Patients Present Earlier and Survival Has Improved, but Pre-ART Attrition Is High in a Six-Year HIV Cohort Data from Ethiopia

Mulissa, Zewdie; Jerene, Degu; Lindtjørn, Bernt

doi:10.1371/journal.pone.0013268

Cited by 102 publications

(121 citation statements)

References 21 publications

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“…In studies specifically looking at sub-Saharan Africa, most data originate from South Africa, where this trend has also been noted [20,21]. The South African national AIDS programme found a significant increase in median baseline CD4 counts [23].…”

Section: Discussionmentioning

confidence: 91%

Earlier initiation of antiretroviral therapy, increased tuberculosis case finding and reduced mortality in a setting of improved HIV care: a retrospective cohort study

et al. 2012

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ObjectivesHigh early mortality after antiretroviral therapy (ART) initiation in resource-limited settings is associated with low baseline CD4 cell counts and a high burden of opportunistic infections. Our large urban HIV clinic in Uganda has made concerted efforts to initiate ART at higher CD4 cell counts and to improve diagnosis and care of patients coinfected with tuberculosis (TB). We sought to determine associated treatment outcomes. MethodsRoutinely collected data for all patients who initiated ART from 2005 to 2009 were analysed. Median baseline CD4 cell counts by year of ART initiation were compared using the Cuzick test for trend. Mortality and TB incidence rates in the first year of ART were computed. Hazard ratios (HRs) were calculated using multivariable Cox proportional hazards models. ResultsFirst-line ART was initiated in 7659 patients; 64% were women, and the mean age was 37 years (standard deviation 9 years). Median baseline CD4 counts increased from 2005 to 2009 [82 cells/mL (interquartile range (IQR) 24, 153) to 148 cells/mL (IQR 61, 197), respectively; P < 0.001]. The mortality rate fell from 6.5/100 person-years at risk (PYAR) [95% confidence interval (CI) 5.5-7.6 PYAR] to 3.6/100 PYAR (95% CI 2.2-5.8 PYAR). TB incidence rates increased from 8.2/100 PYAR (95% CI 7.1-9.5 PYAR) to 15.6/100 PYAR (95% CI 12. . A later year of ART initiation was independently associated with decreased mortality (HR 0.91; 95% CI 0.83-1.00; P = 0.04). ConclusionsBaseline CD4 cell counts have increased over time and are associated with decreased mortality. Additional reductions in mortality might be a result of a better standard of care and increased TB case finding. Further efforts to initiate ART earlier should be prioritized even in a setting of capped or reduced funding for ART programmes.Keywords: antiretroviral therapy, baseline CD4 cell count, mortality, resource-limited setting, tuberculosis Accepted 25 October 2011 IntroductionThe use of antiretroviral therapy (ART) decreases mortality in HIV-infected individuals [1,2]. In recent years, increasing evidence from resource-rich and resource-limited settings has been published to support initiation of ART at higher baseline CD4+T cell (CD4) count to decrease mortality and morbidity even further [3][4][5][6][7]. ART guidelines both in industrialized countries and in resource-limited settings reflect these data [8] CD4 cell counts at ART initiation are often lower in resource-limited settings compared with industrialized countries, and are associated with higher mortality after ART initiation (which is driven by low CD4 cell counts) [10][11][12][13]. The higher mortality is ascribed to late presentation of HIV-infected patients to care, but is also attributable to the higher prevalence of opportunistic infections, especially tuberculosis (TB), and limited access to prophylaxis, diagnostic and treatment facilities for these opportunistic infections [11].Our large urban HIV clinic has made concerted efforts to initiate ART at higher CD4 cell counts and to improve di...

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Section: Discussionmentioning

confidence: 91%

Earlier initiation of antiretroviral therapy, increased tuberculosis case finding and reduced mortality in a setting of improved HIV care: a retrospective cohort study

et al. 2012

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“…Others have noted that fewer than a third of patients not eligible for treatment at the time of enrolment in care are retained in pre-ART care in the region [26]. In one study conducted in Ethiopia, those with less advanced HIV infection were more likely to be lost to follow-up prior to ART initiation than those with advanced HIV infection [12]. Patients enrolling in care at the early stages of HIV infection may therefore be more likely to remain engaged in care where there are services that could be perceived as beneficial to them such as free co-trimoxazole [27] and time-saving clinic-level efficiencies, such as reliable point-of-care CD4+ testing [28].…”

Section: Discussionmentioning

confidence: 99%

Factors associated with initiation of antiretroviral therapy in the advanced stages of HIV infection in six Ethiopian HIV clinics, 2012 to 2013

