Transcript Presentation Title Presentation Information Date, Location

Slide Title
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Integration of HIV Treatment in Primary
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Health Care Centers Impacts Attrition from
Advancing the health and well-being
of people most affected by AIDS
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HIV Treatment Programs in Central
Mozambique
Barrot H. Lambdin, PhD, MPH
Director of Implementation Science
Pangaea Global AIDS Foundation
History of ART Scale-up in Mozambique
Slide Title
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Patients
250000
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218,991
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170,198
• Level 2 content
200000
• Level 3 content
128,330
150000
88,211
31%
In53%
RLS
Coverage
44,100
100000
18,956
7,456
50000
3,314
0
2003
2004
2005
2006
2007
Patients on ART
Year
2008
2009
2010
History of ART Scale-up in Mozambique
Slide Title
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Clinics
Patients
240
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250000
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ART Integrated with PHC Clinics
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180
• Level 3 content
211
229
200000
150000
149
120
213
222
31%
In53%
RLS
Coverage
National ART Program
60
-
100000
50000
13
24
2003
2004
40
0
2005
2006
Patients on ART
Year
2007
2008
2009
Facilities with ART
2010
Study Design, Setting and Population
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Retrospective cohort study of
patients initiating ART in the national
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ART program
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• Level 2 content(Jan 06–Jun 08)
Exclusion
Criteria:
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<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
Methods
Covariates
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• Exposures
• Clinic Model: Vertical
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vs.1Integrated
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• Clinic
Location: Urban
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vs.
Rural
• Clinic Experience: 1st
6-months vs. After
• Outcomes
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Pre-ART CD4 Count
Pre-ART WHO Stage
Age
Sex
Education
Year of Initiation
Pharmacy Staff
Burden
• 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)
Results: Study Population
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• 9,120 person-years
Rate:
Body copy• Attrition
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the
39.22 per 100 py
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Initiated Treatment: 15,232
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Transferred
Children
810
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1,138
Pregnant
1,491
N (%)
Delivery Model
Included in
Study
11,793
Vertical
3 (17%)
Integrated
16 (89%)
Location
Urban
10 (55%)
Rural
8 (45%)
Results: Demographic Characteristics
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13%
18%
36%
43%
In RLS
30%
39%
≥15 to <25
≥25 to <35
≥35 to <45
≥45
57%
Male
Female
Results: Clinical Characteristics
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11%
9%
26%
29%
36%
In RLS
18%
65%
36%
<100
≥100 – <200
≥200 – <300
≥300
I/II
III
IV
Results: Clinic Factors and Attrition
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HR (95% CI)
p-value
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Model
•Clinic
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Integrated
[Ref]
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Vertical
Clinic Location
Rural
Urban
Clinic Experience
First 6-Months
Post First 6-Months
1.00
0.84 (0.73 – 0.97)
0.015
1.00
0.86 (0.61 – 1.22)
0.389
1.00
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
Results: Clinic Factors and Attrition
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1.1 1.2
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Level 1 content
• Level 2Integrated
content
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1st 6 Months
Urban
Vertical
Post 1st 6 Months
.4
.5
.6
.7
.8
.9
1
Rural
Clinic Model
Clinic Location
Clinic Experience
Clinic Characteristics
A Priori Analysis
Reference Group
95% CI
Strengths & Limitations
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• Strengths
• Standardization of Protocols
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• Care delivery
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• Patient tracing
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• Data Recording
• High quality data
• Limitations
• Observational Study
• Unable to adjust for all patient and clinic
characteristics
• Generalizeability
Conclusions
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• However, patients attending integrated
clinics have a higher risk of attrition
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• Integrating HIV services into PHC
dramatically expanded coverage
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• 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
Acknowledgements
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Juvenol Amos
Luis 1Francisco
Level
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Level
2 contentBaloi
Fernando
Level 3 content
Pedro Tenete
Mark Micek
James Pfeiffer
Pablo Montoya
Kenny Sherr
Alejandro Soto
Stephen Gloyd