Predictors of Dropout from Care among HIV-Infected Patients Initiating Antiretroviral Therapy at a Public Sector HIV Treatment Clinic in Sub-Saharan Africa

METHODS:

In a cohort of HIV-infected patients initiating ART at a public sector clinic in Uganda, we assessed predictors of dropout from care (a composite outcome combining death and loss to follow-up). From a large set of socio-demographic, clinical, and laboratory variables routinely collected at ART initiation, we selected those predicting dropout at P <0.1 in unadjusted analyses for inclusion into a multivariable proportional hazards regression model. We then used a stepwise backward selection procedure to identify variables which independently predicted dropout at P <0.05.

RESULTS:

Data from 5,057 patients were analyzed. The median age was 33 years (IQR 28 to 40) and 27.4 % had CD4+ T-cell counts <100 cells/μL at ART initiation. The median duration of follow-up was 24 months (IQR = 14 to 42, maximum follow-up = 64 months). Overall dropout was 26.9 % (established cumulative mortality = 2.3 %, loss to follow-up = 24.6 %), 5.6 % were transferred to other service providers, and 67.5 % were retained in care. A diagnosis of Kaposi's sarcoma (hazard ratio (HR) = 3.3, 95 % CI 2.5 to 4.5); HIV-associated dementia (HR = 2.6, 95 % CI 1.5 to 4.6); history of cryptococcosis (HR = 2.2, 95 % CI 1.4 to 3.3); and reduced hemoglobin concentration (<11 g/dl versus ≥13.8 g/dl (HR = 1.9, 95 % CI 1.6 to 2.2) were strong predictors of dropout. Other independent predictors of dropout were: year of ART initiation; weight loss ≥10 %; reduced total lymphocyte count; chronic diarrhea; male sex; young age (≤28 years); and marital status.

CONCLUSIONS:

Among HIV-infected patients initiating ART at a public sector clinic in SSA, biological factors that usually predict death were especially predictive of dropout. As most of the dropouts were lost to follow-up, this observation suggests that many losses to follow-up may have died. Future studies are needed to identify appropriate interventions that may improve both individual-level patient outcomes and outcome ascertainment among HIV-infected ART initiators in this setting.

Full article at:   http://goo.gl/6c5fTV

By:  Asiimwe SB1,2, Kanyesigye M3, Bwana B4, Okello S5, Muyindike W6.

• 1Department of Medicine, Mbarara Regional Referral Hospital, P.O Box 40, Mbarara, Uganda. asiimwesteve@gmail.com.
• 2Department of Epidemiology and Biostatistics, University of California San Francisco, California, USA. asiimwesteve@gmail.com.
• 3Department of Medicine, Mbarara Regional Referral Hospital, P.O Box 40, Mbarara, Uganda. mkanyesigye2010@gmail.com.
• 4Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda. mwebesa_bwana@yahoo.com.
• 5Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda. okello.samson@must.ac.ug.
• 6Department of Medicine, Mbarara Regional Referral Hospital, P.O Box 40, Mbarara, Uganda. wmuyindike@gmail.com. 
• BMC Infect Dis. 2016 Feb 1;16(1):43. doi: 10.1186/s12879-016-1392-7.

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High School Incompletion and Childhood Maltreatment among Street-Involved Young People in Vancouver, Canada

While the link between educational attainment and future health and wellness is well understood, little investigation has considered the potential impacts of distinct forms of childhood maltreatment on high school completion. 

In the present study, the relationship between five categories of childhood maltreatment (physical, emotional, and sexual abuse, and physical and emotional neglect) and completion of high school education were examined using the Childhood Trauma Questionnaire (CTQ). From September 2005 to May 2013, data were collected for the At-Risk Youth Study (ARYS), a cohort of street-involved young people who use illicit drugs in Vancouver, Canada. We used logistic regression to examine the relationship between childhood maltreatment and high school completion, while controlling for a range of potential confounding variables. Specifically, five separate models for each category of maltreatment and two combined models were employed to examine the relative associations between, and cumulative impact of, different forms of childhood maltreatment and educational attainment. 

Among 974 young people, 737 (76%) reported not completing high school. In separate multivariable analyses physical abuse, emotional abuse, physical neglect, and emotional neglect remained positively and independently associated with an incomplete high school education. In a combined multivariable model with all forms of childhood maltreatment considered together, emotional abuse (adjusted odds ratio = 2.08; 95% confidence interval: 1.51-2.86) was the only form of maltreatment that remained significantly associated with an incomplete high school education. The cumulative impact assessment indicated a moderate dose-dependent trend where the greater the number of different forms of childhood maltreatment the greater the risk of not completing a high school education. 

