Long-term retention on antiretroviral therapy among infants, children, adolescents and adults in Malawi: A cohort study

Malawi's progress towards UNAIDS 95-95-95 fast-track targets: who is lagging?

The HIV and AIDS epidemic remains a critical global health challenge. Malawi accounts for 2.5% of global HIV cases and is a focus country in the UNAIDS 95-95-95 fast-track initiative. Despite reaching 92-95-94 in 2020, there is a need to evaluate Malawi's progress as of 2023 to identify gaps and ensure success before the target period ends. This quantitative descriptive study used secondary data from Malawi's Department of HIV and AIDS Management Information System (DHAMIS) database over a 12-year period (2012-2023) and HIV spectrum estimates. It contains aggregate data from HIV service delivery points. Data included key HIV indicators disaggregated by age and gender. Numerators for the 95-95-95 are: people living with HIV (PLHIV) who know their status, PLHIV on treatment, PLHIV on treatment and virally suppressed. Denominators are: the estimated total PLHIV, PLHIV who know their status and PLHIV on treatment. Statistical analysis was performed using Excel, SPSS and Stata to assess differences between groups. Ethical approval and data access permissions were granted by the Ministry of Health. Between 2012 and 2023, the total number of PLHIV increased from 962 043 to 991 600. The percentage of PLHIV aware of their HIV status increased from 73% to 95%, and those on treatment increased from 58% to 95%. By 2023, 87% of children (under 15 years old) knew their HIV status, compared to 96% of adults. Lower percentages of ART initiation and viral load suppression were also noted among children. While both males and females improved across all indicators, men consistently lagged women in all three indicators. The viral suppression gap narrowed after 2019. Malawi has improved in the HIV treatment cascade between 2012 and 2023. Challenges remain in children ART initiation and access to care for men, requiring targeted efforts to achieve equitable treatment for all and meet the UNAIDS 95-95-95 targets.

Improving HIV testing and retention among adolescents and youths: Lessons from a quasi-experimental study of the Red-Carpet Program in Malawi

Adolescents and youth living with HIV (AYLHIV) often face significant challenges in HIV care. Elizabeth Glaser Pediatric AIDS Foundation in Malawi implemented the Red-Carpet Program (RCP) to provide fast-tracked services for AYLHIV in care.This study aimed to assess the effect of RCP on Provider-Initiated HIV testing, linkage to care and antiretroviral therapy (ART), and retention in care among AYLHIV in Blantyre, Malawi. This quasi-experimental study compared outcomes among newly identified AYLHIV enrolled in four intervention health facilities implementing RCP with those of three non-intervention facilities between July 2020 and March 2021. Non-intervention sites were selected by matching based on patient volumes and baseline retention rates prior to the intervention ensuring comparability with the intervention sites. Proportions and Chi-square tests were used to compare outcomes between the two groups. Kaplan-Meier curves were employed to assess longitudinal outcomes, and Cox regression analysis was used to estimate the hazard of non-retention in care. Data were collected from 475 AYLHIV from RCP sites and 248 AYLHIV from non-intervention sites. In the non-intervention sites, 87% of AYLHIV were female, compared to 78% in the RCP sites. A higher proportion of adolescents (67%) underwent provider-initiated HIV testing at intervention site s than at non-intervention sites (51%), p<0.01. Retention in care was higher in RCP sites, with 67% of AYLHIV in care at 12 months post-initiation compared with 56% in non-intervention sites, p = 0.005. AYLHIV from intervention sites were less likely to experience non-retention than those from non-intervention sites (adjusted Hazard Ratio: 0.47, 95% CI: 0.28-0.80). The implementation of the RCP facilitated higher rates of provider-initiated HIV testing among adolescents and youth. Furthermore, RCP demonstrated the potential to improve retention in care The RCP offers promise for enhancing outcomes among this vulnerable population, emphasizing the need for tailored HIV interventions for adolescents and youth.

Cost-effectiveness analysis of a two-way texting (2wT) intervention to improve ART retention among newly-initiated antiretroviral therapy clients in Malawi

Retention in HIV care is crucial for improved health outcomes. Malawi has a high HIV prevalence and struggles with retention despite significant progress in controlling the epidemic. Mobile health (mHealth) interventions, such as two-way texting (2wT), have shown promise in improving antiretroviral therapy (ART) retention. We explore the cost-effectiveness of a 2wT intervention in Lighthouse Trust's Martin Preuss Center (MPC) in Lilongwe, Malawi, that sends automated SMS visit reminders, weekly motivational messages, and supports direct communication between clients and healthcare workers. Costs and retention (in care at 12 months) rates were compared between 468 2wT and 468 standard of care (SOC) clients. Incremental cost-effectiveness ratios were calculated. Scenario analyses were conducted to estimate costs if 2wT expanded. The 2wT group had higher retention (79%) than SOC (67%) at 12 months post-ART initiation. For 468 clients, the annual costs for 2wT were $36 670.38 compared to SOC's $33 458.72, with an ICER of $24 705 per additional percent of clients retained. With small populations, 2wT is costlier but more effective. However, expanding 2wT to all new ART clients at MPC would save $105 315 per additional percent of clients retained at 12 months. Scaling-up 2wT to four other high-burden facilities (2901 clients) could save $723 739 per additional percent of clients retained in care, suggesting significant potential cost savings. 2wT appears cost-effective to improve 12-month retention among new ART initiates in this setting. Despite potential limitations, mHealth interventions improve client outcomes and save costs, supporting their integration into HIV care programs.

