Abstract
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.
Highlights
In Ethiopia, access to highly active antiretroviral therapy (HAART) started on massive scale in 2005 and by 2013 it has reached to some 317,443 people [1, 2]
In Ethiopia viral load testing is not available in routine practice settings; immunological monitoring is the only option for laboratory based monitoring
Immunological failure at last evaluation was similar to two studies carried out in the Ethiopian capital Addis Ababa (8.2%, n = 79) and western Ethiopia (11.5%, n = 11) [21, 22]; direct comparison is not possible, though, since both studies focused on paediatric patients with a mean age of six years, and follow-up duration was shorter in the second study
Summary
In Ethiopia, access to highly active antiretroviral therapy (HAART) started on massive scale in 2005 and by 2013 it has reached to some 317,443 people [1, 2]. Treatment has been successful as demonstrated by the improvement of survival in many settings in Ethiopia [3, 4] This has changed the course of the epidemic and made Human Immunodeficiency virus (HIV) a chronic manageable disease. As important as it is to get people who need the treatment be on HAART, it is even more important to ensure that patients adhere to the treatment so that they benefit from it in the long run as well. The longer a person is on a failing HAART regimen, the higher the mortality risk [14] For this reason, monitoring HAART treatment response, especially immunological and virologic, which is challenging issue in resource limited chronic HIV care settings, becomes very important. In Ethiopia viral load testing is not available in routine practice settings; immunological monitoring is the only option for laboratory based monitoring
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