ART Uptake Research Articles

Integrating HIV care and treatment into tuberculosis clinics in Lusaka, Zambia: results from a before-after quasi-experimental study

BackgroundPatients with HIV-associated tuberculosis (TB) often have their TB and HIV managed in separate vertical programs that offer care for each disease with little coordination. Such “siloed” approaches are associated with diagnostic and treatment delays, which contribute to unnecessary morbidity and mortality. To improve TB/HIV care coordination and early ART initiation, we integrated HIV care and treatment into two busy TB clinics in Zambia. We report here the effects of our intervention on outcomes of linkage to HIV care, early ART uptake, and TB treatment success for patients with HIV-associated TB in Lusaka, Zambia.MethodsWe provided integrated HIV treatment and care using a “one-stop shop” model intervention. All new or relapse HIV-positive TB patients were offered immediate HIV program enrolment and ART within 8 weeks of anti-TB therapy (ATT) initiation. We used a quasi-experimental design, review of routine program data, and survival analysis and logistic regression methods to estimate study outcomes before (June 1, 2010—January 31, 2011) and after (August 1, 2011—March 31, 2012) our intervention among 473 patients with HIV-associated TB categorized into pre- (n = 248) and post-intervention (n = 225) cohorts.ResultsPatients in the pre- and post-intervention cohorts were mostly male (60.1% and 52.9%, respectively) and young (median age: 33 years). In time-to-event analyses, a significantly higher proportion of patients in the post-intervention cohort linked to HIV care by 4 weeks post-ATT initiation (53.9% vs. 43.4%, p = 0.03), with median time to care linkage being 59 and 25 days in the pre- and post-intervention cohorts, respectively. In Cox proportional hazard modelling, patients receiving the integration intervention started ART by 8 weeks post-ATT at 1.33 times the rate (HR = 1.33, 95% CI: 1.00–1.77) as patients pre-intervention. In logistic regression modelling, patients receiving the intervention were 2.02 times (95% CI: 1.11–3.67) as likely to have a successful TB treatment outcome as patients not receiving the intervention.ConclusionsIntegrating HIV treatment and care services into routine TB clinics using a one-stop shop model increased linkage to HIV care, rates of early ART initiation, and TB treatment success among patients with HIV-associated TB in Lusaka, Zambia.

Client and Provider Perspectives on Antiretroviral Treatment Uptake and Adherence Among People Who Inject Drugs in Indonesia, Ukraine and Vietnam: HPTN 074.

HIV-infected people who inject drugs (PWID) have low uptake of HIV services, increasing the risk of transmission to uninfected injection or sexual partners and the likelihood of AIDS-related deaths. HPTN 074 is a vanguard study assessing the feasibility of an integrated intervention to facilitate treatment as prevention to PWID in Indonesia, Ukraine, and Vietnam. We describe barriers to and facilitators of ART uptake and adherence among PWID. We conducted in-depth interviews with 62 participants, including 25 providers and 37 PWID at baseline across all sites. All interviews were recorded, transcribed, translated into English and coded in NVivo for analysis. Matrices were developed to identify emergent themes and patterns. Overall, differences between provider and PWID perspectives were greater than differences in cross-site perspectives. Providers and PWID recognized clinic access, financial barriers, side effects, and lack of information about HIV testing and ART enrollment as barriers to ART. However, providers tended to emphasize individual level barriers to ART, such as lack of motivation due to drug use, whereas PWID highlighted health systems barriers, such as clinic hours and financial burden, fears, and side effects. Providers did not mention stigma as a barrier though their language reflected stereotypes about drug users. The differences between provider and PWID perspectives suggest a gap in providers' understanding of PWID. This misunderstanding has implications for patient-provider interactions that may affect PWID willingness to access care or adhere to ART. Lessons learned from this study will be important as countries with a significant HIV burden among PWID design and implement programs to engage HIV-infected PWID in care and treatment.

Failure to initiate HIV treatment in patients with high CD4 counts: evidence from demographic surveillance in rural SouthAfrica.

