Patients’ demographic and clinical characteristics and level of care associated with lost to follow-up and mortality in adult patients on first-line ART in Nigerian hospitals (original) (raw)
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Trends in mortality and loss to follow-up in HIV care at the Nkongsamba Regional hospital, Cameroon
BMC Research Notes, 2013
Background: Access to Human Immunodeficiency Virus (HIV) care has been rolled out in Cameroon in the last decade through decentralised delivery of care and timely initiation of free antiretroviral drugs. We sought to describe the evolution of mortality and loss to follow up (LTFU) and their patient-related determinants at an HIV clinic which is facing significant challenges. Methods: A retrospective review of point of care data from HIV patients was conducted in June 2012 at Nkongsamba Regional Hospital in Cameroon to establish mortality and LTFU rates. Univariable and multivariable Cox regression models were used to screen for factors associated with the outcomes. Telephone calls were made to trace patients LTFU. Results: Between June 2005 and December 2010, 2388 HIV infected patients were admitted. Of these, 1858 were aged 15 and above and were included in our analysis. Their median age was 36 years (IQR: 30-44) and they were followed up over a total risk period of 3647.3 person-years (pyrs). The overall mortality rate was 34.6 deaths per 1000 pyrs (95% CI: 29.0-41.1) while the overall LTFU rate was 94.6 per 1000 pyrs (95%CI: 85.1-105.1).The mortality rates steadily rose to a peak of 69.6 deaths per 1000 pyrs in 2009 and then fell drastically to 20.6 per 1000 pyrs in 2010. The LTFU rate increased sharply from 29.7 in 2006 to 138.2 in 2007 and remained virtually stable until 2010. The factors associated with mortality were: being male (aHR = 2.25, 95% CI: 1.58-3.19), clinical disease progression (aHR = 2.0, 95% CI: 1.58-2.53), CD4 count <200 cells/μl (aHR = 3.14, 95% CI: 1.27-7.73), haemoglobin level <10 g/dl (aHR = 2.50, 95% CI: 1.69-3.69). Major factors associated with high LTFU rate were: distance to clinic of over 5 km (aHR = 1.25, 95% CI: 1.00-1.55), being single, having partners with unknown HIV status or taking no treatment and with CD4 count >500 cells/μl. Two-thirds (66.7%) of traced LTFU patients were dead. Conclusion: Mortality and LTFU rates in our cohort were high but there is evidence that patients' outcomes are improving. Interventions to address factors associated with high mortality and LTFU should be implemented for optimal results in patient care.
Aids Research and Therapy, 2011
Background High early mortality rate among HIV infected patients following initiation of antiretroviral therapy (ART) in resource limited settings may indicate high pre-treatment mortality among ART-eligible patients. There is dearth of data on pre-treatment mortality in ART programmes in sub-Sahara Africa. This study aims to determine pre-treatment mortality rate and predictors of pre-treatment mortality among ART-eligible adult patients in a West Africa clinic-based cohort. Methods All HIV-infected patients aged 15 years or older eligible for ART between June 2004 and September 2009 were included in the analysis. Assessment for eligibility was based on the Gambia ART guideline. Survival following ART-eligibility was determined by Kaplan-Meier estimates and predictors of pre-treatment mortality determined by Cox proportional hazard models. Result Overall, 790 patients were assessed as eligible for ART based on their clinical and/or immunological status among whom 510 (64.6%) started treatment, 26 (3.3%) requested transfer to another health facility, 136 (17.2%) and 118 (14.9%) were lost to follow-up and died respectively without starting ART. ART-eligible patients who died or were lost to follow-up were more likely to be male or to have a CD4 T-cell count < 100 cells/μL, while patients in WHO clinical stage 3 or 4 were more likely to die without starting treatment. The overall pre-treatment mortality rate was 21.9 deaths per 100 person-years (95% CI 18.3 - 26.2) and the rate for the composite end point of death or loss to follow-up was 47.1 per 100 person-years (95% CI 41.6 - 53.2). Independent predictors of pre-treatment mortality were CD4 T-cell count <100 cells/μL (adjusted Hazard ratio [AHR] 3.71; 95%CI 2.54 - 5.41) and WHO stage 3 or 4 disease (AHR 1.91; 95% CI 1.12 - 3.23). Forty percent of ART-eligible patients lost to follow-up seen alive at field visit cited difficulty with the requirement of disclosing their HIV status as reason for not starting ART. Conclusion Approximately one third of ART-eligible patients did not start ART and pre-treatment mortality rate was found high among HIV infected patients in our cohort. CD4 T-cell count <100 cells/μL is the strongest independent predictor of pre-treatment mortality. The requirement to disclose HIV status as part of ART preparation counselling constitutes a huge barrier for eligible patients to access treatment.
