Demographic characteristics and opportunistic diseases associated with attrition during preparation for antiretroviral therapy in primary health centres in Kibera, Kenya

Medecins sans Frontieres, Medical Department (Operational Research), Brussels Operational Center, Luxembourg, Luxembourg.
Tropical Medicine & International Health (Impact Factor: 2.33). 02/2011; 16(5):579-84. DOI: 10.1111/j.1365-3156.2011.02740.x
Source: PubMed


Using routine data from HIV-positive adult patients eligible for antiretroviral therapy (ART), we report on routinely collected demographic characteristics and opportunistic diseases associated with pre-ART attrition (deaths and loss to follow-up). Among 2471 ART eligible patients, enrolled between January 2005 and November 2008, 446(18%) were lost to attrition pre-ART. Adjusted risk factors significantly associated with pre-ART attrition included age <35years (Odds Ratio, OR 1.4, 95% Confidence Interval, CI 1.1-1.8), severe malnutrition (OR 1.5, 95% CI 1.1-2.0), active pulmonary tuberculosis (OR 1.6, 95% CI 1.1-2.4), severe bacterial infections including severe bacterial pneumonia (OR 1.9, 95% CI 1.2-2.8) and prolonged unexplained fever (>1month), (OR 2.6, 95% CI 1.3-5.2). This study highlights a number of clinical markers associated with pre-ART attrition that could serve as 'pointers' or screening tools to identify patients who merit fast-tracking onto ART and/or closer clinical attention and follow-up.

