1
|
Kiwuwa-Muyingo S, Abongomera G, Mambule I, Senjovu D, Katabira E, Kityo C, Gibb DM, Ford D, Seeley J. Lessons for test and treat in an antiretroviral programme after decentralisation in Uganda: a retrospective analysis of outcomes in public healthcare facilities within the Lablite project. Int Health 2020; 12:429-443. [PMID: 31730168 DOI: 10.1093/inthealth/ihz090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/20/2019] [Accepted: 08/27/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND We describe the decentralisation of antiretroviral therapy (ART) alongside Option B+ roll-out in public healthcare facilities in the Lablite project in Uganda. Lessons learned will inform programmes now implementing universal test and treat (UTT). METHODS Routine data were retrospectively extracted from ART registers between October 2012 and March 2015 for all adults and children initiating ART at two primary care facilities (spokes) and their corresponding district hospitals (hubs) in northern and central Uganda. We describe ART initiation over time and retention and use of Cox models to explore risk factors for attrition due to mortality and loss to follow-up. Results from tracing of patients lost to follow-up were used to correct retention estimates. RESULTS Of 2100 ART initiations, 1125 were in the north, including 944 (84%) at the hub and 181 (16%) at the spokes; children comprised 95 (10%) initiations at the hubs and 14 (8%) at the spokes. Corresponding numbers were 642 (66%) at the hub and 333 (34%) at the spokes in the central region (77 [12%] and 22 [7%], respectively, in children). Children <3 y of age comprised the minority of initiations in children at all sites. Twenty-three percent of adult ART initiations at the north hub were Option B+ compared with 45% at the spokes (25% and 65%, respectively, in the central region). Proportions retained in care in the north hub at 6 and 12 mo were 92% (95% CI 90 to 93) and 89% (895% CI 7 to 91), respectively. Corresponding corrected estimates in the north spokes were 87% (95% CI 78 to 93) and 82% (95% CI 72 to 89), respectively. In the central hub, corrected estimates were 84% (95% CI 80 to 87) and 78% (95% CI 74 to 82), and were 89% (95% CI 77.9 to 95.1) and 83% (95% CI 64.1 to 92.9) at the spokes, respectively. Among adults newly initiating ART, being older was independently associated with a lower risk of attrition (adjusted hazard ratio [aHR] 0.93 per 5 y [95% CI 0.88 to 0.97]). Other independent risk factors included initiating with a tenofovir-based regimen vs zidovudine (aHR 0.60 [95% CI 0.46 to 0.77]), year of ART initiation (2013 aHR 1.55 [95% CI 1.21 to 1.97], ≥2014 aHR 1.41 [95% CI 1.06 to 1.87]) vs 2012, hub vs spoke (aHR 0.35 [95% CI 0.29 to 0.43]) and central vs north (aHR 2.28 [95% CI 1.86 to 2.81]). Independently, patient type was associated with retention. CONCLUSIONS After ART decentralisation, people living with human immunodeficiency virus (HIV) were willing to initiate ART in rural primary care facilities. Retention on ART was variable across facilities and attrition was higher among some groups, including younger adults and women initiating ART during pregnancy/breastfeeding. Interventions to support these groups are required to optimise benefits of expanded access to HIV services under UTT.
Collapse
Affiliation(s)
- S Kiwuwa-Muyingo
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, PO Box 49, Entebbe, Uganda
- African Population and Health Research Center, P.O. Box 10787-00100, Kitisuru, Nairobi, Kenya
| | - G Abongomera
- Joint Clinical Research Centre, PO Box 10005, Kampala, Uganda
- University of Zurich, Epidemiology, Biostatistics and Prevention Institute, CH 8001, Zurich, Switzerland
| | - I Mambule
- Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda
| | - D Senjovu
- Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda
| | - E Katabira
- Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda
| | - C Kityo
- Joint Clinical Research Centre, PO Box 10005, Kampala, Uganda
| | - D M Gibb
- Medical Research Council, Clinical Trials Unit at University College London, London WC1V 6LH, UK
| | - D Ford
- Medical Research Council, Clinical Trials Unit at University College London, London WC1V 6LH, UK
| | - J Seeley
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, PO Box 49, Entebbe, Uganda
- Global Health and Development Department, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| |
Collapse
|
2
|
Bajpai R, Chaturvedi HK, Car J. How varying CD4 criteria for treatment initiation was associated with mortality of HIV-patients? A retrospective analysis of electronic health records from Andhra Pradesh, India. J Glob Health 2020; 10:010408. [PMID: 32257156 PMCID: PMC7125424 DOI: 10.7189/jogh.10.010408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background HIV treatment and care services were scaled up in 2007 in India with objective to increase HIV-care coverage. CD4 count based criteria was mainly used for treatment initiation with increasing threshold in later years. Therefore, this paper aimed to evaluate the survival by varying CD4 criteria for antiretroviral treatment (ART) initiation among of HIV-positive patients, and independent factors associated with the mortality. Methods This retrospective cohort study included 127 949 HIV-positive patients aged ≥15 years, who initiated ART between 2007 and 2013 in Andhra Pradesh state, India. The patient’s demographic and clinical characteristics were extracted from the patient’s health records from electronic Computerized Management Information System Software (CMIS). Incidence of mortality/100 person-years was calculated for CD4 and treatment initiation categories. Kaplan-Meier and multivariable Cox-regression analyses were used to explore the association. Results Median CD4 count was 172 (inter-quartile range (IQR) = 102-240) at the time of treatment initiation, and 19.3% of them had ≤ 100 CD4 count. Incidence of mortality for the period 2007-08 (CD4 ≤ 200 cells/mm3) was 8.5/100 person-years compared to 6.4/100 person-years at risk for the period 2012 onwards (CD4 ≤ 350 cells/mm3). Earlier thresholds for treatment initiation showed higher risk of mortality (2007-08 (CD4 ≤ 200 cells/mm3), adjusted hazard ratio (HR): 1.86, 95% confidence interval (CI): 1.68-2.07; 2009-11 (CD4 ≤ 250 cells/mm3), HR = 1.67, 95% CI = 1.51-1.85) compared to 2012 onwards (CD4 ≤ 350 cells/mm3) criteria for treatment initiation. Conclusions Increasing CD4 threshold for treatment initiation over time was independently associated with lower risk of mortality. More efforts are required to detect and treat early, monitoring of follow-ups, promote health education to improve ART adherence, and provide supportive environment that encourages HIV-infected patients to disclose their HIV status in confidence.
