Dataset Information

Predictors of antiretroviral therapy initiation in eThekwini (Durban), South Africa: Findings from a prospective cohort study.

ABSTRACT: Despite expanded antiretroviral therapy (ART) eligibility in South Africa, many people diagnosed with HIV do not initiate ART promptly, yet understanding of the reasons is limited. Using data from an 8-month prospective cohort interview study of women and men newly-diagnosed with HIV in three public-sector primary care clinics in the eThekwini (Durban) region, South Africa, 2010-2014, we examined if theoretically-relevant social-structural, social-cognitive, psychosocial, and health status indicators were associated with time to ART initiation. Of 459 diagnosed, 350 returned to the clinic for their CD4+ test results (linkage); 153 (33.3%) were ART-eligible according to treatment criteria at the time; 115 (75.2% of those eligible) initiated ART (median = 12.86 weeks [95% CI: 9.75, 15.97] after linkage). In adjusted Cox proportional hazard models, internalized stigma was associated with a 65% decrease in the rate of ART initiation (Adjusted hazard ratio [AHR] 0.35, 95% CI: 0.19-0.80) during the period less than four weeks after linkage to care, but not four or more weeks after linkage to care, suggesting that stigma-reduction interventions implemented shortly after diagnosis may accelerate ART uptake. As reported by others, older age was associated with more rapid ART initiation (AHR for 1-year age increase: 1.04, 95% CI: 1.01-1.07) and higher CD4+ cell count (?300?L vs. <150?L) was associated with a lower rate of initiation (AHR 0.38, 95% CI: 0.19-0.80). Several other factors that were assessed prior to diagnosis, including stronger belief in traditional medicine, higher endorsement of stigma toward people living with HIV, food insecurity, and higher psychological distress, were found to be in the expected direction of association with ART initiation, but confidence intervals were wide and could not exclude a null finding.

SUBMITTER: Sy KTL

PROVIDER: S-EPMC7895397 | biostudies-literature | 2021

REPOSITORIES: biostudies-literature

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Predictors of antiretroviral therapy initiation in eThekwini (Durban), South Africa: Findings from a prospective cohort study.

Sy Karla Therese L KTL Tariq Shema S Ramjee Gita G Blanchard Kelly K Leu Cheng-Shiun CS Kelvin Elizabeth A EA Exner Theresa M TM Gandhi Anisha D AD Lince-Deroche Naomi N Mantell Joanne E JE O'Sullivan Lucia F LF Hoffman Susie S

PloS one 20210219 2

Despite expanded antiretroviral therapy (ART) eligibility in South Africa, many people diagnosed with HIV do not initiate ART promptly, yet understanding of the reasons is limited. Using data from an 8-month prospective cohort interview study of women and men newly-diagnosed with HIV in three public-sector primary care clinics in the eThekwini (Durban) region, South Africa, 2010-2014, we examined if theoretically-relevant social-structural, social-cognitive, psychosocial, and health status indic ...[more]

PMID: 33606712

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Project description:Multiple land use regression models (LUR) were developed for different air pollutants to characterize exposure, in the Durban metropolitan area, South Africa. Based on the European Study of Cohorts for Air Pollution Effects (ESCAPE) methodology, concentrations of particulate matter (PM10 and PM2.5), sulphur dioxide (SO2), and nitrogen dioxide (NO2) were measured over a 1-year period, at 41 sites, with Ogawa Badges and 21 sites with PM Monitors. Sampling was undertaken in two regions of the city of Durban, South Africa, one with high levels of heavy industry as well as a harbor, and the other small-scale business activity. Air pollution concentrations showed a clear seasonal trend with higher concentrations being measured during winter (25.8, 4.2, 50.4, and 20.9 µg/m3 for NO2, SO2, PM10, and PM2.5, respectively) as compared to summer (10.5, 2.8, 20.5, and 8.5 µg/m3 for NO2, SO2, PM10, and PM2.5, respectively). Furthermore, higher levels of NO2 and SO2 were measured in south Durban as compared to north Durban as these are industrial related pollutants, while higher levels of PM were measured in north Durban as compared to south Durban and can be attributed to either traffic or domestic fuel burning. The LUR NO2 models for annual, summer, and winter explained 56%, 41%, and 63% of the variance with elevation, traffic, population, and Harbor being identified as important predictors. The SO2 models were less robust with lower R2 annual (37%), summer (46%), and winter (46%) with industrial and traffic variables being important predictors. The R2 for PM10 models ranged from 52% to 80% while for PM2.5 models this range was 61-76% with traffic, elevation, population, and urban land use type emerging as predictor variables. While these results demonstrate the influence of industrial and traffic emissions on air pollution concentrations, our study highlighted the importance of a Harbor variable, which may serve as a proxy for NO2 concentrations suggesting the presence of not only ship emissions, but also other sources such as heavy duty motor vehicles associated with the port activities.

