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Hlophe LD, Tamuzi JL, Shumba CS, Nyasulu PS. Barriers and facilitators to anti-retroviral therapy adherence among adolescents aged 10 to 19 years living with HIV in sub-Saharan Africa: A mixed-methods systematic review and meta-analysis. PLoS One 2023; 18:e0276411. [PMID: 37200399 DOI: 10.1371/journal.pone.0276411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 05/02/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Human Immunodeficiency Virus (HIV) significantly affects adolescents globally, with the sub-Saharan Africa (SSA) reporting a high burden of the disease. HIV testing, treatment, and retention to care are low among adolescents. We conducted a mixed-method systematic review to assess anti-retroviral therapy (ART) adherence; barriers and facilitators to ART adherence and ART outcomes among adolescents living with HIV and on ART in sub-Saharan Africa. METHODS We conducted searches in four scientific databases for studies conducted between 2010 and March 2022 to identify relevant primary studies. Studies were screened against inclusion criteria and assessed for quality, and data was extracted. Meta-analysis of rates and odd ratios was used to plot the quantitative studies and meta-synthesis summarized the evidence from qualitative studies. RESULTS A total of 10 431 studies were identified and screened against the inclusion/ exclusion criteria. Sixty-six studies met the inclusion criteria (41 quantitative, 16 qualitative, and 9 mixed-methods study designs). Fifty-three thousand two hundred and seventeen (53 217) adolescents (52 319 in quantitative studies and 899 in qualitative studies) were included in the review. Thirteen support focused interventions for improved ART adherence were identified from quantitative studies. The plotted results from the meta-analysis found an ART adherence rate of 65% (95%CI 56-74), viral load suppression was 55% (95%CI 46-64), un-suppressed viral load rate of 41% (95%CI 32-50), and loss to follow up of 17% (95%CI 10-24) among adolescents. Meta-synthesis found six themes of barriers to ART (social, patient-based, economic, health system-based, therapy-based, and cultural barriers) in both the qualitative and quantitative studies, and three themes of facilitators to ART were also identified (social support, counselling, and ART education and secrecy or confidentiality) from qualitative studies. CONCLUSION ART adherence remains low among adolescents in SSA despite multiple interventions implemented to improve ART adherence. The low adherence rate may hinder the attainment of the UNAIDS 2030 targets. Additionally, various barriers to ART adherence due to lack of support have been reported among this age group. However, interventions aimed at improving social support, educating, and counselling adolescents may improve and sustain ART adherence. TRIAL REGISTRATION Systematic review registration: PROSPERO CRD42021284891.
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Affiliation(s)
- Londiwe D Hlophe
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Environmental Health Sciences, Faculty of Health Sciences, University of Eswatini, Mbabane, Kingdom of Eswatini
| | - Jacques L Tamuzi
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Peter S Nyasulu
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Leshargie CT, Demant D, Burrowes S, Frawley J. The proportion of loss to follow-up from antiretroviral therapy (ART) and its association with age among adolescents living with HIV in sub-Saharan Africa: A systematic review and meta-analysis. PLoS One 2022; 17:e0272906. [PMID: 35951621 PMCID: PMC9371308 DOI: 10.1371/journal.pone.0272906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/29/2022] [Indexed: 11/25/2022] Open
Abstract
Background Human immunodeficiency virus (HIV) remains a global health threat, especially in developing countries. The successful scale-up of antiretroviral therapy (ART) programs to address this threat is hindered by a high proportion of patient loss to follow-up (LTFU). LTFU is associated with poor viral suppression and increased mortality. It is particularly acute among adolescents, who face unique adherence challenges. Although LTFU is a critical obstacle on the continuum of care for adolescents, few regional-level studies report the proportion of LTFU among adolescents receiving ART. Therefore, a systematic review and meta-analysis were conducted to estimate the pooled LTFU in ART programs among adolescents living with HIV in sub-Saharan Africa (SSA). Methods We searched five databases (PubMed, Embase (Elsevier), PsycINFO, CINAHL, and Scopus) for articles published between 2005 and 2020 and reference lists of included articles. The PRISMA guidelines for systematic reviews were followed. A standardised checklist to extract data was used. Descriptive summaries were presented using narrative tables and figures. Heterogeneity within the included studies was examined using the Cochrane Q test statistics and I2 test. Random effect models were used to estimate the pooled prevalence of LTFU among ALHIV. We used Stata version 16 statistical software for our analysis. Results Twenty-nine eligible studies (n = 285,564) were included. An estimated 15.07% (95% CI: 11.07, 19.07) of ALHIV were LTFU. Older adolescents (15–19 years old) were 43% (AOR = 0.57, 95% CI: 0.37, 0.87) more likely to be LTFU than younger (10–14 years old) adolescents. We find an insignificant relationship between gender and LTFU (AOR = 0.95, 95% CI: 0.87, 1.03). A subgroup analysis found that regional differences in the proportion of adolescent LTFU were not statistically significant. The trend analysis indicates an increasing proportion of adolescent LTFU over time. Conclusions and recommendations The proportion of LTFU among HIV-positive adolescents in SSA seems higher than those reported in other regions. Older adolescents in the region are at an increased risk for LTFU than younger adolescents. These findings may help policymakers develop appropriate strategies to retain ALHIV in ART services. Such strategies could include community ART distribution points, appointment spacing, adherence clubs, continuous free access to ART, and community-based adherence support.
