Transportation cost and retention in HIV care in Haiti

Leonard Sowah, MBChB, MPH

Assistant Professor of Medicine

University of Maryland School of Medicine

Acknowledgements

• Dr. Christa Desiral – who helped with data collection

• Miss Blaise – Who was very helpful with our data collection

• Dr. Ivy Mwangi – Who gave advice on data analysis

• Regine – Who helped in data collection

Background

• HIV infection has been shown to disproportionately affect economically disadvantaged individuals

• Studies in most resource limited settings and even in developed world suggest that transportation cost can affect HIV treatment outcomes

Background• Even in the US studies done in Southern USA suggest that

cost of transportation may affect retention in HIV clinic1

• Studies done in Sub-Saharan Africa using qualitative data suggests that patients have to make difficult decisions to make it to clinic appointment2

• In one study on loss to follow-up in Uganda a participant stated; “sometimes I have to do without maybe salt, paraffin, kerosene, so that I can get transportation to come here2

• There is a strong correlation between compliance to clinic appointment and failure of treatment

1. Sherer R, Stieglitz K, Narra J, et al. HIV multidisciplinary teams work: support services improve access to and retention in HIV primary care. AIDS care. 2002;14(S1):31-44.

2. Tuller DM, Bangsberg DR, Senkungu J, Ware NC, Emenyonu N, Weiser SD. Transportation costs impede sustained adherence and access to HAART in a clinic population in southwestern Uganda: a qualitative study. AIDS and Behavior. 2010;14(4):778-784.

Background• Cost of HIV care however increases

significantly if patients fail first line regimens

• HIV treatment interruptions therefore significantly affect the stability and economic indices of the health system1

• Losina et al calculated that treatment interruption on average reduces life-expectancy by 4.67 years2

1. Sanders D, Sambo A. AIDS in Africa: the implications of economic recession and structural adjustment. Health Policy and Planning. 1991;6(2):157-165. Losina E, Touré H, Uhler LM, et al. Cost-effectiveness of preventing loss to follow-up in HIV treatment programs: a Cote d'Ivoire appraisal. PLoS medicine. 2009;6(10):e1000173.

Study Rational

Aim

• To determine if the cost of transportation predicts loss to follow up in HIV Care

• Study Hypothesis– Patients living in locations with transportation cost

greater than $2 are more likely to be lost to care

– Patients living in locations that require two or more public transport trips to travel to clinic would be more likely to be lost to care

Study Rational

• We also considered other variables such as:– Age of patient

– Sex

– Milot residents vrs non-residents

– Residence in proposed clinic catchment area

– Enrolment CD4 count

Study Setting

• Hopital Sacre Coeur de Milot, HIV Clinic

• Located in Northern Haiti 12 miles southwest of Cap Haitien

• There are several other HIV treatment sites in the area

• Clinic offers transportation assistance to patients however policy on assistance has gone through multiple revisions

HÔpital Sacre Coeur de Milot

Study Population

• All patients enrolled in clinic prior to December 31st, 2006

• Exclusion Criteria

– Patients < 18 yrs of age as at December 31st 2006

– Patients without any form of address information in Medical Record

– Patients resident in locales outside the Northern Department

Patient Enrollment

Patient Enrollment Chart599 individuals enrolled in clinic from November 2004 – December 2006

53 individuals with age <18yrs by year end 2006 excluded

546 adult patients

439 adults > 18 years old with addresses remaining

107 individuals without addresses excluded

29 individuals resident outside of the Northern Department

excluded

Final sample of 410 adult patients

Study Methods

• Retrospective cohort design

• Data collection was by chart review of patients enrolled from November 2004 – December 31st, 2006

• Social workers were interviewed to obtain information on clinic policies on patient enrolment follow-up and patient support

• Data was analyzed using Cox’s proportional hazards regression to determine independent predictors of being lost to follow-up.

Data on Transportation CostsMunicipality Cost of two-way Taxi

(Haitien Gourde)Cost of two-waytaxi (US Dollar)

Distance in Miles to Milot

Milot 40.00 0.94

Cap Haitien 40.00 0.94 11.24

Grande Riviere du Nord 80.00 1.88 3.63

Plaine du Nord 80.00 1.88 5.46

Quartier Morin 80.00 1.88 7.58

Limonade 80.00 1.88 8.03

Dondon 240.00 5.65 6.73

Limbe 90.00 2.12 15.21

Acul du Nord 100.00 2.35 9.16

Bahon 140.00 3.29 14.06

Borgne 280.00 6.59 30.06

Bas Limbe 200.00 4.71 19.16

Ranquitte 240.00 5.65 18.75

Sainte Raphael 240.00 5.65 14.61

Pignon 380.00 8.94 24.98

Pilate 340.00 8.00 25.24

Table showing distribution of patients by various covariates and adjusted and unadjusted hazard ratios with age groups up to 60yr and above

Table showing unadjusted and adjusted hazards of

loss to follow by cost of transportation and distance with age as two categories.

Kaplan-Meier curves of retention by transportation cost using $1.00 cut point

Kaplan-Meier curves of retention by transportation cost and number of trips

All p-values are calculated by the log-rank test with the null hypothesis that the retention for the two groups are equal

Table Showing Differences in Mean Four Year Retention time by various categories

Summary of Results

• The four year retention rates for patients from communities with < $2 transportation cost is 81.9% cf 68.9% for those > $2

• Individuals from communities requiring more than $2 for two way transportation costs are 1.91 times as likely to be lost to care in 48 mths (p-value – 0.02)

Summary of Results

• Younger patients aged < 30 yrs were 3 times as likely to be lost to care in 48 mthscompared to older patients (p-value – 0.001)

• Individuals living in Milot did not have significantly better retention in clinic compared to all other patients

• Male patients were 1.7 times as likely to be lost to care compared to their female counterparts (p-value – 0.02)

Summary of Results

• Patients with CD4 counts less than 200 at time of enrolment are 1.68 times more likely to be lost to care after 48 mths (p-value 0.02)

• Male patients were 1.5 times more likely to come from places with transportation cost > $2 (p-value – 0.16)

• Mean transportation cost for females $1.36 (SD: 0.94), males $ 1.67 (SD:1.74)

Discussion

• Are patients with transportation cost > $2 who do not show up in clinic lost to care or just transferred to another facility?

• Why are younger patients < 30 yrs 3 times more likely to be lost to care?

• Why are men more likely to come from places with higher transportation costs?

• Why are some patients coming from places like Hinche 40 miles, Borgne 30 miles and Pilate 25 miles?

Study Team• Leonard Sowah1, MD,

MPH

• Franck Turenne2, MD

• Ulrike Buchwald1, MD

• Nephtalie Mesidor2, MD

• Guesly Delva1, MD

• Camille Dessaigne3, MS

• Anthony Edozien1, MD

• Harold Previl4, MD

• Devang Patel1, MD

• Robert Redfield1, MD

• Anthony Amoroso1, MD

• Institutions– Institute of Human

Virology, Baltimore MD1,

– Université Notre Dame d’Haiti, Port au Prince, Haiti2,

– University of Miami, Miami FL3,

– Hopital Sacre Coeur, Milot, Haiti4

THANK YOU VERY MUCH FOR YOUR

ATTENTION