Timely initiation of HIV antiretroviral therapy in Haiti 2004-2018: a retrospective cohort study.

OBJECTIVE: To describe trends in timing of ART initiation for newly diagnosed people living with HIV before and after Haiti adopted its Test and Start policy for universal HIV antiretroviral therapy (ART) in July 2016, and to explore predictors of timely ART initiation for both newly and previously diagnosed people living with HIV following Test and Start adoption. METHODS: This retrospective cohort study explored timing of ART initiation among 147 900 patients diagnosed with HIV at 94 ART clinics in 2004-2018 using secondary electronic medical record data. The study used survival analysis methods to assess time trends and risk factors for ART initiation. RESULTS: Timely uptake of ART expanded with Test and Start, such that same-day ART initiation rates increased from 3.7% to 45.0%. However, only 11.0% of previously diagnosed patients initiated ART after Test and Start. In adjusted analyses among newly diagnosed people living with HIV, factors negatively associated with timely ART initiation included being a pediatric patient aged 0-14 years (HR = 0.23, p < 0.001), being male (HR = 0.92, p = 0.03), being 50+ years (HR = 0.87, p = 0.03), being underweight (HR = 0.79, p < 0.001), and having WHO stage 3 (HR = 0.73, p < 0.001) or stage 4 disease (HR = 0.49, p < 0.001). Variation in timely ART initiation by geographic department and health facility was observed. CONCLUSIONS: Haiti has made substantial progress in scaling up Test and Start, but further work is needed to enroll previously diagnosed patients and to ensure rapid ART in key patient subgroups. Further research is needed on facility and geographic factors and on strategies for improving timely ART initiation among vulnerable subgroups.

Timely initiation of HIV antiretroviral therapy in Haiti 2004–2018: a retrospective cohort study

[ABSTRACT]. Objective. To describe trends in timing of ART initiation for newly diagnosed people living with HIV before and after Haiti adopted its Test and Start policy for universal HIV antiretroviral therapy (ART) in July 2016, and to explore predictors of timely ART initiation for both newly and previously diagnosed people living with HIV following Test and Start adoption. Methods. This retrospective cohort study explored timing of ART initiation among 147 900 patients diagnosed with HIV at 94 ART clinics in 2004–2018 using secondary electronic medical record data. The study used survival analysis methods to assess time trends and risk factors for ART initiation. Results. Timely uptake of ART expanded with Test and Start, such that same-day ART initiation rates increased from 3.7% to 45.0%. However, only 11.0% of previously diagnosed patients initiated ART after Test and Start. In adjusted analyses among newly diagnosed people living with HIV, factors negatively associated with timely ART initiation included being a pediatric patient aged 0–14 years (HR = 0.23, p < 0.001), being male (HR = 0.92, p = 0.03), being 50+ years (HR = 0.87, p = 0.03), being underweight (HR = 0.79, p < 0.001), and having WHO stage 3 (HR = 0.73, p < 0.001) or stage 4 disease (HR = 0.49, p < 0.001). Variation in timely ART initiation by geographic department and health facility was observed. Conclusions. Haiti has made substantial progress in scaling up Test and Start, but further work is needed to enroll previously diagnosed patients and to ensure rapid ART in key patient subgroups. Further research is needed on facility and geographic factors and on strategies for improving timely ART initiation among vulnerable subgroups.

[RESUMO]. Objetivo. Descrever as tendências para o momento do início da terapia antirretroviral (TAR) em pessoas recém diagnosticadas vivendo com HIV antes de e após o Haiti adotar a política Testar e Tratar com a TAR universal para HIV, em julho de 2016, e analisar os preditores do início precoce da TAR em pessoas recém ou previamente diagnosticadas que vivem com HIV após a adoção da política Testar e Tratar. Métodos. Este estudo de coorte retrospectivo analisou o momento do início da TAR de 147 900 pacientes diagnosticados com HIV em 94 ambulatórios de TAR entre 2004 e 2018, usando dados de registros médicos eletrônicos secundários. O estudo usou métodos de análise de sobrevivência para avaliar as tendências temporais e os fatores de risco para o início da TAR. Resultados. A adoção precoce da TAR foi ampliada com a política Testar e Tratar de tal maneira que as taxas do início da TAR no mesmo dia do diagnóstico aumentaram de 3,7% para 45%. Porém, somente 11% dos pacientes previamente diagnosticados iniciaram a TAR após a política Testar e Tratar. Nas análises ajustadas entre as pessoas recém diagnosticadas vivendo com HIV, os fatores negativamente associados ao início precoce da TAR incluíram: ser paciente pediátrico de 0 a 14 anos de idade (HR = 0,23, p < 0,001), ser do sexo masculino (HR = 0,92, p = 0,03), ter 50 anos de idade ou mais (HR = 0,87, p = 0,03), ter peso inferior ao normal (HR = 0,79, p < 0.001) e estar na fase 3 da OMS (HR = 0,73, p < 0,001) ou fase 4 da doença (HR = 0,49, p < 0,001). Foi observada variação no início precoce da TAR por região geográfica e instituição de saúde. Conclusões. O Haiti obteve avanços substanciais na ampliação da política Testar e Tratar, mas é necessário mais trabalho para inscrever pacientes previamente diagnosticados e para assegurar a TAR rápida em subgrupos-chave de pacientes. Mais pesquisas são necessárias sobre fatores geográficos e de instituições de saúde e sobre estratégias para a melhoria do início precoce da TAR entre subgrupos vulneráveis.