RESUMEN

La retención de pacientes dentro del sistema de salud es crucial en la atención del VIH para obtener mejores resultados de salud. Malaui tiene una alta tasa de prevalencia de VIH y tiene problemas con la retención, a pesar de haber progresado de manera significativa en el control de la epidemia. Intervenciones de salud móvil (mSalud), como los sistemas de mensajes de texto bidireccionales o de doble vía (2wT), han mostrado promesa en términos de aumentar retención en terapia antirretroviral (TAR). Aquí exploramos la relación costo-efectividad de una intervención 2wT en el centro médico Lighthouse Trust's Martin Preuss Center (MPC), en Lilongwe, Malaui, que manda con mensajes SMS recordatorios automatizados de visita, frases motivadoras semanales, y apoya la comunicación directa entre clientes y prestadores de salud. Se compararon los costos y las tasas de retención (aún bajo cuidado tras 12 meses) entre 468 clientes con la intervención 2wT y 468 clientes con el estándar de atención. Se calcularon las relaciones de costo-efectividad incremental (RCEI). Se condujeron análisis de escenarios para estimar el costo de expandir la intervención 2wT. El grupo con 2wT presentó mayor retención (79%) que el de atención estándar (67%), a 12 meses de haber iniciado la TAR. Los costos anuales para 468 clientes con 2wT fueron de $36 670.38, contra $33 458.72 de aquellos que recibieron el estándar, con una RCEI de $24 705 por cada percentil adicional de clientes retenidos. Con poblaciones pequeñas, 2wT es más costoso, aunque más efectivo. Sin embargo, si se expandiera el acceso a 2wT a todos los nuevos clientes de TAR en el MPC, se ahorrarían $105 315 por cada percentil adicional de clientes retenidos 12 meses. Ampliar 2wT a cubrir otros cuatro centros con carga elevada de clientes (2901 clientes) podría ahorrar $723 739 por cada percentil adicional de clientes retenidos bajo cuidado, lo cual sugiere un ahorro potencial muy significativo. en este escenario, el uso de 2wT muestra ser rentable y económicamente eficiente en el aumento de la retención por 12 meses de clientes recién iniciados a la TAR. A pesar de presentar algunas limitaciones potenciales, las intervenciones de mSalud mejoran los resultados de salud de los clientes y ahorran costos, apoyando su expedita integración a los programas de cuidado de VIH.

RESUMO

A retenção nos cuidados de saúde para o VIH é crucial para melhorar os resultados em termos de saúde. O Malawi tem uma elevada prevalência de VIH e debate-se com a retenção, apesar dos progressos significativos no controlo da epidemia. As intervenções de saúde móvel (mHealth), como as mensagens de texto bidireccionais (2wT), mostraram-se promissoras na melhoria da retenção da terapia antirretroviral (ART). Exploramos a relação custo-eficácia de uma intervenção 2wT no Centro Martin Preuss (MPC) da Lighthouse Trust em Lilongwe, Malawi, que envia lembretes automáticos de visitas por SMS, mensagens motivacionais semanais, e apoia a comunicação direta entre clientes e profissionais de saúde. Os custos e as taxas de retenção (nos cuidados de saúde aos 12 meses) foram comparados entre 468 clientes de 2wT e 468 clientes de cuidados padrão (SOC). Foram calculados os rácios de custo-eficácia incrementais (ICER). Foram efetuadas análises de cenários para estimar os custos em caso de expansão do 2wT. O grupo 2wT registou uma maior retenção (79%) do que o grupo SOC (67%) aos 12 meses após o início da TAR. Para 468 clientes, os custos anuais do 2wT foram de 36.670,38 dólares em comparação com os 33.458,72 dólares do SOC, com um ICER de 24.705 dólares por percentagem adicional de clientes retidos. Com populações pequenas, o 2wT é mais caro, mas mais eficaz. No entanto, a expansão do 2wT a todos os novos utentes do TARV no MPC pouparia 105.315 dólares por cada percentagem adicional de utentes retidos aos 12 meses. A expansão do 2wT para quatro outras instalações de alta carga (2.901 clientes) poderia economizar US$ 723.739 por percentagem adicional de clientes retidos nos cuidados, sugerindo um potencial significativo de economia de custos. O 2wT parece ser eficaz em termos de custos para melhorar a retenção de 12 meses entre os novos iniciados no TARV neste contexto. Apesar das potenciais limitações, as intervenções de saúde móvel melhoram os resultados dos clientes e poupam custos, apoiando a sua integração nos programas de cuidados do VIH.

