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Bekolo CE, Ndeso SA, Moifo LL, Mangala N, Yimdjo TD, Ateudjieu J, Kouanfack C, Djam A, Tabah EN, Whegang S, Mapa-Tassou C, Tendongfor N, Nsagha DS, Choukem SP. Universal test and treat in Cameroon: a comparative retrospective analysis of mortality and loss to follow-up before and after a strategic change in approach to HIV care. Pan Afr Med J 2023; 45:191. [PMID: 38020352 PMCID: PMC10656581 DOI: 10.11604/pamj.2023.45.191.40448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/09/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction an increasing number of persons living with HIV (PLHIV) are accessing antiretroviral therapy (ART) since the adoption of the universal test and treat (UTT) policy by Cameroon in 2016. We sought to evaluate the effectiveness of the UTT approach to keep this growing number of PLHIV on a lifelong treatment. Methods a retrospective cohort analysis was conducted at the Nkongsamba Regional Hospital between 2002 and 2020, using routine data to compare the cumulative incidence of loss to follow-up (LTFU) and mortality between PLHIV initiated on ART under UTT guidelines and those initiated under the standard deferred approach. Chi-squared test was used to compare the risk of attrition between the guideline periods while multiple logistic regression modelling was used to adjust for confounders. Results of 1627 PLHIV included for analysis, 756 (46.47%) were enrolled during the era of UTT with 545 (33.54%) initiated on ART on the same day of HIV diagnosis. The transition to the UTT era was associated with an overall reduction in the risk of LTFU by 73% (aOR = 0.27, 95%CI: 0.17 - 0.45). There was modest evidence that the odds of mortality had increased under the UTT policy by about 3-fold (aOR = 2.86, 95%CI: 0.91-8.94). Same-day initiation had no overall effect on LTFU or mortality. LTFU was lower among the same-day initiators in the first 24 months but increased thereafter above the rate among late initiators. Conclusion overall ART programme implementation under the UTT has led to a significant decline in LTFU though mortality appeared to have increased. Ongoing efforts to keep patients on long-term treatment should be sustained while other innovative schemes are sought.
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Affiliation(s)
- Cavin Epie Bekolo
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Sylvester Atanga Ndeso
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Linda Lucienne Moifo
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Nkwele Mangala
- Department of Gynaecology and Obstetrics, University of Douala, Douala, Cameroon
| | | | - Jerome Ateudjieu
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Charles Kouanfack
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Alain Djam
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Earnest Njih Tabah
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Solange Whegang
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Clarisse Mapa-Tassou
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Nicolas Tendongfor
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Dickson Shey Nsagha
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Siméon-Pierre Choukem
- Department of Internal Medicine and Specialities, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
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Makurumidze R, Decroo T, Jacobs BKM, Rusakaniko S, Van Damme W, Lynen L, Gils T. Attrition one year after starting antiretroviral therapy before and after the programmatic implementation of HIV "Treat All" in Sub-Saharan Africa: a systematic review and meta-analysis. BMC Infect Dis 2023; 23:558. [PMID: 37641003 PMCID: PMC10463759 DOI: 10.1186/s12879-023-08551-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Evidence on the real-world effects of "Treat All" on attrition has not been systematically reviewed. We aimed to review existing literature to compare attrition 12 months after antiretroviral therapy (ART) initiation, before and after "Treat All" was implemented in Sub-Saharan Africa and describe predictors of attrition. METHODS We searched Embase, Google Scholar, PubMed, and Web of Science in July 2020 and created alerts up to the end of June 2023. We also searched for preprints and conference abstracts. Two co-authors screened and selected the articles. Risk of bias was assessed using the modified Newcastle-Ottawa Scale. We extracted and tabulated data on study characteristics, attrition 12 months after ART initiation, and predictors of attrition. We calculated a pooled risk ratio for attrition using random-effects meta-analysis. RESULTS Eight articles and one conference abstract (nine studies) out of 8179 screened records were included in the meta-analysis. The random-effects adjusted pooled risk ratio (RR) comparing attrition before and after "Treat All" 12 months after ART initiation was not significant [RR = 1.07 (95% Confidence interval (CI): 0.91-1.24)], with 92% heterogeneity (I2). Being a pregnant or breastfeeding woman, starting ART with advanced HIV, and starting ART within the same week were reported as risk factors for attrition both before and after "Treat All". CONCLUSIONS We found no significant difference in attrition before and after "Treat All" one year after ART initiation. While "Treat All" is being implemented widely, differentiated approaches to enhance retention should be prioritised for those subgroups at risk of attrition. PROSPERO NUMBER CRD42020191582 .