[RESUMEN]. Objetivo. Describir las tendencias en cuanto al momento de iniciar el tratamiento antirretroviral (TAR) de personas con infección por el VIH recién diagnosticadas antes y después de julio del 2016, cuando Haití adoptó la política de prueba e inicio del tratamiento con el TAR universal contra el VIH, y explorar los factores predictivos del inicio oportuno del TAR en personas con infección por el VIH recién diagnosticada y diagnosticada con anterioridad después de la adopción de esta política. Métodos. En este estudio de cohortes retrospectivo se exploró el momento en que se inició el TAR en 147 900 pacientes con diagnóstico de infección por el VIH en 94 consultorios que administran TAR del 2004 al 2018 mediante datos secundarios de expedientes médicos electrónicos. El estudio empleó métodos de análisis de supervivencia para evaluar las tendencias temporales y los factores de riesgo del inicio del TAR. Resultados. La observancia oportuna del TAR se amplió con la política de prueba e inicio del tratamiento, de tal manera que el inicio del TAR en el mismo día aumentó de 3,7 % a 45,0 %. Sin embargo, solo 11,0 % de los pacientes anteriormente diagnosticados iniciaron el TAR tras la adopción de la política. En los análisis ajustados con personas con infección por el VIH recién diagnosticadas, los factores asociados negativamente con el inicio oportuno del TAR comprendían ser un paciente pediátrico entre 0 y 14 años de edad (HR = 0,23, p < 0,001), ser varón (HR = 0,92, p = 0,03), tener más de 50 años (HR = 0,87, p = 0,03), tener un peso bajo (HR = 0,79,p < 0.001) y estar en el estadio 3 (de HR = 0,73, p < 0,001) o en estadio 4 (HR = 0,49, p < 0,001) de la enfermedad según la OMS. Se consideró la variación en el inicio oportuno del TAR según departamento geográfico y establecimiento de salud. Conclusiones. Haití ha logrado avances considerables en la ampliación a mayor escala de la política de prueba e inicio del tratamiento, pero es necesario seguir trabajando para registrar a los pacientes diagnosticados con anterioridad y para asegurar el inicio rápido del TAR en los subgrupos de pacientes clave. Es preciso llevar a cabo investigaciones adicionales sobre los factores geográficos y los relacionados con los establecimientos y sobre las estrategias para mejorar el inicio oportuno del TAR en los subgrupos vulnerables.

Short-Term Effects of the COVID-19 Pandemic on HIV Care Utilization, Service Delivery, and Continuity of HIV Antiretroviral Treatment (ART) in Haiti.

INTRODUCTION: Our study describes changes in HIV care service delivery and continuity of HIV antiretroviral therapy (ART) for people living with HIV (PLHIV) during the 8 weeks before and after diagnosis of the first coronavirus disease 2019 (COVID-19) cases in Haiti on March 19, 2020. METHODS: Using data from 96 out of 167 health facilities offering ART services, we compared four ART program indicators: (1) count of HIV visits; (2) proportion of ART dispenses in community-based settings (DAC); (3) proportion of multi-month dispensing of ART medications > 6 months (> 6 m MMD); and (4) proportion of timely ART refills. We used uncontrolled interrupted time series (ITS) models to estimate slope and level changes in each indicator with the arrival of COVID-19. RESULTS AND DISCUSSION: From week 1 to week 16, the average number of HIV visits fell from 121.5 to 92.5 visits, the proportion of DAC rose from 22.7% to 36.7%, the proportion of > 6 m MMD rose from 29.4% to 48.4%, and the proportion of timely ART refills fell from 51.9% to 43.8%. The ITS models estimated abrupt increases of 36% in > 6 m MMD (p < 0.001) and 37% in DAC (p < 0.001) at the time of COVID-19 arrival, and no change after arrival of COVID-19. The was an abrupt decline of 18% in timely ART refills with the arrival of COVID-19 and a decline of 1% per week thereafter, both non-statistically significant changes. CONCLUSIONS: The sudden changes in HIV service utilization represent dramatic adaptations needed to mitigate primary and secondary effects of the COVID-19 pandemic on PLHIV. This study underscores the urgency of optimizing ART delivery models in Haiti and beyond, in order to maintain progress toward HIV epidemic control.

Expanded access to viral load testing and use of second line regimens in Haiti: time trends from 2010-2017.

