adolescents in need of art a growing challenge
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Sustaining quality while scaling up adolescent ART Findings from Zimbabwe’s largest adolescent cohort. Shroufi A, Dixon M, Gunguwo H, Nyathi M, Ndlovu M, Saint- Sauveur JF, Taziwa F, Ndebele W , Ferreyra C, Carmen Viñoles M. Adolescents in need of ART A growing challenge. - PowerPoint PPT PresentationTRANSCRIPT
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Sustaining quality while scaling up adolescent ART
Findings from Zimbabwe’s largest adolescent cohort
Shroufi A, Dixon M, Gunguwo H, Nyathi M, Ndlovu M, Saint-Sauveur JF, Taziwa F, Ndebele W, Ferreyra C, Carmen Viñoles M
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Adolescents in need of ARTA growing challenge
• Improved treatment means children with HIV are surviving longer
• This means that increasing numbers of adolescents in Southern African are in need of ART 1
• Less experience managing this age group• Adolescents usually managed in adult programmes• Adult programmes may not address specific needs
of adolescents
1. Ferrand et al. AIDS. 2009;23(15):2039-46.
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Will services cope?Adolescents pose particular challenges
• Known challenges in managing chronic disease1
• More unhealthy / high risk behaviours2
• Poor adherence to ART previously documented3
• Sub-optimal virological responses documented4,5
• Present to services relatively late6
1. Sawyer et al. Lancet. 2007;369(9571):1481-9.2. Catalano et al. Lancet. 2012;379(9826):1653-64. 3. Murphy et al. AIDS Care. 2001;13(1):27-40.4. Flynn et al. AIDS Res Hum Retroviruses. 2007;23(10):1208-145. Markowitz et al. N Engl J Med. 1995;333(23):1534-9. 6. Marston et al. J Acquir Immune Defic Syndr. 2005;38(2):219-27.
Washington D.C., USA, 22-27 July 2012www.aids2012.org
• Limited evidence on outcomes in Southern Africa
• Can scale up be achieved successfully?
Will services cope?
1. Bakanda et al. PloS one. 2011;6(4):e192612. Nglazi et al. BMC Infect Dis. 2012;12:21.
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Mpilo ART clinic BulawayoAdolescents were a challenge...
• Zimbabwe pop: 12.5 million HIV prevalence: 13.1% (2010)
• One of 1st OI ART sites in Zimbabwe. MSF has supported ART provision at Mpilo since it opened in 2004
• As adolescent numbers increased, management challenges arose.
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Adolescent model of care• Adolescent clinic located in
separate space from adult & paediatric clinics
• Specifically tailored services:• Dedicated, highly trained
counsellors • Life skills training• Social activities, camp outside
clinic• Youth club, “Chill Room” • Defaulter tracing• Peer counselling
• Adolescents engaged in clinic management decisions through elected peer representatives
An adolescent counsellor counselling an adolescent at Mpilo Hospital in Bulawayo(Written consent for use provided)
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Adolescent model of care• Psychosocial Support:
– Life skills support, pottery, income generating projects, expressing feelings and thoughts through art, Hero book (MMPZ)
• All Mpilo Clinic staff was trained in adolescent customer care
“Chill” Room
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Scale up of ART Initiation
> 7 fold increase in initiations
> 3 fold increase in initiations
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Methods
• Retrospective cohort study, 2004 - 2010• Data electronically recorded after patient
consultations • Cox proportional hazards model used• Age defined at time of ART initiation:
Adolescents 10-19, adults ≥ 19• LFU: appointment missed by ≥ 3 months • Compared adolescent and adult outcomes
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OutcomesMore adolescents initiated late and ill
Adolescents AdultsInitiations, n 1,776 9,360Median age, years* 13.3 34.7Med duration on treatment, days (IQR)*
567 (222.5 – 1082)
490 (191 – 947)
Males, %* 47.9% 30.7%Stage IV disease, %* 32.4% 24.9%
Diagnosed following illness* 91.5% 60.7%
*Statistically significant
Retention at 24 months* 86.0% 78·5%
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Adolescent outcomes maintained during scale up
*Adjusted for age, haemoglobin, CD4 and BMI.
