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Urrio RF, Lyatuu GW, Sando D, Mahande MJ, Philipo E, Naburi H, Lyaruu P, Kimonge A, Mayogu K, Simba B, Kibao AM, Msangi M, Zeebari Z, Biberfeld G, Ekström AM, Kilewo C, Kågesten AE. Long-term retention on antiretroviral treatment after enrolment in prevention of vertical HIV transmission services: a prospective cohort study in Dar es Salaam, Tanzania. J Int AIDS Soc 2024; 27:e26186. [PMID: 38332522 PMCID: PMC10853596 DOI: 10.1002/jia2.26186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 10/09/2023] [Indexed: 02/10/2024] Open
Abstract
INTRODUCTION To prevent vertical HIV transmission and ensure healthy mothers and children, pregnant women with HIV must remain on antiretroviral treatment (ART) for life. However, motivation to remain on ART may decline beyond the standard 2-year breastfeeding/postpartum period. We assessed attrition and retention in ART care among women with HIV up to 6 years since enrolment in vertical transmission prevention services in Dar es Salaam, Tanzania. METHODS A prospective cohort of 22,631 pregnant women with HIV were enrolled in vertical transmission prevention services between January 2015 and December 2017 in routine healthcare settings and followed-up to July 2021. Kaplan-Meier was used to estimate time to ART attrition (died, stopped ART or was lost to follow-up [no show ≥90 days since scheduled appointment]) and the proportion retained in care. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR) of ART attrition in relation to predictors. RESULTS Participants were followed-up to 6 years for a median of 3 years (IQR: 0.1-4). The overall ART attrition rate was 13.8 per 100 person-years (95% CI: 13.5-14.1), highest in the first year of enrolment at 27.1 (26.3-27.9), thereafter declined to 9.5 (8.9-10.1) in year 3 and 2.7 (2.1-3.5) in year 6. The proportion of women retained in care were 78%, 69%, 63%, 60%, 57% and 56% at 1, 2, 3, 4, 5 and 6 years, respectively. ART attrition was higher in young women aged <20 years (aHR 1.63, 95% CI: 1.38-1.92) as compared to 30-39 year-olds and women enrolled late in the third versus first trimester (aHR 1.29, 95% CI: 1.16-1.44). In contrast, attrition was lower in older women ≥40 years, women who initiated ART before versus during the index pregnancy and women attending higher-level health facilities. CONCLUSIONS ART attrition among women with HIV remains highest in the first year of enrolment in vertical transmission prevention services and declines markedly following a transition to chronic HIV care. Targeted interventions to improve ART continuity among women with HIV during and beyond prevention of vertical transmission are vital to ending paediatric HIV and keeping women and children alive and healthy.
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Affiliation(s)
- Roseline Faustine Urrio
- Management and Development for HealthDar es SalaamTanzania
- Department of Obstetrics and GynacologyMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Goodluck Willey Lyatuu
- Management and Development for HealthDar es SalaamTanzania
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - David Sando
- Management and Development for HealthDar es SalaamTanzania
| | | | | | - Helga Naburi
- Department of Pediatric and Child HealthMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Peter Lyaruu
- Management and Development for HealthDar es SalaamTanzania
| | - Amanda Kimonge
- Management and Development for HealthDar es SalaamTanzania
| | - Kasasi Mayogu
- Management and Development for HealthDar es SalaamTanzania
| | - Brenda Simba
- Management and Development for HealthDar es SalaamTanzania
| | | | | | - Zangin Zeebari
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - Gunnel Biberfeld
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - Anna Mia Ekström
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
- Department of Infectious Disease/VenhälsanSouth General HospitalStockholmSweden
| | - Charles Kilewo
- Department of Obstetrics and GynacologyMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Anna E. Kågesten
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
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Katz IT, Musinguzi N, Bell K, Cross A, Bwana MB, Amanyire G, Asiimwe S, Orrell C, Bangsberg DR, Haberer JE. Brief Report: The Impact of Disease Stage on Early Gaps in ART in the "Treatment for All" Era-A Multisite Cohort Study. J Acquir Immune Defic Syndr 2021; 86:562-567. [PMID: 33351529 PMCID: PMC7938906 DOI: 10.1097/qai.0000000000002605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/09/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Adoption of "Treat All" policies has increased antiretroviral therapy (ART) initiation in sub-Saharan Africa; however, unexplained early losses continue to occur. More information is needed to understand why treatment discontinuation continues at this vulnerable stage in care. METHODS The Monitoring Early Treatment Adherence