To assess the relationship between CD4 count at presentation and ART uptake and assess predictors of timely treatment initiation in rural KwaZulu-Natal, South Africa. We used Kaplan-Meier and Cox proportional hazards models to assess the association between first CD4 count and time from first CD4 to ART initiation among all adults presenting to the Hlabisa HIV Treatment and Care Programme between August 2011 and December 2012 with treatment-eligible CD4 counts (≤ 350 cells/mm3 ). For a subset of healthier patients (200<CD4≤350 cells) residing within the population surveillance of the Africa Health Research Institute, we assessed sociodemographic, economic and geographic predictors hypothesised to influence ART uptake. A total of 4739 patients presented for care with eligible CD4 counts. The proportion initiating ART within six months of diagnosis was 67% (95% CI 63, 71) in patients with CD4≤50, 59% (0.55, 0.63) in patients with CD4 151-200 and 48% (95% CI 44, 51) in patients with CD4 301-350. The hazard of starting ART fell by 17% (95% CI 14, 20) for every 100-cell increase in baseline CD4 count. Among healthier patients under demographic surveillance (n=193), observable sociodemographic, economic and geographic predictors did not add discriminatory power beyond CD4 count, age and sex to identify patients at high risk of non-initiation. Individuals presenting for HIV care at higher CD4 counts were less likely to initiate ART than patients presenting at low CD4 counts. Overall, ART uptake was low. Under new guidelines that establish ART eligibility regardless of CD4 count, patients with high CD4 counts may require additional interventions to encourage treatment initiation.

Understanding uptake of an intervention to accelerate antiretroviral therapy initiation in Uganda via qualitative inquiry.

IntroductionThe Streamlined Antiretroviral Therapy Initiation Strategy (START‐ART) study found that a theory‐based intervention using opinion leaders to inform and coach health care providers about the risks of treatment delay, provision of point of care (POC) CD4 testing machines (PIMA) and reputational incentives, led to rapid rise in ART initiation. We used qualitative research methods to explore mechanisms of provider behaviour change.MethodsWe conducted in‐depth interviews (IDIs) with 24 health care providers and nine study staff to understand perceptions, attitudes and the context of changes in ART initiation practices. Analyses were informed by the Theoretical Domains Framework.ResultsRapid dissemination of new practices was enabled in the environmental context of an existing relationship based on communication, implementation and accountability between Makerere University Joint AIDS Program (MJAP), a Ugandan University‐affiliated organization that provided technical oversight for HIV service delivery at the health facilities where the intervention was implemented, and a network of health facilities operated by the Uganda Ministry of Health. Coaching carried out by field coordinators from MJAP strengthened influence and informal accountability for carrying out the intervention. Frontline health workers held a pre‐existing strong sense of professional identity. They were proud of attainment of new knowledge and skills and gratified by providing what they perceived to be higher quality care. Peer counsellors, who were not explicitly targeted in the intervention design, effectively substituted some functions of health care providers; as role models for successful ART uptake, they played a crucial role in creating demand for rapid ART initiation through interactions with patients. Point of care (POC) CD4 testing enabled immediate action and relieved providers from frustrations of lost or delayed laboratory results, and led to higher patient satisfaction (due to reduced costs because of ability to initiate ART right away, requiring fewer return trips to clinic).ConclusionsQualitative data revealed that a multicomponent intervention to change provider behaviour succeeded in the context of strong institutional and individual relationships between a University‐affiliated organization, government facilities, and peer health workers (who acted as a crucial link between stakeholders) and the community. Fostering stable institutional relationships between institutional actors (non‐governmental organization (NGOs) and ministry‐operated facilities) as well as between facilities and the community (through peer health workers) can enhance uptake of innovations targeting the HIV cascade in similar clinical settings.

Time from HIV diagnosis to commencement of antiretroviral therapy as an indicator to supplement the HIV cascade: Dramatic fall from 2011 to 2015.

IntroductionThe HIV care cascade is increasingly used to evaluate HIV treatment programs at the population level. However, the cascade indicators lack the ability to show changes over time, which reduces their utility to guide health policy. Alternatives have been proposed but are complex or result in a delay in results. We propose a new indicator of ART uptake, the time from HIV diagnosis to commencement of ART, and compare it to the existing cascade indicator of proportion of patients on treatment and the WHO proposed cohort cascade indicator of proportion of patients on treatment within one year of diagnosis.Methods and materialsRecords from patients from the two largest HIV treatment centres in the state of Victoria, Australia (Melbourne Sexual Health Centre and The Alfred Hospital Department of Infectious Diseases) from 2011 to 2015 were extracted. The intervals between date of diagnosis, entry into care and initiation of ART were compared.Results and discussionFrom 2011 to 2015 the proportion of in-care patients who were on ART rose from 87% to 93% (p<0.0001). From 2011 to 2014, the proportion of patients in care and on ART within one year of diagnosis increased from 43.4% to 78.9% (p = 0.001). The median time from diagnosis to ART fell from 418 days (IQR: 91–1176) to 77 days (IQR: 39–290)(p<0.001) by calendar year in which ART was commenced.ConclusionsFrom 2011 to 2015 there were substantial and clinically important falls in the median time from diagnosis to commencing ART in those that commenced ART. The size of this dramatic change was not apparent when only reporting the proportion of patients on ART. Time to ART is a useful indicator and can be used to supplement existing cascade indicators in measuring progress toward universal ART coverage.

