Anna Grimsrud

Temporal changes in programme outcomes among adult patients initiating antiretroviral therapy across South Africa, 2002-2007

Objective:Little is known about the temporal impact of the rapid scale-up of large antiretroviral therapy (ART) services on programme outcomes. We describe patient outcomes [mortality, loss-to-follow-up (LTFU) and retention] over time in a network of South African ART cohorts. Design:Cohort analysis utilizing routinely collected patient data. Methods:Analysis included adults initiating ART in eight public sector programmes across South Africa, 2002–2007. Follow-up was censored at the end of 2008. Kaplan–Meier methods were used to estimate time to outcomes, and proportional hazards models to examine independent predictors of outcomes. Results:Enrolment (n = 44 177, mean age 35 years; 68% women) increased 12-fold over 5 years, with 63% of patients enrolled in the past 2 years. Twelve-month mortality decreased from 9% to 6% over 5 years. Twelve-month LTFU increased annually from 1% (2002/2003) to 13% (2006). Cumulative LTFU increased with follow-up from 14% at 12 months to 29% at 36 months. With each additional year on ART, failure to retain participants was increasingly attributable to LTFU compared with recorded mortality. At 12 and 36 months, respectively, 80 and 64% of patients were retained. Conclusion:Numbers on ART have increased rapidly in South Africa, but the programme has experienced deteriorating patient retention over time, particularly due to apparent LTFU. This may represent true loss to care, but may also reflect administrative error and lack of capacity to monitor movements in and out of care. New strategies are needed for South Africa and other low-income and middle-income countries to improve monitoring of outcomes and maximize retention in care with increasing programme size.

Social determinants of psychological distress in a nationally-representative sample of South African adults

There is substantial evidence from developed countries that lower socioeconomic status (SES) is associated with increased occurrence of mental illness, and growing interest in the role of social support and social capital in mental health. However, there are few data on social determinants of mental health from low- and middle-income nations. We examined the association between psychological distress and SES, social support and bonding social capital in a nationally-representative sample of South African adults. As part of a national survey of mental health, a probability sample of 4,351 individuals was interviewed between 2002 and 2004. Non-specific psychological distress was measured using the Kessler K-10 scale. SES was assessed from an aggregate of household income, individual educational and employment status, and household material and financial resources. Social support, bonding social capital and traumatic life events were measured using multi-item scales. The mean age in the sample was 37 years and 76% of participants were black African. Measures of SES and social capital were inversely associated (p<0.001). Both recent and traumatic life events were more common among individuals with low levels of SES and social support. After adjusting for participant demographic characteristics and life events, high levels of psychological distress were most common among individuals with lower levels of SES and social capital. There was no independent association between levels of social support and psychological distress. The occurrence of recent life events appeared to partially mediate the association between SES and psychological distress (p=0.035) but not the association involving social capital (p=0.40). These data demonstrate persistent associations between levels of SES, social capital and psychological distress in South Africa. The increased frequency of recent life events appears to only partially explain higher levels of psychological distress among individuals of lower SES. Additional research is required to understand the temporality of this association as well as mechanisms through which SES and social capital influence mental health in low- and middle-income settings where high levels of poverty and trauma may contribute to excess burden of mental illness.

Universal Definition of Loss to Follow-Up in HIV Treatment Programs: A Statistical Analysis of 111 Facilities in Africa, Asia, and Latin America

Based on a statistical analysis of 111 facilities in Africa, Asia, and Latin America, Benjamin Chi and colleagues develop a standard loss-to-follow-up (LTFU) definition that can be used by HIV antiretroviral programs worldwide.

Traditional healers in the treatment of common mental disorders in South Africa.

Abstract: There are few population-level insights into the use of traditional healers and other forms of alternative care for the treatment of common mental disorders in sub-Saharan Africa. We examined the extent to which alternative practitioners are consulted, and predictors of traditional healer visits. A national survey was conducted with 3651 adult South Africans between 2002 and 2004, using the World Health Organization Composite International Diagnostic Interview (CIDI) to generate DSM-IV diagnoses for common mood, anxiety, and substance use disorders. A minority of participants with a lifetime DSM-IV diagnosis obtained treatment from Western (29%) or alternative (20%) practitioners. Traditional healers were consulted by 9% of the respondents and 11% consulted a religious or spiritual advisor. Use of traditional healers in the full sample was predicted by older age, black race, unemployment, lower education, and having an anxiety or a substance use disorder. Alternative practitioners, including traditional healers and religious advisors, appear to play a notable role in the delivery of mental health care in South Africa.

