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Outcomes of Antiretroviral Treatment Programs in Rural Lesotho: Health Centers and Hospitals Compared
Niklaus Labhardt, Motlalepula Sello, Mamokone A. Mohlaba, Olivia Keiser, Karolin Pfeiffer, Matthias Egger, Jochen Ehmer, Gilles Wandeler
Background
• Scarce human resources limit the scale up of antiretroviral therapy (ART) in rural southern Africa
• Early losses to follow-up are highest in settings with lowest numbers of health-care workers
• Task shifting and decentralization of care are recommended strategies to address chronic health care worker shortages
• Previous reports on ART delivery in decentralized settings are limited to short-term outcomes
Van Damme et al. AIDS 2006Wandeler et al. JAIDS 2012Harries et al. Trop Med Int Health 2010Shumbusho et al. PLoS Med 2009
Objectives
1. To describe programmatic factors and baseline characteristics of patients starting first-line ART in Hospitals and Health centers (HCs) in rural Lesotho
2. To compare short and long-term clinical outcomes between patients who started ART in the two types of facilities accross two different regions
SolidarMed ART Program (SMART)
• Swiss NGO (www.solidarmed.ch)
• 9 hospitals, 40 health centers in 4 countries
• 13,100 patients on ART by 2011
• International epidemiologic Databases to Evaluate AIDS in Southern Africa (IeDEA-SA) network (www.iedea-sa.org)
SMART Lesotho
Seboche1 hospital, 5 health centersPopulation: ~ 55‘000Adult HIV prevalence*: ~16%
Paray1 hospital, 7 health centersPopulation: ~ 77‘000Adult HIV prevalence*: ~20%
• 2005: ART at hospitals• 2007/08: Decentralization
*Demographic Health Survey of Lesotho 2009
SMART Lesotho
Inclusion criteria / definitions
Patients• Over 16 years at start of ART• No previous ART exposure• Started first-line ART including 2 NRTI and 1 NNRTI
Definitions• No follow up: no visit after the start of ART• LTFU: not returning to the clinic ≥ 6 months• Retained in care: alive and on ART
Chi et al. PLoS Med 2011
Statistical analyses
• All analyses compared patients treated in the two facility types (Hospitals and HCs) and were stratified by region (Paray and Seboche)
• Baseline characteristics compared with chi-squared and Mann-Whitney tests
• Kaplan-Meier curves for crude retention• Multivariable logistic regression models for no follow-up • Competing risk regression models for mortality and
LTFU and results shown in a Forest plot
Flow chart
ART start Jan 2008 - April 2011 N=3,969
ART start outside study areaN=222
ART start at hospital N=1,705
ART start at health center N=2,042
Paray N=832 Seboche N=873 Paray N=1,247 Seboche N=795
Resources for ART delivery
Hospitals Health Centers4 Median number of physicians 03 Median number of nurse-clinicians 12 Median number of nurse-assistants 16 Median number of lay-counselors 2
Yes CD4 count on site NoYes Hemoglobin measurement on site InconsistentNo Viral Load measurement on site No
Baseline characteristics of patients
Seboche (1,668) Paray (2,079)
Hospitals Health Centers P-value Hospitals Health Centers P-value
Number of patients 873 795 832 1,247
Number of women (%) 569 (65.2) 515 (64.8) 0.87 517 (62.1) 795 (63.8) 0.478
Median age in years (IQR)
37 (31-47) 39 (31-50) 0.028
37 (30-47) 39 (32-48) 0.007
Median absolute CD4 count in cells/µl (IQR)
169 (86-278) 208 (119-287) <0.001
157 (66-258) 215 (133-290) <0.001
Median hemoglobin level in g/dl (IQR)
11.4 (10-12.7) 12 (10.8-13.3) <0.001
12.1 (10.5-13.6) 12.5 (11.5-13.7) 0.002
WHO stage (%)
I/II 411 (47.1) 546 (68.7) <0.001 438 (52.6) 839 (67.4) <0.001
III/IV 462 (52.9) 249 (31.3) 394 (47.4) 405 (32.6)
Overall retention in care: hospitals vs. HCs
50
100
60
70
80
90
1705 1009 583 245Hospitals2042 1284 677 128HCs
Number at risk
0 1 2 3
Health Centers Hospitals
Years after ART start
Pro
por
tion
of p
atie
nts
reta
ined
(%
)
Retention in care: hospitals vs. HCs by region
50
100
60
70
80
90
Pro
por
tion
of p
atie
nts
reta
ined
(%
)
832 501 289 114Hosp. Paray
873 508 294 131Hosp. Seboche
1247 794 395 56HCs Paray
795 490 282 72HCs Seboche
Number at risk
0 1 2 3
Years after ART start
HCs Seboche HCs Paray
Hospital Seboche Hospital Paray
Clinical outcomes, by region
All analyses are adjusted for gender, age, baseline CD4 cell count, WHO stage, ART regimen and region
Limitations
• Heterogeneity between two regions
• Tracing of patients LTFU not consistent across sites
• Limited death ascertainment
Conclusion
• In rural Lesotho, patients who started ART in health centers had less advanced HIV disease than those in hospitals
• Health centers: overall retention slightly better and early losses less likely compared to hospitals.
• However, the determinants of retention in care (mortality, LTFU) differed across regions, underlining the importance of tracing patients LTFU
All patients and staff of the participating sitesCollaborators from: • SolidarMed Lesotho (N. Labhardt, M. Sello, M.
A. Mohlaba)• SolidarMed, Lucerne, Switzerland (J. Ehmer, K.
Pfeiffer)• University of Bern, Switzerland (M. Egger, O.
Keiser)Financial support: NIH (NIAID, Grant U01AI069924)
Acknowledgments