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Affiliation(s)
- Cheru Tesema Leshargie
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, Australia
- * E-mail:
| | - Daniel Demant
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, Australia
- School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Sahai Burrowes
- Public Health Program, College of Education and Health Sciences, Touro University California, Vallejo, CA, United States of America
| | - Jane Frawley
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, Australia
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Okonji EF, Wyk BV, Mukumbang FC. Two-year retention in care for adolescents on antiretroviral therapy in Ehlanzeni district, South Africa: a baseline cohort analysis. AIDS Care 2022; 35:374-384. [PMID: 35357245 DOI: 10.1080/09540121.2022.2057409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Adolescents living with HIV (ALHIV) struggle to remain engaged in HIV-related care and adhere to antiretroviral treatment (ART) due to a myriad of physical, psychological and cognitive-developmental challenges. We report on the profile of ALHIV aged 10-19 years on ART and the clinical factors associated with their retention in care. A retrospective cohort analysis was conducted with 16,108 ALHIV, aged 10-19 years, who were enrolled in 136 ART clinics in the Ehlanzeni district. Anonymised data were obtained from electronic medical records (Tier.net). Trends in retention in care among adolescents on ART was described using Kaplan-Meier survival estimates. Cox proportional analysis was performed to identify factors associated with retention in care over 2 years. More than half (53%) were females, and median duration on ART was 8 months. Retention in care among adolescents at months 6, 12, 18 and 24 was 90.5%, 85.4%, 80.8% and 76.2%, respectively. After controlling for confounders, risk of dying or lost to follow up increased for female adolescents (aHR = 1.28, 95% CI 1.10-1.49); being initiated on ART while pregnant (aHR = 2.72, 95% CI 1.99-3.69); history of TB infection (aHR = 1.71, 95% CI 1.10-2.65); and started ART at age 10-14 years (aHR = 2.45, 95% CI 1.96-3.05), and 15-19 years (aHR = 9.67, 95% CI 7.25-12.89). Retention in care among adolescents on ART over two-year period was considerably lower than the UNAIDS 2030 target of 95%. Of particular concern for intervention is the lower rates of retention in care among females and pregnant adolescents and starting ART between the ages of 10 and 19 years. Family or caregivers and peer support groups centred interventions designed to promote early initiation and retention in care through early case identification are needed.
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Affiliation(s)
- Emeka F Okonji
- School of Public Health, Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Brian Van Wyk
- School of Public Health, Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Ferdinand C Mukumbang
- School of Public Health, Community and Health Sciences, University of the Western Cape, Cape Town, South Africa.,Department of global Health, School of Medicine, University of Washington, Seattle, WA, USA
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Dejen D, Jara D, Yeshanew F, Fentaw Z, Mengie Feleke T, Girmaw F, Wagaye B. Attrition and Its Predictors Among Adults Receiving First-Line Antiretroviral Therapy in Woldia Town Public Health Facilities, Northeast Ethiopia: A Retrospective Cohort Study. HIV AIDS (Auckl) 2021; 13:445-454. [PMID: 33907472 PMCID: PMC8068483 DOI: 10.2147/hiv.s304657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/30/2021] [Indexed: 02/04/2023]
Abstract
Introduction There is an expansion and advancement of antiretroviral therapy. However, attrition of patients from HIV care is one of the major drivers of poor performance of HIV/AIDS programs, which leads to drug resistance, morbidity and mortality. The study aimed to assess the incidence of attrition and its predictors among adults receiving first-line antiretroviral therapy. Methods An institution-based retrospective cohort study was conducted among 634 adults receiving antiretroviral therapy, and study participants were selected using a simple random sampling technique. Data were cleaned and entered into Epi Data version 3.1 and exported to STATA 14.1 for further analysis. The predictors of attrition were identified using bivariable and multivariable Cox Proportional hazard models; then, variables at a p-value of less than 0.25 and 0.05 were included in the multivariable analysis and statistically significant, respectively. Results The total time observed was found to be 1807.08 person-years of observation with a median follow-up time of 2.67 years (IQR 1.25−4.67). The incidence rate of attrition was 8.36 (95% CI: 7.12−9.80) per 100 person-years. Significant predictors of attrition were being young age [adjusted hazard ratio (AHR) =2.0, 95% CI, (1.11−3.58)], nearest calendar year of ART initiation [AHR =2.32, 95% CI, (1.08–5.01)], bedridden functional status [AHR=3.25, 95% CI, (1.33−7.96)], WHO stage III [AHR=3.57, 95% CI, (1.58−8.06)] and stage IV [AHR=5.46, 95% CI, (1.97−15.13)], viral load result of ≤1000 [AHR=0.11, 95% CI, (0.06−0.23)], disclosure status [AHR=2.03, 95% CI, (1.22−3.37)] and adherence level of poor [AHR=3.19, 95 CI, (1.67−6.09)]. Conclusion The result of this study showed that the incidence of attrition among adults receiving antiretroviral therapy was high. However, as a standard, every client who started antiretroviral therapy should be retained. Positive predictors of attrition were young age (15–24), recent year of ART initiation, baseline functional status, advanced WHO stage III and IV, no disclosure status, fair/poor adherence whereas, viral load result of ≤1000 copies/mL had a preventive effect on attrition.