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Affiliation(s)
- Richard Makurumidze
- Institute of Tropical Medicine, Clinical Sciences Department, Antwerp, Belgium.
- Faculty of Medicine and Health Sciences, Department of Primary Health Care Sciences, University of Zimbabwe, Harare, Zimbabwe.
- Faculty of Medicine & Pharmacy, Gerontology, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Tom Decroo
- Institute of Tropical Medicine, Clinical Sciences Department, Antwerp, Belgium
- Research Foundation of Flanders, Brussels, Belgium
| | - Bart K M Jacobs
- Institute of Tropical Medicine, Clinical Sciences Department, Antwerp, Belgium
| | - Simbarashe Rusakaniko
- Faculty of Medicine and Health Sciences, Department of Primary Health Care Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Wim Van Damme
- Institute of Tropical Medicine, Clinical Sciences Department, Antwerp, Belgium
- Faculty of Medicine & Pharmacy, Gerontology, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Lutgarde Lynen
- Institute of Tropical Medicine, Clinical Sciences Department, Antwerp, Belgium
| | - Tinne Gils
- Institute of Tropical Medicine, Clinical Sciences Department, Antwerp, Belgium
- Global Health Institute, University of Antwerp, Antwerp, Belgium
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Govere SM, Kalinda C, Chimbari MJ. The impact of same-day antiretroviral therapy initiation on retention in care and clinical outcomes at four eThekwini clinics, KwaZulu-Natal, South Africa. BMC Health Serv Res 2023; 23:838. [PMID: 37553685 PMCID: PMC10408100 DOI: 10.1186/s12913-023-09801-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 07/11/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Same-day initiation (SDI) of antiretroviral therapy (ART) increases ART uptake, however retention in care after ART initiation remains a challenge. Public health behaviours, such as retention in HIV care and adherence to antiretroviral therapy (ART) pose major challenges to reducing new Human Immunodeficiency Virus (HIV) transmission and improving health outcomes among HIV patients. METHODS We evaluated 6-month retention in care, and clinical outcomes of an ART cohort comprising of SDI and delayed ART initiators. We conducted a 6 months' observational prospective cohort study of 403 patients who had been initiated on ART. A structured questionnaire was used to abstract data from patient record review which comprised the medical charts, laboratory databases, and Three Interlinked Electronic Registers.Net (TIER.Net). Treatment adherence was ascertained by patient visit constancy for the clinic scheduled visit dates. Retention in care was determined by status at 6 months after ART initiation. RESULTS Among the 403 participants enrolled in the study and followed up, 286 (70.97%) and 267 (66.25%) complied with scheduled clinics visits at 3 months and 6 months, respectively. One hundred and thirteen (28.04%) had been loss to follow-up. 17/403 (4.22%) had died and had been out of care after 6 months. 6 (1.49%) had been transferred to other health facilities and 113 (28.04%) had been loss to follow-up. Among those that had been lost to follow-up, 30 (33.63%) deferred SDI while 75 (66.37%) initiated ART under SDI. One hundred and eighty-nine (70.79%) participants who had remained in care were SDI patients while 78 (29.21%) were SDI deferred patients. In the bivariate analysis; gender (OR: 1.672; 95% CI: 1.002-2.791), number of sexual partners (OR: 2.092; 95% CI: 1.07-4.061), age (OR: 0.941; 95% CI: 0.734-2.791), ART start date (OR: 0.078; 95% CI: 0.042-0.141), partner HIV status (OR: 0.621; 95% CI: 0.387-0.995) and the number of hospitalizations after HIV diagnosis (OR: 0.173; 95% CI: 0.092-0.326). were significantly associated with viral load detection. Furthermore, SDI patients who defaulted treatment were 2.4 (95% CI: 1.165-4.928) times more likely to have increased viral load than those who had been returned in care. CONCLUSION Viral suppression under SDI proved higher but with poor retention in care. However, the results also emphasise a vital need, to not only streamline processes to increase immediate ART uptake further, but also to ensure retention in care.