Factor Influencing HIV Care Continuum among People Living with HIV in Western Kenya

HIV infection is associated with a lot of morbidity and mortality especially in high burden countries in Sub Saharan Africa. Despite great progress in improving HIV testing and access to ART for people living with HIV/AIDS (PLWHA) in Sub Saharan Africa, ART coverage remains low and majority of people with HIV are still unaware of their status. Therefore, the aim of this study was to determine the predictors of HIV continuum care in Gucha Sub County in Kisii, an area with a high HIV prevalence of 8.9% in Kenya. This was carried out through a cross-sectional study and participants were randomly selected amongst HIV positive clients in comprehensive care centers and community based support groups in Gucha. Data was collected using a semi structured interview guided questionnaires Categorical data was analysed using Chi-Square. SPSS was used to compute the statistics. This study revealed that majority 97 (80.17%) of the participants were female since men are less likely to report and enroll in HIV care when they test HIV positive. Male tend to seek health care when severely ill. The study results show that participants had low HIV knowledge to make informed choice only 21 (17.36%) had informed choice. This study reveals that the main determinants of ART uptake are associated with patient's education, food by prescription, site location for patient support centre and privacy. Therefore, there is need to enhance the uptake of HIV care among PLWHA an interventions targeting multiple stage must be designed, which may improve linkages throughout the HIV care continuum in the short and long term. Strategies to improve Identification of the undiagnosed PLHIV and linking them to HIV care and management is a priority in order to achieve UNAIDS goal by 2020.

Trends in ART Initiation among Men and Non-Pregnant/Non-Breastfeeding Women before and after Option B+ in Southern Malawi.

BackgroundOption B+ is promoted as a key component to eliminating vertical transmission of HIV; however, little is known about the policy’s impact on non-targeted populations, such as men and non-pregnant/non-breastfeeding women. We compare ART uptake among non-targeted populations during pre/post Option B+ periods in Zomba District, Malawi.MethodsIndividual-level ART registry data from 27 health facilities were digitized and new ART initiates were disaggregated by sex and type of initiate (Option B+ or not). Data were analyzed over the pre- (January 2009-June 2011) and post- (July 2011- December 2013) Option B+ periods.ResultsAfter the implementation of Option B+, the total number of new female initiates increased significantly (quarterly median: 547 vs. 816; P = 0.001) and their median age decreased from 34 to 31 years (P = <0.001). Both changes were the result of the rapid and sustained uptake of ART among Option B+ clients. Post-policy, Option B+ clients represented 48% of all new female initiates while the number of females who initiated through CD4 or WHO staging criteria significantly decreased (quarterly median: 547 vs. 419; P = 0.005). The number and age of male initiates remained stable; however, the proportion of men among new initiates decreased (36% vs. 31%; P = <0.001).ConclusionsOption B+ shifted the profile of first-time initiates towards younger and fertile women. Declines among non-Option B+ women most likely reflect earlier initiation during pregnancies before deteriorations in health. The decreased proportion of men among first-time initiates represents a growing gender disparity in HIV services that deserves immediate attention.

Retention in care and reasons for discontinuation of lifelong antiretroviral therapy in a cohort of Cameroonian pregnant and breastfeeding HIV-positive women initiating 'Option B+' in the South West Region.

To assess linkage and retention in care along the PMTCT cascade in HIV-positive pregnant and breastfeeding women initiating Option B+ in Cameroon. We prospectively determined uptake of HIV testing and counselling (HTC), uptake of ART and retention in care after Option B+ initiation between October 2013 and December 2014 in pregnant and breastfeeding women from five sites within the Kumba Health District. Retention in care was assessed over at least 12 months follow-up and estimated by Kaplan-Meier analysis. During follow-up, tracing outcomes and reasons for discontinuing treatment were documented. The uptake of HTC of 5813 women with unknown HIV status was 98.5%, 251 (4.4%) were newly diagnosed HIV positive, and ART uptake in women eligible to start Option B+ was 96.8%. We enrolled 268 women initiating lifelong ART in the follow-up. Overall, 65 (24.3%) discontinued treatment, either defined by loss to follow-up (44.6%) or actively stopped treatment (55.8%). Retention in care was 88.0% and 81.1% at 6 and 12 months, respectively. Discontinuation was significantly associated in multivariate analysis with small sites and high staff turnover [aOR 2.5 (95% CI 1.6, 3.9), P < 0.001]. Main reasons for stopping treatment were HIV status denial and stigma (52.8%), religious reasons (25.0%) and lack of transport fare (11.1%). We observed good uptake of HTC, ART and retention in care, which declined over time. Discontinuation of Option B+ was highest at small sites with a high staff turnover. Improved staffing, adequate task shifting and community interventions to track defaulters including reducing stigma and religious beliefs may improve Option B+ retention.