Collapse
Affiliation(s)
- Ram Bajpai
- School of Primary Community and Social Care, Keele University, Newcastle-Under-Lyme, Staffordshire, UK.,National Institute of Medical Statistics, Indian Council of Medical Research, New Delhi, India
| | - Himanshu K Chaturvedi
- National Institute of Medical Statistics, Indian Council of Medical Research, New Delhi, India
| | - Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| |
Collapse
|
3
|
Determinants of loss to follow-up among HIV positive patients receiving antiretroviral therapy in a test and treat setting: A retrospective cohort study in Masaka, Uganda. PLoS One 2020; 15:e0217606. [PMID: 32255796 PMCID: PMC7138304 DOI: 10.1371/journal.pone.0217606] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 03/15/2020] [Indexed: 12/20/2022] Open
Abstract
Background Retaining patients starting antiretroviral therapy (ART) and ensuring good adherence remain cornerstone of long-term viral suppression. In this era of test and treat (T&T) policy, ensuring that patients starting ART remain connected to HIV clinics is key to achieve the UNAIDS 90-90-90 targets. Currently, limited studies have evaluated the effect of early ART initiation on loss to follow up in a routine health care delivery setting. We studied the cumulative incidence, incidence rate of loss to follow up (LTFU), and factors associated with LTFU in a primary healthcare clinic that has practiced T&T since 2012. Methods We retrospectively analyzed extracted routine program data on patients who started ART from January 2012 to 4th July 2016. We defined LTFU as failure of a patient to return to the HIV clinic for at least 90 days from the date of their last appointment. We calculated cumulative incidence, incidence rate and fitted a multivariable Cox proportion hazards regression model to determine factors associated with LTFU. Results Of the 7,553 patients included in our sample, 3,231 (42.8%) started ART within seven days following HIV diagnosis. There were 1,180 cases of LTFU observed over 15,807.7 person years at risk. The overall incidence rate (IR) of LTFU was 7.5 (95% CI, 7.1–7.9) per 100 person years of observation (pyo). Cumulative incidence of LTFU increased with duration of follow up from 8.9% (95% CI, 8.2–9.6%) at 6 months to 20.2% (95% CI, 19.0–21.4%) at 48 months. Predictors of elevated risk of LTFU were: starting ART within 7 days following HIV diagnosis ((aHR) = 1.69, 95% CI, 1.50–1.91), lack of a telephone set (aHR = 1.52, 95% CI, 1.35–1.71), CD4 cell count of 200–350μ/ml (aHR = 1.21, 95% CI, 1.01–1.45) and baseline WHO clinical stage 3 or 4 (aHR = 1.35, 95% CI, 1.10–1.65). Factors associated with a reduced risk of LTFU were: baseline age ≥25 years (aHR ranging from 0.62, 95% CI, 0.47–0.81 for age group 25–29 years to 0.24, 95% CI, 0.13–0.44 for age group ≥50 years), at least primary education level (aHR ranging from aHR = 0.77, 95% CI, 0.62–0.94 for primary education level to 0.50, 95% CI, 0.34–0.75 for post-secondary education level), and having a BMI ≥ 30 (aHR = 0.28, 95% CI, 0.15–0.51). Conclusion The risk of loss to follow up increased with time and was higher among patients who started ART within seven days following HIV diagnosis, higher among patients without a telephone set, lower among patients aged ≥ 25 years, lower among patients with at least primary education and lower among patients with BMI of ≥ 30. In this era of T&T, it will be important for HIV programs to initiate and continue enhanced therapeutic education programs that target high risk groups, as well as leveraging on mHealth to improve patients’ retention on ART throughout the cascade of care.
Collapse
|
4
|
Tymejczyk O, Vo Q, Kulkarni SG, Antelman G, Boshe J, Reidy W, Parcesepe A, Nash D, Elul B. Tracing-corrected estimates of disengagement from HIV care and mortality among patients enrolling in HIV care without overt immunosuppression in Tanzania. AIDS Care 2019; 33:47-53. [PMID: 31826640 DOI: 10.1080/09540121.2019.1699642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In the era of "test and treat", it is important to understand HIV care outcomes and their determinants in patients presenting to care with early-stage disease. We surveyed 924 adults newly enrolling in HIV care at four clinics in Tanzania before the adoption of universal treatment eligibility, and collected longitudinal clinical data. Participants who defaulted from care were tracked in the community. Cumulative incidence of disengagement from care and death was estimated using competing risk methods. By 12 months after enrollment, 18.2% of patients had disengaged from care and 6.9% had died. Factors associated with disengagement included male sex (adjusted subhazard ratio [aSHR] versus female = 1.75, 95% confidence interval [CI]: 1.06-2.89), provider-initiated HIV diagnosis (aSHR versus self-referred = 1.71, 95% CI: 1.03-2.86), ineligibility for antiretroviral treatment (ART) at enrollment (aSHR versus eligibility = 2.82, 95% CI: 1.84-4.32) and increased anticipated stigma score (aSHR = 1.04 per 5-point increase, 95% CI: 1.02-1.05). Higher life satisfaction score (aSHR = 0.97 per 5-point increase, 95% CI: 0.95-0.99) and having 1-2 close friends (aSHR versus none = 0.58, 95% CI: 0.47-0.71) were protective. The findings highlight the continued importance of social environment for HIV care outcomes and the potential of universal ART eligibility to reduce HIV care attrition.
Collapse
Affiliation(s)
- Olga Tymejczyk
- Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA.,Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - Quynh Vo
- ICAP, Columbia University, New York, NY, USA
| | - Sarah Gorrell Kulkarni
- Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA.,Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA.,ICAP, Columbia University, New York, NY, USA
| | | | | | - William Reidy
- ICAP, Columbia University, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Angela Parcesepe
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA.,Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - Batya Elul
- ICAP, Columbia University, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| |
Collapse
|
5
|
Maheswaran H, Clarke A, MacPherson P, Kumwenda F, Lalloo DG, Corbett EL, Petrou S. Cost-Effectiveness of Community-based Human Immunodeficiency Virus Self-Testing in Blantyre, Malawi. Clin Infect Dis 2019; 66:1211-1221. [PMID: 29136117 PMCID: PMC5889018 DOI: 10.1093/cid/cix983] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 11/08/2017] [Indexed: 12/24/2022] Open
Abstract
Background Human immunodeficiency virus self-testing (HIVST) is effective, with scale-up underway in sub-Saharan Africa. We assessed cost-effectiveness of adding HIVST to existing facility-based HIV testing and counseling (HTC) services. Both 2010 (initiate at CD4 <350 cells/μL) and 2015 (initiate all) World Health Organization (WHO) guidelines for antiretroviral treatment (ART) were considered. Methods A microsimulation model was developed to evaluate cost-effectiveness, from both health provider and societal perspectives, of an HIVST service implemented in a cluster-randomized trial (CRT; ISRCTN02004005) in Malawi. Costs and health outcomes were evaluated over a 20-year time horizon, using a discount rate of 3%. Probabilistic sensitivity analysis was conducted to account for parameter uncertainty. Results From the health provider perspective and 20-year time horizon, facility HTC using 2010 WHO ART guidelines was the least costly ($294.71 per person; 95% credible interval [CrI], 270.79–318.45) and least effective (11.64 quality-adjusted life-years [QALYs] per person; 95% CrI, 11.43–11.86) strategy. Compared with this strategy, the incremental cost-effectiveness ratio (ICER) for facility HTC using 2015 WHO ART guidelines was $226.85 (95% CrI, 198.79–284.35) per QALY gained. The strategy of facility HTC plus HIVST, using 2010 WHO ART guidelines, was extendedly dominated. The ICER for facility HTC plus HIVST, using 2015 WHO ART guidelines, was $253.90 (95% CrI, 201.71–342.02) per QALY gained compared with facility HTC and using 2015 WHO ART guidelines. Conclusions HIVST may be cost-effective in a Malawian population with high HIV prevalence. HIVST is suited to an early HIV diagnosis and treatment strategy. Clinical Trials registration ISRCTN02004005.
Collapse
Affiliation(s)
- Hendramoorthy Maheswaran
- Department of Public Health and Policy, University of Liverpool, United Kingdom.,Division of Health Sciences, University of Warwick Medical School, Coventry, United Kingdom.,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Aileen Clarke
- Division of Health Sciences, University of Warwick Medical School, Coventry, United Kingdom
| | - Peter MacPherson
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, United Kingdom
| | - Felistas Kumwenda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - David G Lalloo
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, United Kingdom
| | - Elizabeth L Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,London School of Hygiene and Tropical Medicine, United Kingdom
| | - Stavros Petrou
- Division of Health Sciences, University of Warwick Medical School, Coventry, United Kingdom
| |
Collapse
|
6
|
Opio D, Semitala FC, Kakeeto A, Sendaula E, Okimat P, Nakafeero B, Nankabirwa JI, Karamagi C, Kalyango JN. Loss to follow-up and associated factors among adult people living with HIV at public health facilities in Wakiso district, Uganda: a retrospective cohort study. BMC Health Serv Res 2019; 19:628. [PMID: 31484571 PMCID: PMC6727328 DOI: 10.1186/s12913-019-4474-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 08/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Loss to follow-up (LTFU) from care among people living with HIV (PLHIV) is thought to be more common in the public setting compared to the private health care. It is anticipated that the problem may become worse with the current "test and treat" policy in Uganda due to the likely increases in patient loads and its attendant pressure on health care providers to support patient counseling. This study determined the incidence and factors associated with LTFU from HIV care among adult PLHIV in public health facilities in Wakiso district, Uganda. METHODS This was a retrospective cohort study that involved the review of 646 records of patients initiated on antiretroviral therapy (ART) between January 1st, 2015 and December 31st, 2017 at 13 randomly selected public health facilities in Wakiso district. The cox proportional hazards regression was used to determine the factors associated with LTFU. The results were supported by sequential in-depth and key informant interviews to explore reasons for LTFU. RESULTS Of the 646 patients enrolled, 391 were female (60.5%), 282 were below 30 years (43.6%) and 207 were married (50.1%). A total of 216 patients (33.4%) had no documented outcomes and were considered LTFU. The incidence of LTFU was 21 per 1000 person months (95% confidence interval (CI): 18-25 per 1000 person months). Factors associated with LTFU included having normal weight compared to underweight (adjusted hazard ratio (aHR) 0.64, 95% CI: 0.45-0.90, p = 0.011), receiving HIV care from hospitals compared to lower level facilities (aHR 0.22, 95% CI: 0.12-0.41, p < 0.001), and no telephone contact compared to those with a telephone contact (aHR 2.16, 95% CI: 1.33-3.51, p = 0.002). Stigmatization and long waiting times were the prominent reasons for LTFU reported from the in-depth and key informant interviews. CONCLUSIONS The incidence of LTFU in public health facilities in Uganda is quite high and is associated with being underweight, not having a telephone contact to receive reminders and receiving care at lower level facilities. Early diagnosis, routine use of patient address locator forms and improved quality of HIV care at lower level health facilities may reduce LTFU among PLHIV.
