lana School of Public Health, University of Toronto.,Fairbanks School of Public Health, Indiana University, Indiana, USA.,Regenstrief Institute, Indiana, USA
| |
Collapse
|
15
|
Rebeiro PF, Bakoyannis G, Musick BS, Braithwaite RS, Wools-Kaloustian KK, Nyandiko W, Some F, Braitstein P, Yiannoutsos CT. Observational Study of the Effect of Patient Outreach on Return to Care: The Earlier the Better. J Acquir Immune Defic Syndr 2017; 76:141-148. [PMID: 28604501 PMCID: PMC5597469 DOI: 10.1097/qai.0000000000001474] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The burden of HIV remains heaviest in resource-limited settings, where problems of losses to care, silent transfers, gaps in care, and incomplete mortality ascertainment have been recognized. METHODS Patients in care at Academic Model Providing Access to Healthcare (AMPATH) clinics from 2001-2011 were included in this retrospective observational study. Patients missing an appointment were traced by trained staff; those found alive were counseled to return to care (RTC). Relative hazards of RTC were estimated among those having a true gap: missing a clinic appointment and confirmed as neither dead nor receiving care elsewhere. Sample-based multiple imputation accounted for missing vital status. RESULTS Among 34,522 patients lost to clinic, 15,331 (44.4%) had a true gap per outreach, 2754 (8.0%) were deceased, and 837 (2.4%) had documented transfers. Of 15,600 (45.2%) remaining without active ascertainment, 8762 (56.2%) with later RTC were assumed to have a true gap. Adjusted cause-specific hazard ratios (aHRs) showed early outreach (a ≤8-day window, defined by grid-search approach) had twice the hazard for RTC vs. those without (aHR = 2.06; P < 0.001). HRs for RTC were lower the later the outreach effort after disengagement (aHR = 0.86 per unit increase in time; P < 0.001). Older age, female sex (vs. male), antiretroviral therapy use (vs. none), and HIV status disclosure (vs. none) were also associated with greater likelihood of RTC, and higher enrollment CD4 count with lower likelihood of RTC. CONCLUSION Patient outreach efforts have a positive impact on patient RTC, regardless of when undertaken, but particularly soon after the patient misses an appointment.
Collapse
Affiliation(s)
| | - Giorgos Bakoyannis
- Indiana University Fairbanks School of Public Health, Indianapolis, IN, USA
| | | | - Ronald S. Braithwaite
- New York University School of Medicine, New York City, NY, USA
- Moi University School of Medicine, Eldoret, Kenya
| | | | | | - Fatma Some
- Moi University School of Medicine, Eldoret, Kenya
| | - Paula Braitstein
- Indiana University Fairbanks School of Public Health, Indianapolis, IN, USA
- Moi University School of Medicine, Eldoret, Kenya
- University of Toronto Dalla Lana School of Public Health, Toronto, ON, Canada
| | | |
Collapse
|
16
|
Fritz CQ, Blevins M, Lindegren ML, Wools-Kaloutsian K, Musick BS, Cornell M, Goodwin K, Addison D, Dusingize JC, Messou E, Poda A, Duda SN, McGowan CC, Law MG, Moore RD, Freeman A, Nash D, Wester CW. Comprehensiveness of HIV care provided at global HIV treatment sites in the IeDEA consortium: 2009 and 2014. J Int AIDS Soc 2017; 20:20933. [PMID: 28364561 PMCID: PMC5463912 DOI: 10.7448/ias.20.1.20933] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 12/12/2016] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION An important determinant of the effectiveness of HIV treatment programs is the capacity of sites to implement recommended services and identify systematic changes needed to ensure that invested resources translate into improved patient outcomes. We conducted a survey in 2014 of HIV care and treatment sites in the seven regions of the International epidemiologic Database to Evaluate AIDS (IeDEA) Consortium to evaluate facility characteristics, HIV prevention, care and treatment services provided, laboratory capacity, and trends in the comprehensiveness of care compared to data obtained in the 2009 baseline survey. METHODS Clinical staff from 262 treatment sites in 45 countries in IeDEA completed a site survey from September 2014 to January 2015, including Asia-Pacific with Australia (n = 50), Latin America and the Caribbean (n = 11), North America (n = 45), Central Africa (n = 17), East Africa (n = 36), Southern Africa (n = 87), and West Africa (n = 16). For the 55 sites with complete data from both the 2009 and 2014 survey, we evaluated change in comprehensiveness of care. RESULTS The majority of the 262 sites (61%) offered seven essential services (ART adherence, nutritional support, PMTCT, CD4+ cell count testing, tuberculosis screening, HIV prevention, and outreach). Sites that were publicly funded (64%), cared for adults and children (68%), low or middle Human Development Index (HDI) rank (68%, 68%), and received PEPFAR support (71%) were most often fully comprehensive. CD4+ cell count testing was universally available (98%) but only 62% of clinics offered it onsite. Approximately two-thirds (69%) of sites reported routine viral load testing (44-100%), with 39% having it onsite. Laboratory capacity to monitor antiretroviral-related toxicity and diagnose opportunistic infections varied widely by testing modality and region. In the subgroup of 55 sites with two surveys, comprehensiveness of services provided significantly increased across all regions from 2009 to 2014 (5.7 to 6.5, p < 0.001). CONCLUSION The availability of viral load monitoring remains suboptimal and should be a focus for site capacity, particularly in East and Southern Africa, where the majority of those initiating on ART reside. However, the comprehensiveness of care provided increased over the past 5 years and was related to type of funding received (publicly funded and PEPFAR supported).
