Validation of HIV risk screening tool to identify infected adults and adolescents greater than 14 years at community level in Tanzania and Zambia

Introduction: There are several risk factors being used to identify undiagnosed HIV-infected adults. As the number of undiagnosed people gets less and less, it is important to know if existing risk factors and risk assessment tools are valid for use. Methods: Data from the Tanzania and Zambia Population-Based HIV Impact Assessment (PHIA) household surveys which were conducted during 2016 was used. We first included 12 risk factors (being divorced, separated or widowed; having an HIV+ spouse; having one of the following within 12-months of the survey: paid work, slept away from home for ≥1-month, having multiple sexual partners, clients of sex workers, sexually transmitted infection, being tuberculosis suspect, being very sick for ≥3-months; ever sold sex; diagnosed with cervical cancer; and had TB disease into a risk assessment tool and assessed its validity by comparing it against HIV test result. Sensitivity, specificity and predictive value of the tool were assessed. Receiver Operating Characteristic (ROC) curve comparison statistics was also used to determine which risk assessment tool was better. Results: HIV prevalence was 2.3% (2.0%-2.6%) (n=14,820). For the tool containing all risk factors, HIV prevalence was 1.0% when none of the risk factors were present (Score 0) compared to 3.2% when at least one factor (Score ≥1) was present and 8.0% when ≥4 risk factors were present. Sensitivity, specificity, PPV, and NPV were 82.3% (78.6%-85.9%), 41.9%(41.1%-42.7%), 3.2%(2.8%-3.6%), and 99.0%(98.8%-99.3%), respectively. The use of a tool containing conventional risk factors (all except those related with working and sleeping away) was found to have higher AUC (0.65 vs 0.61) compared to the use of all risk factors (p value <0.001). Conclusions: The use of a screening tool containing conventional risk factors improved HIV testing yield compared to doing universal testing. Prioritizing people who fulfill multiple risk factors should be explored further to improve HIV testing yield.

Breakthrough tuberculosis disease among people with HIV - Should we be worried? A retrospective longitudinal study.

INTRODUCTION: Isoniazid preventive therapy (IPT) is a proven means to prevent tuberculosis (TB) disease among people living with HIV (PLHIV). However, there is a concern that patients often develop tuberculosis disease while receiving IPT, defined here as breakthrough tuberculosis, which may affect treatment outcome. In this study, we assessed the magnitude and determinants of breakthrough tuberculosis. METHODS: A multisite retrospective longitudinal study from the year 2005 to 2014 involving 11 randomly selected hospitals from the Addis Ababa, SNNPR (Southern Nations Nationalities and Peoples Region), and Gambela regions of Ethiopia was carried out to assess the occurrence of breakthrough tuberculosis. Cox regression analysis was used to study factors associated with breakthrough TB. RESULTS: 4,484 patients in chronic HIV care received IPT. Eighty percent of the same number received antiretroviral therapy (ART). Tuberculosis developed in 88 of 4,484 (2%) patients of which 24 (0.5%) were diagnosed while receiving IPT. Breakthrough TB incidence was 1106 per 100,000 person-years (PY) (95% CI: 742-1651) while TB incidence after completing IPT was 624 per 100,000 PY (95% CI: 488-797). Seven of the 24 (29%) breakthrough TB cases were diagnosed within the first month of IPT initiation. Of 15 patients who developed breakthrough TB while on ART, nine (60%) were diagnosed within the first six months of ART initiation. Having high CD4 cell count and being on ART were associated with having lower risk of developing TB and breakthrough TB. CONCLUSION: Breakthrough TB was uncommon in the study setting. Even then, taking ART reduced the risk of its occurrence. Slightly more than a quarter of the cases of breakthrough TB occurred in the first month of treatment and may be existing undiagnosed TB cases which were missed during diagnostic work-up.

ART EXPERIENCED PATIENTS FOR TACKLING ATTRITION FROM HIV CARE: A MULTI-SITE COHORT STUDY.