Collapse
Affiliation(s)
- Denis Opio
- Clinical Epidemiology Unit, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Makerere University- Johns Hopkins University Research Collaboration (MU-JHU), P.O. Box 23491, Kampala, Uganda
| | - Fred C. Semitala
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
- Infectious Diseases Research Collaboration (IDRC), P.O. Box 7475, Kampala, Uganda
| | - Alex Kakeeto
- Clinical Epidemiology Unit, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Emmanuel Sendaula
- Clinical Epidemiology Unit, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Paul Okimat
- Clinical Epidemiology Unit, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Institute of Public Health and Management, Clarke International University, P.O. Box 7782, Kampala, Uganda
| | - Brenda Nakafeero
- Clinical Epidemiology Unit, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Joaniter I. Nankabirwa
- Clinical Epidemiology Unit, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Infectious Diseases Research Collaboration (IDRC), P.O. Box 7475, Kampala, Uganda
| | - Charles Karamagi
- Clinical Epidemiology Unit, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Joan N. Kalyango
- Clinical Epidemiology Unit, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Department of Pharmacy, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| |
Collapse
|
7
|
Balogun M, Meloni ST, Igwilo UU, Roberts A, Okafor I, Sekoni A, Ogunsola F, Kanki PJ, Akanmu S. Status of HIV-infected patients classified as lost to follow up from a large antiretroviral program in southwest Nigeria. PLoS One 2019; 14:e0219903. [PMID: 31344057 PMCID: PMC6657856 DOI: 10.1371/journal.pone.0219903] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 07/04/2019] [Indexed: 11/19/2022] Open
Abstract
Background Loss to follow-up (LTFU) is a term used to classify patients no longer being seen in a clinical care program, including HIV treatment programs. It is unclear if these patients have transferred their care services elsewhere, died, or if there are other reasons for their LTFU. To better understand the status of patients meeting the criteria of LTFU, we traced a sample of HIV-infected patients that were LTFU from the Lagos University Teaching Hospital (LUTH) antiretroviral program. Methods We conducted a cross-sectional study of HIV-infected adult patients who enrolled for care between 2010 and 2014 at LUTH and were considered LTFU. Patients with locator information were traced using phone calls. Face-to-face interviews were used to collect data from successfully traced and consenting participants. Predictors of LTFU from LUTH, disengagement from care and willingness to re-engage in care in LUTH were assessed. Results Of 6108 registered patients, 3397 (56%) were LTFU and being unmarried was a predictor of being LTFU from LUTH. Of 425 patients that were traced, 355 (84%) were alive and 70 (16%) were dead. Two hundred and sixty-eight patients consented to interviews; 96 (35.8%) of these had transferred to another clinic for care while 172 (64.2%) were disengaged from care. More than half (149/268; 55.6%) were not on antiretroviral therapy (ART). Some of the primary reasons for LTFU were; long distance to clinic (56%) and feeling healthy (6.7%). Predictor of disengagement from care within the interviewed cohort was not having started ART. The predictors of willingness to re-engage in care included, not having started ART, male sex and longer duration in HIV care prior to LTFU. Conclusion Most of the interviewed cohort that was LTFU were truly disengaged from care and not on ART. Interventions are required to address processes of re-engagement of patients that are LTFU.
Collapse
Affiliation(s)
- Mobolanle Balogun
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria
- * E-mail:
| | - Seema Thakore Meloni
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | | | - Alero Roberts
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Ifeoma Okafor
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Adekemi Sekoni
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Folasade Ogunsola
- Department of Medical Microbiology and Parasitology, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Phyllis J. Kanki
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | - Sulaimon Akanmu
- Department of Haematology and Blood Transfusion, College of Medicine of the University of Lagos, Lagos, Nigeria
| |
Collapse
|
8
|
Boeke CE, Nabitaka V, Rowan A, Guerra K, Nawaggi P, Mulema V, Bigira V, Magongo E, Mucheri P, Musoke A, Katureebe C. Results from a proactive follow-up intervention to improve linkage and retention among people living with HIV in Uganda: a pre-/post- study. BMC Health Serv Res 2018; 18:949. [PMID: 30522484 PMCID: PMC6282267 DOI: 10.1186/s12913-018-3735-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 11/19/2018] [Indexed: 11/12/2022] Open
Abstract
Background Despite gains in HIV testing and treatment access in sub-Saharan Africa, patient attrition from care remains a problem. Evidence is needed of real-world implementation of low-cost, scalable, and sustainable solutions to reduce attrition. We hypothesized that more proactive patient follow-up and enhanced counseling by health facilities would improve patient linkage and retention. Methods At 20 health facilities in Central Uganda, we implemented a quality of care improvement intervention package that included training lay health workers in best practices for patient follow-up and counseling, including improved appointment recordkeeping, phone calls and home visits to lost patients, and enhanced adherence counseling strategies; and strengthening oversight of these processes. We compared patient linkage to and retention in HIV care in the 9 months before implementation of the intervention to the 9 months after implementation. Data were obtained from facility-based registers and files and analysed using multivariable logistic regression. Results Among 1900 patients testing HIV-positive during the study period, there was not a statistically significant increase in linkage to care after implementing the intervention (52.9% versus 54.9%, p = 0.63). However, among 1356 patients initiating antiretroviral therapy during the follow-up period, there were statistically significant increases in patient adherence to appointment schedules (44.5% versus 55.2%, p = 0.01) after the intervention. There was a small increase in Ministry of Health-defined retention in care (71.7% versus 75.7%, p = 0.12); when data from the period of intervention ramp-up was dropped, this increase became statistically significant (71.7% versus 77.6%, p = 0.01). The increase in retention was more dramatic for patients under age 19 years (N = 84; 64.0% versus 83.9%, p = 0.01). The cost per additional patient retained in care was $47. Conclusions Improving patient tracking and counseling practices was relatively low cost and enhanced patient retention in care, particularly for pediatric and adolescent patients. This approach should be considered for scale-up in Uganda and elsewhere. However, no impact was seen in improved patient linkage to care with this proactive follow-up intervention. Trial registration Pan African Clinical Trial Registry #PACTR201611001756166. Registered August 31, 2016.
