outcomes of antiretroviral treatment programs in rural lesotho: health centers and hospitals...
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Outcomes of Antiretroviral Treatment Programs in Rural Lesotho: Health Centers and Hospitals Compared
Niklaus Labhardt, Motlalepula Sello, Mamokone A. Mohlaba, Olivia Keiser, Karolin Pfeiffer, Matthias Egger, Jochen Ehmer, Gilles Wandeler
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Background
• Scarce human resources limit the scale up of antiretroviral therapy (ART) in rural southern Africa
• Early losses to follow-up are highest in settings with lowest numbers of health-care workers
• Task shifting and decentralization of care are recommended strategies to address chronic health care worker shortages
• Previous reports on ART delivery in decentralized settings are limited to short-term outcomes
Van Damme et al. AIDS 2006Wandeler et al. JAIDS 2012Harries et al. Trop Med Int Health 2010Shumbusho et al. PLoS Med 2009
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Objectives
1. To describe programmatic factors and baseline characteristics of patients starting first-line ART in Hospitals and Health centers (HCs) in rural Lesotho
2. To compare short and long-term clinical outcomes between patients who started ART in the two types of facilities accross two different regions
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SolidarMed ART Program (SMART)
• Swiss NGO (www.solidarmed.ch)
• 9 hospitals, 40 health centers in 4 countries
• 13,100 patients on ART by 2011
• International epidemiologic Databases to Evaluate AIDS in Southern Africa (IeDEA-SA) network (www.iedea-sa.org)
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SMART Lesotho
Seboche1 hospital, 5 health centersPopulation: ~ 55‘000Adult HIV prevalence*: ~16%
Paray1 hospital, 7 health centersPopulation: ~ 77‘000Adult HIV prevalence*: ~20%
• 2005: ART at hospitals• 2007/08: Decentralization
*Demographic Health Survey of Lesotho 2009
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SMART Lesotho
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Inclusion criteria / definitions
Patients• Over 16 years at start of ART• No previous ART exposure• Started first-line ART including 2 NRTI and 1 NNRTI
Definitions• No follow up: no visit after the start of ART• LTFU: not returning to the clinic ≥ 6 months• Retained in care: alive and on ART
Chi et al. PLoS Med 2011
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Statistical analyses
• All analyses compared patients treated in the two facility types (Hospitals and HCs) and were stratified by region (Paray and Seboche)
• Baseline characteristics compared with chi-squared and Mann-Whitney tests
• Kaplan-Meier curves for crude retention• Multivariable logistic regression models for no follow-up • Competing risk regression models for mortality and
LTFU and results shown in a Forest plot
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Flow chart
ART start Jan 2008 - April 2011 N=3,969
ART start outside study areaN=222
ART start at hospital N=1,705
ART start at health center N=2,042
Paray N=832 Seboche N=873 Paray N=1,247 Seboche N=795
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Resources for ART delivery
Hospitals Health Centers4 Median number of physicians 03 Median number of nurse-clinicians 12 Median number of nurse-assistants 16 Median number of lay-counselors 2
Yes CD4 count on site NoYes Hemoglobin measurement on site InconsistentNo Viral Load measurement on site No
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Baseline characteristics of patients
Seboche (1,668) Paray (2,079)
Hospitals Health Centers P-value Hospitals Health Centers P-value
Number of patients 873 795 832 1,247
Number of women (%) 569 (65.2) 515 (64.8) 0.87 517 (62.1) 795 (63.8) 0.478
Median age in years (IQR)
37 (31-47) 39 (31-50) 0.028
37 (30-47) 39 (32-48) 0.007
Median absolute CD4 count in cells/µl (IQR)
169 (86-278) 208 (119-287) <0.001
157 (66-258) 215 (133-290) <0.001
Median hemoglobin level in g/dl (IQR)
11.4 (10-12.7) 12 (10.8-13.3) <0.001
12.1 (10.5-13.6) 12.5 (11.5-13.7) 0.002
WHO stage (%)
I/II 411 (47.1) 546 (68.7) <0.001 438 (52.6) 839 (67.4) <0.001
III/IV 462 (52.9) 249 (31.3) 394 (47.4) 405 (32.6)
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Overall retention in care: hospitals vs. HCs
50
100
60
70
80
90
1705 1009 583 245Hospitals2042 1284 677 128HCs
Number at risk
0 1 2 3
Health Centers Hospitals
Years after ART start
Pro
por
tion
of p
atie
nts
reta
ined
(%
)
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Retention in care: hospitals vs. HCs by region
50
100
60
70
80
90
Pro
por
tion
of p
atie
nts
reta
ined
(%
)
832 501 289 114Hosp. Paray
873 508 294 131Hosp. Seboche
1247 794 395 56HCs Paray
795 490 282 72HCs Seboche
Number at risk
0 1 2 3
Years after ART start
HCs Seboche HCs Paray
Hospital Seboche Hospital Paray
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Clinical outcomes, by region
All analyses are adjusted for gender, age, baseline CD4 cell count, WHO stage, ART regimen and region
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Limitations
• Heterogeneity between two regions
• Tracing of patients LTFU not consistent across sites
• Limited death ascertainment
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Conclusion
• In rural Lesotho, patients who started ART in health centers had less advanced HIV disease than those in hospitals
• Health centers: overall retention slightly better and early losses less likely compared to hospitals.
• However, the determinants of retention in care (mortality, LTFU) differed across regions, underlining the importance of tracing patients LTFU
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All patients and staff of the participating sitesCollaborators from: • SolidarMed Lesotho (N. Labhardt, M. Sello, M.
A. Mohlaba)• SolidarMed, Lucerne, Switzerland (J. Ehmer, K.
Pfeiffer)• University of Bern, Switzerland (M. Egger, O.
Keiser)Financial support: NIH (NIAID, Grant U01AI069924)
Acknowledgments