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Affiliation(s)
- Demeke Dejen
- Care and Treatment, Amhara Regional Health Bureau CDC Project Cluster Health Facilities HIV Case Detection Linkage, Woldia, Ethiopia
| | - Dube Jara
- Department of Epidemiology and Biostatics, School of Public Health, College of Medicine and Health Science, Addis Ababa University, Addis Ababa, Ethiopia
| | - Fanos Yeshanew
- Department of Public Health Nutrition, School of Public Health, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Zinabu Fentaw
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Tesfa Mengie Feleke
- Amhara Regional Health Bureau CDC Project Zonal Monitoring and Evaluation, Dessie, Ethiopia
| | - Fentaw Girmaw
- Department of Pharmacy, College of Health Science, Woldia University, Woldia, Ethiopia
| | - Birhanu Wagaye
- Department of Public Health Nutrition, School of Public Health, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
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Chirenda J, Nhlema Simwaka B, Sandy C, Bodnar K, Corbin S, Desai P, Mapako T, Shamu S, Timire C, Antonio E, Makone A, Birikorang A, Mapuranga T, Ngwenya M, Masunda T, Dube M, Wandwalo E, Morrison L, Kaplan R. A feasibility study using time-driven activity-based costing as a management tool for provider cost estimation: lessons from the national TB control program in Zimbabwe in 2018. BMC Health Serv Res 2021; 21:242. [PMID: 33736629 PMCID: PMC7977596 DOI: 10.1186/s12913-021-06212-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/24/2021] [Indexed: 11/17/2022] Open
Abstract
Background Insufficient cost data and limited capacity constrains the understanding of the actual resources required for effective TB control. This study used process maps and time-driven activity-based costing to document TB service delivery processes. The analysis identified the resources required to sustain TB services in Zimbabwe, as well as several opportunities for more effective and efficient use of available resources. Methods A multi-disciplinary team applied time-driven activity-based costing (TDABC) to develop process maps and measure the cost of clinical pathways used for Drug Susceptible TB (DS-TB) at urban polyclinics, rural district and provincial hospitals, and community based targeted screening for TB (Tas4TB). The team performed interviews and observations to collect data on the time taken by health care worker-patient pairs at every stage of the treatment pathway. The personnel’s practical capacity and capacity cost rates were calculated on five cost domains. An MS Excel model calculated diagnostic and treatment costs. Findings Twenty-five stages were identified in the TB care pathway across all health facilities except for community targeted screening for TB. Considerable variations were observed among the facilities in how health care professionals performed client registration, taking of vital signs, treatment follow-up, dispensing medicines and processing samples. The average cost per patient for the entire DS-TB care was USD324 with diagnosis costing USD69 and treatment costing USD255. The average cost for diagnosis and treatment was higher in clinics than in hospitals (USD392 versus USD256). Nurses in clinics were 1.6 time more expensive than in hospitals. The main cost components were personnel (USD130) and laboratory (USD119). Diagnostic cost in Tas4TB was twice that of health facility setting (USD153 vs USD69), with major cost drivers being demand creation (USD89) and sputum specimen transportation (USD5 vs USD3). Conclusion TDABC is a feasible and effective costing and management tool in low-resource settings. The TDABC process maps and treatment costs revealed several opportunities for innovative improvements in the NTP under public health programme settings. Re-engineering laboratory testing processes and synchronising TB treatment follow-up with antiretroviral treatments could produce better and more uniform TB treatments at significantly lower cost in Zimbabwe.
