Incidence and factors associated with being lost to follow-up among people living with HIV and receiving antiretroviral therapy in Nyarugenge the central business district of Kigali city, Rwanda

BACKGROUND

Lost to follow-up (LTFUP) continues to threaten the sustainability of antiretroviral therapy (ART) benefits and success of ART programs. We determined the incidence and predictors of LTFUP among people living with HIV (PLHIV) on ART in Nyarugenge the Central Business District of Kigali city.

METHODS

A cohort of PLHIV who initiated ART in 2018 was retrospectively studied for 24 months. Using health facility records, a person who had no record of contact with the health facility for at least three consecutive months was considered LTFUP. LTFUP incidence rates were computed, and the Fine-Gray's competing risk regression models were used to determine factors associated with time to first LTFUP. Generalized estimating equations (GEEs) were used to analyze repeated measurement outcomes of LTFUP and predictors of LTFUP.

RESULTS

Of 950 participants, 581 (61.2%) were females and 866 (91.2%) were 15 to 49 years old. From 1,586.1 person years of observation (pyo), 148 participants got LTFUP for 451 times. The incidence rate to first event was 9.4 per 100 pyo (95%CI:7.9-10.9) and 31.8 per 100 pyo (95%CI:29.0-34.4) to multiple events. WHO stage, marital status, employment status and person to contact when PLHIV is not reachable were associated with time to first LTFUP event. However, an average participant with a contact person who was not a Community Health Worker (CHW) or a peer educator had higher incidence of LTUP (aIRR = 2.69, 95%CI: 1.43-5.06), an average single patients had higher incidence of LTFUP (aIRR = 1.74, 95%CI: 1.28-2.34) compared to married/co-habiting, and an average self-employed had higher incidence of LTFUP (aIRR = 1.51, 95%CI: 1.14-2.01) compared to participants employed by others. Furthermore, an average PLHIV living out-of-the health facility catchment area had higher incidence of LTFUP (aIRR = 1.55, 95%CI: 1.19-2.01) compared to an average PLHIV living in the health facility catchment area whereas, an average children initiated on first line had lower incidence of LTUP (aIRR = 0.43, 95%CI: 0.21-0.86) compared to adults.

CONCLUSION

Using CHW and peer educators as contact persons can help to reduce LTFUP while, targeted sensitization and service delivery are needed for single, self-employed and, patients living out of the health facility catchment area.

HIV incidence and prevalence among adults aged 15-64 years in Rwanda: Results from the Rwanda Population-based HIV Impact Assessment (RPHIA) and District-level Modeling, 2019

OBJECTIVES

The 2018-2019 Rwanda Population-based HIV Impact Assessment (RPHIA) was conducted to measure national HIV incidence and prevalence. District-level estimates were modeled to inform resources allocation.

METHODS

RPHIA was a nationally representative cross-sectional household survey. Consenting adults were interviewed and tested for HIV using the national diagnostic algorithm followed by laboratory-based confirmation of HIV status and testing for viral load (VL), limiting antigen (LAg) avidity, and presence of antiretrovirals. Incidence was calculated using normalized optical density ≤ 1·5, VL ≥ 1,000 copies/mL, and undetectable antiretrovirals. Survey and programmatic data were used to model district-level HIV incidence and prevalence.

RESULTS

Of 31,028 eligible adults, 98·7% participated in RPHIA and 934 tested HIV positive. HIV prevalence among adults in Rwanda was 3·0% (95% CI:2·7-3·3). National HIV incidence was 0·08% (95% CI:0·02-0·14) and 0·11% (95% CI:0·00-0·26) in the City of Kigali (CoK). Based on district-level modeling, HIV incidence was greatest in the 3 CoK districts (0·11% to 0·15%) and varied across other districts (0·03% to 0·10%).

CONCLUSIONS

HIV prevalence among adults in Rwanda is 3.0%; HIV incidence is low at 0.08%. District-level modeling has identified disproportionately affected urban hotspots: areas to focus resources.

