Factors associated with initiation of antiretroviral therapy in the advanced stages of HIV infection in six Ethiopian HIV clinics, 2012 to 2013

Introduction: Most HIV-positive persons in sub-Saharan Africa initiate antiretroviral therapy (ART) with advanced infection (late ART initiation). Intervening on the drivers of late ART initiation is a critical step towards achieving the full potential of HIV treatment scale-up. This study aimed to identify modifiable factors associated with late ART initiation in Ethiopia. Methods: From 2012 to 2013, Ethiopian adults (n=1180) were interviewed within two weeks of ART initiation. Interview data were merged with HIV care histories to assess correlates of late ART initiation (CD4+ count \u3c150 cells/mL or World Health Organization Stage IV). Results: The median CD4 count at enrolment in HIV care was 263 cells/mL (interquartile range (IQR): 140 to 390) and 212 cells/mL (IQR: 119 to 288) at ART initiation. Overall, 31.2% of participants initiated ART late, of whom 85.1% already had advanced HIV disease at enrolment. Factors associated with higher odds of late ART initiation included male sex (vs. non-pregnant females; adjusted odds ratio (aOR): 2.02; 95% CI: 1.50 to 2.73), high levels of psychological distress (vs. low/none, aOR: 1.96; 95% CI: 1.34 to 2.87), perceived communication barriers with providers (aOR: 2.42, 95% CI: 1.24 to 4.75), diagnosis via provider initiated testing (vs. voluntary counselling and testing, aOR: 1.47, 95% CI: 1.07 to 2.04), tuberculosis (TB) treatment prior to ART initiation (aOR: 2.16, 95% CI: 1.43 to 3.25) and a gap in care of six months or more prior to ART initiation (aOR: 2.02, 95% CI: 1.10 to 3.72). Testing because of partner illness/death (aOR: 0.64, 95% CI: 0.42 to 0.95) was associated with lower odds of late ART initiation. Conclusions: Programmatic initiatives promoting earlier diagnosis, engagement in pre-ART care, and integration of TB and HIV treatments may facilitate earlier ART initiation. Men and those experiencing psychological distress may also benefit from targeted support prior to ART initiation

IeDEA-WHO Research-Policy Collaboration: contributing real-world evidence to HIV progress reporting and guideline development.

Partnerships between researchers and policymakers can improve uptake and integration of scientific evidence. This article describes the research-policy partnership between the International epidemiology Databases to Evaluate AIDS (IeDEA) ( www.iedea.org) and the World Health Organization (WHO), which was established in 2014. IeDEA is an international research consortium, which analyses data on almost 2 million people living with HIV under care in routine settings in 46 countries in Asia-Pacific, the Caribbean, Central and South America, North America and sub-Saharan Africa. Five multiregional analyses were identified to inform the WHO on progress towards the second and third 90s of the 90-90-90 targets in adults and children: (i) trends in CD4 cell counts at the start of antiretroviral therapy (ART); (ii) delays from enrolment in HIV care to ART initiation; (iii) the impact of ART guideline changes; (iv) retention in care, mortality and loss to follow-up; and (v) viral suppression within the first 3 years after initiating ART. Results from these analyses were contributed to the 2015 and 2016 WHO global HIV progress reports, will contribute to the 2018 report, and were published in academic journals. The partnership has been mutually beneficial: discussion of WHO policy agendas led to more policy-framed, relevant and timely IeDEA research, and the collaboration provided the WHO with timely access to the latest data from IeDEA, as it was shared prior to peer-review publication

