CD4 cell counts should no longer be a criterion for HIV treatment initiation. As 'test and treat' rolls out in Myanmar, 'attrition' should become a thing of the past. One hopes that 'dropout' does not replace it.
Jamie
Alarming attrition rates among HIV-infected individuals in pre-antiretroviral therapy care in Myanmar, 2011–2014
Myo Minn Oo1*, Vivek Gupta2,3,4, Thet Ko Aung1, Nang Thu Thu Kyaw3, Htun Nyunt Oo5 and Ajay MV Kumar2,3
1International Union Against Tuberculosis and Lung Disease, Mandalay, Myanmar; 2International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office, New Delhi, India; 3International Union Against Tuberculosis and Lung Disease, Paris, France; 4Community Ophthalmology, Dr. RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India; 5National AIDS Program, Ministry of Health, Myanmar
Abstract
Background: High retention rates have been documented among patients receiving antiretroviral therapy (ART) in Myanmar. However, there is no information on human immunodeficiency virus (HIV)-infected individuals in care before initiation of ART (pre-ART care). We assessed attrition (loss-to-follow-up [LTFU] and death) rates among HIV-infected individuals in pre-ART care and their associated factors over a 4-year period.
Design: In this retrospective cohort study, we extracted routinely collected data of HIV-infected adults (>15 years old) entering pre-ART care (June 2011–June 2014) as part of an Integrated HIV Care (IHC) programme, Myanmar. Attrition rates per 100 person-years and cumulative incidence of attrition were calculated. Factors associated with attrition were examined by calculating hazard ratios (HRs).
Results: Of 18,037 HIV-infected adults enrolled in the IHC programme, 11,464 (63%) entered pre-ART care (60% men, mean age 37 years, median cluster of differentiation 4 (CD4) cell count 160 cells/µL). Of the 11,464 eligible participants, 3,712 (32%) underwent attrition of which 43% were due to deaths and 57% were due to LTFU. The attrition rate was 78 per 100 person-years (95% CI, 75–80). The cumulative incidence of attrition was 70% at the end of a 4-year follow-up, of which nearly 90% occurred in the first 6 months. Male sex (HR 1.5, 95% CI 1.4–1.6), WHO clinical Stage 3 and 4, CD4 count <200 cells/µL, abnormal BMI, and anaemia were statistically significant predictors of attrition.
Conclusions: Pre-ART care attrition among persons living with HIV in Myanmar was alarmingly high – with most attrition occurring within the first 6 months. Strategies aimed at improving early HIV diagnosis and initiation of ART are needed. Suggestions include comprehensive nutrition support and intensified monitoring to prevent pre-ART care attrition by tracking patients who do not return for pre-ART care appointments. It is high time that Myanmar moves towards a ‘test and treat’ approach and ultimately eliminates the need for pre-ART care.
Keywords: pre-ART care; retention; lost to follow-up; death; SORT IT; operational research
Citation: Glob Health Action 2016, 9: 31280 - http://dx.doi.org/10.3402/gha.v9.31280
Responsible Editor: Jennifer Stewart Williams, Umeå University, Sweden.
Copyright: © 2016 Myo Minn Oo et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.
Received: 10 February 2016; Revised: 26 July 2016; Accepted: 26 July 2016; Published: 24 August 2016
Competing interests and funding: None declared. The programme was funded by the Department for International Development (DFID), UK. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
*Correspondence to: Myo Minn Oo, No.36, 27th Street, Between: 72nd and 73rd Street, Mandalay, Myanmar, Email: dr.myominnoo@gmail.com
http://www.globalhealthaction.net/index.php/gha/article/view/31280
