Social & Clinical Attributes of Patients Who Restart Antiretroviral Therapy in Central & Copperbelt Provinces, Zambia

Background

About 30 % of the patients initiated on antiretroviral therapy in Zambia default treatment. Some of these patients later restart treatment; however, the characteristics of these patients have not been well described and documented. The aim of this study was to describe and document the socio-demographic and clinical characteristics of patients who default and restart antiretroviral therapy, and to determine the socio-demographic characteristics associated with CD4 count response at 6 and 24 months of restarting antiretroviral therapy.

Methods

A longitudinal retrospective analysis was performed on data from 535 adult patients restarting antiretroviral therapy in 2009 and 2010 at five antiretroviral therapy centres in Copperbelt and Central provinces of Zambia. To determine the association between the socio-demographic characteristics and CD4 cell count, quantile regression models were used.

Results

Older age above 45 years was associated with a significantly lower CD4 cell response by 38.1 cells/mm³ compared to the younger age (15–29 years). Patients in formal employment and self-employment gained significantly higher CD4 cells than those unemployed. In addition, baseline CD4 count, type of treatment, WHO staging, total duration on treatment and duration lost to follow-up were found to be strong predictors of CD4 cell count at 6 and 24 months after restarting antiretroviral therapy treatment.

Conclusion

Age and occupation were the only socio-demographic characteristics predicting CD4 count in the patients at 6 months after restarting antiretroviral therapy after adjusting for other confounding clinical variables.  

Below:  Boxplots of Interquartile range of CD4 count at restarting ART, 6 and 24 months after restaring ART

Full article at:  http://goo.gl/8P145h

By:  Chama Mulubwa, Oliver Mweemba, Patrick Katayamoyo, and Hikabasa Halwindi

Department of Public Health, School of Medicine, University of Zambia, PO Box 50110, Lusaka, Zambia

FHI 360, Plot 2374, Farmers Village, ZNFU Complex, Lusaka, Zambia

BMC Public Health. 2016; 16: 289.

Published online 2016 Mar 29. doi:  10.1186/s12889-016-2922-3

Department of Public Health, School of Medicine, University of Zambia, PO Box 50110, Lusaka, Zambia

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A Risk Score to Identify HIV-Infected Women Most Likely to Become Lost to Follow-Up in the Postpartum Period

Access to lifelong combination antiretroviral therapy (cART) is expanding among HIV-infected pregnant and breastfeeding women throughout sub-Saharan Africa (SSA). For this strategy to meaningfully improve maternal HIV outcomes, retention in HIV care is essential. 

We developed a risk score to identify women with high likelihood of loss to follow-up (LTFU) at 6 months postpartum from HIV care, using data from public health facilities in Lusaka, Zambia. LTFU was defined as not presenting for HIV care within 60 days of the last scheduled appointment. We used logistic regression to assess demographic, obstetric and HIV predictors of LTFU and to develop a simple risk score. Sensitivity and specificity were assessed at each risk score cut-point. 

Among 2029 pregnant women initiating cART between 2009 and 2011, 507 (25%) were LTFU by 6 months postpartum. Parity, education, employment status, WHO clinical stage, duration of cART during pregnancy and number of antenatal care visits were associated with LTFU (p-value < .10). A risk score cut-point of 11 (42nd percentile) had 85% sensitivity (95% CI 82%, 88%) and 22% specificity (95% CI 20%, 24%) to detect women LTFU and would exclude 20% of women from a retention intervention. A risk score cut-point of 18 (69th percentile) identified the 23% of women with the highest probability of LTFU and had sensitivity 32% (95% CI 28%, 36%) and specificity 80% (95% CI 78%, 82%). 

A risk score approach may be useful to triage a subset of women most likely to be LTFU for targeted retention interventions.

Purchase full article at:   http://goo.gl/YZW67P

By:  Bengtson AM1, Chibwesha CJ2, Westreich D1, Mubiana-Mbewe M3, Chi BH2,3, Miller WC1,4, Mapani M2, Pence BW1, Musonda P5, Stringer JS2, Pettifor A1.