Collapse
Affiliation(s)
- Caroline E Boeke
- Clinton Health Access Initiative (CHAI), 383 Dorchester Road, Suite 400, Boston, MA, 02127, USA.
| | | | | | - Katherine Guerra
- Clinton Health Access Initiative (CHAI), 383 Dorchester Road, Suite 400, Boston, MA, 02127, USA
| | | | | | | | | | | | | | | |
Collapse
|
9
|
Kelly JD, Hickey MD, Schlough GW, Conteh S, Sesay M, Rutherford GW, Giordano TP, Weiser SD. Understanding why HIV-infected persons disengaged from pre-ART care in Freetown, Sierra Leone: a qualitative study .. AIDS Care 2018; 31:494-497. [PMID: 30146898 DOI: 10.1080/09540121.2018.1515467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In countries that have not implemented universal antiretroviral treatment (ART), loss to follow-up (LTFU) during pre-ART care remains a problem. We conducted semi-structured interviews with 41 HIV-infected persons who were LTFU during pre-ART care from a prospective cohort of persons newly diagnosed with HIV infection in Freetown, Sierra Leone, in 2012-2013. Interviews determined whether the participant disengaged or transferred care and explored the reasons for being LTFU. Of the 41 participants, 34 (83%) disengaged from care. For persons who disengaged from care, socioeconomic barriers emerged as a dominant theme in both ART-eligible and -ineligible groups while psychosocial barriers emerged as a dominant theme in the ART-ineligible group. Structural barriers emerged as a dominant theme for participants who transferred care. Interventions designed to address socioeconomic and psychosocial barriers may help reduce disengagement from pre-ART care.
Collapse
Affiliation(s)
- J Daniel Kelly
- a Department of Epidemiology and Biostatistics , University of California , San Francisco , CA , USA.,b Wellbody Alliance , Koidu Town , Sierra Leone.,c National HIV/AIDS Secretariat , Freetown , Sierra Leone
| | - Matthew D Hickey
- a Department of Epidemiology and Biostatistics , University of California , San Francisco , CA , USA
| | | | - Sulaiman Conteh
- c National HIV/AIDS Secretariat , Freetown , Sierra Leone.,d College of Medicine and Allied Health Sciences of University of Sierra Leone , Freetown , Sierra Leone
| | - Momodu Sesay
- c National HIV/AIDS Secretariat , Freetown , Sierra Leone
| | - George W Rutherford
- a Department of Epidemiology and Biostatistics , University of California , San Francisco , CA , USA
| | - Thomas P Giordano
- e Department of Medicine , Baylor College of Medicine , Houston , TX , USA
| | - Sheri D Weiser
- a Department of Epidemiology and Biostatistics , University of California , San Francisco , CA , USA
| |
Collapse
|
10
|
Nyakato P, Kiragga AN, Kambugu A, Bradley J, Baisley K. Correction of estimates of retention in care among a cohort of HIV-positive patients in Uganda in the period before starting ART: a sampling-based approach. BMJ Open 2018; 8:e017487. [PMID: 29678963 PMCID: PMC5914905 DOI: 10.1136/bmjopen-2017-017487] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE The aim of this study was to use a sampling-based approach to obtain estimates of retention in HIV care before initiation of antiretroviral treatment (ART), corrected for outcomes in patients who were lost according to clinic registers. DESIGN Retrospective cohort study of HIV-positive individuals not yet eligible for ART (CD4 >500). SETTING Three urban and three rural HIV care clinics in Uganda; information was extracted from the clinic registers for all patients who had registered for pre-ART care between January and August 2015. PARTICIPANTS A random sample of patients who were lost according to the clinic registers (>3 months late to scheduled visit) was traced to ascertain their outcomes. OUTCOME MEASURES The proportion of patients lost from care was estimated using a competing risks approach, first based on the information in the clinic records alone and then using inverse probability weights to incorporate the results from tracing. Cox regression was used to determine factors associated with loss from care. RESULTS Of 1153 patients registered for pre-ART care (68% women, median age 29 years, median CD4 count 645 cells/µL), 307 (27%) were lost according to clinic records. Among these, 195 (63%) were selected for tracing; outcomes were ascertained in 118 (61%). Seven patients (6%) had died, 40 (34%) were in care elsewhere and 71 (60%) were out of care. Loss from care at 9 months was 30.2% (95% CI 27.3% to 33.5%). After incorporating outcomes from tracing, loss from care decreased to 18.5% (95% CI 13.8% to 23.6%). CONCLUSION Estimates of loss from HIV care may be too high if based on routine clinic data alone. A sampling-based approach is a feasible way of obtaining more accurate estimates of retention, accounting for transfers to other clinics.
Collapse
Affiliation(s)
- Patience Nyakato
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Agnes N Kiragga
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Andrew Kambugu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John Bradley
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Kathy Baisley
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
11
|
Boeke CE, Nabitaka V, Rowan A, Guerra K, Kabbale A, Asire B, Magongo E, Nawaggi P, Mulema V, Mirembe B, Bigira V, Musoke A, Katureebe C. Assessing linkage to and retention in care among HIV patients in Uganda and identifying opportunities for health systems strengthening: a descriptive study. BMC Infect Dis 2018; 18:138. [PMID: 29566666 PMCID: PMC5865302 DOI: 10.1186/s12879-018-3042-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 03/12/2018] [Indexed: 12/31/2022] Open
Abstract
Background While antiretroviral therapy (ART) availability for HIV patients has increased dramatically in Uganda, patient linkage to and retention in care remains a challenge. We assessed patterns of engagement in care in 20 Ugandan health facilities with low retention based on national reporting. Methods We assessed patient linkage to care (defined as registering for pre-ART or ART care at the facility within 1 month of HIV diagnosis) and 6-month retention in care (having a visit 3-6 months after ART initiation) and associations with patient−/facility-level factors using multivariate logistic regression. Results Among 928 newly HIV-diagnosed patients, only 53.0% linked to care within 1 month. Of these, 83.7% linked within 1 week. Among 678 newly initiated ART patients, 14.5% never returned for a follow-up visit at the facility. Retention was 71.7% according to our primary definition but much lower if stricter definitions were used. Most patients were already falling behind appointment schedules at their first ART follow-up (median: 28 days post-initiation vs. recommended 14 days). 27.3% of newly-initiated patients had follow-up appointments scheduled 45+ days apart rather than monthly per national guidelines. Linkage and retention were not strongly correlated with each other within facilities (rs = 0.06; p = 0.82). Females, adolescents, and patients in rural settings tended to have lower linkage and retention in multivariable-adjusted models. Conclusions Linkage support may be most critical immediately after testing positive, as patients are less likely to link over time. More information is needed on reasons for appointment schedules by clinicians and implications on retention. Trial registration This study was registered in the Pan African Clinical Trial Registry database (#PACTR201611001756166). Electronic supplementary material The online version of this article (10.1186/s12879-018-3042-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Caroline E Boeke
- Clinton Health Access Initiative (CHAI), Boston, USA. .,, 383 Dorchester Road, Suite 400, Boston, Massachusetts, 02127, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Muhumuza S, Akello E, Kyomugisha-Nuwagaba C, Baryamutuma R, Sebuliba I, Lutalo IM, Kansiime E, Kisaakye LN, Kiragga AN, King R, Bazeyo W, Lindan C. Retention in care among HIV-infected pregnant and breastfeeding women on lifelong antiretroviral therapy in Uganda: A retrospective cohort study. PLoS One 2017; 12:e0187605. [PMID: 29272268 PMCID: PMC5741223 DOI: 10.1371/journal.pone.0187605] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 10/23/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In 2013, Uganda updated its prevention of maternal-to-child transmission of HIV program to Option B+, which requires that all HIV-infected pregnant and breastfeeding women be started on lifelong antiretroviral therapy (ART) regardless of CD4 count. We describe retention in care and factors associated with loss to follow-up (LTFU) among women initiated on Option B+ as part of an evaluation of the effectiveness of the national program. METHODS We conducted a retrospective cohort analysis of data abstracted from records of 2,169 women enrolled on Option B+ between January and March 2013 from a representative sample of 145 health facilities in all 24 districts of the Central region of Uganda. We defined retention as "being alive and receiving ART at the last clinic visit". We used Kaplan-Meier analysis to estimate retention in care and compared differences between women retained in care and those LTFU using the chi-squared test for dichotomized or categorical variables. RESULTS The median follow-up time was 20.2 months (IQR 4.2-22.5). The proportion of women retained in HIV care at 6, 12 and 18 months post-ART initiation was 74.2%, 66.7% and 62.0%, respectively. Retention at 18 months varied significantly by level of health facility and ranged from 70.0% among those seen at hospitals to 56.6% among those seen at lower level health facilities. LTFU was higher among women aged less than 25 years, 59.3% compared to those aged 25 years and above, 40.7% (p = 0.02); among those attending care at lower level facilities, 44.0% compared to those attending care at hospitals, 34.1% (p = 0.01), and among those who were not tested for CD4 cell count at ART initiation, 69.4% compared to those who were tested, 30.9% (p = 0.002). CONCLUSION Retention of women who were initiated on Option B+ during the early phases of roll-out was only moderate, and could undermine the effectiveness of the program. Identifying reasons why women drop out and designing targeted interventions for improved retention should be a priority.