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Affiliation(s)
- J Chirenda
- College of Health Sciences, Department of Community Medicine, University of Zimbabwe, Harare, Zimbabwe
| | - B Nhlema Simwaka
- The Global Fund to Fight TB, HIV and Malaria, Global Health Campus, Chemin du Pommier 40, 1218 Grand-Saconnex, Geneva, Switzerland.
| | - C Sandy
- Ministry of Health and Child Care, National TB Control Program, Harare, Zimbabwe
| | - K Bodnar
- Harvard Business School, Boston, MA, USA
| | - S Corbin
- The Global Fund to Fight TB, HIV and Malaria, Global Health Campus, Chemin du Pommier 40, 1218 Grand-Saconnex, Geneva, Switzerland
| | - P Desai
- Harvard Business School, Boston, MA, USA
| | - T Mapako
- College of Health Sciences, Department of Community Medicine, University of Zimbabwe, Harare, Zimbabwe.,National Blood Service, Harare, Zimbabwe
| | - S Shamu
- College of Health Sciences, Department of Community Medicine, University of Zimbabwe, Harare, Zimbabwe
| | - C Timire
- Ministry of Health and Child Care, National TB Control Program, Harare, Zimbabwe
| | - E Antonio
- Price Waterhouse Coopers (PWC), Harare, Zimbabwe
| | - A Makone
- Price Waterhouse Coopers (PWC), Harare, Zimbabwe
| | - A Birikorang
- The Global Fund to Fight TB, HIV and Malaria, Global Health Campus, Chemin du Pommier 40, 1218 Grand-Saconnex, Geneva, Switzerland
| | - T Mapuranga
- Ministry of Health and Child Care, National TB Control Program, Harare, Zimbabwe
| | - M Ngwenya
- World Health Organisation, Harare, Zimbabwe
| | - T Masunda
- Ministry of Health and Child Care, National TB Control Program, Harare, Zimbabwe
| | - M Dube
- Ministry of Health and Child Care, National TB Control Program, Harare, Zimbabwe
| | - E Wandwalo
- The Global Fund to Fight TB, HIV and Malaria, Global Health Campus, Chemin du Pommier 40, 1218 Grand-Saconnex, Geneva, Switzerland
| | - L Morrison
- The Global Fund to Fight TB, HIV and Malaria, Global Health Campus, Chemin du Pommier 40, 1218 Grand-Saconnex, Geneva, Switzerland
| | - R Kaplan
- Harvard Business School, Boston, MA, USA
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van Wyk B, Kriel E, Mukumbang F. Retention in care for adolescents who were newly initiated on antiretroviral therapy in the Cape Metropole in South Africa. South Afr J HIV Med 2020. [DOI: 10.4102/sajhivmed.v21i1.1077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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van Wyk B, Kriel E, Mukumbang F. Retention in care for adolescents who were newly initiated on antiretroviral therapy in the Cape Metropole in South Africa. South Afr J HIV Med 2020; 21:1077. [PMID: 32832112 PMCID: PMC7433256 DOI: 10.4102/hivmed.v21i1.1077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 05/23/2020] [Indexed: 12/01/2022] Open
Abstract
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.
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Affiliation(s)
- Brian van Wyk
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Ebrahim Kriel
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Ferdinand Mukumbang
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
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Makurumidze R, Mutasa-Apollo T, Decroo T, Choto RC, Takarinda KC, Dzangare J, Lynen L, Van Damme W, Hakim J, Magure T, Mugurungi O, Rusakaniko S. Retention and predictors of attrition among patients who started antiretroviral therapy in Zimbabwe's national antiretroviral therapy programme between 2012 and 2015. PLoS One 2020; 15:e0222309. [PMID: 31910445 PMCID: PMC6946589 DOI: 10.1371/journal.pone.0222309] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/17/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The last evaluation to assess outcomes for patients receiving antiretroviral therapy (ART) through the Zimbabwe public sector was conducted in 2011, covering the 2007-2010 cohorts. The reported retention at 6, 12, 24 and 36 months were 90.7%, 78.1%, 68.8% and 64.4%, respectively. We report findings of a follow-up evaluation for the 2012-2015 cohorts to assess the implementation and impact of recommendations from this prior evaluation. METHODS A nationwide retrospective study was conducted in 2016. Multi-stage proportional sampling was used to select health facilities and study participants records. The data extracted from patient manual records included demographic, baseline clinical characteristics and patient outcomes (active on treatment, died, transferred out, stopped ART and lost to follow-up (LTFU)) at 6, 12, 24 and 36 months. The data were analysed using Stata/IC 14.2. Retention was estimated using survival analysis. The predictors associated with attrition were determined using a multivariate Cox regression model. RESULTS A total of 3,810 participants were recruited in the study. The median age in years was 35 (IQR: 28-42). Overall, retention increased to 92.4% (p-value = 0.060), 86.5% (p-value<0.001), 79.2% (p-value<0.001) and 74.4% (p-value<0.001) at 6, 12, 24 and 36 months respectively. LTFU accounted for 98% of attrition. Being an adolescent or a young adult (15-24 years) (vs adult;1.41; 95% CI:1.14-1.74), children (<15years) (vs adults; aHR 0.64; 95% CI:0.46-0.91), receiving care at primary health care facility (vs central and provincial facility; aHR 1.23; 95% CI:1.01-1.49), having initiated ART between 2014-2015 (vs 2012-2013; aHR1.45; 95%CI:1.24-1.69), having WHO Stage IV (vs Stage I-III; aHR2.06; 95%CI:1.51-2.81) and impaired functional status (vs normal status; aHR1.25; 95%CI:1.04-1.49) predicted attrition. CONCLUSION The overall retention was higher in comparison to the previous 2007-2010 evaluation. Further studies to understand why attrition was found to be higher at primary health care facilities are warranted. Implementation of strategies for managing patients with advanced HIV disease, differentiated care for adolescents and young adults and tracking of LTFU clients should be prioritised to further improve retention.