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Affiliation(s)
- Sabina M Govere
- School of Nursing and Public Health, Discipline of Public Health Medicine, Howard College Campus, University of KwaZulu-Natal, Durban, South Africa.
| | - Chester Kalinda
- School of Nursing and Public Health, Discipline of Public Health Medicine, Howard College Campus, University of KwaZulu-Natal, Durban, South Africa
- Bill and Joyce Cummings Institute of Global Health and Institute of Global Health Equity Research (IGHER), University of Global Health Equity Kigali Heights, Kigali, Rwanda
| | - Moses J Chimbari
- School of Nursing and Public Health, Discipline of Public Health Medicine, Howard College Campus, University of KwaZulu-Natal, Durban, South Africa
- Department of Public Health, Great Zimbabwe University, P.O Box 1235, Masvingo, Zimbabwe
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Teeraananchai S, Kerr SJ, Ruxrungtham K, Khananuraksa P, Puthanakit T. Long-term outcomes of rapid antiretroviral NNRTI-based initiation among Thai youth living with HIV: a national registry database study. J Int AIDS Soc 2023; 26:e26071. [PMID: 36943729 PMCID: PMC10029993 DOI: 10.1002/jia2.26071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 02/17/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION The Thai National AIDS programme (NAP) treatment guidelines have recommended rapid antiretroviral therapy (ART) initiation, regardless of CD4 count since 2014. We assessed treatment outcomes among youth living with HIV (YLHIV), initiating first-line ART and assessed the association between virological failure (VF) and timing of ART initiation. METHODS We retrospectively reviewed data for YLHIV aged 15-24 years, initiating non-nucleoside reverse transcriptase inhibitor-based ART from 2014 to 2019, through the NAP database. We classified the timing of ART into three groups based on duration from HIV-positive diagnosis or system registration to ART initiation: (1) <1 month (rapid ART); (2) 1-3 months (intermediate ART); and (3) >3 months (delayed ART). VF was defined as viral load (VL) ≥ 1000 copies/ml after at least 6 months of first-line ART. Factors associated with VF were analysed using generalized estimating equations. RESULTS Of 19,825 YLHIV who started ART, 78% were male. Median (interquartile range, IQR) age was 21 (20-23) years and CD4 count was 338 (187-498) cells/mm3 . After registration, 12,216 (62%) started rapid ART, 4272 (22%) intermediate ART and 3337 (17%) delayed ART. The proportion of YLHIV starting ART <30 days significantly increased from 43% to 57% from 2014-2016 to 2017-2019 (p < 0.001). The median duration of first-line therapy was 2 (IQR 1-3) years and 89% started with efavirenz-based regimens. Attrition outcomes showed that 325 (2%) died (0.73 [95% CI 0.65-0.81] per 100 person-years [PY]) and 1762 (9%) were loss to follow-up (3.96 [95% CI 3.78-4.15] per 100 PY). Of 17,512 (88%) who had VL checked from 6 to 12 months after starting treatment, 80% achieved VL <200 copies/ml. Overall, 2512 experienced VF 5.87 (95% CI 5.65-6.11) per 100 PY). In a multivariate model, the adjusted incidence rate ratio for VF was 1.47 (95% CI 1.33-1.63, p < 0.001) in the delayed ART group and 1.14 (95% CI 1.03-1.25, p< 0.001) in the intermediate ART group, compared to YLHIV in the rapid ART group. CONCLUSIONS Rapid ART initiation after diagnosis was associated with significantly reduced risks of VF and death in YLHIV, supporting the implementation of rapid ART for optimizing health outcomes.