Collapse
Affiliation(s)
- Simon Muhumuza
- School of Public Health, Makerere University, Kampala, Uganda
- * E-mail:
| | - Evelyn Akello
- School of Public Health, Makerere University, Kampala, Uganda
| | | | | | - Isaac Sebuliba
- School of Public Health, Makerere University, Kampala, Uganda
| | | | - Edgar Kansiime
- School of Public Health, Makerere University, Kampala, Uganda
| | | | - Agnes N. Kiragga
- Infectious Disease Institute, School of Medicine, Makerere University, Kampala, Uganda
| | - Rachel King
- Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - William Bazeyo
- School of Public Health, Makerere University, Kampala, Uganda
| | - Christina Lindan
- Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| |
Collapse
|
13
|
Flynn AG, Anguzu G, Mubiru F, Kiragga AN, Kamya M, Meya DB, Boulware DR, Kambugu A, Castelnuovo BC. Socioeconomic position and ten-year survival and virologic outcomes in a Ugandan HIV cohort receiving antiretroviral therapy. PLoS One 2017; 12:e0189055. [PMID: 29244807 PMCID: PMC5731768 DOI: 10.1371/journal.pone.0189055] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 11/18/2017] [Indexed: 11/18/2022] Open
Abstract
Lifelong ART is essential to reducing HIV mortality and ending the epidemic, however the interplay between socioeconomic position and long-term outcomes of HIV-infected persons receiving antiretroviral therapy (ART) in sub-Saharan Africa is unknown. Furthering the understanding of factors related to long-term ART outcomes in this important region will aid the successful scale-up of ART programs. We enrolled 559 HIV-infected Ugandan adults starting ART in 2004-2005 at the Infectious Diseases Institute in Kampala, Uganda and followed them for 10 years. We documented baseline employment status, regular household income, education level, housing description, physical ability, and CD4 count. Viral load was measured every six months. Proportional hazard regression tested for associations between baseline characteristics and 1) mortality, 2) virologic failure, and 3) mortality or virologic failure as a composite outcome. Over ten years 23% (n = 127) of participants died, 6% (n = 31) were lost-to-follow-up and 23% (107/472) experienced virologic treatment failure. In Kaplan-Meier analysis we observed an association between employment and mortality, with the highest cumulative probability of death occurring in unemployed individuals. In univariate analysis unemployment and disease severity were associated with mortality, but in multivariable analysis the only association with mortality was disease severity. We observed an association between higher household income and an increased incidence of both virologic failure and the combined outcome, and an association between self-employment and lower incidence of virologic failure and the combined outcome when compared to unemployment. Formal education level and housing status were unrelated to outcomes. It is feasible to achieve good ten-year survival, retention-in-care, and viral suppression in a socioeconomically diverse population in a resource-limited setting. Unemployment appears to be related to adverse 10-year ART outcomes. A low level of formal education does not appear to be a barrier to successful long-term ART.
Collapse
Affiliation(s)
| | | | | | | | - Moses Kamya
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - David B. Meya
- Infectious Diseases Institute, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - David R. Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Andrew Kambugu
- Infectious Diseases Institute, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
| | | |
Collapse
|
14
|
Barriers to Care and 1-Year Mortality Among Newly Diagnosed HIV-Infected People in Durban, South Africa. J Acquir Immune Defic Syndr 2017; 74:432-438. [PMID: 28060226 PMCID: PMC5321110 DOI: 10.1097/qai.0000000000001277] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Prompt entry into HIV care is often hindered by personal and structural barriers. Our objective was to evaluate the impact of self-perceived barriers to health care on 1-year mortality among newly diagnosed HIV-infected individuals in Durban, South Africa. Methods: Before HIV testing at 4 outpatient sites, adults (≥18 years) were surveyed regarding perceived barriers to care including (1) service delivery, (2) financial, (3) personal health perception, (4) logistical, and (5) structural. We assessed deaths via phone calls and the South African National Population Register. We used multivariable Cox proportional hazards models to determine the association between number of perceived barriers and death within 1 year. Results: One thousand eight hundred ninety-nine HIV-infected participants enrolled. Median age was 33 years (interquartile range: 27–41 years), 49% were females, and median CD4 count was 192/μL (interquartile range: 72–346/μL). One thousand fifty-seven participants (56%) reported no, 370 (20%) reported 1–3, and 460 (24%) reported >3 barriers to care. By 1 year, 250 [13%, 95% confidence interval (CI): 12% to 15%] participants died. Adjusting for age, sex, education, baseline CD4 count, distance to clinic, and tuberculosis status, participants with 1–3 barriers (adjusted hazard ratio: 1.49, 95% CI: 1.06 to 2.08) and >3 barriers (adjusted hazard ratio: 1.81, 95% CI: 1.35 to 2.43) had higher 1-year mortality risk compared with those without barriers. Conclusions: HIV-infected individuals in South Africa who reported perceived barriers to medical care at diagnosis were more likely to die within 1 year. Targeted structural interventions, such as extended clinic hours, travel vouchers, and streamlined clinic operations, may improve linkage to care and antiretroviral therapy initiation for these people.
Collapse
|
15
|
Gesesew HA, Ward P, Hajito KW, Feyissa GT, Mohammadi L, Mwanri L. Discontinuation from Antiretroviral Therapy: A Continuing Challenge among Adults in HIV Care in Ethiopia: A Systematic Review and Meta-Analysis. PLoS One 2017; 12:e0169651. [PMID: 28107430 PMCID: PMC5249214 DOI: 10.1371/journal.pone.0169651] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 12/20/2016] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Discontinuation of antiretroviral therapy (ART) reduces the immunological benefit of treatment and increases complications related to human immune-deficiency virus (HIV). However, the risk factors for ART discontinuation are poorly understood in developing countries particularly in Ethiopia. This review aimed to assess the best available evidence regarding risk factors for ART discontinuation in Ethiopia. METHODS Quantitative studies conducted in Ethiopia between 2002 and 2015 that evaluated factors associated with ART discontinuation were sought across six major databases. Only English language articles were included. This review considered studies that included the following outcome: ART treatment discontinuation, i.e. 'lost to follow up', 'defaulting' and 'stopping medication'. Meta- analysis was performed with Mantel Haenszel method using Revman-5 software. Summary statistics were expressed as pooled odds ratio with 95% confidence intervals at a p-value of <0.05. RESULTS Nine (9) studies met the criteria of the search. Five (5) were retrospective studies, 3 were case control studies, and 1 was a prospective cohort study. The total sample size in the included studies was 62,156. Being rural dweller (OR = 2.1, 95%CI: 1.5-2.7, I2 = 60%), being illiterate (OR = 1.5, 95%CI: 1.1-2.1), being not married (OR = 1.4, 95%CI: 1.1-1.8), being alcohol drinker (OR = 2.9, 95%CI: 1.9-4.4, I2 = 39%), being tobacco smoker (OR = 2.6, 95%CI: 1.6-4.3, I2 = 74%), having mental illness (OR = 2.7, 95%CI: 1.6-4.6, I2 = 0%) and being bed ridden functional status (OR = 2.3, 95%CI: 1.5-3.4, I2 = 37%) were risk factors for ART discontinuation. Whereas, having HIV positive partner (OR = 0.4, 95%CI: 0.3-0.6, I2 = 69%) and being co-infected with Tb/HIV (OR = 0.6, 95%CI: 0.4-0.9, I2 = 0%) were protective factors. CONCLUSION Demographic, behavioral and clinical factors influenced ART treatment discontinuation. Hence, we recommend strengthening decentralization of HIV care services in remote areas, strengthening of ART task shifting, application of seek-test-treat-succeed model, and integration of smoking cession strategies and mental health care into the routine HIV care program.
