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Tiam A, Paulin H, Machekano R, Oboho I, Agyemang E, Mugyenyi FA, Maama-Maime L, Mengistu Y, Chatora T, Mungati M, Mokone M, Mots’oane T, Masheane A, Tukei V. Rapid antiretroviral therapy initiation in patients with advanced HIV disease: 6-month outcomes of an observational cohort evaluation in Lesotho. PLoS One 2023; 18:e0292660. [PMID: 37819941 PMCID: PMC10566720 DOI: 10.1371/journal.pone.0292660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 09/26/2023] [Indexed: 10/13/2023] Open
Abstract
For adults and adolescents, the World Health Organization defines advanced HIV disease (AHD) as a CD4 (cluster of differentiation 4) count of <200 cells/mm3 or a clinical stage 3 or 4 event. We describe clinical outcomes in a cohort of AHD patients at two regional hospitals in Lesotho. From November 2018-June 2019, we prospectively enrolled eligible patients (≥15 years) not on antiretroviral therapy (ART) presenting with WHO-defined AHD into a differentiated model of care for AHD (including rapid ART initiation) and followed them for six months. All patients received Tuberculosis (TB) symptom screening with further diagnostic testing; serum cryptococcal antigen (CrAg) screening was done for CD4 <100 cells/mm3 or WHO clinical stage 3 or 4. Medical record data were abstracted using visit checklist forms. Categorical and continuous variables were summarized using frequencies, percentages, and means, respectively. Kaplan-Meier was used to estimate survival. Of 537 HIV-positive patients screened, 150 (27.9%) had AHD of which 109 were enrolled. Mean age was 38 years and 62 (56.9%) were men. At initial clinic visit, 8 (7.3%) were already on treatment and 33% (36/109) had presumptive TB per symptom screening. Among 39/109 (40.2%) patients screened for CrAg at initial visit, five (12.8%) were CrAg-positive. Among 109 enrolled, 77 (70.6%) initiated ART at their initial clinic visit, while 32 delayed ART initiation (median delay: 14 days). Of the 109 participants enrolled, 76 (69.7%) completed the 6-month follow-up, 17 (15.6%) were lost to follow-up, 5 (4.6%) transferred to other health facilities and 11 (10.1%) died. The 6-month survival was 87.4%; among 74 patients with a viral load result, 6-month viral suppression (<1,000 copies/ml) was 85.1%. Our study found that even after the implementation of Test and Treat of ART in 2016 in Lesotho, over 25% of patients screened had AHD. Patients with AHD had a high prevalence of TB and CrAg positivity, underscoring the need to assess for AHD and rapidly initiate ART within a package of AHD care for optimal patient outcomes.
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Affiliation(s)
- Appolinaire Tiam
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, United States of America
| | - Heather Paulin
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Rhoderick Machekano
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, United States of America
| | - Ikwo Oboho
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Elfriede Agyemang
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | | | | | - Tsitsi Chatora
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - More Mungati
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | | | | | | | - Vincent Tukei
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
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Mesic A, Homan T, Lenglet A, Thit P, Mar HT, Sabai SM, Thandar MP, Thwe TT, Kyaw AA, Decroo T, Spina A, Ariti C, Ritmeijer K, Van Olmen J, Oo HN, Lynen L. Advanced HIV disease and associated attrition after re-engagement in HIV care in Myanmar from 2003 to 2019: a retrospective cohort study. Int Health 2023; 15:453-461. [PMID: 36318805 PMCID: PMC10318975 DOI: 10.1093/inthealth/ihac069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/02/2022] [Accepted: 10/12/2022] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND The burden of advanced HIV disease (AHD) and predictors of outcomes among people living with HIV (PLHIV) re-engaging in care are not well known. METHODS We conducted a retrospective cohort study of PLHIV who re-engaged in care after being lost to follow-up (LFU), from 2003 to 2019, in Myanmar. We calculated the incidence rates of attrition after re-engagement and performed Cox regression to identify risk factors for attrition. RESULTS Of 44 131 PLHIV who started antiretroviral treatment, 12 338 (28.0%) were LFU at least once: 7608 (61.6%) re-engaged in care, 4672 (61.4%) with AHD at re-engagement. The death and LFU rates were 2.21-fold (95% CI 1.82 to 2.67) and 1.46-fold (95% CI 1.33 to 1.61) higher among patients who re-engaged with AHD (p>0.001). Death in patients who re-engaged with AHD was associated with male sex (adjusted HR [aHR] 2.63; 95% CI 1.31 to 5.26; p=0.006), TB coinfection (aHR 2.26; 95% CI 1.23 to 4.14; p=0.008) and sex work (aHR 7.49, 95% CI 2.29 to 22.52; p<0.001). History of intravenous drug use was identified as a predictor of being LFU. CONCLUSIONS Re-engagement in HIV care in Myanmar is frequent and those who re-engage carry a high burden of AHD. As AHD at re-engagement is associated with higher attrition rates, implementation of differentiated interventions that enable earlier linkage to care and prompt identification and management of AHD in this population is necessary.
