Trends in Disease Stage at Presentation to Care and Pre-ART Outcomes: a Six-Year HIV Cohort Data from Southern Ethiopia

Degu Jerene MD, PhD, WCO, EthiopiaZewdie Mullisa MD, Arba Minch Hospital, EthiopiaBernt Lindtjørn MD, PhD, University of Bergen, Norway

Background and objectives• Access to antiretroviral therapy improved• Delayed visit contributes to higher death• Trends in patient presentation unknown• Little data on pre-ART patient outcomes• Our objective was to document;

– If there had been shift in disease stage– Pre-ART patient outcomes including loss

METHODS

Study Setting• Ethiopia, population: 73.9 m

(CSA 2007)• HIV prevalence: 2.4% (FMOH,

2007)• ART started in 2003, free ART

in 2005• Arba Minch Hospital: public

hospital• The first hospital to start ART in

the southern region – University of Bergen, Norway

• Technical support since mid-2006– PEPFAR through Johns Hopkins

University

Study Design• Retrospective cohort, Jan ‘03-Dec 31,’08• Reviewed routine patient records• Eligibility; adults, treatment-naïve• Excluded; child, treatment experienced• Enrolment stratified into 3 phases;

– Jan 2003-Aug 2006 (Early phase)– Sept 2006-Aug 2007 (Rapid scale-up)– Sept 2007-Dec 2008 (Recent phase)(Assefa Y et al 2009. PLoS Med 6: e1000056).

Definitions• Pre-ART loss to follow-up (pLFU): if patient

did not have follow up visit at least 30 days after the date of clinic appointment

• Advanced disease: Those in WHO Clinical Stage III & IV– NB: No CD4 until 2006

Statistical Methods• SPSS used for entry and analysis• Logistic regression method

– Advanced stage vs less advanced• Kaplan Meier and Cox Regression

– Time to pre-ART outcomes (death or loss)• Demographic and clinical characteristics as

co-variates

Ethics• Arba Minch Hospital HIV Cohort has

National clearance• Approval obtained locally for this specific

study• De-identified secondary data used

RESULTS

Cohort profile

Participant characteristicsCharacteristic ValueTotal analyzed 2191

Median age, yrs (IQR) 33 (26-38)

Sex, % women 56

Residence, % urban 83

WHO stage (number, %)

I 398 (18.2)

II 424 (19.4)

III 1077 (49.2)

IV 292 (13.3)

Median TLC (IQR) 1.4 (1, 2)

Median CD4 (IQR) 207 (97, 355)

Factors: advanced diseaseVariable Adjusted OR (95%CI)Phase of enrolment

Recent 1.0 Rapid scale-up 2.1 (1.7-2.6)Early 4.0 (3.1-5.3)

Marital statusMarried 1.00Unmarried 1.1 (0.9-1.5)Divorced, widowed or separated

1.4 (1.1-1.7)

SexFemale 1.00Male 1.8 (1.5-2.2)

Age, yrs15-44 145+ 2.0 (1.5-2.8)

Pre-ART loss to follow up• 25% were lost to follow-upPredictors: aHR (95%CI)

Less advanced disease 2.4 (1.3-2.6)Recent cohort 2.0 (1.6-2.6)Rural residence 1.8 (1.5-2.2)

• Age, sex, and marital status not associated

Pre-ART mortality• 5% died during pre-ART care• Mortality rate: 13.1 per 100 PYO

– Rapid scale-up phase: 1.4– Recent phase: 8.4– Early phase: 25.9

Predictors aHR (95% CI)Early vs rapid scale-up 2.4 (1.3-4.6)Advanced disease 2.8 (1.6-4.8)

Survival: Cox Regression

Conclusions• Patients started to present earlier• Pre-ART death was highest among the

oldest cohort irrespective of disease stage• Pre-ART loss to follow-up is a common but

less clearly recognized challenge• Patients in the recent cohort, rural residents

and those with less advanced disease are more likely to default

Recommendations• Need to strengthen pre-ART patient care

– Standardize definitions for pre-ART loss– Monitoring and evaluation tools– Re-package existing interventions (IPT, bed

nets, food, prevention, psychosocial, etc)– Pre-ART patient tracing/adherence support

• Further studies needed– Multiple cohorts, various settings, qualitative– Effectiveness and cost of interventions

Acknowledgements• University of Bergen, Norway• WHO Country Office, Ethiopia• Regional Health Bureau, Gamo Goffa Zone

Health Desk, and Arba Minch Hospital

THANK YOU!