Introduction: Retention of patients on anti-retroviral treatment in Ethiopia is a challenge. Use of anti-retroviral treatment experienced patients to prepare and re-engage them when they miss follow-ups is recommended, but evidence on its effectiveness is limited. This study evaluated its effectiveness. Methods: : A retrospective cohort study in 10 randomly selected health facilities was conducted to compare outcomes before and after initiation of the adherence supporters program in HIV care and treatment from September 2001 to August 2013. Data analysis involved Kaplan-Meier survival and Log-rank test analysis on STATA statistical software Version 12 to compare survival experiences. Results: Of 18,835 records that were available, 938 (4.36%) records with missing values were excluded and data from the remaining 17,897 was analyzed. The incidence of first instance lost to follow-up was 22.2 per 100 person-years (95% confidence interval 21.7-22.7). The risk of missing follow-ups after initiation of the program was high (Hazard Ratio ­1.22, P < 0.001). The incidence of restarting after missed follow-ups was 23 per 100 PY (95% CI 22.2-24.0). The likelihood of restarting after missed follow-ups was four times higher during the period adherence supporters were present (P<0.001). Patients who stayed longer in care before missing follow ups were more likely to restart (5.7 times the chance of restarting treatment for those whose first lost to follow-up occurred at≥12 months compared to <3 months, P< 0.001).Time to restarting treatment was shorter after the initiation of the adherence supporters program (median 37 vs. 115 days). The risk of recurrence of being lost to follow-up in the presence of adherence supporters was significantly higher than when there were no adherence supporters; 38.8 (95% CI 36.3-41.6) per 100 PY vs. 26.1 (95% CI 19.8-34.4) per 100 PY, respectively. Conclusion: Adherence supporters were effective in improving re-engagement of patients in treatment and care after they were lost to follow-up. Yet, prevention of lost to follow-up cases has remained a challenge to the program.

ART experienced patients for tackling attrition from HIV care: a multi-site cohort study

Introduction: Retention of patients on anti-retroviral treatment in Ethiopia is a challenge. Use of anti-retroviral treatment experienced patients to prepare and re-engage them when they miss follow-ups is recommended, but evidence on its effectiveness is limited. This study evaluated its effectiveness.Methods: A retrospective cohort study in 10 randomly selected health facilities was conducted to compare outcomes before and after initiation of the adherence supporters program in HIV care and treatment from September 2001 to August 2013. Data analysis involved Kaplan-Meier survival and Log-rank test analysis on STATA statistical software Version 12 to compare survival experiences.Results: Of 18,835 records that were available, 938 (4.36%) records with missing values were excluded and data from the remaining 17,897 was analyzed. The incidence of first instance lost to follow-up was 22.2 per 100 person-years (95% confidence interval 21.7-22.7). The risk of missing follow-ups after initiation of the program was high (Hazard Ratio ­1.22, P < 0.001). The incidence of restarting after missed follow-ups was 23 per 100 PY (95% CI 22.2-24.0). The likelihood of restarting after missed follow-ups was four times higher during the period adherence supporters were present (P<0.001). Patients who stayed longer in care before missing follow ups were more likely to restart (5.7 times the chance of restarting treatment for those whose first lost to follow-up occurred at≥12 months compared to <3 months, P< 0.001).Time to restarting treatment was shorter after the initiation of the adherence supporters program (median 37 vs. 115 days). The risk of recurrence of being lost to follow-up in the presence of adherence supporters was significantly higher than when there were no adherence supporters; 38.8 (95% CI 36.3-41.6) per 100 PY vs. 26.1 (95% CI 19.8-34.4) per 100 PY, respectively. Conclusion: Adherence supporters were effective in improving re-engagement of patients in treatment and care after they were lost to follow-up. Yet, prevention of lost to follow-up cases has remained a challenge to the program

Prevalence and Predictors of Immunological Failure among HIV Patients on HAART in Southern Ethiopia.

