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Suffrin JCD, Rosenthal A, Kamtsendero L, Kachimanga C, Munyaneza F, Kalua J, Ndarama E, Trapence C, Aron MB, Connolly E, Dullie LW. Re-engagement and retention in HIV care after preventive default tracking in a cohort of HIV-infected patients in rural Malawi: A mixed-methods study. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002437. [PMID: 38381760 PMCID: PMC10880992 DOI: 10.1371/journal.pgph.0002437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/02/2024] [Indexed: 02/23/2024]
Abstract
Loss-to-follow-up (LTFU) in the era of test-and-treat remains a universal challenge, especially in rural areas. To mitigate LTFU, the HIV program in Neno District, Malawi, utilizes a preventive default tracking strategy named Tracking for Retention and Client Enrollment (TRACE). We utilized a mixed-methods descriptive study of the TRACE program on patient's re-engagement and retention in care (RiC). In the quantitative arm, we utilized secondary data of HIV-infected patients in the TRACE program from January 2018 to June 2019 and analyzed patients' outcomes at 6-, 12-, and 24-months post-tracking. In the qualitative arm, we analyzed primary data from 25 semi-structured interviews. For the study period, 1028 patients were eligible with median age was 30 years, and 52% were women. We found that after tracking, 982 (96%) of patients with a 6-week missed appointment returned to care. After returning to care, 906 (88%), 864 (84%), and 839 (82%) were retained in care respectively at 6-,12-, and 24-months. In the multivariate analysis, which included all the covariates from the univariate analysis (including gender, BMI, age, and the timing of ART initiation), the results showed that RiC at 6 months was linked to WHO stage IV at the start of treatment (with an adjusted odds ratio (aOR) of 0.18; 95% confidence interval (CI) of 0.06-0.54) and commencing ART after the test-and-treat recommendation (aOR of 0.08; 95% CI: 0.06-0.18). RiC after 12 months was associated with age between 15 and 29 years (aOR = 0.18; 95%CI: 0.03-0.88), WHO stage IV (aOR = 0.12; 95%CI: 0.04-0.16) and initiating ART after test-and-treat recommendations (aOR = 0.08; 95%CI: 0.04-0.16). RiC at 24 months post-tracking was associated with being male (aOR = 0.61; 95%CI: 0.40-0.92) and initiating ART after test-and-treat recommendations (aOR = 0.16; 95%CI:0.10-0.25). The qualitative analysis revealed that clarity of the visit's purpose, TRACE's caring approach changed patient's mindset, enhanced sense of responsibility and motivated patients to resume care. We recommend integrating tracking programs in HIV care as it led to increase patient follow up and patient behavior change.
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Affiliation(s)
| | - Anat Rosenthal
- Department of Health Policy and Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | | | | | | | - Jonathan Kalua
- Ministry of Health, Neno District Hospital, Donda, Malawi
| | - Enoch Ndarama
- Ministry of Health, Neno District Hospital, Donda, Malawi
| | | | - Moses Banda Aron
- Partners In Health, Neno, Malawi
- Research Group Snake Bite Envenoming, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Emilia Connolly
- Partners In Health, Neno, Malawi
- Division of Pediatrics, College of Medicine University of Cincinnati, Cincinnati, Ohio, United States of America
- Division of Hospital Medicine, Cincinnati Children Hospital Medical Center, Cincinnati, Ohio, United States of America
| | - Luckson W. Dullie
- Partners In Health, Neno, Malawi
- Department of Family Medicine, School of Medicine and Oral Health, Kamuzu University of Health Sciences, Blantyre, Malawi
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Beres LK, Mwamba C, Bolton-Moore C, Kennedy CE, Simbeza S, Topp SM, Sikombe K, Mukamba N, Mody A, Schwartz SR, Geng E, Holmes CB, Sikazwe I, Denison JA. Trajectories of re-engagement: factors and mechanisms enabling patient return to HIV care in Zambia. J Int AIDS Soc 2023; 26:e26067. [PMID: 36840391 PMCID: PMC9958345 DOI: 10.1002/jia2.26067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/31/2023] [Indexed: 02/26/2023] Open
Abstract