These findings point to the need for trauma-informed interventions to improve educational attainment among vulnerable young people, as well as evidence-based prevention programmes, such as the Nurse-Family Partnership, aimed at supporting at-risk families before maltreatment occurs.

Purchase full article at:   http://goo.gl/YsT9yn

By:   Barker B^1,2, Kerr T^1,3, Dong H¹, Wood E^1,3, DeBeck K^1,4.

¹Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.

²Interdisciplinary Studies Graduate Program, University of British Columbia, Vancouver, British Columbia, Canada.

³Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

⁴School of Public Policy, Simon Fraser University at Harbour Centre, Vancouver, British Columbia, Canada. 

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Factors Associated with Dropout in a Long Term Observational Cohort of Fishing Communities Around Lake Victoria, Uganda

Background

Fishing communities are potentially suitable for Human immunodeficiency virus (HIV) efficacy trials due to their high risk profile. However, high mobility and attrition could decrease statistical power to detect the impact of a given intervention. We report dropout and associated factors in a fisher-folk observational cohort in Uganda.

Methods

Human immunodeficiency virus-uninfected high-risk volunteers aged 13–49 years living in five fishing communities around Lake Victoria were enrolled and followed every 6 months for 18 months at clinics located within each community. Volunteers from two of the five communities had their follow-up periods extended to 30 months and were invited to attend clinics 10–40 km (km) away from their communities. Human immunodeficiency virus counseling and testing was provided, and data on sexual behaviour collected at all study visits. Study completion was defined as completion of 18 or 30 months or visits up to the date of sero-conversion and dropout as missing one or more visits. Discrete time survival models were fitted to find factors independently associated with dropout.

Results

A total of 1000 volunteers (55 % men) were enrolled. Of these, 91.9 % completed 6 months, 85.2 % completed 12 months and 76.0 % completed 18 months of follow-up. In the two communities with additional follow-up, 76.9 % completed 30 months. In total 299 (29.9 %) volunteers missed at least one visit (dropped out). Dropout was independently associated with age (volunteers aged 13–24 being most likely to dropout), gender [men being more likely to dropout than women [adjusted hazard ratio (aHR) 1.4; 95 % confidence interval (CI) 1.1–1.8)], time spent in the fishing community (those who stayed <1 year being most likely to dropout), History of marijuana use (users being more likely to dropout than non-users [1.7; (1.2–2.5)], ethnicity (non-Baganda being more likely to dropout than Baganda [1.5; (1.2–1.9)], dropout varied between the five fishing communities, having a new sexual partner in the previous 3 months [1.3 (1.0–1.7)] and being away from home for ≥2 nights in the month preceding the interview [1.4 (1.1–1.8)].

Conclusion

Despite a substantial proportion dropping out, retention was sufficient to suggest that by incorporating retention strategies it will be possible to conduct HIV prevention efficacy trials in this community.

...The results suggest a number of factors that are associated with dropout from the fisher-folk cohort including young age, male gender, ethnicity, having a new sexual partner, time spent in the fishing communities, being away from home for ≥2 nights and marijuana use. Consistent with other studies in the neighbouring fishing [8] and non-fishing communities [9, 10], USA [15] and Brazil [16], study dropout was associated with age, with those in the youngest age group (13–24) being most likely to dropout. Since there were nearly equal proportions of men (49 %) and women (51 %) in this age group, this could be due to both looking for work and new relationships.

Dropping out was associated with the ethnicity of the volunteers, with non-Baganda being more likely to dropout. This has been indicated in the previous study further North of Lake Victoria [8]. The majority of non-Baganda volunteers come from further afield, including neighbouring countries (Kenya, Tanzania and Rwanda) and some are traders and transporters who might spend relatively long periods away from the fishing communities. These were more likely to be involved in fishing or related activities compared to the Baganda who were likely to be engaged in small scale businesses. Furthermore, number of years spent in the fishing site was independently associated with study dropout, with those who have spent more than 1 year in the fishing communities being less likely to dropout. This further demonstrates that individuals who have lived in a community for a long time are more likely to be available for recruitment in prevention studies. Additionally these could easily be retained in study follow up. The finding that dropout was associated with use of marijuana is consistent with findings from cohorts in the USA [17] and Japan [18], where similar dropout rates were observed among illicit drug users.

In this cohort we ascertained the frequency of reporting a new sexual partner for both men and women and this was independently associated with cohort dropout. This is consistent with the results from the inland non-fishing community in which the reported number of lifetime partners was higher in those who changed residence to other neighboring villages and there was also more risky sexual behavior reported among those who changed residence [14]. The fact that higher risk volunteers were more likely to drop out could lead to underestimation of HIV incidence in a prevention trial...

