214
views
0
recommends
+1 Recommend
0 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      Attrition from HIV treatment after enrollment in a differentiated service delivery model: A cohort analysis of routine care in Zambia

      research-article

      Read this article at

      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Background

          Many sub-Saharan Africa countries are scaling up differentiated service delivery (DSD) models for HIV treatment to increase access and remove barriers to care. We assessed factors associated with attrition after DSD model enrollment in Zambia, focusing on patient-level characteristics.

          Methods

          We conducted a retrospective record review using electronic medical records (EMR) of adults (≥15 years) initiated on antiretroviral (ART) between 01 January 2018 and 30 November 2021. Attrition was defined as lost to follow-up (LTFU) or died by November 30, 2021. We categorized DSD models into eight groups: fast-track, adherence groups, community pick-up points, home ART delivery, extended facility hours, facility multi-month dispensing (MMD, 4–6-month ART dispensing), frequent refill care (facility 1–2 month dispensing), and conventional care (facility 3 month dispensing, reference group). We used Fine and Gray competing risk regression to assess patient-level factors associated with attrition, stratified by sex and rural/urban setting.

          Results

          Of 547,281 eligible patients, 68% (n = 372,409) enrolled in DSD models, most commonly facility MMD (n = 306,430, 82%), frequent refill care (n = 47,142, 13%), and fast track (n = 14,433, 4%), with <2% enrolled in the other DSD groups. Retention was higher in nearly all DSD models for all dispensing intervals, compared to the reference group, except fast track for the ≤2 month dispensing group. Retention benefits were greatest for patients in the extended clinic hours group and least for fast track dispensing.

          Conclusion

          Although retention in HIV treatment differed by DSD type, dispensing interval, and patient characteristics, nearly all DSD models out-performed conventional care. Understanding the factors that influence the retention of patients in DSD models could provide an important step towards improving DSD implementation.

          Related collections

          Most cited references16

          • Record: found
          • Abstract: found
          • Article: not found

          Competing risk analysis using R: an easy guide for clinicians.

          In the last decade with widespread use of quantitative analyses in medical research, close co-operation between statisticians and physicians has become essential from the experimental design through all phases of complex statistical analysis. On the other hand, easy-to-use statistical packages allow clinicians to perform basic statistical analyses themselves. Since the software they most commonly use does not perform in depth competing risk analysis, we recommend an add-on package for the R statistical software. We provide all the instructions for downloading it from internet and illustrate how to use it for analysis of a sample dataset of patients who underwent haematopoietic stem cell transplantation for acute leukaemia.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: found
            Is Open Access