Collapse
Affiliation(s)
- Cristin Q Fritz
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Meridith Blevins
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
- Vanderbilt Institute for Global Health (VIGH), Nashville, TN, USA
| | - Mary Lou Lindegren
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Institute for Global Health (VIGH), Nashville, TN, USA
- Department of Health Policy, Vanderbilt University School of Medicine
| | - Kara Wools-Kaloutsian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Beverly S Musick
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology & Research & Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly Goodwin
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Dianne Addison
- Department of Epidemiology and Biostatistics, City University of New York, School of Public Health, New York, NY, USA
| | | | - Eugène Messou
- Centre de Prise en charge de Recherche et de Formation, Hôpital Yopougon Attié, Abidjan, Côte d’Ivoire
| | - Armel Poda
- Institut Supérieur des Sciences de la santé, Université Polytechnique de Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso
| | - Stephany N Duda
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Catherine C McGowan
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Richard D Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aimee Freeman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Denis Nash
- Department of Epidemiology and Biostatistics, City University of New York, School of Public Health, New York, NY, USA
| | - C William Wester
- Vanderbilt Institute for Global Health (VIGH), Nashville, TN, USA
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA
| |
Collapse
|
17
|
Tran L, Yiannoutsos CT, Musick BS, Wools-Kaloustian KK, Siika A, Kimaiyo S, van der Laan MJ, Petersen M. Evaluating the Impact of a HIV Low-Risk Express Care Task-Shifting Program: A Case Study of the Targeted Learning Roadmap. Epidemiol Methods 2016; 5:69-91. [PMID: 28736692 PMCID: PMC5520542 DOI: 10.1515/em-2016-0004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In conducting studies on an exposure of interest, a systematic roadmap should be applied for translating causal questions into statistical analyses and interpreting the results. In this paper we describe an application of one such roadmap applied to estimating the joint effect of both time to availability of a nurse-based triage system (low risk express care (LREC)) and individual enrollment in the program among HIV patients in East Africa. Our study population is comprised of 16,513 subjects found eligible for this task-shifting program within 15 clinics in Kenya between 2006 and 2009, with each clinic starting the LREC program between 2007 and 2008. After discretizing follow-up into 90-day time intervals, we targeted the population mean counterfactual outcome (i. e. counterfactual probability of either dying or being lost to follow up) at up to 450 days after initial LREC eligibility under three fixed treatment interventions. These were (i) under no program availability during the entire follow-up, (ii) under immediate program availability at initial eligibility, but non-enrollment during the entire follow-up, and (iii) under immediate program availability and enrollment at initial eligibility. We further estimated the controlled direct effect of immediate program availability compared to no program availability, under a hypothetical intervention to prevent individual enrollment in the program. Targeted minimum loss-based estimation was used to estimate the mean outcome, while Super Learning was implemented to estimate the required nuisance parameters. Analyses were conducted with the ltmle R package; analysis code is available at an online repository as an R package. Results showed that at 450 days, the probability of in-care survival for subjects with immediate availability and enrollment was 0.93 (95% CI: 0.91, 0.95) and 0.87 (95% CI: 0.86, 0.87) for subjects with immediate availability never enrolling. For subjects without LREC availability, it was 0.91 (95% CI: 0.90, 0.92). Immediate program availability without individual enrollment, compared to no program availability, was estimated to slightly albeit significantly decrease survival by 4% (95% CI 0.03,0.06, p<0.01). Immediately availability and enrollment resulted in a 7 % higher in-care survival compared to immediate availability with non-enrollment after 450 days (95% CI-0.08,-0.05, p<0.01). The results are consistent with a fairly small impact of both availability and enrollment in the LREC program on incare survival.
