Category Archives: HIV

Westerlund E, Jerene D, Mulissa Z, Hallström I and Lindtjørn B. Pre-ART retention in care and prevalence of tuberculosis among HIV-infected children at a district hospital in southern Ethiopia. BMC Pediatrics 2014, 14:250

Abstract

Background  The Ethiopian epidemic is currently on the wane. However, the situation for infected children is in some ways lagging behind due to low treatment coverage and deficient prevention of mother-to-child transmission. Too few studies have examined HIV infected children presenting to care in low-income countries in general. Considering the presence of local variations in the nature of the epidemic a study in Ethiopia could be of special value for the continuing fight against HIV. The aim of this study is to describe the main characteristics of children with HIV presenting to care at a district hospital in a resource-limited area in southern Ethiopia. The aim was also to analyse factors affecting pre-ART loss to follow-up, time to ART-initiation and disease stage upon presentation.

Methods  This was a prospective cohort study. The data analysed were collected in 2009 for the period January 2003 through December 2008 at Arba Minch Hospital and additional data on the ART-need in the region were obtained from official reports.

Results   The pre-ART loss to follow-up rate was 29.7%. Older children (10-14 years) presented in a later stage of their disease than younger children (76.9% vs. 45.0% in 0-4 year olds, chi-square test, chi2 = 8.8, P = 0.01). Older girls presented later than boys (100.0% vs. 57.1%, Fisher’s exact test, P = 0.02). Children aged 0-4 years were more likely to be lost to follow-up (40.0 vs. 21.8%, chi-square test, chi2 = 5.4, P = 0.02) and had a longer time to initiate ART (Cox regression analysis, HR: 0.50, 95% CI: 0.25-0.97, P = 0.04, controlling for sex, place of residence, enrolment phase and WHO clinical stage upon presentation). Neither sex was overrepresented in the sample. Tuberculosis prevalence upon presentation and previous history of tubercolosis were 14.5% and 8% respectively.

Conclusions  The loss to follow-up is alarmingly high and children present too late. Further research is needed to explore specific causes and possible solutions.

It is important for HIV infected patients to take their drugs regularly. Interruptions in treatment lead to viral strains that are resistant to the cheapest medications, and to higher rates of illness and death. Unfortunately, many AIDS patients do not come for their antiretroviral medications. Such patients are labelled as “lost to follow-up.”

During the early years of antiretroviral treatment (ART) drug distribution in Africa, researchers reported high rates of adherence to treatment, often as high as in Europe or the United States. At the same time, studies showed higher early mortality rates among patients treated with antiretroviral drugs in settings with limited resources. A reason for the high death rates was late presentation of patients to care.

In a recent review of 2191 adult HIV patients in south Ethiopia, we show that patients now start to present at earlier stages of their illness, and death has decreased among adult HIV patients. Early treatment start contributed to improved survival (Mulissa, Jerene and Lindtjørn, 2010).

Unfortunately, 25 per cent were lost before that started treatment. This means they were diagnosed, but did not return for treatment, and this have increased during the recent years. We also found that 15% per cent of those who start treatment were lost to follow up. 40% of the latter group had died, and 20% had started treatment in another institution.

Some ART programmes in Africa are experimenting with different programmes to reduce loss to follow-up. Some organizations offer a two- or three-month supply of medication for each clinic visit, others deliver drugs to patients’ homes, and some have tried to refund patients for transport costs. None of these efforts have been evaluated.

Mulissa, Z., Jerene, D., & Lindtjørn, B. (2010). Patients Present Earlier and Survival Has Improved, but Pre-ART Attrition Is High in a Six-Year HIV Cohort Data from Ethiopia PLoS ONE, 5 (10) DOI: 10.1371/journal.pone.0013268

We are reviewing the treatment results among patients receiving antiretroviral therapy at Arba Minch Hospital.

From Ethiopia there are few results published on treatment outcome in children with HIV infection. We have therefore reviewed the survival of children 14 years or younger.

The preliminary results (se Figure) show the five-year survival rate is about 90 %.

Most of the deaths occur during the first twelve months, and usually occurs among patients with advanced disease when we started treatment.

We are reviewing the outcome of antiretroviral treatment at Arba Minch Hospital. We started treating patients in 2003, and since then about 1550 patients have received the antiviral drugs.

Our early papers showed the death rates among patients were high during the first months of treatment. We thought the reasons for these high death rates were the patients came late for treatment; that is, they presented themselves with late stage disease.

Our objective for the study is to see if the treatment results improve over time, and if patients present with earlier stage disease. Dr Zewdie Mulissa and Dr Degu Dare take part in this study.

Our preliminary findings confirm improved survival, and that patients come earlier for treatment. We are now also trying to find out what happens to patients after they are diagnosed with HIV until they start treatment.