PLoS Med

BACKGROUND: The effect of antiretroviral treatment (ART) eligibility expansions on patient outcomes, including rates of timely ART initiation among those enrolling in care, has not been assessed on a large scale. In addition, it is not known whether ART eligibility expansions may lead to "crowding out" of sicker patients. METHODS AND FINDINGS: We examined changes in timely ART initiation (within 6 months) at the original site of HIV care enrollment after ART eligibility expansions among 284,740 adult ART-naive patients at 171 International Epidemiology Databases to Evaluate AIDS (IeDEA) network sites in 22 countries where national policies expanding ART eligibility were introduced between 2007 and 2015. Half of the sites included in this analysis were from Southern Africa, one-third were from East Africa, and the remainder were from the Asia-Pacific, Central Africa, North America, and South and Central America regions. The median age of patients enrolling in care at contributing sites was 33.5 years, and the median percentage of female patients at these clinics was 62.5%. We assessed the 6-month cumulative incidence of timely ART initiation (CI-ART) before and after major expansions of ART eligibility (i.e., expansion to treat persons with CD4 </= 350 cells/muL [145 sites in 22 countries] and CD4 </= 500 cells/muL [152 sites in 15 countries]). Random effects metaregression models were used to estimate absolute changes in CI-ART at each site before and after guideline expansion. The crude pooled estimate of change in CI-ART was 4.3 percentage points (95% confidence interval [CI] 2.6 to 6.1) after ART eligibility expansion to CD4 </= 350, from a baseline median CI-ART of 53%; and 15.9 percentage points (pp) (95% CI 14.3 to 17.4) after ART eligibility expansion to CD4 </= 500, from a baseline median CI-ART of 57%. The largest increases in CI-ART were observed among those newly eligible for treatment (18.2 pp after expansion to CD4 </= 350 and 47.4 pp after expansion to CD4 </= 500), with no change or small increases among those eligible under prior guidelines (CD4 </= 350: -0.6 pp, 95% CI -2.0 to 0.7 pp; CD4 </= 500: 4.9 pp, 95% CI 3.3 to 6.5 pp). For ART eligibility expansion to CD4 </= 500, changes in CI-ART were largest among younger patients (16-24 years: 21.5 pp, 95% CI 18.9 to 24.2 pp). Key limitations include the lack of a counterfactual and difficulty accounting for secular outcome trends, due to universal exposure to guideline changes in each country. CONCLUSIONS: These findings underscore the potential of ART eligibility expansion to improve the timeliness of ART initiation globally, particularly for young adults