Cervical cancer screening uptake and challenges in Malawi from 2011 to 2015: retrospective cohort study.

BackgroundMalawi has the highest cervical cancer incidence and mortality in the world with age-standardized rate (ASR) of 75.9 and 49.8 per 100,000 population respectively. In response, Ministry of Health established a cervical cancer screening programme using visual inspection with acetic acid (VIA) and treatment of precancerous lesions with cryotherapy. This paper highlights the roll out, integration with family planning services and HIV ART Programme, uptake and challenges of VIA and Cryotherapy programme.MethodsWe analyzed program data, supportive supervision, quarterly and annual reports from the National Cervical Cancer Control Program. We evaluated the uptake and challenges of screening services by age, HIV serostatus and trends over a five year period (2011–2015).ResultsBetween 2011 and 2015, number of cervical cancer screening sites, number of women screened and coverage per annum increased from 75 to 130, 15,331 to 49,301 and 9.3 % to 26.5 % respectively. In this five year period, a total of 145,015 women were screened. Of these, 7,349 (5.1 %) and 6,289 (4.3 %) were VIA positive and suspect cancer respectively. Overall 13,638 (9.4 %) were detected to be VIA positive or had suspect cancer. Of the 48,588 women with known age screened in 2015; 13,642 (28.1 %), 27,275 (56.1 %) and 7,671 (15.8 %) were aged 29 or less, 30–45, 46 years or more. Among 39,101 women with data on HIV serostatus; 21,546 (55.1 %) were HIV negative, 6,209 (15.9 %) were HIV positive and 11, 346 (29.0 %) status was unknown. VIA positivity rate and prevalence of suspect cancer were significantly higher in HIV positive than HIV negative women (8.8 % vs 5.0 %, 6.4 % vs 3.0 %); in women aged 30–45 years than women aged 29 years or less (5.6 % vs 2.3 %, 2.6 % vs 1.2 %) respectively, all p <0.05). The main challenge of the programme was failure to treat VIA positive women eligible for cryotherapy. Over the five year period, the programme only treated 1,001 (43.3 %) out of 2,311 eligible women and only 266 (31.8 %) of the 836 women with large lesion or suspect cancer who were referred, received the health care at the referral centre. The reasons for failure to provide cryotherapy treatment were stock out of gas, faulty/broken cryotherapy machine (usually connectors or probes) or no cryotherapy machine at all in the whole district. For women with large lesion or suspect cancer; lack of loop electrosurgical excision procedure (LEEP) machine or inadequate gynaecologists at the referral centre, were the major reasons. Cancer radiotherapy services were not available in Malawi.ConclusionsThis study provided data on VIA positivity rate, prevalence of suspect cancer, failure rate of cryotherapy and challenges in the provision of cryotherapy and LEEP treatment in Malawi. These data could be used as baseline for monitoring and evaluation of Human Papillomavirus (HPV) vaccination programme which the country introduced in 2013, the linkage of cervical cancer screening and women on HIV ART and the long term effect of ART, voluntary male medical circumcision on the prevalence and incidence of cervical cancer.

The association between substance use and sub-optimal HIV treatment engagement among HIV-infected female sex workers in Lilongwe, Malawi

ABSTRACTFemale sex workers (FSW) have a high prevalence of substance use and HIV, but the impact of substance use on HIV treatment engagement is not well established. We evaluated the association between alcohol and marijuana use and sub-optimal HIV treatment engagement outcomes among HIV-infected FSW in Lilongwe, Malawi. We enroled FSW using venue-based recruitment into a cross-sectional evaluation assessing substance use and HIV treatment engagement. Seropositive FSW, identified through HIV rapid testing, received rapid CD4 count and viral load testing. We used Poisson regression with robust variance estimates to ascertain associations of alcohol and marijuana use with sub-optimal HIV treatment outcomes: (1) lack of ART use among previously diagnosed, ART-eligible FSW and (2) viral nonsuppression among FSW on ART. Of previously diagnosed, ART-eligible FSW (n = 96), 29% were not using ART. Patterns of hazardous drinking were identified in 30%, harmful drinking in 10%, and alcohol dependence in 12%. ART-eligible FSW with harmful drinking or alcohol dependency were 1.9 (95% CI: 1.0, 3.8) times as likely to not use ART compared to FSW without harmful or dependent drinking. Among those on ART, 14% were virally nonsuppressed. The prevalence ratio for viral nonsuppression was 2.0 (95% CI: 0.6, 6.5) for harmful drinkers and alcohol-dependent FSW. Over 30% of ART-eligible FSW reported using marijuana. Marijuana-using FSW were 1.9 (95% CI: 0.8, 4.6) times as likely to not use ART compared to FSW who were not using marijuana. Given the high prevalence of alcohol use and its association with lack of ART use, ART uptake and alcohol reduction strategies should be tailored for alcohol-using FSW in Malawi.