Project description:BACKGROUND:Low birthweight (LBW) and preterm birth (PB) remain the leading cause of morbidity and mortality in neonates worldwide. The aim of this study was to identify maternal demographic and antenatal factors associated with PB and LBW among low socio-economic communities. METHODS:Pregnant women (n?=?1099) were recruited in the first trimester into the Mother and Child in the Environment (MACE) birth cohort in Durban, South Africa. Maternal factors such as demographic information, health status, residential area, occupational, personal and environmental smoking and biomass fuel use were obtained through standardised interviews, while clinical status was obtained in each trimester and antenatal information on HIV status and treatment, syphilis and conditions such as pregnancy induced hypertension, diabetes etc. was extracted from the antenatal assessments. Key outcomes of interest were preterm birth and low birthweight. The latter data was obtained from the clinical assessments performed by midwives at delivery. Logistic regression models identified factors associated with PB and LBW. RESULTS:Of the 760 live births, 16.4 and 13.5% were preterm and LBW, respectively. Mothers who delivered by caesarean section had an increased odds of having LBW babies (Adjusted odds ratio (AOR): 1.7; 95% CI: 1.1-2.7) and PB (AOR: 1.7, 95% CI: 1.1-2.7) versus normal vaginal deliveries. Mothers >?30?years (AOR: 1.8, 95% CI: 1.1-2.9) and current smokers (AOR: 2.7, 95% CI: 1.3-5.8) had an increased odds of having PB babies. Compared to younger mothers and non-smokers respectively. An effect of PB and LBW was seen among mothers with high BMI (25.0-29.9?kg/m2) (PB: AOR: 0.5, 95% CI: 0.3-0.9 and LBW: AOR: 0.5, 0.5, CI: 0.3-0.8), and obese BMI (>?30?kg/m2) (PB: AOR: 0.5, 95% CI: 0.3-0.9 and LBW: AOR: 0.4, CI: 0.2-0.7). Maternal HIV (PB AOR: 1.4 and LBW AOR: 1.2) and history of sexually transmitted infections (PB AOR: 2.7 and LBW AOR: 4.2) were not statistically significant. CONCLUSION:Maternal age, cigarette smoking and caesarean delivery were associated with LBW and PB. Findings highlight the need of maternal health interventions to improve new-born health outcomes.

Project description:BackgroundGlobally, an estimated 8.1 million children under 5 years die annually in developing countries. Ensuring essential medicines are accessible and affordable to the population is key to saving lives. This study investigated accessibility, availability and affordability of a basket of priority medicines for children under 5 years in public and private healthcare sector pharmacies in the eThekwini Metropolitan area in Durban, South Africa.MethodsThe WHO/HAI survey tool for assessing medicine prices, availability and affordability was adapted and employed for a basket of WHO Priority life-saving medicines for children under 5 years. Six district hospitals in the north, south and central eThekwini Metropolitan were selected as major facility reference points and for data collection and pharmacies within a 5 km radius from each major facility were also invited to participate in the study, as outlined in the WHO/HAI tool methodology. Of the 58 pharmacies selected, a total of 27 pharmacies from both private and public healthcare sectors agreed to participate and were surveyed, representing a 47% response rate. Data was analysed using Microsoft excel.ResultsAll participating pharmacies (and hence the selected basket of priority medicines at these facilities) were deemed accessible. Overall the public sector had more medicines available on the shelf (averaging 64%) than the private sector (48%) which had more medicines available on order (84%). At least one medicine for each of the eight (8) conditions was available at both sectors which meant patients could be treated for these conditions. Medicines for priority conditions (except HIV, which was a 28-day course) were deemed affordable as these regimens were obtainable within a day's wage for the lowest paid unskilled worker. Priority medicines for children under 5 years were more available and more affordable in the public sector.ConclusionThe basket of WHO essential medicines for priority conditions for children under 5 years were accessible, available and affordable in the eThekwini Metropolitan areas. This was the first study in eThekwini to determine access to the WHO basket of priority medicines for children and can be scaled-up to a national study to provide a holistic comparison of these medicines in the country, and also for global comparison.