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Affiliation(s)
- Richard Makurumidze
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
- Institute of Tropical Medicine, Antwerp, Belgium
- Gerontology, Faculty of Medicine & Pharmacy, Free University of Brussels (VUB), Brussels, Belgium
| | | | - Tom Decroo
- Institute of Tropical Medicine, Antwerp, Belgium
- Research Foundation of Flanders, Brussels, Belgium
| | - Regis C. Choto
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
| | - Kudakwashe C. Takarinda
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Janet Dzangare
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
| | | | - Wim Van Damme
- Institute of Tropical Medicine, Antwerp, Belgium
- Gerontology, Faculty of Medicine & Pharmacy, Free University of Brussels (VUB), Brussels, Belgium
| | - James Hakim
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | - Owen Mugurungi
- AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe
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Mugglin C, Haas AD, van Oosterhout JJ, Msukwa M, Tenthani L, Estill J, Egger M, Keiser O. Long-term retention on antiretroviral therapy among infants, children, adolescents and adults in Malawi: A cohort study. PLoS One 2019; 14:e0224837. [PMID: 31725750 PMCID: PMC6855432 DOI: 10.1371/journal.pone.0224837] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 06/03/2019] [Accepted: 10/22/2019] [Indexed: 12/01/2022] Open
Abstract
Objectives We examine long-term retention of adults, adolescents and children on antiretroviral therapy under different HIV treatment guidelines in Malawi. Design Prospective cohort study. Setting and participants Adults and children starting ART between 2005 and 2015 in 21 health facilities in southern Malawi. Methods We used survival analysis to assess retention at clinic level, Cox regression to examine risk factors for loss to follow up, and competing risk analysis to assess long-term outcomes of people on antiretroviral therapy (ART). Results We included 132,274 individuals in our analysis, totalling 270,256 person years of follow up (PYFU; median per patient 1.3, interquartile range (IQR) 0.26–3.1), 62% were female and the median age was 32 years. Retention on ART was lower in the first year on ART compared to subsequent years for all guideline periods and age groups. Infants (0–3 years), adolescents and young adults (15–24 years) were at highest risk of LTFU. Comparing the different calendar periods of ART initiation we found that retention improved initially, but remained stable thereafter. Conclusion Even though the number of patients and the burden on health care system increased substantially during the study period of rapid ART expansion, retention on ART improved in the early years of ART provision, but gains in retention were not maintained over 5 years on ART. Reducing high attrition in the first year of ART should remain a priority for ART programs, and so should addressing poor retention among adolescents, young adults and men.
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Affiliation(s)
- Catrina Mugglin
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- * E-mail:
| | - Andreas D. Haas
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Joep J. van Oosterhout
- Dignitas International, Zomba, Malawi
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Malango Msukwa
- Baobab Health Trust, Lilongwe, Malawi
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Lyson Tenthani
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- I-TECH Malawi, Lilongwe, Malawi
| | - Janne Estill
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Olivia Keiser
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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Enane LA, Vreeman RC, Foster C. Retention and adherence: global challenges for the long-term care of adolescents and young adults living with HIV. Curr Opin HIV AIDS 2019; 13:212-219. [PMID: 29570471 DOI: 10.1097/coh.0000000000000459] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Adolescents living with HIV are the only age group with increasing HIV mortality at a time of global scale-up of access to antiretroviral therapy (ART). As a 'treat all' strategy is implemented worldwide, it is critically important to optimize retention and adherence for this vulnerable group. RECENT FINDINGS Adolescents and young adults living with HIV have poorer outcomes when compared with adults at each stage of the HIV care cascade, irrespective of income setting. Rates of viral suppression are lowest for adolescents living with HIV, and adherence to ART remains an enormous challenge. High-quality studies of interventions to improve linkage to, and retention in, care on suppressive ART are starkly lacking for adolescents and young adults living with HIV across the globe. However, examples of good practice are beginning to emerge but require large-scale implementation studies with outcome data disaggregated by age, route of infection, and income setting, and include young pregnant women and key populations groups. SUMMARY There is an urgent need for evidence-based interventions addressing gaps in the adolescent HIV care cascade, including supporting retention in care and adherence to ART.
