Programmatic outcomes and impact of rapid public sector antiretroviral therapy expansion in adults prior to introduction of the WHO treat‐all approach in rural Eswatini

Kerschberger, Bernhard; Schomaker, Michael; Ciglenečki, Iza; Pasipamire, Lorraine; Mabhena, Edwin; Telnov, Alex; Rusch, Barbara; Lukhele, Nomthandazo; Teck, Roger; Boulle, Andrew

doi:10.1111/tmi.13234

Cited by 17 publications

(17 citation statements)

References 58 publications

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“…Firstly, the rapid decentralisation of HIV-TB services between 2008 and 2010 may have improved access to diagnosis and case detection of active TB for this predominantly rural population. Secondly, ART coverage increased rapidly in this high-HIV prevalence setting, from an estimated 7.1% in 2006 [42] to 82.7% in 2016/2017 [43]. In southern Africa, expansion of HIV treatment and high ART coverage are suggested key factors to decrease the burden of TB in people living with HIV and possibly also in the HIV-negative population [44].…”

Section: Findings In Contextmentioning

confidence: 99%

Successful expansion of community‐based drug‐resistant TB care in rural Eswatini – a retrospective cohort study

Kerschberger

Telnov

Yano³

et al. 2019

Tropical Med Int Health

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Objectives Provision of drug‐resistant tuberculosis (DR‐TB) treatment is scarce in resource‐limited settings. We assessed the feasibility of ambulatory DR‐TB care for treatment expansion in rural Eswatini. Methods Retrospective patient‐level data were used to evaluate ambulatory DR‐TB treatment provision in rural Shiselweni (Eswatini), from 2008 to 2016. DR‐TB care was either clinic‐based led by nurses or community‐based at the patient's home with involvement of community treatment supporters for provision of treatment to patients with difficulties in accessing facilities. We describe programmatic outcomes and used multivariate flexible parametric survival models to assess time to adverse outcomes. Both care models were costed in supplementary analyses. Results Of 698 patients initiated on DR‐TB treatment, 57% were women and 84% were HIV‐positive. Treatment initiations increased from 27 in 2008 to 127 in 2011 and decreased thereafter to 51 in 2016. Proportionally, community‐based care increased from 19% in 2009 to 77% in 2016. Treatment success was higher for community‐based care (79%) than clinic‐based care (68%, P = 0.002). After adjustment for covariate factors among adults (n = 552), the risk of adverse outcomes (death, loss to follow‐up, treatment failure) in community‐based care was reduced by 41% (adjusted hazard ratio 0.59, 95% CI: 0.39–0.91). Findings were supported by sensitivity analyses. The care provider's per‐patient costs for community‐based (USD13 345) and clinic‐based (USD12 990) care were similar. Conclusions Ambulatory treatment outcomes were good, and community‐based care achieved better treatment outcomes than clinic‐based care at comparable costs. Contextualised DR‐TB care programmes are feasible and can support treatment expansion in rural settings.

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Section: Findings In Contextmentioning

confidence: 99%

Successful expansion of community‐based drug‐resistant TB care in rural Eswatini – a retrospective cohort study

Kerschberger

Telnov

Yano³

et al. 2019

Tropical Med Int Health

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“…In several cohort studies of ART programmes in sub-Saharan Africa, there have been reports of higher rates of LTFU among patients who initiated ART in later years compared to earlier years (26)(27)(28). This may be explained by patients increasingly initiating treatment while less severely ill (29), as well as a negative consequence of patient numbers increasing such as facility workloads (30), raising concerns about the sustainability of these programmes. Some systematic reviews have shown that the percentage of patients LTFU who have died has decreased in later years as eligibility criteria have evolved to include less immunologically compromised patients, and as the proportion of patients LTFU has increased (13,31).…”

Section: Introductionmentioning

confidence: 99%

Misreporting of Patient Outcomes in the South African National HIV Treatment Database: Consequences for Programme Planning, Monitoring, and Evaluation

