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      Retention and Risk Factors for Attrition in a Large Public Health ART Program in Myanmar: A Retrospective Cohort Analysis

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          Abstract

          Background

          The outcomes from an antiretroviral treatment (ART) program within the public sector in Myanmar have not been reported. This study documents retention and the risk factors for attrition in a large ART public health program in Myanmar.

          Methods

          A retrospective analysis of a cohort of adult patients enrolled in the Integrated HIV Care (IHC) Program between June 2005 and October 2011 and followed up until April 2012 is presented. The primary outcome was attrition (death or loss-follow up); a total of 10,223 patients were included in the 5-year cumulative survival analysis. Overall 5,718 patients were analyzed for the risk factors for attrition using both logistic regression and flexible parametric survival models.

          Result

          The mean age was 36 years, 61% of patients were male, and the median follow up was 13.7 months. Overall 8,564 (84%) patients were retained in ART program: 750 (7%) were lost to follow-up and 909 (9%) died. During the 3 years follow-up, 1,542 attritions occurred over 17,524 person years at risk, giving an incidence density of 8.8% per year. The retention rates of participants at 12, 24, 36, 48 and 60 months were 86, 82, 80, 77 and 74% respectively. In multivariate analysis, being male, having high WHO staging, a low CD4 count, being anaemic or having low BMI at baseline were independent risk factors for attrition; tuberculosis (TB) treatment at ART initiation, a prior ART course before program enrollment and literacy were predictors for retention in the program.

          Conclusion

          High retention rate of IHC program was documented within the public sector in Myanmar. Early diagnosis of HIV, nutritional support, proper investigation and treatment for patients with low CD4 counts and for those presenting with anaemia are crucial issues towards improvement of HIV program outcomes in resource-limited settings.

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          Most cited references20

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          Survival rate and risk factors of mortality among HIV/tuberculosis-coinfected patients with and without antiretroviral therapy.

          Achara Chaovavanich, Suthat Chottanapand, Weerawat Manosuthi … (2006)
          The impact of antiretroviral therapy (ART) on survival among patients coinfected with HIV and tuberculosis (TB) has not been well established. A retrospective cohort study was conducted among HIV-infected patients with TB between January 2000 and December 2004. Patients were categorized into ART+ group (received ART) and ART- group (did not receive ART) and were followed until April 2005. A total of 1003 patients were identified; 411 in ART+ group and 592 in ART- group. Median (interquartile range) CD4 count was 53 (20-129) cells/mm3. Survival rates at 1, 2, and 3 years after TB diagnosis were 96.1%, 94.0%, and 87.7% for ART+ group and 44.4%, 19.2%, and 9.3% for ART- group (log-rank test, P or=6 months after TB diagnosis had a higher mortality rate than those who initiated ART<6 months after TB diagnosis (P 0.018, hazard ratio=2.651, 95% confidence interval=1.152-6.102). Antiretroviral therapy substantially reduces mortality rate among HIV/TB-coinfected patients. Initiation of ART within 6 months of TB diagnosis is associated with greater survival.
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            Positive outcomes of HAART at 24 months in HIV-infected patients in Cambodia.

            Laurent Ferradini, Didier Laureillard, Narom Prak … (2007)
            African and Asian cohort studies have demonstrated the feasibility and efficacy of HAART in resource-poor settings. The long-term virological outcome and clinico-immunological criteria of success remain important questions. We report the outcomes at 24 months of antiretroviral therapy (ART) in patients treated in a Médecins Sans Frontières/Ministry of Health programme in Cambodia. Adults who started HAART 24 +/- 2 months ago were included. Plasma HIV-RNA levels were assessed by real-time polymerase chain reaction. Factors associated with virological failure were analysed using logistic regression. Of 416 patients, 59.2% were men; the median age was 33.6 years. At baseline, 95.2% were ART naive, 48.9% were at WHO stage IV, and 41.6% had a body mass index less than 18 kg/m. The median CD4 cell count was 11 cells/microl. A stavudine-lamivudine-efavirenz-containing regimen was initiated predominantly (81.0%). At follow-up (median 23.8 months), 350 (84.1%) were still on HAART, 53 (12.7%) had died, six (1.4%) were transferred, and seven (1.7%) were lost to follow-up. Estimates of survival were 85.5% at 24 months. Of 346 tested patients, 259 (74.1%) had CD4 cell counts greater than 200 cells/microl and 306 (88.4%) had viral loads of less than 400 copies/ml. Factors associated with virological failure at 24 months were non-antiretroviral naive, an insufficient CD4 cell gain of less than 350 cells/microl or a low trough plasma ART concentration. In an intention-to-treat analysis, 73.6% of patients were successfully treated. Positive results after 2 years of advanced HIV further demonstrate the efficacy of HAART in the medium term in resource-limited settings.
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              Comparison of Tenofovir, Zidovudine, or Stavudine as Part of First-Line Antiretroviral Therapy in a Resource-Limited-Setting: A Cohort Study

