Patients present earlier and survival has improved, but pre-ART attrition is high in a six-year HIV cohort data from Ethiopia

Background Previous studies showed higher early mortality rates among patients treated with antiretroviral drugs in settings with limited resources. One of the reasons was late presentation of patients to care. With improved access to HIV services, we expect improvements in disease stage at presentation. Our objective was to assess the effect of improved availability of HIV services on patient presentation to care and subsequent pre-ART and on-ART outcomes. Methodology and Principal Findings At Arba Minch Hospital in Ethiopia, we reviewed baseline characteristics and outcomes of 2191 adult HIV patients. Nearly a half were in WHO stage III at presentation. About two-thirds of the patients (1428) started ART. Patients enrolled in the early phase (OR = 4.03, 95% CI 3.07–5.27), men (OR = 1.78, 95%CI 1.47–2.16), and those aged 45 years and above (OR = 2.04, 95%CI 1.48–2.82) were at higher risk of being in advanced clinical stage at presentation. The pre-treatment mortality rate was 13.1 per 100 PYO, ranging from 1.4 in the rapid scale-up phase to 25.9 per 100 PYO in the early phase. A quarter of the patients were lost to follow-up before starting treatment. Being in less advanced stage (HR = 1.9, 95% CI = 1.6, 2.2), being in the recent cohort (HR = 2.0, 95% CI = 1.6, 2.6), and rural residence (HR = 1.8, 95% CI = 1.5, 2.2) were independent predictors of pre-ART loss to follow-up. Of those who started ART, 13.4% were lost to follow-up and 15.4% died. The survival improved during the study. Patients with advanced disease, men and older people had higher death rates. Conclusions and Significance Patients started to present at earlier stages of their illness and death has decreased among adult HIV patients visiting Arba Minch Hospital. However, many patients were lost from pre-treatment follow-up. Early treatment start contributed to improved survival. Both pre-ART and on-ART patient retention mechanisms should be strengthened

Pre-ART retention in care and prevalence of tuberculosis among HIV-infected children at a district hospital in southern Ethiopia

Background: The Ethiopian epidemic is currently on the wane. However, the situation for infected children is in some ways lagging behind due to low treatment coverage and deficient prevention of mother-to-child transmission. Too few studies have examined HIV infected children presenting to care in low-income countries in general. Considering the presence of local variations in the nature of the epidemic a study in Ethiopia could be of special value for the continuing fight against HIV. The aim of this study is to describe the main characteristics of children with HIV presenting to care at a district hospital in a resource-limited area in southern Ethiopia. The aim was also to analyse factors affecting pre-ART loss to follow-up, time to ART-initiation and disease stage upon presentation. Methods: This was a prospective cohort study. The data analysed were collected in 2009 for the period January 2003 through December 2008 at Arba Minch Hospital and additional data on the ART-need in the region were obtained from official reports. Results: The pre-ART loss to follow-up rate was 29.7%. Older children (10–14 years) presented in a later stage of their disease than younger children (76.9% vs. 45.0% in 0–4 year olds, chi-square test, χ2 = 8.8, P = 0.01). Older girls presented later than boys (100.0% vs. 57.1%, Fisher’s exact test, P = 0.02). Children aged 0–4 years were more likely to be lost to follow-up (40.0 vs. 21.8%, chi-square test, χ2 = 5.4, P = 0.02) and had a longer time to initiate ART (Cox regression analysis, HR: 0.50, 95% CI: 0.25-0.97, P = 0.04, controlling for sex, place of residence, enrolment phase and WHO clinical stage upon presentation). Neither sex was overrepresented in the sample. Tuberculosis prevalence upon presentation and previous history of tubercolosis were 14.5% and 8% respectively. Conclusions: The loss to follow-up is alarmingly high and children present too late. Further research is needed to explore specific causes and possible solutions

Kaplan –Meier (3 A) and Cox-proportional hazard's (3 B) survival plots according to the three periods of ART initiation, Arba Minch Hospital, 2010.

<p>Kaplan –Meier (3 A) and Cox-proportional hazard's (3 B) survival plots according to the three periods of ART initiation, Arba Minch Hospital, 2010.</p

Baseline characteristics of all treatment-naïve adult patients at enrollment, Arba Minch Hospital, 2010.

<p>Baseline characteristics of all treatment-naïve adult patients at enrollment, Arba Minch Hospital, 2010.</p

Survival curve according to Cox regression analysis after adjusting for disease stage, age and place of residence, Arba Minch Hospital, 2010

<p>. At about 48 weeks of pre-ART follow-up, about 25% of patients in the ‘early phase’ were not alive (See 2A). On the other hand, over 95% of those in the ‘rapid scale-up’ phase were alive at 48 weeks. Pre-ART loss to follow-up was less in the ‘early phase’ (See 2B).</p

Hazard ratio (HR) for death among patients on antiretroviral treatment at Arba Minch Hospital, 2010.

<p>CI =  Confidence Interval, HR =  Hazard ratio, PYO =  Person Years of Observation.</p

Hazard ratio (HR) for lost to follow up among patients on antiretroviral treatment at Arba Minch Hospital, 2010.

<p>CI =  Confidence Interval, HR =  Hazard ratio, Person Years of Observation.</p

Cohort profile, Arba Minch Hospital, 2010.

<p>Of 2391 patients enrolled for care, 2191 were eligible for analysis. At the end of the pre-ART follow-up period, 25% were not in care.</p

WHO clinical stage at start of antiretroviral treatment at Arba Minch Hospital, 2010.

<p>Chi–square for trend (X² = 83.3; df  = 1; P<0.001).</p