Temporal Trends in Treatment Outcomes for HIV-1 and HIV-2-Infected Adults Enrolled in Côte d'Ivoire's National Antiretroviral Therapy Program

Abstract

BackgroundIn Côte d'Ivoire during 2004–2007, numbers of ART enrollees increased from <5,000 to 36,943. Trends in nationally representative ART program outcomes have not yet been reported.Methodology/Principal FindingsWe conducted a retrospective chart review to assess trends in patient characteristics and attrition [death or loss to follow-up (LTFU)] over time, among a nationally representative sample of 3,682 adults (≥15 years) initiating ART during 2004–2007 at 34 health facilities. Among ART enrollees during 2004–2007, median age was 36, the proportion female was 67%, the proportion HIV-2-infected or dually HIV-1&2 reactive was 5%, and median baseline CD4+ T-cell (CD4) count was 135 cells/µL. Comparing cohorts initiating ART in 2004 with cohorts initiating ART in 2007, median baseline weight declined from 55 kg to 52 kg (p = 0.008) and the proportion weighing <45 kg increased from 17% to 22% (p = 0.014). During 2004–2007, pharmacy-based estimates of the percentage of new ART enrollees ≥95% adherent to ART declined from 74% to 60% (p = 0.026), and twelve-month retention declined from 86% to 69%, due to increases in 12-month mortality from 2%–4% and LTFU from 12%–28%. In univariate analysis, year of ART initiation was associated with increasing rates of both LTFU and mortality. Controlling for baseline CD4, weight, adherence, and other risk factors, year of ART initiation was still strongly associated with LTFU but not mortality. In multivariate analysis, weight <45 kg and adherence <95% remained strong predictors of LTFU and mortality.ConclusionsDuring 2004–2007, increasing prevalence among ART enrollees of measured mortality risk factors, including weight <45 kg and ART adherence <95%, might explain increases in mortality over time. However, the association between later calendar year and increasing LTFU is not explained by risk factors evaluated in this analysis. Undocumented transfers, political instability, and patient dissatisfaction with crowded facilities might explain increasing LTFU.

Impact of Support Groups for People Living With HIV on Clinical Outcomes

“…Decroo et al reported high retention with approximately 97.5% patients remaining in care for a median follow-up period of 12.9 months (range 8.5–14 months) 16 and 91.8% at 4 years. 17 Overall, the authors reported that attrition in the cohort was lower than the national 12 month average for Mozambique (15%) 28 and lower still than rates reported in the literature for sub-Saharan Africa (1.2–26%). 29 A large study with more than 300,000 participants aged 10–24 years from four sub-Saharan countries showed that youth participating in support groups provided by clinics experienced slightly lower attrition after ART initiation (AHR=0.73, 95% CI: 0.52–1.0); in the pre-ART period, the authors reported no significant associations between attrition and participation in support groups or other adolescent friendly services—availability of adolescent peer educators, or education on high-risk substance abusing behaviour.…”

Implementation of a pragmatic, stepped-wedge cluster randomized trial to evaluate impact of Botswana’s Xpert MTB/RIF diagnostic algorithm on TB diagnostic sensitivity and early antiretroviral therapy mortality

“…As described earlier, because cohorts R and B do not overlap during the stepped-wedge portion of this trial, a comparison of 6-month mortality rates in cohorts R and B cannot make use of the stepped-wedge design to control for secular trends [26]. However, since most variation in 6-month ART mortality over successive annual ART cohorts is accounted for by changes in health status of ART enrollees (e.g., changes in baseline CD4 count), incorporation of these known risk factors for 6-month ART mortality into the multivariable model may fully account for secular mortality trends [7, 50]. …”

“…Healthcare facility-related reasons for missed or late TB diagnoses among PLHIV include: (1) failure of healthcare workers (HCW) to screen for TB symptoms [7–9]), (2) failure of HCWs to request sputum or other diagnostic samples from symptomatic patients [10], (3) inability to collect high quality sputa or other appropriate diagnostic samples from symptomatic patients [11], (4) insensitive TB diagnostics, with smear microscopy alone having a sensitivity of about 45 % in diagnosing culture-positive disease among PLHIV [12], (5) inability to diagnose drug-resistant TB timeously [13], and (6) long turn-around times for some TB diagnostic tests or failure to return results to clinicians and patients [14]. …”

Beyond Indicators

“…Because such system strengthening is a long-term endeavor, complimentary data collection exercises help to meet immediate information needs for HIV program information. [64][65][66] …”