The psychometric properties of the K10 and K6 scales in screening for mood and anxiety disorders in the South African Stress and Health study

Emerging research has provided support for the use of the Kessler Psychological Distress Scales in developing countries; however, this research has yet to be extended to southern Africa. This study sought to evaluate the performance of the Kessler scales in screening for depression and anxiety disorders in the South African population. The scales along with the Composite International Diagnostic Interview (CIDI) were included in the South African Stress and Health study, a nationally representative household survey. The K10/K6 demonstrated moderate discriminating ability in detecting depression and anxiety disorders in the general population; evidenced by area under the receiver operating curves of 0.73 and 0.72 respectively. However, both scales failed to meet our acceptability criteria of high sensitivity and high positive predictive value. Examinations of differences in responding by race/ethnicity revealed that the K10/K6 [Kessler Psychological Distress Scale 10‐item (K10) and the abbreviated six‐item (K6)] had significantly lower discriminating ability with respect to depression and anxiety disorders among the Black group (0.71) than among the combined minority race/ethnic groups of White, Colored, and Indian/Asian (0.78; p = 0.016). The difference in time period assessed on the K10/K6 (past 30 days) versus the CIDI (past 12 months) was a notable limitation of this study. Additional validation studies using clinician diagnostic instruments are recommended. Copyright

Implementation of community-based adherence clubs for stable antiretroviral therapy patients in Cape Town, South Africa

Community‐based models of antiretroviral therapy (ART) delivery have been recommended to support ART expansion and retention in resource‐limited settings. However, the evidence base for community‐based models of care is limited. We describe the implementation of community‐based adherence clubs (CACs) at a large, public‐sector facility in peri‐urban Cape Town, South Africa.

Effects of the SATZ teacher-led school HIV prevention programmes on adolescent sexual behaviour: cluster randomised controlled trials in three sub-Saharan African sites

In this study, the effects on young adolescent sexual risk behaviour of teacher-led school HIV prevention programmes were examined in two sites in South Africa (Cape Town and Mankweng) and one site in Tanzania (Dar es Salaam). In Cape Town, Dar es Salaam and Mankweng, 26, 24 and 30 schools, respectively, were randomly allocated to intervention or comparison groups. Primary outcomes were delayed sexual debut and condom use among adolescents aged 12-14 years (grade 8 in South Africa and grades 5 and 6 in Tanzania). In total, 5352, 4197 and 2590 students participated at baseline in 2004 in Cape Town, Dar es Salaam and Mankweng, respectively, and 73% (n = 3926), 88% (n = 3693) and 83% (n = 2142) were retained 12-15 months later. At baseline, 13% (n = 224), 5% (n = 100) and 17% (n = 164) had had their sexual debut, and 44% (n = 122), 20% (n = 17) and 37% (n = 57) of these used a condom at last sex, respectively. In Dar es Salaam, students in the intervention were less likely to have their sexual debut during the study (OR 0.65, 95% CI 0.48-0.87). In Cape Town and Mankweng, the intervention had no impact. The current interventions were effective at delaying sexual debut in Dar es Salaam but not in South Africa, where they need to be supplemented with programmes to change the environment in which adolescents make decisions about sexual behaviour.

Outcomes of antiretroviral therapy over a 10-year period of expansion: a multicohort analysis of African and Asian HIV programs.

