Evidence of improving antiretroviral therapy treatment delays: an analysis of eight years of programmatic outcomes in Blantyre, Malawi

BMC Public Health

Peter MacPherson⁴  Bernadette O’Hare³  David G Lalloo¹  Eddie M Phiri³  Ken Malisita³  Joep J van Oosterhout³  Derek J Sloan² 

[1]Faculty of Infectious and Tropical Diseases, Department of Clinical Sciences, Keppel Street, London, UK

[2]Centre for Global Health and Infection, University of Liverpool, Liverpool, UK

[3]College of Medicine, University of Malawi, Mahatma Ghandi Road, Blantyre, Malawi

[4]Clinical Group, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK

关键词: Programmatic research;    Africa;    HIV testing and counselling;    Linkage to care;    Antiretroviral therapy;    HIV;   

Others  :  1162191
DOI  :  10.1186/1471-2458-13-490

 received in 2012-11-26, accepted in 2013-05-14,  发布年份 2013

【 摘 要 】

Background

Impressive achievements have been made towards achieving universal coverage of antiretroviral therapy (ART) in sub-Saharan Africa. However, the effects of rapid ART scale-up on delays between HIV diagnosis and treatment initiation have not been well described.

Methods

A retrospective cohort study covering eight years of ART initiators (2004–2011) was conducted at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi. The time between most recent positive HIV test and ART initiation was calculated and temporal trends in delay to initiation were described. Factors associated with time to initiation were investigated using multivariate regression analysis.

Results

From 2004–2011, there were 15,949 ART initiations at QECH (56% female; 8% children [0–10 years] and 5% adolescents [10–20 years]). Male initiators were likely to have more advanced HIV infection at initiation than female initiators (70% vs. 64% in WHO stage 3 or 4). Over the eight years studied, there were declines in treatment delay, with 2011 having the shortest delay at 36.5 days. On multivariate analysis CD4 count <50 cells/μl (adjusted geometric mean ratio [aGMR]: aGMR: 0.53, bias-corrected accelerated [BCA] 95% CI: 0.42-0.68) was associated with shorter ART treatment delay. Women (aGMR: 1.12, BCA 95% CI: 1.03-1.22) and patients diagnosed with HIV at another facility outside QECH (aGMR: 1.61, BCA 95% CI: 1.47-1.77) had significantly longer treatment delay.

Conclusions

Continued improvements in treatment delays provide evidence that universal access to ART can be achieved using the public health approach adopted by Malawi However, the longer delays for women and patients diagnosed at outlying sites emphasises the need for targeted interventions to support equitable access for these groups.

