Validity of reported retention in antiretroviral therapy after roll-out to peripheral facilities in Mozambique: Results of a retrospective national cohort analysis

<div><p>Background</p><p>Retention in anti-retroviral therapy (ART) presents a challenge in sub-Saharan Africa. In Mozambique, after roll-out to peripheral facilities, the 12-month retention rate was reported mostly from sites with an electronic patient tracking system (EPTS), representing only 65% of patients. We conducted a nationally representative study, compared 12-month retention at EPTS and non-EPTS sites, and its predictors.</p><p>Methods</p><p>Applying a proportionate to population size sampling strategy, we obtained a nationally representative sample of patients who initiated ART between January 2013 and June 2014. We calculated weighted proportions of the patients’ status at 12 months after ART initiation, and 12-month incidence of lost to follow-up (LTFU) and death. We assessed determinants of LTFU and death by calculating adjusted hazard ratios (AHR) through multivariate cox-proportional hazard models.</p><p>Results</p><p>Among 19,297 patients sampled, 54.3% were still active, 33.1% LTFU, 2.0% dead, 2.6% transferred-out and 8.0% had unknown status, 12 months after ART initiation. Total attrition rate (LTFU or dead) was 45.5/100PY, higher at facilities without EPTS (51.8/100PY) than with EPTS (37.7/100PY). Clinical stage IV (AHR = 1.7), CD4 count ≤150 (AHR = 1.3) and being pregnant (AHR = 1.6) were significantly associated with LTFU. Clinical stage III or IV (AHR = 2.1 and 3.8), CD4 count ≤150 (AHR = 3.0), not being pregnant (AHR = 3.0), and ART regimens with stavudine (AHR = 4.28) were significantly associated with deaths. Patients enrolled in adherence support groups were 4.6 times less likely to be LTFU, but the number (n = 174) was too small to be significant (p = 0.273).</p><p>Conclusion</p><p>Retention in ART was substantially lower at non-EPTS sites. EPTS should be expanded to all ART sites to facilitate comprehensive routine monitoring of retention in care. Retention in Mozambique is low and needs to be improved, especially among pregnant women and patients with advanced disease at ART initiation. The effect of ART adherence support groups needs to be further monitored.</p></div

Adoption of Rapid Diagnostic Tests for the Diagnosis of Malaria, a Preliminary Analysis of the Global Fund Program Data, 2005 to 2010

<div><h3>Introduction</h3><p>The World Health Organization Guidelines for the Treatment of Malaria, in 2006 and 2010, recommend parasitological confirmation of malaria before commencing treatment. Although microscopy has been the mainstay of malaria diagnostics, the magnitude of diagnostic scale up required to follow the Guidelines suggests that rapid diagnostic tests (RDTs) will be a large component. This study analyzes the adoption of rapid diagnostic testing in malaria programs supported by the Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund), the leading international funder of malaria control globally.</p> <h3>Methods and Findings</h3><p>We analyzed, for the period 2005 to 2010, Global Fund programmatic data for 81 countries on the quantity of RDTs planned; actual quantities of RDTs and artemisinin-based combination treatments (ACTs) procured in 2009 and 2010; RDT-related activities including RDTs distributed, RDTs used, total diagnostic tests including RDTs and microscopy performed, health facilities equipped with RDTs; personnel trained to perform rapid diagnostic malaria test; and grant budgets allocated to malaria diagnosis. In 2010, diagnosis accounted for 5.2% of malaria grant budget. From 2005 to 2010, the procurement plans include148 million RDTs through 96 malaria grants in 81 countries. Around 115 million parasitological tests, including RDTs, had reportedly been performed from 2005 to 2010. Over this period, 123,132 health facilities were equipped with RDTs and 137,140 health personnel had been trained to perform RDT examinations. In 2009 and 2010, 41 million RDTs and 136 million ACTs were purchased. The ratio of procured RDTs to ACTs was 0.26 in 2009 and 0.34 in 2010.</p> <h3>Conclusions/significance</h3><p>Global Fund financing has enabled 81 malaria-endemic countries to adopt WHO guidelines by investing in RDTs for malaria diagnosis, thereby helping improve case management of acute febrile illness in children. However, roll-out of parasitological diagnosis lags behind the roll-out of ACT-based treatment, and will require prioritization of investments.</p> </div

Determinants of deaths (N = 15,750)^*.

<p>Determinants of deaths (N = 15,750)^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0198916#t005fn001" target="_blank">*</a>}.</p

Planned procurement of rapid diagnostic tests funded by the Global Fund, 2005 to 2010.

<p>Planned procurement of rapid diagnostic tests funded by the Global Fund, 2005 to 2010.</p

Global Fund programmatic results on distribution, use of RDTs and microscopy, and health service readiness, by malaria endemicity, 2005 to 2010.

<p>Global Fund programmatic results on distribution, use of RDTs and microscopy, and health service readiness, by malaria endemicity, 2005 to 2010.</p

Attrition rate by type of facility (PY = 17,068).

<p>Attrition rate by type of facility (PY = 17,068).</p

Patient characteristics by EPTS/non-EPTS facility (N = 19,297).

<p>Patient characteristics by EPTS/non-EPTS facility (N = 19,297).</p

Programmatic results reported by Global Fund malaria grant recipients on planning, distribution and use of rapid diagnostic tests (RDTs), parasitological confirmation and health service readiness over the years 2005 to 2010.

<p>Programmatic results reported by Global Fund malaria grant recipients on planning, distribution and use of rapid diagnostic tests (RDTs), parasitological confirmation and health service readiness over the years 2005 to 2010.</p

Global Fund programmatic results on distribution, use of RDTs and microscopy, and health service readiness, by region, 2005 to 2010.

<p>Global Fund programmatic results on distribution, use of RDTs and microscopy, and health service readiness, by region, 2005 to 2010.</p

Patients’ status 12 months after ART initiation by type of facility (N = 19,927).

<p>Patients’ status 12 months after ART initiation by type of facility (N = 19,927).</p