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Affiliation(s)
- Anita Mesic
- Corresponding author: Tel: +31(0)657879595; E-mail:
| | - Tobias Homan
- Médecins Sans Frontières, No 5/59, Ayeyadanar Street, Thirigon Villa, Waizayandar Road, Thingangyun Township, 11071, Yangon, Myanmar
| | - Annick Lenglet
- Médecins Sans Frontières, Public Health Department, Plantage Middenlaan 14, 1001DD, Amsterdam, The Netherlands
- Department of Medical Microbiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Phone Thit
- Médecins Sans Frontières, No 5/59, Ayeyadanar Street, Thirigon Villa, Waizayandar Road, Thingangyun Township, 11071, Yangon, Myanmar
| | - Htay Thet Mar
- Médecins Sans Frontières, No 5/59, Ayeyadanar Street, Thirigon Villa, Waizayandar Road, Thingangyun Township, 11071, Yangon, Myanmar
| | - Saw Myat Sabai
- Médecins Sans Frontières, No 5/59, Ayeyadanar Street, Thirigon Villa, Waizayandar Road, Thingangyun Township, 11071, Yangon, Myanmar
| | - Moe Pyae Thandar
- Médecins Sans Frontières, No 5/59, Ayeyadanar Street, Thirigon Villa, Waizayandar Road, Thingangyun Township, 11071, Yangon, Myanmar
| | - Thin Thin Thwe
- Médecins Sans Frontières, No 5/59, Ayeyadanar Street, Thirigon Villa, Waizayandar Road, Thingangyun Township, 11071, Yangon, Myanmar
| | - Aung Aung Kyaw
- Médecins Sans Frontières, No 5/59, Ayeyadanar Street, Thirigon Villa, Waizayandar Road, Thingangyun Township, 11071, Yangon, Myanmar
| | - Tom Decroo
- Department of Clinical Sciences, Institute of Tropical Medicine, Kronenburgstraat 43, 2000, Antwerpen, Belgium
- Research Foundation Flanders, Egmontstraat 5, 1000, Brussels, Belgium
| | - Alexander Spina
- University of Exeter Medical School, Heavitree Road, Exeter EX1 2LU, UK
| | - Cono Ariti
- Centre for Trials Research, Cardiff University Medical School, Heath Park Cardiff, CF14 4XN, Cardiff, UK
| | - Koert Ritmeijer
- Médecins Sans Frontières, Public Health Department, Plantage Middenlaan 14, 1001DD, Amsterdam, The Netherlands
| | - Josefien Van Olmen
- Department of Clinical Sciences, Institute of Tropical Medicine, Kronenburgstraat 43, 2000, Antwerpen, Belgium
- Department of Family Medicine and Population Health, University of Antwerp, Doornstraat 331 2610, Antwerpen, Belgium
| | - Htun Nyunt Oo
- Ministry of Health and Sports, National AIDS Programme, Office No. 47, 15011, Nay Pyi Taw, Myanmar
| | - Lutgarde Lynen
- Department of Family Medicine and Population Health, University of Antwerp, Doornstraat 331 2610, Antwerpen, Belgium
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Stöger L, Katende A, Mapesi H, Kalinjuma AV, van Essen L, Klimkait T, Battegay M, Weisser M, Letang E. Persistent High Burden and Mortality Associated With Advanced HIV Disease in Rural Tanzania Despite Uptake of World Health Organization "Test and Treat" Guidelines. Open Forum Infect Dis 2022; 9:ofac611. [PMID: 36540386 PMCID: PMC9757676 DOI: 10.1093/ofid/ofac611] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Information about burden, characteristics, predictors, and outcomes of advanced human immunodeficiency virus disease (AHD) is scarce in rural settings of sub-Saharan Africa. Human immunodeficiency virus (HIV) infections and associated deaths remain high despite specific guidelines issued by the World Health Organization (WHO). METHODS Burden of AHD and 6-month death/loss to follow-up (LTFU) were described among 2498 antiretroviral therapy (ART)-naive nonpregnant people with HIV (PWH) aged >15 years enrolled in the Kilombero Ulanga Antiretroviral Cohort in rural Tanzania between 2013 and 2019. Baseline characteristics associated with AHD and predictors of death/LTFU among those with AHD were analyzed using multivariate logistic and Cox regression, respectively. RESULTS Of the PWH, 62.2% had AHD at diagnosis (66.8% before vs 55.7% after national uptake of WHO "test and treat" guidelines in 2016). At baseline, older age, male sex, lower body mass index, elevated aminotransferase aspartate levels, severe anemia, tachycardia, decreased