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Kilapilo MS, Sangeda RZ, Bwire GM, Sambayi GL, Mosha IH, Killewo J. Adherence to Antiretroviral Therapy and Associated Factors Among People Living With HIV Following the Introduction of Dolutegravir Based Regimens in Dar es Salaam, Tanzania. J Int Assoc Provid AIDS Care 2022; 21:23259582221084543. [PMID: 35243923 PMCID: PMC8902016 DOI: 10.1177/23259582221084543] [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] [Indexed: 11/25/2022] Open
Abstract
Background: Adherence to antiretroviral therapy (ART) is the key determinant of virological suppression in people living with HIV (PLHIV). This study reports factors associated with non-adherence among PLHIV one year after introducing dolutegravir (DTG) based regimens in Tanzania. Methods: A hospital-based cross-sectional study was conducted in two health facilities in Dar es Salaam, Tanzania, in 2020. Results: A total of 406 PLHIV were recruited, where the majority (73.4%) were females, with 94.6% of patients being on DTG based regimens. Factors such as refill interval and sharing of antiretrovirals had significant effects on adherence. Multivariate analysis found that patients attending care and treatment center (CTC) at Temeke Regional Referral Hospital (RRH) were 4.3 times more likely to have non-adherence compared to those attending Amana RRH (aOR [adjusted odds ratio] 4.3, 95% CI [confidence interval]: 2.38 – 7.91, p-value < 0.0001). Conclusions: Sustainable adherence counseling is warranted to overcome non-adherence to ART.
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Affiliation(s)
- Mary Spicar Kilapilo
- Department of Pharmaceutical Microbiology, 92976Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Raphael Zozimus Sangeda
- Department of Pharmaceutical Microbiology, 92976Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - George M Bwire
- Department of Pharmaceutical Microbiology, 92976Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Godfrey Leonard Sambayi
- Department of Pharmacognosy,92976 Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Idda Hubert Mosha
- Department of Behavioural Sciences, 92976Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Japhet Killewo
- Department of Biostatistics and Epidemiology, 92976Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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2
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Kroidl A, Burger T, Urio A, Mugeniwalwo R, Mgaya J, Mlagalila F, Hoelscher M, Däumer M, Salehe O, Sangare A, Lennemann T, Maganga L. High turnaround times and low viral resuppression rates after reinforced adherence counselling following a confirmed virological failure diagnostic algorithm in HIV-infected patients on first-line antiretroviral therapy from Tanzania. Trop Med Int Health 2020; 25:579-589. [PMID: 31984634 DOI: 10.1111/tmi.13373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Early identification of confirmed virological failure is paramount to avoid accumulation of drug resistance in patients on antiretroviral therapy (ART). Scale-up of HIV-RNA monitoring in Africa and timely switch to second-line regimens are challenged. METHODS A WHO adapted confirmed virological treatment screening algorithm (HIV-RNA screening, enhanced adherence counselling, confirmatory HIV-RNA testing) was evaluated in HIV-infected patients on first-line ART from Tanzania. The main endpoints included viral resuppression and virological failure rates, retention and turnaround time of the screening algorithm until second-line ART initiation. Secondary endpoints included risk factors for virological treatment failure and patterns of genotypic drug resistance. RESULTS HIV-RNA >1000 copies/ml at first screening was detected in 58/356 (16.3%) patients (median time-on-treatment 6.3 years, 25% immunological treatment failure). Adjusted risk factors for virological failure were age <30 years (RR 5.2 [95% CI: 2.5-10.8]), years on ART ≥3 years (RR 3.0 [1.0-8.9]), CD4-counts <200 cells/µl (RR 9.3 [4.0-21.8]) and poor self-reported treatment adherence (RR 2.0 [1.2-3.4]). Resuppression of HIV-RNA <1000 copies/ml was observed in 5/50 (10%) cases after enhanced adherence counselling. Confirmatory testing within 3 months was performed in only 46.6% and switch to second-line ART within 6 months in 60.4% of patients. Major NNRTI-mutation were detected in all of 30 patients, NRTI mutations in 96.7% and ≥3 thymidine-analogue mutations in 40%. No remaining NRTI options were predicted in 57% and limited susceptibility in 23% of patients. CONCLUSION We observed low levels of viral resuppression following adherence counselling, associated with high levels of accumulated drug resistance. High visit burden and turnaround times for confirmed virological failure diagnosis further delayed switching to second-line treatment which could be improved using novel point-of-care viral load monitoring systems.