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    • "Timely initiation of ART in patients enrolling for care has implications for early mortality, loss to follow-up, and other outcomes during subsequent follow-ups. Delays in initiation of ART could be due to health system, or patient-related factors, including pre-ART attrition and system-mandated delays to allow for appropriate pretreatment counseling [35, 36]. These delays were associated with excess rates of preventable morbidity and mortality, especially in ART-eligible patients with advanced HIV disease who are already at elevated risk of death. "
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    ABSTRACT: Background. Decentralization of antiretroviral therapy (ART) services is a key strategy to achieving universal access to treatment for people living with HIV/AIDS. Our objective was to assess clinical and laboratory outcomes within a decentralized program in Nigeria. Methods. Using a tiered hub-and-spoke model to decentralize services, a tertiary hospital scaled down services to 13 secondary-level hospitals using national and program guidelines. We obtained sociodemographic, clinical, and immunovirologic data on previously antiretroviral drug nave patients aged ≥15 years that received HAART for at least 6 months and compared treatment outcomes between the prime and satellite sites. Results. Out of 7,747 patients, 3729 (48.1%) were enrolled at the satellites while on HAART, prime site patients achieved better immune reconstitution based on CD4+ cell counts at 12 (íµí±ƒ < 0.001) and 24 weeks (íµí±ƒ < 0.001) with similar responses at 48 weeks (íµí±ƒ = 0.11) and higher rates of viral suppression (<400 c/mL) at 12 (íµí±ƒ < 0.001) and 48 weeks (íµí±ƒ = 0.03), but similar responses at 24 weeks (íµí±ƒ = 0.21). Mortality was 2.3% versus 5.0% (íµí±ƒ < 0.001) at prime and satellite sites, while transfer rate was 8.7% versus 5.5% (íµí±ƒ = 0.001) at prime and satellites. Conclusion. ART decentralization is feasible in resource-limited settings, but efforts have to be intensified to maintain good quality of care.
    AIDS research and treatment 06/2014; 2014. DOI:10.1155/2014/560623
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    • "The design of some studies may explain why the proportion of patients with a CD4 cell count differed (Larson et al. 2010b; Kohler et al. 2011; Pepper et al. 2011). Larson et al. distinguished between measured and completed CD4 cell count testing: 84.6% of the HIV positive patients had a CD4 cell count measured but only 53.1% of the eligible, and 45.7% of the not yet eligible ART eligible patients Loss to programme ART ineligible patients Loss to follow-up Mortality Overall with estimated prediction interval Tayler-Smith 2010 Murphy 2010 Lawn 2006 Zachariah 2011 Pepper 2011 Mc Grath 2010 Bassett 2009 Togun 2011 Ingle 2010 Amuron 2009 Tayler-Smith 2011 24.57 (18.81, 30.33) 24.52 (21.44, 27.90) 26.53 (16.07, 40.51) 15.47 (13.55, 17.59) 20.78 (20.14, 21.44) 40.54 (31.82, 49.90) 13.90 (11.42, 16.82) 16.97 (13.93, 20.51) 35.44 (32.18, 38.84) 35.79 (35.16, 36.43) "
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    ABSTRACT: Objectives  To assess the proportion of patients lost to programme (died, lost to follow-up, transferred out) between HIV diagnosis and start of antiretroviral therapy (ART) in sub-Saharan Africa, and determine factors associated with loss to programme. Methods  Systematic review and meta-analysis. We searched PubMed and EMBASE databases for studies in adults. Outcomes were the percentage of patients dying before starting ART, the percentage lost to follow-up, the percentage with a CD4 cell count, the distribution of first CD4 counts and the percentage of eligible patients starting ART. Data were combined using random-effects meta-analysis. Results  Twenty-nine studies from sub-Saharan Africa including 148 912 patients were analysed. Six studies covered the whole period from HIV diagnosis to ART start. Meta-analysis of these studies showed that of the 100 patients with a positive HIV test, 72 (95% CI 60-84) had a CD4 cell count measured, 40 (95% CI 26-55) were eligible for ART and 25 (95% CI 13-37) started ART. There was substantial heterogeneity between studies (P < 0.0001). Median CD4 cell count at presentation ranged from 154 to 274 cells/μl. Patients eligible for ART were less likely to become lost to programme (25%vs. 54%, P < 0.0001), but eligible patients were more likely to die (11%vs. 5%, P < 0.0001) than ineligible patients. Loss to programme was higher in men, in patients with low CD4 cell counts and low socio-economic status and in recent time periods. Conclusions  Monitoring and care in the pre-ART time period need improvement, with greater emphasis on patients not yet eligible for ART.
    Tropical Medicine & International Health 09/2012; 17(12). DOI:10.1111/j.1365-3156.2012.03089.x · 2.33 Impact Factor
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    ABSTRACT: To determine rates and predictors of treatment refusal in newly identified HIV-infected individuals in Soweto, South Africa. It is designed as a cross-sectional study. We analyzed data from adult clients (>18 years) presenting for voluntary counseling and testing (VCT) at the Zazi Testing Center, Perinatal HIV Research Unit to determine rates of antiretroviral therapy (ART) refusal among treatment-eligible, HIV-infected individuals (CD4(+) cell count < 200 cells/μl or WHO stage 4). Multiple logistic regression models were used to investigate factors associated with refusal. From December 2008 to December 2009, 7287 adult clients were HIV tested after counseling. Two thousand, five hundred and sixty-two (35%) were HIV-infected, of whom 743 (29%) were eligible for immediate ART. One hundred and forty-eight (20%) refused referral to initiate ART, most of whom (92%) continued to refuse after 2 months of counseling. The leading reason for ART refusal was given as 'feeling healthy' (37%), despite clients having a median CD4(+) cell count of 110 cells/μl and triple the rate of active tuberculosis as seen in nonrefusers. In adjusted models, single clients [adjusted odds ratio (AOR) 1.80, 95% confidence interval (CI) 1.06-3.06] and those with active tuberculosis (AOR 3.50, 95% CI 1.55-6.61) were more likely to refuse ART. Nearly one in five treatment-eligible HIV-infected individuals in Soweto refused to initiate ART after VCT, putting them at higher risk for early mortality. 'Feeling healthy' was given as the most common reason to refuse ART, despite a suppressed CD4(+) count and comorbidities such as tuberculosis. These findings highlight the urgent need for research to inform interventions targeting ART refusers.
    AIDS (London, England) 08/2011; 25(17):2177-81. DOI:10.1097/QAD.0b013e32834b6464 · 5.55 Impact Factor
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