Objective:Little is known about the evolution of program outcomes associated with rapid expansion of antiretroviral therapy (ART) in resource-limited settings. We describe temporal trends and assess associations with mortality and loss to follow-up (LTFU) in HIV cohorts from 8 countries. Design:Multicohort study using electronic health records. Methods:Analysis included adults in 25 Médecins Sans Frontières–supported programs initiating ART between 2001 and 2011. Kaplan–Meier methods were used to describe time to death or LTFU and proportional hazards models to assess associations with individual and program factors. Results:ART programs (n = 132,334, median age 35 years, 61% female) expanded rapidly. Whereas 36-month mortality decreased from 22% to 9% over 5 years (⩽2003–2008), LTFU increased from 11% to 21%. Hazard ratios (HR) of early (0–12 months) and late (12–72 months) LTFU increased over time, from 1.09 [95% confidence interval (CI): 0.83 to 1.43] and 1.04 (95% CI: 0.84 to 1.28) in 2004 to 3.29 (95% CI: 2.42 to 4.46) and 6.86 (95% CI: 4.94 to 9.53) in 2011, compared with 2001–2003. Rate of program expansion was strongly associated with increased early and late LTFU, adjusted HR (aHR) = 2.31 (95% CI: 1.78 to 3.01) and HR = 2.29 (95% CI: 1.76 to 2.99), respectively, for ≥125 vs. 0–24 patients per month. Larger program size was associated with decreased early mortality (aHR = 0.49, 95% CI: 0.31 to 0.77 for ≥20,000 vs. <500 patients) and increased early LTFU (aHR = 1.77, 95% CI: 1.04 to 3.04 for ≥20,000 vs. <500 patients). Conclusions:As ART expands in resource-limited settings, challenges remain in improving access to ART and preventing program attrition. There is an urgent need for novel and sustainable models of care to increase long-term retention of patients.

Intermittent Explosive Disorder in South Africa: Prevalence, Correlates, and the Role of Traumatic Exposures

Background: The epidemiology of DSM-IV intermittent explosive disorder (IED) is not well characterized in developing country settings. In South Africa, given the high rates of violence and trauma, there is particular interest in traumatic exposures as potential risk factors for IED. Methods: We examined the prevalence and predictors of IED in a nationally representative sample of 4,351 South African adults. IED and other diagnoses based on DSM-IV criteria were assessed using the World Health Organization Composite International Diagnostic Interview (CIDI). A 28-item scale was constructed to measure exposure to traumatic events. Results: Overall, 2.0% of participants (95% CI: 0–4.9%) fulfilled criteria for the narrow definition of IED, and 9.5% (95% CI: 6.6–12.3%) fulfilled criteria for the broad definition of IED. Individuals with IED experienced high rates of comorbid anxiety, mood and substance use disorders compared to non-IED participants. In multivariate analysis, a diagnosis of IED was associated with Caucasian and mixed-race ethnicity, psychiatric comorbidity and exposure to multiple traumatic events. Conclusion: These data suggest a relatively high prevalence of IED in South Africa. By reducing violence and trauma, and by providing appropriate psychological support to trauma survivors, we may be able to reduce rates of IED.

Impact of definitions of loss to follow-up (LTFU) in antiretroviral therapy program evaluation: variation in the definition can have an appreciable impact on estimated proportions of LTFU

OBJECTIVE To examine the impact of different definitions of loss to follow-up (LTFU) on estimates of program outcomes in cohort studies of patients on antiretroviral therapy (ART). STUDY DESIGN AND SETTING We examined the impact of different definitions of LTFU using data from the International Epidemiological Databases to Evaluate AIDS-Southern Africa. The reference approach, Definition A, was compared with five alternative scenarios that differed in eligibility for analysis and the date assigned to the LTFU outcome. Kaplan-Meier estimates of LTFU were calculated up to 2 years after starting ART. RESULTS Estimated cumulative LTFU were 14% and 22% at 12 and 24 months, respectively, using the reference approach. Differences in the proportion LTFU were reported in the alternative scenarios with 12-month estimates of LTFU varying by up to 39% compared with Definition A. Differences were largest when the date assigned to the LTFU outcome was 6 months after the date of last contact and when the site-specific definition of LTFU was used. CONCLUSION Variation in the definitions of LTFU within cohort analyses can have an appreciable impact on estimated proportions of LTFU over 2 years of follow-up. Use of a standardized definition of LTFU is needed to accurately measure program effectiveness and comparability between programs.