26 research outputs found
Loss to follow-up and opportunities for reengagement in HIV care in rural Mozambique: A prospective cohort study.
"Patients lost to follow-up (LTFU) over the human
immunodeficiency virus (HIV) cascade have poor clinical outcomes
and contribute to onward HIV transmission. We assessed true care
outcomes and factors associated with successful reengagement in
patients LTFU in southern Mozambique.Newly diagnosed
HIV-positive adults were consecutively recruited in the
Manhi\xC3\xA7a District. Patients LTFU within 12 months after
HIV diagnosis were visited at home from June 2015 to July 2016
and interviewed for ascertainment of outcomes and reasons for
LTFU. Factors associated with reengagement in care within 90
days after the home visit were analyzed by Cox proportional
hazards model.Among 1122 newly HIV-diagnosed adults, 691 (61.6%)
were identified as LTFU. Of those, 557 (80.6%) were approached
at their homes and 321 (57.6%) found at home. Over 50% had died
or migrated, 10% had been misclassified as LTFU, and 252 (78.5%)
were interviewed. Following the visit, 79 (31.3%) reengaged in
care. Having registered in care and a shorter time between LTFU
and visit were associated with reengagement in multivariate
analyses: adjusted hazards ratio of 3.54 [95% confidence
interval (CI): 1.81-6.92; P\xE2\x80\x8A<\xE2\x80\x8A.001] and
0.93 (95% CI: 0.87-1.00; P\xE2\x80\x8A=\xE2\x80\x8A.045),
respectively. The most frequently reported barriers were the
lack of trust in the HIV-diagnosis, the perception of being in
good health, and fear of being badly treated by health personnel
and differed by type of LTFU.Estimates of LTFU in rural areas of
sub-Saharan Africa are likely to be overestimated in the absence
of active tracing strategies. Home visits are resource-intensive
but useful strategies for reengagement for at least one-third of
LTFU patients when applied in the context of differentiated care
for those LTFU individuals who had already enrolled in HIV care
at some point.
Trends in Prevalence of Advanced HIV Disease at Antiretroviral Therapy Enrollment - 10 Countries, 2004-2015.
Monitoring prevalence of advanced human immunodeficiency virus (HIV) disease (i.e., CD4+ T-cell count <200 cells/μL) among persons starting antiretroviral therapy (ART) is important to understand ART program outcomes, inform HIV prevention strategy, and forecast need for adjunctive therapies.*,†,§ To assess trends in prevalence of advanced disease at ART initiation in 10 high-burden countries during 2004-2015, records of 694,138 ART enrollees aged ≥15 years from 797 ART facilities were analyzed. Availability of national electronic medical record systems allowed up-to-date evaluation of trends in Haiti (2004-2015), Mozambique (2004-2014), and Namibia (2004-2012), where prevalence of advanced disease at ART initiation declined from 75% to 34% (p<0.001), 73% to 37% (p<0.001), and 80% to 41% (p<0.001), respectively. Significant declines in prevalence of advanced disease during 2004-2011 were observed in Nigeria, Swaziland, Uganda, Vietnam, and Zimbabwe. The encouraging declines in prevalence of advanced disease at ART enrollment are likely due to scale-up of testing and treatment services and ART-eligibility guidelines encouraging earlier ART initiation. However, in 2015, approximately a third of new ART patients still initiated ART with advanced HIV disease. To reduce prevalence of advanced disease at ART initiation, adoption of World Health Organization (WHO)-recommended "treat-all" guidelines and strategies to facilitate earlier HIV testing and treatment are needed to reduce HIV-related mortality and HIV incidence
Four-Year Treatment Outcomes of Adult Patients Enrolled in Mozambique's Rapidly Expanding Antiretroviral Therapy Program
BACKGROUND: In Mozambique during 2004-2007 numbers of adult patients (≥15 years old) enrolled on antiretroviral therapy (ART) increased about 16-fold, from <5,000 to 79,500. All ART patients were eligible for co-trimoxazole. ART program outcomes, and determinants of outcomes, have not yet been reported. METHODOLOGY/PRINCIPAL FINDINGS: In a retrospective cohort study, we investigated rates of mortality, attrition (death, loss to follow-up, or treatment cessation), immunologic treatment failure, and regimen-switch, as well as determinants of selected outcomes, among a nationally representative sample of 2,596 adults initiating ART during 2004-2007. At ART initiation, median age of patients was 34 and 62% were female. Malnutrition and advanced disease were common; 18% of patients weighed <45 kilograms, and 15% were WHO stage IV. Median baseline CD4(+) T-cell count was 153/µL and was lower for males than females (139/µL vs. 159/µL, p<0.01). Stavudine, lamivudine, and nevirapine or efavirenz were prescribed to 88% of patients; only 31% were prescribed co-trimoxazole. Mortality and attrition rates were 3.4 deaths and 19.8 attritions per 100 patient-years overall, and 12.9 deaths and 57.2 attritions per 100 patient-years in the first 90 days. Predictors of attrition included male sex [adjusted hazard ratio (AHR) 1.5; 95% confidence interval (CI), 1.3-1.8], weight <45 kg (AHR 2.1; 95% CI, 1.6-2.9, reference group >60 kg), WHO stage IV (AHR 1.7; 95% CI, 1.3-2.4, reference group WHO stage I/II), lack of co-trimoxazole prescription (AHR 1.4; 95% CI, 1.0-1.8), and later calendar year of ART initiation (AHR 1.5; 95% CI, 1.2-1.8). Rates of immunologic treatment failure and regimen-switch were 14.0 and 0.6 events per 100-patient years, respectively. CONCLUSIONS: ART initiation at earlier disease stages and scale-up of co-trimoxazole among ART patients could improve outcomes. Research to determine reasons for low regimen-switch rates and increasing rates of attrition during program expansion is needed
Antiretroviral therapy enrollment characteristics and outcomes among HIV-infected adolescents and young adults compared with older adults--seven African countries, 2004-2013.