RÉSUMÉ

La rétention dans les soins du VIH est cruciale pour améliorer les résultats en matière de santé. Le Malawi a une prévalence élevée du VIH et a des difficultés pour la rétention malgré des progrès significatifs dans le contrôle de l'épidémie. Les interventions de santé mobile (mHealth), telles que les SMS bidirectionnels (2wT), se sont révélées prometteuses pour améliorer la rétention du traitement antirétroviral (ART). Nous explorons le coût-efficacité d'une intervention 2wT au Martin Preuss Center (MPC) du Lighthouse Trust à Lilongwe, Malawi, qui envoie des rappels de visite par SMS automatisés, des messages de motivation hebdomadaires et assiste la communication directe entre les clients et les agents de santé. Les coûts et les taux de rétention (en soins à 12 mois) ont été comparés entre 468 clients 2wT et 468 clients en soins standards (SS). Des rapports coût-efficacité différentiels (RCED) ont été calculés. Des analyses de scénarios ont été menées pour estimer les coûts si l'intervention 2wT s'étendait. Le groupe 2wT présentait une rétention plus élevée (79%) que le groupe SS (67%) 12 mois après le début de l'ART. Pour 468 clients, les coûts annuels du 2wT étaient de 36 670,38 $, contre 33 458,72 $ pour SS, avec un RCED de 24 705 $ par pourcentage supplémentaire de clients retenus. Avec de petites populations, le 2wT est plus coûteux mais plus efficace. Cependant, l'extension du 2wT à tous les nouveaux clients ART du MPC permettrait d'économiser 105 315 $ par pourcentage supplémentaire de clients retenus à 12 mois. L'extension du 2wT à quatre autres établissements à forte charge de travail (2901 clients) pourrait permettre d'économiser 723 739 $ par pourcentage supplémentaire de clients retenus dans les soins, ce qui suggère des économies potentielles importantes. Le 2wT semble rentable pour améliorer la rétention à 12 mois parmi les nouveaux initiés à l'ART dans ce contexte. Malgré leurs limites potentielles, les interventions mHealth améliorent les résultats pour les clients et permettent de réduire les coûts, favorisant ainsi leur intégration dans les programmes de soins du VIH.

The effect of proactive, interactive, two-way texting on 12-month retention in antiretroviral therapy: Findings from a quasi-experimental study in Lilongwe, Malawi

BACKGROUND

Retaining clients on antiretroviral therapy (ART) is challenging, especially during the first year on ART. Mobile health (mHealth) interventions show promise to close retention gaps. We aimed to assess reach (who received the intervention?) and effectiveness (did it work?) of a hybrid two-way texting (2wT) intervention to improve ART retention at a large public clinic in Lilongwe, Malawi.

METHODS

Between August 2021-June 2023, in a quasi-experimental study, outcomes were compared between two cohorts of new ART clients: 1) those opting into 2wT who received automated, weekly motivation short messaging service (SMS) messages and response-requested appointment reminders; and 2) a matched historical cohort receiving standard of care (SoC). Reach was defined as "the proportion clients ≤6 months of ART initiation eligible for 2wT". 2wT effectiveness was assessed in time-to-event analysis. Retention was presented in a Kaplan-Meier plot and compared between 2wT and SoC using a log-rank test. The effect of 2wT on ART dropout (lost to follow-up or stopped ART) was estimated using Fine-Gray competing risk regression models, adjusting for sex, age and WHO HIV stage at ART initiation.

RESULTS

Of 1,146 clients screened, 501 were eligible for 2wT, a reach of 44%. Lack of phone (393/645; 61%) and illiteracy (149/645; 23%) were the most common ineligibility reasons. Among 468 participants exposed to 2wT, 12-month probability of ART retention was 91% (95% CI: 88% - 94%) compared to 76% (95% CI: 72% - 80%) among 468 SoC participants (p<0.001). Compared to SoC, 2wT participants had a 65% lower hazard of ART dropout at any timepoint (sub-distribution hazard ratio 0.35, 95% CI: 0.24-0.51; p<0.001).

CONCLUSIONS

2wT did not reach all clients. For those who opted-in, 2wT significantly increased 12-month ART retention. Expansion of 2wT as a complement to other retention interventions should be considered in other low-resource, routine ART settings.