glomerular filtration rate, clinical complaints, impaired functional status, and enrollment into care before 2018 were independently associated with AHD. Among people with AHD, incidence of mortality, and LTFU were 16 and 34 per 100 person-years, respectively. WHO clinical stage 3 or 4, CD4 counts <100 cells/µL, severe anemia, tachypnea, and liver disease were associated with death/LTFU. CONCLUSIONS More than 50% of PWH enrolled in our cohort after test and treat implementation still had AHD at diagnosis. Increasing HIV testing and uptake and implementation of the WHO-specific guidelines on AHD for prevention, diagnosis, treatment of opportunistic infections, and reducing the risks of LTFU are urgently needed to reduce morbidity and mortality.
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Affiliation(s)
- Linda Stöger
- ISGlobal, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | | | - Herry Mapesi
- Ifakara Health Institute, Ifakara, Tanzania,Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Aneth V Kalinjuma
- Ifakara Health Institute, Ifakara, Tanzania,Faculty of Health Sciences, Department of Epidemiology and Biostatistics, University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Liselot van Essen
- Gerion, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Thomas Klimkait
- Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland
| | - Manuel Battegay
- Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Maja Weisser
- Ifakara Health Institute, Ifakara, Tanzania,Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland,Swiss Tropical and Public Health Institute, Basel, Switzerland,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Emilio Letang
- Correspondence: Emilio Letang, MD, MPH, PhD, Barcelona Institute for Global Health, Rosselló 132, 4.1, Barcelona 08036, Spain ()
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Longitudinal analysis of sociodemographic, clinical and therapeutic factors of HIV-infected individuals in Kinshasa at antiretroviral therapy initiation during 2006-2017. PLoS One 2021; 16:e0259073. [PMID: 34739506 PMCID: PMC8570501 DOI: 10.1371/journal.pone.0259073] [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] [Received: 10/29/2020] [Accepted: 10/12/2021] [Indexed: 11/22/2022] Open
Abstract
Background The benefits of antiretroviral therapy (ART) underpin the recommendations for the early detection of HIV infection and ART initiation. Late initiation (LI) of antiretroviral therapy compromises the benefits of ART both individually and in the community. Indeed, it promotes the transmission of infection and higher HIV-related morbidity and mortality with complicated and costly clinical management. This study aims to analyze the evolutionary trends in the median CD4 count, the median time to initiation of ART, the proportion of patients with advanced HIV disease at the initiation of ART between 2006 and 2017 and their factors. Methods and findings HIV-positive adults (≥ 16 years old) who initiated ART between January 1, 2006 and December 31, 2017 in 25 HIV care facilities in Kinshasa, the capital of DRC, were eligible. The data were processed anonymously. LI is defined as CD4≤350 cells/μl and/or WHO clinical stage III or IV and advanced HIV disease (AHD), as CD4≤200 cells/μl and/or stage WHO clinic IV. Factors associated with advanced HIV disease at ART initiation were analyzed, irrespective of year of enrollment in HIV care, using logistic regression models. A total of 7278 patients (55% admitted after 2013) with an average age of 40.9 years were included. The majority were composed of women (71%), highly educated women (68%) and married or widowed women (61%). The median CD4 was 213 cells/μl, 76.7% of patients had CD4≤350 cells/μl, 46.1% had CD4≤200 cells/μl, and 59% of patients were at WHO clinical stages 3 or 4. Men had a more advanced clinical stage (p <0.046) and immunosuppression (p<0.0007) than women. Overall, 70% of patients started ART late, and 25% had AHD. Between 