Collapse
Affiliation(s)
- Hailay Abrha Gesesew
- Public Health, Flinders University, Adelaide, Australia
- Epidemiology, Jimma University, Jimma, Ethiopia
| | - Paul Ward
- Public Health, Flinders University, Adelaide, Australia
| | | | - Garumma Tolu Feyissa
- Joanna Briggs Institute, Adelaide University, Adelaide, Australia
- Department of Health Education and Behavioral Sciences, Jimma, Ethiopia
| | - Leila Mohammadi
- Gus Fraenkel Medical Library, Flinders University, Adelaide, Australia
| | | |
Collapse
|
16
|
Retention in Care among HIV-Infected Pregnant Women in Haiti with PMTCT Option B. AIDS Res Treat 2016; 2016:6284290. [PMID: 27651953 PMCID: PMC5019862 DOI: 10.1155/2016/6284290] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/28/2016] [Accepted: 08/03/2016] [Indexed: 01/08/2023] Open
Abstract
Background. Preventing mother-to-child transmission of HIV relies on engagement in care during the prenatal, peripartum, and postpartum periods. Under PMTCT Option B, pregnant women with elevated CD4 counts are provided with antiretroviral prophylaxis until cessation of breastfeeding. Methods. Retrospective analysis of retention in care among HIV-infected pregnant women in Haiti was performed. Logistic regression was used to identify risk factors associated with loss to follow-up (LFU) defined as no medical visit for at least 6 months and Kaplan-Meier curves were created to show LFU timing. Results. Women in the cohort had 463 pregnancies between 2009 and 2012 with retention rates of 80% at delivery, 67% at one year, and 59% at 2 years. Among those who were LFU, the highest risk period was during pregnancy (60%) or shortly afterwards (24.4% by 12 months). Never starting on antiretroviral therapy (aRR 2.29, 95% CI 1.4–3.8) was associated with loss to follow-up. Conclusions. Loss to follow-up during and after pregnancy was common in HIV-infected women in Haiti under PMTCT Option B. Since sociodemographic factors and distance from home to facility did not predict LFU, future work should elicit and address barriers to retention at the initial prenatal care visit in all women. Better tracking systems to capture engagement in care in the wider network are needed.
Collapse
|
17
|
Kelly JD, Schlough GW, Conteh S, Barrie MB, Kargbo B, Giordano TP. The Majority of the Pre-Antiretroviral Population Who Were Lost to Follow-Up Stopped Their Care in Freetown, Sierra Leone: A 12-Month Prospective Cohort Study Starting with HIV Diagnosis. PLoS One 2016; 11:e0149584. [PMID: 26901765 PMCID: PMC4763157 DOI: 10.1371/journal.pone.0149584] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 02/01/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The heterogeneity of the pre-antiretroviral (pre-ART) population calls for more granular depictions of the cascade of HIV care. METHODS We studied a prospective cohort of persons newly diagnosed with HIV infection from a single center in Freetown, Sierra Leone, over a 12-month period and then traced those persons who were lost to follow-up (LTFU) during pre-ART care (before ART initiation). ART eligibility was based on a CD4 cell count result of ≤ 350 mm/cells and/or WHO clinical stage 3 or 4. Persons who attended an appointment in the final three months were considered to be retained in care. Adherence to ART was measured using pharmacy refill dates. "Effective HIV care" was defined as completion of the cascade of care at 12-months regardless of whether patients are on ART. Tracing outcomes were obtained for those who were LTFU during pre-ART care. RESULTS 408 persons newly diagnosed with HIV infection were screened, 338 were enrolled, and 255 persons were staged for ART. ART-ineligible persons had higher retention rates than ART-eligible persons (59.6% vs 41.8%, p = 0.03). 77 (22.8%) of 338 persons received effective HIV care. Most attrition (61.9%) occurred with persons during pre-ART care. 123 of 138 persons (89.1%) who were LTFU prior to ART initiation were found, and 91 of those 123 (74.0%) were alive. Of the 74 persons who were alive and described their engagement in care, 40 (54.1%) stopped care. Nearly half (42.5%) of those 40 stopped after assessment of ART-eligibility but before ART initiation. The main limitation of this study was the lack of tracing outcomes for those lost during ART care. CONCLUSIONS The majority of the pre-ART LTFU population stopped their care, particularly after ART-eligibility but before ART initiation. Interventions to hasten ART initiation and retain this at-risk group may have significant downstream impact on effective HIV care.
Collapse
Affiliation(s)
- J. Daniel Kelly
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
- Wellbody Alliance, Koidu Town, Sierra Leone
- National HIV/AIDS Secretariat, Freetown, Sierra Leone
- * E-mail:
| | | | - Sulaiman Conteh
- National HIV/AIDS Secretariat, Freetown, Sierra Leone
- College of Medicine and Allied Health Sciences of University of Sierra Leone, Freetown, Sierra Leone
| | | | - Brima Kargbo
- National HIV/AIDS Secretariat, Freetown, Sierra Leone
| | - Thomas P. Giordano
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| |
Collapse
|
18
|
Shankar D, Kumar AMV, Rewari B, Kumar S, Shastri S, Satyanarayana S, Ananthakrishnan R, Nagaraja SB, Devi M, Bhargava N, Das M, Zachariah R. Retention in pre-antiretroviral treatment care in a district of Karnataka, India: how well are we doing? Public Health Action 2015; 4:210-5. [PMID: 26400698 DOI: 10.5588/pha.14.0073] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 08/28/2014] [Indexed: 11/10/2022] Open
Abstract
SETTING Antiretroviral treatment (ART) Centre in Tumkur district of Karnataka State, India. There is no published information about pre-ART loss to follow-up from India. OBJECTIVE To assess the proportion lost to follow-up (defined as not visiting the ART Centre within 1 year of registration) and associated socio-demographic and immunological variables. DESIGN Retrospective cohort study involving a review of medical records of adult HIV-infected persons (aged ⩾15 years) registered in pre-ART care during January 2010-June 2012. RESULTS Of 3238 patients registered, 2519 (78%) were eligible for ART, while 719 (22%) were not. Four of the latter were transferred out; the remaining 715 individuals were enrolled in pre-ART care, of whom 290 (41%) were lost to follow-up. Factors associated with loss to follow-up on multivariate analysis included age group ⩾45 years, low educational level, not being married, World Health Organization Stage III or IV and rural residence. CONCLUSION About four in 10 individuals in pre-ART care were lost to follow-up within 1 year of registration. This needs urgent attention. Routine cohort analysis in the national programme should include those in pre-ART care to enable improved review, monitoring and supervision. Further qualitative research to ascertain reasons for loss to follow-up is required to design future interventions.