INTRODUCTION While disengagement from HIV care threatens the health of persons living with HIV (PLWH) and incidence-reduction targets, re-engagement is a critical step towards positive outcomes. Studies that establish a deeper understanding of successful return to clinical care among previously disengaged PLWH and the factors supporting re-engagement are essential to facilitate long-term care continuity. METHODS We conducted narrative, patient-centred, in-depth interviews between January and June 2019 with 20 PLWH in Lusaka, Zambia, who had disengaged and then re-engaged in HIV care, identified through electronic medical records (EMRs). We applied narrative analysis techniques, and deductive and inductive thematic analysis to identify engagement patterns and enablers of return. RESULTS We inductively identified five trajectories of care engagement, suggesting patterns in patient characteristics, experienced barriers and return facilitators that may aid intervention targeting including: (1) intermittent engagement;(2) mostly engaged; (3) delayed linkage after testing; (4) needs time to initiate antiretroviral therapy (ART); and (5) re-engagement with ART initiation. Patient-identified periods of disengagement from care did not always align with care gaps indicated in the EMR. Key, interactive re-engagement facilitators experienced by participants, with varied importance across trajectories, included a desire for physical wellness and social support manifested through verbal encouragement, facility outreach or personal facility connections and family instrumental support. The mechanisms through which facilitators led to return were: (1) the promising of living out one's life priorities; (2) feeling valued; (3) fostering interpersonal accountability; (4) re-entry navigation support; (5) facilitated care and treatment access; and (6) management of significant barriers, such as depression. CONCLUSIONS While preliminary, the identified trajectories may guide interventions to support re-engagement, such as offering flexible ART access to patients with intermittent engagement patterns instead of stable patients only. Further, for re-engagement interventions to achieve impact, they must activate mechanisms underlying re-engagement behaviours. For example, facility outreach that reminds a patient to return to care but does not affirm a patient's value or navigate re-entry is unlikely to be effective. The demonstrated importance of positive health facility connections reinforces a growing call for patient-centred care. Additionally, interventions should consider the important role communities play in fostering treatment motivation and overcoming practical barriers.
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Affiliation(s)
- Laura K Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Stephanie M Topp
- College of Public Health Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Kombatende Sikombe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Aaloke Mody
- University of Washington St. Louis, St. Louis, Missouri, USA
| | - Sheree R Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elvin Geng
- University of Washington St. Louis, St. Louis, Missouri, USA
| | - Charles B Holmes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Georgetown University, Washington, DC, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Julie A Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Lesko CR, Mugavero MJ, Shen NM, Fojo AT, Moore RD, Keruly JC, Cachay ER, Napravnik S, Mayer KH, Christopoulos KA, Jacobson JM, Rebeiro PF, Chander G. Exploring definitions of retention in care for people living with HIV in the United States in the modern treatment era. AIDS 2022; 36:1181-1189. [PMID: 35796732 PMCID: PMC9273016 DOI: 10.1097/qad.0000000000003232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To describe retention in HIV care based on various definitions of retention in the modern treatment era. DESIGN A cohort study of people enrolled in care at seven mostly urban HIV clinics across the United States, 2010-2018. METHODS We estimated retention based on missed visits, kept visits, kept encounters (clinical visits, CD4 counts, and viral loads), and HIV labs. We contrasted risk factors for retention by different definitions and estimated odds ratios for of viral suppression and hazard ratios for mortality in 2 years immediately following the year in which retention was defined (the study year). RESULTS Across 108 171 person-years (N = 21 481 people), in 71% of years people kept ≥75% of scheduled visits; in 78%, people kept ≥2 visits >90 days apart; in 74%, people had ≥2 HIV labs >90 days apart; and in 47%, people had no gaps >6 months in clinic visits. Missing >25% of scheduled visits despite attending ≥2 visits >90 days apart was associated with nonwhite non-Hispanic race/ethnicity, history of injection drug use, and prior AIDS diagnosis. In contrast, attending ≥75% of scheduled visits while not attending ≥2 visits >90 days apart was associated with male sex, white race, no injection drug use history, and no prior AIDS diagnosis. Subsequent viral nonsuppression was more strongly associated with missed- than kept-visit measures of retention; 2-year mortality was only associated with failure to be retained by missed-visit measures. DISCUSSION Missed and kept-visit definitions of retention capture different constructs. Missed-visit measures are more strongly associated with poor HIV outcomes.