2006 and 2017, the median CD4 count increased from 190 cells/μl to 331 cells/μl (p<0.0001), and the proportions of patients with LI and AHD decreased from 76% to 47% (p< 0.0001) and from 18.7% to 8.9% (p<0.0001), respectively. The median time to initiation of ART after screening for HIV infection decreased from 40 to zero months (p<0.0001), and the proportion of time to initiation of ART in the month increased from 39 to 93.3% (p<0.0001) in the same period. The probability of LI of ART was higher in married couples (OR: 1.7; 95% CI: 1.3–2.3) (p<0.0007) and lower in patients with higher education (OR: 0.74; 95% CI: 0.64–0.86) (p<0.0001). Conclusion Despite increasingly rapid treatment, the proportions of LI and AHD remain high. New approaches to early detection, the first condition for early ART and a key to ending the HIV epidemic, such as home and work HIV testing, HIV self-testing and screening at the point of service, must be implemented.
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Izco S, Murias‐Closas A, Jordan AM, Greene G, Catorze N, Chiconela H, Garcia JI, Blanco‐Arevalo A, Febrer A, Casellas A, Saavedra B, Chiller T, Nhampossa T, Garcia‐Basteiro A, Letang E. Improved detection and management of advanced HIV disease through a community adult TB-contact tracing intervention with same-day provision of the WHO-recommended package of care including ART initiation in a rural district of Mozambique. J Int AIDS Soc 2021; 24:e25775. [PMID: 34347366 PMCID: PMC8336616 DOI: 10.1002/jia2.25775] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 06/02/2021] [Accepted: 07/05/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION AIDS-mortality remains unacceptably high in sub-Saharan Africa, largely driven by advanced HIV disease (AHD). We nested a study in an existing tuberculosis (TB) contact-tracing intervention (Xpatial-TB). The aim was to assess the burden of AHD among high-risk people living with HIV (PLHIV) identified and to evaluate the provision of the WHO-recommended package of care to this population. METHODS All PLHIV ≥14 years old identified between June and December 2018 in Manhiça District by Xpatial-TB were offered to participate in the study if ART naïve or had suboptimal ART adherence. Consenting individuals were screened for AHD. Patients with AHD (CD4 < 200 cells/μL or WHO stage 3 or 4) were offered a package of interventions in a single visit, including testing for cryptococcal antigen (CrAg) and TB-lipoarabinomannan (TB-LAM), prophylaxis and treatment for opportunistic infections, adherence support or accelerated ART initiation. We collected information on follow-up visits carried out under routine programmatic conditions for six months. RESULTS A total of 2881 adults were identified in the Xpatial TB-contact intervention. Overall, 23% (673/2881) were HIV positive, including 351 TB index (64.2%) and 322 TB contacts (13.8%). Overall, 159/673 PLHIV (24%) were ART naïve or had suboptimal ART adherence, of whom 155 (97%, 124 TB index and 31 TB-contacts) consented to the study and were screened for AHD. Seventy percent of TB index-patients (87/124) and 16% of TB contacts (5/31) had CD4 < 200 cells/µL. Four (13%) of the TB contacts had TB, giving an overall AHD prevalence among TB contacts of 29% (9/31). Serum-CrAg was positive in 4.6% (4/87) of TB-index patients and in zero TB contacts. All ART naïve TB contacts without TB initiated ART within 48 hours of HIV diagnosis. Among TB cases, ART timing was tailored to the presence of TB and cryptococcosis. Six-month mortality was 21% among TB-index cases and zero in TB contacts. CONCLUSIONS A TB contact-tracing outreach intervention identified undiagnosed HIV and AHD in TB patients and their contacts, undiagnosed cryptococcosis among TB patients, and resulted in an adequate provision of the WHO-recommended package of care in this rural Mozambican population. Same-day and accelerated ART initiation was feasible and safe in this population including among those with AHD.