Cost-effectiveness analysis of two-way texting (2wT) intervention to improve ART retention among newly-initiated antiretroviral therapy clients in Malawi

Background

Retention in HIV care is crucial for improved health outcomes. Malawi has a high HIV prevalence and struggles with retention despite significant progress in controlling the epidemic. Mobile health (mHealth) interventions, such as two-way texting (2wT), have shown promise in improving anti-retroviral therapy (ART) retention. We explore the cost-effectiveness of a 2wT intervention in Lighthouse Trust's Martin Preuss Center (MPC) in Lilongwe, Malawi, that sends automated SMS visit reminders, weekly motivational messages, and supports direct communication between clients and healthcare workers.

Methods

Costs and retention rates were compared between 2wT and standard of care (SOC) for 468 clients enrolled in each. Incremental cost-effectiveness ratios (ICERs) were calculated. Scenario analyses were conducted to estimate costs if 2wT expanded.

Results

The 2wT group had higher retention (80%) than SOC (67%) at 12 months post-ART initiation. For 468 clients, the total annual costs for 2wT were $36,670.38 as compared to SOC costs at $33,458.72, resulting in an ICER of $24,705. Among scenarios, the ICER was -$105,315 if 2wT expanded to all new clients (2678 at MPC and -$723,739 as 2wT expanded to other four high-burden facilities (2901 clients), suggesting high cost savings if 2wT was effectively scaled.

Conclusion

The 2wT intervention appears cost-effective to improve ART retention among new ART initiates in a high-burden ART clinic. While mHealth interventions have potential limitations, their benefits in improving patient outcomes and cost savings support their integration into HIV care programs.

The effect of proactive, interactive, two-way texting on 12-month retention in antiretroviral therapy: findings from a quasi-experimental study in Lilongwe, Malawi

Background

Retaining clients on antiretroviral therapy (ART) is challenging especially during the first year on ART. Mobile health (mHealth) interventions show promise to close retention gaps. We aimed to assess reach (who received the intervention?) and effectiveness (did it work?) of a hybrid two-way texting (2wT) intervention to improve ART retention at a large public clinic in Lilongwe, Malawi.

Methods

Between August 2021 - June 2023, a quasi-experimental study compared outcomes between two cohorts of new ART clients: 1) those opting into 2wT with combined automated, weekly motivation short messaging service (SMS) messages and response-requested appointment reminders; and 2) a matched historical cohort receiving standard of care (SoC). Reach was defined as "the proportion clients ≤6 months of ART initiation eligible for 2wT". 2wT effectiveness was assessed in time-to-event analysis comparing Kaplan-Meier plots of 6- and 12-month retention between 2wT and SoC using a log-rank test. The effect of 2wT on ART drop out was estimated using multivariable Cox proportional hazard models, adjusting for sex, age and WHO stage at ART initiation.

Results

Of the 1,146 clients screened, 645 were ineligible (56%) largely due to lack of phone access (393/645; 61%) and illiteracy (149/645; 23%): a reach of 44%. Among 468 2wT participants, the 12-month probability of ART retention was 91% (95%CI: 88% - 93%) compared to 75% (95%CI: 71% - 79%) among 468 SoC participants (p<0.0001). Compared to SoC participants, 2wT participants had a 62% lower hazard of dropping out of ART care at all time points (hazard ratio 0.38, 95% CI: 0.26-0.54; p<0.001).

Conclusions

Not all clients were reached with 2wT. For those who opted-in, 2wT reduced drop out throughout the first year on ART and significantly increased 12-month retention. The proactive 2wT approach should be expanded as a complement to other interventions in routine, low-resource settings to improve ART retention.

The Positive Impact of Foods Support on Loss to Follow Up Among Children and Adolescents on HIV Antiretroviral Therapy in a District Hospital in East Cameroon

Introduction

The pediatric HIV treatment coverage in Cameroon remains low at 35%. The high loss to follow up (LTFU) remains a major factor to this dismal performance which is related to the lack of implementation of effective interventions to improve retention in care. This study assessed the impact of foods support (FS) on LTFU among children and adolescents in a rural district hospital in eastern Cameroon.

Methods

This was a retro-prospective study conducted in Abong Mbang District Hospital (ADH) in the East Region of Cameroon. We provided foods kits to children and adolescents initiated on antiretroviral therapy (ART) in this facility during the study and followed them up prospectively (prospective phase). On the other hand, using medical records, we collected retrospectively data for children and adolescents who enrolled on ART in the hospital prior to the study (retrospective phase). We then compared the proportions of children and adolescents LTFU before (no FS) and after (with FS) the study, using the Fisher's exact test, logistic regression, Kaplan-Meier survival curves and Cox proportional-hazards model at 5% significant level.

Results

We found that with FS, the proportion of children and adolescents LTFU was 11 times lower (2.4% vs 26.7%, p=0.014), the mean time of retention in care was 30% higher (17 months vs 12 months, p<0.001) and children and adolescents who did not receive FS were 10 times more likely to be LTFU [aHR=10.3 (4.0-26.2), p<0.001)].