Collapse
Affiliation(s)
- Linh Tran
- Department of Biostatistics, UC Berkeley, 101 Haviland Hall, Berkeley, CA 94720, USA
| | - Constantin T. Yiannoutsos
- Department of Biostatistics, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA
| | - Beverly S. Musick
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Abraham Siika
- Moi University School of Medicine, Eldoret, Central Kenya
| | | | - Mark J. van der Laan
- Department of Biostatistics, School of Public Health, UC Berkeley, 108 Haviland Hall, Berkeley, CA 94720-7360, USA
| | - Maya Petersen
- Department of Biostatistics, UC Berkeley, 101 Haviland Hall, Berkeley, CA 94720, USA
| |
Collapse
|
18
|
Siika AM, Yiannoutsos CT, Wools-Kaloustian KK, Musick BS, Mwangi AW, Diero LO, Kimaiyo SN, Tierney WM, Carter JE. Active tuberculosis is associated with worse clinical outcomes in HIV-infected African patients on antiretroviral therapy. PLoS One 2013; 8:e53022. [PMID: 23301015 PMCID: PMC3534658 DOI: 10.1371/journal.pone.0053022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 11/22/2012] [Indexed: 11/20/2022] Open
Abstract
Objective This cohort study utilized data from a large HIV treatment program in western Kenya to describe the impact of active tuberculosis (TB) on clinical outcomes among African patients on antiretroviral therapy (ART). Design We included all patients initiating ART between March 2004 and November 2007. Clinical (signs and symptoms), radiological (chest radiographs) and laboratory (mycobacterial smears, culture and tissue histology) criteria were used to record the diagnosis of TB disease in the program’s electronic medical record system. Methods We assessed the impact of TB disease on mortality, loss to follow-up (LTFU) and incident AIDS-defining events (ADEs) through Cox models and CD4 cell and weight response to ART by non-linear mixed models. Results We studied 21,242 patients initiating ART–5,186 (24%) with TB; 62% female; median age 37 years. There were proportionately more men in the active TB (46%) than in the non-TB (35%) group. Adjusting for baseline HIV-disease severity, TB patients were more likely to die (hazard ratio – HR = 1.32, 95% CI 1.18–1.47) or have incident ADEs (HR = 1.31, 95% CI: 1.19–1.45). They had lower median CD4 cell counts (77 versus 109), weight (52.5 versus 55.0 kg) and higher ADE risk at baseline (CD4-adjusted odds ratio = 1.55, 95% CI: 1.31–1.85). ART adherence was similarly good in both groups. Adjusting for gender and baseline CD4 cell count, TB patients experienced virtually identical rise in CD4 counts after ART initiation as those without. However, the overall CD4 count at one year was lower among patients with TB (251 versus 269 cells/µl). Conclusions Clinically detected TB disease is associated with greater mortality and morbidity despite salutary response to ART. Data suggest that identifying HIV patients co-infected with TB earlier in the HIV-disease trajectory may not fully address TB-related morbidity and mortality.
Collapse
Affiliation(s)
- Abraham M. Siika
- School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
- * E-mail:
| | - Constantin T. Yiannoutsos
- USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
- Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Kara K. Wools-Kaloustian
- USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
- Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Beverly S. Musick
- USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
- Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Ann W. Mwangi
- USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Lameck O. Diero
- School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
| | - Sylvester N. Kimaiyo
- School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
| | - William M. Tierney
- USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
- Indiana University School of Medicine, Indianapolis, Indiana, United States of America
- Regenstrief Institute, Inc., Indianapolis, Indiana, United States of America
| | - Jane E. Carter
- USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
- Regenstrief Institute, Inc., Indianapolis, Indiana, United States of America
| |
Collapse
|
19
|
Geng EH, Hunt PW, Diero LO, Kimaiyo S, Somi GR, Okong P, Bangsberg DR, Bwana MB, Cohen CR, Otieno JA, Wabwire D, Elul B, Nash D, Easterbrook PJ, Braitstein P, Musick BS, Martin JN, Yiannoutsos CT, Wools-Kaloustian K. Trends in the clinical characteristics of HIV-infected patients initiating antiretroviral therapy in Kenya, Uganda and Tanzania between 2002 and 2009. J Int AIDS Soc 2011; 14:46. [PMID: 21955541 PMCID: PMC3204275 DOI: 10.1186/1758-2652-14-46] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2011] [Accepted: 09/28/2011] [Indexed: 11/10/2022] Open
Abstract
Background East Africa has experienced a rapid expansion in access to antiretroviral therapy (ART) for HIV-infected patients. Regionally representative socio-demographic, laboratory and clinical characteristics of patients accessing ART over time and across sites have not been well described. Methods We conducted a cross-sectional analysis of characteristics of HIV-infected adults initiating ART between 2002 and 2009 in Kenya, Uganda and Tanzania and in the International Epidemiologic Databases to Evaluate AIDS Consortium. Characteristics associated with advanced disease (defined as either a CD4 cell count level of less than 50 cells/mm3 or a WHO Stage 4 condition) at the time of ART initiation and use of stavudine (D4T) or nevirapine (NVP) were identified using a log-link Poisson model with robust standard errors. Results Among 48, 658 patients (69% from Kenya, 22% from Uganda and 9% from Tanzania) accessing ART at 30 clinic sites, the median age at the time of ART initiation was 37 years (IQR: 31-43) and 65% were women. Pre-therapy CD4 counts rose from 87 cells/mm3 (IQR: 26-161) in 2002-03 to 154 cells/mm3 (IQR: 71-233) in 2008-09 (p < 0.001). Accessing ART at advanced disease peaked at 35% in 2005-06 and fell to 27% in 2008-09. D4T use in the initial regimen fell from a peak of 88% in 2004-05 to 59% in 2008-09, and a greater extent of decline was observed in Uganda than in Kenya and Tanzania. Self-pay for ART peaked at 18% in 2003, but fell to less than 1% by 2005. In multivariable analyses, accessing ART at advanced immunosuppression was associated with male sex, women without a history of treatment for prevention of mother to child transmission (both as compared with women with such a history) and younger age after adjusting for year of ART initiation and country of residence. Receipt of D4T in the initial regimen was associated with female sex, earlier year of ART initiation, higher WHO stage, and lower CD4 levels at ART initiation and the absence of co-prevalent tuberculosis. Conclusions Public health ART services in east Africa have improved over time, but the fraction of patients accessing ART with advanced immunosuppression is still high, men consistently access ART with more advanced disease, and D4T continues to be common in most settings. Strategies to facilitate access to ART, overcome barriers among men and reduce D4T use are needed.
