Degu Jerene

Patients Present Earlier and Survival Has Improved, but Pre-ART Attrition Is High in a Six-Year HIV Cohort Data from Ethiopia

Background Previous studies showed higher early mortality rates among patients treated with antiretroviral drugs in settings with limited resources. One of the reasons was late presentation of patients to care. With improved access to HIV services, we expect improvements in disease stage at presentation. Our objective was to assess the effect of improved availability of HIV services on patient presentation to care and subsequent pre-ART and on-ART outcomes. Methodology and Principal Findings At Arba Minch Hospital in Ethiopia, we reviewed baseline characteristics and outcomes of 2191 adult HIV patients. Nearly a half were in WHO stage III at presentation. About two-thirds of the patients (1428) started ART. Patients enrolled in the early phase (OR = 4.03, 95% CI 3.07–5.27), men (OR = 1.78, 95%CI 1.47–2.16), and those aged 45 years and above (OR = 2.04, 95%CI 1.48–2.82) were at higher risk of being in advanced clinical stage at presentation. The pre-treatment mortality rate was 13.1 per 100 PYO, ranging from 1.4 in the rapid scale-up phase to 25.9 per 100 PYO in the early phase. A quarter of the patients were lost to follow-up before starting treatment. Being in less advanced stage (HR = 1.9, 95% CI = 1.6, 2.2), being in the recent cohort (HR = 2.0, 95% CI = 1.6, 2.6), and rural residence (HR = 1.8, 95% CI = 1.5, 2.2) were independent predictors of pre-ART loss to follow-up. Of those who started ART, 13.4% were lost to follow-up and 15.4% died. The survival improved during the study. Patients with advanced disease, men and older people had higher death rates. Conclusions and Significance Patients started to present at earlier stages of their illness and death has decreased among adult HIV patients visiting Arba Minch Hospital. However, many patients were lost from pre-treatment follow-up. Early treatment start contributed to improved survival. Both pre-ART and on-ART patient retention mechanisms should be strengthened.

Rapid Scale-Up of Antiretroviral Treatment in Ethiopia: Successes and System-Wide Effects

Yibeltal Assefa and colleagues describe the successes and challenges of the scale-up of antiretroviral treatment across Ethiopia, including its impact on other health programs and the countrys human resources for health.

Antiretroviral therapy at a district hospital in Ethiopia prevents death and tuberculosis in a cohort of HIV patients

BackgroundAlthough highly active antiretroviral therapy (HAART) reduces mortality in the developed world, it remains undocumented in resource-poor settings. We assessed the effect of HAART on patient mortality and tuberculosis incidence rate under routine clinical care conditions in Ethiopia. The objective of this study was to assess the effect of HAART on patient mortality and tuberculosis incidence rate under routine clinical care conditions in a resource-limited setting in south Ethiopia. Starting in January 2003, we followed all consecutive adult HIV infected patients who visited the HIV clinic. Since August 2003, we treated patients with HAART. Only basic laboratory services were available.ResultsWe followed 185 patients in the pre-HAART cohort and 180 patients in the HAART cohort. The mortality rate was 15.4 per 100 person-years of observation (PYO) in the HAART group and tuberculosis incidence rate was 3.7 per 100 PYO. In the pre-HAART group, the mortality rate was 58.1 per 100 PYO and the tuberculosis incidence rate was 11.1 per 100 PYO. HAART resulted in a 65% decline in mortality (adjusted hazard ratio [95%CI] = 0.35 [0.19–0.63]; P < 0.001). Tuberculosis incidence rate was lower in the HAART group (adjusted hazard ratio [95%CI] = 0.11 [0.03–0.48]; P < 0.01). Most of the deaths occurred during the first three months of treatment.ConclusionHAART improved survival and decreased tuberculosis incidence to a level similar to that achieved in the developed countries during the early years of HAART. However, both the mortality and the tuberculosis incidence rate were much higher in terms of absolute figures in this resource-limited setting. Attention should be paid to the early weeks of treatment when mortality is high. The high tuberculosis incidence rate, when coupled with the improved survival, may lead to increased tuberculosis transmission. This highlights the need for strengthening tuberculosis prevention efforts with the scale-up of treatment programmes

Predictors of early death in a cohort of Ethiopian patients treated with HAART

BackgroundHAART has improved the survival of HIV infected patients. However, compared to patients in high-income countries, patients in resource-poor countries have higher mortality rates. Our objective was to identify independent risk factors for death in Ethiopian patients treated with HAART.MethodsIn a district hospital in Ethiopia, we treated adult HIV infected patients with HAART based on clinical and total lymphocyte count (TLC) criteria. We measured body weight and complete blood cell count at baseline, 4 weeks later, then repeated weight every month and complete blood cell count every 12 weeks. Time to death was the main outcome variable. We used the Kaplan Meier and Cox regression survival analyses to identify prognostic markers. Also, we calculated mortality rates for the different phases of the follow-up.ResultsOut of 162 recruited, 152 treatment-naïve patients contributed 144.1 person-years of observation (PYO). 86 (57%) of them were men and their median age was 32 years. 24 patients died, making the overall mortality rate 16.7 per 100 PYO. The highest death rate occurred in the first month of treatment. Compared to the first month, mortality declined by 9-fold after the 18th week of follow-up. Being in WHO clinical stage IV and having TLC<= 750/mcL were independent predictors of death. Haemoglobin (HGB) <= 10 g/dl and TLC<= 1200/mcL at baseline were not associated with increased mortality. Body mass index (BMI) <= 18.5 kg/m2 at baseline was associated with death in univariate analysis. Weight loss was seen in about a third of patients who survived up to the fourth week, and it was associated with increased death. Decline in TLC, HGB and BMI was associated with death in univariate analysis only.ConclusionThe high mortality rate seen in this cohort was associated with advanced disease stage and very low TLC at presentation. Patients should be identified and treated before they progress to advanced stages. The underlying causes for early death in patients presenting at late stages should be investigated.