Project description:BackgroundRetention in care is an essential component of meeting the UNAIDS "90-90-90" HIV treatment targets. In Khayelitsha township (population ~500,000) in Cape Town, South Africa, more than 50,000 patients have received antiretroviral therapy (ART) since the inception of this public-sector program in 2001. Disengagement from care remains an important challenge. We sought to determine the incidence of and risk factors associated with disengagement from care during 2013-2014 and outcomes for those who disengaged.Methods and findingsWe conducted a retrospective cohort study of all patients ?10 years of age who visited 1 of the 13 Khayelitsha ART clinics from 2013-2014 regardless of the date they initiated ART. We described the cumulative incidence of first disengagement (>180 days not attending clinic) between 1 January 2013 and 31 December 2014 using competing risks methods, enabling us to estimate disengagement incidence up to 10 years after ART initiation. We also described risk factors for disengagement based on a Cox proportional hazards model, using multiple imputation for missing data. We ascertained outcomes (death, return to care, hospital admission, other hospital contact, alive but not in care, no information) after disengagement until 30 June 2015 using province-wide health databases and the National Death Registry. Of 39,884 patients meeting our eligibility criteria, the median time on ART to 31 December 2014 was 33.6 months (IQR 12.4-63.2). Of the total study cohort, 592 (1.5%) died in the study period, 1,231 (3.1%) formally transferred out, 987 (2.5%) were silent transfers and visited another Western Cape province clinic within 180 days, 9,005 (22.6%) disengaged, and 28,069 (70.4%) remained in care. Cumulative incidence of disengagement from care was estimated to be 25.1% by 2 years and 50.3% by 5 years on ART. Key factors associated with disengagement (age, male sex, pregnancy at ART start [HR 1.58, 95% CI 1.47-1.69], most recent CD4 count) and retention (ART club membership, baseline CD4) after adjustment were similar to those found in previous studies; however, notably, the higher hazard of disengagement soon after starting ART was no longer present after adjusting for these risk factors. Of the 9,005 who disengaged, the 2 most common initial outcomes were return to ART care after 180 days (33%; n = 2,976) and being alive but not in care in the Western Cape (25%; n = 2,255). After disengagement, a total of 1,459 (16%) patients were hospitalized and 237 (3%) died. The median follow-up from date of disengagement to 30 June 2015 was 16.7 months (IQR 11-22.4). As we included only patient follow-up from 2013-2014 by design in order to maximize the generalizability of our findings to current programs, this limited our ability to more fully describe temporal trends in first disengagement.ConclusionsTwenty-three percent of ART patients in the large cohort of Khayelitsha, one of the oldest public-sector ART programs in South Africa, disengaged from care at least once in a contemporary 2-year period. Fifty-eight percent of these patients either subsequently returned to care (some "silently") or remained alive without hospitalization, suggesting that many who are considered "lost" actually return to care, and that misclassification of "lost" patients is likely common in similar urban populations. A challenge to meeting ART retention targets is developing, testing, and implementing program designs to target mobile populations and retain them in lifelong care. This should be guided by risk factors for disengagement and improving interlinkage of routine information systems to better support patient care across complex care platforms.

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Project description:Same-day initiation (SDI) of antiretroviral therapy (ART) has been recommended to improve ART programme outcomes in South Africa since August 2017. This study assessed implementation of SDI over time in two South African districts, describing the characteristics of same-day initiators and evaluating the impact of SDI on retention in ART care. Routine data were analysed for HIV-infected adults who were newly initiating ART in Johannesburg or Mopani Districts between October 2017 and June 2018. Characteristics of same-day ART initiators were compared to later initiators, and losses to follow-up (LTFU) to six months were assessed using Kaplan Meier survival analysis and multivariate logistic regression. The dataset comprised 32 290 records (29 964 from Johannesburg and 2 326 from Mopani). The overall rate of SDI was 40.4% (n = 13 038), increasing from 30.3% in October 2017 to 54.2% in June 2018. Same-day ART initiators were younger, more likely to be female and presented with less advanced clinical disease than those initiating treatment at later times following diagnosis (p<0.001 for all). SDI was associated with disengagement from care: LTFU was 30.1% in the SDI group compared to 22.4%, 19.8% and 21.9% among clients initiating ART 1-7 days, 8-21 days and ≥22 days after HIV diagnosis, respectively (p<0.001). LTFU was significantly more likely among clients in Johannesburg versus Mopani (adjusted odds ratio (aOR) = 1.43, p<0.001) and among same-day versus later initiators (aOR = 1.45, p<0.001), while increasing age reduced LTFU (aOR = 0.97, p<0.001). In conclusion, SDI has increased over time as per national guidelines, but there is serious concern regarding the reduced rate of retention among same-day initiators. Nevertheless, SDI may result in a net programmatic benefit provided that interventions are implemented to support client readiness for treatment and ongoing engagement in ART care, particularly among younger adults in large ART programmes such as Johannesburg.

Dataset Information

Predictors of antiretroviral therapy initiation in eThekwini (Durban), South Africa: Findings from a prospective cohort study.

Publications

Predictors of antiretroviral therapy initiation in eThekwini (Durban), South Africa: Findings from a prospective cohort study.

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