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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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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 Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia

  • 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 Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia


Study setting
Study Setting Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia

  • 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 Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia

  • 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 Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia

  • 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 Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia

  • 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 Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia

  • Arba Minch Hospital HIV Cohort has National clearance

  • Approval obtained locally for this specific study

  • De-identified secondary data used


Results
Results Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia


Cohort profile
Cohort profile Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia


Participant characteristics
Participant characteristics Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia


Factors advanced disease
Factors: advanced disease Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia


Pre art loss to follow up
Pre-ART loss to follow up Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia

  • 25% were lost to follow-up

    Predictors:aHR (95%CI)

    Less advanced disease 2.4 (1.3-2.6)

    Recent cohort 2.0 (1.6-2.6)

    Rural residence 1.8 (1.5-2.2)

  • Age, sex, and marital status not associated


Pre art mortality
Pre-ART mortality Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia

  • 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-up 2.4 (1.3-4.6)

      Advanced disease 2.8 (1.6-4.8)


Survival cox regression
Survival: Cox Regression Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia


Conclusions
Conclusions Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia

  • 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 Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia

  • 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 Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia

  • University of Bergen, Norway

  • WHO Country Office, Ethiopia

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


Thank you
Thank You! Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia


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