Good continuum of HIV care in Belgium despite weaknesses in retention and linkage to care among migrants.

BackgroundThe Belgian HIV epidemic is largely concentrated among men who have sex with men and Sub-Saharan Africans. We studied the continuum of HIV care of those diagnosed with HIV living in Belgium and its associated factors.MethodsData on new HIV diagnoses 2007–2010 and HIV-infected patients in care in 2010–2011 were analysed. Proportions were estimated for each sequential stage of the continuum of HIV care and factors associated with attrition at each stage were studied.ResultsOf all HIV diagnosed patients living in Belgium in 2011, an estimated 98.2 % were linked to HIV care, 90.8 % were retained in care, 83.3 % received antiretroviral therapy and 69.5 % had an undetectable viral load (<50 copies/ml). After adjustment for sex, age at diagnosis, nationality and mode of transmission, we found lower entry into care in non-Belgians and after preoperative HIV diagnoses; lower retention in non-Belgians and injecting drug users; higher retention in men who have sex with men and among those on ART. Younger patients had lower antiretroviral therapy uptake and less viral suppression; those with longer time from diagnosis had higher ART uptake and more viral suppression; Sub-Saharan Africans on ART had slightly less viral suppression.ConclusionsThe continuum of HIV care in Belgium presents low attrition rates over all stages. The undiagnosed HIV-infected population, although not precisely estimated, but probably close to 20 % based on available survey and surveillance results, could be the weakest stage of the continuum of HIV care. Its identification is a priority along with improving the HIV care continuum of migrants.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-015-1230-3) contains supplementary material, which is available to authorized users.

P17.16 Personal decisions around anti-retroviral therapies (art): findings from the literature and from a qualitative longitudinal study with people living with hiv (plhiv) in regional queensland, australia

Introduction Patient-centred care is cornerstone of effective management of complex illnesses, yet little is known about personal decision processes around ART, especially among PLHIV living in remote areas. This paper examines how PLHIV living in regional Queensland make treatment decisions, and compares it with findings from the literature. Methods The narratives around ART were elicited as part of a three year qualitative longitudinal study with 69 PLHIV over 35 from regional Queensland, recruited by key HIV organisations. Thematic analysis will continue at each and across time points. A comprehensive literature review (2003–13) on factors impacting people’s decisions around ART in Australia, Canada and the UK is under review [AC-2015–03–0185]. Results Decisions around treatment depended upon a range of psychosocial and structural factors. Some PLHIV discontinued ART and engaged in ‘cleansing’ of the body using natural therapies. ART was also experienced symbolically, as a reminder of one’s HIV status, but also as a means to a full life. The active coping style and treatment adherence of the peer models were seen as expressions of not succumbing to fear and stigma. The constructive and destructive influences of significant others on one’s continuum of care were highlighted. Non-medical advice was often sought when the health system was felt lacking. Conclusion PLHIV in regional Queensland engage in nuanced analysis of various costs and benefits of ART uptake, in which biomedical concerns play an important yet often minor role. These findings are congruent with the literature: people’s abilities and motivations around ART are influenced by a host of interconnected, broader social factors. Findings have implications for the management of HIV and other complex diseases in that patient-centred care needs to move beyond purely biomedical considerations. This presentation will outline psychosocial factors providers can focus on to effectively address patient’s underlying concerns and support their choices around treatment. Disclosure of interest statement The Living Positive in Queensland Study is funded by the Australia Research Council as a Linkage Project Grant [LP110200318]. Queensland Positive People, Queensland AIDS Council, and Positive Directions - Anglicare (now closed) were the original partner organisations of the study.

Influence of Food Supplements on Testing for HIV and Aids and Adhering to Treatment in a Resource Poor Rural Setting: A Case of Chivuna, Southern Zambia

Background: There is a serious dearth of literature, particularly on Zambia, on the influential role of food supplements on people’s decision to take up an HIV test, start and adhere to AIDS treatment. Methods: Using data from a large ethnographic qualitative study in a resource poor rural setting in Zambia, this paper examines and documents the critical role of food supplements in influencing people to go for HIV testing, initiate treatment and stick to it. Results: Findings show that people who felt food insecure were reluctant to go for a test, thereby not accessing treatment and care services. The narratives revealed numerous aspects of food supplements, HIV testing, ART uptake and adherence, including desire to have access to food due to food insecurity, hoping and wishing to be found positive to access food, envying the HIV positive accessing food, desiring to have physical transformation and healthy-looking bodies enabled by increased access to food, reluctance and avoidance of taking the drugs without food, and worries about food once on medication. Conclusion: The study has shown a close link between food supplements, willingness to test, start taking medication and adherence. Therefore, food supplements should be made an integral part of HIV and AIDS related services in resource poor settings. This means devising more sustainable cross-sectional approaches to foster food security and general livelihoods, such as initiation of income generating activities among vulnerable rural poor, particularly those living with HIV and AIDS.