• 1 Department of Epidemiology , University of North Carolina , Chapel Hill , NC , USA.
• 2 Department of Obstetrics and Gynecology , University of North Carolina , Chapel Hill , NC , USA.
• 3 Centre for Infectious Disease Research , Zambia , Africa.
• 4 Department of Medicine , University of North Carolina , Chapel Hill , NC , USA.
• 5 Department of Public Health, University of Zambia School of Medicine , Lusaka , Zambia , Africa. 
• AIDS Care. 2016 Feb 17:1-11

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Factors Associated with Retention among Non-Perinatally HIV-Infected Youth in the HIV Research Network

BACKGROUND:

The transmission of human immunodeficiency virus (HIV) among youth through high-risk behaviors continues to increase. Retention in Care is associated with positive clinical outcomes and a decrease in HIV transmission risk behaviors. We evaluated the clinical and demographic characteristics of non-perinatally HIV (nPHIV)-infected youth associated with retention 1 year after initiating care and in the 2 years thereafter. We also assessed the impact retention in year 1 had on retention in years 2 and 3.

METHODS:

This was a retrospective analysis of treatment-naive nPHIV-infected 12- to 24-year-old youth presenting for care in 16 US HIV clinical sites within the HIV Research Network between 2002 and 2008. Multivariate logistic regression identified factors associated with retention.

RESULTS:

Of 1160 nPHIV-infected youth, 44.6% were retained in care during the first year, and 22.4% were retained in all 3 years. Retention in the first year was associated with starting antiretroviral therapy in the first year (adjusted odds ratio [AOR], 3.47 [95% confidence interval (CI), 2.57-4.67]), Hispanic ethnicity (AOR, 1.66 [95% CI, 1.08-2.56]), men who have sex with men (AOR, 1.59 [95% CI, 1.07-2.36]), and receiving care at a pediatric site (AOR, 5.37 [95% CI, 3.20-9.01]). Retention in years 2 and 3 was associated with being retained 1 year after initiating care (AOR, 7.44 [95% CI, 5.11-10.83]).

CONCLUSION:

A high proportion of newly enrolled nPHIV-infected youth were not retained for 1 year, and only 1 in 4 were retained for 3 years. Patients who were Hispanic, were men who have sex with men, or were seen at pediatric clinics were more likely to be retained in care. Interventions that target those at risk of being lost to follow up are essential for this high-risk population.

Purchase full article at:   http://goo.gl/p6ezEI

By:  Farmer C1, Yehia BR2, Fleishman JA3, Rutstein R4, Mathews WC5, Nijhawan A6, Moore RD7, Gebo KA8, Agwu AL9; HIV Research Network.

• 1Johns Hopkins School of Medicine, Baltimore, Maryland.
• 2Division of Infectious Diseases, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia.
• 3Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, Maryland.
• 4Division of General Pediatrics, Children's Hospital of Philadelphia, Pennsylvania.
• 5Department of Clinical Medicine, University of California San Diego Medical Center.
• 6Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas.
• 7Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
• 8Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.
• 9Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland. 
• J Pediatric Infect Dis Soc. 2016 Mar;5(1):39-46. doi: 10.1093/jpids/piu102. Epub 2014 Oct 19.

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The Majority of the Pre-Antiretroviral Population Who Were Lost to Follow-Up Stopped Their Care in Freetown, Sierra Leone

BACKGROUND:

The heterogeneity of the pre-antiretroviral (pre-ART) population calls for more granular depictions of the cascade of HIV care.

METHODS:

We studied a prospective cohort of persons newly diagnosed with HIV infection from a single center in Freetown, Sierra Leone, over a 12-month period and then traced those persons who were lost to follow-up (LTFU) during pre-ART care (before ART initiation). ART eligibility was based on a CD4 cell count result of ≤ 350 mm/cells and/or WHO clinical stage 3 or 4. Persons who attended an appointment in the final three months were considered to be retained in care. Adherence to ART was measured using pharmacy refill dates. "Effective HIV care" was defined as completion of the cascade of care at 12-months regardless of whether patients are on ART. Tracing outcomes were obtained for those who were LTFU during pre-ART care.