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Affiliation(s)
- Santiago Izco
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | | | - Alexander M Jordan
- Mycotic Diseases BranchUnited States Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | - Gregory Greene
- Mycotic Diseases BranchUnited States Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | - Nteruma Catorze
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | | | - Juan Ignacio Garcia
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
- PhD Program in Methodology of Biomedical ResearchFaculty of MedicineUniversity of BarcelonaBarcelonaSpain
| | | | - Anna Febrer
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
| | - Aina Casellas
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
| | - Belén Saavedra
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | - Tom Chiller
- Mycotic Diseases BranchUnited States Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | | | - Alberto Garcia‐Basteiro
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Centro de Investigação em Saude de Manhiça (CISM)ManhiçaMozambique
| | - Emilio Letang
- ISGlobal, Hospital Clínic‐Universitat de BarcelonaBarcelonaSpain
- Department of Infectious Diseases Hospital del MarHospital del Mar Research Institute (IMIM)BarcelonaSpain
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Ngongo NM, Nani-Tuma HS, Mambimbi MM, Mashi ML, Izizag BB, Ndolumingu FK, Maes N, Moutschen M, Darcis G. Decrease in late presentation for HIV care in Kinshasa, DRC, 2006-2020. AIDS Res Ther 2021; 18:41. [PMID: 34271957 PMCID: PMC8283988 DOI: 10.1186/s12981-021-00366-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/07/2021] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Late presentation for HIV care is a well-described issue for the success of ART outcomes and the cause of higher morbidity, mortality and further transmission. Monitoring the level of late presentation and understanding the factors associated with it would help to tailor screening and information strategies for better efficiency. We performed a retrospective cohort study in Kinshasa, the capital of the DRC. The studied population included HIV-positive adults newly enrolled in HIV care between January 2006 and June 2020 at 25 HIV urban care facilities. Patient information collected at presentation for HIV care included age, sex, WHO clinical stage and screening context. We used 2 definitions of late presentation: the WHO definition of advanced HIV disease (WHO stage 3/4 or CD4 cell count < 200 cells/mm3) and a more inclusive definition (WHO stage 3/4 or CD4 cell count < 350 cells/mm3). RESULTS A total of 10,137 HIV-infected individuals were included in the analysis. The median age was 40 years; 68% were female. A total of 45.9% or 47.5% of the patients were late presenters, depending on the definition used. The percentage of patients with late presentation (defined as WHO stage 3/4 or CD4 cell count < 350 cells/mm3) decreased during recent years, from 70.7% in 2013 to 46.5% in 2017 and 23.4% in 2020. Age was associated with a significantly higher risk of LP (p < 0.0001). We did not observe any impact of sex. CONCLUSIONS The frequency of late presentation for care is decreasing in Kinshasa, DRC. Efforts have to be continued. In particular, the issue of late diagnosis in older individuals should be addressed.
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Affiliation(s)
- Nadine Mayasi Ngongo
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo.
| | - Hippolyte Situakibanza Nani-Tuma
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Marcel Mbula Mambimbi
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Murielle Longokolo Mashi
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Ben Bepouka Izizag
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Faustin Kitetele Ndolumingu
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Nathalie Maes
- Biostatistics and Medico-economic Information Department, University Hospital of Liege, Liège, Belgium
| | - Michel Moutschen
- Department of Internal Medicine and Infectious Diseases, Liège University Hospital, Liège, Belgium
- AIDS reference laboratory, University of Liège, Liège, Belgium
| | - Gilles Darcis
- Department of Internal Medicine and Infectious Diseases, Liège University Hospital, Liège, Belgium.