AIDS, 2008
Objective: To assess the rates and determinants of mortality, loss-to-follow-up (LTFU) and immunological failure in a non governmental organization implemented program of access to antiretroviral treatment (ART) in Côte d'Ivoire. Methods: In each new treatment center, professionals were trained in HIV care, and a computerized data system was implemented. Individual patient and program level determinants of survival, LTFU and immunological failure were assessed by multivariate analysis. Results: Between May 2004 and February 2007, 10,211 patients started ART in 19 clinics (median pre-ART CD4 count 123/mm 3 , initial regimen ZDV-3TC-EFV 20%, d4T-3TC-EFV 22%, d4T-3TC-NVP 52%). At 18 months on ART, the median gain in CD4 cells was +202/mm 3 , the probability of death was 0.15 and the probability of being LTFU was 0.21. In addition to the commonly reported determinants of impaired outcomes (low CD4 count, low body mass index, low hemoglobin, advanced clinical stage, older age and poor adherence), two factors were also shown to independently jeopardize prognosis: (i) male sex (men vs. women: hazard ratio [HR]=1.52 for death, HR=1.27 for LTFU, HR=1.31 for immunological failure); and (ii) attending a recently opened clinic (unexperienced vs. experienced centres: HR=1.40 for death, HR=1.58 for LTFU). None of the three outcomes was associated with the drug regimen. Discussion: In this rapidly scaling-up programme: survival and immune reconstitution were good; women and patients followed-up in centres with longer experience had better outcomes; outcomes were similar in ZDV/d4t-based regimens and in EFV/NVP-based regimens. Decreasing the rate of LTFU should now be the top priority in ART roll-out.
Long-Term Outcomes on Antiretroviral Therapy in a Large Scale-Up Program in Nigeria
PLOS ONE, 2016
Background While there has been a rapid global scale-up of antiretroviral therapy programs over the past decade, there are limited data on long-term outcomes from large cohorts in resourceconstrained settings. Our objective in this evaluation was to measure multiple outcomes during first-line antiretroviral therapy in a large treatment program in Nigeria. Methods We conducted a retrospective multi-site program evaluation of adult patients (age !15 years) initiating antiretroviral therapy between June 2004 and February 2012 in Nigeria. The baseline characteristics of patients were described and longitudinal analyses using primary endpoints of immunologic recovery, virologic rebound, treatment failure and longterm adherence patterns were conducted. Results Of 70,002 patients, 65.2% were female and median age was 35 (IQR: 29-41) years; 54.7% were started on a zidovudine-containing and 40% on a tenofovir-containing first-line regimen. Median CD4+ cell counts for the cohort started at 149 cells/mm 3 (IQR: 78-220) and increased over duration of ART. Of the 70,002 patients, 1.8% were reported as having died, 30.1% were lost to follow-up, and 0.1% withdrew from treatment. Overall, of those patients retained and with viral load data, 85.4% achieved viral suppression, with 69.3% achieving suppression by month 6. Of 30,792 patients evaluated for virologic failure, 24.4% met criteria for failure and of 45,130 evaluated for immunologic failure, 34.0% met criteria for immunologic failure, with immunologic criteria poorly predicting virologic failure. In adjusted analyses, older age, ART regimen, lower CD4+ cell count, higher viral load, and inadequate adherence were all predictors of virologic failure. Predictors of immunologic PLOS ONE |