Survival by AIDS defining condition in rural Uganda

OBJECTIVES

To report the initial AIDS defining conditions, CD4 lymphocyte counts around the time of AIDS diagnosis, and survival by AIDS defining condition in a population based cohort in rural Uganda.

METHODS

Participants in an HIV natural history cohort in rural Uganda were reviewed every 3 months at routine visits and at other times when they were ill. The date and nature of the first AIDS defining condition in participants developing AIDS during follow up between the start of the cohort in 1990 and the end of 1998 were noted. The CD4 count at, or within, 3 months of this time was recorded for those participants who developed AIDS (WHO stage 4) after 1993.

RESULTS

The median survival from developing AIDS to death was 9.3 months and the median CD4 lymphocyte count around the time of developing AIDS was 150 cells x 10(6)/l. The most frequent AIDS defining conditions were wasting syndrome, oesophageal candidiasis, and mucocutaneous herpes simplex virus infection (HSV) for more than 1 month. The median survival with wasting syndrome, Kaposi's sarcoma, and oesophageal candidiasis was less than 3.5 months; however, survival with cryptosporidial diarrhoea, chronic HSV, and extrapulmonary tuberculosis was greater than 20 months. There was little relation between CD4 count around the time of development of the AIDS defining condition and the median survival with that condition.

CONCLUSIONS

The survival for most AIDS defining conditions was generally shorter and the median CD4 lymphocyte count higher than studies reported from developed countries. However, the conditions with the longest survival (cryptosporidial diarrhoea, chronic HSV, and extrapulmonary tuberculosis) had a similar survival to that in developed countries and these conditions have a high background level in this population.

Case-control study of risk factors for incident HIV infection in rural Uganda

OBJECTIVE

To identify risk factors associated with HIV incidence in a rural Ugandan population.

DESIGN

Case-control study.

METHODS

Men and women who seroconverted between 1990 and 1997 (cases) and seronegative subjects (controls) were drawn from a general population cohort of approximately 5000 adults in rural, southwestern Uganda. Information on risk factors was ascertained through a detailed interview and physical examination by clinicians who were blind to the study subjects' HIV status. All patients were interviewed within 2 years of their estimated date of seroconversion.

RESULTS

Data were available on 130 men (37 cases, 93 controls) and 133 women (46 cases, 87 controls). There was a significantly higher risk of infection in men (odds ratio [OR], 6.51; 95% confidence interval [CI], 1.06-39.84) and women (OR, 4.75; 95% CI, 1.26-17.9) who were unmarried and in a steady relationship, and in men who were divorced, separated, or widowed (OR, 4.33; 95% CI, 1.32-14.25) compared with those who were married. There was a significantly higher risk of HIV infection in men (OR, 3.78; 95% CI, 1.20-11.93) and women (OR, 20.78; 95% CI, 2.94-141.2) who reported > or =5 lifetime sexual partners compared with those who reported at most 1 partner. For men, there was an increased risk of infection associated with receiving increasing numbers of injections in the 6 months prior to interview (p < .001 for trend). Women reporting sex against their will in the year prior to interview were at higher risk of infection (OR, 7.84; 95% CI, 1.29-47.86; p = .020).

CONCLUSIONS

The strongest risk factor for HIV incidence in this rural Ugandan population is lifetime sexual partners. The increased risks found for women reporting coercive sex and men reporting injections require further investigation.

The prognostic value of the World Health Organisation staging system for HIV infection and disease in rural Uganda

OBJECTIVE

To assess whether the WHO staging classification for HIV provides prognostically valuable and applicable information in rural Uganda.

PATIENTS AND STUDY DESIGN

Data were obtained from a population-based cohort of 232 HIV-infected individuals.