Study involved a prospective observational cohort of individuals initiating ART at early-stage versus late-stage disease in South Africa and Uganda. Surveys and HIV-1 RNA levels were performed at baseline, 6, and 12 months, with adherence monitored electronically. This analysis included nonpregnant participants in the first 6 months of follow-up; demographic and clinical factors were compared across groups with χ2, univariable, and multivariable models. RESULTS Of 669 eligible participants, 91 (14%) showed early gaps of ≥30 days in ART use (22% in South Africa and 6% in Uganda) with the median time to gap of 77 days (interquartile range: 43-101) and 87 days (74, 105), respectively. Although 71 (78%) ultimately resumed care, having an early gap was still significantly associated with detectable viremia at 6 months (P ≤ 0.01). Multivariable modeling, restricted to South Africa, found secondary education and higher physical health score protected against early gaps [adjusted odds ratio (aOR) 0.4, 95% confidence interval (CI): 0.2 to 0.8 and (aOR 0.93, 95% CI: 0.9 to 1.0), respectively]. Participants reporting clinics as "too far" had double the odds of early gaps (aOR 2.2: 95% CI: 1.2 to 4.1). DISCUSSION Early gaps in ART persist, resulting in higher odds of detectable viremia, particularly in South Africa. Interventions targeting health management and access to care are critical to reducing early gaps.
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Affiliation(s)
- Ingrid T. Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Harvard Global Health Institute, Cambridge, MA
| | | | - Kathleen Bell
- Massachusetts General Hospital Center for Global Health, Boston, MA
| | - Anna Cross
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | | | - Gideon Amanyire
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Stephen Asiimwe
- Mbarara University of Science and Technology, Mbarara, Uganda
- Kabwohe Clinical Research Center, Kabwohe, Uganda; and
| | - Catherine Orrell
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - David R. Bangsberg
- Oregon Health and Science University-Portland State University School of Public Health, Portland, OR
| | - Jessica E. Haberer
- Harvard Medical School, Boston, MA
- Massachusetts General Hospital Center for Global Health, Boston, MA
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Naanyu V, Ruff J, Goodrich S, Spira T, Bateganya M, Toroitich-Ruto C, Otieno-Nyunya B, Siika AM, Wools-Kaloustian K. Qualitative exploration of perceived benefits of care and barriers influencing HIV care in trans Nzoia, Kenya. BMC Health Serv Res 2020; 20:355. [PMID: 32334601 PMCID: PMC7183649 DOI: 10.1186/s12913-020-05236-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 04/17/2020] [Indexed: 01/13/2023] Open
Abstract
Background Substantial efforts have been made to ensure people living with HIV (PLHIV) are linked to and retained in care but many challenges deter care utilization. We report perceived benefits of seeking HIV care and barriers to HIV care that were identified through a formative assessment conducted to advise the development of an alternative care model to deliver antiretroviral treatment therapy (ART) in Trans Nzoia County, Kenya. Methods Data were collected in 2015 through key informant interviews (KIIs), in-depth interviews (IDIs), and focus group discussions (FGDs). The study involved 55 participants of whom 53% were female. Ten KIIs provided community contextual information and viewpoints on the HIV epidemic in Trans Nzoia County while 20 PLHIV (10 male and 10 female) participated in IDIs. Twenty-five individuals living with HIV participated in four FGDs - two groups for men and two for women. Key informants were purposively selected, while every third patient above 18 years at the Kitale HIV Clinic was invited to share their HIV care experience through IDIs or FGDs. Trained research assistants moderated all sessions and audio recordings were transcribed and analyzed thematically. Results Findings showed that PLHIV in Trans Nzoia County used both conventional and complementary alternative care for HIV; however, public health facilities were preferred. Popular perceived benefits of adopting care were relief from symptoms and the chance to live longer. Benefits of care uptake included weight gain, renewed energy, and positive behavior change. Individual-level barriers to HIV care included lack of money and food, use of alternative care, negative side effects of ART, denial, and disclosure difficulties. At the community level, stigma, limited social support for conventional HIV treatment, and poor means of transport were reported. The health system barriers were limited supplies and staff, long distance to conventional HIV care, and unprofessional providers. Conclusions Diverse individual, community and health system barriers continue to affect HIV care-seeking efforts in Kenya. Appreciation of context and lived experiences allows for development of realistic care models.