RESULTS:

408 persons newly diagnosed with HIV infection were screened, 338 were enrolled, and 255 persons were staged for ART. ART-ineligible persons had higher retention rates than ART-eligible persons (59.6% vs 41.8%, p = 0.03). 77 (22.8%) of 338 persons received effective HIV care. Most attrition (61.9%) occurred with persons during pre-ART care. 123 of 138 persons (89.1%) who were LTFU prior to ART initiation were found, and 91 of those 123 (74.0%) were alive. Of the 74 persons who were alive and described their engagement in care, 40 (54.1%) stopped care. Nearly half (42.5%) of those 40 stopped after assessment of ART-eligibility but before ART initiation. The main limitation of this study was the lack of tracing outcomes for those lost during ART care.

CONCLUSIONS:

The majority of the pre-ART LTFU population stopped their care, particularly after ART-eligibility but before ART initiation. Interventions to hasten ART initiation and retain this at-risk group may have significant downstream impact on effective HIV care.

Below:  Cascade of care for newly diagnosed persons to receive effective HIV care

Full article at:   http://goo.gl/Q3jzn6

By:  Kelly JD1,2,3, Schlough GW2, Conteh S3,4, Barrie MB2, Kargbo B3, Giordano TP1.

• 1Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America.
• 2Wellbody Alliance, Koidu Town, Sierra Leone.
• 3National HIV/AIDS Secretariat, Freetown, Sierra Leone.
• 4College of Medicine and Allied Health Sciences of University of Sierra Leone, Freetown, Sierra Leone. 
• PLoS One. 2016 Feb 22;11(2):e0149584. doi: 10.1371/journal.pone.0149584. eCollection 2016.

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Loss to Follow-Up among Youth Accessing Outpatient HIV Care & Treatment Services in Kisumu, Kenya

Youth are particularly vulnerable to acquiring HIV, yet reaching them with HIV prevention interventions and engaging and retaining those infected in care and treatment remains a challenge. 

We sought to determine the incidence rate of loss to follow-up (LTFU) and explore socio-demographic and clinical characteristics associated with LTFU among HIV-positive youth aged 15-21 years accessing outpatient care and treatment clinics in Kisumu, Kenya. Between July 2007 and September 2010, youth were enrolled into two different HIV care and treatment clinics, one youth specific and the other family oriented. An individual was defined as LTFU when absent from the HIV treatment clinic for ≥ 4 months regardless of their antiretroviral treatment status. 

The incidence rate of LTFU was calculated and Cox regression analysis used to identify factors associated with LTFU. A total of 924 youth (79% female) were enrolled, with a median age of 20 years (IQR 18-21). Over half, (529 (57%)), were documented as LTFU, of whom 139 (26%) were LTFU immediately after enrollment. The overall incidence rate of LTFU was 52.9 per 100 person-years (p-y). Factors associated with LTFU were pregnancy during the study period; CD4 cell count >350 (adjusted hazard ratios (AHR) 0.59, 95% CI 0.39-0.90); not being on antiretroviral therapy; and non-disclosure of HIV infection status (AHR 1.43, 95% CI 1.10-1.89). The clinic of enrolment, age, marital status, employment status, WHO clinical disease stage and education level were not associated with LTFU. 

Interventions to identify and enrol youth into care earlier, support disclosure, and initiate ART earlier may improve retention of youth and need further investigation. Further research is also needed to explore the reasons for LTFU from care among HIV-infected youth and the true outcomes of these patients.

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

By:  Ojwang' VO1, Penner J1,2, Blat C1,3, Agot K4, Bukusi EA1, Cohen CR1,3.

• 1 Family AIDS Care & Education Services (FACES) , Centre for Microbiology Research (CMR), Kenya Medical Research Institute (KEMRI) , Nairobi , Kenya.
• 2 Department of Family Practice , University of British Columbia , Vancouver , Canada.
• 3 Department of Obstetrics, Gynaecology & Reproductive Sciences , University of California , San Francisco , CA , USA.
• 4 Impact Research and Development Organization , Kisumu , Kenya. 
• AIDS Care. 2016 Apr;28(4):500-7. doi: 10.1080/09540121.2015.1110234. Epub 2015 Nov 12.