PLOS ONE, 2015
Background Short-medium term studies from sub-Saharan Africa show that, despite high early mortality, substantial loss to program, and high rates toxicity, patients on antiretroviral treatment have achieved outcomes comparable to those in developed settings. However, these studies were unable to account for long term outcomes of patients as they stayed longer on treatment. Objectives We aim to describe ten years outcomes of one of the first cohort of HIV positive patients started on antiretroviral treatment (ART) in Sub-Saharan Africa. Methods We report 10-years outcomes including mortality, retention, CD4-count response, virological outcomes, ART regimens change from a prospective cohort of 559 patients initiating ART and followed up for 10 years Uganda. Results Of 559 patients, 69.1% were female, median age (IQR) was 38 (33-44) years, median CD4-count (IQR) 98 (21-163) cell/μL; 74% were started on stavudine, lamivudine and nevirapine, 26% on zidovudine, lamivudine and efavirenz. After 10 years 361 (65%) patients were still in the study; 127 (22.7%) had died; 30 (5%) were lost to follow-up; 27 (5%) transferred; 18 (3%) withdrew consent. The probability of death was high in the first year (0.15, 95%, CI 0.12-0.18). The median CD4 count increased from 98 to 589 cell/μL (IQR: 450-739 cell/μL) with a median increase of 357 cells/μL (IQR: 128-600 cells/μL); 7.4% never attained initial viral suppression and of those who did 31.7% experienced viral failure. Three hundred and two patients had at least one drug substitution while on first line after a median PLOS ONE |
ISRN AIDS, 2012
Background. There has been a rapid scale up of antiretroviral therapy (ART) in Ethiopia since 2005. We aimed to evaluate mortality, loss to followup, and retention in care at HIV Clinic, University of Gondar Hospital, north-west Ethiopia. Method. A retrospective patient chart record analysis was performed on adult AIDS patients enrolled in the treatment program starting from 1 March 2005. We performed survival analysis to determine, mortality, loss to followup and retention in care. Results. A total of 3012 AIDS patients were enrolled in the ART Program between March 2005 and August 2010. At the end of the 66 months of the program initiation, 61.4% of the patients were retained on treatment, 10.4% died, and 31.4% were lost to followup. Fifty-six percent of the deaths and 46% of those lost to followup occurred in the first year of treatment. Male gender (adjusted hazard ratio (AHR) was 3.26; 95% CI: 2.19-4.88); CD4 count ≤200 cells/µL (AHR 5.02; 95% CI: 2.03-12.39), tuberculosis (AHR 2.91; 95% CI: 2.11-4.02); bed-ridden functional status (AHR 12.88;) were predictors of mortality, whereas only CD4 count <200 cells/µL (HR = 1.33; 95% CI: (0.95, 1.88) and ambulatory functional status (HR = 1.65; 95% CI: (1.22, 2.23) were significantly associated with LTF. Conclusion. Loss to followup and mortality in the first year following enrollment remain a challenge for retention of patients in care. Strengthening patient monitoring can improve patient retention AIDS care.