Full article at:   http://goo.gl/fzVnth

By:   Andrew Abaasa, Gershim Asiki, Juliet Mpendo, Jonathan Levin, Janet Seeley, Leslie Nielsen, Ali Ssetaala, Annet Nanvubya, Jan De Bont, Pontiano Kaleebu, and Anatoli Kamali

Uganda Research Unit on AIDS, Medical Research Council/Uganda Virus Research Institute (MRC/UVRI), P.O Box 49, Entebbe, Uganda

Uganda Virus Research Institute/International AIDS Vaccine Initiative (UVRI/IAVI)-HIV Vaccine Program, Entebbe, Uganda

London School of Hygiene and Tropical Medicine, London, UK

International AIDS Vaccine Initiative, New York, USA

Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

Andrew Abaasa, Phone: 256 (0)417 704000, Email: gro.adnagucrm@asaabA.werdnA, Email: moc.oohay@asaaba.werdna.

  

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Contextual Predictors of Injection Drug Use among Black Adolescents and Adults in US Metropolitan Areas, 1993-2007

OBJECTIVES:

We sought to determine whether contextual factors shape injection drug use among Black adolescents and adults.

METHODS:

For this longitudinal study of 95 US metropolitan statistical areas (MSAs), we drew annual MSA-specific estimates of the prevalence of injection drug use (IDU) among Black adolescents and adults in 1993 through 2007 from 3 surveillance databases. We used existing administrative data to measure MSA-level socioeconomic status; criminal justice activities; expenditures on social welfare, health, and policing; and histories of Black uprisings (1960-1969) and urban renewal funding (1949-1974). We regressed Black IDU prevalence on these predictors by using hierarchical linear models.

RESULTS:

Black IDU prevalence was lower in MSAs with declining Black high-school dropout rates, a history of Black uprisings, higher percentages of Black residents, and, in MSAs where 1992 White income was high, higher 1992 Black income. Incarceration rates were unrelated.

CONCLUSIONS:

Contextual factors shape patterns of drug use among Black individuals. Structural interventions, especially those that improve Black socioeconomic security and political strength, may help reduce IDU among Black adolescents and adults. 

Purchase full article at:   http://goo.gl/NTfKhF

By:   Cooper HL1, West B1, Linton S1, Hunter-Jones J1, Zlotorzynska M1, Stall R1, Wolfe ME1, Williams L1, Hall HI1, Cleland C1, Tempalski B1, Friedman SR1.

1Hannah L. F. Cooper, Sabriya Linton, Josalin Hunter-Jones, Maria Zlotorzynska, and Mary E. Wolfe are with the Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA. Brooke West is with the Division of Global Public Health, University of California at San Diego, La Jolla. Leslie Williams, Barbara Tempalski, and Samuel R. Friedman are with National Development and Research Institutes Inc, New York, NY. Ron Stall is with the Department of Behavioral and Community Health Sciences and Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. H. Irene Hall is with the HIV Incidence and Case Surveillance Branch, Centers for Disease Control and Prevention, Atlanta. Charles Cleland is at the School of Nursing, New York University, New York, NY.

 

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'He is the one who is providing you with everything so whatever he says is what you do': A Qualitative Study on Factors Affecting Secondary Schoolgirls’ Dropout in Rural Western Kenya

Education is an effective way to improve girls’ self-worth, health, and productivity; however there remains a gender gap between girls’ and boys’ completion of school. The literature around factors influencing girls’ decision to stay in school is limited. Seven focus group discussions took place among 79 girls in forms 2 to 4 at secondary schools in rural western Kenya, to examine their views on why girls absent themselves or dropout from school. Data were analysed thematically. 

Lack of resources, sexual relationships with boyfriends, and menstrual care problems were reported to lead directly to dropout or school absence. These were tied to girls increased vulnerability to pregnancy, poor performance in school, and punishments, which further increase school absence and risk of dropout. Poverty, unmet essential needs, coercive sexual relationships, and an inequitable school environment collude to counter girls’ resolve to complete their schooling. 

Lack of resources drive girls to have sex with boyfriends or men who provide them with essentials their family cannot afford, such as sanitary pads and transport to school. While these improve quality of their school life, this dynamic increases their exposure to sexual risk, pregnancy, punishment, and dropout. Evaluation of interventions to ameliorate these challenges is warranted, including provision of pocket money to address their needs.