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Affiliation(s)
- Sirinya Teeraananchai
- Department of Statistics, Faculty of Science, Kasetsart University, Bangkok, Thailand
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Stephen J Kerr
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Biostatistics Excellence Centre, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Kiat Ruxrungtham
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Chula Vaccine Research Center (ChulaVRC), School of Global Health, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Thanyawee Puthanakit
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
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Wüthrich-Grossenbacher U, Mutsinze A, Wolf U, Maponga CC, Midzi N, Mutsaka-Makuvaza MJ, Merten S. A validation of the religious and spiritual struggles scale among young people living with HIV in Zimbabwe: Mokken scale analysis and exploratory factor analysis. Front Psychol 2023; 14:1051455. [PMID: 37143595 PMCID: PMC10153667 DOI: 10.3389/fpsyg.2023.1051455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 03/29/2023] [Indexed: 05/06/2023] Open
Abstract
Introduction Religious/spiritual convictions and practices can influence health- and treatment-seeking behavior, but only few measures of religiousness or spirituality have been validated and used outside of the US. The Religious and Spiritual Struggles scale (RSS) measures internal and external conflict with religion and spirituality and has been validated mainly in different high-income contexts. The aim of this study was the validation of the RSS in the Zimbabwean context and among young people living with human immunodeficiency virus (YPLHIV) aged 14-24. Methods Data collection with an Open Data Kit (ODK) questionnaire with 804 respondents took place in 2021. The validation was performed by confirmatory factor analysis (CFA), using statistical equation modeling (SEM), and Mokken scale analysis (MSA). After the low confirmability of the original scale sub-dimensions exploratory factor analysis (EFA) was applied. Results The EFA resulted in four new sub-domains that were different from the original six domains in the RSS but culturally more relevant. The new sub-domains are significantly related to health. Discussion The findings support the validity and relevance of the RSS and the new sub-domains in this context. As our study was limited to YPLHIV, further validation of the RSS among different population groups and contexts in the sub-Saharan region is encouraged.
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Affiliation(s)
- Ursula Wüthrich-Grossenbacher
- Centre for African Studies, Faculty of Humanities and Social Sciences, University of Basel, Basel, Switzerland
- *Correspondence: Ursula Wüthrich-Grossenbacher,
| | | | - Ursula Wolf
- Institute of Complementary and Integrative Medicine, School of Medicine, University of Bern, Bern, Switzerland
| | - Charles Chiedza Maponga
- School of Pharmacy, University of Zimbabwe, Harare, Zimbabwe
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, United States
| | - Nicholas Midzi
- Ministry of Health and Child Care, National Institute of Health Research, Harare, Zimbabwe
| | | | - Sonja Merten
- Epidemiology and Public Health, Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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Bantie B, Abate MW, Nigat AB, Birlie TA, Dires T, Minuye T, Kerebeh G, Tiruneh CM, Misganaw NM, Chanie ES, Feleke DG, Mulu AT, Demssie B, Fentie TA, Abate MD, Abate M, Ali AS, Dessie G. Attrition rate and its predictors among adults receiving anti-retroviral therapy following the implementation of the “Universal Test and Treat strategy” at public health institutions in Northern Ethiopia. A retrospective follow-up study. Heliyon 2022; 8:e11527. [DOI: 10.1016/j.heliyon.2022.e11527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 05/10/2022] [Accepted: 11/01/2022] [Indexed: 11/13/2022] Open
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Bantie B, Seid A, Kerebeh G, Alebel A, Dessie G. Loss to follow-up in "test and treat era" and its predictors among HIV-positive adults receiving ART in Northwest Ethiopia: Institution-based cohort study. Front Public Health 2022; 10:876430. [PMID: 36249247 PMCID: PMC9557930 DOI: 10.3389/fpubh.2022.876430] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 08/29/2022] [Indexed: 01/21/2023] Open
Abstract
Background People living with HIV/AIDS are enrolled in lifelong Anti-Retroviral Treatment (ART) irrespective of their clinical staging as well as CD4 cell count. Although this "Universal Test and Treat" strategy of ART was found to have numerous benefits, loss from follow-up and poor retention remained a long-term challenge for the achievement of ART program targets. Hence, this study is aimed at addressing the much-needed effect of the test and treat strategy on the incidence of loss to follow-up (LTFU) in Ethiopia. Method and materials An institution-based follow-up study was conducted on 513 adults (age ≥15) who enrolled in ART at a public health institution in Bahir Dar City, Northwest Ethiopia. Data were extracted from the charts of selected patients and exported to Stata 14.2 software for analysis. Basic socio-demographic, epidemiological, and clinical characteristics were described. The Kaplan-Meier curve was used to estimate the loss to follow-up free (survival) probability of HIV-positive adults at 6, 12, 24, and 48 months of ART therapy. We fitted a multivariable Cox model to determine the statistically significant predictors of LTFU. Result The incidence density of LTFU was 9.7 per 100 person-years of observation (95% CI: 7.9-11.9 per 100 PYO). Overall, LTFU is higher in the rapid ART initiation (24% in rapid initiated vs. 11.3% in lately initiated, AHR 2.08, P = 0.004), in males (23% males vs. 14.7% females, AHR1.96, P = 0.004), in singles (34% single vs. 11% married, with AHR1.83, P = 0.044), in non-disclosed HIV-status (33% non-disclosed 11% disclosed, AHR 2.00 p = 0.001). Patients with poor/fair ART adherence were also identified as another risk group of LTFU (37% in poor vs. 10.5% in good adherence group, AHR 4.35, P = 0.001). Conclusion The incidence of LTFU in this universal test and treat era was high, and the highest figure was observed in the first 6 months. Immediate initiation of ART in a universal test and treat strategy shall be implemented cautiously to improve patient retention and due attention shall be given to those high-risk patients.