Etoori

Wringe

Kabudula

et al. 2020

Front. Public Health

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Background: Monitoring progress toward global treatment targets using HIV programme data in sub-Saharan Africa has proved challenging. Constraints in routine data collection and reporting can lead to biased estimates of treatment outcomes. In 2010, South Africa introduced an electronic patient monitoring system for HIV patient visits, TIER.Net. We compare treatment status and outcomes recorded in TIER.Net to outcomes ascertained through detailed record review and tracing in order to assess discrepancies and biases in retention and mortality rates. Methods: The Agincourt Health and Demographic Surveillance System (HDSS) in northeastern South Africa is served by eight public primary healthcare facilities. Since 2014, HIV patient visits are logged electronically at these clinics, with patient records individually linked to their HDSS record. These data were used to generate a list of patients >90 days late for their last scheduled clinic visit and deemed lost to follow-up (LTFU). Patient outcomes were ascertained through a review of the TIER.Net database, physical patient files, registers kept by two non-government organizations that assist with patient tracing, cross-referencing with the HDSS records and supplementary physical tracing. Descriptive statistics were used to compare patient outcomes reported in TIER.Net to their outcome ascertained in the study. Results: Of 1,074 patients that were eligible for this analysis, TIER.Net classified 533 (49.6%) as LTFU, 80 (7.4%) as deceased, and 186 (17.3%) as transferred out. TIER.Net misclassified 36% of patient outcomes, overestimating LTFU and underestimating mortality and transfers out. TIER.Net missed 40% of deaths and 43% of transfers out. Patients categorized as LTFU in TIER.Net were more likely to be misclassified than patients classified as deceased or transferred out. Discussion: Misclassification of patient outcomes in TIER.Net has consequences for programme forecasting, monitoring and evaluation. Undocumented transfers accounted for the majority of misclassification, suggesting that the transfer process between clinics Etoori et al. Misreporting HIV Patient Treatment Outcomes should be improved for more accurate reporting of patient outcomes. Processes that lead to correct classification of patient status including patient tracing should be strengthened. Clinics could cross-check all available data sources before classifying patients as LTFU. Programme evaluators and modelers could consider using correction factors to improve estimates of outcomes from TIER.Net.

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“…Overall retention was comparable to ART programmes in low‐ and middle‐income countries and two Treat‐All trials in Southern Africa . However, point estimates of retention tended to be lower than under SOC, than previous retention estimates from this setting before the introduction of Treat‐All and than in a streamlined combination intervention trial in Eastern Africa . Similarly to another Treat‐All trial in South Africa , 6% of patients never returned for a clinic visit after ART initiation (vs. 3% under SOC).…”

Section: Discussionmentioning

confidence: 61%

“…The setting has been described previously . The predominantly rural Shiselweni region has a population of ~210,000 and HIV prevalence is 31% in 18‐ to 49‐year‐olds .…”

Section: Methodsmentioning

confidence: 99%

HIV programmatic outcomes following implementation of the ‘Treat‐All’ policy in a public sector setting in Eswatini: a prospective cohort study

et al. 2020

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Introduction The Treat‐All policy – antiretroviral therapy (ART) initiation irrespective of CD4 cell criteria – increases access to treatment. Many ART programmes, however, reported increasing attrition and viral failure during treatment expansion, questioning the programmatic feasibility of Treat‐All in resource‐limited settings. We aimed to describe and compare programmatic outcomes between Treat‐All and standard of care (SOC) in the public sectors of Eswatini. Methods This is a prospective cohort study of ≥16‐year‐old HIV‐positive patients initiated on first‐line ART under Treat‐All and SOC in 18 health facilities of the Shiselweni region, from October 2014 to March 2016. SOC followed the CD4 350 and 500 cells/mm3 treatment eligibility thresholds. Kaplan‐Meier estimates were used to describe crude programmatic outcomes. Multivariate flexible parametric survival models were built to assess associations of time from ART initiation with the composite unfavourable outcome of all‐cause attrition and viral failure. Results Of the 3170 patients, 1888 (59.6%) initiated ART under Treat‐All at a median CD4 cell count of 329 (IQR 168 to 488) cells/mm3 compared with 292 (IQR 161 to 430) (p < 0.001) under SOC. Although crude programme retention at 36 months tended to be lower under Treat‐All (71%) than SOC (75%) (p = 0.002), it was similar in covariate‐adjusted analysis (adjusted hazard ratio [aHR] 1.06, 95% CI 0.91 to 1.23). The hazard of viral suppression was higher for Treat‐All (aHR 1.12, 95% CI 1.01 to 1.23), while the hazard of viral failure was comparable (Treat‐All: aHR 0.89, 95% CI 0.53 to 1.49). Among patients with advanced HIV disease (n = 1080), those under Treat‐All (aHR 1.13, 95% CI 0.88 to 1.44) had a similar risk of an composite unfavourable outcome to SOC. Factors increasing the risk of the composite unfavourable outcome under both interventions were aged 16 to 24 years, being unmarried, anaemia, ART initiation on the same day as HIV care enrolment and CD4 ≤ 100 cells/mm3. Under Treat‐All only, the risk of the unfavourable outcome was higher for pregnant women, WHO III/IV clinical stage and elevated creatinine. Conclusions Compared to SOC, Treat‐All resulted in comparable retention, improved viral suppression and comparable composite outcomes of retention without viral failure.

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Programmatic outcomes and impact of rapid public sector antiretroviral therapy expansion in adults prior to introduction of the WHO treat‐all approach in rural Eswatini

Cited by 17 publications

References 58 publications

Successful expansion of community‐based drug‐resistant TB care in rural Eswatini – a retrospective cohort study

Successful expansion of community‐based drug‐resistant TB care in rural Eswatini – a retrospective cohort study

Misreporting of Patient Outcomes in the South African National HIV Treatment Database: Consequences for Programme Planning, Monitoring, and Evaluation

HIV programmatic outcomes following implementation of the ‘Treat‐All’ policy in a public sector setting in Eswatini: a prospective cohort study

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