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Affiliation(s)
- Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Michael J Mugavero
- Division of Infectious Diseases, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nicola M Shen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Anthony T Fojo
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Richard D Moore
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jeanne C Keruly
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Edward R Cachay
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California
| | - Sonia Napravnik
- Division of Infectious Diseases, Department of Medicine
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Kenneth H Mayer
- The Fenway Institute, Fenway Health
- Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts
| | - Katerina A Christopoulos
- Division of Infectious Diseases, HIV, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | | | - Peter F Rebeiro
- Department of Medicine & Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Ford N, Eshun-Wilson I, Ameyan W, Newman M, Vojnov L, Doherty M, Geng E. Future directions for HIV service delivery research: Research gaps identified through WHO guideline development. PLoS Med 2021; 18:e1003812. [PMID: 34555010 PMCID: PMC8496797 DOI: 10.1371/journal.pmed.1003812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 10/07/2021] [Indexed: 11/19/2022] Open
Abstract
Nathan Ford and co-authors discuss the systematic identification of research gaps in improving HIV service delivery.
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Affiliation(s)
- Nathan Ford
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Wole Ameyan
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Morkor Newman
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Lara Vojnov
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Meg Doherty
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Elvin Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America
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Beres LK, Schwartz S, Simbeza S, McGready J, Eshun-Wilson I, Mwamba C, Sikombe K, Topp SM, Somwe P, Mody A, Mukamba N, Ehrenkranz PD, Padian N, Pry J, Moore CB, Holmes CB, Sikazwe I, Denison JA, Geng E. Patterns and Predictors of Incident Return to HIV Care Among Traced, Disengaged Patients in Zambia: Analysis of a Prospective Cohort. J Acquir Immune Defic Syndr 2021; 86:313-322. [PMID: 33149000 PMCID: PMC7878284 DOI: 10.1097/qai.0000000000002554] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/28/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dynamic movement of patients in and out of HIV care is prevalent, but there is limited information on patterns of patient re-engagement or predictors of return to guide HIV programs to better support patient engagement. METHODS From a probability-based sample of lost to follow-up, adult patients traced by peer educators from 31 Zambian health facilities, we prospectively followed disengaged HIV patients for return clinic visits. We estimated the cumulative incidence of return and the time to return using Kaplan-Meier methods. We used univariate and multivariable Cox proportional hazards regression to conduct a risk factor analysis identifying predictors of incident return across a social ecological framework. RESULTS Of the 556 disengaged patients, 73.0% [95% confidence interval (CI): 61.0 to 83.8] returned to HIV care. The median follow-up time from disengagement was 32.3 months (interquartile range: 23.6-38.9). The rate of return decreased with time postdisengagement. Independent predictors of incident return included a previous gap in care [adjusted Hazard Ratio (aHR): 1.95, 95% CI: 1.23 to 3.09] and confronting a stigmatizer once in the past year (aHR: 2.14, 95% CI: 1.25 to 3.65). Compared with a rural facility, patients were less likely to return if they sought care from an urban facility (aHR: 0.68, 95% CI: 0.48 to 0.96) or hospital (aHR: 0.52, 95% CI: 0.33 to 0.82). CONCLUSIONS Interventions are needed to hasten re-engagement in HIV care. Early and differential interventions by time since disengagement may improve intervention effectiveness. Patients in urban and tertiary care settings may need additional support. Improving patient resilience, outreach after a care gap, and community stigma reduction may facilitate return. Future re-engagement research should include causal evaluation of identified factors.