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Affiliation(s)
- Berihun Bantie
- Department of Adult Health Nursing, College of Medicine and Health Science, Debre Tabor University, Debre Tabor, Ethiopia,*Correspondence: Berihun Bantie
| | - Awole Seid
- Department of Adult Health Nursing, School of Health Science, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
| | - Gashaw Kerebeh
- Department of Pediatrics and Child Health Nursing, College of Medicine and Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Animut Alebel
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Getenet Dessie
- Department of Adult Health Nursing, School of Health Science, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
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Mayasi N, Situakibanza H, Mbula M, Longokolo M, Maes N, Bepouka B, Ossam JO, Moutschen M, Darcis G. Retention in care and predictors of attrition among HIV-infected patients who started antiretroviral therapy in Kinshasa, DRC, before and after the implementation of the 'treat-all' strategy. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000259. [PMID: 36962315 PMCID: PMC10022330 DOI: 10.1371/journal.pgph.0000259] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 02/13/2022] [Indexed: 11/18/2022]
Abstract
The retention of patients in care is a key pillar of the continuum of HIV care. It has been suggested that the implementation of a "treat-all" strategy may favor attrition (death or lost to follow-up, as opposed to retention), specifically in the subgroup of asymptomatic people living with HIV (PLWH) with high CD4 counts. Attrition in HIV care could mitigate the success of universal antiretroviral therapy (ART) in resource-limited settings. We performed a retrospective study of PLWH at least 15 years old initiating ART in 85 HIV care centers in Kinshasa, Democratic Republic of Congo (DRC), between 2010 and 2019, with the objective of measuring attrition and to define factors associated with it. Sociodemographic and clinical characteristics recorded at ART initiation included sex, age, weight, height, WHO HIV stage, pregnancy, baseline CD4 cell count, start date of ART, and baseline and last ART regimen. Attrition was defined as death or loss to follow-up (LTFU). LTFU was defined as "not presenting to an HIV care center for at least 180 days after the date of a last missed visit, without a notification of death or transfer". Kaplan-Meier curves were used to present attrition data, and mixed effects Cox regression models determined factors associated with attrition. The results compared were before and after the implementation of the "treat-all" strategy. A total of 15,762 PLWH were included in the study. Overall, retention in HIV care was 83% at twelve months and 77% after two years of follow-up. The risk of attrition increased with advanced HIV disease and the size of the HIV care center. Time to ART initiation greater than seven days after diagnosis and Cotrimoxazole prophylaxis was associated with a reduced risk of attrition. The implementation of the "treat-all" strategy modified the clinical characteristics of PLWH toward higher CD4 cell counts and a greater proportion of patients at WHO stages I and II at treatment initiation. Initiation of ART after the implementation of the 'treat all" strategy was associated with higher attrition (p<0.0001) and higher LTFU (p<0.0001). Attrition has remained high in recent years. The implementation of the "treat-all" strategy was associated with higher attrition and LTFU in our study. Interventions to improve early and ongoing commitment to care are needed, with specific attention to high-risk groups to improve ART coverage and limit HIV transmission.
