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Outcomes of Antiretroviral Treatment Programs in Rural Lesotho: Health Centers and Hospitals Compared

Outcomes of Antiretroviral Treatment Programs in Rural Lesotho: Health Centers and Hospitals Compared . Niklaus Labhardt , Motlalepula Sello , Mamokone A. Mohlaba , Olivia Keiser , Karolin Pfeiffer, Matthias Egger, Jochen Ehmer , Gilles Wandeler. Background.

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Outcomes of Antiretroviral Treatment Programs in Rural Lesotho: Health Centers and Hospitals Compared

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  1. Outcomes of Antiretroviral Treatment Programs in Rural Lesotho:Health Centers and Hospitals Compared NiklausLabhardt, MotlalepulaSello, Mamokone A. Mohlaba, Olivia Keiser, Karolin Pfeiffer, Matthias Egger, Jochen Ehmer, Gilles Wandeler

  2. Background • Scarcehumanresourceslimit the scale up of antiretroviraltherapy (ART) in rural southern Africa • Early losses to follow-up are highest in settings with lowest numbers of health-care workers • Taskshifting and decentralization of care are recommendedstrategies to addresschronichealth care workershortages • Previousreports on ART delivery in decentralizedsettingsare limited toshort-term outcomes Van Damme et al. AIDS 2006 Wandeleret al. JAIDS2012 Harries et al. TropMedIntHealth2010 Shumbusho et al. PLoS Med 2009

  3. Objectives • Todescribeprogrammaticfactorsandbaselinecharacteristicsofpatientsstarting first-line ART in Hospitals andHealthcenters (HCs) in rural Lesotho • Tocompareshortandlong-term clinicaloutcomesbetweenpatientswhostarted ART in thetwotypesoffacilitiesaccrosstwo different regions

  4. SolidarMed ART Program (SMART) • Swiss NGO (www.solidarmed.ch) • 9 hospitals, 40 healthcenters in 4 countries • 13,100 patients on ART by 2011 • International epidemiologic Databases toEvaluate AIDS in Southern Africa (IeDEA-SA) network (www.iedea-sa.org)

  5. SMART Lesotho • 2005: ART athospitals • 2007/08: Decentralization Seboche 1 hospital, 5 healthcenters Population: ~ 55‘000 Adult HIV prevalence*: ~16% Paray 1 hospital, 7 healthcenters Population: ~ 77‘000 Adult HIV prevalence*: ~20% *DemographicHealth Survey of Lesotho 2009

  6. SMART Lesotho

  7. Inclusioncriteria / definitions Patients • Over 16 yearsatstartof ART • Noprevious ART exposure • Started first-line ART including 2 NRTI and 1 NNRTI Definitions • Nofollowup: novisit after thestartof ART • LTFU: not returningtotheclinic ≥ 6 months • Retained in care: aliveand on ART Chi et al. PLoSMed2011

  8. Statistical analyses • All analysescomparedpatientstreated in thetwofacilitytypes (Hospitals and HCs) andwerestratifiedbyregion (ParayandSeboche) • Baseline characteristicscomparedwithchi-squaredand Mann-Whitney tests • Kaplan-Meier curvesforcruderetention • Multivariable logisticregressionmodelsfornofollow-up • Competingriskregressionmodelsformortalityand LTFU andresultsshown in a Forestplot

  9. Flow chart ART start Jan 2008 - April 2011 N=3,969 ART start outside studyarea N=222 ART startathealthcenter N=2,042 ART startathospital N=1,705 Paray N=832 Seboche N=873 Paray N=1,247 Seboche N=795

  10. Resources for ART delivery

  11. Baseline characteristicsofpatients

  12. Overall retention in care: hospitals vs. HCs 100 90 80 70 Proportion ofpatientsretained (%) 60 50 0 1 2 3 Numberatrisk Years after ART start HCs 2042 1284 677 128 Hospitals 1705 1009 583 245 Hospitals Health Centers

  13. Retention in care: hospitals vs. HCs byregion 100 90 80 Proportion ofpatientsretained (%) 70 60 50 0 1 2 3 Years after ART start Numberatrisk HCs Seboche 795 490 282 72 HCs Paray 1247 794 395 56 Hosp. Seboche 873 508 294 131 Hosp. Paray 832 501 289 114 HCs Seboche HCs Paray Hospital Seboche Hospital Paray

  14. Clinical outcomes, byregion All analyses are adjusted for gender, age, baseline CD4 cell count, WHO stage, ART regimen and region

  15. Limitations • Heterogeneitybetweentworegions • Tracing of patients LTFU not consistent across sites • Limited deathascertainment

  16. Conclusion • In rural Lesotho, patients who started ART in health centers had less advanced HIV disease than those in hospitals • Health centers: overall retention slightly better and early losses less likely compared to hospitals. • However, the determinants of retention in care (mortality, LTFU) differed across regions, underlining the importance of tracing patients LTFU

  17. Acknowledgments All patientsandstaffoftheparticipatingsites Collaboratorsfrom: • SolidarMed Lesotho (N. Labhardt, M. Sello, M. A. Mohlaba) • SolidarMed, Lucerne, Switzerland (J. Ehmer, K. Pfeiffer) • University of Bern, Switzerland (M. Egger, O. Keiser) Financial support: NIH (NIAID, Grant U01AI069924)

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