Scaling up antiretroviral therapy in developing countries: what are the benefits and challenges?

Self-reported adherence to highly active antiretroviral therapy in a tertiary hospital in Nigeria

Background

Non-adherence to highly active antiretroviral therapy (HAART) favours drug resistance and wastes resources. These have negative implications for personal and public health.

Objective

To assess adherence levels, the associated factors and its association with increase in CD4 cell count in people living with HIV (PLHIVs).

Methods

In a cross-sectional survey, systematically selected adult PLHIVs attending a tertiary hospital in Nigeria self-reported their 28-day adherence to HAART and reasons for missing doses using an interviewer-administered questionnaire. Their 6-month difference in CD4 cell count was also assessed.

Results

The participants totalled 425. Their mean age was 38.6 (SD, 10.1) years and 309 (72.7%) had secondary or tertiary education. The 28-day mean adherence level was 96.8% (SD, 7.9%) and 354 (83.3%) participants had optimal adherence (≥ 95%). Socio-demographic characteristics, side effects and having human reminders were not associated with adherence level, but 100% adherence level since placement on HAART was positively associated with a 6-month increase in CD4 cell count (p < 0.01; OR = 1.87, 95%CI = 1.21 – 2.89). Reasons given by 156 respondents for missing doses included being too busy, 100 (64.1%), forgetting, 85 (54.5%) and sleeping off, 42 (26.9%).

Conclusion

Mean adherence was high and the majority of participants had optimal adherence. “Never missing a dose” was associated with improved CD4 cell counts, indicating better prognosis. Socio-demographic factors, side effects and human reminders were not associated with an increase in adherence. However, as there is no evidence that adherence improvement measures are detrimental, their use is still recommended.

Funding

None declared

'You'll always stay right': understanding vaginal products and the motivations for use among adolescent and young women in rural KZN

The use of vaginal products may increase the risk of HIV infection by affecting the vaginal biome. Understanding what vaginal products young women are using, and why, is key to assessing the complexity of sexual health and risk. This study reports on findings from research with adolescent and young women in rural KwaZulu-Natal about the vaginal products they use and motivations for using them. The study identified over 26 products that young women used to enhance their sexual experience and found some young women spent time preparing and sourcing vaginal products in order to pleasure and retain partners. Opinions differed about vaginal product use. While some women perceived that vaginal products could provide a means of out-performing other women, retaining a partner and providing sexual autonomy, there was a stigma attached to using them. Study findings highlight the social value of using vaginal products, especially in settings where partner retention is linked to economic survival. Expanding our understanding of what products are used and the reasons young women use them warrants continued investigation.

Predictors of non adherence to antiretroviral therapy at an urban HIV care and treatment center in Tanzania

BACKGROUND

Measurement of adherence to antiretroviral therapy (ART) can serve as a proxy for virologic failure in resource-limited settings. The aim of this study was to determine the factors underlying nonadherence measured by three methods.

PATIENTS AND METHODS

This is a prospective longitudinal cohort of 220 patients on ART at Amana Hospital in Dar es Salaam, Tanzania. We measured adherence using a structured questionnaire combining a visual analog scale (VAS) and Swiss HIV Cohort Study Adherence Questionnaire (SHCS-AQ), pharmacy refill, and appointment keeping during four periods over 1 year. Overall adherence was calculated as the mean adherence for all time points over the 1 year of follow-up. At each time point, adherence was defined as achieving a validated cutoff for adherence previously defined for each method.

RESULTS

The proportion of overall adherence was 86.4% by VAS, 69% by SHCS-AQ, 79.8% by appointment keeping, and 51.8% by pharmacy refill. Forgetfulness was the major reported reason for patients to skip their medications. In multivariate analysis, significant predictors to good adherence were older age, less alcohol consumption, more advanced World Health Organization clinical staging, and having a lower body mass index with odds ratio (CI): 3.11 (1.55-6.93), 0.24 (0.09-0.62), 1.78 (1.14-2.84), and 0.93 (0.88-0.98), respectively.

CONCLUSION

We found relatively good adherence to ART in this setting. Barriers to adherence include young age and perception of well-being.