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Affiliation(s)
- Nadine Mayasi
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo [DRC]
| | - Hippolyte Situakibanza
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo [DRC]
| | - Marcel Mbula
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo [DRC]
| | - Murielle Longokolo
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo [DRC]
| | - Nathalie Maes
- Biostatistics and Medico-Economic Information Department, University Hospital of Liège, Liège, Belgium
| | - Ben Bepouka
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo [DRC]
| | - Jérôme Odio Ossam
- Department of Internal Medicine, Infectious and Tropical Diseases, University Clinics of Kinshasa, Kinshasa, Democratic Republic of the Congo [DRC]
| | - 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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Gray KL, Kiazolu M, Jones J, Konstantinova A, Zawolo JSW, Gray WMH, Walker NF, Garbo JT, Caldwell S, Odo M, Bhadelia N, DeMarco J, Skrip LA. Liberia adherence and loss-to-follow-up in HIV and AIDS care and treatment: A retrospective cohort of adolescents and adults from 2016-2019. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000198. [PMID: 36962289 PMCID: PMC10021315 DOI: 10.1371/journal.pgph.0000198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 02/23/2022] [Indexed: 11/18/2022]
Abstract
Antiretroviral therapy (ART) is a lifesaving intervention for people living with HIV infection, reducing morbidity and mortality; it is likewise essential to reducing transmission. The "Treat all" strategy recommended by the World Health Organization has dramatically increased ART eligibility and improved access. However, retaining patients on ART has been a major challenge for many national programs in low- and middle-income settings, despite actionable local policies and ambitious targets. To estimate retention of patients along the HIV care cascade in Liberia, and identify factors associated with loss-to-follow-up (LTFU), death, and suboptimal treatment adherence, we conducted a nationwide retrospective cohort study utilizing facility and patient-level records. Patients aged ≥15 years, from 28 facilities who were first registered in HIV care from January 2016 -December 2017 were included. We used Cox proportional hazard models to explore associations between demographic and clinical factors and the outcomes of LTFU and death, and a multinomial logistic regression model to investigate factors associated with suboptimal treatment adherence. Among the 4185 records assessed, 27.4% (n = 1145) were males and the median age of the cohort was 37 (IQR: 30-45) years. At 24 months of follow-up, 41.8% (n = 1751) of patients were LTFU, 6.6% (n = 278) died, 0.5% (n = 21) stopped treatment, 3% (n = 127) transferred to another facility and 47.9% (n = 2008) were retained in care and treatment. The incidence of LTFU was 46.0 (95% CI: 40.8-51.6) per 100 person-years. Relative to patients at WHO clinical stage I at first treatment visit, patients at WHO clinical stage III [adjusted hazard ratio (aHR) 1.59, 95%CI: 1.21-2.09; p <0.001] or IV (aHR 2.41, 95%CI: 1.51-3.84; p <0.001) had increased risk of LTFU; whereas at registration, age category 35-44 (aHR 0.65, 95%CI: 0.44-0.98, p = 0.038) and 45 years and older (aHR 0.60, 95%CI: 0.39-0.93, p = 0.021) had a decreased risk. For death, patients assessed with WHO clinical stage II (aHR 2.35, 95%CI: 1.53-3.61, p<0.001), III (aHR 2.55, 95%CI: 1.75-3.71, p<0.001), and IV (aHR 4.21, 95%CI: 2.57-6.89, p<0.001) had an increased risk, while non-pregnant females (aHR 0.68, 95%CI: 0.51-0.92, p = 0.011) and pregnant females (aHR 0.42, 95%CI: 0.20-0.90, p = 0.026) had a decreased risk when compared to males. Suboptimal adherence was strongly associated with the experience of drug side effects-average adherence [adjusted odds ratio (aOR) 1.45, 95% CI: 1.06-1.99, p = 0.02) and poor adherence (aOR 1.75, 95%CI: 1.11-2.76, p = 0.016), and attending rural facility decreased the odds of average adherence (aOR 0.01, 95%CI: 0.01-0.03, p<0.001) and poor adherence (aOR 0.001, 95%CI: 0.0004-0.003, p<0.001). Loss-to-follow-up and poor adherence remain major challenges to achieving viral suppression targets in Liberia. Over two-fifths of patients engaged with the national HIV program are being lost to follow-up within 2 years of beginning care and treatment. WHO clinical stage III and IV were associated with LTFU while WHO clinical stage II, III and IV were associated with death. Suboptimal adherence was further associated with experience of drug side effects. Active support and close monitoring of patients who have signs of clinical progression and/or drug side effects could improve patient outcomes.