Collapse
Affiliation(s)
- Elvin H Geng
- Department of Medicine, San Francisco General Hospital, University of California at San Francisco, 995 Potrero Avenue, San Francisco, CA, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Vreeman RC, Nyandiko WM, Sang E, Musick BS, Braitstein P, Wiehe SE. Impact of the Kenya post-election crisis on clinic attendance and medication adherence for HIV-infected children in western Kenya. Confl Health 2009; 3:5. [PMID: 19344523 PMCID: PMC2670263 DOI: 10.1186/1752-1505-3-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Accepted: 04/04/2009] [Indexed: 11/10/2022] Open
Abstract
Background Kenya experienced a political and humanitarian crisis following presidential elections on 27 December 2007. Over 1,200 people were killed and 300,000 displaced, with disproportionate violence in western Kenya. We sought to describe the immediate impact of this conflict on return to clinic and medication adherence for HIV-infected children cared for within the USAID-Academic Model Providing Access to Healthcare (AMPATH) in western Kenya. Methods We conducted a mixed methods analysis that included a retrospective cohort analysis, as well as key informant interviews with pediatric healthcare providers. Eligible patients were HIV-infected children, less than 14 years of age, seen in the AMPATH HIV clinic system between 26 October 2007 and 25 December 2007. We extracted demographic and clinical data, generating descriptive statistics for pre- and post-conflict antiretroviral therapy (ART) adherence and post-election return to clinic for this cohort. ART adherence was derived from caregiver-report of taking all ART doses in past 7 days. We used multivariable logistic regression to assess factors associated with not returning to clinic. Interview dialogue from was analyzed using constant comparison, progressive coding and triangulation. Results Between 26 October 2007 and 25 December 2007, 2,585 HIV-infected children (including 1,642 on ART) were seen. During 26 December 2007 to 15 April 2008, 93% (N = 2,398) returned to care. At their first visit after the election, 95% of children on ART (N = 1,408) reported perfect ART adherence, a significant drop from 98% pre-election (p < 0.001). Children on ART were significantly more likely to return to clinic than those not on ART. Members of tribes targeted by violence and members of minority tribes were less likely to return. In qualitative analysis of 9 key informant interviews, prominent barriers to return to clinic and adherence included concerns for personal safety, shortages of resources, hanging priorities, and hopelessness. Conclusion During a period of humanitarian crisis, the vulnerable, HIV-infected pediatric population had disruptions in clinical care and in medication adherence, putting children at risk for viral resistance and increased morbidity. However, unique program strengths may have minimized these disruptions.
Collapse
Affiliation(s)
- Rachel C Vreeman
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
| | | | | | | | | | | |
Collapse
|
21
|
Yiannoutsos CT, An MW, Frangakis CE, Musick BS, Braitstein P, Wools-Kaloustian K, Ochieng D, Martin JN, Bacon MC, Ochieng V, Kimaiyo S. Sampling-based approaches to improve estimation of mortality among patient dropouts: experience from a large PEPFAR-funded program in Western Kenya. PLoS One 2008; 3:e3843. [PMID: 19048109 PMCID: PMC2585792 DOI: 10.1371/journal.pone.0003843] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Accepted: 11/03/2008] [Indexed: 12/01/2022] Open
Abstract
Background Monitoring and evaluation (M&E) of HIV care and treatment programs is impacted by losses to follow-up (LTFU) in the patient population. The severity of this effect is undeniable but its extent unknown. Tracing all lost patients addresses this but census methods are not feasible in programs involving rapid scale-up of HIV treatment in the developing world. Sampling-based approaches and statistical adjustment are the only scaleable methods permitting accurate estimation of M&E indices. Methodology/Principal Findings In a large antiretroviral therapy (ART) program in western Kenya, we assessed the impact of LTFU on estimating patient mortality among 8,977 adult clients of whom, 3,624 were LTFU. Overall, dropouts were more likely male (36.8% versus 33.7%; p = 0.003), and younger than non-dropouts (35.3 versus 35.7 years old; p = 0.020), with lower median CD4 count at enrollment (160 versus 189 cells/ml; p<0.001) and WHO stage 3–4 disease (47.5% versus 41.1%; p<0.001). Urban clinic clients were 75.0% of non-dropouts but 70.3% of dropouts (p<0.001). Of the 3,624 dropouts, 1,143 were sought and 621 had their vital status ascertained. Statistical techniques were used to adjust mortality estimates based on information obtained from located LTFU patients. Observed mortality estimates one year after enrollment were 1.7% (95% CI 1.3%–2.0%), revised to 2.8% (2.3%–3.1%) when deaths discovered through outreach were added and adjusted to 9.2% (7.8%–10.6%) and 9.9% (8.4%–11.5%) through statistical modeling depending on the method used. The estimates 12 months after ART initiation were 1.7% (1.3%–2.2%), 3.4% (2.9%–4.0%), 10.5% (8.7%–12.3%) and 10.7% (8.9%–12.6%) respectively. Conclusions/Significance Abstract Assessment of the impact of LTFU is critical in program M&E as estimated mortality based on passive monitoring may underestimate true mortality by up to 80%. This bias can be ameliorated by tracing a sample of dropouts and statistically adjust the mortality estimates to properly evaluate and guide large HIV care and treatment programs.