Conclusion

Foods support is an effective intervention in reducing LTFU among children and adolescents on ART. This intervention should be adequately funded to enable a large-scale implementation in the field. This could help to improve the outcome of pediatric ART coverage in resource-limited settings.

Historical visit attendance as predictor of treatment interruption in South African HIV patients: Extension of a validated machine learning model

Retention of antiretroviral (ART) patients is a priority for achieving HIV epidemic control in South Africa. While machine-learning methods are being increasingly utilised to identify high risk populations for suboptimal HIV service utilisation, they are limited in terms of explaining relationships between predictors. To further understand these relationships, we implemented machine learning methods optimised for predictive power and traditional statistical methods. We used routinely collected electronic medical record (EMR) data to evaluate longitudinal predictors of lost-to-follow up (LTFU) and temporal interruptions in treatment (IIT) in the first two years of treatment for ART patients in the Gauteng and North West provinces of South Africa. Of the 191,162 ART patients and 1,833,248 visits analysed, 49% experienced at least one IIT and 85% of those returned for a subsequent clinical visit. Patients iteratively transition in and out of treatment indicating that ART retention in South Africa is likely underestimated. Historical visit attendance is shown to be predictive of IIT using machine learning, log binomial regression and survival analyses. Using a previously developed categorical boosting (CatBoost) algorithm, we demonstrate that historical visit attendance alone is able to predict almost half of next missed visits. With the addition of baseline demographic and clinical features, this model is able to predict up to 60% of next missed ART visits with a sensitivity of 61.9% (95% CI: 61.5-62.3%), specificity of 66.5% (95% CI: 66.4-66.7%), and positive predictive value of 19.7% (95% CI: 19.5-19.9%). While the full usage of this model is relevant for settings where infrastructure exists to extract EMR data and run computations in real-time, historical visits attendance alone can be used to identify those at risk of disengaging from HIV care in the absence of other behavioural or observable risk factors.

Improving retention and HIV viral load suppression among adolescents living with HIV in TASO Soroti and TASO Mbale centers of excellence using Operation Triple Zero model: a before and after study protocol

BACKGROUND

Retention in care and HIV viral load suppression remains sub-optimal among HIV positive adolescents in many settings including TASO Uganda, despite the implementation of interventions such as regimen optimization and community-based approaches like multi-month drug dispensing. To this end, the implementation of additional intervention is urgently required to address gaps in current programming which include inadequate centralization of the HIV positive adolescents and their caregivers in the designs. This study, thus, proposes to adapt and implement the Operation Triple Zero (OTZ) model in TASO Soroti and Mbale centers to improve both retention and viral load suppression among the adolescents living with HIV.

METHODOLOGY

A before and after study design is preferred, employing both qualitative and quantitative approaches. To identify barriers and facilitators to retention and HIV viral load suppression among the HIV positive adolescents, secondary data, focused group discussions, and key informant interviews will be used to understand perspectives of the adolescents, their caregivers, and the health-workers. The Consolidated Framework for Implementation Research (CFIR) will help in designing the intervention, while Knowledge to Action (K2A) will support the adaptation process. To test the intervention, Reach, Effectiveness, Adaption, Implementation and Maintenance (RE-AIM) framework will be used. A paired t-test will be used to compare means of retention and viral load suppression in the before and after study periods.

DISCUSSION

This study aims at adapting and implementing the OTZ model in TASO Soroti and Mbale Centers of Excellence (COEs) to attain optimal retention and HIV viral load suppression rates among the HIV positive adolescents in care. Uganda is yet to adapt the touted OTZ model and findings from this study will be important in providing the necessary lessons to inform a policy shift for potential scale up of the model. Furthermore, results of this study could provide additional evidence for the effectiveness of OTZ in attaining optimal HIV treatment outcomes among the adolescents living with HIV.

Understanding the Unique Barriers and Facilitators that Affect Men’s Initiation and Retention in HIV Care: A Qualitative Study to Inform Interventions for Men Across the Treatment Cascade in Malawi

Men in sub-Saharan Africa are underrepresented in antiretroviral therapy (ART) programs. Our secondary analysis of 40 in-depth interviews with Malawian men living with HIV examined barriers and facilitators for ART initiation versus retention. Interviewees included men who never initiated or initiated ART late (initiation respondents, n = 19); and men who initiated ART but were late for an appointment (retention respondents, n = 21). Transcribed interviews were coded using deductive and inductive coding techniques and analyzed using constant comparison methods. Long wait times, frequent facility visits, and insufficient in-clinic privacy were barriers for initiation and retention. Poor knowledge of ART was primarily a barrier for initiation; unexpected travel was a barrier for retention. Key facilitators for initiation and retention included previous positive experiences with health facilities. Having examples of successful men using ART primarily facilitated initiation; support from spouses and male peers facilitated retention. Results may inform interventions to increase men’s engagement in ART services.