...Poverty was a constant underlying element in girls’ narratives [11], and responsible either directly or indirectly for the greater proportion of absenteeism or dropout. Lack of cash for fees or personal needs was noted as a main factor directly leading to dropout. Although the Kenyan government extended free education from primary into secondary schools in 2008, girls’ narratives describing ‘school fees’ drove us to examine what comprised ‘fees’ in the area since tuition fees were already paid. Schools provided us with standard invoices per student; these included PTA / development levies, and fees for lunch, exams, activities, PE, district evaluation, and ICT maintenance. Adding further costs for uniforms and books, we estimate around Ksh 20,000 (~£126) is required per girl each year. A separate study suggested these additional costs amount to 55% of the average rural households’ annual per capita expenditure [13]. Should such fees be afforded for a girl (assuming no competing male sibling), any further personal items required by girls would be beyond the reach of many families who have a mean wealth index of ~£426 [33]. We noted two-thirds of the annual fees are requested in the first school term. Girls’ dropout over the year thus occurs after the bulk of fees are paid, with a lack of smaller sums of money acting as a barrier to completion.

Girls in our study describe many items they need that are beyond the household budget. Top among these were sanitary pads for menstrual care. The reporting of menstrual care problems in school was very common in the present study, with girls discussing this as a main cause of school absence, and some considering repeated absence resulted in eventual dropout. Teasing and public humiliation, discomfort from poor quality sanitary items, and poor engagement due to fear of leakage and odour are well described in the literature [20,21,34]. Sanitary pads are a frequently cited item girls say they need, but parents’ budgets seldom stretch to provide the quality or amount required. Girls’ narratives indicate some boyfriends provide pads directly, while other girls request money from sexual partners to buy pads. In a study among girls and women below 30 years of age in the same area, half said they received commercial pads from a sexual partner [35]. While sex for money in order to purchase pads was seldom recorded (~3% among young single females), it was reported among 10% of 15 year olds. It was significantly higher among girls dependent on family for source of income, and among girls reporting two or more sexual partners in the past 12 months [35]. Removing menstrual need as a burden for schoolgirls would improve their dignity, engagement in school, and potentially improve their performance. It would also reduce one reason for dependence on sexual partners, and could contribute to reducing their exposure to sexual and reproductive harms, and possible school dropout.

Along with menstrual items, a variety of relatively low budget items such as face cream, body oil, panties, sodas, and snacks were also seen as necessary items for girls to have. Having a boyfriend was considered essential, as boys (and men) buy them or provide money for these needs. A strong literature exists on procurement of socially desirable items from sexual partners in impoverished communities [36–38], with a particular focus around implications for HIV risk for young females [39,40]...

Full article at:  http://goo.gl/iolCfQ

By:  

Kelvin Oruko, Elizabeth Nyothach, John Vulule, Penelope A. Phillips-Howard

Kenya Medical Research Institute (KEMRI), Center for Global Health Research, Kisumu, Kenya

Emily Zielinski-Gutierrez, Kayla F. Laserson

Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States of America

Linda Mason, Kelly Alexander, Penelope A. Phillips-Howard

Department of Clinical Studies, Liverpool School of Tropical Medicine, Liverpool, United Kingdom

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Migration as a Risk Factor for School Dropout amongst Children Made Vulnerable by HIV/AIDS: A Prospective Study in Eastern Zimbabwe

Orphans and other children made vulnerable by HIV in sub-Saharan Africa are at increased risk of moving household and of dropping out of school. However, the relationship between child migration and school enrollment has not been established. Multivariable regression models and prospective data from a cohort of children in Manicaland, Zimbabwe, were used to investigate the effect of migration on school enrollment. Children who had moved household were at increased risk of dropping out of school after adjusting for orphan status, relationship to primary caregiver, and household wealth. Interventions are needed to ensure that children who migrate are re-enrolled in school.

Below:  Adjusted odds ratios for dropping out of school comparing children aged 6–18 years who migrated locally, and those who migrated further away, with children who did not migrate between baseline and follow-up. *AOR: Adjusted for orphan status, relationship to primary caregiver, wealth tercile and location at baseline and age and sex of child at follow-up.

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By:  Erica L. Pufall, a , * Constance Nyamukapa, a , b Laura Robertson, a Paradzai George Mushore, b Albert Takaruza, b andSimon Gregson a , b

^bBiomedical Research & Training Institute

aDepartment of Infectious Disease Epidemiology, Imperial College London, St. Mary’s Campus, Norfolk Place, London, UK, W2 1PG

bBiomedical Research & Training Institute, No. 10 Seagrave Road, Avondale, Harare, Zimbabwe

aDepartment of Infectious Disease Epidemiology, Imperial College London, St. Mary’s Campus, Norfolk Place, London, UK, W2 1PG