Characteristics and clinical outcomes of patients presenting with advanced HIV disease in the “treat all” era: a retrospective cohort study from rural Rwanda

Abstract

Background In 2016 Rwanda adopted “treat all” where all patients with HIV are immediately eligible for ART regardless of disease progression. Despite widespread availability of treatment, it is unknown whether presentation with advanced HIV persists. Methods We conducted a retrospective cohort among patients aged ≥ 15 who enrolled in care between July 2016 and July 2018 in three rural Rwandan districts. We estimated the prevalence of advanced HIV, defined as presenting with CD4 count < 200 cells/mm3 or WHO stage 3 or 4, and compared baseline characteristics of patients with and without advanced HIV. We compared cumulative incidences and time to events using Chi squared tests and Cox proportional hazards models, respectively, for (a) viral load tests; (b) viral suppression; (c) death; and (d) treatment failure (a composite of death, lost to follow up, or virologic failure). Results Among 957 patients, 105 (11.0%) presented with advanced HIV. These patients were significantly more likely to have low body mass index, come from Burera district, be older, and be identified through inpatient settings rather than through voluntary or prenatal testing. Patients with advanced HIV had significantly higher risks of death at 12-months (9.5% vs 1.5%, p < 0.001) and 18-months (10.5% vs 1.9%, p < 0.001) and significantly higher risk of treatment failure at 12-months (21.9% vs. 14.2%, p = 0.037). After adjusting for confounders, patients with advanced HIV had still higher rates of death (adjusted Hazard ratio [aHR] = 4.4, 95% CI: 1.9, 10.2, p < 0.001) and treatment failure (aHR = 1.7, 95% CI: 1.1, 2.5, p = 0.017), but no difference in viral load testing (aHR = 1.1, 95% CI: 0.8, 1.5, p = 0.442) or viral suppression (aHR = 1.0, 95% CI: 0.8, 1.4, p = 0.949). When allowing for the hazard ratio to vary over time, patients with advanced HIV experienced elevated rates of treatment failure in the first six of enrollment, but not after nine months. Conclusion Presenting with advanced HIV remains common and is still associated with poor patient outcomes. Sensitization of the community to the benefits of early ART initiation, identification of patients with advanced HIV, and holistic support programs for the first 6 months of treatment may be needed to improve outcomes.

Understanding health systems challenges in providing Advanced HIV Disease (AHD) care in a hub and spoke model: a qualitative analysis to improve AHD care program in Malawi

“…Frank et al [ 12 ] and Gupta et al [ 13 ] echoed similar success stories in different regions, highlighting the consistent feasibility and acceptability of enhanced care packages in diverse healthcare settings. Additionally, studies conducted by Thurman et al [ 14 ] and Musengimana et al [ 15 ] not only reiterated the feasibility but also emphasized the significant impact of these packages in improving patient outcomes, reinforcing the importance of their implementation in combating the AIDS epidemic.…”

Rapid antiretroviral therapy initiation in patients with advanced HIV disease: 6-month outcomes of an observational cohort evaluation in Lesotho

“…The REALITY trial that included patients starting ART with a CD4 count <100 cell/mm 3 , reported a mortality of 12.2% at 24 weeks and 14.4% at 48 weeks among patients who received standard prophylaxis [ 9 ]. More recently, 9.5% mortality at 12 months of follow-up was reported in a Rwandan cohort of patients with AHD [ 19 ]. In our study, most of the participants who died were diagnosed with active tuberculosis.…”