Immunological monitoring is part of the standard of care for patients on antiretroviral treatment. Yet, little is known about the routine implementation of immunological laboratory monitoring and utilization in clinical care in Ethiopia. This study assessed the pattern of immunological monitoring, immunological response, level of immunological treatment failure and factors related to it among patients on antiretroviral therapy in selected hospitals in southern Ethiopia. A retrospective longitudinal analytic study was conducted using documents of patients started on antiretroviral therapy. Adequacy of timely immunological monitoring was assessed every six months the first year and every one year thereafter. Immunological response was assessed every six months at cohort level. Immunological failure was based on the criteria: fall of follow-up CD4 cell count to baseline (or below), or CD4 levels persisting below 100 cells/mm3, or 50% fall from on-treatment peak value. A total of 1,321 documents of patients reviewed revealed timely immunological monitoring were inadequate. There was adequate immunological response, with pediatric patients, females, those with less advanced illness (baseline WHO Stage I or II) and those with higher baseline CD4 cell count found to have better immunological recovery. Thirty-nine patients (3%) were not evaluated for immunological failure because they had frequent treatment interruption. Despite overall adequate immunological response at group level, the prevalence of those who ever experienced immunological failure was 17.6% (n=226), while after subsequent re-evaluation it dropped to 11.5% (n=147). Having WHO Stage III/IV of the disease or a higher CD4 cell count at baseline was identified as a risk for immunological failure. Few patients with confirmed failure were switched to second line therapy. These findings highlight the magnitude of the problem of immunological failure and the gap in management. Prioritizing care for high risk patients may help in effective utilization of meager resources.

Beneficial effect of isoniazid preventive therapy and antiretroviral therapy on the incidence of tuberculosis in people living with HIV in Ethiopia.

BACKGROUND: IPT with or without concomitant administration of ART is a proven intervention to prevent tuberculosis among PLHIV. However, there are few data on the routine implementation of this intervention and its effectiveness in settings with limited resources. OBJECTIVES: To measure the level of uptake and effectiveness of IPT in reducing tuberculosis incidence in a cohort of PLHIV enrolled into HIV care between 2007 and 2010 in five hospitals in southern Ethiopia. METHODS: A retrospective cohort analysis of electronic patient database was done. The independent effects of no intervention, "IPT-only," "IPT-before-ART," "IPT-and-ART started simultaneously," "ART-only," and "IPT-after-ART" on TB incidence were measured. Cox-proportional hazards regression was used to assess association of treatment categories with TB incidence. RESULTS: Of 7,097 patients, 867 were excluded because they were transferred-in; a further 823 (12%) were excluded from the study because they were either identified to have TB through screening (292 patients) or were on TB treatment (531). Among the remaining 5,407 patients observed, IPT had been initiated for 39% of eligible patients. Children, male sex, advanced disease, and those in Pre-ART were less likely to be initiated on IPT. The overall TB incidence was 2.6 per 100 person-years. As compared to those with no intervention, use of "IPT-only" (aHR = 0.36, 95% CI = 0.19-0.66) and "ART-only" (aHR = 0.32, 95% CI = 0.24-0.43) were associated with significant reduction in TB incidence rate. Combining ART and IPT had a more profound effect. Starting IPT-before-ART (aHR = 0.18, 95% CI = 0.08-0.42) or simultaneously with ART (aHR = 0.20, 95% CI = 0.10-0.42) provided further reduction of TB at ∼ 80%. CONCLUSIONS: IPT was found to be effective in reducing TB incidence, independently and with concomitant ART, under programme conditions in resource-limited settings. The level of IPT provision and effectiveness in reducing TB was encouraging in the study setting. Scaling up and strengthening IPT service in addition to ART can have beneficial effect in reducing TB burden among PLHIV in settings with high TB/HIV burden.