Trends in Disease Stage at Presentation to Care and Pre-ART Outcomes: a Six-Year HIV Cohort Data fro...
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Degu Jerene MD, PhD , WCO, Ethiopia Zewdie Mullisa MD , Arba Minch Hospital, Ethiopia PowerPoint PPT Presentation


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Trends in Disease Stage at Presentation to Care and Pre-ART Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia. Degu Jerene MD, PhD , WCO, Ethiopia Zewdie Mullisa MD , Arba Minch Hospital, Ethiopia Bernt Lindtj ø rn MD, PhD, University of Bergen, Norway.

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Degu Jerene MD, PhD , WCO, Ethiopia Zewdie Mullisa MD , Arba Minch Hospital, Ethiopia

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Degu jerene md phd wco ethiopia zewdie mullisa md arba minch hospital ethiopia

Trends in Disease Stage at Presentation to Care and Pre-ART Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia

Degu Jerene MD, PhD, WCO, Ethiopia

ZewdieMullisa MD, Arba Minch Hospital, Ethiopia

BerntLindtjørn MD, PhD, University of Bergen, Norway


Background and objectives

Background and objectives

  • Access to antiretroviral therapy improved

  • Delayed visit contributes to higher death

  • Trends in patient presentation unknown

  • Little data on pre-ART patient outcomes

  • Our objective was to document;

    • If there had been shift in disease stage

    • Pre-ART patient outcomes including loss


Methods

Methods


Study setting

Study Setting

  • Ethiopia, population: 73.9 m (CSA 2007)

  • HIV prevalence: 2.4% (FMOH, 2007)

  • ART started in 2003, free ART in 2005

  • Arba Minch Hospital: public hospital

  • The first hospital to start ART in the southern region

    • University of Bergen, Norway

  • Technical support since mid-2006

    • PEPFAR through Johns Hopkins University


Study design

Study Design

  • Retrospective cohort, Jan ‘03-Dec 31,’08

  • Reviewed routine patient records

  • Eligibility; adults, treatment-naïve

  • Excluded; child, treatment experienced

  • Enrolment stratified into 3 phases;

    • Jan 2003-Aug 2006 (Early phase)

    • Sept 2006-Aug 2007 (Rapid scale-up)

    • Sept 2007-Dec 2008 (Recent phase)

      (Assefa Y et al 2009. PLoS Med 6: e1000056).


Definitions

Definitions

  • Pre-ART loss to follow-up (pLFU): if patient did not have follow up visit at least 30 days after the date of clinic appointment

  • Advanced disease: Those in WHO Clinical Stage III & IV

    • NB: No CD4 until 2006


Statistical methods

Statistical Methods

  • SPSS used for entry and analysis

  • Logistic regression method

    • Advanced stage vs less advanced

  • Kaplan Meier and Cox Regression

    • Time to pre-ART outcomes (death or loss)

  • Demographic and clinical characteristics as co-variates


Ethics

Ethics

  • Arba Minch Hospital HIV Cohort has National clearance

  • Approval obtained locally for this specific study

  • De-identified secondary data used


Results

Results


Cohort profile

Cohort profile


Participant characteristics

Participant characteristics


Factors advanced disease

Factors: advanced disease


Pre art loss to follow up

Pre-ART loss to follow up

  • 25% were lost to follow-up

    Predictors:aHR (95%CI)

    Less advanced disease 2.4 (1.3-2.6)

    Recent cohort2.0 (1.6-2.6)

    Rural residence1.8 (1.5-2.2)

  • Age, sex, and marital status not associated


Pre art mortality

Pre-ART mortality

  • 5% died during pre-ART care

  • Mortality rate: 13.1 per 100 PYO

    • Rapid scale-up phase: 1.4

    • Recent phase: 8.4

    • Early phase: 25.9

      Predictors aHR (95% CI)

      Early vs rapid scale-up2.4 (1.3-4.6)

      Advanced disease2.8 (1.6-4.8)


Survival cox regression

Survival: Cox Regression


Conclusions

Conclusions

  • Patients started to present earlier

  • Pre-ART death was highest among the oldest cohort irrespective of disease stage

  • Pre-ART loss to follow-up is a common but less clearly recognized challenge

  • Patients in the recent cohort, rural residents and those with less advanced disease are more likely to default


Recommendations

Recommendations

  • Need to strengthen pre-ART patient care

    • Standardize definitions for pre-ART loss

    • Monitoring and evaluation tools

    • Re-package existing interventions (IPT, bed nets, food, prevention, psychosocial, etc)

    • Pre-ART patient tracing/adherence support

  • Further studies needed

    • Multiple cohorts, various settings, qualitative

    • Effectiveness and cost of interventions


Acknowledgements

Acknowledgements

  • University of Bergen, Norway

  • WHO Country Office, Ethiopia

  • Regional Health Bureau, Gamo Goffa Zone Health Desk, and Arba Minch Hospital


Thank you

Thank You!


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