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Affiliation(s)
- Laura K. Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | - John McGready
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | | | - Stephanie M. Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia;
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | - Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | | | - Nancy Padian
- Division of Epidemiology, University of California Berkeley, Berkeley, CA; and
| | - Jake Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL
| | - Charles B. Holmes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
- Department of Medicine, Georgetown University, Washington, DC
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | - Julie A. Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
| | - Elvin Geng
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
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Bakoyannis G, Diero L, Mwangi A, Wools-Kaloustian KK, Yiannoutsos CT. A semiparametric method for the analysis of outcomes during a gap in HIV care under incomplete outcome ascertainment. ACTA ACUST UNITED AC 2020; 12. [PMID: 34113423 DOI: 10.1515/scid-2019-0013] [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: 11/15/2022]
Abstract
Objectives Estimation of the cascade of HIV care is essential for evaluating care and treatment programs, informing policy makers and assessing targets such as 90-90-90. A challenge to estimating the cascade based on electronic health record concerns patients "churning" in and out of care. Correctly estimating this dynamic phenomenon in resource-limited settings, such as those found in sub-Saharan Africa, is challenging because of the significant death under-reporting. An approach to partially recover information on the unobserved deaths is a double-sampling design, where a small subset of individuals with a missed clinic visit is intensively outreached in the community to actively ascertain their vital status. This approach has been adopted in several programs within the East Africa regional IeDEA consortium, the context of our motivating study. The objective of this paper is to propose a semiparametric method for the analysis of competing risks data with incomplete outcome ascertainment. Methods Based on data from double-sampling designs, we propose a semiparametric inverse probability weighted estimator of key outcomes during a gap in care, which are crucial pieces of the care cascade puzzle. Results Simulation studies suggest that the proposed estimators provide valid estimates in settings with incomplete outcome ascertainment under a set of realistic assumptions. These studies also illustrate that a naïve complete-case analysis can provide seriously biased estimates. The methodology is applied to electronic health record data from the East Africa IeDEA Consortium to estimate death and return to care during a gap in care. Conclusions The proposed methodology provides a robust approach for valid inferences about return to care and death during a gap in care, in settings with death under-reporting. Ultimately, the resulting estimates will have significant consequences on program construction, resource allocation, policy and decision making at the highest levels.
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Affiliation(s)
- Giorgos Bakoyannis
- Indiana University Purdue University at Indianapolis, Biostatistics, 410 West 10th Street, Suite 3000, Indianapolis, 46202, IN, USA
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Kerkhoff AD, Sikombe K, Eshun-Wilson I, Sikazwe I, Glidden DV, Pry JM, Somwe P, Beres LK, Simbeza S, Mwamba C, Bukankala C, Hantuba C, Moore CB, Holmes CB, Padian N, Geng EH. Mortality estimates by age and sex among persons living with HIV after ART initiation in Zambia using electronic medical records supplemented with tracing a sample of lost patients: A cohort study. PLoS Med 2020; 17:e1003107. [PMID: 32401797 PMCID: PMC7219718 DOI: 10.1371/journal.pmed.1003107] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 04/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Men in sub-Saharan Africa have lower engagement and retention in HIV services compared to women, which may result in differential survival. However, the true magnitude of difference in HIV-related mortality between men and women receiving antiretroviral therapy (ART) is incompletely characterized. METHODS AND FINDINGS We evaluated HIV-positive adults ≥18 years old newly initiating ART in 4 Zambian provinces (Eastern, Lusaka, Southern, and Western). In addition to mortality data obtained from routine electronic medical records, we intensively traced a random sample of patients lost to follow-up (LTFU) and incorporated tracing outcomes through inverse probability weights. Sex-specific mortality rates and rate differences were determined using Poisson regression. Parametric g-computation was used to estimate adjusted mortality rates by sex and age. The study included 49,129 adults newly initiated on ART between August 2013 and July 2015; overall, the median age among patients was 35 years, the median baseline CD4 count was 262 cells/μl, and 37.2% were men. Men comprised a smaller proportion of individuals starting ART (37.2% versus 62.8%), tended to be older (median age 37 versus 33 years), and tended to have lower CD4 counts (median 220 versus 289 cells/μl) at the time of ART initiation compared to women. The overall rate of mortality among men was 10.3 (95% CI 8.2-12.4) deaths/100 person-years (PYs), compared to 5.5 (95% CI 4.3-6.8) deaths/100 PYs among women (difference +4.7 [95% CI 2.3-7.2] deaths/100 PYs; p < 0.001). Compared to women in the same age groups, men's mortality rates were particularly elevated among those <30 years old (+6.7 deaths/100 PYs difference), those attending rural health centers (+9.4 deaths/100 PYs difference), those who had an initial CD4 count < 100 cells/μl (+9.2 deaths/100 PYs difference), and those who were unmarried (+8.0 deaths/100 PYs difference). After adjustment for potential confounders and mediators including CD4 count, a substantially higher mortality rate was predicted among men <30 years old compared to women of the same age, while women ≥50 years old had a mortality rate similar to that of age-matched men, but considerably higher than that predicted among young women (<30 years old). No clinically significant differences were evident with respect to rates of facility transfer or care disengagement between men and women. The main study limitations were the inability to successfully ascertain outcomes in all patients selected for tracing and missing clinical and laboratory data due to the use of medical records. CONCLUSIONS In this study, we found that among HIV-positive adults newly initiating ART, mortality among men exceeded mortality among women; disparities were most pronounced among young patients. Older women, however, also experienced high mortality. Specific interventions for men and older women at highest mortality risk are needed to improve HIV treatment outcomes.