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Decentralizing Access to Antiretroviral Therapy for Children Living with HIV in Swaziland

BACKGROUND:

In 2007, Swaziland initiated a hub-and-spoke model for decentralizing antiretroviral therapy (ART) access for HIV-infected children (<15 years old). Decentralization was facilitated through: (1) down-referral of stable children on ART from overburdened central facilities (hubs) to primary healthcare clinics (spokes), and (2) pediatric ART initiation at spokes (spoke-initiation).

METHODS:

We conducted a nationally representative retrospective cohort study among children starting ART during 2004-2010 to assess effect of down-referral and spoke-initiation on rates of loss to follow-up (LTFU), death, and attrition (death or LTFU). Twelve of 28 pediatric ART hubs were randomly selected using probability-proportional-to-size sampling. Seven selected facilities had initiated hub-and-spoke decentralization by study start; at these facilities, 901 of 1,893 hub-initiated and maintained (hub-maintained) children, and 495 of 1,105 down-referred or spoke-initiated children were randomly selected for record abstraction. At the five hub-only facilities, 612 of 1,987 children were randomly selected. Multivariable proportional hazards regression was used to estimate adjusted hazards ratios (AHR) for effect of down-referral (a time-varying covariate) and spoke-initiation on outcomes.

RESULTS:

Among 2,008 children at ART initiation, median age was 5.0 years, median CD4 percentage 12.0%, median CD4 count 358 cells/µL, and median weight-for-age z-score -1.91. Controlling for known confounders, down-referral was strongly protective against LTFU (AHR 0.40; 95% CI, 0.20-0.79) and attrition (AHR 0.46; 95% CI, 0.26-0.83) but not mortality. Compared with hub-only children or hub-maintained children, spoke-initiated children had similar outcomes.

CONCLUSIONS:

Decentralization of pediatric ART through down-referral and spoke-initiation within a hub-and-spoke system should be continued and might improve program outcomes.

Purchase full article at:   http://goo.gl/Eax9ej

By:  Auld AF1, Nuwagaba-Biribonwoha H, Azih C, Kamiru H, Baughman AL, Agolory S, Abrams E, Ellerbrock TV, Okello V, Bicego G, Ehrenkranz P.

• 1 Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, U.S.A 
• 2 ICAP, Columbia University, Mailman School of Public Health, New York, U.S.A 
• 3 Ministry of Health, Government of the Kingdom of Swaziland, Mbabane, Swaziland 
• 4 Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Mbabane, Swaziland. 
• Pediatr Infect Dis J. 2016 Feb 4

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Risk Factors for Loss to Follow-Up among People Who Inject Drugs in a Risk Reduction Program at Karachi, Pakistan

INTRODUCTION:

Retention of male people who inject drugs (PWIDs) is a major challenge for harm reduction programs that include sterile needle/syringe exchange in resource-limited settings like Pakistan. We assessed the risk factors for loss to follow-up among male PWIDs enrolled in a risk reduction program in Karachi, Pakistan.

METHODS:

We conducted a prospective cohort study among 636 HIV-uninfected male PWIDs enrolled during March-June 2009 in a harm reduction program for the estimation of incidence rate. At 24 months post-enrollment, clients who had dropped out of the program were defined as lost to follow-up and included as cases for case-cohort study.

RESULTS:

The median age of the participants was 29 years (interquartile range: 23-36). Active outreach accounted for 76% (483/636) of cohort recruits. Loss to follow-up at 24 months was 25.5% (162/636). In multivariable logistic regression, younger age (AOR: 0.97, 95% CI: 0.92-0.99, p = 0.028), clients from other provinces than Sindh (AOR: 1.49, 95% CI: 1.01-2.22, p = 0.046), having no formal education (AOR: 3.44, 95% CI: 2.35-4.90, p<0.001), a history of incarceration (AOR: 1.68, 95% CI: 1.14-2.46, p<0.008), and being homeless (AOR: 1.47, 95% CI: 1.00-2.19, p<0.049) were associated with loss to follow-up.

CONCLUSIONS:

Our cohort retained 74.5% of male PWIDs in Karachi for 24 months. Its loss to follow up rate suggested substantial ongoing programmatic challenges. Programmatic enhancements are needed for the highest risk male PWIDs, i.e., younger men, men not from Sindh Province, men who are poorly educated, formerly incarcerated, and/or homeless.