Collapse
Affiliation(s)
- D Shankar
- Antiretroviral Treatment Centre (ART), District Hospital, Tumkur, Karnataka, India
| | - A M V Kumar
- International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office, New Delhi, India
| | - B Rewari
- National AIDS Control Organization, New Delhi, India
| | - S Kumar
- National AIDS Control Organization, New Delhi, India ; Karnataka State AIDS Prevention Society, Bengaluru, India
| | - S Shastri
- Lady Willingdon State TB Centre, Bengaluru, India
| | - S Satyanarayana
- International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office, New Delhi, India
| | - R Ananthakrishnan
- Resource Group for Education and Advocacy for Community Health (REACH), Chennai, India
| | - S B Nagaraja
- Employees' State Insurance Corporation (ESIC) Medical College and Post Graduate Institute of Medical Sciences & Research (PGIMSR), Bengaluru, India
| | - M Devi
- Antiretroviral Treatment Centre (ART), District Hospital, Tumkur, Karnataka, India
| | - N Bhargava
- Antiretroviral Treatment Centre (ART), District Hospital, Tumkur, Karnataka, India
| | - M Das
- Médecins Sans Frontières, Operational Centre Brussels, Luxembourg
| | - R Zachariah
- Médecins Sans Frontières, Operational Centre Brussels, Luxembourg
| |
Collapse
|
19
|
Plazy M, Orne-Gliemann J, Dabis F, Dray-Spira R. Retention in care prior to antiretroviral treatment eligibility in sub-Saharan Africa: a systematic review of the literature. BMJ Open 2015; 5:e006927. [PMID: 26109110 PMCID: PMC4479994 DOI: 10.1136/bmjopen-2014-006927] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE We aimed at summarising rates and factors associated with retention in HIV care prior to antiretroviral treatment (ART) eligibility in sub-Saharan Africa. DESIGN We conducted a systematic literature review (2002-2014). We searched Medline/Pubmed, Scopus and Web of Science, as well as proceedings of conferences. We included all original research studies published in peer-reviewed journals, which used quantitative indicators of retention in care prior to ART eligibility. PARTICIPANTS People not yet eligible for ART. PRIMARY AND SECONDARY OUTCOMES Rate of retention in HIV care prior to ART eligibility and associated factors. RESULTS 10 papers and 2 abstracts were included. Most studies were conducted in Southern and Eastern Africa between 2004 and 2011 and reported retention rates in pre-ART care up to the second CD4 measurement. Definition of retention in HIV care prior to ART eligibility differed substantially across studies. Retention rates ranged between 23% and 88% based on series ranging from 112 to 10,314 individuals; retention was higher in women, individuals aged >25 years, those with low CD4 count, high body mass index or co-infected with tuberculosis, and in settings with free cotrimoxazole use. CONCLUSIONS Retention in HIV care prior to ART eligibility in sub-Saharan Africa has been insufficiently described so far leaving major research gaps, especially regarding long-term retention rates and sociodemographic, economic, clinical and programmatic logistic determinants. The prospective follow-up of newly diagnosed individuals is required to better evaluate attrition prior to ART eligibility among HIV-infected people.
Collapse
Affiliation(s)
- Mélanie Plazy
- Centre de recherche Inserm U897 Epidémiologie et Biostatistique, Université de Bordeaux, Bordeaux, France
- Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université de Bordeaux, Bordeaux, France
| | - Joanna Orne-Gliemann
- Centre de recherche Inserm U897 Epidémiologie et Biostatistique, Université de Bordeaux, Bordeaux, France
- Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université de Bordeaux, Bordeaux, France
| | - François Dabis
- Centre de recherche Inserm U897 Epidémiologie et Biostatistique, Université de Bordeaux, Bordeaux, France
- Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université de Bordeaux, Bordeaux, France
| | - Rosemary Dray-Spira
- Department of Social Epidemiology, INSERM, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
- Department of Social Epidemiology, Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
| |
Collapse
|
20
|
Time to initiation of antiretroviral therapy among patients who Are ART eligible in Rwanda: improvement over time. J Acquir Immune Defic Syndr 2015; 68:314-21. [PMID: 25415291 DOI: 10.1097/qai.0000000000000432] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Delayed initiation of antiretroviral therapy (ART) in eligible patients is a concern in resource-limited countries. METHODS We analyzed data on HIV-positive patients ≥15 years enrolled at 41 ICAP-supported health care facilities in Rwanda, 2005-2010, to determine time to ART initiation among patients eligible at enrollment compared with those ineligible or of indeterminate eligibility who become eligible during follow-up. ART eligibility was based on CD4 cell count (CD4) and WHO staging; patients lacking CD4 and WHO stage were considered indeterminate. Cumulative incidence of reaching ART eligibility and to ART initiation after eligibility was generated using competing risk estimators. RESULTS A total of 31,033 ART-naive adults were enrolled; 64.2% were female. At enrollment, 10,158 (32.7%) patients were ART eligible, 13,372 (43.1%) were ineligible for ART, and 7503 (24.2%) patients were indeterminate. Among patients retained in care pre-ART eligibility, 17.9% [95% confidence interval (CI): 17.2 to 18.6] of ineligible and 22.8% (95% CI: 21.7 to 23.8) of indeterminate patients at enrollment reached ART eligibility within 12 months. Cumulative incidence of ART initiation within 3 months for patients eligible at enrollment was 77.2% (95% CI: 76.4 to 78.0) compared with 67.9% (95% CI: 66.4 to 69.3) for ineligible and 63.8% (95% CI: 61.9 to 65.8) for patients with indeterminate eligibility at enrollment (P < 0.05). Over the study period, there was more rapid ART initiation for patients who became ART eligible. CONCLUSIONS We found higher rates of ART initiation within 3 months among patients who were ART eligible at enrollment compared with those who reached eligibility during follow-up. From 2006 to 2011, earlier initiation of ART after eligibility was observed likely reflecting improved program quality.
Collapse
|
21
|
Sigaloff KCE, Lange JMA, Montaner J. Global response to HIV: treatment as prevention, or treatment for treatment? Clin Infect Dis 2015; 59 Suppl 1:S7-S11. [PMID: 24926037 DOI: 10.1093/cid/ciu267] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The concept of "treatment as prevention" has emerged as a means to curb the global HIV epidemic. There is, however, still ongoing debate about the evidence on when to start antiretroviral therapy in resource-poor settings. Critics have brought forward multiple arguments against a "test and treat" approach, including the potential burden of such a strategy on weak health systems and a presumed lack of scientific support for individual patient benefit of early treatment initiation. In this article, we highlight the societal and individual advantages of treatment as prevention in resource-poor settings. We argue that the available evidence renders the discussion on when to start antiretroviral therapy unnecessary and that, instead, efforts should be aimed at offering treatment as soon as possible.
Collapse
Affiliation(s)
- Kim C E Sigaloff
- Department of Global Health Department of Internal Medicine, Academic Medical Center, University of Amsterdam Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | | | - Julio Montaner
- British Columbia Center for Excellence in HIV/AIDS, Vancouver, Canada
| |
Collapse
|
22
|
Geng EH, Odeny TA, Lyamuya RE, Nakiwogga-Muwanga A, Diero L, Bwana M, Muyindike W, Braitstein P, Somi GR, Kambugu A, Bukusi EA, Wenger M, Wools-Kaloustian KK, Glidden DV, Yiannoutsos CT, Martin JN. Estimation of mortality among HIV-infected people on antiretroviral treatment in East Africa: a sampling based approach in an observational, multisite, cohort study. Lancet HIV 2015; 2:e107-16. [PMID: 26424542 DOI: 10.1016/s2352-3018(15)00002-8] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 12/29/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mortality in HIV-infected people after initiation of antiretroviral treatment (ART) in resource-limited settings is an important measure of the effectiveness and comparative effectiveness of the global public health response. Substantial loss to follow-up precludes accurate accounting of deaths and limits our understanding of effectiveness. We aimed to provide a better understanding of mortality at scale and, by extension, the effectiveness and comparative effectiveness of public health ART treatment in east Africa. METHODS In 14 clinics in five settings in Kenya, Uganda, and Tanzania, we intensively traced a sample of patients randomly selected using a random number generator, who were infected with HIV and on ART and who were lost to follow-up (>90 days late for last scheduled visit). We incorporated the vital status outcomes for these patients into analyses of the entire clinic population through probability-weighted survival analyses. FINDINGS We followed 34 277 adults on ART from Mbarara and Kampala in Uganda, Eldoret, and Kisumu in Kenya, and Morogoro in Tanzania. The median age was 35 years (IQR 30-42), 11 628 (34%) were men, and median CD4 count count before therapy was 154 cells per μL (IQR 70-234). 5780 patients (17%) were lost to follow-up, 991 (17%) were selected for tracing between June 10, 2011, and Aug 27, 2012, and vital status was ascertained for 860 (87%). With incorporation of outcomes from the patients lost to follow-up, estimated 3 year mortality increased from 3·9% (95% CI 3·6-4·2) to 12·5% (11·8-13·3). The sample-corrected, unadjusted 3 year mortality across settings was lowest in Mbarara (7·2%) and highest in Morogoro (23·6%). After adjustment for age, sex, CD4 count before therapy, and WHO stage, the sample-corrected hazard ratio comparing the settings with highest and lowest mortalities was 2·2 (95% CI 1·5-3·4) and the risk difference for death at 3 years was 11% (95% CI 5·0-17·7). INTERPRETATION A sampling-based approach is widely feasible and important to an understanding of mortality after initiation of ART. After adjustment for measured biological drivers, mortality differs substantially across settings despite delivery of a similar clinical package of treatment. Implementation research to understand the systems, community, and patients' behaviours driving these differences is urgently needed. FUNDING The US National Institutes of Health and President's Emergency Fund for AIDS Relief.