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Affiliation(s)
- Arne Kroidl
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany.,German Center for Infection Research, Partner site Munich, Munich, Germany
| | - Tassilo Burger
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany
| | - Agatha Urio
- NIMR-Mbeya Medical Research Center, Mbeya, Tanzania
| | | | - Jimson Mgaya
- NIMR-Mbeya Medical Research Center, Mbeya, Tanzania
| | | | - Michael Hoelscher
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany.,German Center for Infection Research, Partner site Munich, Munich, Germany
| | - Martin Däumer
- Institute of Immunology and Genetics, Kaiserslautern, Germany
| | - Omar Salehe
- Mbeya Zonal Referral Hospital, Mbeya, Tanzania
| | | | - Tessa Lennemann
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany.,NIMR-Mbeya Medical Research Center, Mbeya, Tanzania
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Ntamatungiro AJ, Muri L, Glass TR, Erb S, Battegay M, Furrer H, Hatz C, Tanner M, Felger I, Klimkait T, Letang E. Strengthening HIV therapy and care in rural Tanzania affects rates of viral suppression. J Antimicrob Chemother 2018; 72:2069-2074. [PMID: 28387865 DOI: 10.1093/jac/dkx095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 02/28/2017] [Indexed: 12/19/2022] Open
Abstract
Objectives To assess viral suppression rates, to assess prevalence of acquired HIV drug resistance and to characterize the spectrum of HIV-1 drug resistance mutations (HIV-DRM) in HIV-1-infected patients in a rural Tanzanian HIV cohort. Methods This was a cross-sectional study nested within the Kilombero and Ulanga Antiretroviral Cohort. Virological failure was defined as HIV-1 RNA ≥50 copies/mL. Risk factors associated with virological failure and with the development of HIV-DRM were assessed using logistic regression. Results This study included 304 participants with a median time on ART of 3.5 years (IQR = 1.7-5.3 years); 91% were on an NNRTI-based regimen and 9% were on a boosted PI-based regimen. Viral suppression was observed in 277/304 patients (91%). Of the remaining 27 patients, 21 were successfully genotyped and 17/21 (81%) harboured ≥1 clinically relevant HIV-DRM. Of these, 13/17 (76.5%) had HIV-1 plasma viral loads of >1000 copies/mL. CD4 cell count <200 cells/mm(3) at the time of recruitment was independently associated with a close to 8-fold increased odds of virological failure [adjusted OR (aOR) = 7.71, 95% CI = 2.86-20.78, P < 0.001] and with a >8-fold increased odds of developing HIV-DRM (aOR = 8.46, 95% CI = 2.48-28.93, P = 0.001). Conclusions High levels of viral suppression can be achieved in rural sub-Saharan Africa when treatment and care programmes are well managed. In the absence of routine HIV sequencing, the WHO-recommended threshold of 1000 viral RNA copies/mL largely discriminates virological failure secondary to HIV-DRM.