Using social network methods to reach out-of-care or ART-nonadherent HIV+ injection drug users in Russia: addressing a gap in the treatment cascade.

Introduction HIV treatment to reduce downstream HIV incidence and to decrease disease mortality and morbidity at a population level both require that hidden, out-of-care people living with HIV (PLH) in the community be reached and engaged to enter care. This research evaluated the feasibility of reaching out-of-care or non-adherent PLH through members of their social networks in St Petersburg, Russia.Materials and Methods To recruit a social network sample of HIV-positive injection drug users, 16 HIV+ seeds were enrolled into the study through PLH-oriented websites and online forums using recruitment ads or approached in needle exchange sites. Interested persons called the study phone number and completed a brief eligibility interview. Seed inclusion criteria were HIV+ status, being 18 years or older, having ever injected drugs, and having not visited an HIV doctor in the past 6 months. Seeds provided blood specimens tested for HIV to confirm their self-reported status. Eligible seeds were enrolled, completed brief network elicitation interview, and were asked to invite their own HIV+ friends into the study. Incentives were provided as compensation for participants’ time and additional smaller incentives were provided for inviting each HIV+ network member to also participate. The seed's PLH friends established the first ring of participants who, in turn were asked to invite their own PLH friends (second ring). All study participants completed assessment of psychosocial wellbeing and sexual and injection-related HIV risk behaviour. Blood samples were collected from all participants to confirm their HIV+ status.Results Through this chain referral process, the initial 16 seeds led to the enrolment of a total of 66 PLH from the community (mean=4 per initial seed), most of whom – like the seed – were not presently in HIV care or were ART non-adherent.Conclusions Implementation of treatment cascade goals requires complementing conventional paths of identifying PLH with feasible and effective community-based approaches such as described in this study. This research establishes that PLH are connected in their day-to-day social networks with other HIV+ persons and shows that social network methods can be employed to reach infected persons through their connections with other PLH. This method has the potential to expand the reach of medical care efforts and ART uptake.

PD34-04 IS ADJUVANT RADIATION THERAPY UNDER-UTILIZED IN HIGH-RISK POST-PROSTATECTOMY PATIENTS?

You have accessJournal of UrologyProstate Cancer: Epidemiology & Natural History II1 Apr 2014PD34-04 IS ADJUVANT RADIATION THERAPY UNDER-UTILIZED IN HIGH-RISK POST-PROSTATECTOMY PATIENTS? Matthew Maurice, Hui Zhu, and Robert Abouassaly Matthew MauriceMatthew Maurice More articles by this author , Hui ZhuHui Zhu More articles by this author , and Robert AbouassalyRobert Abouassaly More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2429AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Based on level 1 evidence, adjuvant radiation therapy (aRT) improves cancer control in post-prostatectomy patients with adverse pathologic features. We sought to evaluate its utilization and to identify factors affecting of its use. METHODS Using the National Cancer Database, a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society, we identified men diagnosed with prostate cancer between 2004-2011 who were found to have pT3 disease or pT2 disease with positive margins following prostatectomy. We defined aRT as radiation to the prostate and/or pelvis ≤6 months after prostatectomy. We then used univariate and multivariate logistic regression models to assess potential patient and provider predictors of aRT use. RESULTS We evaluated 103,092 men who had either pT3 disease (81%) or pT2 with positive margins (19%). Of these, we identified 10,043 men (9.7%) who received aRT. Since 2004, there has been a steady decline in aRT usage with time (range, 11.5% to 7.8%). Compared to 2004, patients diagnosed in 2011 were significantly less likely to receive aRT (odds ratio [OR] 0.78, confidence interval [CI] 0.71-0.85, p<0.0001). Higher Gleason score and T stage were strongly associated with positive aRT utilization (p<0.0001), while increasing age was associated with decreased use (p<0.0001). Another strong predictor of aRT uptake was hospital type. Compared to patients treated at community hospitals, patients treated at comprehensive cancer centers or teaching hospitals were significantly less likely to receive aRT (OR 0.63, 0.58-0.68, p<0.0001 or OR 0.42, CI 0.39-0.46, p<0.0001, respectively). Charlson score and hospital location were significantly but weakly associated with aRT. Other demographic variables were not predictive of aRT. CONCLUSIONS Post-prostatectomy aRT use is declining despite evidence of its benefit. Consistent with the evidence, patients with risk factors for biochemical relapse (i.e. high Gleason score or T3 disease) and younger patients, who are more likely to benefit, are receiving aRT. Surprisingly, aRT use is lower at teaching hospitals, which may reflect higher usage of salvage radiation. Multivariate Analysis of Predictive Factors for Adjuvant Radiation Therapy Utilization Variable Odds Ratio Confidence Interval P-value Year of Diagnosis, 2007 vs 2004 0.826 0.752-0.907 0.0257 Year of Diagnosis, 2008 vs 2004 0.81 0.738-0.889 < 0.01 Year of Diagnosis, 2009 vs 2004 0.868 0.792-0.951 0.5230 Year of Diagnosis, 2010 vs 2004 0.855 0.782-0.934 0.2157 Year of Diagnosis, 2011 vs 2004 0.781 0.714-0.854 < 0.0001 Age, 50-59 years vs < 50 years 0.821 0.742-0.910 < 0.0001 Age, 60-69 years vs < 50 years 0.677 0.611-0.751 0.0184 Age, 70-79 years vs < 50 yrs 0.566 0.501-0.641 0.3871 Age, >80 years vs < 50 years 0.239 0.143-0.399 < 0.0001 Charlson score, 1 vs 0 0.826 0.775-0.880 < 0.01 Charlson score, ≥2 vs 0 0.922 0.789-1.077 0.8557 Gleason score, >6 vs ≤6 1.940 1.812-2.078 < 0.0001 Stage, pT3 vs pT2 3.039 2.796-3.303 < 0.0001 Hospital type, comprehensive cancer center vs community 0.628 0.581-0.680 < 0.0001 Hospital type, teaching vs community 0.424 0.390-0.461 < 0.0001 Hospital type, other vs community 0.372 0.306-0.452 < 0.0001 Hospital location, south vs northeast 0.840 0.786-0.897 < 0.0001 © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e897 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Matthew Maurice More articles by this author Hui Zhu More articles by this author Robert Abouassaly More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