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Affiliation(s)
- Andrew D. Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, United States of America
| | | | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Department of Medicine, Washington University, St. Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - David V. Glidden
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, United States of America
| | - Jake M. Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, Department of Medicine, Washington University, St. Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Laura K. Beres
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Chama Bukankala
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Cardinal Hantuba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Charles B. Holmes
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
- Georgetown University, Washington, District of Columbia, United States of America
| | - Nancy Padian
- University of California, Berkeley, Berkeley, California, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, Department of Medicine, Washington University, St. Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
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8
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Ford N, Geng E, Ellman T, Orrell C, Ehrenkranz P, Sikazwe I, Jahn A, Rabkin M, Ayisi Addo S, Grimsrud A, Rosen S, Zulu I, Reidy W, Lejone T, Apollo T, Holmes C, Kolling AF, Phate Lesihla R, Nguyen HH, Bakashaba B, Chitembo L, Tiriste G, Doherty M, Bygrave H. Emerging priorities for HIV service delivery. PLoS Med 2020; 17:e1003028. [PMID: 32059023 PMCID: PMC7021280 DOI: 10.1371/journal.pmed.1003028] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Nathan Ford and co-authors discuss global priorities in the provision of HIV prevention and treatment services.
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Affiliation(s)
- Nathan Ford
- Department HIV & Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
- * E-mail:
| | - Elvin Geng
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
| | - Tom Ellman
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | - Catherine Orrell
- Department of Medicine, Faculty of Health Sciences, Cape Town, South Africa
| | - Peter Ehrenkranz
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Miriam Rabkin
- ICAP, Columbia University Mailman School of Public Health, New York, New York, United States of America
| | | | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Isaac Zulu
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - William Reidy
- ICAP, Columbia University Mailman School of Public Health, New York, New York, United States of America
| | - Thabo Lejone
- SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho
| | - Tsitsi Apollo
- Ministry of Health and Child Care Zimbabwe, Harare, Zimbabwe
| | - Charles Holmes
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Georgetown University, Washington, DC, United States of America
| | - Ana Francisca Kolling
- Department of Surveillance, Prevention and Control of STIs, HIV/AIDS and Viral Hepatitis, Ministry of Health, Brasilia, Brazil
| | | | - Huu Hai Nguyen
- Treatment and Care Department, Viet Nam Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam
| | | | | | - Ghion Tiriste
- Department HIV, World Health Organization, Addis Ababa, Ethiopia
| | - Meg Doherty
- Department HIV & Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
| | - Helen Bygrave
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
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Angelim RCDM, Brandão BMGDM, Marques SC, Oliveira DCD, Abrão FMDS. Representations and care practices of health professionals for people with HIV. Rev Esc Enferm USP 2019; 53:e03478. [PMID: 31365725 DOI: 10.1590/s1980-220x2018017903478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 10/29/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To analyze the social representations of health professionals regarding the care of people living with HIV. METHOD A descriptive and exploratory study with a qualitative approach in light of the Theory of Social Representations, carried out with health professionals. The semi-structured interview technique was used, which was analyzed using the lexical content analysis technique. RESULTS Forty-six (46) professionals participated. The analyzed results reveal that the representations and care practices referred to by health professionals are technical, relational and organizational, ensuring the confidentiality of the diagnosis and taking care to develop embracement actions, provide guidance, clarification and emotional and psychological support, as well as being based on confidentiality, multi-professional care practice and addressing structural difficulties. CONCLUSION It is important to encourage multiprofessional care for people living with HIV, so that professionals engage, develop critical thinking and are able to act in improving healthcare services.
