Longitudinal Care Cascade Outcomes Among People Eligible for Antiretroviral Therapy Who Are Newly Linking to Care in Zambia: A Multistate Analysis

Author:

Mody Aaloke1ORCID,Glidden David V2,Eshun-Wilson Ingrid1,Sikombe Kombatende3,Simbeza Sandra3,Mukamba Njekwa3,Somwe Paul3,Beres Laura K4,Pry Jake13,Bolton-Moore Carolyn35,Padian Nancy6,Holmes Charles B7,Sikazwe Izukanji3,Geng Elvin H1

Affiliation:

1. Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA

2. Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA

3. Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia

4. Department of International Health, Johns Hopkins University School of Public Health, Baltimore, Maryland, USA

5. Division of Infectious Diseases, University of Alabama, Birmingham, Alabama, USA

6. Division of Epidemiology, University of California, Berkeley, Berkeley, California, USA

7. Department of Medicine, Georgetown University, Washington, D.C., USA

Abstract

Abstract Background Retention in human immunodeficiency virus (HIV) care is dynamic, with patients frequently transitioning in and out of care. Analytical approaches (eg, survival analyses) commonly used to assess HIV care cascade outcomes fail to capture such transitions and therefore incompletely represent care outcomes over time. Methods We analyzed antiretroviral therapy (ART)-eligible adults newly linking to care at 64 clinics in Zambia between 1 April 2014 and 31 July 2015. We used electronic medical record data and supplemented these with updated care outcomes ascertained by tracing a multistage random sample of patients lost to follow-up (LTFU, >90 days late for last appointment). We performed multistate analyses, incorporating weights from sampling, to estimate the prevalence of 9 care states over time since linkage with respect to ART initiation, retention in care, transfers, and mortality. Results In sum, 23 227 patients (58% female; median age 34 years [interquartile range 28–41]) were ART-eligible at enrollment. At 1 year, 75.2% had initiated ART and were in care: 61.8% were continuously retained, 6.1% had reengaged after LTFU, and 7.3% had transferred. Also, 10.1% were LTFU within 7 days of enrollment, and 15.2% were LTFU at 1 year (6.7% prior to ART). One year after LTFU, 51.6% of those LTFU prior to ART remained out of care compared to 30.2% of those LTFU after initiating ART. Overall, 6.9% of patients had died by 1 year with 3.0% dying prior to ART. Conclusion Multistate analyses provide more complete assessments of longitudinal HIV cascade outcomes and reveal treatment gaps at distinct timepoints in care that will still need to be addressed even with universal treatment.

Funder

National Institute of Allergy and Infectious Diseases

Bill and Melinda Gates Foundation

National Institutes of Health

Publisher

Oxford University Press (OUP)

Subject

Infectious Diseases,Microbiology (medical)

Reference39 articles.

1. Using the side door: non-linear patterns within the HIV treatment cascade in Zambia.;Holmes,2014

2. A side door into care cascade for HIV-infected patients?;Hallett;J Acquir Immune Defic Syndr,2013

3. Understanding patient mobility in HIV-positive adults across multiple clinic in Zambia.;Sikombe,2018

4. A state transition framework for patient-level modeling of engagement and retention in HIV care using longitudinal cohort data;Lee;Stat Med,2018

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