Retention and mortality outcomes from a community‐supported public–private HIV treatment programme in Myanmar

Abstract

IntroductionThere is a growing interest in the potential contribution the private sector can make towards increasing access to antiretroviral therapy (ART) in low- and middle-income settings. This article describes a public–private partnership that was developed to expand HIV care capacity in Yangon, Myanmar. The partnership was between private sector general practitioners (GPs) and a community-based non-governmental organization (International HIV/AIDS Alliance).MethodsRetrospective analysis of 2119 patient records dating from March 2009 to April 2015 was conducted. Outcomes assessed were immunological response, loss to follow-up, all-cause mortality, and alive and retained in care. Follow-up time was calculated from the date of registration to the date of death, loss to follow-up, transfer out, or if still alive and known to be in care, until April 2015. Cox proportional hazards model was used to identify predictors of loss to follow-up and mortality. Kaplan–Meier survival analysis was used to estimate survival function of being alive and retained in care.ResultsThe median number of patients for each of the 16 GPs was 42 (interquartile range (IQR): 25–227), and the median follow-up period was 13 months. The median patient age was 35 years (IQR: 30–41); 56.6% were men, 62 and 11.8% were in WHO Stage III and Stage IV at registration, respectively; median CD4 count at registration was 177 cells/mm3; and 90.7% were on ART in April 2015. The median CD4 count at registration increased from 122 cells/mm3 in 2009 to 194 cells/mm3 in 2014. Among patients on ART, CD4 counts increased from a median of 187 cells/mm3 at registration to 436 cells/mm3 at 36 months. The median time to initiation of ART among eligible patients was 29 days, with 93.8% of eligible patients being initiated on ART within 90 days. Overall, 3.3% patients were lost to follow-up, 4.2% transferred out to other health facilities, and 8.3% died during the follow-up period. Crude mortality rate was 48.6/1000 person-years; 42% (n=74) of deaths occurred during the pre-ART period and 39.8% (n=70) occurred during the first six months of ART. Of those who died during the pre-ART period, 94.5% were eligible for ART. In multivariate regression, baseline CD4 count and ART status were independent predictors of mortality, whereas ART status, younger age and patient volumes per provider were predictors of loss to follow-up. Probability of being alive and retained in care at six months was 96.8% among those on ART, 38.5% among pre-ART but eligible patients, and 20.0% among ART-ineligible patients.ConclusionsEffectively supported private sector GPs successfully administered and monitored ART in Myanmar, suggesting that community-supported private sector partnerships can contribute to expansion of HIV treatment and care capacity. To further improve patient outcomes, early testing and initiation of ART, combined with close clinical monitoring and support during the initial periods of enrolling in treatment and care, are required.

Early suboptimal ART adherence was associated with missed clinical visits in HIV-infected patients in Asia

“…There is limited literature investigating the association of other clinical characteristics with missed visits, especially in resource-limited settings. However, our results are comparable to reported studies which showed that younger patients, males, and those with hepatitis C co-infection were more likely to have discontinuous engagement in care(Asiimwe, Kanyesigye, Bwana, Okello, & Muyindike, 2016; Mburu et al, 2016; Megerso et al, 2016; Rachlis et al, 2016; F. Zhang et al, 2014).…”

Nationwide Cohort Study of Antiretroviral Therapy Timing: Treatment Dropout and Virological Failure in China, 2011–2015

“…A study in rural Uganda and Kenya found that delay in ART initiation of more than 30 days after HIV diagnosis was associated with elevated rates of treatment dropout at 12 months [22]. In Myanmar, 94% of ART-eligible study participants were on ART by 90 days, and only 3% had dropped out of treatment in a median of 13 months of follow-up [23]. A very large, retrospective analysis of newly diagnosed PLWH in high-income countries has found that immediate initiation of ART increases viral suppression earlier in follow-up [24].…”

Long-term clinical, immunological and virological outcomes of patients on antiretroviral therapy in southern Myanmar

“…The Ugandan study’s cumulative death rate of 22.7% similarly had 63% of deaths occurring within one year of initiating ART. Another Myanmar study of a five-year program in Yangon, the country’s most populous city and former capital, found that 39.8% of deaths occurred six months after ART initiation [ 16 ], and multivariate analysis suggested that only ART exposure status and baseline CD4 count were independently predictive of mortality.…”