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Affiliation(s)
- Leslie A Enane
- Department of Pediatrics, The Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Academic Model Providing Access to Healthcare (AMPATH)
| | - Rachel C Vreeman
- Department of Pediatrics, The Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Academic Model Providing Access to Healthcare (AMPATH).,Department of Child Health and Pediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Caroline Foster
- Departments of GUM/HIV and Pediatrics, Imperial College Healthcare NHS Trust, London, United Kingdom
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Bock P, Fatti G, Ford N, Jennings K, Kruger J, Gunst C, Louis F, Grobbelaar N, Shanaube K, Floyd S, Grimwood A, Hayes R, Ayles H, Fidler S, Beyers N. Attrition when providing antiretroviral treatment at CD4 counts >500cells/μL at three government clinics included in the HPTN 071 (PopART) trial in South Africa. PLoS One 2018; 13:e0195127. [PMID: 29672542 PMCID: PMC5909512 DOI: 10.1371/journal.pone.0195127] [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: 11/02/2017] [Accepted: 03/16/2018] [Indexed: 12/02/2022] Open
Abstract
Introduction WHO recommends antiretroviral treatment (ART) for all HIV-positive individuals. This study evaluated the association between baseline CD4 count and attrition in a cohort of HIV positive adults initiating ART at three department of health (DOH) clinics routinely providing ART at baseline CD4 counts >500cells/μL for the HPTN 071 (PopART) trial. Methods All clients attending the DOH clinics were managed according to standard care guidelines with the exception that those starting ART outside of pertinent local guidelines signed research informed consent. DOH data on all HIV-positive adult clients recorded as having initiated ART between January 2014 and November 2015 at the three study clinics was analysed. Attrition, included clients lost to follow up or died, and was defined as ‘being three or more months late for an antiretroviral pharmacy pick-up appointment’. All clients were followed until attrition, transfer out or end May 2016. Results A total of 2423 clients with a median baseline CD4 count of 328 cells/μL (IQR 195–468) were included of whom 631 (26.0%) experienced attrition and 140 (5.8%) were TFO. Attrition was highest during the first six months of ART (IR 38.3/100 PY; 95% CI 34.8–42.1). Higher attrition was found amongst those with baseline CD4 counts > 500 cells/μL compared to those with baseline CD4 counts of 0–500 cells/μL (aHR 1.26, 95%CI 1.05 to 1.52) This finding was confirmed on subset analyses when restricted to individuals non-pregnant at baseline and when restricted to individuals with follow up of > 12months. Conclusions Attrition in this study was high, particularly during the first six months of treatment. Attrition was highest amongst clients starting ART at baseline CD4 counts > 500 cells/μL. Strategies to improve retention amongst ART clients, particularly those starting ART at baseline CD4 counts >500cells/μL, need strengthening. Improved monitoring of clients moving in and out of ART care and between clinics will assist in better understanding attrition and ART coverage in high burden countries.