Loss to Follow-up Trends in HIV-Positive Patients Receiving Antiretroviral Treatment in Asia From 2003 to 2013

INTRODUCTION

Over time, there has been a substantial improvement in antiretroviral treatment (ART) programs, including expansion of services and increased patient engagement. We describe time trends in, and factors associated with, loss to follow-up (LTFU) in HIV-positive patients receiving ART in Asia.

METHODS

Analysis included HIV-positive adults initiating ART in 2003-2013 at 7 ART programs in Asia. Patients LTFU had not attended the clinic for ≥180 days, had not died, or transferred to another clinic. Patients were censored at recent clinic visit, follow-up to January 2014. We used cumulative incidence to compare LTFU and mortality between years of ART initiation. Factors associated with LTFU were evaluated using a competing risks regression model, adjusted for clinical site.

RESULTS

A total of 8305 patients were included. There were 743 patients LTFU and 352 deaths over 26,217 person-years (pys), a crude LTFU, and mortality rate of 2.83 (2.64-3.05) per 100 pys and 1.34 (1.21-1.49) per 100 pys, respectively. At 24 months, the cumulative LTFU incidence increased from 4.3% (2.9%-6.1%) in 2003-05 to 8.1% (7.1%-9.2%) in 2006-09 and then decreased to 6.7% (5.9%-7.5%) in 2010-13. Concurrently, the cumulative mortality incidence decreased from 6.2% (4.5%-8.2%) in 2003-05 to 3.3% (2.8%-3.9%) in 2010-13. The risk of LTFU reduced in 2010-13 compared with 2006-09 (adjusted subhazard ratio = 0.73, 0.69-0.99).

CONCLUSIONS

LTFU rates in HIV-positive patients receiving ART in our clinical sites have varied by the year of ART initiation, with rates declining in recent years whereas mortality rates have remained stable. Further increases in site-level resources are likely to contribute to additional reductions in LTFU for patients initiating in subsequent years.

Strategies for monitoring and evaluation of resource-limited national antiretroviral therapy programs: the two-phase design

BACKGROUND

In resource-limited settings, monitoring and evaluation (M&E) of antiretroviral treatment (ART) programs often relies on aggregated facility-level data. Such data are limited, however, because of the potential for ecological bias, although collecting detailed patient-level data is often prohibitively expensive. To resolve this dilemma, we propose the use of the two-phase design. Specifically, when the outcome of interest is binary, the two-phase design provides a framework within which researchers can resolve ecological bias through the collection of patient-level data on a sub-sample of individuals while making use of the routinely collected aggregated data to obtain potentially substantial efficiency gains.

METHODS

Between 2005-2007, the Malawian Ministry of Health conducted a one-time cross-sectional survey of 82,887 patients registered at 189 ART clinics. Using these patient data, an aggregated dataset is constructed to mimic the type of data that it routinely available. A hypothetical study of risk factors for patient outcomes at 6 months post-registration is considered. Analyses are conducted based on: (i) complete patient-level data; (ii) aggregated data; (iii) a hypothetical case-control study; (iv) a hypothetical two-phase study stratified on clinic type; and, (v) a hypothetical two-phase study stratified on clinic type and registration year. A simulation study is conducted to compare statistical power to detect an interaction between clinic type and year of registration across the designs.

RESULTS

Analyses and conclusions based solely on aggregated data may suffer from ecological bias. Collecting and analyzing patient data using either a case-control or two-phase design resolves ecological bias to provide valid conclusions. To detect the interaction between clinic type and year of registration, the case-control design would require a prohibitively large sample size. In contrast, a two-phase design that stratifies on clinic and year of registration achieves greater than 85% power with as few as 1,000 patient samples.

CONCLUSIONS

Two-phase designs have the potential to augment current M&E efforts in resource-limited settings by providing a framework for the collection and analysis of patient data. The design is cost-efficient in the sense that it often requires far fewer patients to be sampled when compared to standard designs.

Transitions in caregiving and health dynamics of caregivers for people with AIDS: a prospective study of caregivers in Nairobi Slums, Kenya

OBJECTIVE

A cohort of older people living in a low-resource setting in Nairobi is followed to understand the transitions in caregiving status and trajectories in health over a 3-year period.