            Reframing HIV care: putting people at the centre of antiretroviral delivery

            The delivery of HIV care in the initial rapid scale-up of HIV care and treatment was based on existing clinic-based models, which are common in highly resourced settings and largely undifferentiated for individual needs. A new framework for treatment based on variable intensities of care tailored to the specific needs of different groups of individuals across the cascade of care is proposed here. Service intensity is characterised by four delivery components: (i) types of services delivered, (ii) location of service delivery, (iii) provider of health services and (iv) frequency of health services. How these components are developed into a service delivery framework will vary across countries and populations, with the intention being to improve acceptability and care outcomes. The goal of getting more people on treatment before they become ill will necessitate innovative models of delivering both testing and care. As HIV programmes expand treatment eligibility, many people entering care will not be ‘patients’ but healthy, active and productive members of society 1. To take the framework to scale, it will be important to: (i) define which individuals can be served by an alternative delivery framework; (ii) strengthen health systems that support decentralisation, integration and task shifting; (iii) make the supply chain more robust; and (iv) invest in data systems for patient tracking and for programme monitoring and evaluation. La délivrance des soins du VIH dans le déploiement initial rapide des soins et du traitement du VIH a été basée sur des modèles existants dans les cliniques, qui sont courants dans les régions bénéficiant d’importantes ressources et largement indifférenciées pour les besoins individuels. Un nouveau cadre est proposé ici pour le traitement basé selon les intensités variables de soins, adaptés aux besoins spécifiques des différents groupes de personnes à travers la cascade de soins. L’intensité des services est caractérisée par quatre éléments de délivrance: (1) les types de services délivrés, (2) l’emplacement de la délivrance des services, (3) Les prestataires des services de santé et (4) la fréquence des services de santé. La façon dont ces éléments sont développés dans un cadre de prestation de services peut varier selon les pays et les populations, l’intention étant d’améliorer les résultats d’acceptabilité et des soins. Le but d’obtenir plus de personnes sous traitement avant qu’ils ne tombent malades nécessitera des modèles innovateurs de prestation à la fois pour dépistage et pour les soins. Comme les programmes VIH étendent l’éligibilité au traitement, beaucoup de gens qui entrent dans les soins ne seront pas des “malades- mais des éléments sains de la société, actifs et productifs. Afin de tenir le cadre à l’échelle, il sera important de: (1) définir les individus qui peuvent être traités par un cadre alternatif de prestation, (2) renforcer les systèmes de santé qui soutiennent la décentralisation, l’intégration et le transfert des tâches; (3) rendre la chaîne d’approvisionnement plus robuste et (4) investir dans des systèmes de données pour le suivi des patients et pour le suivi et l’évaluation du programme. Los servicios de atención del VIH durante el inicio de la primera etapa de rápida expansión del tratamiento y cuidados del VIH estaban basados en modelos clínicos existentes, comunes en lugares con abundancia de recursos y poco diferenciados en cuanto a necesidades individuales. Aquí se propone un nuevo marco para el tratamiento basado en intensidades variables de cuidados, hecho a medida según las necesidades específicas de los diferentes grupos de individuos a lo largo del tratamiento. La intensidad del servicio se caracteriza por cuatro componentes de entrega: (1) tipología de los servicios ofrecidos, (2) lugar de entrega de los servicios, (3) proveedor de los servicios sanitarios, y (4) frecuencia de los servicios sanitarios. El cómo estos componentes conforman un marco de entrega de servicios variará según el país y la población, con la intención de mejorar la aceptabilidad y los resultados de los cuidados. El objetivo de conseguir que más personas reciban tratamiento antes de que enfermen requerirá de modelos innovadores en la oferta tanto de pruebas para detección como de los cuidados. A medida que los programas para el VIH expandan los criterios de elegibilidad para el tratamiento, muchas de las personas que comiencen a recibir cuidados no serán “pacientes- sino miembros sanos, activos y productivos de la sociedad. Con el fin de expandir la escala de esta estructura, sería importante: (1) definir cuales individuos pueden ser atendidos dentro de un marco de entrega de servicios alternativo; (2) fortalecer los sistemas sanitarios que apoyan la descentralización, integración y delegación de funciones; (3) robustecer la cadena de proveedores; e (4) invertir en sistemas de datos para el seguimiento de pacientes y para la monitorización y evaluación de programas.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: found
              Is Open Access

              Retention and mortality on antiretroviral therapy in sub‐Saharan Africa: collaborative analyses of HIV treatment programmes

              Abstract Introduction By 2020, 90% of all people diagnosed with HIV should receive long‐term combination antiretroviral therapy (ART). In sub‐Saharan Africa, this target is threatened by loss to follow‐up in ART programmes. The proportion of people retained on ART long‐term cannot be easily determined, because individuals classified as lost to follow‐up, may have self‐transferred to another HIV treatment programme, or may have died. We describe retention on ART in sub‐Saharan Africa, first based on observed data as recorded in the clinic databases, and second adjusted for undocumented deaths and self‐transfers. Methods We analysed data from HIV‐infected adults and children initiating ART between 2009 and 2014 at a sub‐Saharan African HIV treatment programme participating in the International epidemiology Databases to Evaluate AIDS (IeDEA). We used the Kaplan–Meier method to calculate the cumulative incidence of retention on ART and the Aalen–Johansen method to calculate the cumulative incidences of death, loss to follow‐up, and stopping ART. We used inverse probability weighting to adjust clinic data for undocumented mortality and self‐transfer, based on estimates from a recent systematic review and meta‐analysis. Results We included 505,634 patients: 12,848 (2.5%) from Central Africa, 109,233 (21.6%) from East Africa, 347,343 (68.7%) from Southern Africa and 36,210 (7.2%) from West Africa. In crude analyses of observed clinic data, 52.1% of patients were retained on ART, 41.8% were lost to follow‐up and 6.0% had died 5 years after ART initiation. After accounting for undocumented deaths and self‐transfers, we estimated that 66.6% of patients were retained on ART, 18.8% had stopped ART and 14.7% had died at 5 years. Conclusions Improving long‐term retention on ART will be crucial to attaining the 90% on ART target. Naïve analyses of HIV cohort studies, which do not account for undocumented mortality and self‐transfer of patients, may severely underestimate both mortality and retention on ART.
                Bookmark