METHODS

Clinical information was obtained using a detailed questionnaire and ascertained by physical examination. Participants were seen routinely every 3 months and when they were sick. A computer algorithm based on clinical history, examination and laboratory findings was used to stage HIV-positive participants at each routine visit. Kaplan-Meier survival estimates and the Cox proportional hazard model were used to assess the prognostic strength of the clinical and laboratory categories of the system.

RESULTS

An attendance rate of 81% and 799 person-years of follow-up were achieved. Survival probability estimates at 6 years from being seen in clinical stages 1, 2, 3 and 4 were 63, 46, 24 and 6% respectively. When staging was revised to incorporate lymphocyte categories, the survival probabilities were 73, 62, 39 and 6% respectively. Unexplained prolonged fever and severe bacterial infection had survival probabilities closer to stage 2 conditions, mucocutaneous herpes simplex virus infection for more than 1 month and crytosporidiosis with diarrhoea for more than 1 month closer to stage 3 and oral candidiasis closer to stage 4 conditions.

CONCLUSIONS

Even without the laboratory markers, the clinical category of the WHO staging system is useful for predicting survival in individuals with HIV disease. This is important for areas with limited access to laboratory markers. A simple rearrangement of a few clinical conditions could improve the prognostic significance of the WHO system.

Rates of HIV-1 transmission within marriage in rural Uganda in relation to the HIV sero-status of the partners

OBJECTIVE

To assess the efficacy of transmission of HIV-1 within married couples in rural Uganda according to the sero-status of the partners.

DESIGN

Estimation of HIV incidence rates for 2200 adults in a population cohort followed for 7 years comparing male-to-female with female-to-male transmission and sero-discordant with concordant sero-negative couples.

METHODS

Each year, adults (over 12 years of age) resident in the study area were linked to their spouses if also censused as resident. The HIV sero-status was determined annually.

RESULTS

At baseline 7% of married adults were in sero-discordant marriages and in half of these the man was HIV-positive. Among those with HIV-positive spouses, the age-adjusted HIV incidence in women was twice that of men (rate ratio (RR) = 2.2 95% confidence interval (CI) 0.9-5.4) whereas, among those with HIV-negative spouses, the incidence in women was less than half that of men (RR = 0.4, 95% CI 0.2-0.8). The age-adjusted incidence among women with HIV-positive spouses was 105.8 times (95% CI 33.6-332.7) that of women with HIV-negative spouses, the equivalent ratio for men being 11.6 (95% CI 5.8-23.4).

CONCLUSION

Men are twice as likely as women to bring HIV infection into a marriage, presumably through extra-marital sexual behaviour. Within sero-discordant marriages women become infected twice as fast as men, probably because of increased biological susceptibility. Married adults, particularly women, with HIV-positive spouses are at very high risk of HIV infection. Married couples in this population should be encouraged to attend for HIV counselling together so that sero-discordant couples can be identified and advised accordingly.

HIV-1 disease progression and AIDS-defining disorders in rural Uganda

BACKGROUND

The majority of people infected with HIV-1 live in Africa, yet little is known about the natural history of the disease in that continent. We studied survival times, disease progression, and AIDS-defining disorders, according to the proposed WHO staging system, in a population-based, rural cohort in Uganda.

METHODS

In 1990 we recruited a random sample of people already infected with HIV-1 (as prevalent cases) detected during the initial survey round of a general-population study to form a natural-history cohort. Individuals from the general-population cohort who seroconverted between 1990 and 1995 (incident cases) were also invited to enroll. Participants were seen routinely every 3 months and when they were III.

FINDINGS

By the end of 1995, 93 prevalent cases and 86 incident cases had been enrolled. Four patients in the prevalent group were in stage 4 (AIDS) at the initial visit. During the next 5 years, 37 prevalent cases progressed to AIDS. Seven incident cases progressed to AIDS and the cumulative progression to AIDS at 1, 3, and 5 years after seroconversion was 2%, 6%, and 22%, respectively. The cumulative probability of AIDS at 4 years from entering stages 1, 2, and 3 was 11%, 33%, and 58%, respectively. There were 47 deaths among prevalent cases and seven among incident cases during follow-up. The cumulative mortality 4 years after patients entered stages 1, 2, 3, and 4 was 9%, 33%, 56%, and 86%, respectively. The median survival after the onset of AIDS was 9.3 months.