A population-based study of factors associated with post-prostatectomy radiation therapy utilization.

182 Background: Based on level one evidence, adjuvant radiation therapy (aRT) improves cancer control in post-prostatectomy patients with adverse pathologic features. We sought to evaluate its utilization and to identify factors affecting of its use. Methods: Using the National Cancer Database, a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society, we identified men diagnosed with prostate cancer between 2004 and 2011 who were found to have pT3 disease or pT2 disease with positive margins following prostatectomy. We defined aRT as radiation to the prostate and/or pelvis 6 months or less after prostatectomy. We then used univariate and multivariate logistic regression models to assess potential patient and provider predictors of aRT use. Results: We evaluated 103,092 men who had either pT3 disease (81%) or pT2 with positive margins (19%). Of these, we identified 10,043 men (9.7%) who received aRT. Since 2004, there has been a steady decline in aRT usage with time (range, 11.5% to 7.8%). Compared to 2004, patients diagnosed in 2011 were significantly less likely to receive aRT (odds ratio [OR] 0.78, confidence interval [CI] 0.71-0.85, p&lt;0.0001). Higher Gleason score and T stage were strongly associated with positive aRT utilization (p&lt;0.0001), while increasing age was associated with decreased use (p&lt;0.0001). Another strong predictor of aRT uptake was hospital type. Compared to patients treated at community hospitals, patients treated at comprehensive cancer centers or teaching hospitals were significantly less likely to receive aRT (OR 0.63, 0.58-0.68, p&lt;0.0001 or OR 0.42, CI 0.39-0.46, p&lt;0.0001, respectively). Charlson score and hospital location were significantly but weakly associated with aRT. Other demographic variables were not predictive of aRT. Conclusions: Post-prostatectomy aRT use is declining despite clear proof of its benefit. Consistent with the evidence, patients with risk factors for biochemical relapse (i.e. high Gleason score or T3 disease) and younger patients, who are more likely to benefit, are receiving aRT. Surprisingly, aRT use is lower at teaching hospitals, which may reflect higher usage of salvage radiation.

P6.042 ART Uptake and CD4 Recovery Rates Post ART Initiation in a Cohort of HIV-1 Infected Individuals Referred For ART at Jinja Partners PREP Site

BackgroundThe current WHO recommendation for ART initiation at CD4 cell count ≤ 350 is premised on the need for achieving better immune recovery. However, not every HIV infected person meeting...