Collapse
|
22
|
Abstract
In 2007, there were 33.2 million people around the world living with HIV/AIDS (UNAIDS/WHO, 2007). In May 2003, the U.S. President announced a global program, known as the President's Emergency Plan for AIDS Relief (PEPFAR), to address this epidemic. We seek to estimate patient mortality in PEPFAR in an effort to monitor and evaluate this program. This effort, however, is hampered by loss to follow-up that occurs at very high rates. As a consequence, standard survival data and analysis on observed nondropout data are generally biased, and provide no objective evidence to correct the potential bias. In this article, we apply double-sampling designs and methodology to PEPFAR data, and we obtain substantially different and more plausible estimates compared with standard methods (1-year mortality estimate of 9.6% compared to 1.7%). The results indicate that a double-sampling design is critical in providing objective evidence of possible nonignorable dropout and, thus, in obtaining accurate data in PEPFAR. Moreover, we show the need for appropriate analysis methods coupled with double-sampling designs.
Collapse
Affiliation(s)
- Ming-Wen An
- Department of Biostatistics, Johns Hopkins University, Baltimore, Maryland 21205, USA.
| | | | | | | |
Collapse
|
23
|
Imperiale TF, Dominitz JA, Provenzale DT, Boes LP, Rose CM, Bowers JC, Musick BS, Azzouz F, Perkins SM. Predicting poor outcome from acute upper gastrointestinal hemorrhage. ACTA ACUST UNITED AC 2007; 167:1291-6. [PMID: 17592103 DOI: 10.1001/archinte.167.12.1291] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Uncertainty about the outcome of acute upper gastrointestinal bleeding often results in a longer-than-necessary hospital stay. METHODS We derived and internally validated clinical prediction rules (CPRs) to predict outcome from upper gastrointestinal bleeding. This multisite, prospective cohort study involved consecutive patients admitted for acute upper gastrointestinal bleeding. Multivariate logistic regression was used to derive CPRs on two thirds of the cohort (derivation set) that predicted bleeding-specific outcomes (rebleeding, need for urgent surgery, or hospital death [poor outcome 1]) and bleeding-specific outcomes plus new or worsening comorbidity (poor outcome 2). Both CPRs were then tested on the remaining third of the cohort (validation set). RESULTS A total of 391 individuals (99% men; mean age, 63.4 years) were enrolled, of which 4.6% rebled and 3.1% died. Independent predictors of poor outcome 1 were APACHE (Acute Physiology and Chronic Health Evaluation) II score of 11 or greater, esophageal varices, and stigmata of recent hemorrhage. Predictors of poor outcome 2 were these 3 factors plus unstable comorbidity on admission. Of patients with no risk factors, only 1 (1.1%) of 92 experienced poor outcome 1 and only 6 (6.2%) of 97 experienced poor outcome 2. Risks in the validation set were comparable. The CPRs identified 37.8% and 32.2% of patients in the derivation and validation sets, respectively, who were eligible for a shorter hospital stay. CONCLUSIONS Patients admitted with acute upper gastrointestinal bleeding were unlikely to have a poor outcome if these risk factors were absent. These CPRs might make hospital management more efficient by identifying low-risk patients for whom early hospital discharge is possible.
Collapse
Affiliation(s)
- Thomas F Imperiale
- Department of Medicine, Roudebush Veterans Affairs Medical Center, The Center of Excellence on Implementing Evidence-Based Practice, Indiana University School of Medicine, Indianapolis 46202, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Ogunniyi A, Hall KS, Gureje O, Baiyewu O, Gao S, Unverzagt FW, Smith-Gamble V, Evans RE, Dickens J, Musick BS, Hendrie HC. Risk factors for incident Alzheimer's disease in African Americans and Yoruba. Metab Brain Dis 2006; 21:235-40. [PMID: 16850256 PMCID: PMC3199593 DOI: 10.1007/s11011-006-9017-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2005] [Accepted: 10/11/2005] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The incidence rate of Alzheimer's disease (AD) was found to be 2 times lower in Yoruba than in African Americans. This study was aimed at identifying the factors associated with increased risk of incident AD in the two communities. METHODOLOGY A two-stage design with initial screening using the CSI'D followed by neuropsychological test battery, relations' interview and physician assessment in a sub-sample.NINCDS-ADRDA criteria were met for AD. The risk factor variables assessed included demographic, lifestyle, medical and family history items. RESULTS In the Yoruba, AD was associated with age (OR = 1.07) and female gender (OR = 2.93). In African Americans, age (OR = 1.09) and rural living (OR = 2.08) were the significant risk factors, while alcohol was protective (OR = 0.49). DISCUSSION Age was a significant risk factor for AD at both sites. The higher risk of incident AD in the Yoruba female, and in African Americans who resided in rural areas in childhood were similar with the prevalence cases. Alcohol emerged a protective factor in African Americans. More studies are required, including biological measurements, to adequately explain the differences in rates.
