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Barrot H. Lambdin, PhD, MPHDirector of Implementation SciencePangaea Global AIDS Foundation
Integration of HIV Treatment in Primary Health Care Centers Impacts Attrition from HIV Treatment Programs in Central Mozambique
Advancing the health and well-being of people most affected by AIDS
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53% Coverage
31% In RLS
0
50000
100000
150000
200000
250000
2003 2004 2005 2006 2007 2008 2009 2010
YearPatients on ART
Patients
History of ART Scale-up in Mozambique
3,314
7,45618,95
6
44,100
88,211
128,330
170,198
218,991
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53% Coverage
31% In RLS
13 24 40
149
211 213222 229
0
50000
100000
150000
200000
250000
-
60
120
180
240
2003 2004 2005 2006 2007 2008 2009 2010
YearPatients on ART Facilities with ART
Clinics
Patients
National ART Program
ART Integrated with PHC Clinics
History of ART Scale-up in Mozambique
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Study Design, Setting and Population
• Retrospective cohort study of patients initiating ART in the national ART program (Jan 06–Jun 08)• Exclusion Criteria:
• <15 years of age• Transfer in • Pregnancy• Post Historical Events–Flooding & Temporary
Closure
• 18 HIV care and treatment clinics managed by MOH in Manica or Sofala Province• Standardized approach for care
delivery, patient tracing and data recording
• Routine Clinic Databases
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Methods
• Outcomes• Time until Attrition: Lost to Follow-up or Mortality
• Concern for Differential Misclassification• Analysis: Cox proportional hazards models
• Accounted for clinic-level clustering (robust variances)
• Pre-ART CD4 Count• Pre-ART WHO Stage• Age• Sex• Education• Year of Initiation• Pharmacy Staff
Burden
• Clinic Model: Vertical vs. Integrated
• Clinic Location: Urban vs. Rural
• Clinic Experience: 1st 6-months vs. After
• Covariates• Exposures
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Results: Study Population
Transferred810 Children 1,138
Pregnant 1,491
Included in Study 11,793
Initiated Treatment: 15,232
N (%) Delivery Model Vertical 3 (17%) Integrated 16
(89%) Location Urban 10
(55%) Rural 8 (45%)
• 9,120 person-years
• Attrition Rate: 39.22 per 100 py
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Results: Demographic Characteristics
36% In RLS
SexAge13%
39%30%
18%
≥15 to <25 ≥25 to <35≥35 to <45 ≥45
43%57%
Male Female
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Results: Clinical Characteristics
36% In RLS
WHO StageCD4 Count
29%
36%
18%
11%
<100≥100 – <200
26%
65%
9%
I/II III IV
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Results: Clinic Factors and Attrition
HR (95% CI) p-value Clinic Model Integrated [Ref] 1.00 Vertical 0.84 (0.73 –
0.97)0.015
Clinic Location Rural 1.00 Urban 0.86 (0.61 –
1.22)0.389
Clinic Experience First 6-Months 1.00 Post First 6-Months 0.72 (0.51-1.02) 0.065*adjusted for pre-ART CD4 count, WHO stage, age (with quadratic term), education, year of initiation and pharmacy staff burden
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Results: Clinic Factors and Attrition
.4.5
.6.7
.8.9
11.
11.
2H
azar
d R
atio
Clinic Model Clinic Location Clinic Experience
Clinic Characteristics
A Priori Analysis Reference Group 95% CI
Vertical
Integrated
Urban
Rural
Post 1st 6 Months
1st 6 Months
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Strengths & Limitations• Strengths
• Standardization of Protocols• Care delivery• Patient tracing• Data Recording
• High quality data
• Limitations• Observational Study• Unable to adjust for all patient and
clinic characteristics• Generalizeability
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Conclusions• Integrating HIV services into PHC
dramatically expanded coverage
• However, patients attending integrated clinics have a higher risk of attrition
• Need to address the obstacles patients face in the integrated setting
• Qualitative Study Theme: Dissatisfaction with Pharmacy in Integrated setting• Lower quality of service• Lack of Privacy
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Acknowledgements• Juvenol Amos • Luis Francisco• Fernando Baloi• Pedro Tenete• Mark Micek• James Pfeiffer• Pablo Montoya• Kenny Sherr• Alejandro Soto• Stephen Gloyd