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Affiliation(s)
- Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Campus, Western Cape, South Africa
- * E-mail:
| | | | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Karen Jennings
- City of Cape Town Health Services, Foreshore, Cape Town, South Africa
| | - James Kruger
- Western Cape Department of Health, HIV Treatment & PMTCT programme, Cape Town, South Africa
| | - Colette Gunst
- Western Cape Department of Health Cape Winelands District Brewelskloof Hospital, Worcester, South Africa
- Stellenbosch University Division of Family Medicine and Primary Health Care, Faculty of Medicine and Health Sciences,Tygerberg Campus, Western Cape, South Africa
| | | | | | - Kwame Shanaube
- Zambart, University of Zambia, Ridgeway Campus, Lusaka, Zambia
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Helen Ayles
- Zambart, University of Zambia, Ridgeway Campus, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sarah Fidler
- Department of Medicine, Imperial College London, St Mary’s Campus, London, United Kingdom
| | - Nulda Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Campus, Western Cape, South Africa
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Teeraananchai S, Kerr SJ, Puthanakit T, Bunupuradah T, Ruxrungtham K, Chaivooth S, Law MG, Chokephaibulkit K. Attrition and Mortality of Children Receiving Antiretroviral Treatment through the Universal Coverage Health Program in Thailand. J Pediatr 2017; 188:210-216.e1. [PMID: 28606372 DOI: 10.1016/j.jpeds.2017.05.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 03/30/2017] [Accepted: 05/12/2017] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To assess mortality and loss to follow-up of children with HIV infection who started antiretroviral therapy (ART) through the Universal Coverage Health Program (UC) in Thailand. STUDY DESIGN Children with HIV infection who initiated ART at age <15 years through the UC between 2008 and 2013 were included in the analysis. Death was ascertained through linkage with the National Death Registry. A competing-risks method was used to calculate subdistribution hazard ratios (SHRs) of predictors for loss to follow-up. Death was considered a competing risk. Cox proportional hazards models were used to assess predictors of mortality. RESULTS A total of 4618 children from 497 hospitals in Thailand were included in the study. Median age at ART initiation was 9 years (IQR, 6-12 years), and the median duration of tracking was 4.1 years (a total of 18 817 person-years). Three hundred and ninety-five children (9%) died, for a mortality rate of 2.1 (95% CI, 1.9-2.3) per 100 person-years, and 525 children (11%) were lost to follow-up, for a lost to follow-up rate of 2.9 (95% CI, 2.7-3.2) per 100 person-years. The cumulative incidence of loss to follow-up increased from 4% at 1 year to 8.8% at 3 years. Children who started ART at age ≥12 years were at the greatest risk of loss to follow-up. The probability of death was 3.2% at 6 months and 6.4% at 3 years. Age ≥12 years at ART initiation, lower baseline CD4%, advanced HIV staging, and loss to follow-up were associated with mortality. CONCLUSION The Thai national HIV treatment program has been very effective in treating children with HIV infection, with low mortality and modest rates of loss to follow-up.
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Affiliation(s)
- Sirinya Teeraananchai
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand; Kirby Institute, University of New South Wales, Sydney, Australia.
| | - Stephen J Kerr
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand; Kirby Institute, University of New South Wales, Sydney, Australia
| | - Thanyawee Puthanakit
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand; Department of Pediatrics, Faculty of Medicine, Chulalongkorn University
| | | | - Kiat Ruxrungtham
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand; Department of Medicine, Faculty of Medicine, Chulalongkorn University
| | - Suchada Chaivooth
- The HIV/AIDS, Tuberculosis and Infectious Diseases Program, National Health Security Office (NHSO)
| | - Matthew G Law
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Kulkanya Chokephaibulkit
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Vogt F, Rehman AM, Kranzer K, Nyathi M, Van Griensven J, Dixon M, Ndebele W, Gunguwo H, Colebunders R, Ndlovu M, Apollo T, Ferrand RA. Relationship Between Time to Initiation of Antiretroviral Therapy and Treatment Outcomes: A Cohort Analysis of ART Eligible Adolescents in Zimbabwe. J Acquir Immune Defic Syndr 2017; 74:390-8. [PMID: 28002183 DOI: 10.1097/QAI.0000000000001274] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is Available in the Text. Background: Age-specific retention challenges make antiretroviral therapy (ART) initiation in adolescents difficult, often requiring a lengthy preparation process. This needs to be balanced against the benefits of starting treatment quickly. The optimal time to initiation duration in adolescents is currently unknown. Objective: To assess the effect of time to ART initiation on mortality and loss to follow-up (LTFU) among treatment eligible adolescents. Methods: We conducted a retrospective cohort analysis among 1499 ART eligible adolescents aged ≥10 to <19 years registered in a public sector HIV program in Bulawayo, Zimbabwe, between 2004 and 2011. Hazard ratios (HR) for mortality and LTFU were calculated for different time to ART durations using multivariate Cox regression models. Results: Median follow-up duration was 1.6 years. Mortality HRs of patients who initiated at 0 to ≤7 days, >14 days to ≤1 month, >1 to ≤2 months, >2 months, and before initiation were 1.59, 1.19, 1.56, 1.08, and 0.94, respectively, compared with the reference group of >7 to ≤14 days. LTFU HRs were 1.02, 1.07, 0.85, 0.97, and 3.96, respectively. Among patients not on ART, 88% of deaths and 85% of LTFU occurred during the first 3 months after becoming ART eligible, but only 37% and 29% among adolescents on ART, respectively. Conclusions: Neither mortality or LTFU was associated with varying time to ART. The initiation process can be tailored to the adolescents' needs and individual life situations without risking to increase poor treatment outcomes. Early mortality was high despite rapid ART initiation, calling for earlier rather than faster initiation through HIV testing scale-up.