              Kavindhran Velen, James J Lewis, Salome Charalambous … (2013)
              Background Tenofovir (TDF) is part of the WHO recommended first-line antiretroviral therapy (ART); however, there are limited data comparing TDF to other nucleoside reverse transcriptase inhibitors in resource-limited-settings. Using a routine workplace and community-based ART cohort in South Africa, we assessed single drug substitution, HIV RNA suppression, CD4 count increase, loss-from-care, and mortality between TDF, stavudine (d4T) 30 mg dose, and zidovudine (AZT). Methods In a prospective cohort study we included ART naïve patients aged ≥17 years-old who initiated ART containing TDF, d4T, or AZT between 2007 and 2009. For analysis of single drug substitutions we used a competing-risks time-to-event analysis; for loss-from-care, mixed-effect Poisson modeling; for HIV RNA suppression, competing-risks logistic regression; for CD4 count slope, mixed-effects linear regression; and for mortality, proportional hazards modeling. Results Of 6,196 patients, the initial drug was TDF for 665 (11%), d4T for 4,179 (68%), and AZT for 1,352 (22%). During the first 6 months of ART, the adjusted hazard ratio for a single drug substitution was 2.3 for d4T (95% confidence interval [CI]: 0.27, 19) and 5.2 for AZT (95% CI: 1.1, 23), compared to TDF; whereas, after 6 months, it was 10 (95% CI: 5.8, 18) and 4.4 (95% CI: 2.5, 7.8) for d4T and AZT, respectively. Virologic suppression was similar by agent; however, CD4 count rise was lowest for AZT. The adjusted hazard ratio for loss-from-care, when compared to TDF, was 1.5 (95% CI: 1.1, 1.9) for d4T and 1.2 (95% CI: 1.1, 1.4) for AZT. The adjusted hazard ratio for mortality, when compared to TDF, was 2.7 (95% CI: 2.0, 3.5) and 1.4 (95% CI: 1.3, 1.5) and for d4T and AZT, respectively. Discussion In routine care, TDF appeared to perform better than either d4T or AZT, most notably with less drug substitution and mortality than for either other agent.
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                Author and article information

                Contributors
                Eduard J. Beck: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2014
                Publication date (Electronic): 30 September 2014
                Volume: 9
                Issue: 9
                Electronic Location Identifier: e108615
                Affiliations
                [1 ]The Union Office in Myanmar, International Union Against Tuberculosis and Lung Disease, Mandalay, Myanmar
                [2 ]Infectious Diseases Programme, Saw Swee Hock School of Public Health, National University of Singapore, Singapore
                [3 ]Innovation Unit, Médecins Sans Frontières, Geneva, Switzerland
                [4 ]Maths and Statistics Help Centre, James Cook University, Singapore
                [5 ]Medical Care Division, Department of Health, Mandalay, Myanmar
                [6 ]National AIDS Program, Department of Health, Nay Pyi Taw, Myanmar
                [7 ]Disease Control Division, Department of Health, Nay Pyi Taw, Myanmar
                UNAIDS, Trinidad And Tobago
                Author notes

                Competing Interests: Total Yadana, a commercial source, was among other funders. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

                Conceived and designed the experiments: AT STTT SKKZ ZHW P. Clevenbergh AAL P. Cavailler JC. Performed the experiments: MMA PP KWN KNZ MS TTK SKKZ P. Clevenbergh. Analyzed the data: AAL P. Cavailler JC STTT AT P. Clevenbergh. Contributed reagents/materials/analysis tools: AT STTT SKKZ AAL P. Cavailler JC ZHW P. Clevenbergh. Wrote the paper: AT AAL P. Cavailler JC P. Clevenbergh.

                Article
                Publisher ID: PONE-D-13-45432
                DOI: 10.1371/journal.pone.0108615
                PMC ID: 4182661
                PubMed ID: 25268903
                SO-VID: 9fee213f-f886-417a-b519-ab883ab16a53
                Copyright statement: Copyright @ 2014
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 20 January 2014
                Date accepted : 1 September 2014
                Page count
                Pages: 12
                Funding
                Total Yadana, GF round 9 and 3 Diseases Fund have supported the work. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Subject: Research Article
                Subject: Biology and Life Sciences
                Subject: Microbiology
                Subject: Medical Microbiology
                Subject: Microbial Pathogens
                Subject: Viral Pathogens
                Subject: Immunodeficiency Viruses
                Subject: HIV
                Subject: Plant Science
                Subject: Plant Pathology
                Subject: Infectious Disease Epidemiology
                Subject: Medicine and health sciences
                Subject: Diagnostic medicine
                Subject: HIV clinical manifestations
                Subject: Epidemiology
                Subject: HIV epidemiology
                Subject: Health Care
                Subject: Socioeconomic Aspects of Health
                Subject: Infectious Diseases
                Subject: Viral Diseases
                Subject: AIDS
                Subject: Infectious Disease Control
                Subject: Sexually Transmitted Diseases
                Subject: Public and Occupational Health
                Subject: Behavioral and Social Aspects of Health
                Subject: Preventive Medicine
                Subject: Research and Analysis Methods
                Subject: Research Design
                Subject: Clinical Research Design
                Subject: Cohort Studies

                ScienceOpen disciplines: Uncategorized
                Data availability:
                ScienceOpen disciplines: Uncategorized

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