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Affiliation(s)
- Keith L Gray
- Health Services, Ministry of Health, Monrovia, Liberia
| | | | - Janjay Jones
- Health Services, Ministry of Health, Monrovia, Liberia
| | | | - Jethro S W Zawolo
- College of Health Sciences, University of Liberia, Monrovia, Liberia
| | | | - Naomi F Walker
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Julia T Garbo
- Health Services, Ministry of Health, Monrovia, Liberia
| | | | | | - Nahid Bhadelia
- Boston University, Massachusetts, United States of America
| | - Jean DeMarco
- University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Laura A Skrip
- College of Health Sciences, University of Liberia, Monrovia, Liberia
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Effects of implementing universal and rapid HIV treatment on initiation of antiretroviral therapy and retention in care in Zambia: a natural experiment using regression discontinuity. Lancet HIV 2021; 8:e755-e765. [PMID: 34656208 DOI: 10.1016/s2352-3018(21)00186-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 07/29/2021] [Accepted: 08/02/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Universal testing and treatment (UTT) for all people living with HIV has only been assessed under experimental conditions in cluster-randomised trials. The public health effectiveness of UTT policies on the HIV care cascade under real-world conditions is not known. We assessed the real-world effectiveness of universal HIV treatment policies that were implemented in Zambia on Jan 1, 2017. METHODS We used data from Zambia's routine electronic health record system to analyse antiretroviral therapy (ART)-naive adults who newly enrolled in HIV care up to 1 year before and after the implementation of universal treatment (ie, Jan 1, 2016, to Jan 1, 2018) at 117 clinics supported by the Centre for Infectious Disease Research in Zambia. We used a regression discontinuity design to estimate the effects of implementing UTT on same-day ART initiation, ART initiation within 1 month, and retention on ART at 12 months (defined as clinic attendance 9-15 months after enrolment and at least 6 months on ART), under the assumption that patients presenting immediately before and after UTT implementation were balanced on both measured and unmeasured characteristics. We did an instrumental variable analysis to estimate the effect of same-day ART initiation under routine conditions on 12-month retention on ART. FINDINGS 65 673 newly enrolled patients with HIV (40 858 [62·2%] female, median age 32 years [IQR 26-39], median CD4 count 287 cells per μL [IQR 147-466]) were eligible for inclusion in the analyses; 31 145 enrolled before implementation of UTT, and 34 528 enrolled after UTT. Implementation of universal treatment increased same-day ART initiation from 41·7% to 74·8% (risk difference [RD] 33·1%, 95% CI 30·5-35·7), ART initiation by 1 month from 69·6% to 87·0% (RD 17·4%, 15·5-19·3), and 12-month retention on ART from 56·2% to 63·3% (RD 7·1%, 4·3-9·9). ART initiation rates became more uniform across patient subgroups after implementation of universal treatment, but heterogeneity in 12-month retention on ART between subgroups was unchanged. Instrumental variable analyses indicated that same-day ART initiation in routine settings led to a 15·8% increase (95% CI 12·1-19·5) in 12-month retention on ART. INTERPRETATION UTT policies implemented in Zambia increased the rapidity and uptake of ART, as well as retention on ART at 12 months, although overall retention on ART remained suboptimal. UTT policies reduced disparities in treatment initiation, but not 12-month retention on ART. Natural experiments reveal both the anticipated and unanticipated effects of real-world implementation and indicate the need for new strategies leveraging the short-term effects of UTT to cultivate long-term treatment success. FUNDING National Institutes of Health.