Collapse
Affiliation(s)
- A Ogunniyi
- Departments of Medicine and Psychiatry, University College Hospital, Ibadan, Nigeria
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Doescher JS, deGrauw TJ, Musick BS, Dunn DW, Kalnin AJ, Egelhoff JC, Byars AW, Mathews VP, Austin JK. Magnetic resonance imaging (MRI) and electroencephalographic (EEG) findings in a cohort of normal children with newly diagnosed seizures. J Child Neurol 2006; 21:491-5. [PMID: 16948933 PMCID: PMC1560181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
In the initial assessment of children with new-onset seizures, the suggestion that electroencephalography (EEG) should be standard and that magnetic resonance imaging (MRI) should be optional has been questioned. The purposes of this study were to (1) describe the frequency of EEG and MRI abnormalities and (2) explore relationships between MRI and EEG findings to determine their relevance in the assessment of children with new-onset seizures who are otherwise developing normally. As part of an ongoing, prospective study of children with new-onset seizures, we studied 181 children (90 girls and 91 boys). Children were entered into the study within 3 months of their first-recognized seizure. The association between EEG and MRI abnormalities was explored using a chi-square test. Abnormal MRI findings were found in 32.6% (n = 59) of the sample. The EEG and MRI results agreed with respect to classification into normal or abnormal in 37% (n = 67). Of the 50 children with a normal EEG, however, 21 (42%) were found to have an abnormal MRI. We found an unexpectedly high frequency of imaging abnormalities in our sample of otherwise normal children, although the significance of these findings is not clear. Follow-up of these patients will help us interpret the importance of the abnormalities. Despite our relatively small sample, however, our findings indicate that a normal EEG does not reliably predict a normal MRI in children with first seizures.
Collapse
|
26
|
Unverzagt FW, Gao S, Lane KA, Musick BS, Evans RM, Dickens JI, Smith-Gamble V, Baiyewu O, Gureje O, Ogunniyi AO, Hall KS, Hendrie HC. P3-140 Risk factors for incident cognitive impairment (CIND): data from the Indianapolis study of health and aging. Neurobiol Aging 2004. [DOI: 10.1016/s0197-4580(04)81292-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
27
|
Perkins AJ, Hui SL, Ogunniyi A, Gureje O, Baiyewu O, Unverzagt FW, Gao S, Hall KS, Musick BS, Hendrie HC. Risk of mortality for dementia in a developing country: the Yoruba in Nigeria. Int J Geriatr Psychiatry 2002; 17:566-73. [PMID: 12112181 DOI: 10.1002/gps.643] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Limited data exist on the impact of dementia in developing nations, including its association with mortality. OBJECTIVE The purpose of this paper is to assess the relationship between dementia and five-year mortality on a community dwelling elderly Yoruba population in the developing country of Nigeria and to compare those results with those from an elderly African-American community in Indianapolis. METHODS A two-phase design was used to ascertain dementia status in two sites. In the first phase, the Community Screening Instrument for Dementia (CSI-D) was administered. In the second phase, subjects were sampled for the clinical assessment according to their CSI-D performance category. Proportional hazards regression was used to assess the relationship between mortality and cognitive status at both sites after adjusting for demographics and chronic disease conditions. RESULTS For the entire screened population, poor and intermediate performance on the CSI-D is associated with increased mortality at both sites; however the effect of CSI-D performance did not significantly differ between the two sites. For the clinically assessed sample, dementia was significantly associated with increased mortality at both sites (Ibadan RR = 2.83, Indianapolis RR = 2.05), but the effect was not significantly different across the two sites. CONCLUSION Dementia resulted in an increased risk of mortality for Yoruba of a magnitude similar to African-Americans suggesting that the impact of dementia on mortality risk may be similar for developing and developed countries.
Collapse
Affiliation(s)
- Anthony J Perkins
- Regenstrief Institute for Health Care, 1050 Wishard Boulevard, RG6, Indianapolis, IN 46202-2872, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Abstract
The Indianapolis-Ibadan Dementia Project compares the rates of dementia at two sites, one in the U.S.A. and one in Nigeria. This paper concentrates on the data management issues in this longitudinal cross-cultural study. Approximately 2500 elderly people were recruited at each site, and continue to be re-assessed every two years. All the data are collected on paper and then entered into a FoxPro relational database. Most of the data management, including data cleaning, is done in Indianapolis. The design of the data collection forms is particularly important in a cross-cultural study, with the questions and the coding of responses clear and simple. Since Nigeria and the U.S.A. have different levels of technological development, the computer hardware and software were chosen to be suitable for use at either site. Exchange visits have been needed to address data management issues and resolve unexpected problems. The data management on cross-cultural studies can be handled successfully, given careful planning.
