Lost-to-follow up

Pilot study on assessment of LTFU of HIV-infected patients

Rwandan PI: Jean Claude Dusingize, MD; Co-investigators:

  • Denis Nash MD
  • Qiuhu Shi PhD
  • Eugene Mutimura PhD
  • Jean D’Amour Sinayobye MD
  • Kathryn Anastos MD
  • Background

    The purpose of this study is to improve our understanding of barriers and enablers to timely antiretroviral treatment (ART) initiation in Rwanda as part of the sub-Saharan Africa by further examining the comparatively more successful experience of Rwanda, and contrasting it to the less successful experiences of nearby countries. Despite this considerable successes in initiating millions of patients on ART in resource-limited settings1, most sub-Saharan African patients initiate ART late2,3 resulting in substantial early mortality4, more complicated and costly clinical management5, and missed opportunities to prevent HIV transmission.6-10 Many sub-Saharan African national HIV treatment programs have recently adopted the 2010 WHO guidelines for ART eligibility of CD4<350 cells/µL (irrespective of WHO stage) and WHO stage 3 or 4 (irrespective of CD4 count). 11 However, the majority of patients in sub-Saharan Africa initiate ART at levels well below these thresholds (e.g., median of 80-212 cells/µL).12-32 A recent global analysis of data from 48 countries from the International epidemiologic Databases to Evaluate AIDS (IeDEA) and European cohorts in the ART Cohort Collaboration found that the US had the highest median CD4 count at ART initiation (307 cells/µL [National guidelines 500 cells/µL until very recently) followed, remarkably, by Rwanda (287 cells/µL [National guidelines 350 cells/µL]).33,34 For sub-Saharan Africa and other regions scaling up access to ART, the most recent published data suggest there are important lessons to be learned from the successes around the HIV scale-up experience in Rwanda35, where universal coverage of ART has nearly been achieved and the median CD4 count at ART initiation is the highest in the region.

    Aim:

    To examine factors associated with

    1. Non-retention in care prior to ART initiation

    2. Late ART initiation in Rwanda in the context of recently expanded treatment guidelines. Rwanda expanded ART eligibility to 350 cells in 2008 and again in 2012 to 500 cells/µL. Through one-time structured interviews at 4 HIV care clinics, Aim 1 will characterize potential determinants of:

  • Non-retention in HIV care prior to ART initiation among a sample of persons enrolling in HIV care who are not yet eligible for ART (n=400).
  • Late ART initiation (CD4<150 cells or WHO
  • Among a sample of patients initiating ART (n=400). Interviews will allow us to look at determinants beyond basic demographic and clinical factors in Rwanda, including those related to the timing of HIV diagnosis, testing circumstances, HIV knowledge and treatment literacy, perceived/enacted stigma, mental health, and care experiences. By linking baseline interview information with the existing longitudinal clinical database at each site, we will assess the determinants of non-retention prior to ART initiation, and, for those initiating ART, retention in care following ART initiation among other key outcomes. Since we will use existing protocols and instruments from an existing study of late ART initiation in the region (1R01MH089831, PIs Nash and Elul), substantial time and effort will be saved.

    The HIV treatment program in Rwanda is anticipated to have a status Quo scenario that would have similar results in a >25% increase in demand for HIV treatment over a 5-year period (Figure 1). The analysis finds simultaneous improvements in engagement along the care continuum will result in ART coverage estimates that exceed WHO targets. In this preliminary work, the study team also evaluated the model’s performance.36-38 We compared model predictions to country-level reports of the number on ART over time.39-40 Model estimates of the number on ART closely approximate country reports of the number on treatment in Rwanda between 2004 and 2012 (Figure 2). We will carry out a pilot study under Kicukiro and Gahanga health Centers under Masaka district hospital.

    LTFU_figure1

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