washington d.c., usa, 22-27 july 2012 acceptable adherence and treatment outcomes among refugees and...
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Washington D.C., USA, 22-27 July 2012www.aids2012.org
Acceptable adherence and treatment outcomes among refugees and host community on HAART in an urban refugee setting in Kuala Lumpur, Malaysia
THPDD0103
Poor treatment outcomes among both refugees and host community accessing HAART from Kakuma refugee camp, Northwestern Kenya
THPDD0102
J.B. Mendelsohn,
P. Spiegel,
M. Schilperoord,
S. Balasundaram,
A. Radhakrishnan, C. Lee,
N. Larke, A. Grant,
D.A. Ross
J.B. Mendelsohn,
M. Schilperoord, P. Spiegel,
J.W. Burton, J.A. Okonji,
B. Muhindo, P. Njogu, N. Larke,
A. Grant, I.M. Mohamed,
I.N. Mukui,
D.A. Ross
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Background/Objective• Refugee Convention: refugees should receive
equitable access to public relief/health care • Tight link between adherence and treatment
outcomes• Few data on adherence and treatment outcomes in
clinics providing HAART to refugees in asylum; comparison with host nationals
• Are refugees and host community clients achieving – Optimal adherence?– Acceptable and equitable treatment outcomes?– What is driving outcomes?
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Methods• Cross-sectional surveys
– Sungai Buloh Hospital: public urban reference hospital on the outskirts of Kuala Lumpur
– Comprehensive Care Clinic, Kakuma Refugee Camp, an NGO-run, remote clinic, Northwestern Kenya
• ≥18 years; HAART for ≥30 days; ≥6 mo. defaulters excluded
• Structured questionnaire with self-reported (SR) adherence measures
• Pharmacy-based measure of adherence to prescription (Rx) refills over 24 months prior
• HIV viral loads (phlebotomy / dried blood spots)
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Malaysia• 91,985 registered by UNHCR as refugees and
asylum seekers• 171 refugees on HAART, 98% Burmese• 2,900 Malaysians on HAART at SB hospital• 153 refugees;148 Malaysians serially-recruited• 90% participation rate among refugees; 89%
response rate among Malaysians
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Results - MalaysiaRefugee (%) Host (%) p-value
Viral suppression 81 84 0.54Adherence - Rx 74 66 0.15Adherence - SR 72 70 0.79
Risk factors for lack of viral suppression (≥25wks)•Refugee status (aOR=1.28, 0.52-3.14, p=0.60)•Female (aOR=0.39, 0.14-1.05, p=0.05)•Optimal adherence Rx (aOR=0.47, 0.27- 0.81, p=0.007)•Longer time from diagnosis to HAART (aOR=0.64, 0.41-0.99, p=0.04)•Temporary migration, ≥1 mo. in the past year (aOR=4.12, 1.70-9.99, p=0.002)•Clinic transit times ≥1hr (aOR=3.05, 95%CI 1.09-8.49, p=0.02)
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Kenya• 446,946 refugees from the Horn of Africa
registered by UNHCR• Kakuma Refugee Camp, pop. 82,409 • 84 refugees;104 Kenyans on HAART• 73 refugees, 86 Kenyans serially recruited /
actively traced • ~85% participation rates in each group
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Results - KenyaRefugee (%) Host (%) p-value
Viral suppression 12 11 0.89Adherence - Rx 85 74 0.09Adherence - SR 62 28 0.002
Risk factors for lack of viral suppression (≥25wks)•Refugee status (aOR=0.64, 0.20-2.08, p=0.46)•Larger household sizes (aOR=0.26, 0.11-0.61, p<0.001) •Underdosing (aOR=7.48, 0.74-27.22, p=0.07)
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Conclusions• Adherence and viral suppression: refugee=host• Equal HAART provision and support to refugees
and the host community has public health and clinical benefits
• Enlightened self-interest of host countries• Outcomes in Kenya require urgent response
– Implementing partner working to improve adherence; assessment planned
– Past adherence lapses may not be well captured by Rx or self-reported adherence
– High levels of resistance?– Drug potency?
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Acknowledgements
Canadian Institutes of Health Research
The Parkes Foundation
UNHCR
London School of Hygiene and Tropical Medicine
Hospital Sungai Buloh
International Rescue Committee Kenya
KEMRI (Kisumu)
Washington D.C., USA, 22-27 July 2012www.aids2012.org
UNHCR Alan Vernon, Liz Ahua, Nadine Cornier, Herve Isambert, Ann Burton, Chunting Wong, Fiona Chuah, Madhavi Madhu, Rajeswari Elumalai, Peter Daniels, Jacqueline Dache, Sathya Doraiswamy
Hospital Sungai Buloh Chung Han Yang, Mohamed Sufian, Bernard Lee, Hui Moon, Jayanthi Arumugam, Wong Kok Mun
Standard Pharmacy, Kuala Lumpur M. Lim
IRC Kenya Mwiti Mungania, Jonathan Imaana, Geoffrey Lutta, Monica Eshikeda
KEMRI (Kisumu) Clement Zeh
Refugee and local research staff Jerry Manuel, Ngui Sui Sin (Mai Mai), William Khor, Angelina Hejazi, Min Ye Tun, Par Mawii, La Seng, Maran Seng Raw, Aung Win, Juliana Ooi, Tan Sok Teng, Aung Zan Wai (Saw), Frankie Kai-Pong Law, El Sheila Kavanathi, Sangeetha Shyam, Liang Yaw Wen, Betty Akot, Habiba Abdi Adan, Abdikarim Sharif Mohamed, Honey Abdi Isse, Kevin Ekal Ekutan, Patrick Ejori Lobali, Muthomi Phineas Gitonga, Rhoda Payo, Moses Lujang, Kagoyire Marie Louise, Jean De Dieu Kiza, Tibeyen Mekonnen, Fasil Asmara, Consolata Wanyonyi, Nicodemus Erupe, Richard Loris, Mohammed Ahmed Osman, Abraham Dulacha, Sauda Mukanyarwaya, Lula Gabratasea, Lapson Opaka Lot, Amina Hamadi Osma, and Esther Tito.