PLOS ONE, 2020
BackgroundRetaining patients starting antiretroviral therapy (ART) and ensuring good adherence remain cornerstone of long-term viral suppression. In this era of test and treat (T&T) policy, ensuring that patients starting ART remain connected to HIV clinics is key to achieve the UNAIDS 90-90-90 targets. Currently, limited studies have evaluated the effect of early ART initiation on loss to follow up in a routine health care delivery setting. We studied the cumulative incidence, incidence rate of loss to follow up (LTFU), and factors associated with LTFU in a primary healthcare clinic that has practiced T&T since 2012.MethodsWe retrospectively analyzed extracted routine program data on patients who started ART from January 2012 to 4th July 2016. We defined LTFU as failure of a patient to return to the HIV clinic for at least 90 days from the date of their last appointment. We calculated cumulative incidence, incidence rate and fitted a multivariable Cox proportion hazards regression model to determine factors associated with LTFU.ResultsOf the 7,553 patients included in our sample, 3,231 (42.8%) started ART within seven days following HIV diagnosis. There were 1,180 cases of LTFU observed over 15,807.7 person years at risk. The overall incidence rate (IR) of LTFU was 7.5 (95% CI, 7.1–7.9) per 100 person years of observation (pyo). Cumulative incidence of LTFU increased with duration of follow up from 8.9% (95% CI, 8.2–9.6%) at 6 months to 20.2% (95% CI, 19.0–21.4%) at 48 months. Predictors of elevated risk of LTFU were: starting ART within 7 days following HIV diagnosis ((aHR) = 1.69, 95% CI, 1.50–1.91), lack of a telephone set (aHR = 1.52, 95% CI, 1.35–1.71), CD4 cell count of 200–350μ/ml (aHR = 1.21, 95% CI, 1.01–1.45) and baseline WHO clinical stage 3 or 4 (aHR = 1.35, 95% CI, 1.10–1.65). Factors associated with a reduced risk of LTFU were: baseline age ≥25 years (aHR ranging from 0.62, 95% CI, 0.47–0.81 for age group 25–29 years to 0.24, 95% CI, 0.13–0.44 for age group ≥50 years), at least primary education level (aHR ranging from aHR = 0.77, 95% CI, 0.62–0.94 for primary education level to 0.50, 95% CI, 0.34–0.75 for post-secondary education level), and having a BMI ≥ 30 (aHR = 0.28, 95% CI, 0.15–0.51).ConclusionThe risk of loss to follow up increased with time and was higher among patients who started ART within seven days following HIV diagnosis, higher among patients without a telephone set, lower among patients aged ≥ 25 years, lower among patients with at least primary education and lower among patients with BMI of ≥ 30. In this era of T&T, it will be important for HIV programs to initiate and continue enhanced therapeutic education programs that target high risk groups, as well as leveraging on mHealth to improve patients’ retention on ART throughout the cascade of care.
BMC Health Services Research, 2015
Background: The number of Human Immunodeficiency Virus (HIV) infected people eligible for initiation on antiretroviral Therapy (ART) is increasing. ART programmatic success requires that patients who are taking ART remain on treatment and are followed up regularly. This study investigated factors associated with being lost to follow-up, in a cohort of patients enrolled in a pharmacovigilance study in South Africa. Methods: This was a retrospective observational cohort study performed at one of the Medunsa National Pharmacovigilance Centre's (MNPC) ART sentinel surveillance sites. Loss to Follow-up (LTFU) was defined as "a patient who had been followed up at the sentinel site, who had not had contact with the health facility for 180 days or more since their last recorded expected date of return or if there were 180 days or more between the expected date of return and the next clinic visit". Results: Out of 595 patients, 65.5 % (n = 390) were female and 23.4 % (n = 139) were LTFU. The median time on ART before LTFU was 21.5 months (interquartile range: 12.9-34.7 months). The incidence rate of LTFU was 103 per 1000 person-years in the first year on ART and increased to 405 per 1000 person-years in the eighth year of taking ART. Factors associated with becoming LTFU included not having a committed partner (Adjusted Hazard Ratio (aHR): 2.9, 95 % Confidence Interval (CI):1.19-6.97, p = 0.019), being self-employed (aHR: 13.9, 95 % CI:2.81-69.06, p = 0.001), baseline CD4 count > 200 cells/ml (aHR: 3.8, 95 % CI: 1.85-7.85, p < 0.001), detectable last known Viral Load (VL) (aHR: 3.6, 95 % CI:1.98-6.52, p < 0.001) and a last known World Health Organisation clinical stage three or four (aHR: 2.0, 95 % CI:1.22-3.27, p = 0.006). Patients that previously had an ART adverse event had a lower risk (aHR: 0.6, 95 % CI: 0.38-0.99, p = 0.044) of becoming LTFU than those that had not. Conclusion: The incidence rate of LTFU increases with additional years on ART. Intensified measures to improve patient retention on ART must be prioritised with increasing patient time on ART and in patients that are at increased risk of becoming lost to follow-up.