BACKGROUND: Haiti initiated the scale-up of HIV viral load (VL) testing in 2015-2016, with plans to achieve 100% coverage for all patients on antiretroviral therapy (ART) for treatment of HIV/AIDS. In the absence of HIV drug susceptibility testing, VL testing is a key tool for monitoring response to ART and optimizing treatment results. This study describes trends in expanded use of VL testing, VL results, and use of second-line ART regimens, and explores the association between VL testing and second-line regimen switching in Haiti from 2010 to 2017. METHODS: We conducted a retrospective cohort study with 66,042 patients drawn from 88 of Haiti's 160 national ART clinics. Longitudinal data from the iSanté electronic data system was used to analyze the trends of interest. We described patients' VL testing status in five categories based on up to two most recent VL test results: no test; suppressed; unsuppressed followed by no test; re-suppressed; and confirmed failure. Among those with confirmed failure, we described ART adherence level. Finally, we used Cox proportional hazards regression to estimate the risk of second-line regimen switching by VL testing status, after adjusting for other individual characteristics. RESULTS: The number of patients who had tests done increased annually from 11 in 2010 to 18,828 in the first 9 months of 2017, while the number of second-line regimen switches rose from 21 to 279 during this same period. Compared with patients with no VL test, the hazard ratio (HR) for switching to a second-line regimen was 22.2 for patients with confirmed VL failure (95% confidence interval [CI] for HR: 18.8-26.3; p < 0.005) after adjustment for individual characteristics. Among patients with confirmed VL failure, 44.7% had strong adherence, and fewer than 20% of patients switched to a second-line regimen within 365 days of VL failure. CONCLUSIONS: Haiti has significantly expanded access to VL testing since 2016. In order to promote optimal patient health outcomes, it is essential for Haiti to continue broadening access to confirmatory VL testing, to expand evidence-based initiatives to promote strong ART adherence, and to embrace timely switching for patients with confirmed ART failure despite strong ART adherence.

Toward Universal HIV Treatment in Haiti: Time Trends in ART Retention After Expanded ART Eligibility in a National Cohort From 2011 to 2017.

BACKGROUND: The World Health Organization (WHO) recommends universal antiretroviral therapy (ART) for persons living with HIV (PLWH), but evidence about effects of expanded ART access on ART retention in low-resource settings is limited. SETTING: Haiti's Ministry of Health endorsed universal ART for pregnant women in March 2013 (Option B+) and for all PLWH in July 2016. This study included 51,579 ART patients from 2011 to 2017 at 94 hospitals and clinics in Haiti. METHODS: This observational, retrospective cohort study described time trends in 6-month ART retention using secondary data, and compared results during 3 periods using an interrupted time series model: pre-Option B+ (period 1: 1/11-2/13), Option B+ (period 2: 3/13-6/16), and Test and Start (T&S, period 3: 7/16-9/17). RESULTS: From the pre-Option B+ to the T&S period, the monthly count of new ART patients increased from 366/month to 877/month, and the proportion with same-day ART increased from 6.3% to 42.1% (P < 0.001). The proportion retained on ART after 6 months declined from 78.4% to 75.0% (P < 0.001). In the interrupted time series model, ART retention improved by a rate of 1.4% per quarter during the T&S period after adjusting for patient characteristics (adjusted incidence rate ratio = 1.014; 95% confidence interval: 1.002 to 1.026, P < 0.001). However, patients with same-day ART were 14% less likely to be retained compared to those starting ART >30 days after HIV diagnosis (adjusted incidence rate ratio = 0.86; 95% confidence interval: 0.84-0.89, P < 0.001). CONCLUSIONS: Achieving targets for HIV epidemic control will require increasing ART retention and reducing the disparity in retention for those with same-day ART.

Trends in Tuberculosis Case Notification and Treatment Success, Haiti, 2010-2015.

Since the 2010 earthquake, tuberculosis (TB) control has been a major priority for health sector response and recovery efforts in Haiti. The goal of this study was to analyze trends in TB case notification in Haiti from the aggregate data reported by the National TB Control Program to understand the effects of such efforts. A total of 95,745 TB patients were registered for treatment in Haiti between 2010 and 2015. Three regions, the West, Artibonite, and North departments accounted for 68% of the TB cases notified during the period. Patients in the 15-34 age groups represented 53% (50,560) of all cases. Case notification rates of all forms of TB increased from 142.7/100,000 in 2010 to 153.4 in 2015, peaking at 163.4 cases/100,000 in 2013. Case notification for smear-positive pulmonary TB increased from 85.5 cases/100,000 to 105.7 cases/100,000, whereas treatment success rates remained stable at 79-80% during the period. Active TB case finding efforts in high-risk communities and the introduction of new diagnostics have contributed to increasing TB case notification trends in Haiti from 2010 to 2015. Targeted interventions and novel strategies are being implemented to reach high-risk populations and underserved communities.