Collapse
Affiliation(s)
- R J Roberts
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, USA.
| | | | | | | | | | | |
Collapse
|
29
|
Callahan CM, Hall KS, Hui SL, Musick BS, Unverzagt FW, Hendrie HC. Relationship of age, education, and occupation with dementia among a community-based sample of African Americans. Arch Neurol 1996; 53:134-40. [PMID: 8639062 DOI: 10.1001/archneur.1996.00550020038013] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To explore the relationship between age, education, and occupation with dementia among African Americans. DESIGN Community-based survey to identify subjects with and without evidence of cognitive impairment and subsequent diagnostic evaluation of a stratified sample of these subjects using formal diagnostic criteria for dementia. SETTING Urban neighborhoods in Indianapolis, Ind. SUBJECTS A random sample of 2212 African Americans aged 65 years and older residing in 29 contiguous census tracts. MEASUREMENTS Subjects's scores on the Community Screening Instrument for Dementia (CSI-D), formal diagnostic clinical assessments for dementia, years of education, rural residence, primary occupation, self-reported disease, and alcohol and smoking history. Caseness was defined by four separate criteria: (1) cognitive impairment as defined by the subject's performance on the CSI-D cognitive scale; (2) cognitive impairment as defined by the total CSI-D score that included a relative's assessment of the subject's functional abilities; (3) dementia as defined by explicit diagnostic criteria; and (4) possible or probable Alzheimer's disease as defined by explicit diagnostic criteria. RESULTS The mean age was 74 years (age range, 65 to 100 years), 65% of subjects were women, the mean education was 9.6 years (age range, 0 to 16 years), 98% of the subjects were literate, and 32% reported living in a rural area until age 19 years. Service, domestic, and production occupations accounted for 55.2% of the subjects' primary occupations with a mean of 25.8 years (range, 1 to 75 years) in the primary occupation. Years of education, rural residence to age 60 years, and primary occupation were highly correlated. Caseness defined by any of the four criteria was associated with functional impairment, but the frequency of impairment increased with increasing diagnostic specificity. Age, education, and rural residence to age 60 years were significantly independently associated with caseness for cognitive impairment, dementia, and Alzheimer's type dementia. White-collar occupation was independently associated only with caseness for cognitive impairment. History of stroke was associated with caseness for cognitive impairment and dementia but not Alzheimer's disease, while history of smoking was negatively correlated with Alzheimer's disease. CONCLUSIONS Education was independently associated with cognitive impairment and dementia among a representative community-based sample of African Americans and the association remains significant across a variety of sensitivity analyses designed to control for measurement and confounding biases. The potential protective role of education against the development of dementia among African Americans deserves further evaluation.
Collapse
Affiliation(s)
- C M Callahan
- Department of Medicine, Indiana University School of Medicine, Indianapolis, USA
| | | | | | | | | | | |
Collapse
|
30
|
Hendrie HC, Osuntokun BO, Hall KS, Ogunniyi AO, Hui SL, Unverzagt FW, Gureje O, Rodenberg CA, Baiyewu O, Musick BS. Prevalence of Alzheimer's disease and dementia in two communities: Nigerian Africans and African Americans. Am J Psychiatry 1995; 152:1485-92. [PMID: 7573588 DOI: 10.1176/ajp.152.10.1485] [Citation(s) in RCA: 302] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE This article reports on a prevalence study of dementia and Alzheimer's disease among two groups of subjects with the same ethnic background but widely differing environments. METHOD The study was conducted among residents aged 65 years and older in two communities: Yorubas (N = 2,494) living in Ibadan, Nigeria, and African Americans (N = 2,212 in the community and N = 106 in nursing homes) living in Indianapolis, Indiana. The study design consisted of a screening stage followed by a clinical assessment stage for selected subjects on the basis of their performance on the screening tests. RESULTS The age-adjusted prevalence rates of dementia (2.29%) and Alzheimer's disease (1.41%) in the Ibadan sample were significantly lower than those in the Indianapolis sample, both in the community-dwelling subjects alone (4.82% and 3.69%, respectively) and in the combined nursing home and community samples (8.24% and 6.24%, respectively). The prevalence rates of dementia and Alzheimer's disease increased consistently with advancing age in both study groups. CONCLUSIONS To the authors' knowledge, this is the first study, using the same research method at the two sites, to report significant differences in rates of dementia and Alzheimer's disease in two different communities with similar ethnic origins.
Collapse
Affiliation(s)
- H C Hendrie
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis 46202-5111, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Abstract
OBJECTIVE To describe the prevalence and 9-month incidence of depressive symptoms among a cohort of elderly primary care patients and to determine whether different patterns of depression are associated with different patterns of health services use. DESIGN Prospective study of depressive symptoms as measured by the Center for Epidemiologic Studies Depression (CES-D) scale and identification of patients' outpatient health services use through an electronic medical record system. SETTING An academic primary care group practice at an urban ambulatory care clinic. PATIENTS/PARTICIPANTS 1711 patients aged 60 and older who completed the CES-D at baseline and 9 months later; 935 of these patients also completed the CES-D at 6 months. MEASUREMENT AND MAIN RESULTS The prevalence of significant symptoms of depression (CES-D > or = 16) was 17.1% at baseline and 18.8% at 9 months; 26.8% of patients exceeded the threshold on the CES-D either at baseline or 9 months, and the 9-month incidence was 11.7%. Among the patients re-interviewed at both 6 and 9 months, the 6-month incidence was 12%, and the incidence between the 6- and 9-month assessments was 10%. Of the 292 patients with depression at baseline, 140 (47.6%) remained depressed at the 9-month follow-up. Baseline and 6-month CES-D score, in addition to perceived health at 6 months, explained 45% of the variance in the 9-month CES-D score. Patients above the threshold on the CES-D at any time were more likely to rate their health as fair or poor (69.8% vs 43.7%) and more likely to have an emergency room visit (40.4% vs 29.4%). These patients also had 38% more outpatient visits (7.7 vs 5.6) and 61% higher total outpatient charges ($1209 vs $751) than patients who never exceeded the CES-D threshold over the 9-month window (all P values < 0.01). CONCLUSIONS Depressive symptoms were frequent and often persistent in this patient population. We identified patterns of oscillating severity of symptoms within individuals but relatively stable incidence and prevalence rates over a 9-month period. Patients who exceeded the threshold on the CES-D at any time during the study had significantly greater health services use and poorer perceived health.