METHODS

Three categories of older people comprising 65 AIDS caregivers, 102 Other caregivers and 1,322 noncaregivers identified at baseline were assessed at end-line based on two self-reported health outcome measures, a functionality score and having a severe health problem.

RESULTS

A majority of caregivers were still providing care at the end of the study, and or had taken on new care recipients. Compared with noncaregivers, AIDS caregivers reported poor health, with men more likely to report poor health than women. New caregivers also reported poorer health compared with noncaregivers.

DISCUSSION

The results indicate improvement in health over time among male caregivers supporting the adaptation model. We recommend timely programs to support caregivers particularly at the onset of caregiving.

A novel Markov model projecting costs and outcomes of providing antiretroviral therapy to public patients in private practices versus public clinics in South Africa

INTRODUCTION

Providing private antiretroviral therapy (ART) care for public sector patients could increase access to ART in low- and middle-income countries. We compared the costs and outcomes of a private-care and a public-care ART program in South Africa.

METHODS

A novel Markov model was developed from the public-care program. Patients were first tunneled for 6 months in their baseline CD4 category before being distributed into a dynamic CD4 and viral load model. Patients were allowed to return to ART care from loss to follow up (LTFU). We then populated this modeling framework with estimates derived from the private-care program to externally validate the model.

RESULTS

Baseline characteristics were similar in the two programs. Clinic visit utilization was higher and death rates were lower in the first few years on ART in the public-care program. After 10 years on ART we estimated the following outcomes in the public-care and private-care programs respectively: viral load <1000 copies/ml 89% and 84%, CD4 >500 cells/μl 33% and 37%, LTFU 14% and 14%, and death 27% and 32%. Lifetime undiscounted survival estimates were 14.1 (95%CI 13.2-14.9) and (95%CI 12.7-14.5) years with costs of 18,734 (95%CI 12,588-14,022) and 13,062 (95%CI 12,077-14,047) USD in the private-care and public-care programs respectively. When clinic visit utilization in the public-care program was reduced by two thirds after the initial 6 months on ART, which is similar to their current practice, the costs were comparable between the programs.

CONCLUSIONS

Using a novel Markov model, we determined that the private-care program had similar outcomes but lower costs than the public-care program, largely due to lower visit frequencies. These findings have important implications for increasing and sustaining coverage of patients in need of ART care in resource-limited settings.

Temporal changes in programme outcomes among adult patients initiating antiretroviral therapy across South Africa, 2002-2007

OBJECTIVE

Little is known about the temporal impact of the rapid scale-up of large antiretroviral therapy (ART) services on programme outcomes. We describe patient outcomes [mortality, loss-to-follow-up (LTFU) and retention] over time in a network of South African ART cohorts.

DESIGN

Cohort analysis utilizing routinely collected patient data.

METHODS

Analysis included adults initiating ART in eight public sector programmes across South Africa, 2002-2007. Follow-up was censored at the end of 2008. Kaplan-Meier methods were used to estimate time to outcomes, and proportional hazards models to examine independent predictors of outcomes.

RESULTS

Enrolment (n = 44 177, mean age 35 years; 68% women) increased 12-fold over 5 years, with 63% of patients enrolled in the past 2 years. Twelve-month mortality decreased from 9% to 6% over 5 years. Twelve-month LTFU increased annually from 1% (2002/2003) to 13% (2006). Cumulative LTFU increased with follow-up from 14% at 12 months to 29% at 36 months. With each additional year on ART, failure to retain participants was increasingly attributable to LTFU compared with recorded mortality. At 12 and 36 months, respectively, 80 and 64% of patients were retained.

CONCLUSION

Numbers on ART have increased rapidly in South Africa, but the programme has experienced deteriorating patient retention over time, particularly due to apparent LTFU. This may represent true loss to care, but may also reflect administrative error and lack of capacity to monitor movements in and out of care. New strategies are needed for South Africa and other low-income and middle-income countries to improve monitoring of outcomes and maximize retention in care with increasing programme size.

