A decade of HIV care in rural Tanzania: Trends in clinical outcomes and impact of clinic optimisation in an open, prospective cohort

Abstract

ObjectivesOur objectives were to describe trends in enrolment and clinical outcomes in the open, prospective Kilombero and Ulanga Antiretroviral Cohort (KIULARCO) in the Morogoro region of southern Tanzania, and identify strengths and areas for improvement in the care of HIV-positive individuals in rural Tanzania.MethodsWe included adults (≥15 years) and children (<15 years) enrolled in the cohort in 2005–2014. The cohort underwent significant changes from autumn 2012 to optimise care. We evaluated mortality and loss to follow-up (LTFU) using competing risks methods, ART usage, opportunistic infections (OI), co-infections and laboratory abnormalities.ResultsOverall, 7010 adults and 680 children were enrolled; enrolment peaked in 2008 but has increased steadily since 2011. Among adults (65% female; median age 37 [interquartile range 31–45] years), the proportion referred from hospital wards quadrupled in 2013–14 versus earlier years. 653 (9%) adults died and 2648 (38%) were LTFU; the five-year cumulative probabilities of death and LTFU were 10.3% and 44.0%, respectively. Among children, 69 (10%) died and 225 (33%) were LTFU. The corresponding five-year probabilities were 12.1% and 39.6%. Adult ART use (regardless of eligibility) increased from 5% in 2005 to 89% in 2014 (similarly among children), with 9% on second-line therapy in 2014 (17% of children). OI diagnoses increased over time; tuberculosis prevalence at enrolment quadrupled from 6% in 2011 to 26% in 2014. The proportion of newly-enrolled participants assessed for laboratory abnormalities peaked at nearly 100% in 2014 (from a minimum of 24%), yet abnormality prevalences remained fairly constant.ConclusionsIn this cohort, ART usage improved dramatically and is approaching targets of 90%. Improved screening led to increases in detection of OIs and laboratory abnormalities, suggesting that a large number of these co-morbidities previously went undetected and untreated. Further work will address the high LTFU rates and implications for mortality estimates, and the management and outcomes of co-morbidities.

Laboratory-Reflex Cryptococcal Antigen Screening Is Associated With a Survival Benefit in Tanzania

“…The CDCI is the first rural clinic accredited to be a care and treatment center for PLHIV in Tanzania, with >9,000 patients enrolled. Further KIULARCO cohort details are published [23,24].…”

“…Treatment adherence, failure and toxicity, IRIS and other clinical details were assessed, recorded, and captured in the electronic databases of the cohort [23,24]. Tuberculosis screening was performed in all individuals at baseline and during follow-up visits.…”

“…All data were extracted from the KIULARCO cohort databases [23,24]. Baseline was defined as the date of the first CrAg assessment.…”

Extrapulmonary tuberculosis in HIV-infected patients in rural Tanzania: The prospective Kilombero and Ulanga antiretroviral cohort

“…Within routine care, stable patients are assessed by a clinician 4 times per year. During clinical visits, information on demographics, clinical parameters, co-morbidities, prescription of cART and co-medications, adherence and laboratory monitoring are entered into a customized electronic clinical record system designed for subsequent scientific analysis (OpenMRS, http://openmrs.org) [19,20]. In 2012, the clinic integrated TB services and implemented systematic screening for TB with the World Health Organization (WHO) symptom screening tool and Xpert 1 MTB/RIF for patients with suspected TB (Cepheid, USA) [21][22][23][24].…”

Ultrasound in managing extrapulmonary tuberculosis: a randomized controlled two-center study

“…Francis Referral Hospital serves a rural population of about 1 million people as a referral center. It includes the Chronic Diseases Clinic of Ifakara (CDCI), which cares for over 4000 people living with HIV [11,12] and/ or tuberculosis [13]. Mwananyamala Regional Referral Hospital serves an urban population of Dar es Salaam and is a referral center for tuberculosis within the Kinondoni district.…”