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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 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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  1. 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

  2. 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

  3. Methods

  4. 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

  5. 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).

  6. 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

  7. 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

  8. Ethics • Arba Minch Hospital HIV Cohort has National clearance • Approval obtained locally for this specific study • De-identified secondary data used

  9. Results

  10. Cohort profile

  11. Participant characteristics

  12. Factors: advanced disease

  13. 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 cohort 2.0 (1.6-2.6) Rural residence 1.8 (1.5-2.2) • Age, sex, and marital status not associated

  14. 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-up 2.4 (1.3-4.6) Advanced disease 2.8 (1.6-4.8)

  15. Survival: Cox Regression

  16. 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

  17. 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

  18. Acknowledgements • University of Bergen, Norway • WHO Country Office, Ethiopia • Regional Health Bureau, Gamo Goffa Zone Health Desk, and Arba Minch Hospital

  19. Thank You!

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