Scale-up of a decentralized HIV treatment programme in rural KwaZulu-Natal, South Africa: does rapid expansion affect patient outcomes?

OBJECTIVE

To describe the scale-up of a decentralized HIV treatment programme delivered through the primary health care system in rural KwaZulu-Natal, South Africa, and to assess trends in baseline characteristics and outcomes in the study population.

METHODS

The programme started delivery of antiretroviral therapy (ART) in October 2004. Information on all patients initiated on ART was captured in the programme database and follow-up status was updated monthly. All adult patients (> or = 16 years) who initiated ART between October 2004 and September 2008 were included and stratified into 6-month groups. Clinical and sociodemographic characteristics were compared between the groups. Retention in care, mortality, loss to follow-up and virological outcomes were assessed at 12 months post-ART initiation.

FINDINGS

A total of 5719 adults initiated on ART were included (67.9% female). Median baseline CD4+ lymphocyte count was 116 cells/microl (interquartile range, IQR: 53-173). There was an increase in the proportion of women who initiated ART while pregnant but no change in other baseline characteristics over time. Overall retention in care at 12 months was 84.0% (95% confidence interval, CI: 82.6-85.3); 10.9% died (95% CI: 9.8-12.0); 3.7% were lost to follow-up (95% CI: 3.0-4.4). Mortality was highest in the first 3 months after ART initiation: 30.1 deaths per 100 person-years (95% CI: 26.3-34.5). At 12 months 23.0% had a detectable viral load (> 25 copies/ml) (95% CI: 19.5-25.5).

CONCLUSION

Outcomes were not affected by rapid expansion of this decentralized HIV treatment programme. The relatively high rates of detectable viral load highlight the need for further efforts to improve the quality of services.

Scaling up in international health: what are the key issues?

The term 'scaling up' is now widely used in the international health literature, though it lacks an agreed definition. We review what is meant by scaling up in the context of changes in international health and development over the last decade. We argue that the notion of scaling up is primarily used to describe the ambition or process of expanding the coverage of health interventions, though the term has also referred to increasing the financial, human and capital resources required to expand coverage. We discuss four pertinent issues in scaling up the coverage of health interventions: the costs of scaling up coverage; constraints to scaling up; equity and quality concerns; and key service delivery issues when scaling up. We then review recent progress in scaling up the coverage of health interventions. This includes a considerable increase in the volume of aid, accompanied by numerous new health initiatives and financing mechanisms. There have also been improvements in health outcomes and some examples of successful large-scale programmes. Finally, we reflect on the importance of obtaining a better understanding of how to deliver priority health interventions at scale, the current emphasis on health system strengthening and the challenges of sustaining scaling up in the prevailing global economic environment.

What happens to patients on antiretroviral therapy who transfer out to another facility?

BACKGROUND

Long term retention of patients on antiretroviral therapy (ART) in Africa's rapidly expanding programmes is said to be 60% at 2 years. Many reports from African ART programmes make little mention of patients who are transferred out to another facility, yet Malawi's national figures show a transfer out of 9%. There is no published information about what happens to patients who transfer-out, but this is important because if they transfer-in and stay alive in these other facilities then national retention figures will be better than previously reported.

METHODOLOGY/PRINCIPAL FINDINGS

Of all patients started on ART over a three year period in Mzuzu Central Hospital, North Region, Malawi, those who transferred out were identified from the ART register and master cards. Clinic staff attempted to trace these patients to determine whether they had transferred in to a new ART facility and their outcome status. There were 805 patients (19% of the total cohort) who transferred out, of whom 737 (92%) were traced as having transferred in to a new ART facility, with a median time of 1.3 months between transferring-out and transferring-in. Survival probability was superior and deaths were lower in the transfer-out patients compared with those who did not transfer.

CONCLUSION/SIGNIFICANCE

In Mzuzu Central Hospital, patients who transfer-out constitute a large proportion of patients not retained on ART at their original clinic of registration. Good documentation of transfer-outs and transfer-ins are needed to keep track of national outcomes. Furthermore, the current practice of regarding transfer-outs as being double counted in national cohorts and subtracting this number from the total national registrations to get the number of new patients started on ART is correct.