Collapse
Affiliation(s)
- C M Callahan
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | | | | | | | | |
Collapse
|
32
|
Abstract
Eighty-nine consecutive patients undergoing needle localization at two facilities were alternately assigned to "local-anesthesia" (n = 46) and "no-local-anesthesia" (n = 43) groups. Those in the local-anesthesia group received 1-2 mL lidocaine hydrochloride 1% subcutaneously at the expected site of insertion of the localizing needle. All patients were asked to rate the level of pain they experienced from the procedure as a whole by using a 10-cm horizontal visual analog pain scale. Data about patient age, menopausal and menstrual status, average daily caffeine intake, and whether the patients considered mammography to be a painful procedure were collected. Patients who did not receive local anesthesia had a lower mean pain score (2.52) than those who did (3.27, P = .18). Premenopausal patients in the second half of their menstrual cycle at the time of the procedure had a significantly higher pain score than those in the first half (3.54 vs. 1.70, P = .05). Patients who considered mammography a painful procedure reported a higher level of pain than those who did not (3.79 vs 2.38, P = .012). There was no relationship between age, caffeine intake, or menopausal status and pain experienced.
Collapse
Affiliation(s)
- H E Reynolds
- Department of Radiology, Indiana University Hospital, Indianapolis 46202
| | | | | |
Collapse
|
33
|
Abstract
To evaluate the current state of interventional mammography in the United States, surveys were sent to 1,000 randomly selected active members of the American College of Radiology (group 1) and the entire 1991 membership (n = 73) of the Society of Breast Imaging (group 2). Three hundred seventy-one (37%) group 1 and 49 (67%) group 2 responses were received. Some respondents did not answer all questions. Of group 1 respondents, 331 (93%) performed preoperative needle localization and 272 (73%) used a hook wire; 92 (25%), a J wire; and 55 (15%), a needle-dye technique. For group 2 respondents and these techniques, the results were 45 (94%), 32 (65%), eight (16%), and seven (14%), respectively. One hundred ninety-nine (62%) group 1 and 24 (55%) group 2 physicians administered local anesthetic during needle localization. Fifty-six (16%) group 1 and 25 (56%) group 2 physicians performed fine-needle aspiration cytology, as opposed to 11 (3%) and nine (20%) for core-needle biopsy, respectively. Cyst aspiration was performed by 245 (70%) group 1 and 40 (82%) group 2 respondents, galactography by 126 (36%) of group 1 and 30 (61%) of group 2, and pneumocystography by 57 (16%) of group 1 and 23 (48%) of group 2. For most procedures, informed consent was obtained by a minority of radiologists in both groups.
Collapse
Affiliation(s)
- H E Reynolds
- Department of Radiology, Indiana University Hospital, Indianapolis 46202
| | | | | |
Collapse
|
34
|
Mazzuca SA, Brandt KD, Anderson SL, Musick BS, Katz BP. The therapeutic approaches of community based primary care practitioners to osteoarthritis of the hip in an elderly patient. J Rheumatol Suppl 1991; 18:1593-600. [PMID: 1765987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Predispositions to prescribe a pure analgesic, a cyclooxygenase inhibiting nonsteroidal antiinflammatory drug (NSAID) or a nonacetylated salicylate for a fictitious, uncomplicated case of osteoarthritis (OA) were surveyed in a sample of 152 community based primary care practitioners who had been characterized with respect to medical education and practice characteristics. Only 2 respondents (1%) prescribed a pure analgesic; 35% prescribed subantiinflammatory doses of cyclooxygenase inhibiting NSAID. The remainder (64%) recommended nonacetylated salicylates and cyclooxygenase inhibiting NSAID in doses large enough to achieve an antiinflammatory effect. Past participants in postgraduate rheumatology electives prescribed more costly regimens than those who had not participated (p = 0.05). When the case was altered to include a history of previous peptic ulcer, 44% chose cyclooxygenase inhibiting NSAID with adjunctive prophylaxis against NSAID induced gastropathy (e.g., misoprostol). When the complication was changed to renal insufficiency, recommendations for sulindac increased 3-fold over those for the uncomplicated case (34 vs 11%), and were most common among more recent medical school graduates and past participants in rheumatology electives (p less than 0.05 for both). The potential effects of educational and practice variables on the therapeutic strategies and costs of OA care in the community merit further systematic study.
Collapse
Affiliation(s)
- S A Mazzuca
- Rheumatology Division, Indiana University School of Medicine, Indianapolis 46202-5103
| | | | | | | | | |
Collapse
|