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Mesic A, Spina A, Mar HT, Thit P, Decroo T, Lenglet A, Thandar MP, Thwe TT, Kyaw AA, Homan T, Sangma M, Kremer R, Grieg J, Piriou E, Ritmeijer K, Van Olmen J, Lynen L, Oo HN. Predictors of virological failure among people living with HIV receiving first line antiretroviral treatment in Myanmar: retrospective cohort analysis. AIDS Res Ther 2021; 18:16. [PMID: 33882962 PMCID: PMC8059266 DOI: 10.1186/s12981-021-00336-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/08/2021] [Indexed: 12/31/2022] Open
Abstract
Background Progress toward the global target for 95% virological suppression among those on antiretroviral treatment (ART) is still suboptimal. We describe the viral load (VL) cascade, the incidence of virological failure and associated risk factors among people living with HIV receiving first-line ART in an HIV cohort in Myanmar treated by the Médecins Sans Frontières in collaboration with the Ministry of Health and Sports Myanmar. Methods We conducted a retrospective cohort study, including adult patients with at least one HIV viral load test result and having received of at least 6 months’ standard first-line ART. The incidence rate of virological failure (HIV viral load ≥ 1000 copies/mL) was calculated. Multivariable Cox’s regression was performed to identify risk factors for virological failure. Results We included 25,260 patients with a median age of 33.1 years (interquartile range, IQR 28.0–39.1) and a median observation time of 5.4 years (IQR 3.7–7.9). Virological failure was documented in 3,579 (14.2%) participants, resulting in an overall incidence rate for failure of 2.5 per 100 person-years of follow-up. Among those who had a follow-up viral load result, 1,258 (57.1%) had confirmed virological failure, of which 836 (66.5%) were switched to second-line treatment. An increased hazard for failure was associated with age ≤ 19 years (adjusted hazard ratio, aHR 1.51; 95% confidence intervals, CI 1.20–1.89; p < 0.001), baseline tuberculosis (aHR 1.39; 95% CI 1.14–1.49; p < 0.001), a history of low-level viremia (aHR 1.60; 95% CI 1.42–1.81; p < 0.001), or a history of loss-to-follow-up (aHR 1.24; 95% CI 1.41–1.52; p = 0.041) and being on the same regimen (aHR 1.37; 95% CI 1.07–1.76; p < 0.001). Cumulative appointment delay was not significantly associated with failure after controlling for covariates. Conclusions VL monitoring is an important tool to improve programme outcomes, however limited coverage of VL testing and acting on test results hampers its full potential. In our cohort children and adolescents, PLHIV with history of loss-to-follow-up or those with low-viremia are at the highest risk of virological failure and might require more frequent virological monitoring than is currently recommended. Supplementary Information The online version contains supplementary material available at 10.1186/s12981-021-00336-0.
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Dejen D, Jara D, Yeshanew F, Fentaw Z, Mengie Feleke T, Girmaw F, Wagaye B. Attrition and Its Predictors Among Adults Receiving First-Line Antiretroviral Therapy in Woldia Town Public Health Facilities, Northeast Ethiopia: A Retrospective Cohort Study. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2021; 13:445-454. [PMID: 33907472 PMCID: PMC8068483 DOI: 10.2147/hiv.s304657] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/30/2021] [Indexed: 02/04/2023]
Abstract
Introduction There is an expansion and advancement of antiretroviral therapy. However, attrition of patients from HIV care is one of the major drivers of poor performance of HIV/AIDS programs, which leads to drug resistance, morbidity and mortality. The study aimed to assess the incidence of attrition and its predictors among adults receiving first-line antiretroviral therapy. Methods An institution-based retrospective cohort study was conducted among 634 adults receiving antiretroviral therapy, and study participants were selected using a simple random sampling technique. Data were cleaned and entered into Epi Data version 3.1 and exported to STATA 14.1 for further analysis. The predictors of attrition were identified using bivariable and multivariable Cox Proportional hazard models; then, variables at a p-value of less than 0.25 and 0.05 were included in the multivariable analysis and statistically significant, respectively. Results The total time observed was found to be 1807.08 person-years of observation with a median follow-up time of 2.67 years (IQR 1.25−4.67). The incidence rate of attrition was 8.36 (95% CI: 7.12−9.80) per 100 person-years. Significant predictors of attrition were being young age [adjusted hazard ratio (AHR) =2.0, 95% CI, (1.11−3.58)], nearest calendar year of ART initiation [AHR =2.32, 95% CI, (1.08–5.01)], bedridden functional status [AHR=3.25, 95% CI, (1.33−7.96)], WHO stage III [AHR=3.57, 95% CI, (1.58−8.06)] and stage IV [AHR=5.46, 95% CI, (1.97−15.13)], viral load result of ≤1000 [AHR=0.11, 95% CI, (0.06−0.23)], disclosure status [AHR=2.03, 95% CI, (1.22−3.37)] and adherence level of poor [AHR=3.19, 95 CI, (1.67−6.09)]. Conclusion The result of this study showed that the incidence of attrition among adults receiving antiretroviral therapy was high. However, as a standard, every client who started antiretroviral therapy should be retained. Positive predictors of attrition were young age (15–24), recent year of ART initiation, baseline functional status, advanced WHO stage III and IV, no disclosure status, fair/poor adherence whereas, viral load result of ≤1000 copies/mL had a preventive effect on attrition.