Nash

Tymejczyk

Gadisa

et al. 2016

Journal of the International AIDS Society

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IntroductionMost HIV-positive persons in sub-Saharan Africa initiate antiretroviral therapy (ART) with advanced infection (late ART initiation). Intervening on the drivers of late ART initiation is a critical step towards achieving the full potential of HIV treatment scale-up. This study aimed to identify modifiable factors associated with late ART initiation in Ethiopia.MethodsFrom 2012 to 2013, Ethiopian adults (n=1180) were interviewed within two weeks of ART initiation. Interview data were merged with HIV care histories to assess correlates of late ART initiation (CD4+ count <150 cells/µL or World Health Organization Stage IV).ResultsThe median CD4 count at enrolment in HIV care was 263 cells/µL (interquartile range (IQR): 140 to 390) and 212 cells/µL (IQR: 119 to 288) at ART initiation. Overall, 31.2% of participants initiated ART late, of whom 85.1% already had advanced HIV disease at enrolment. Factors associated with higher odds of late ART initiation included male sex (vs. non-pregnant females; adjusted odds ratio (aOR): 2.02; 95% CI: 1.50 to 2.73), high levels of psychological distress (vs. low/none, aOR: 1.96; 95% CI: 1.34 to 2.87), perceived communication barriers with providers (aOR: 2.42, 95% CI: 1.24 to 4.75), diagnosis via provider initiated testing (vs. voluntary counselling and testing, aOR: 1.47, 95% CI: 1.07 to 2.04), tuberculosis (TB) treatment prior to ART initiation (aOR: 2.16, 95% CI: 1.43 to 3.25) and a gap in care of six months or more prior to ART initiation (aOR: 2.02, 95% CI: 1.10 to 3.72). Testing because of partner illness/death (aOR: 0.64, 95% CI: 0.42 to 0.95) was associated with lower odds of late ART initiation.ConclusionsProgrammatic initiatives promoting earlier diagnosis, engagement in pre-ART care, and integration of TB and HIV treatments may facilitate earlier ART initiation. Men and those experiencing psychological distress may also benefit from targeted support prior to ART initiation.

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“…A critical gap in the HIV cascade of care has been the transition from pre-ART to ART, with high attrition from pre-ART care 3,44,45 and many patients still initiating ART at low CD4 counts. 3,45 One common explanation for this gap is the perception that the patient-borne costs of ART are significantly higher than the costs during pre-ART due to the burden of frequent and lengthy clinic visits to pick up medicines, and that these costs discourage patients from initiating as early as they might.…”

Section: Discussionmentioning

confidence: 99%

“…3,45 One common explanation for this gap is the perception that the patient-borne costs of ART are significantly higher than the costs during pre-ART due to the burden of frequent and lengthy clinic visits to pick up medicines, and that these costs discourage patients from initiating as early as they might. This theory, in this setting, appears to be a canard.…”

Section: Discussionmentioning

confidence: 99%

Time and Money

Chimbindi

Bor

Newell

et al. 2015

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Background HIV and TB services are provided free-of-charge in many sub-Saharan African countries, but patients still incur costs. Methods Patient-exit interviews were conducted with a representative sample of 200 HIV-infected patients not yet on ART (pre-ART), 300 ART patients, and 300 TB patients receiving public sector care in rural South Africa. For each group, we calculated health expenditures across different spending categories, time spent traveling to and utilizing services, and how patients financed their spending. Associations between patient group and costs were assessed in multivariate regression models. Results Total monthly health expenditures (1 USD = 7.3 South African Rand, ZAR) were: ZAR 171 (95% CI 134, 207) for pre-ART, ZAR 164 (95% CI 141, 187) for ART, and ZAR 122 (95% CI 105, 140) for TB patients (p=0.01). Total monthly time costs (in hours) were: 3.4 (95% CI 3.3, 3.5) for pre-ART, 5.0 (95% CI 4.7, 5.3) for ART and 3.2 (95% CI 2.9, 3.4) for TB patients (p<0.01). Though overall patient costs were similar across groups, pre-ART patients spent on average ZAR 29.2 more on traditional healers and ZAR 25.9 more on chemists and private doctors than ART patients, while ART patients spent ZAR 34.0 more than pre-ART patients on transport to clinics (p<0.05 for all results). 31% of pre-ART, 39% of ART and 41% of TB patients borrowed money or sold assets to finance health costs. Conclusions Patients receiving nominally free care for HIV/TB face large private costs, commonly leading to financial distress. Subsidized transport, fewer clinic visits, and drug pickup points closer to home could reduce costs for ART patients, potentially improving retention and adherence. Large expenditure on alternative care among pre-ART patients suggests that transitioning patients to ART earlier, as under HIV treatment-as-prevention policies, may not substantially increase patients’ financial burden.

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Patients Present Earlier and Survival Has Improved, but Pre-ART Attrition Is High in a Six-Year HIV Cohort Data from Ethiopia

Cited by 102 publications

References 21 publications

Earlier initiation of antiretroviral therapy, increased tuberculosis case finding and reduced mortality in a setting of improved HIV care: a retrospective cohort study

Earlier initiation of antiretroviral therapy, increased tuberculosis case finding and reduced mortality in a setting of improved HIV care: a retrospective cohort study

Factors associated with initiation of antiretroviral therapy in the advanced stages of HIV infection in six Ethiopian HIV clinics, 2012 to 2013

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