【 授权许可】

   
2013 Sloan et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]UNAIDS: World AIDS Day Report. Geneva, Switzerland: UNAIDS; 2011.
• [2]World Health Organization: Global HIV/AIDS response. Epidemic update and health sector progress towards universal access. Progress report. Geneva, Switerland: World Health Organization; 2011.
• [3]Lowrance DW, Makombe S, Harries AD, Shiraishi RW, Hochgesang M, Aberle-Grasse J, Libamba E, Schouten E, Ellerbrock T, Kamoto K: A public health approach to rapid scale-up of antiretroviral treatment in Malawi during 2004–2006. J Acquir Immune Defic Syndr 2008, 49(3):287-293.
• [4]World Health Organization: Antiretroviral therapy for HIV infection in adults and adolescents: recommendations for a public health approach. Geneva, Switerland: World Health Organization; 2010.
• [5]Harries AD, Makombe SD, Libamba E, Schouten EJ: Why did the scale-up of hiv treatment work?: a case example from Malawi. J Acquir Immune Defic Syndr 2011, 57(Suppl 2):S64-67.
• [6]Ministry of Health: Quarterly HIV Programme Report 2011, Q2. Lilongwe, Malawi: Ministry of Health, Government of Malawi; 2011.
• [7]Rosen S, Fox MP: Retention in HIV care between testing and treatment in Sub-Saharan Africa: a systematic review. PLoS Med 2011, 8(7):e1001056.
• [8]Macpherson P, Lalloo DG, Choko AT, Mann GH, Squire SB, Mwale D, Manda E, Makombe SD, Desmond N, Heyderman R: Suboptimal patterns of provider initiated HIV testing and counselling, antiretroviral therapy eligibility assessment and referral in primary health clinic attendees in Blantyre, Malawi. TM & IH 2012, 17(4):507-517.
• [9]van Oosterhout JJ, Kumwenda JK, Hartung T, Mhango B, Zijlstra EE: Can the initial success of the Malawi ART scale-up programme be sustained? The example of Queen Elizabeth Central Hospital, Blantyre. AIDS Care 2007, 19(10):1241-1246.
• [10]Douglas GP, Gadabu OJ, Joukes S, Mumba S, McKay MV, Ben-Smith A, Jahn A, Schouten EJ, Landis Lewis Z, van Oosterhout JJ: Using touchscreen electronic medical record systems to support and monitor national scale-up of antiretroviral therapy in Malawi. PLoS Med 2010, 7(8):e1000319.
• [11]Ministry of Health: Clinical Management of HIV in Children and Adults. Lilongwe, Malawi: Ministry of Health, Government of Malawi; 2011.
• [12]Kranzer K, Govindasamy D, Ford N, Johnston V, Lawn SD: Quantifying and addressing losses along the continuum of care for people living with HIV infection in sub-Saharan Africa: a systematic review. J Int AIDS Soc 2012, 15(2):17383.
• [13]Micek MA, Gimbel-Sherr K, Baptista AJ, Matediana E, Montoya P, Pfeiffer J, Melo A, Gimbel-Sherr S, Johnson W, Gloyd S: Loss to follow-up of adults in public HIV care systems in central Mozambique: identifying obstacles to treatment. J Acquir Immune Defic Syndr 2009, 52(3):397-405.
• [14]Bassett IV, Regan S, Chetty S, Giddy J, Uhler LM, Holst H, Ross D, Katz JN, Walensky RP, Freedberg KA: Who starts antiretroviral therapy in Durban, South Africa?… not everyone who should. AIDS 2010, 24(Suppl 1):S37-44.
• [15]Bemelmans M, Van Den Akker T, Ford N, Philips M, Zachariah R, Harries A, Schouten E, Hermann K, Mwagomba B, Massaquoi M: Providing universal access to antiretroviral therapy in Thyolo, Malawi through task shifting and decentralization of HIV/AIDS care. Trop Med Int Health 2010.
• [16]Macpherson P, Corbett EL, Makombe SD, van Oosterhout JJ, Manda E, Choko AT, Thindwa D, Squire SB, Mann GH, Lalloo DG: Determinants and consequences of failure of linkage to antiretroviral therapy at primary care level in Blantyre, Malawi: a prospective cohort study. PLoS One 2012, 7(9):e44794.
• [17]Roura M, Busza J, Wringe A, Mbata D, Urassa M, Zaba B: Barriers to sustaining antiretroviral treatment in Kisesa, Tanzania: a follow-up study to understand attrition from the antiretroviral program. AIDS Patient Care STDS 2009, 23(3):203-210.
• [18]Druyts E, Dybul M, Kanters S, Nachega J, Birungi J, Ford N, Thorlund K, Negin J, Lester R, Yaya S: Male sex and the risk of mortality among individuals enrolled in antiretroviral therapy programs in Africa: a systematic review and meta-analysis. AIDS 2013, 27(3):417-425.
• [19]Braitstein P, Boulle A, Nash D, Brinkhof MW, Dabis F, Laurent C, Schechter M, Tuboi SH, Sprinz E, Miotti P: Gender and the use of antiretroviral treatment in resource-constrained settings: findings from a multicenter collaboration. J Wom Health (2002) 2008, 17(1):47-55.
• [20]Lawn SD, Harries AD, Anglaret X, Myer L, Wood R: Early mortality among adults accessing antiretroviral treatment programmes in sub-Saharan Africa. AIDS 2008, 22(15):1897-1908.
• [21]MacPherson P, Moshabela M, Martinson N, Pronyk P: Mortality and loss to follow-up among HAART initiators in rural South Africa. Trans R Soc Trop Med Hyg 2009, 103(6):588-593.
• [22]Bassett IV, Wang B, Chetty S, Mazibuko M, Bearnot B, Giddy J, Lu Z, Losina E, Walensky RP, Freedberg KA: Loss to care and death before antiretroviral therapy in Durban, South Africa. J Acquir Immune Defic Syndr 2009, 51(2):135-139.
• [23]Zachariah R, Harries AD, Manzi M, Gomani P, Teck R, Phillips M, Firmenich P: Acceptance of anti-retroviral therapy among patients infected with HIV and tuberculosis in rural Malawi is low and associated with cost of transport. PLoS One 2006, 1:e121.
• [24]Jani IV, Sitoe NE, Alfai ER, Chongo PL, Quevedo JI, Rocha BM, Lehe JD, Peter TF: Effect of point-of-care CD4 cell count tests on retention of patients and rates of antiretroviral therapy initiation in primary health clinics: an observational cohort study. Lancet 2011, 378(9802):1572-1579.
• [25]Schouten EJ, Jahn A, Midiani D, Makombe SD, Mnthambala A, Chirwa Z, Harries AD, van Oosterhout JJ, Meguid T, Ben-Smith A: Prevention of mother-to-child transmission of HIV and the health-related Millennium Development Goals: time for a public health approach. Lancet 2011, 378(9787):282-284.
• [26]Ferrand RA, Munaiwa L, Matsekete J, Bandason T, Nathoo K, Ndhlovu CE, Munyati S, Cowan FM, Gibb DM, Corbett EL: Undiagnosed HIV infection among adolescents seeking primary health care in Zimbabwe. Clin Infect Dis 2010, 51(7):844-851.
• [27]Desai SR, Copley SJ, Barker RD, Elston CM, Miller RF, Wells AU, Munyati S, Nathoo K, Corbett EL, Ferrand RA: Chest radiography patterns in 75 adolescents with vertically-acquired human immunodeficiency virus (HIV) infection. Clin Radiol 2011, 66(3):257-263.
• [28]Ferrand RA, Bandason T, Musvaire P, Larke N, Nathoo K, Mujuru H, Ndhlovu CE, Munyati S, Cowan FM, Gibb DM: Causes of acute hospitalization in adolescence: burden and spectrum of HIV-related morbidity in a country with an early-onset and severe HIV epidemic: a prospective survey. PLoS Med 2010, 7(2):e1000178.