Incorporating Loss to Follow-up in Estimates of Survival Among HIV-Infected Individuals in Sub-Saharan Africa Enrolled in Antiretroviral Therapy Programs

ArticleinThe Journal of Infectious Diseases 207(1) · October 2012with7 Reads
DOI: 10.1093/infdis/jis635 · Source: PubMed
Background: Measuring the survival of human immunodeficiency virus-infected adult patients enrolled in antiretroviral therapy (ART) programs is complicated by short observation periods and loss to follow-up. We synthesized data from treatment cohorts in sub-Saharan Africa to estimate survival over 5 years after initiation of ART. Methods: We used data on retention, mortality, and loss to follow-up from 34 cohorts, including a total of 102,306 adult patients from 18 sub-Saharan African countries. These data were augmented by data from 13 sub-Saharan African studies tracking death rates among adult patients who were lost to follow-up (LTFU). We used a Poisson regression model to estimate survival over time, incorporating predicted mortality among LTFU patients. Results: Across studies, the median CD4(+) cell count at ART initiation was 104 cells/mm(3), 65% of patients were female, and the median age was 37 years. Survival at 1 year and 5 years were estimated to be 0.87 (95% confidence interval [CI], 0.72-0.94) and 0.70 (95% CI, 0.36-0.86), respectively, after adjustment for loss to follow-up. The life-years gained by a patient during the 5-year period after starting ART were estimated at 2.1 (95% CI, 1.6-2.3) in the adjusted model, compared with 1.7 (95% CI, 1.1-2.0) if there was 100% mortality among LTFU patients and with 2.4 (1.7-2.7) if there was 0% mortality among LTFU patients. Conclusions: Accounting for loss to follow-up produces substantial changes in the estimated life-years gained during the first 5 years of ART receipt.
    • "Another issue that requires proper attention when analyzing cohort data is when patients are lost to follow-up. A recent study examining the effect of lost to follow-up among HIV-infected individuals showed that estimated survival with and without adjustment of mortality amongst those lost to follow-up can lead to overestimation of the treatment effect by as much as 40% [41]. Despite the rich information contained in cohort registration, maintenance of the system can be costly. "
    [Show abstract] [Hide abstract] ABSTRACT: A major challenge in monitoring universal health coverage (UHC) is identifying an indicator that can adequately capture the multiple components underlying the UHC initiative. Effective coverage, which unites individual and intervention characteristics into a single metric, offers a direct and flexible means to measure health system performance at different levels. We view effective coverage as a relevant and actionable metric for tracking progress towards achieving UHC. In this paper, we review the concept of effective coverage and delineate the three components of the metric - need, use, and quality - using several examples. Further, we explain how the metric can be used for monitoring interventions at both local and global levels. We also discuss the ways that current health information systems can support generating estimates of effective coverage. We conclude by recognizing some of the challenges associated with producing estimates of effective coverage. Despite these challenges, effective coverage is a powerful metric that can provide a more nuanced understanding of whether, and how well, a health system is delivering services to its populations.
    Full-text · Article · Sep 2014
    • "Using information collected from cohort studies in West Africa, Cote d'Ivoire, and Burkina Faso, Lewden et al. [44] reported that the highest estimates of mortality were seen in cohorts with the lowest rates of loss to follow-up. Verguet et al. [45] subsequently reported that whereas the best estimate of life years gained by a person in Africa in the first 5 years after starting cART was 2.1 [45], this estimate could drop by approximately 14% if mortality rates among those lost to follow-up were assumed to be 100%, or could increase by 19% if zero mortality was assumed in this group. In cohorts participating in the ART-CC, incomplete death ascertainment was reported to contribute to the higher mortality rates seen in the North American compared with European cohorts, although other patient factors also played a role [46]. "
    [Show abstract] [Hide abstract] ABSTRACT: There is evidence that the life expectancy (LE) of individuals infected with the human immunodeficiency virus (HIV) has increased since the introduction of combination antiretroviral therapy (cART). However, mortality rates in recent years in HIV-positive individuals appear to have remained higher than would be expected based on rates seen in the general population. A low CD4 count, whether due to late HIV diagnosis, late initiation of cART, or incomplete adherence to cART, remains the dominant predictor of LE, and thus the individual's disease stage at initiation of cART (or thereafter) certainly contributes to these higher mortality rates. However, individuals with HIV also tend to exhibit lifestyles and behaviors that place them at increased risk of mortality, particularly from non-AIDS causes. Thus, although mortality rates among the HIV population may indeed remain slightly higher than those seen in the general population, they may be no higher than those seen in a more appropriately matched control group. Thus, further improvements in LE may now only be possible if some of the other underlying issues (for example, modification of lifestyle or behavioral factors) are tackled.
    Article · Nov 2013
    • "About 25 million people are living with HIV-infection in Africa, of whom approximately seven million are on antiretroviral therapy [1]. Various studies, including systematic reviews, have described the challenges of retaining patients on antiretroviral therapy programmes but the evidence-base on adherence to therapy remains weak [2-6]. "
    [Show abstract] [Hide abstract] ABSTRACT: We report on the adherence experience of a group of people living with HIV on ART over six years in Uganda. Between 2005 and 2009, we followed up 41 participants who were also part of a clinical trial comparing home and facility based delivery of ART in Jinja, eastern Uganda. We conducted qualitative in-depth interviews at enrolment, 3, 6, 18 and 30 months to capture experiences with adherence over time. In 2011 we returned to these participants to find out how they were fairing with long term adherence. We managed to retrace 24 participants and interviewed them about their experience. We thematically analysed the data and compared findings over time. Initially there were few barriers to adherence and many followed the adherence guidance closely. By year six, relaxation of these rules was noticeable although self-reported adherence continued to be high. Alcohol consumption was more common than before. Some relatives of the participants who had died claimed that some deaths were a result of alcohol. While participants reported that ART had allowed them to reclaim independence and return to work the changes in work and social routines created new challenges for adherence. Side effects like lipodystrophy were not only causing some stigma but for some tested their faith in the drugs. Many participants reported resumption of sexual lives but apart from those who selected same status partners, disclosure to new partners was minimal. Good adherence practice to ART wanes over the long-term, and people who may have disclosed at initiation find it difficult to do so to new partners once they are healthy. Further adherence interventions and support with disclosure over the course of therapy may need to be considered. (Words: 283).
    Full-text · Article · Oct 2013
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