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Affiliation(s)
- Demeke Dejen
- Care and Treatment, Amhara Regional Health Bureau CDC Project Cluster Health Facilities HIV Case Detection Linkage, Woldia, Ethiopia
| | - Dube Jara
- Department of Epidemiology and Biostatics, School of Public Health, College of Medicine and Health Science, Addis Ababa University, Addis Ababa, Ethiopia
| | - Fanos Yeshanew
- Department of Public Health Nutrition, School of Public Health, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Zinabu Fentaw
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Tesfa Mengie Feleke
- Amhara Regional Health Bureau CDC Project Zonal Monitoring and Evaluation, Dessie, Ethiopia
| | - Fentaw Girmaw
- Department of Pharmacy, College of Health Science, Woldia University, Woldia, Ethiopia
| | - Birhanu Wagaye
- Department of Public Health Nutrition, School of Public Health, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
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Ndlovu Z, Burton R, Stewart R, Bygrave H, Roberts T, Fajardo E, Mataka A, Szumilin E, Kerschberger B, Van Cutsem G, Ellman T. Framework for the implementation of advanced HIV disease diagnostics in sub-Saharan Africa: programmatic perspectives. Lancet HIV 2020; 7:e514-e520. [PMID: 32473102 DOI: 10.1016/s2352-3018(20)30101-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/16/2020] [Accepted: 03/23/2020] [Indexed: 01/21/2023]
Abstract
Patients with advanced HIV disease have a high risk of mortality, mainly from tuberculosis and cryptococcal meningitis. The advanced HIV disease management package recommended by WHO, which includes diagnostics, therapeutics, and patient psychosocial support, is barely implemented in many different countries. Here, we present a framework for the implementation of advanced HIV disease diagnostics. Laboratory and point-of-care-based reflex testing, coupled with provider-initiated requested testing, for cryptococcal antigen and urinary Mycobacterium tuberculosis lipoarabinomannan antigen, should be done for all patients with CD4+ cell counts of 200 cells per μL or less. Implementation of the advanced HIV disease package should be encouraged within primary health-care facilities and task shifting of testing to lay cadres could facilitate access to rapid results. Implementation of differentiated antiretroviral therapy delivery models can allow clinicians enough time to focus on the management of patients with advanced HIV disease. Efficient up-referral and post-discharge systems, including the development of patient-centric advanced HIV disease literacy, are also crucial. Implementation of the advanced HIV disease package is feasible at all health-care levels, and it should be part of the core of the global response towards ending AIDS as a public health threat.
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Affiliation(s)
- Zibusiso Ndlovu
- Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa.
| | - Rosie Burton
- Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa
| | | | - Helen Bygrave
- Médecins Sans Frontières, Access Campaign, Geneva, Switzerland
| | - Teri Roberts
- Médecins Sans Frontières, Access Campaign, Geneva, Switzerland
| | | | - Anafi Mataka
- African Society for Laboratory Medicine, Addis Ababa, Ethiopia
| | | | | | - Gilles Van Cutsem
- Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Tom Ellman
- Médecins Sans Frontières, Southern African Medical Unit, Cape Town, South Africa
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