Collapse
Affiliation(s)
- Elvin H Geng
- Division of HIV/AIDS at San Francisco General Hospital in the Department of Medicine, University of California, San Francisco, CA, USA; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium.
| | - Thomas A Odeny
- Kenya Medical Research Institute and the Family AIDS Care and Education Services Program, Kisumu, Kenya; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium
| | - Rita E Lyamuya
- National AIDS Control Program, Dar Es Salaam, Tanzania; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium
| | - Alice Nakiwogga-Muwanga
- Infectious Diseases Institute, Kampala, Uganda; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium
| | - Lameck Diero
- College of Health Sciences, School of Medicine, Department of Medicine, Moi University, Eldoret, Kenya; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium
| | - Mwebesa Bwana
- Mbarara University of Science and Technology, Mbarara, Uganda; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium
| | - Winnie Muyindike
- Mbarara University of Science and Technology, Mbarara, Uganda; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium
| | - Paula Braitstein
- College of Health Sciences, School of Medicine, Department of Medicine, Moi University, Eldoret, Kenya; Department of Medicine, School of Medicine, Indiana University School of Public Health, Indiana University, Indianapolis, IN, USA; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium
| | - Geoffrey R Somi
- National AIDS Control Program, Dar Es Salaam, Tanzania; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium
| | - Andrew Kambugu
- Infectious Diseases Institute, Kampala, Uganda; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium
| | - Elizabeth A Bukusi
- Kenya Medical Research Institute and the Family AIDS Care and Education Services Program, Kisumu, Kenya; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium
| | - Megan Wenger
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium
| | - Kara K Wools-Kaloustian
- Department of Medicine, School of Medicine, Indiana University School of Public Health, Indiana University, Indianapolis, IN, USA; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium
| | - Constantin T Yiannoutsos
- Department of Biostatistics, Indiana University School of Public Health, Indiana University, Indianapolis, IN, USA; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium
| | - Jeffrey N Martin
- Division of HIV/AIDS at San Francisco General Hospital in the Department of Medicine, University of California, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA; East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium
| |
Collapse
|
23
|
Mûnene E, Ekman B. Association between patient engagement in HIV care and antiretroviral therapy medication adherence: cross-sectional evidence from a regional HIV care center in Kenya. AIDS Care 2014; 27:378-86. [PMID: 25298265 DOI: 10.1080/09540121.2014.963020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Consistent individual effort in engagement in HIV medical services has been associated with positive health outcomes in people living with HIV (PLHIV). However, whether these benefits are facilitated by improved medication adherence has not been widely studied. This study aimed to investigate the marginal effect of engagement in HIV care on medication adherence at a public health facility in Kenya. Between February and April 2013, 392 patients on HIV care at Nyeri Provincial General Hospital participated in this study. Data were collected using a self-administered health survey questionnaire assessing health and sociodemographic statuses. A manual stepwise general linear model was specified to measure the effect of engagement in HIV and other associated predictors on medication adherence. Engagement in HIV care was significantly associated with log-transformed medication adherence in the sample (100·β = 9.2%, 95% CI 3.2-15.1) irrespective of gender and other selected predictors. Longer duration on antiretroviral therapy was also a significant predictor of better medication adherence (100·β = 3.2%, 95% CI 2.3-4.1). Despite inter-gender differences in adherence and engagement determinants, gender's independent effect on medication adherence and engagement in care were not statistically significant. Poor medication adherence was associated with lower patient engagement in HIV care services, suggesting that interventions which remove obstacles to regular observance of scheduled clinic appointments and eventual retention may have a beneficial impact on medication adherence and, accordingly, health outcomes in PLHIV.
Collapse
Affiliation(s)
- Edwin Mûnene
- a Department of Pharmacy , Nyeri Provincial General Hospital , Nyeri , Nyeri County , Kenya
| | | |
Collapse
|
24
|
Socioeconomic determinants of mortality in HIV: evidence from a clinical cohort in Uganda. J Acquir Immune Defic Syndr 2014; 66:41-7. [PMID: 24378727 DOI: 10.1097/qai.0000000000000094] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To delineate the association between baseline socioeconomic status (SES) indicators and mortality and lost to follow-up (LTFU) in a cohort of HIV-infected individuals enrolled in antiretroviral therapy (ART) in urban Uganda. DESIGN Retrospective cohort study nested in an antiretroviral clinic-based cohort. METHODS SES indicators including education, employment status, and a standardized wealth index, and other demographic and clinical variables were assessed at baseline among ART-treated patients in a clinic-based cohort in Kampala, Uganda. Confirmed mortality (primary outcome) and LTFU (secondary outcome) were actively ascertained over a 4-year follow-up period from 2005 to 2009. RESULTS Among 1763 adults [70.5% female; mean age, 36.2 years (SD = 8.4)] enrolled in ART, 14.4% (n = 253) were confirmed dead and 19.7% (n = 346) were LTFU at 4-year follow-up. No formal education [adjusted odds ratio (AOR) 1.76; 95% confidence interval (CI): 1.19 to 2.59], having fewer than 6 dependents (AOR 1.39; 95% CI: 1.04 to 1.86), unemployment (AOR 1.98; 95% CI: 1.48 to 2.66), and housing tenure index score (a component of the wealth index) (AOR 1.11; 95% CI: 1.00 to 1.23) were significantly associated with confirmed mortality at 4 years. SES indicators were not associated with LTFU at 4 years. CONCLUSIONS Baseline SES indicators, including education, number of dependents, employment status, and components of a standard wealth index may indicate long-term vulnerability to mortality in patients with HIV/AIDS, despite uniform access to ART. Future studies delineating the pathways through which poverty and limited assets affect clinical outcomes may lead to more effective HIV interventions in low-resource settings.
Collapse
|
25
|
Outcomes of antiretroviral treatment programmes in rural Lesotho: health centres and hospitals compared. J Int AIDS Soc 2013; 16:18616. [PMID: 24267671 PMCID: PMC3838571 DOI: 10.7448/ias.16.1.18616] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Revised: 09/20/2013] [Accepted: 10/18/2013] [Indexed: 11/26/2022] Open
Abstract
Introduction Lesotho was among the first countries to adopt decentralization of care from hospitals to nurse-led health centres (HCs) to scale up the provision of antiretroviral therapy (ART). We compared outcomes between patients who started ART at HCs and hospitals in two rural catchment areas in Lesotho. Methods The two catchment areas comprise two hospitals and 12 HCs. Patients ≥16 years starting ART at a hospital or HC between 2008 and 2011 were included. Loss to follow-up (LTFU) was defined as not returning to the facility for ≥180 days after the last visit, no follow-up (no FUP) as not returning after starting ART, and retention in care as alive and on ART at the facility. The data were analysed using logistic regression, competing risk regression and Kaplan-Meier methods. Multivariable analyses were adjusted for sex, age, CD4 cell count, World Health Organization stage, catchment area and type of ART. All analyses were stratified by gender. Results Of 3747 patients, 2042 (54.5%) started ART at HCs. Both women and men at hospitals had more advanced clinical and immunological stages of disease than those at HCs. Over 5445 patient-years, 420 died and 475 were LTFU. Kaplan-Meier estimates for three-year retention were 68.7 and 69.7% at HCs and hospitals, respectively, among women (p=0.81) and 68.8% at HCs versus 54.7% at hospitals among men (p<0.001). These findings persisted in adjusted analyses, with similar retention at HCs and hospitals among women (odds ratio (OR): 0.89, 95% confidence interval (CI): 0.73–1.09) and higher retention at HCs among men (OR: 1.53, 95% CI: 1.20–1.96). The latter result was mainly driven by a lower proportion of patients LTFU at HCs (OR: 0.68, 95% CI: 0.51–0.93). Conclusions In rural Lesotho, overall retention in care did not differ significantly between nurse-led HCs and hospitals. However, men seemed to benefit most from starting ART at HCs, as they were more likely to remain in care in these facilities compared to hospitals.
Collapse
|