Access to HIV/AIDS care: a systematic review of socio-cultural determinants in low and high income countries

BackgroundThe role of socio-cultural factors in influencing access to HIV/AIDS treatment, care and support is increasingly recognized by researchers, international donors and policy makers. Although many of them have been identified through qualitative studies, the evidence gathered by quantitative studies has not been systematically analysed. To fill this knowledge gap, we did a systematic review of quantitative studies comparing surveys done in high and low income countries to assess the extent to which socio-cultural determinants of access, identified through qualitative studies, have been addressed in epidemiological survey studies.MethodsTen electronic databases were searched (Cinahl, EMBASE, ISI Web of Science, IBSS, JSTOR, MedLine, Psyinfo, Psyindex and Cochrane). Two independent reviewers selected eligible publications based on the inclusion/exclusion criteria. Meta-analysis was used to synthesize data comparing studies between low and high income countries.ResultsThirty-four studies were included in the final review, 21 (62%) done in high income countries and 13 (38%) in low income countries. In low income settings, epidemiological research on access to HIV/AIDS services focused on socio-economic and health system factors while in high income countries the focus was on medical and psychosocial factors. These differences depict the perceived different barriers in the two regions. Common factors between the two regions were also found to affect HIV testing, including stigma, high risk sexual behaviours such as multiple sexual partners and not using condoms, and alcohol abuse. On the other hand, having experienced previous illness or other health conditions and good family communication was associated with adherence to ART uptake. Due to insufficient consistent data, a meta-analysis was only possible on adherence to treatment.ConclusionsThis review offers evidence of the current challenges for interdisciplinary work in epidemiology and public health. Quantitative studies did not systematically address in their surveys important factors identified in qualitative studies as playing a critical role on the access to HIV/AIDS services. The evidences suggest that the problem lies in the exclusion of the qualitative information during the questionnaire design. With the changing face of the epidemic, we need a new and improved research strategy that integrates the results of qualitative studies into quantitative surveys.

Effectiveness of a community-based positive prevention intervention for people living with HIV who are not receiving antiretroviral treatment: a prospective cohort study.

We report effectiveness of an HIV-prevention intervention delivered by community health workers (CHWs) in Mombasa, Kenya, to PLHIV who have not initiated or who have discontinued ART-an often difficult-to-reach population because they fall outside the ambit of health care and prevention services. A 2-arm cohort study assessed a structured risk-reduction intervention involving at least 4 one-to-one counseling sessions and personalized support. The control group received standard prevention services. CHWs recruited treatment-naïve people living with HIV (PLHIV) or those who had previously taken antiretroviral drugs. Data were analyzed using a Propensity Score Matched (PSM)-sample to control for baseline differences between the groups. 634 PLHIV were recruited and followed for 6 months. Median age was 35 years, and 74.3% were female. Participants in the intervention group reported reduced risky sexual behaviors both at endline compared with baseline and compared with the control group. At endline, in the PSM analysis, participants in the intervention arm were less likely than participants in the control group to report unprotected sex with a spouse (Odds Ratio [OR] = 0.08, 95% confidence interval [CI] = 0.03-0.24), and they reported fewer unprotected sex acts (12.3% versus 46.0%, respectively; OR = 0.16, 95% CI = 0.09-0.29; P<0.001). Further, 92.4% of participants in the intervention group reported zero unsafe sex acts (with partners of negative or unknown HIV status) compared with 70.8% in the control group (P<0.001), and more participants in the intervention arm were receiving ART (34.3% versus 12.7%, respectively; P<0.001). CHWs effectively reached PLHIV who had never received or who had discontinued ART, and they delivered a risk-reduction intervention that led to declines in reported sexual risk behaviors, as well as to increases in ART uptake. A scaled-up intervention warrants consideration.

Characteristics of adults and children diagnosed with tuberculosis in Lilongwe, Malawi: findings from an integrated HIV/TB clinic

To describe initial registration characteristics of adult and paediatric TB patients at a large, public, integrated TB and HIV clinic in Lilongwe, Malawi, between January 2008 and December 2010. Routine data on patient with TB category and TB type, stratified by HIV and ART status, were used to explore differences in proportions among TB only, TB/HIV co-infected patients not on ART and TB/HIV co-infected patients on ART using chi-square tests. Trends over time illustrate strengths and weaknesses of integrated service provision. Among 10 143 adults, HIV ascertainment and ART uptake were high and increased over time. The proportion of relapse was highest among those on ART (5%). The proportion of smear-positive pulmonary TB (PTB) was highest among HIV-negative patients with TB (34.9%); extra-pulmonary TB (EPTB) was lowest among TB only (16.2%). Among 338 children <15 years, EPTB and smear-positive PTB were more common among TB-only patients. Time trends showed significant increases in the proportion of adults with smear-positive PTB and the proportion of adults already on ART before starting TB treatment. However, some co-infected patients still delay ART initiation. HIV ascertainment and ART uptake among co-infected patients are successful and improving over time. However, delays in ART initiation indicate some weakness linking TB/HIV patients into ART during TB follow-up care. Improved TB diagnostics and screening efforts, especially for paediatric patients, may help improve quality care for co-infected patients. These results may aid efforts to prioritise TB and HIV prevention, education and treatment campaigns for specific populations.