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Washington D.C., USA, 22-27 July 2012www.aids2012.org Sustaining quality while scaling up adolescent ART Findings from Zimbabwe’s largest adolescent cohort.

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Presentation on theme: "Washington D.C., USA, 22-27 July 2012www.aids2012.org Sustaining quality while scaling up adolescent ART Findings from Zimbabwe’s largest adolescent cohort."— Presentation transcript:

1 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

2 Washington D.C., USA, 22-27 July 2012www.aids2012.org Adolescents in need of ART A 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.

3 Washington D.C., USA, 22-27 July 2012www.aids2012.org Will services cope? Adolescents pose particular challenges Known challenges in managing chronic disease 1 More unhealthy / high risk behaviours 2 Poor adherence to ART previously documented 3 Sub-optimal virological responses documented 4,5 Present to services relatively late 6 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):1208-14 5.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.

4 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):e19261 2. Nglazi et al. BMC Infect Dis. 2012;12:21.

5 Washington D.C., USA, 22-27 July 2012www.aids2012.org Mpilo ART clinic Bulawayo Adolescents 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.

6 Washington D.C., USA, 22-27 July 2012www.aids2012.org 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)

7 Washington D.C., USA, 22-27 July 2012www.aids2012.org 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

8 Washington D.C., USA, 22-27 July 2012www.aids2012.org Scale up of ART Initiation > 7 fold increase in initiations> 3 fold increase in initiations

9 Washington D.C., USA, 22-27 July 2012www.aids2012.org 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

10 Washington D.C., USA, 22-27 July 2012www.aids2012.org Outcomes More adolescents initiated late and ill AdolescentsAdults Initiations, n1,7769,360 Median age, years*13.334.7 Med 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%

11 Washington D.C., USA, 22-27 July 2012www.aids2012.org 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

12 Washington D.C., USA, 22-27 July 2012www.aids2012.org Mortality and LFU Adolescent LFU lower than in adults P=0.83P<0.0001

13 Washington D.C., USA, 22-27 July 2012www.aids2012.org Summary Findings Much adolescent HIV undiagnosed + untreated Diagnosis usually after clinical illness, consistent with estimates that 75% of adolescent HIV is undiagnosed 1 By the end of study period, 17% of all actively followed patients were adolescents (1,610 / 9,387*) compared to estimate of 5% nationally 1 1. Ferrand et al. Bull World Health Organ. 2010;88(6):428-34

14 Washington D.C., USA, 22-27 July 2012www.aids2012.org Summary Findings Good 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

15 Washington D.C., USA, 22-27 July 2012www.aids2012.org 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

16 Washington D.C., USA, 22-27 July 2012www.aids2012.org 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

17 Washington D.C., USA, 22-27 July 2012www.aids2012.org Supplementary information

18 Washington D.C., USA, 22-27 July 2012www.aids2012.org Death rates + LFU rates Crude and adjusted for LFU At the most plausible levels of death among those lost to follow up no difference in death rates between groups

19 Washington D.C., USA, 22-27 July 2012www.aids2012.org Adolescents, n MortalityLoss to follow up Retention 24 months Mpilo cohort. Zimbabwe 1,7763.8 (3.2 – 4.5) 4.8 (4.1 – 5.6) 86% Bakanda et al. Uganda (1) 5753.6 (2.6-4.7) -- Nglazi et al. South Africa (2) 651.2 (0.3-4.8) 7.2 (4.1 –12.6) - Results

20 Washington D.C., USA, 22-27 July 2012www.aids2012.org Entry to ART services Few adolescents came from VCT services Most adolescents referred from hospital after becoming unwell, subsequently being offered provider initiated testing and counselling (PITC)

21 Washington D.C., USA, 22-27 July 2012www.aids2012.org Regimen info Most common regimens used at initiation AdultsAdolescents (D4T-3TC-NVPp) Stavudine, Lamivudine, Nevirapine 7,4121,543 FDC (AZT-3TC-NVP) Zidovudine, Lamivudine, Nevirapine 83916 EFV+FDC (D4T30-3TC) Efavirenz, Stavudine, Lamivudine 70585

22 Washington D.C., USA, 22-27 July 2012www.aids2012.org Results More adolescents initiated late AdolescentsAdults Initiations, n1,7769,360 Median age, years13.334.7 Males, %47.9%30.7% Stage IV disease, %32.4%24.9% VCT referrals2.8%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 yrs4.8 (4.1-5.6)9.2 (8.8 - 9.6) Retention at 24 months86.0%78·5% *30% of those lost to follow up assumed to have died

23 Washington D.C., USA, 22-27 July 2012www.aids2012.org 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.

24 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.

25 Washington D.C., USA, 22-27 July 2012www.aids2012.org Full references used slides 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

26 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.

27 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.


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