Background: Many view attrition as one of the biggest barriers to effective delivery of cART in resource-limited settings in sub-Saharan Africa (SSA). In this study, our objective was to describe the incidence and predictors of attrition among adults enrolled in cART programs in two referral hospitals in the northern coastal areas of Eritrea. Methods: This was a retrospective review of patient records of 464 patients [Male: 149(35.6%) vs. Females: 269(64.4%)] aged 18 years who initiated cART between 2005 and 2021. The main outcome measures were attrition (loss-to-follow-up (LTFU) plus mortality) and associated outcomes. Kaplan-Meier statistics were used to evaluate survival probability of attrition. Independent predictors of attrition were evaluated using a multivariable Cox proportional hazard model. Results: A total of 418 patients [Male: 149(35.6%) vs. Female: 269 (64.4%)] were studied. At baseline, the mean (±SD) age (SD) was 34(±11.2) years; median (±IQR) CD4 T-cell count was 151 (IQR: 87-257) cells/µL. After a follow-up time of 39,883 months, 127 ((30.4%), 95% CI [26-35]) attrition events were reported, translating into a cumulative incidence of 2.9/1000(2.4-3.5) per 1,000 people-months (PMs) were reported. During the same period, 97 (23.11%) patients died, 32(7.7%) were LTFU, and 47(11.2%) transferred out. In the adjusted multivariate Cox regression model, an increased risk of attrition was associated with the year of enrollment (aHR = 1.07, 95% CI 1.00-1.15, p-value = 0.04); ethnicity (Afar: aHR=3.21, 95% CI: 1.84-5.59, p value < 0.001) (Others: aHR = 2.67, 95% CI: 1.14-6.25, p value = 0.024) and cART backbone: (TDF+FTC: aHR=2, 95% CI: 1.21-3.32, p value = 0.007). On the contrary, the risk of attrition decreased per unit increase in baseline CD4 T-cells/μL (uHR=0.998, 95% CI 0.996-0.999, p-value<0.001). Conclusion: Despite expanded treatment and decentralization of cART programs, mortality due to advanced disease at enrollment remains high in peripheral settings. A concerted effort is required to reduce late enrollment and improve the management of patients with advanced disease in decentralized programs.
Background Information on treatment failure (TF) in People living with HIV in a data-poor setting is necessary to counter the epidemic of TF with first-line combined antiretroviral therapies (cART) in sub-Saharan Africa (SSA). In this study, we examined the risk factors associated with TF in Asmara, Eritrea from 2001 to 2020. Methods A multicenter, retrospective 1:2 matched (by age and gender) case–control study was conducted in four major hospitals in Asmara, Eritrea on adults aged ≥ 18 years who were on treatment for at least 6 months. Cases were patients who fulfills at least one of the WHO therapy failure criterion during the study period. Controls were randomly selected patients on first-line treatment and plasma viral load < 1000 copies/ml in their latest follow-up measurement. Multivariable logistic regression analysis was conducted to identify risk factors for TF. All P-values were 2-sided and the level of significance was set at P < 0.05 for all analyses. Results Of the 1068 participants (356 cases; 712 controls), 585 (54.7%) were females. The median age at treatment initiation was 46 years [interquartile range (IQR): 39–51]. Median time to combined antiretroviral therapy (cART) failure was 37 months (IQR = 24–47). In the multivariate analysis, factors associated with increased likelihood of TF included initial nucleoside reverse transcriptase inhibitors (NRTI) backbone (Zidovudine + Lamivudine (AZT + 3TC): adjusted odds ratio (aOR) = 2.70, 95% Confidence interval (CI): 1.65–4.41, P-value < 0.001), (Abacavir + lamivudine (ABC + 3TC): aOR = 4.73, 95%CI: 1.18–18.92, P-value = 0.028], and (Stavudine + Lamivudine (D4T + 3TC): aOR = 5.00; 95% CI: 3.03–8.20, P-value < 0.001) in comparison to Emtricitabine and Tenofovir diproxil fumarate (FTC + TDF). Additional associations included prior exposure to cART (aOR = 2.28, 95%CI: 1.35–3.86; P- value = 0.002), record of sub-optimal drug adherence (aOR = 3.08, 95%CI: 2.22–4.28; P < 0.001), ambulatory/bedridden at presentation (aOR = 1.61, 95%CI: 1.12–4.28; P-value = 0.010), presence of comorbidities (aOR = 2.37; 95%CI: 1.36–4.10, P-value = 0.002), duration of cART (< 5 years: aOR: 5.90; 95% CI: 3.95–8.73, P-value < 0.001), and use of SMX-TMP prophylaxis (aOR = 2.00, 95%CI, 1.44–2.78, P-value < 0.001). Conclusion Our findings underscore the importance of optimizing cART adherence, diversification of cART regimens, and interventions directed at enhancing early HIV diagnosis, prompt initiations of treatment, and improved patient-focused monitoring of treatment response.
Background Information on treatment failure (TF) in People living with HIV in data-poor jurisdictions is necessary to counter the rapidly escalating epidemic of TF to first-line combined anti-retroviral therapies (cART) in sub-Saharan Africa (SSA). In this study, we examined the risk factors associated with TF in Asmara, Eritrea.Methods: A multicenter, retrospective 1:2 matched (by age and gender) case-control study was conducted in four major hospitals in Asmara, Eritrea on adults aged >15 years who were on treatment for at least 6 months. Cases were patients with viral load ≥1000 copies/mL anytime between 2019-2021 and/or patients switched to second line cART. Controls were randomly selected from patients on first-line ART with viral load < 1000 copies/mL. Data was extracted using a checklist from the master data set and analyzed using SPSS version 26. Multivariable logistic regression analysis was conducted to identify risk factors for TF. All p-values were 2-sided and the level of significance was set at p < 0.05 for all analyses.Results: Of the 1068 participants, 585 (54.7%) were females. The median age at treatment initiation was 46 years (interquartile range (IQR): 39–51). Median time to combined antiretroviral therapy (cART) failure was 37 months (IQR =24–47). In multivariate analysis factors associated with increased likelihood of virologic failure (VF) were the type of initially used nucleoside reverse transcriptase inhibitors (NRTI) backbone ( (Zidovudine+Lamivudine (AZT+3TC): adjusted odds ratio (aOR): 2.70; 95% Confidence interval (CI): 1.65-4.41, p-value<0.001), (Abacavir+lamivudine (ABC+3TC): aOR: 4.73; 95%CI: 1.18-18.92, p-value=0.028), and (Stavudine+Lamivudine (D4T+3TC): aOR: 5.00; 95% CI: 3.03-8.20, p-value<0.001), prior exposure to ART (aOR: 2.28; 95%CI:1.35–3.86; p=0.002), record of sub-optimal drug adherence (aOR: 3.08; 95%CI: 2.22–4.28; p<0.001), ambulatory/bedridden at presentation (aOR:1.61; 95%CI: 1.12-4.28; p-value=0.010), presence of comorbidities (aOR: 2.37; 95%CI: 1.36-4.10, p-value=0.002), duration of cART (<5 years: aOR: 5.90; 95% CI: 3.95-8.73, p-value<0.001), and use of SMX-TMP prophylaxis ( aOR : 2.00, 95%CI, 1.44-2.78, p-value<0.001). Conclusion: Our findings underscore the importance of optimizing cART adherence, diversification of cART regimens, and interventions directed at enhancing early HIV diagnosis, prompt initiations of treatment and improved patient focused monitoring of treatment response.
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