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Tonen-Wolyec S, Kayembe Tshilumba C, Batina-Agasa S, Tagoto Tepungipame A, Bélec L. Uptake of HIV/AIDS Services Following a Positive Self-Test Is Lower in Men Than Women in the Democratic Republic of the Congo. Front Med (Lausanne) 2021; 8:667732. [PMID: 34395469 PMCID: PMC8360881 DOI: 10.3389/fmed.2021.667732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 06/24/2021] [Indexed: 11/13/2022] Open
Abstract
As far as HIV self-testing (HIVST) is concerned, proving the link to HIV care for users with a positive result contributes to understanding the implementation of HIVST. We sought to examine whether there were differences by sex in the uptake of HIV services following a positive self-test in the Democratic Republic of the Congo (DRC). This was a mixed-methods study exploring linkage to care for HIVST through a secondary analysis of collected data from three pilot surveys recently conducted in three cities (Kinshasa, Kisangani, and Kindu) during 2018 and 2020 in the DRC. Linkage to HIV care was defined as delayed when observed beyond 1 week. A total of 1,652 individuals were self-tested for HIV. Overall, the proportion of linkage to HIV care was high (n = 258; 82.2%) among individuals having a positive result with HIV self-test (n = 314), but it was significantly lower in men (65.2%) than women (89.2%). Furthermore, linkage to HIV care of men was significantly delayed as compared with that of women (40.0 vs. 20.7%). These findings show a lower uptake of care following a positive self-test in men than women. This trend already previously observed in sub-Saharan Africa shed light on the need to increase linkages to care among men newly diagnosed through HIV self-testing.
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Affiliation(s)
- Serge Tonen-Wolyec
- Ecole Doctorale Régionale d'Afrique Centrale en Infectiologie Tropicale, Franceville, Gabon.,Faculty de Medicine, University de Bunia, Bunia, Democratic Republic of the Congo.,Faculty of Medicine and Pharmacy, University of Kisangani, Kisangani, Democratic Republic of the Congo
| | - Charles Kayembe Tshilumba
- Faculty of Medicine and Pharmacy, University of Kisangani, Kisangani, Democratic Republic of the Congo
| | - Salomon Batina-Agasa
- Faculty of Medicine and Pharmacy, University of Kisangani, Kisangani, Democratic Republic of the Congo
| | | | - Laurent Bélec
- Laboratory of Virology, Hôpital Européen Georges Pompidou, University de Paris, Paris Sorbonne Cité, Paris, France
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Tlhajoane M, Dzamatira F, Kadzura N, Nyamukapa C, Eaton JW, Gregson S. Incidence and predictors of attrition among patients receiving ART in eastern Zimbabwe before, and after the introduction of universal 'treat-all' policies: A competing risk analysis. PLOS GLOBAL PUBLIC HEALTH 2021; 1:e0000006. [PMID: 36962073 PMCID: PMC10021537 DOI: 10.1371/journal.pgph.0000006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 09/15/2021] [Indexed: 11/18/2022]
Abstract
As HIV treatment is expanded, attention is focused on minimizing attrition from care. We evaluated the impact of treat-all policies on the incidence and determinants of attrition amongst clients receiving ART in eastern Zimbabwe. Data were retrospectively collected from the medical records of adult patients (aged≥18 years) enrolled into care from July 2015 to June 2016-pre-treat-all era, and July 2016 to June 2017-treat-all era, selected from 12 purposively sampled health facilities. Attrition was defined as an absence from care >90 days following ART initiation. Survival-time methods were used to derive incidence rates (IRs), and competing risk regression used in bivariate and multivariable modelling. In total, 829 patients had newly initiated ART and were included in the analysis (pre-treat-all 30.6%; treat-all 69.4%). Incidence of attrition (per 1000 person-days) increased between the two time periods (pre-treat-all IR = 1.18 (95%CI: 0.90-1.56) versus treat-all period IR = 1.62 (95%CI: 1.37-1.91)). In crude analysis, patients at increased risk of attrition were those enrolled into care during the treat-all period, <34 years of age, WHO stage I at enrolment, and had initiated ART on the same day as HIV diagnosis. After accounting for mediating clinical characteristics, the difference in attrition between the pre-treat-all, and treat-all periods ceased to be statistically significant. In a full multivariable model, attrition was significantly higher amongst same-day ART initiates (aSHR = 1.47, 95%CI:1.05-2.06). Implementation of treat-all policies was associated with an increased incidence of ART attrition, driven largely by ART initiation on the same day as HIV diagnosis which increased significantly in the treat all period. Differentiated adherence counselling for patients at increased risk of attrition, and improved access to clinical monitoring may improve retention in care.
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Affiliation(s)
- Malebogo Tlhajoane
- Department for Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Noah Kadzura
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Constance Nyamukapa
- Department for Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Jeffrey W Eaton
- Department for Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Simon Gregson
- Department for Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
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