Although scale-up of antiretroviral therapy (ART) since 2005 has contributed to declines of about 30% in the global annual number of human immunodeficiency (HIV)-related deaths and declines in global HIV incidence, estimated annual HIV-related deaths among adolescents have increased by about 50% and estimated adolescent HIV incidence has been relatively stable. In 2012, an estimated 2,500 (40%) of all 6,300 daily new HIV infections occurred among persons aged 15-24 years. Difficulty enrolling adolescents and young adults in ART and high rates of loss to follow-up (LTFU) after ART initiation might be contributing to mortality and HIV incidence in this age group, but data are limited. To evaluate age-related ART retention challenges, data from retrospective cohort studies conducted in seven African countries among 16,421 patients, aged ≥15 years at enrollment, who initiated ART during 2004-2012 were analyzed. ART enrollment and outcome data were compared among three groups defined by age at enrollment: adolescents and young adults (aged 15-24 years), middle-aged adults (aged 25-49 years), and older adults (aged ≥50 years). Enrollees aged 15-24 years were predominantly female (81%-92%), commonly pregnant (3%-32% of females), unmarried (54%-73%), and, in four countries with employment data, unemployed (53%-86%). In comparison, older adults were more likely to be male (p<0.001), employed (p<0.001), and married, (p<0.05 in five countries). Compared with older adults, adolescents and young adults had higher LTFU rates in all seven countries, reaching statistical significance in three countries in crude and multivariable analyses. Evidence-based interventions to reduce LTFU for adolescent and young adult ART enrollees could help reduce mortality and HIV incidence in this age group
Incidence and determinants of tuberculosis among adults initiating antiretroviral therapy--Mozambique, 2004-2008.
In Mozambique, tuberculosis (TB) is thought to be the most common cause of death among antiretroviral therapy (ART) enrollees. Monitoring proportions of enrollees screened for TB, and incidence and determinants of TB during ART can help clinicians and program managers identify program improvement opportunities.We conducted a retrospective cohort study among a nationally representative sample of the 79,500 adults (>14 years old) initiating ART during 2004-2007 to estimate clinician compliance with TB screening guidelines, factors associated with active TB at ART initiation, and incidence and predictors of documented TB during ART follow-up. Of 94 sites enrolling >50 adults on ART, 30 were selected using probability-proportional-to-size sampling; 2,596 medical records at these sites were randomly selected for abstraction and analysis. At ART initiation, median age of patients was 34, 62% were female, median baseline CD4(+) T-cell count was 153/µL, and 11% were taking TB treatment. Proportions of records with TB screening documentation before ART initiation improved from 31% to 66% during 2004-2007 (p<0.001). TB screening compliance varied widely by ART clinic [n = 30, 2%-98% (p<0.001)] and supporting non-Governmental Organization (NGO) [n = 7, 27%-83% (p<0.001)]. Receiving TB treatment at ART enrollment was associated with male sex (p<0.001), weight <45 kg (p<0.001) and CD4<50/µL (p = 0.001). Isoniazid preventive therapy (IPT) was prescribed to <1% of ART enrollees not taking TB treatment. TB incidence during ART was 2.32 cases per 100 person-years. Factors associated with TB incidence included adherence to ART <95% (AHR 2.06; 95% CI, 1.32-3.21).Variations in TB screening by clinic and NGO may reflect differing investments in TB screening activities. Future scale-up should target under-performing clinics. Scale-up of TB screening at ART initiation, IPT, and ART adherence interventions could significantly reduce incident TB during ART
Patient characteristics at antiretroviral therapy initiation associated with attrition and treatment failure.
<p>Abbreviations: Rate/100PY, rate per 100 person-years; HR, hazards
ratio; AHR, adjusted hazards ratio; CI, confidence interval; TB,
tuberculosis; WHO, World Health Organization; BMI, body mass index;
CTX, co-trimoxazole.</p><p>*Stratified by CD4<sup>+</sup> T-cell count
(cells/µL).</p>†<p>All variables listed in this table were included in the multivariate
Cox proportional hazards regression model.</p><p>**Hazard ratios associated with a 10-year increase in
age.</p>‡<p>Date of ART initiation was entered into the model; hazard ratios
represent a yearly increase rather than a daily increase.</p
Modeled changes in weight over time for surviving patients initiating ART during 2004–2007.
<p>Modeled changes in weight over time for surviving patients initiating
ART during 2004–2007.</p
Modeled changes in CD4 count for surviving patients initiating antiretroviral therapy during 2004–2007.
<p>Modeled changes in CD4 count for surviving patients initiating
antiretroviral therapy during 2004–2007.</p
TB Incidence Rates during ART Follow-up among Patients Assessed as TB-free at ART Initiation (n = 2,325).
<p>TB Incidence Rates during ART Follow-up among Patients Assessed as TB-free at ART Initiation (n = 2,325).</p