                Author and article information

                Contributors
                Role: Formal analysisRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Project administrationRole: Writing – review & editing
                Role: MethodologyRole: Writing – review & editing
                Role: Data curationRole: Writing – review & editing
                Role: Project administrationRole: Writing – review & editing
                Role: Project administrationRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: MethodologyRole: Project administrationRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS One
                plos
                PLOS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                14 March 2023
                2023
                : 18
                : 3
                : e0280748
                Affiliations
                [1 ] Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA, United States of America
                [2 ] Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
                [3 ] Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, Netherlands
                [4 ] Clinton Health Access Initiative, Lusaka, Zambia
                [5 ] HIV Programmes and Advocacy, International AIDS Society, Cape Town, South Africa
                [6 ] Ministry of Health, Lusaka, Zambia
                [7 ] Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
                [8 ] Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
                University of New South Wales, AUSTRALIA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                https://orcid.org/0000-0002-1199-8377
                https://orcid.org/0000-0002-6560-2964
                Article
                PONE-D-22-19252
                10.1371/journal.pone.0280748
                10013882
                36917568
                c010ea76-eb2f-4002-9a28-2853e1d70ea6
                © 2023 Jo et al

                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
                : 7 July 2022
                : 7 January 2023
                Page count
                Figures: 3, Tables: 2, Pages: 10
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100000865, Bill and Melinda Gates Foundation;
                Award ID: OPP1192640
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100006084, Office of AIDS Research;
                Award ID: 1F32MH128120-01
                Award Recipient :
                Funding for the study was provided by the Bill & Melinda Gates Foundation through OPP1192640 to Boston University. YJ is supported by the Ruth L. Kirschstein National Research Service Award, National Institutes of Health F32 Individual Fellowship Grant (grant number: 1F32MH128120-01). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Health Care
                Health Care Facilities
                Medicine and Health Sciences
                Epidemiology
                Medical Risk Factors
                Biology and Life Sciences
                Immunology
                Vaccination and Immunization
                Antiviral Therapy
                Antiretroviral Therapy
                Medicine and Health Sciences
                Immunology
                Vaccination and Immunization
                Antiviral Therapy
                Antiretroviral Therapy
                Medicine and Health Sciences
                Public and Occupational Health
                Preventive Medicine
                Vaccination and Immunization
                Antiviral Therapy
                Antiretroviral Therapy
                People and Places
                Geographical Locations
                Africa
                Zambia
                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Viral Pathogens
                Immunodeficiency Viruses
                HIV
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Pathogens
                Microbial Pathogens
                Viral Pathogens
                Immunodeficiency Viruses
                HIV
                Biology and Life Sciences
                Organisms
                Viruses
                Viral Pathogens
                Immunodeficiency Viruses
                HIV
                Biology and Life Sciences
                Organisms
                Viruses
                Immunodeficiency Viruses
                HIV
                Biology and life sciences
                Organisms
                Viruses
                RNA viruses
                Retroviruses
                Lentivirus
                HIV
                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Viral Pathogens
                Retroviruses
                Lentivirus
                HIV
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Pathogens
                Microbial Pathogens
                Viral Pathogens
                Retroviruses
                Lentivirus
                HIV
                Biology and Life Sciences
                Organisms
                Viruses
                Viral Pathogens
                Retroviruses
                Lentivirus
                HIV
                Medicine and Health Sciences
                Health Care
                Health Information Technology
                Electronic Medical Records
                Computer and Information Sciences
                Information Technology
                Health Information Technology
                Electronic Medical Records
                Medicine and Health Sciences
                Epidemiology
                Pandemics
                People and places
                Geographical locations
                Africa
                South Africa
                Custom metadata
                The data used in this manuscript, which comprise a patient-level data set that contains individual patient information, are owned by the Zambian Ministry of Health. Permission to access these data must be obtained from the Ministry of Health. For information on how to request permission, researchers may contact the Zambia National Health Research Authority (NHRA), Paediatric Centre of Excellence, University Teaching Hospital, P.O. Box 30075, Lusaka, Zambia. Tel: +260211 250309; email: znhrasec@ 123456gmail.com ; website: www.nhra.org.zm.

                Uncategorized
                Uncategorized

                Comments

                Comment on this article