Service delivery models for enhancing linkage to and retention in HIV care services for adolescent girls and young women and adolescent boys and young men: a protocol for an overview of systematic reviews

INTRODUCTION

Recent advances in the HIV care continuum have shown that an individual diagnosed with HIV should be initiated on antiretroviral therapy as soon as possible regardless of the CD4 count levels and retained in HIV care services. Studies have reported large losses in the HIV continuum of care, before and after the era of universal test and treat. Several systematic reviews have reported on the strategies for improving linkage to and retention in HIV treatment and care. The purpose of this overview of systematic reviews is to identify HIV care interventions or service delivery models (SDMs) and synthesise evidence on the effects of these to link adolescent girls and young women (AGYW) and adolescent boys and young men (ABYM) to care and retain them in care. We also aim to highlight gaps in the evidence on interventions and SDMs to improve linkage and retention in HIV care of AGYW and ABYM.

METHODS AND ANALYSIS

An electronic search of four online databases: PubMed, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science will be performed to identify systematic reviews on the effects of linkage to and retention in HIV care interventions or SDMs for AGYW aged 15-24 years and ABYM aged 15-35 years. Our findings on the effects of interventions and SDMs will be interpreted considering the intervention and or SDMs' effectiveness by the time period, setting and population of interest. Two or more authors will independently screen articles for inclusion using a priori criteria.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study as only published secondary data will be used. Our findings will be disseminated through peer-reviewed publication, conference abstracts and through presentations to stakeholders and other community fora. The findings from this overview of systematic reviews will inform mixed-methods operations research on HIV intervention programming and delivery of HIV care services for AGYW and ABYM in South Africa.

PROSPERO REGISTRATION NUMBER

CRD42020177933.

Rates and Determinants of Retention on ART Among Orphans and Vulnerable Children Living With HIV in Tanzania

Despite the global progress in response to HIV and AIDS, notable challenges remain for children, especially identification, linkage, and retention in HIV care and treatment services. To succeed in pediatric HIV programming requires the linkage and retention of the children in those services over time. This study assessed the level of retention to antiretroviral therapy (ART) and its associated factors among orphans and vulnerable children living with HIV (OVCLHIV) in Tanzania. Data were obtained from the USAID Kizazi Kipya project that collected pediatric ART data from October 2017 to October 2019 in 81 district councils of Tanzania. Community-based volunteers supported the linkage and retention of the OVCLHIV on ART. Analysis of on-ART status was conducted in a cohort of OVCLHIV aged 0–20 years enrolled in the project and monitored for 24 months. OVCLHIV who remained on ART until the end of the follow-up period were referred to as “retained,” otherwise, “not retained”. Multivariable analysis was conducted using logistic regression, adjusting for baseline characteristics. Of the 5,304 OVCLHIV analyzed, the mean age was 13.1 years, 51.5% were female, and 72.2% were living with female caregivers. Their overall rate of retention on ART over the 24 months was 86.7%. Multivariable analysis showed that as the higher frequency of home visit by the project staff increased, the likelihood of retention increased by 8% [adjusted odds ratio (aOR) = 1.08, 95% CI 1.06–1.11, p < 0.001]. Membership in people living with HIV (PLHIV) support groups was associated with a higher likelihood of retention compared to nonmembership (aOR = 3.31, 95% CI 2.60–4.21, p < 0.001). Children in larger family size were 22% less likely to sustain ART (aOR = 0.78, 95% CI 0.72–0.84, p < 0.001). Urban OVCLHIV were 18% less likely to remain on ART than their rural counterparts (aOR = 0.82, 95% CI 0.69–0.98, p = 0.030). Remaining on ART was 49% more likely for OVC in economically better-off households than those in destitute households (aOR = 1.49, 95% CI 1.22–1.81, p < 0.001). Male OVC were 17% less likely to be retained on ART than their female counterparts (aOR = 0.83, 95% CI 0.71–0.99, p = 0.033). Community-based OVC support resulted in a high pediatric retention rate over the 24 months of follow-up. While key enablers of retention were higher frequency of home visits by the project volunteer, participation in PLHIV support groups, and better economic status, large family sizes, urban place of residence, and male gender of the OVC were barriers. This study brings useful evidence to inform strategies for advancing retention of OVCLHIV on ART for their better health outcomes and overall wellbeing.