INTERPRETATION

Our results are important for the setting of priorities and rationalisation of treatment availability in countries with poor resources. We found that progression rates to AIDS are similar to those in developed countries for homosexual cohorts and greater than for cohorts infected by other modes of transmission. However, we have found that the rates of all-cause mortality are much higher and the progression times to death are shorter than in developed countries.

An HIV-1 natural history cohort and survival times in rural Uganda

OBJECTIVE

To describe a population-based rural cohort of HIV-1-seropositive and seronegative individuals established in 1990 in south-west Uganda, and determine survival times in the cohort.

DESIGN

Prospective cohort study.

METHODS

Participants were recruited from a large population study, and invited to attend a clinic every 3 months. They were seen by clinicians who administered detailed medical questionnaires and undertook a physical examination.

RESULTS

By the end of 1995, 390 (79%) of the 491 people asked to enrol in the natural history cohort (NHC) had done so. Ninety-three were prevalent cases of HIV infection detected during the initial survey round of the general population cohort in 1989/1990, 66 were subsequent incident cases, 177 were age-matched HIV-negative controls and 54 were HIV-negative spouses of HIV-positive individuals. Twenty participants seroconverted in the NHC. The age-standardized mortality rates per 1000 person-years for the prevalent, incident, and negative cases were 156.5 [95% confidence interval (CI), 115.8-211.4], 35.0 (95% CI, 16.4 75.0) and 13.5 (95% CI, 7.3-25.1), respectively. The median survival time from enrolment to death for the prevalent cases was 4.5 years (95% CI, 3.5- > 5.2); > 5.4 years from seroconversion for the incident cases; and > 5.2 years from enrolment for the HIV-negative cases. The 5-year cumulative survival for prevalents, incidents and HIV-negative participants was 46%, 83% and 94%, respectively.

CONCLUSIONS

We have described an NHC of HIV-positive and HIV-negative participants which is representative of the general population. The NHC was established over 5 years ago; it is continuing and we are maintaining good compliance rates. Survival probabilities in the cohort were lower than most other reported studies.

HIV-1 infection in a Ugandan town on the trans-African highway: prevalence and risk factors

All adult residents (aged 13 years or more) of 154 randomly selected households in 3 urban and one semi-rural ward of a town in South West Uganda on the trans-African highway were invited to participate in a socio-demographic, behavioural and medical survey. An unambiguous HIV-1 serostatus was obtained for 389 (80%) adults. The overall sero-prevalence rate was 40.4%; all age groups except males aged 13-19 years had infection rates in excess of 20%. Rates above 50% were found in females aged 20-34 years and males aged 35-44 years. For females seropositivity rates increased steeply with increasing numbers of lifetime sexual partners up to a maximum of 3; in contrast, for males rates continued to increase with increasing numbers of partners. The risk of infection amongst those with only one reported partner was 17%. A high proportion of males (14%) and females (18%) reported a history of genital ulcer disease within the previous 6 months; on examination genital lesions were observed in 12% of all participants. Interventions with a single focus are unlikely to have much impact in such a situation and a strategy is suggested which includes 3 components, namely improved STD control, a reduction in partner change and an increase in condom utilization.