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Affiliation(s)
- V Naanyu
- Department of Health Policy and Management, School of Public Health, College of Health Science, Moi University, Eldoret, Kenya.
| | - J Ruff
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - S Goodrich
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - T Spira
- Division of Global HIV &TB, United States Centers for Disease Control & Prevention (CDC), Atlanta, GA, USA
| | - M Bateganya
- Division of Global HIV &TB, United States Centers for Disease Control & Prevention (CDC), Atlanta, GA, USA
| | | | | | - A M Siika
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - K Wools-Kaloustian
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Apondi E, Humphrey JM, Sang E, Mwangi A, Keter A, Musick BS, Nalugoda FK, Ssali J, Bukusi E, Yiannoutsos CT, Wools-Kaloustian K, Ayaya S. Trends Over Time for Adolescents Enrolling in HIV Care in Kenya, Tanzania, and Uganda From 2001-2014. J Acquir Immune Defic Syndr 2018; 79:164-72. [PMID: 29985263 DOI: 10.1097/QAI.0000000000001796] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The data needed to understand the characteristics and outcomes, over time, of adolescents enrolling in HIV care in East Africa are limited. SETTING Six HIV care programs in Kenya, Tanzania, and Uganda. METHODS This retrospective cohort study included individuals enrolling in HIV care as younger adolescents (10-14 years) and older adolescents (15-19 years) from 2001-2014. Descriptive statistics were used to compare groups at enrollment and antiretroviral therapy (ART) initiation over time. The proportion of adolescents was compared with the total number of individuals aged 10 years and older enrolling over time. Competing-risk analysis was used to estimate 12-month attrition after enrollment/pre-ART initiation; post-ART attrition was estimated by Kaplan-Meier method. RESULTS A total of 6344 adolescents enrolled between 2001 and 2014. The proportion of adolescents enrolling among all individuals increased from 2.5% (2001-2004) to 3.9% (2013-2014, P < 0.0001). At enrollment, median CD4 counts in 2001-2004 compared with 2013-2014 increased for younger (188 vs. 379 cells/mm, P < 0.0001) and older (225 vs. 427 cells/mm, P < 0.0001) adolescents. At ART initiation, CD4 counts increased for younger (140 vs. 233 cells/mm, P < 0.0001) and older (64 vs. 323 cells/mm, P < 0.0001) adolescents. Twelve-month attrition also increased for all adolescents both after enrollment/pre-ART initiation (4.7% vs. 12.0%, P < 0.001) and post-ART initiation (18.7% vs. 31.2%, P < 0.001). CONCLUSIONS Expanding HIV services and ART coverage was likely associated with earlier adolescent enrollment and ART initiation but also with higher attrition rates before and after ART initiation. Interventions are needed to promote retention in care among adolescents.