The Collaborative Initiative for Paediatric HIV Education and Research (CIPHER) Global Cohort Collaboration, Jesson J, Crichton S, Quartagno M, Yotebieng M, Abrams EJ, Chokephaibulkit K, Le Coeur S, Aké‐Assi M, Patel K, Pinto J, Paul M, Vreeman R, Davies M, Ben‐Farhat J, Van Dyke R, Judd A, Mofenson L, Vicari M, Seage G, Bekker L, Essajee S, Gibb D, Penazzato M, Collins IJ, Wools‐Kaloustian K, Slogrove A, Powis K, Williams P, Matshaba M, Thahane L, Nyasulu P, Lukhele B, Mwita L, Kekitiinwa‐Rukyalekere A, Wanless S, Goetghebuer T, Thorne C, Warszawski J, Galli L, van Rossum AM, Giaquinto C, Marczynska M, Marques L, Prata F, Ene L, Okhonskaya L, Navarro M, Frick A, Naver L, Kahlert C, Volokha A, Chappell E, Pape JW, Rouzier V, Marcelin A, Succi R, Sohn AH, Kariminia A, Edmonds A, Lelo P, Lyamuya R, Ogalo EA, Odhiambo FA, Haas AD, Bolton C, Muhairwe J, Tweya H, Sylla M, D'Almeida M, Renner L, Abzug MJ, Oleske J, Purswani M, Teasdale C, Nuwagaba‐Biribonwoha H, Goodall R, Leroy V. Growth and CD4 patterns of adolescents living with perinatally acquired HIV worldwide, a CIPHER cohort collaboration analysis

INTRODUCTION

Adolescents living with HIV are subject to multiple co-morbidities, including growth retardation and immunodeficiency. We describe growth and CD4 evolution during adolescence using data from the Collaborative Initiative for Paediatric HIV Education and Research (CIPHER) global project.

METHODS

Data were collected between 1994 and 2015 from 11 CIPHER networks worldwide. Adolescents with perinatally acquired HIV infection (APH) who initiated antiretroviral therapy (ART) before age 10 years, with at least one height or CD4 count measurement while aged 10-17 years, were included. Growth was measured using height-for-age Z-scores (HAZ, stunting if <-2 SD, WHO growth charts). Linear mixed-effects models were used to study the evolution of each outcome between ages 10 and 17. For growth, sex-specific models with fractional polynomials were used to model non-linear relationships for age at ART initiation, HAZ at age 10 and time, defined as current age from 10 to 17 years of age.

RESULTS

A total of 20,939 and 19,557 APH were included for the growth and CD4 analyses, respectively. Half were females, two-thirds lived in East and Southern Africa, and median age at ART initiation ranged from <3 years in North America and Europe to >7 years in sub-Saharan African regions. At age 10, stunting ranged from 6% in North America and Europe to 39% in the Asia-Pacific; 19% overall had CD4 counts <500 cells/mm3 . Across adolescence, higher HAZ was observed in females and among those in high-income countries. APH with stunting at age 10 and those with late ART initiation (after age 5) had the largest HAZ gains during adolescence, but these gains were insufficient to catch-up with non-stunted, early ART-treated adolescents. From age 10 to 16 years, mean CD4 counts declined from 768 to 607 cells/mm3 . This decline was observed across all regions, in males and females.

CONCLUSIONS

Growth patterns during adolescence differed substantially by sex and region, while CD4 patterns were similar, with an observed CD4 decline that needs further investigation. Early diagnosis and timely initiation of treatment in early childhood to prevent growth retardation and immunodeficiency are critical to improving APH growth and CD4 outcomes by the time they reach adulthood.

Long-term retention and predictors of attrition for key populations receiving antiretroviral treatment through community-based ART in Benue State Nigeria: A retrospective cohort study

BACKGROUND

Key populations (KP) are disproportionately infected with HIV and experience barriers to HIV care. KP include men who have sex with men (MSM), female sex workers (FSW), persons who inject drugs (PWID) and transgender people (TG). We implemented three different approaches to the delivery of community-based antiretroviral therapy for KP (KP-CBART) in Benue State Nigeria, including One Stop Shop clinics (OSS), community drop-in-centres (DIC), and outreach venues. OSS are community-based health facilities serving KP only. DIC are small facilities led by lay healthcare providers and supported by an outreach team. Outreach venues are places in the community served by the outreach team. We studied long-term attrition of KP and virological non-suppression.

METHOD

This is a retrospective cohort study of KP living with HIV (KPLHIV) starting ART between 2016 and 2019 in 3 0SS, 2 DIC and 8 outreach venues. Attrition included lost to follow-up (LTFU) and death. A viral load >1000 copies/mL showed viral non-suppression. Survival analysis was used to assess retention on ART. Cox regression and Firth logistic regression were used to assess risk factors for attrition and virological non-suppression respectively.

