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ATTRITION AMONG PREGNANT AND NON-PREGNANT PATIENTS INITIATING ART IN
HAITI FOLLOWING ADOPTION OF OPTION B+
Jean Wysler Domercant1, Nancy Puttkammer2, Lydia Lu3, Kesner Francois4, Dana Duncan5, Reynold Grand’Pierre4, David Lowrance1, Michelle Adler5
1Centers for Disease Control and Prevention, Port au Prince Haiti; 2International Training and Education Center for Health, Seattle WA, USA; 3Eagle Applied Sciences, Atlanta, GA; 4Ministry of Health of the
Government of Haiti; 5Centers for Disease Control and Prevention, Atlanta GA, USA.
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Background ART services started in 2003
Rapid scale-up with service access in all 42 Districts
High national coverage of HTC in ANC (80%) and ART among HIV infected pregnant women (87%)
Option B+ policy adopted in March 2012 and implementation started in October 2012
Limited data on level of attrition among ART patients following the adoption of Option B+ policy
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Methods Retrospective cohort analysis
Clinical data for 17,084 adult patients at 73 health facilities initiating ART from Oct. 2012 – Aug. 2014
Kaplan-Meier method and Cox proportional hazards regression
Option B+ ART initiation during or within 12 weeks of pregnancy
No breastfeeding data available
Attrition 90 day lapse after a missed clinical or pharmacy-dispensing
appointment Officially-recorded discontinuation due to death or patient
preference
Assessment of “silent transfer” phenomenon
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0.2
50
.75
1.0
00
.50
Pro
po
rtio
n r
eta
ine
d o
n A
RT
0 .5 1 1.5 2Analysis time (years after ART start)
Non-pregnant women Option B+Men
Kaplan-Meier Estimates of Retention on ART
Attrition by Patient Group
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Factors Associated with Attrition
a p<0.10, b p<0.05, c p<0.01, d p<0.001After controlling for health facility, marital status, ART regimen, calendar period of ART start, household size, having treatment buddy named, facility-based ART selection committee met to discuss patient case prior to ART start.
Patient Characteristics Hazard Ratio 95% Confidence Interval
Patient group (reference = Non-pregnant women, WHO stage I or II) d
Non-pregnant women, WHO stage III or IV 1.14 (1.03, 1.26) Option B+, WHO stage I or II 1.63 (1.44, 1.83) Option B+, WHO stage III or IV 1.32 (1.14, 1.53) Men, WHO stage I or II 1.11 (0.96, 1.29) Men, WHO stage III or IV 1.35 (1.21, 1.50)
Age (each 10-year increase) d 0.86 (0.84, 0.88) Residence in same commune as health facility b 0.93 (0.88, 1.00) Any known HIV+ household members d 0.80 (0.71, 0.90) Starting ART within 7 days of enrollment in care d 1.41 (1.32, 1.51) Baseline BMI (each 1 unit increase) d 0.97 (0.96, 0.98) Moderate or severe anemia d 1.31 (1.22, 1.42) Pre-ART counseling provided d 0.84 (0.78, 0.91) TB treatment or prophylaxis at baseline a 0.94 (0.89, 1.00) Cotrimoxizole prophylaxis at baseline c 0.88 (0.80, 0.97)
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Role of “Silent Transfers”
5,904 attrition cases from iSanté matched to records in the HIV/AIDS Surveillance System (HASS) database
“Silent transfer” among attrition cases: Overall: 418 of 5,904 (7.1%) Option B+: 143 of 1,766 (8.1%) Non-pregnant women: 151 of 2,440 (6.2%) Men: 124 of 2,043 (6.1%)
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When Option B+ Cases Drop Out of Care Relative to Delivery
prenatal within 1 mo (+/-)
1-2 mo after 2-3 mo after 3-6 mo after >6 mo after0
50
100
150
200
250
0%
10%
20%
30%
40%
50%
60%
Count Percent
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Conclusion Risk of attrition up to 63% higher for Option B+
group compared with non-pregnant of similar characteristics
Modifiable risk factors: Initiating ART immediately after enrollment in HIV care Initiating ART late in pregnancy
Key protective factors: Pre-ART counseling Living in the catchment area of the health facility OI prophylaxis
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Limitations Routine data source, varying quality across sites
Potential misclassification of Option B+ Difficulty of assigning dates of pregnancy, lack of
breastfeeding data
Modest overestimate of attrition due to “silent transfers” and individual-level data on transfers not available for this analysis
Observational data, so findings may reflect selection bias and confounding, or other types of bias
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Recommendations Effort to attract pregnant women into care early in
pregnancy
Ensure access to appropriate social support
Intense adherence counseling Importance of staying on medication Benefit for patient in addition to infant and partners Assessing risk of attrition and barriers to adherence
Proactivity in the retention strategy
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AcknowledgementsMinistère de la Santé Publique et de la Population
US Centers for Disease Control and Prevention Paul Rashad Young, Barbara Marston, Patrice Joseph, Valerie Pelletier,
Reginald Jean Louis
University of Washington Department of Global HealthMartine Myrtil
University of Washington Center for AIDS Research Biometrics CoreKrista Yuhas
Implementing PartnersMSPP-UGP, GHESKIO, PIH, CMMB, IHV, UM, I-TECH, CDS
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