Adolescents• No change in deaths over time• HR = 0.92*, p=0.59• No change in LFU over time• HR=1.02*, p=0.59
Adults• No change in deaths over time• HR=0.9*, p=0.131• Increase in LFU over time• HR=1.2*, p=0.004
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Mortality and LFUAdolescent LFU lower than in adults
P=0.83 P<0.0001
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Summary FindingsMuch adolescent HIV undiagnosed + untreated
• Diagnosis usually after clinical illness, consistent with estimates that 75% of adolescent HIV is undiagnosed1
• By the end of study period, 17% of all actively followed patients were adolescents (1,610 / 9,387*) compared to estimate of 5% nationally1
1. Ferrand et al. Bull World Health Organ. 2010;88(6):428-34
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Summary FindingsGood retention and low LFU can be achieved
• Despite challenges, low LFU and high retention were achieved in adolescents
• Despite later presentation, survival in adolescents equalled adult survival
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Conclusions• As more HIV positive children survive into
adolescence, scale-up of specific services is needed
• Need to increase case-finding efforts by incorporating innovative approaches to identify HIV-positive adolescents, then link them to care tailored to their needs.
• Good adolescent results are feasible with dedicated services in resource-constrained settings
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Acknowledgements
• We acknowledge the work of all patients, MoHCW and MSF staff at Mpilo OI ART clinic
• We also acknowledge the work of Million Memory Project Zimbabwe (MMPZ)
• And the Contact Counselling Trust of Bulawayo
Conflict of Interest• The authors declare that they have no conflicts of interest
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Supplementary information
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Death rates + LFU ratesCrude and adjusted for LFU
Overall Adults Adolescents p-value
(logrank test)
Unadjusted death rate, per 100 person years (95% CI)
2·9 (2·7-3·2) 2·8 ( 2·5 – 3·0) 3·8 (3·2 – 4·5) 0·0007
Rate of loss to follow up, per 100 person years (95% CI)
8·5 (8·2-8·9) 9·2 (8·8 – 9·6) 4·8 (4·1 – 5·6) <0·00005
30% of those LTFU assumed dead
5·4 (5·1-5·.8) 5·4 (5·1-5·8) 5·5 (4·8-6·4) 0·8271
50% of those LTFU assumed dead
7·2 (6·8-7·5) 7·3 (6·9-7·7) 6·4 (5·6-7·3) 0·753
50% of those LTFU assumed dead
8·9 (8·5-9·3) 9·2 (8·8-9·6) 7·3 (6·5-8·3) 0·0011
At the most plausible levels of death among those lost to follow up no difference in death rates between groups
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Adolescents, n
Mortality Loss to follow up
Retention 24 months
Mpilo cohort. Zimbabwe
1,776 3.8 (3.2 – 4.5)
4.8(4.1 – 5.6)
86%
Bakanda et al. Uganda (1)
575 3.6 (2.6-4.7)
- -
Nglazi et al. South Africa (2)
65 1.2 (0.3-4.8)
7.2 (4.1 –12.6)
-
Results
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Entry to ART servicesFew adolescents came from VCT services
• Most adolescents referred from hospital after becoming unwell, subsequently being offered provider initiated testing and counselling (PITC)
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Regimen infoMost common regimens used at initiation
Adults Adolescents (D4T-3TC-NVPp)Stavudine, Lamivudine, Nevirapine
7,412 1,543
FDC (AZT-3TC-NVP) Zidovudine, Lamivudine, Nevirapine
839 16
EFV+FDC (D4T30-3TC) Efavirenz, Stavudine, Lamivudine
705 85
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ResultsMore adolescents initiated late
Adolescents AdultsInitiations, n 1,776 9,360Median age, years 13.3 34.7Males, % 47.9% 30.7%Stage IV disease, % 32.4% 24.9%VCT referrals 2.8% 17.5%Med duration on treatment, days (IQR)
567 (222.5 – 1082)
490 (191 – 947)
Mortality rate / 100 p yrs* 5.5 (4.8-6.4) 5.4 (5.1-5.8)LFU rate / 100 p yrs 4.8 (4.1-5.6) 9.2 (8.8 - 9.6)Retention at 24 months 86.0% 78·5%
*30% of those lost to follow up assumed to have died
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Full references used slides 3+4
• Ferrand RA, Corbett EL, Wood R, Hargrove J, Ndhlovu CE, Cowan FM et al. AIDS among older children and adolescents in Southern Africa: projecting the time course and magnitude of the epidemic. AIDS. 2009;23(15):2039-46.