Hypertension and HIV in an Urban Slum Setting, Port-au-Prince, Haiti

Background: Rapidly growing urban slum settings increasingly face co-occurring communicable and non-communicable health crises, against the backdrop of extreme poverty, and social and environmental vulnerability. In Haiti, sparse data suggest a growing burden of hypertension and cardiovascular disease (CVD), along with substantial prevalence of HIV, increasingly recognized as a major CVD risk factor. As life-saving antiretroviral treatment (ART) is extended to more people living with HIV (PLWH), their risk of CVD increases with longer life expectancy and possibly cumulative ART exposure. Pregnant HIV-positive women may face additional cardiovascular vulnerability, due to the risk of gestational hypertension and pre-eclampsia. Integration of hypertension and broader non-communicable disease (NCD) services is increasingly recommended and piloted in vertical HIV programs, though often complicated by challenges with facility preparedness. The goal of this dissertation was to examine the burden and patterns of hypertension, as well as related healthcare needs, among slum community residents and PLWH receiving standard HIV care services at a clinic serving large slum communities in Port-au-Prince, Haiti. Methods: This work utilizes cross-sectional primary data from a population-representative community survey (aim 1) and longitudinal secondary data from the electronic medical records of a local HIV clinic (aims 2 and 3), altogether spanning the period from 2007 to 2017. In aim 1, data from a multistage randomized survey were used to characterize the prevalence, correlates, and care continuum of hypertension among residents of four slum communities in Port-au-Prince. In aim 2, hypertension prevalence, incidence, and patterns following onset were examined among newly diagnosed with HIV patients initiating ART at a local HIV clinic. In aim 3, trends in the prevalence and incidence of gestational and chronic hypertension, and longitudinal blood pressure trajectories, were assessed among HIV-positive pregnant women with and without prior ART exposure in a prevention-of-maternal-to-child-transmission (PMTCT) program. Results: In aim 1, among adult slum community residents with a median age of 28 years, 20% screened positive for hypertension using a single-day blood pressure measurement, with overweight and obesity being the most common risk factor (21% among men and 49% among women), and a low prevalence of smoking (12% among men and 4% among women). Individual’s odds of hypertension rose with hypertension prevalence in immediate surroundings. Four out of ten persons with hypertension on the day of the survey had been previously told by a clinician that they had the condition, but fewer than one in ten reported receiving treatment. In aims 2 and 3, the gold standard two-day definition of hypertension was applied. In aim 2, among newly diagnosed with HIV persons with a median age of 37 years, and relatively low prevalence of overweight and obesity (16%), 12% of patients had hypertension at enrollment and among those initially hypertension-free, 19% developed hypertension within the first 18 months of HIV care and treatment. While patients with lowest enrollment CD4 counts (≤ 100 cells/µl) at enrollment had lower hypertension prevalence (8%), they were at a greater risk of hypertension incidence than patients with higher CD4 counts (15 versus 10 per 100 person-years of follow-up). Following onset, 44% of patients had hypertension on half or more of the subsequent measurements over a median of 24 months of follow-up. Patients with initial stage 1 hypertension and younger patients were less likely to maintain hypertensive status during follow-up. In aim 3, threefold increases in the rates of chronic and gestational hypertension were observed over time among pregnant women (median age of 29 years) enrolled in a PMTCT program between 2007 and 2016. In the most recent period, 2013-2016, 4% of pregnancies were affected by chronic hypertension and another 7% - by gestational hypertension. Increased duration of prior ART exposure was strongly associated with higher latent class model-derived trajectories of mean arterial pressure (MAP), a possible risk factor for pre-eclampsia. In multinomial regression, pregnancies among women with more than a year of prior ART had almost three times the adjusted odds of a higher MAP trajectory as pregnancies without prior ART exposure. Discussion: The findings highlight the potential for continued growth in the hypertension and CVD burden in Haiti, as well as unmet need for prevention, screening, and quality treatment services, among both the general urban population and among HIV patients specifically. In addition to secular trends in these conditions, the increase in cumulative exposure to ART might further fuel the rise in hypertension and CVD in settings with high prevalence of HIV, such as urban Haiti. Further research is needed into multimodal interventions and facility- and community-based long-term care models, increasingly for multimorbidity, among mobile urban slum community residents, with consideration of possible network effects. Quality of hypertension screening is also of importance, as white-coat and masked hypertension, as well as potential measurement error and natural blood pressure variability, may complicate the identification of true cases, in particular on the lower part of the age spectrum. Facility- and community-based programs have an opportunity to meaningfully improve individual and population health through expanding existing HIV services to encompass hypertension and broader NCD care, and through leveraging community health workers to reach families and networks in need of prevention, screening, and management services

The contribution of observational studies in supporting the WHO 'treat all' recommendation for HIV/AIDS.

In 2015, the World Health Organization (WHO) recommended that all people living with HIV (PLWH) should start antiretroviral therapy (ART) irrespective of clinical or immune status. This recommendation followed almost 20 years of research into the clinical and population-level benefits and risks of starting ART early compared with deferring treatment. This article summarises the ways in which observational data support the work of WHO, including the support provided by the International epidemiology Databases to Evaluate AIDS (IeDEA), taking the example of 'treat all'

Outcomes of HIV-positive patients lost to follow-up in African treatment programmes.

