Delayed Antiretroviral Therapy (ART) Initiation among Hospitalized Adults in a Resource-Limited Settings: A Challenge to the Global Target of ART for 90% of HIV-Infected Individuals

Abstract

Background. Combination antiretroviral therapy (cART) initiation in hospital settings, where individuals often present with undiagnosed, untreated, advanced HIV disease, is not well understood. Methods. A cross-sectional study was conducted to determine a period prevalence of cART initiation within two weeks of eligibility, as determined at hospitalization. Using a pretested and precoded data extraction tool, data on cART initiation status and reason for not initiating cART was collected. Phone calls were made to patients that had left the hospital by the end of the two-week period. Delayed cART initiation was defined as failure to initiate cART within two weeks. Sociodemographic characteristics, WHO clinical stage, CD4 count, cART initiation status, and reasons for delayed cART initiation were extracted and analyzed. Results. Overall, 386 HIV-infected adults were enrolled, of whom 289/386 (74.9%) had delayed cART initiation, 77/386 (19.9%) initiated cART, and 20/386 (5.2%) were lost-to-follow-up, within two weeks of cART eligibility. Of 289 with delayed ART initiation, 94 (32.5%) died within two weeks of cART eligibility. Patients with a CD4 cell count≥ 50 cells/μl and who resided in ≥8 kilometers from the hospital were more likely to have delayed cART initiation [adjusted odds ratio (AOR) 2.34, 95% CI: 1.33-4.10, p value 0.003; and AOR 1.92, 95% CI: 1.09-3.40, p value 0.025; respectively]. Conclusion. Up to 75% of hospitalized HIV-infected, cART-naïve, cART-eligible patients did not initiate cART and had a 33% pre-ART mortality rate within two weeks of eligibility for cART. Hospital based strategies to hasten cART initiation during hospitalization and electronic patient tracking systems could promote active linkage to HIV treatment programs, to prevent HIV/AIDS-associated mortality in resource-limited settings.

Effect of the Test and Treat Strategy on Mortality Among HIV-Positive Adult Clients on Antiretroviral Treatment in Public Hospitals of Addis Ababa, Ethiopia

“…The current study demonstrated poor adherence is also a significant predictor of mortality. Our result is consistent with the results of studies done in Debre Markos, 21 in southwest Ethiopia 23 and in Uganda 15 , 16 which may be explained by the fact that clients who have poor adherence are at risk of developing resistance to medication and lastly treatment failure which can lead to mortality if it does not detect early.…”

“…It might be since during the time before the test and treat the clients were not eligible for treatment until they have advanced disease and low CD4, so that they may have not responded well to treatment which results in the death of many clients due to immune reconstitution syndrome IRIS. 16,17 The effect of the test and treat strategy found by this study is in line with the studies done in the Gurage zone in Ethiopia 18 and South Africa, 1 but in a study done in Nigeria, the mortality rate after implementation of test and treat was 2%, 17 which was much less than our finding 13.4%. This may happen despite the implementation of the test and treat strategy because clients are still presenting for care and treatment late as evidenced by 22% of clients in the test and treat cohort who presented with CD4 lower than 200cells/cubic mm and 28% who presented with WHO stages III and IV at baseline.…”

“…This may be because these clients are highly immunecompromised and prone to other opportunistic infections, and this is in line with the studies done in Uganda, central Tigray, and Debre Markos. 15,16,21 However, clients without CD4 count records were considerably different between the two groups, variation has not been noted in sensitivity analysis after excluding cases with missing CD4 count. Thus, the result we have reported is robust.…”

“…It might be since during the time before the test and treat the clients were not eligible for treatment until they have advanced disease and low CD4, so that they may have not responded well to treatment which results in the death of many clients due to immune reconstitution syndrome IRIS. 16 , 17 …”

Prevalence of Opportunistic Infections and Associated Factors Among HIV-infected Patients on Antiretroviral Therapy in Eastern Zone of Tigray, Ethiopia:A Cross-sectional Study

“…However, about 75% of HIV-infected patients delayed ART initiation and had 33% pre-ART mortality rate because of HIV-related OIs [15]. Different studies done in Sub-Saharan Africa showed that still there is a high prevalence of OIs among HIV-infected patients taking ART [16,17].…”