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Goel N, Ritchie AV, Mtapuri-Zinyowera S, Zeh C, Stepchenkova T, Lehga J, De Ruiter A, Farleigh LE, Edemaga D, So R, Sembongi H, Wisniewski C, Nadala L, Schito M, Lee H. Performance of the SAMBA I and II HIV-1 Semi-Q Tests for viral load monitoring at the point-of-care. J Virol Methods 2017; 244:39-45. [PMID: 28274744 DOI: 10.1016/j.jviromet.2017.03.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 03/03/2017] [Accepted: 03/04/2017] [Indexed: 12/01/2022]
Abstract
Although access to antiretroviral therapy for HIV infection is increasing in resource-poor countries, viral load testing for monitoring of treatment efficacy remains limited, expensive, and confined to centralized laboratories. The SAMBA HIV-1 Semi-Q Test is a nucleic acid-based amplification assay developed for viral load monitoring performed on either the semi-automated SAMBA I system for laboratory use or the fully automated SAMBA II system for point-of care use. We have assessed the performance characteristics of the SAMBA HIV-1 Semi-Q Test on SAMBA I and SAMBA II systems according to the Common Technical Specifications of the European Community's 98/79 In Vitro Diagnostic Medical Devices Directive. The sensitivity, specificity, reproducibility, and viral subtype coverage of the test were similar on the SAMBA I and SAMBA II platforms. The clinical performance on the SAMBA I system was compared with the Roche CAP/CTM assay and evaluated in-house with 130 patient specimens from London as well as in the field with 390 specimens in Kenya and Zimbabwe. The overall concordance between the SAMBA and CAP/CTM assays was 98.1%. The clinical performance of the test on the SAMBA II platform in comparison with the Abbott HIV-1 RealTime Assay was evaluated in-house with 150 specimens from Ukraine, yielding a concordance of 98.0%. The results thus show that the SAMBA HIV-1 Semi-Q Test performs equivalently on SAMBA I and SAMBA II, and they suggest that the test is suitable for implementation at the point-of-care in resource-poor regions where viral load testing is desperately needed but often unavailable.
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Affiliation(s)
- Neha Goel
- Diagnostics Development Unit, Department of Haematology, University of Cambridge, Science Village, Chesterford Research Park, Little Chesterford CB10 1XL, UK
| | - Allyson V Ritchie
- Diagnostics Development Unit, Department of Haematology, University of Cambridge, Science Village, Chesterford Research Park, Little Chesterford CB10 1XL, UK
| | | | - Clement Zeh
- Kenya Medical Research Institute/US CDC Research and Public Health Collaboration (KEMRI-CDC), Kisumu, Kenya
| | | | - Jesse Lehga
- Diagnostics for the Real World Ltd., 840 Del Rey Avenue, Sunnyvale 94085, CA, USA
| | - Annemiek De Ruiter
- Department of Genitourinary Medicine and HIV, Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
| | - Laura E Farleigh
- Diagnostics Development Unit, Department of Haematology, University of Cambridge, Science Village, Chesterford Research Park, Little Chesterford CB10 1XL, UK
| | - Daniel Edemaga
- Diagnostics for the Real World Ltd., 840 Del Rey Avenue, Sunnyvale 94085, CA, USA
| | - Rosario So
- Diagnostics for the Real World Ltd., 840 Del Rey Avenue, Sunnyvale 94085, CA, USA
| | - Hiroshi Sembongi
- Diagnostics for the Real World (Europe) Ltd., Science Village, Chesterford Research Park, Little Chesterford CB10 1XL, UK
| | - Craig Wisniewski
- Diagnostics Development Unit, Department of Haematology, University of Cambridge, Science Village, Chesterford Research Park, Little Chesterford CB10 1XL, UK; Diagnostics for the Real World Ltd., 840 Del Rey Avenue, Sunnyvale 94085, CA, USA
| | - Lourdes Nadala
- Diagnostics for the Real World Ltd., 840 Del Rey Avenue, Sunnyvale 94085, CA, USA
| | - Marco Schito
- Division of AIDS, Henry M. Jackson Foundation for Advancement of Military Medicine, National Institutes of Health, Fishers Lane, Rockville 5601, MD, USA
| | - Helen Lee
- Diagnostics Development Unit, Department of Haematology, University of Cambridge, Science Village, Chesterford Research Park, Little Chesterford CB10 1XL, UK; Diagnostics for the Real World Ltd., 840 Del Rey Avenue, Sunnyvale 94085, CA, USA.
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Affiliation(s)
- Rashida A Ferrand
- London School of Hygiene & Tropical Medicine, London, UK ; Biomedical Research and Training Institute, Harare, Zimbabwe
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