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Affiliation(s)
| | - Lukas Muri
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Tracy R Glass
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Stefan Erb
- University of Basel, Basel, Switzerland.,Division of Infectious Diseases and Hospital Epidemiology, Department of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Manuel Battegay
- University of Basel, Basel, Switzerland.,Division of Infectious Diseases and Hospital Epidemiology, Department of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Hatz
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Marcel Tanner
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Ingrid Felger
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Thomas Klimkait
- Molecular Virology, Department Biomedicine Petersplatz, University of Basel, Basel, Switzerland
| | - Emilio Letang
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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Geldsetzer P, Francis JM, Ulenga N, Sando D, Lema IA, Mboggo E, Vaikath M, Koda H, Lwezaula S, Hu J, Noor RA, Olofin I, Larson E, Fawzi W, Bärnighausen T. The impact of community health worker-led home delivery of antiretroviral therapy on virological suppression: a non-inferiority cluster-randomized health systems trial in Dar es Salaam, Tanzania. BMC Health Serv Res 2017; 17:160. [PMID: 28228134 PMCID: PMC5322683 DOI: 10.1186/s12913-017-2032-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 01/17/2017] [Indexed: 11/18/2022] Open
Abstract
Background Home delivery of antiretroviral therapy (ART) by community health workers (CHWs) may improve ART retention by reducing the time burden and out-of-pocket expenditures to regularly attend an ART clinic. In addition, ART home delivery may shorten waiting times and improve quality of care for those in facility-based care by decongesting ART clinics. This trial aims to determine whether ART home delivery for patients who are clinically stable on ART combined with facility-based care for those who are not stable on ART is non-inferior to the standard of care (facility-based care for all ART patients) in achieving and maintaining virological suppression. Methods This is a non-inferiority cluster-randomized trial set in Dar es Salaam, Tanzania. A cluster is one of 48 healthcare facilities with its surrounding catchment area. 24 clusters were randomized to ART home delivery and 24 to the standard of care. The intervention consists of home visits by CHWs to provide counseling and deliver ART to patients who are stable on ART, while the control is the standard of care (facility-based ART and CHW home visits without ART home delivery). In addition, half of the healthcare facilities in each study arm were randomized to standard counseling during home visits (covering family planning, prevention of HIV transmission, and ART adherence), and half to standard plus nutrition counseling (covering food production and dietary advice). The non-inferiority design applies to the endpoints of the ART home delivery trial; the primary endpoint is the proportion of ART patients at a healthcare facility who are virally suppressed at the end of the study period. The margin of non-inferiority for this primary endpoint was set at nine percentage points. Discussion As the number of ART patients in sub-Saharan Africa is expected to rise, this trial provides causal evidence on the effectiveness of a home-based care model that could decongest ART clinics and reduce patients’ healthcare expenditures. More broadly, this trial will inform the increasing policy interest in task-shifting of chronic disease care from facility- to community-based healthcare workers. Trial registration ClinicalTrials.gov: NCT02711293. Registration date: 16 March 2016. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2032-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pascal Geldsetzer
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Joel M Francis
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania. .,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA. .,National Institute for Medical Research, 3 Barack Obama Drive, 11101, Dar es Salaam, Tanzania.
| | - Nzovu Ulenga
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Irene A Lema
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - Eric Mboggo
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - Maria Vaikath
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Happiness Koda
- Management and Development for Health, Plot #802, Mwai Kibaki Road, Mikocheni, Dar es Salaam, Tanzania
| | - Sharon Lwezaula
- National AIDS Control Program, Lithuli Street, P.O. Box 11857, Dar es Salaam, Tanzania
| | - Janice Hu
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.,Duke University School of Medicine, Duke University, 8 Duke University Medical Center Greenspace, Durham, NC, 27703, USA
| | - Ramadhani A Noor
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.,Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA.,Africa Academy for Public Health (AAPH), Plot #802, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - Ibironke Olofin
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Elysia Larson
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
| | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.,Department of Nutrition, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.,Institute for Public Health, Faculty of Medicine, Heidelberg University, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.,Africa Health Research Institute, Mtubatuba 3935, KwaZulu-Natal, South Africa
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Hawkins C, Ulenga N, Liu E, Aboud S, Mugusi F, Chalamilla G, Sando D, Aris E, Carpenter D, Fawzi W. HIV virological failure and drug resistance in a cohort of Tanzanian HIV-infected adults. J Antimicrob Chemother 2016; 71:1966-74. [PMID: 27076106 DOI: 10.1093/jac/dkw051] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/05/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES There are few data on ART failure rates and drug resistance from Tanzania, where there is a wide diversity of non-B HIV subtypes. We assessed rates and predictors of virological failure in HIV-infected Tanzanians and describe drug resistance patterns in a subgroup of these patients. METHODS ART-naive, HIV-1-infected adults enrolled in a randomized controlled trial between November 2006 and 2008 and on ≥24 weeks of first-line NNRTI-containing ART were included. Population-based genotyping of HIV-1 protease and reverse transcriptase was performed on stored plasma from patients with virological failure (viral load >1000 copies/mL at ≥24 weeks of ART) and at baseline, where available. RESULTS A total of 2403 patients [median (IQR) age 37 (32-43) years; 70% female] were studied. The median (IQR) baseline CD4+ T cell count was 128 (62-190) cells/μL. Predominant HIV subtypes were A, C and D (92.2%). The overall rate of virological failure was 14.9% (95% CI 13.2%-16.1%). In adjusted analyses, significant predictors of virological failure were lower CD4+ T cell count (P = 0.01) and non-adherence to ART (P < 0.01). Drug resistance mutations were present in 87/115 samples (75.7%); the most common were M184V/I (52.2%) and K103N (35%). Thymidine analogue mutations were uncommon (5.2%). The prevalence of mutations in 45 samples pre-ART was 22%. CONCLUSIONS High levels of early ART failure and drug resistance were observed among Tanzanian HIV-1-infected adults enrolled in a well-monitored study. Initiating treatment early and ensuring optimal adherence are vital for the success and durability of first-line ART in these settings.
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Affiliation(s)
- Claudia Hawkins
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nzovu Ulenga
- Management and Development for Health, Dar es Salaam, Tanzania Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA, USA
| | - Enju Liu
- Departments of Nutrition, Epidemiology, Biostatistics, and Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | - Said Aboud
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ferdinand Mugusi
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - David Sando
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Eric Aris
- Management and Development for Health, Dar es Salaam, Tanzania
| | | | - Wafaie Fawzi
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
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Factors Influencing Antiretroviral Adherence and Virological Outcomes in People Living with HIV in the Highlands of Papua New Guinea. PLoS One 2015; 10:e0134918. [PMID: 26244516 PMCID: PMC4526685 DOI: 10.1371/journal.pone.0134918] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 07/15/2015] [Indexed: 11/24/2022] Open
Abstract
Adherence to antiretroviral therapy (ART) is paramount for virological suppression and positive treatment outcomes. ART has been rapidly scaled up in Papua New Guinea (PNG) in recent years, however clinical monitoring of HIV+ individuals on ART is limited. A cross-sectional study was conducted at two major sexual health clinics in high HIV prevalence provinces in the Highlands Region of PNG to assess ART adherence, factors affecting adherence and the relationship between ART adherence and virological outcomes. Ninety-five HIV+ individuals were recruited and administered a questionnaire to gather demographic and ART adherence information whilst clinical data and pill counts were extracted from patient charts and blood was collected for viral load testing. Bivariate analysis was performed to identify independent predictors of ART adherence. Fourteen percent (n = 12) of participants showed evidence of virological failure. Although the majority of participants self-reported excellent ART adherence in the last seven days (78.9%, 75/91), pill count measurements indicated only 40% (34/84) with >95% adherence in the last month. Taking other medications while on ART (p = 0.01) and taking ART for ≥1 year (p = 0.037) were positively associated with adherence by self-report and pill count, respectively. Participants who had never heard of drug resistance were more likely to show virological failure (p = 0.033). Misconception on routes of HIV transmission still persists in the studied population. These findings indicate that non-adherence to ART is high in this region of PNG and continued education and strategies to improve adherence are required to ensure the efficacy of ART and prevent HIV drug resistance.
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