• Sawyer SM, Drew S, Yeo MS, Britto MT. Adolescents with a chronic condition: challenges living, challenges treating. Lancet. 2007;369(9571):1481-9.
•Murphy DA, Wilson CM, Durako SJ, Muenz LR, Belzer M, Adolescent Medicine HIV/AIDS Research Network. Antiretroviral medication adherence among the REACH HIV-infected adolescent cohort in the USA. AIDS Care. 2001;13(1):27-40.
• Flynn PM, Rudy BJ, Lindsey JC, Douglas SD, Lathey J, Spector SA et al. Long-term observation of adolescents initiating HAART therapy: three-year follow-up. AIDS Res Hum Retroviruses. 2007;23(10):1208-14.
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Full references used slide 4
• Markowitz M, Saag M, Powderly WG, Hurley AM, Hsu A, Valdes JM et al. A preliminary
study of ritonavir, an inhibitor of HIV-1 protease, to treat HIV-1 infection. N Engl J Med.
1995;333(23):1534-9.
Marston M, Zaba B, Salomon JA, Brahmbhatt H, Bagenda D. Estimating the net effect of HIV
on child mortality in African populations affected by generalized HIV epidemics. J Acquir
Immune Defic Syndr. 2005;38(2):219-27.
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Full references usedslides 5 and 14
Bakanda C, Birungi J, Mwesigwa R, Nachega JB, Chan K, Palmer A et al. Survival of HIV-infected adolescents on antiretroviral
therapy in Uganda: findings from a nationally representative cohort in Uganda. PloS one. 2011;6(4):e19261.
Nglazi MD, Kranzer K, Holele P, Kaplan R, Mark D, Jaspan H et al. Treatment outcomes in HIV-infected adolescents attending a
community-based antiretroviral therapy clinic in South Africa. BMC Infect Dis. 2012;12:21.
Ferrand R, Lowe S, Whande B, Munaiwa L, Langhaug L, Cowan F et al. Survey of children accessing HIV services in a high
prevalence setting: time for adolescents to count? Bull World Health Organ. 2010;88(6):428-34
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Full references used
Catalano RF, Fagan AA, Gavin LE, Greenberg MT, Irwin CE, Ross DA et al. Worldwide
application of prevention science in adolescent health. Lancet. 2012;379(9826):1653-64.
Nachega JB, Hislop M, Nguyen H, Dowdy DW, Chaisson RE, Regensberg L et al.
Antiretroviral therapy adherence, virologic and immunologic outcomes in adolescents
compared with adults in southern Africa. J Acquir Immune Defic Syndr. 2009;51(1):65-71.
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Full references used• Fox, M. P., & Rosen, S. (2010). Patient retention in antiretroviral therapy programs
up to three years on treatment in sub-Saharan Africa, 2007-2009: systematic
review. Tropical medicine & international health : TM & IH, 15 Suppl 1, 1-15.
doi:10.1111/j.1365-3156.2010.02508.x
Rosen S, Fox MP. Retention in HIV care between testing and treatment in sub-
Saharan Africa: a systematic review. PLoS Med. 2011;8(7):e1001056.