Human immunodeficiency virus (HIV-1) seropositivity among children in a rural population of south-west Uganda: probable routes of exposure

Serological studies on 7796 rural Ugandans showed 377 (4.8%) were HIV-1 antibody-positive, of whom 343 (8.2%) were adults, ten (0.4%) 5-12-year-olds and 24 (1.7%) under 5 years of age. Serological tests done on 18 mothers of the under-5s showed 17 to be HIV-1-positive. One mother was persistently negative. Her child had a history of multiple injections. Structured interviews with parents or guardians of the ten HIV-1-seropositive children aged 5-12 years to determine possible sources of exposure revealed that six were vertically infected and that blood transfusion, injections and sexual exposure each accounted for one case. It was not possible to identify a source of exposure in one instance. There was no evidence that casual household contact or scarifications played a role in the transmission of HIV-1 in children in this population. Our data show that in this rural population HIV-1 seropositivity in children is mainly associated with seropositivity in the mothers and that HIV-1 infection in children aged between 5 and 12 years is rare.

Risk factors for HIV-1 infection in adults in a rural Ugandan community: a case-control study

OBJECTIVE

To study in depth sexual history and sexual behaviour variables as risk factors for HIV-1 infection in a rural Ugandan population.

METHODS

Following a socioeconomic and serological survey of a rural population in Masaka District, south-west Uganda, 233 randomly selected HIV-1-positive cases and 233 negative controls matched on age and village of residence, were invited in October 1990 to participate in a case-control study. A total of 132 cases and 161 controls attended for in-depth investigation including an interview about sexual behaviour.

RESULTS

The factor most strongly associated with increased risk of infection was a greater number of lifetime sexual partners, with odds ratios (OR) of 2.1 and 4.9 for those reporting 4-10 and 11 or more partners, respectively, compared with those reporting less than four partners. Having only one sexual partner did not provide complete protection, a total of seven (one male, six female) subjects reporting only one sexual partner were HIV-1-positive. Other significant factors were a history of genital ulcers [OR, 2.9; 95% confidence intervals (CI), 1.0-9.1) and not being a Muslim (OR, 5.4; 95% CI, 1.8-16.5) suggesting a possible protective effect of circumcision. There was a suggestion that those who married within the last 7 years (OR, 2.4; 95% CI, 0.9-6.1) and men exposed to menstrual blood (OR, 5.7; 95% CI, 0.7-49.8) were at an increased risk of HIV-1 infection.

CONCLUSIONS

These results confirm the predominant role of sexual behaviour in the HIV-1 epidemic. Of particular concern is the observation of HIV-1 infection among those reporting only one partner. Where HIV-1 infection is widely distributed in the general population, risk reduction strategies should, in addition to the promotion of partner reduction, place strong emphasis on safe-sex techniques.

Risk factors for HIV-1 infection in adults in a rural Ugandan community: a population study

OBJECTIVE

To determine sociodemographic risk factors associated with HIV-1 infection in a rural Ugandan population.

DESIGN

A population-based survey.

METHODS

All adult residents (aged > or = 13 years) in a cluster of 15 neighbouring villages of the Masaka District of south-west Uganda were invited to participate in a sociodemographic and serological survey. Questions relating to sexual behaviour were asked separately in an accompanying case-control study. Socioeconomic data and an unambiguous HIV-1 serostatus were obtained by house-to-house survey for 3809 (72%) of the adult population. The association between serostatus and the following variables were analysed: age, sex, marital status, tribe, religion, education, occupational group, place and frequency of travel and recent history of sexually transmitted disease.

RESULTS

Women aged 13-21 years were at a much higher risk than men of the same age [odds ratio (OR), 8.6; 95% confidence interval (CI), 3.0-24.5]. Married people aged < 25 years were twice as likely to be infected as those who were not currently married (OR, 2.3; 95% CI, 1.5-3.7). In contrast, in those aged > or = 25 years, women were at a lower risk than men (OR, 0.72; 95% CI, 0.52-0.98) as were those who were currently married compared with those who were not (OR, 0.47; 95% CI, 0.34-0.64). In both age groups those with a history of a recent genital ulcer were approximately three times more likely to be infected. Muslims had lower risks than non-Muslims (OR, 0.58 for both age groups).

CONCLUSIONS

The people most at risk of HIV-1 infection in this rural Ugandan population are young married women who had, presumably, commenced sexual activity recently.