OBJECTIVE The retention of patients on antiretroviral therapy (ART) is key to achieving global targets in response to the HIV epidemic. Loss to follow-up (LTFU) can be substantial, with unknown outcomes for patients lost to ART programmes. We examined changes in outcomes of patients LTFU over calendar time, assessed associations with other study and programme characteristics and investigated the relative success of different tracing methods. METHODS We performed a systematic review and logistic random-effects meta-regression analysis of studies that traced adults or children who started ART and were LTFU in sub-Saharan African treatment programmes. The primary outcome was mortality, and secondary outcomes were undocumented transfer to another programme, treatment interruption and the success of tracing attempts. RESULTS We included 32 eligible studies from 12 countries in sub-Saharan Africa: 20 365 patients LTFU were traced, and 15 708 patients (77.1%) were found. Compared to telephone calls, tracing that included home visits increased the probability of success: the adjusted odds ratio (aOR) was 9.35 (95% confidence interval [CI] 1.85-47.31). The risk of death declined over calendar time (aOR per 1-year increase 0.86, 95% CI 0.78-0.95), whereas undocumented transfers (aOR 1.13, 95% CI 0.96-1.34) and treatment interruptions (aOR 1.31, 95% CI 1.18-1.45) tended to increase. Mortality was lower in urban than in rural areas (aOR 0.59, 95% CI 0.36-0.98), but there was no difference in mortality between adults and children. The CD4 cell count at the start of ART increased over time. CONCLUSIONS Mortality among HIV-positive patients who started ART in sub-Saharan Africa, were lost to programmes and were successfully traced has declined substantially during the scale-up of ART, probably driven by less severe immunodeficiency at the start of therapy

Mathematical modelling to inform 'treat all' implementation in sub-Saharan Africa: a scoping review

Despite widespread uptake, only half of sub-Saharan African countries have fully implemented the World Health Organization's 'treat all' policy, hindering achievement of global HIV targets. We examined literature on mathematical modelling studies that sought to inform scale-up and implementation of 'treat all' in sub-Saharan Africa

Psychosocial Factors Associated with Food Insufficiency Among People Living with HIV/AIDS (PLWH) Initiating ART in Ethiopia

Food insufficiency is associated with suboptimal HIV treatment outcomes. Less is known about psychosocial correlates of food insufficiency among PLWH. This sample includes 1176 adults initiating antiretroviral therapy at HIV clinics in Ethiopia. Logistic regression modeled the association of psychological distress, social support, and HIV-related stigma with food insufficiency. Among respondents, 21.4% reported frequent food insufficiency. Psychological distress [adjusted odds ratio (aOR) 2.61 (95% CI 1.79, 3.82)], low social support [aOR 2.20 (95% CI 1.57, 3.09)] and enacted stigma [aOR 1.69 (95% CI 1.26, 2.25)] were independently associated with food insufficiency. Food insufficiency interventions should address its accompanying psychosocial context

Estimated blood pressure trajectories and hypertension patterns among pregnant women living with HIV, Haiti, 2007–2017

Abstract Hypertension in pregnancy is a key driver of mortality and morbidity among Haitian women. HIV infection and treatment may worsen hypertension and increase cardiovascular disease risk. The authors examined blood pressure and hypertension patterns among 1965 women (2306 pregnancies ending in live births) in a prevention of maternal‐to‐child transmission (PMTCT) program in Port‐au‐Prince, Haiti, between 2007 and 2017. Hypertension was defined as blood pressure ≥140/90 mm Hg on two consecutive visits. Latent class analysis assessed trajectories of mean arterial pressure (MAP) and multinomial ordinal logistic regression examined factors associated with higher trajectories. Between 2007–2009 and 2013–2016, hypertension at PMTCT entry increased from 1.3% to 3.8% (p = .005), while incidence at any time during PMTCT follow‐up increased from 5.0 to 16.1 per 100 person‐years (p  20 weeks of gestation (possible gestational hypertension) increased from 1.1% to 3.5% (p = .003) and from 2.3% to 6.9% (p < .001), respectively. Five MAP trajectories ranged from low‐stable to high‐increasing. In multivariable analysis controlling for history of antiretroviral therapy, age, parity, and weight, program entry in more recent years was associated with greater odds of higher MAP trajectory (adjusted odds ratio for 2013–2016 vs. 2007–2009 = 3.1, 95% confidence interval: 1.7–5.6). The increasing prevalence and incidence of hypertension highlight a need for screening and management prior to PMTCT entry and during follow‐up. In a population with limited access to chronic disease care, and where many deliveries occur outside of a clinical setting, the period of PMTCT follow‐up represents an opportunity to diagnose and initiate management of preexisting and pregnancy‐related hypertension