Acceptability of HIV counselling and testing among tuberculosis patients in south Ethiopia

BackgroundTo benefit from available care and treatment options, patients should first be counselled and tested for HIV. Our aim was to assess the acceptability of HIV testing among tuberculosis patients under routine care conditions in south Ethiopia.MethodsWe interviewed all adult tuberculosis patients who were treated at Arba Minch Hospital in Ethiopia between January and August 2005. After recording socio-demographic information and tuberculosis treatment history, we referred those patients who showed initial willingness to a counsellor for HIV counselling and testing. Rapid test methods were used following a pretest counselling session. The results were disclosed during a post-test counselling session. We used the logistic regression method to assess factors associated with willingness and acceptability.Results190 adult tuberculosis patients were treated at the hospital and all of them consented to take part in the study. Their median age was 30 years (range, 15–68) and 52% of them were males. 49 patients (26%) were previously tested including 29 (59%) HIV positive. Of 161 patients (excluding the 29 already positive), 118 (73%) were willing to be tested and 58% (68/118) of those willing accepted the test. The overall acceptability rate was 35% (56/161). Fourteen (20.6%) were HIV positive and women were more likely to be HIV infected (p = 0.029). Unemployment and self-perceived high risk of HIV infection were associated with initial willingness (OR [95%CI]:2.6 [1.3–5.5] vs. 5.0 [1.1–22.4], respectively). However, only being unemployed was associated with accepting the test (OR = 4.2; 95%CI = 1.9–9.3).ConclusionThe low acceptability of HIV counselling and testing among tuberculosis patients poses a challenge to the scale-up of TB/HIV collaborative efforts. There is a need for alternative counselling and testing strategies.

Disease Progression Among Untreated HIV-Infected Patients in South Ethiopia: Implications for Patient Care

ContextThe natural course of HIV disease progression among resource-poor patient populations has not been clearly defined.ObjectiveTo describe predictors of HIV disease progression as seen at an outpatient clinic in a resource-limited setting in rural Ethiopia.DesignThis prospective cohort study included all adult HIV patients who visited an outpatient clinic at Arba Minch hospital in South Ethiopia between January 30, 2003 and April 1, 2004. Clinical and hematologic measurements were done at baseline and every 12 weeks thereafter until the patient was transferred, put on antiretroviral therapy, was lost to follow-up, or died. Community agents reported patient status every month.SettingA district hospital with basic facilities for HIV testing and patient monitoring.Main Outcome MeasuresDeath, diagnosis of tuberculosis, and change in disease stage.ResultsWe followed 207 patients for a median duration of 19 weeks (range, 0–60 weeks). A total of 132 (64%) of them were in WHO stage III. The overall mortality rate was 46 per 100 person-years of observation (PYO). Mortality increased with advancing disease stage. Diarrhea, oral thrush, and low total lymphocyte count were significant markers of mortality. The incidence of tuberculosis was 9.9 per 100 PYO. Baseline history of easy fatigability and fever were strongly associated with subsequent development of tuberculosis.ConclusionThe mortality rate and the incidence of tuberculosis in our cohort are among the highest ever reported in sub-Saharan Africa. We identified oral thrush, diarrhea, and total lymphocyte count as predictors of mortality, and easy fatigability and fever as predictors of tuberculosis. The findings have practical implications for patient care in resource-limited settings.

Cost estimates of HIV care and treatment with and without anti-retroviral therapy at Arba Minch Hospital in southern Ethiopia

BackgroundLittle is known about the costs of HIV care in Ethiopia.ObjectiveTo estimate the average per person year (PPY) cost of care for HIV patients with and without anti-retroviral therapy (ART) in a district hospital.MethodsData on costs and utilization of HIV-related services were taken from Arba Minch Hospital (AMH) in southern Ethiopia. Mean annual outpatient and inpatient costs and corresponding 95% confidence intervals (CI) were calculated. We adopted a district hospital perspective and focused on hospital costs.FindingsPPY average (95% CI) costs under ART were US

Incidence of tuberculosis and early mortality in a large cohort of HIV infected patients receiving antiretroviral therapy in a tertiary hospital in Addis Ababa, Ethiopia.

235.44 (US

National HIV treatment guidelines in Tanzania and Ethiopia: are they legitimate rationing tools?

218.11–252.78) and US

The yield of a tuberculosis household contact investigation in two regions of Ethiopia.

29.44 (US