Full article at:  http://goo.gl/nhE42m

By:  Samo RN1, Agha A2, Shah SA3, Altaf A3, Memon A4, Blevins M5, Qian HZ6, Vermund SH7.

• 1Polio Eradication Initiative, World Health Organization, Larkana, Pakistan.
• 2Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
• 3Bridge Consultants Foundation, Karachi, Pakistan.
• 4Sindh AIDS Control Program, Karachi, Pakistan.
• 5Vanderbilt Institute for Global Health & Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America.
• 6Vanderbilt Institute for Global Health & Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America.
• 7Vanderbilt Institute for Global Health & Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America. 
• PLoS One. 2016 Feb 3;11(2):e0147912. doi: 10.1371/journal.pone.0147912. eCollection 2016.

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Retention & Risk Factors for Attrition among Adults in Antiretroviral Treatment Programs in Tanzania, Uganda & Zambia

OBJECTIVES

We assessed retention and predictors of attrition (recorded death or loss to follow-up) in antiretroviral treatment (ART) clinics in Tanzania, Uganda and Zambia.

METHODS

We conducted a retrospective cohort study among adults (≥18 years) starting ART during 2003–2010. We purposefully selected six health facilities per country and randomly selected 250 patients from each facility. Patients who visited clinics at least once during the 90 days before data abstraction were defined as retained. Data on individual and programme level risk factors for attrition were obtained through chart review and clinic manager interviews. Kaplan–Meier curves for retention across sites were created. Predictors of attrition were assessed using a multivariable Cox-proportional hazards model, adjusted for site-level clustering.

RESULTS

From 17 facilities, 4147 patients were included. Retention ranged from 52.0% to 96.2% at 1 year to 25.8%–90.4% at 4 years. Multivariable analysis of ART initiation characteristics found the following independent risk factors for attrition: younger age [adjusted hazard ratio (aHR) and 95% confidence interval (95%CI) = 1.30 (1.14–1.47)], WHO stage 4 ([aHR (95% CI): 1.56 (1.29–1.88)], >10% bodyweight loss [aHR (95%CI) = 1.17 (1.00–1.38)], poor functional status [ambulatory aHR (95%CI) = 1.29 (1.09–1.54); bedridden aHR1.54 (1.15–2.07)], and increasing years of clinic operation prior to ART initiation in government facilities [aHR (95%CI) = 1.17 (1.10–1.23)]. Patients with higher CD4 cell count were less likely to experience attrition [aHR (95%CI) = 0.88 (0.78–1.00)] for every log (tenfold) increase. Sites offering community ART dispensing [aHR (95% CI) = 0.55 (0.30–1.01) for women; 0.40 (0.21–0.75) for men] had significantly less attrition.

CONCLUSIONS

Patient retention to an individual programme worsened over time especially among males, younger persons and those with poor clinical indicators. Community ART drug dispensing programmes could improve retention.

Below:  Kaplan-Meier estimates by site in Tanzania, Uganda and Zambia

Below:  Kaplan-Meier estimates by Community-Based Distribution (CBD) of ARVs in Tanzania, Uganda and Zambia

Full article at:   http://goo.gl/f62sCn

By:  Olivier Koole,1,2 Sharon Tsui,3,4 Fred Wabwire-Mangen,5 Gideon Kwesigabo,6 Joris Menten,2 Modest Mulenga,7Andrew Auld,8 Simon Agolory,8 Ya Diul Mukadi,3 Robert Colebunders,2,9 David R. Bangsberg,10,11 Eric van Praag,3Kwasi Torpey,3 Seymour Williams,8 Jonathan Kaplan,8 Aaron Zee,8 and Julie Denison3,4

¹Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK

²Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium

³FHI 360, Durham, NC, USA

⁴Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

⁵Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda

⁶Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania

⁷Tropical Diseases Research Centre, Ndola, Zambia

⁸Division of Global AIDS, United States Centers for Disease Control and Prevention, Atlanta, GA, USA

⁹Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium

¹⁰Massachusetts General Hospital, Boston, MA, USA

¹¹Harvard Medical School, Boston, MA, USA

Corresponding Author Olivier Koole, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Tel.: +265 997 680 108; Email: ku.ca.mthsl@elook.reivilo

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