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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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

  • 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


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

  • 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

  • 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

  • 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

  • Arba Minch Hospital HIV Cohort has National clearance

  • Approval obtained locally for this specific study

  • De-identified secondary data used


Results


Cohort profile


Participant characteristics


Factors: advanced disease


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

  • 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


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

  • 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

  • University of Bergen, Norway

  • WHO Country Office, Ethiopia

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


Thank You!


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