Risk of death among those awaiting treatment for HIV infection in Zimbabwe: adolescents are

at particular risk

ZIMA CONGRESS 20-23 AUGUST 2015VICTORIA FALLS

ARTICLE in JOURNAL OF THE INTERNATIONAL AIDS SOCIETY · FEBRUARY

2015 • AUTHORS: Amir Shrouf,1, Wedu Ndebele2,3, Mary Nyathi2, Hilary

Gunguwo2,3, Mark Dixon2,3, Jean F Saint-Sauveur1, Fabian Taziwa1, Mari C Vin oles1 and Rashida A Ferrand4 ̃�

• Authors’ affiliations • 1Me’decins Sans Frontie`res, Harare, Zimbabwe; 2Mpilo OI/ART

Clinic, Bulawayo, Zimbabwe; 3Faculty of Medicine, National University of Science and Technology, Bulawayo, Zimbabwe; 4Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK

• Competing interest • The authors declare that they have no conflicts of interest.

Introduction

• There has been a rapid scale up of ART in sub Saharan Africa over the last decade

• This has led to increased survival rates in HIV • Focus has been on outcomes in those who

start ART.• Those awaiting ART, have largely been

overlooked in most programmes• Mortality and LTFU is high in this group

Introduction

• Delayed presenation and diagnosis are thought to be responsible for mortality in adolescents.

• A significant number of perinatally acquired HIV reach adolescence un diagnosed, in Zimbabwe

• Unnecessary further delay at registration can compound this.

• We therefore conducted a retrospective study to investigate the following:

Introduction

• Retention in care• Mortality in the pre ART period• Factors associated with early mortality in

adults and adolescents at Mpilo central hospital HIV clinic.

Methods

• ART STARTED 2004• STUDY PERIOD ENROLLMENT 2004-2010 AT

Mpilo• At the time was done by Mpilo staff as well as

partners like MSF.• Eligibility were adults and adolescents(10-

19yrs WHO), at registration• Pre ART, time from registration to initiation

Methods

• LTFU defined as missing scheduled appointment by 3 or more months

• Data collection: was entered into FUCHIA, software systematically

• Statistical analysis: used STATA version 10• Comparison of means and proportions were done using

two tailed T-tests & Chi square test for normally distributed data & Man-Whitney U- test for non normal distribution data

• Linear regression was used for secular trends in early mortality.

Ethical consideration

• Only routine data was used hence no written consents were required, as no personal information was extracted.

• The Mpilo central hospital ethical board also approved the study

Results

• Dermographic and registration data was missing for 167 records, which were excluded

• 1973 adolescents & 11106 adults completed initial registration at this clinic

• 345 adolescents and 2056 had insufficient data to determine ART eligibilty hence were excluded from the study.

• There was no difference in the hazard of mortality between those excluded and the study p= 0,37

Results

• 1628 adolescents and 9050 adults were included in the study analysis

• 1382(85%) adolescents & 7557(84%) adults satisfied ART eligibility at that time of enrollment.

Results Baseline characteristics of patients

characteristics

total adults adolescents P- value

Total patients

10678 9050 1628 -

Median age- years(IQR)

34,7 36,6 13,1 -

Male 35% 32% 47% <0,001

Prev ARV Hx 14% 15% 3% <0,001

VCT self referral

16% 18% 3% <0,001

%eligible for ART

84% 84% 85% 0,164

WHO stage 3/4

74% 73% 83% <0,001

Median CD4 count(IQR)

167 162 210 <0,001

CD4 <200 58% 60% 49% <0,001

Haemoglobin < 11 g/dl

85% 40% 47% 0,005

Pulmonary TB

10% 9% 11% 0,055

Severe Pneumonia

3% 2% 4% <0,001

Results – secular trends in eligibility and early mortality

year Numbers Adolesc/adults

Never started ARTAdo/adults

Median(IQT) in days pre ART

NO, who died in first year

2004 69/784 9/183 21/0♯ 16/137

2005 117/1194 13/219 45/65 13/123

2006 170/1195 19/110 23/21♯ 15/59♯

2007 224/768 28/67 21/19 13/43

2008 259/1162 31/114 19,5/14♯ 12/22♯

2009 260/1246 15/100 14/14♯ 13/32♯

2010 283/1208 23/149 14/14♯ 21/12♯

♯P<0,05

Discussion

• Adolescents are significantly at higher risk of death than adults while awaiting ART, probably due to late diagnosis & more advanced disease.

• Most adolescent were treatment naïve• If most were vertically infected then there was

delayed diagnosis.• There are inadequate current case finding

strategies in children.( Is this ethical?)

Discussion

• VCT services though scaled up in this period, this was for adults

• Testing among adolescents was primarily in hospital, presenting with illness

• Delays in ART were possibly due to a number of factors: parent or gaurdian dependency, lack of money for transport, & lack of independent access to services.

• LTFU was 10%, reasons to explored in this study

Recommendations

• There is need for more innovative HIV case finding and testing services in adolescents, such as allowing access to VCT centers.

• There will be need to link this to care and treatment

• Defaulter tracing must include those who have yet started ART, especially in adolescents

Acknowledgements

• We would like to thank all the MOHCC, at Mpilo, Hospital

• MSF Staff who worked in OI• The parents/gaurdians and clients who

attended the clinic, at the time.• All the reviewers, and authors.

Thank You and GOD BLESS YOU