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Affiliation(s)
| | | | - Sergio Corrêa Marques
- Universidade do Estado do Rio de Janeiro, Programa de Pós-graduação em Enfermagem, Rio de Janeiro, RJ, Brasil
| | - Denize Cristina de Oliveira
- Universidade do Estado do Rio de Janeiro, Programa de Pós-graduação em Enfermagem, Rio de Janeiro, RJ, Brasil
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Sikazwe I, Eshun-Wilson I, Sikombe K, Czaicki N, Somwe P, Mody A, Simbeza S, Glidden DV, Chizema E, Mulenga LB, Padian N, Duncombe CJ, Bolton-Moore C, Beres LK, Holmes CB, Geng E. Retention and viral suppression in a cohort of HIV patients on antiretroviral therapy in Zambia: Regionally representative estimates using a multistage-sampling-based approach. PLoS Med 2019; 16:e1002811. [PMID: 31150380 PMCID: PMC6544202 DOI: 10.1371/journal.pmed.1002811] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/23/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although the success of HIV treatment programs depends on retention and viral suppression, routine program monitoring of these outcomes may be incomplete. We used data from the national electronic medical record (EMR) system in Zambia to enumerate a large and regionally representative cohort of patients on treatment. We traced a random sample with unknown outcomes (lost to follow-up) to document true care status and HIV RNA levels. METHODS AND FINDINGS On 31 July 2015, we selected facilities from 4 provinces in 12 joint strata defined by facility type and province with probability proportional to size. In each facility, we enumerated adults with at least 1 clinical encounter after treatment initiation in the previous 24 months. From this cohort, we identified lost-to-follow-up patients (defined as 90 or more days late for their last appointment), selected a random sample, and intensively reviewed their records and traced them via phone calls and in-person visits in the community. In 1 of 4 provinces, we also collected dried blood spots (DBSs) for plasma HIV RNA testing. We used inverse probability weights to incorporate sampling outcomes into Aalen-Johansen and Cox proportional hazards regression to estimate retention and viremia. We used a bias analysis approach to correct for the known inaccuracy of plasma HIV RNA levels obtained from DBSs. From a total of 64 facilities with 165,464 adults on ART, we selected 32 facilities with 104,966 patients, of whom 17,602 (17%) were lost to follow-up: Those lost to follow-up had median age 36 years, 60% were female (N = 11,241), they had median enrollment CD4 count of 220 cells/μl, and 38% had WHO stage 1 clinical disease (N = 10,690). We traced 2,892 (16%) and found updated outcomes for 2,163 (75%): 412 (19%) had died, 836 (39%) were alive and in care at their original clinic, 457 (21%) had transferred to a new clinic, 255 (12%) were alive and out of care, and 203 (9%) were alive but we were unable to determine care status. Estimates using data from the EMR only suggested that 42.7% (95% CI 38.0%-47.1%) of new ART starters and 72.3% (95% CI 71.8%-73.0%) of all ART users were retained at 2 years. After incorporating updated data through tracing, we found that 77.3% (95% CI 70.5%-84.0%) of new initiates and 91.2% (95% CI 90.5%-91.8%) of all ART users were retained (at original clinic or transferred), indicating that routine program data underestimated retention in care markedly. In Lusaka Province, HIV RNA levels greater than or equal to 1,000 copies/ml were present in 18.1% (95% CI 14.0%-22.3%) of patients in care, 71.3% (95% CI 58.2%-84.4%) of lost patients, and 24.7% (95% CI 21.0%-29.3%). The main study limitations were imperfect response rates and the use of self-reported care status. CONCLUSIONS In this region of Zambia, routine program data underestimated retention, and the point prevalence of unsuppressed HIV RNA was high when lost patients were accounted for. Viremia was prevalent among patients who unofficially transferred: Sustained engagement remains a challenge among HIV patients in Zambia, and targeted sampling is an effective strategy to identify such gaps in the care cascade and monitor programmatic progress.
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Affiliation(s)
- Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- * E-mail:
| | - Ingrid Eshun-Wilson
- University of California, San Francisco, San Francisco, California, United States of America
| | | | - Nancy Czaicki
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of California, San Francisco, San Francisco, California, United States of America
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Aaloke Mody
- University of California, San Francisco, San Francisco, California, United States of America
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - David V. Glidden
- University of California, San Francisco, San Francisco, California, United States of America
| | | | | | - Nancy Padian
- University of California, Berkeley, Berkeley, California, United States of America
| | - Chris J. Duncombe
- International Association of Providers of AIDS Care, Washington, District of Columbia, United States of America
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Laura K. Beres
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Charles B. Holmes
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Johns Hopkins University, Baltimore, Maryland, United States of America
- Georgetown University, Washington, District of Columbia, United States of America
| | - Elvin Geng
- University of California, San Francisco, San Francisco, California, United States of America
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