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Taha TE, Yende-Zuma N, Aizire J, Chipato T, Wambuzi Ogwang L, Makanani B, Chinula L, Nyati MM, Hanley S, Brummel SS, Fowler MG. The multi-country PROMOTE HIV antiretroviral treatment observational cohort in Sub-Saharan Africa: Objectives, design, and baseline findings. PLoS One 2018; 13:e0208805. [PMID: 30543692 PMCID: PMC6292608 DOI: 10.1371/journal.pone.0208805] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/25/2018] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The PROMOTE study aims to measure long-term antiretroviral treatment (ART) safety and adherence; compare HIV disease progression; assess subsequent adverse pregnancy outcomes; evaluate effect of ART exposure on growth and development in HIV-exposed uninfected children; and assess long-term survival of mothers and children. This report primarily describes cohort characteristics at baseline to better understand long-term outcomes. METHODS AND FINDINGS This is a prospective study. HIV-infected mothers and their children originally recruited in a multisite randomized clinical trial for prevention of perinatal HIV transmission were re-enrolled in PROMOTE. A total of 1987 mothers and 1784 children were enrolled from eight sites in Uganda, Malawi, Zimbabwe and South Africa. Most women (≥75%) reported being married in Malawi and Zimbabwe compared to low proportions in South Africa (4.4% in Durban and 15% in Soweto), and 43.5% in Uganda (p<0.001). There were variabilities in contraceptive practices: injectable contraceptive was the commonest reported method (40.9% overall); implant was the second commonest (15.7% overall); oral contraceptives were common in Zimbabwe; and tubal ligation was common in Malawi and South Africa. At baseline, 97.8% of women reported currently using ART; 96.4% were in WHO clinical class 1 or 2; median CD4 cell count was 825 cells per uL; and viral load was undetectable in 1637 (~85%) of the women. Approximately, 14% of women did not inform their primary partners of their own HIV status, 18% reported that they knew their partners were not HIV tested, and 9% did not know if partner was tested. Overall mean age of children at enrollment was 3.5 years; and 5.7% and 25.0% had weight-for-age and height-for-age z-scores <2 standard deviations, respectively. CONCLUSIONS These baseline data show high adherence to ART use. However, issues of HIV disclosure and reproductive intentions remain important. In addition to ART and ensuring high adherence, other preventive measures should be included.
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Affiliation(s)
- Taha E. Taha
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Nonhlanhla Yende-Zuma
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Jim Aizire
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Tsungai Chipato
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | - Lillian Wambuzi Ogwang
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Bonus Makanani
- University of Malawi College of Medicine, Blantyre, Malawi
| | - Lameck Chinula
- UNC Project-Malawi, Lilongwe, Malawi; UNC-CH Department of Obstetrics and Gynecology, Chapel Hill, NC, United States of America
| | - Mandisa M. Nyati
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Sherika Hanley
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Umlazi Clinical Research Site, Durban, South Africa
| | - Sean S. Brummel
- Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Mary Glenn Fowler
- Johns Hopkins School of Medicine, Baltimore, MD, United States of America
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Johnson M, Lemi BL, Tonny HL, David AD, Boru W, Ransom J. Late entry to HIV and AIDS care and treatment, Juba Teaching Hospital, Juba, South Sudan, 2013-2016. Afr J AIDS Res 2018; 17:213-216. [PMID: 29745288 DOI: 10.2989/16085906.2018.1467473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Late diagnosis of HIV and enrolment to care are global public health challenges. This study aimed to characterise late HIV diagnoses and initiation of treatment among patients at Juba Teaching Hospital (JTH) in South Sudan. We conducted a retrospective review of lab-confirmed HIV patients at JTH, 2013-2016. Demographic, clinical, and laboratory data were entered into and descriptive statistics were calculated using Microsoft Excel. We identified 401 patients, with mean age 33.71±4.54 years, 235 (59%) were female, 307 (77%) were late entry, 64 (16%) were lost to follow-up, and 57 (14%) died within 12 months of diagnosis. Among patients who presented late, 122 (57%) were female, and 112 (53%) were <34 years old. Among patients who died, 33 (58%) were male, and 52 (91%) had CD4 counts <350 cells/mm3 and World Health Organization (WHO) stage >2 at diagnosis. Late diagnosis of HIV infection is a significant public health problem in South Sudan, particularly for younger and female patients.
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Affiliation(s)
- Muki Johnson
- a Immunization and Field Epidemiology Training Project , Juba , South Sudan.,b Field Epidemiology and Laboratory Training Program , Nairobi , Kenya
| | | | | | | | - Waqo Boru
- b Field Epidemiology and Laboratory Training Program , Nairobi , Kenya
| | - James Ransom
- b Field Epidemiology and Laboratory Training Program , Nairobi , Kenya.,d Piret Partners Consulting , Washington, DC , USA
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