RESULT

Of 3495 KPLHIV initiated on ART in KP-CBART, 51.8% (n = 1812) were enrolled in OSS, 28.1% (n = 982) in DIC, and 20.1% (n = 701) through outreach venues. The majority of participants were FSW-54.2% (n = 1896), while 29.8% (n = 1040), 15.8% (n = 551) and 0.2% (n = 8) were MSM, PWID, and TG respectively. The overall retention in the programme was 63.5%, 55.4%, 51.2%, and 46.7% at 1 year, 2 years, 3 years, and 4 years on ART. Of 1650 with attrition, 2.5% (n = 41) died and others were LTFU. Once adjusted for other factors (age, sex, place of residence, year of ART enrollment, WHO clinical stage, type of KP group, and KP-CBART approach), KP-CBART approach did not predict attrition. MSM were at a higher risk of attrition (vs FSW; adjusted hazard ratio (aHR) 1.27; 95%CI: 1.14-1.42). Of 3495 patients, 48.4% (n = 1691) had a viral load test. Of those, 97.8% (n = 1654) were virally suppressed.

CONCLUSION

Although long-term retention in care is low, the virological suppression was optimal for KP on ART and retained in community-based ART care. However, viral load testing coverage was sub-optimal. Future research should explore the perspectives of clients on reasons for LTFU and how to adapt approach to CBART to meet individual client needs.

Ten-year attrition and antiretroviral therapy response among HIV-positive adults: a sex-based cohort analysis from eight West African countries

INTRODUCTION

Sex differences have already been reported in sub-Saharan Africa for attrition and immunological response after antiretroviral therapy (ART) initiation, but follow-up was usually limited to the first two to three years after ART initiation. We evaluated sex differences on the same outcomes in the 10 years following ART initiation in West African adults.

METHODS

We used cohort data of patients included in the IeDEA West Africa collaboration, who initiated ART between 2002 and 2014. We modelled no-follow-up and 10-year attrition risks, and immunological response by sex using logistic regression analysis, survival analysis with random effect and linear mixed models respectively.

RESULTS

A total of 71,283 patients (65.8% women) contributed to 310,007 person-years of follow-up in 16 clinics in eight West African countries. The cumulative attrition incidence at 10-year after ART initiation reached 75% and 68% for men and women respectively. Being male was associated with an increased risk of no follow-up after starting ART (5.1% vs. 4.0%, adjusted Odds Ratio: 1.25 [95% CI: 1.15 to 1.35]) and of 10-year attrition throughout the 10-year period following ART initiation: adjusted Hazard Ratios were 1.22 [95% CI: 1.17 to 1.27], 1.08 [95% CI: 1.04 to 1.12] and 1.04 [95% CI: 1.01 to 1.08] during year 1, years 2 to 4 and 5 to 10 respectively. A better immunological response was achieved by women than men: monthly CD4 gain was 30.2 and 28.3 cells/mL in the first four months and 2.6 and 1.9 cells/μL thereafter. Ultimately, women reached the average threshold of 500 CD4 cells/μL in their sixth year of follow-up, whereas men failed to reach it even at the end of the 10-year follow-up period. The proportion of patients reaching the threshold was much higher in women than in men after 10 years since ART initiation (65% vs. 44%).

CONCLUSIONS

In West Africa, attrition is unacceptably high in both sexes. Men are more vulnerable than women on both attrition and immunological response to ART in the 10 years following ART initiation. Innovative tracing strategies that are sex-adapted are needed for patients in care to monitor attrition, detect early high-risk groups so that they can stay in care with a durably controlled infection.

Retention in care for adolescents who were newly initiated on antiretroviral therapy in the Cape Metropole in South Africa

BACKGROUND

Long-term retention of adolescents aged 10 -19 years on antiretroviral therapy (ART) is crucial to achieve viral load suppression. However, it is reported globally that adolescents have lower retention in care (RiC) on ART, compared with children and adults.

OBJECTIVES

To determine the prevalence and predictors of RiC of adolescents over 2 years following initiation onto ART in public health facilities in the Metropole District Health Services of the Western Cape province in 2013.

METHODS

Data of 220 adolescent patients who were newly initiated on ART in 2013 were extracted from the provincial electronic database, and subjected to univariate and bivariate analyses using SPSS.

RESULTS

The rate of RiC post-initiation was low throughout the study period, that is, 68.6%, 50.5% and 36.4% at 4, 12 and 24 months, respectively. The corresponding post-initiation viral load suppression levels on ART of those remaining in care and who had viral loads monitored were 84.1%, 77.4% and 68.8% at 4, 12 and 24 months, respectively. Retention in care after initiation on ART was higher amongst younger adolescents (10-14 years), compared with older adolescents (15-19 years). Male adolescents were significantly more likely to be retained, compared with females. Pregnant adolescents were significantly less likely to be retained compared with those who were not pregnant.

CONCLUSION

Key interventions are needed to motivate adolescents to remain in care, and to adhere to their treatment regimen to achieve the target of 90% viral load suppression, with specific emphasis on older and pregnant adolescents.