Outcomes of Antiretroviral Treatment Programs in Rural Lesotho: Health Centers and Hospitals Compared

Niklaus Labhardt, Motlalepula Sello, Mamokone A. Mohlaba, Olivia Keiser, Karolin Pfeiffer, Matthias Egger, Jochen Ehmer, Gilles Wandeler

Background

• Scarce human resources limit the scale up of antiretroviral therapy (ART) in rural southern Africa

• Early losses to follow-up are highest in settings with lowest numbers of health-care workers

• Task shifting and decentralization of care are recommended strategies to address chronic health care worker shortages

• Previous reports on ART delivery in decentralized settings are limited to short-term outcomes

Van Damme et al. AIDS 2006Wandeler et al. JAIDS 2012Harries et al. Trop Med Int Health 2010Shumbusho et al. PLoS Med 2009

Objectives

1. To describe programmatic factors and baseline characteristics of patients starting first-line ART in Hospitals and Health centers (HCs) in rural Lesotho

2. To compare short and long-term clinical outcomes between patients who started ART in the two types of facilities accross two different regions

SolidarMed ART Program (SMART)

• Swiss NGO (www.solidarmed.ch)

• 9 hospitals, 40 health centers in 4 countries

• 13,100 patients on ART by 2011

• International epidemiologic Databases to Evaluate AIDS in Southern Africa (IeDEA-SA) network (www.iedea-sa.org)

SMART Lesotho

Seboche1 hospital, 5 health centersPopulation: ~ 55‘000Adult HIV prevalence*: ~16%

Paray1 hospital, 7 health centersPopulation: ~ 77‘000Adult HIV prevalence*: ~20%

• 2005: ART at hospitals• 2007/08: Decentralization

*Demographic Health Survey of Lesotho 2009

SMART Lesotho

Inclusion criteria / definitions

Patients• Over 16 years at start of ART• No previous ART exposure• Started first-line ART including 2 NRTI and 1 NNRTI

Definitions• No follow up: no visit after the start of ART• LTFU: not returning to the clinic ≥ 6 months• Retained in care: alive and on ART

Chi et al. PLoS Med 2011

Statistical analyses

• All analyses compared patients treated in the two facility types (Hospitals and HCs) and were stratified by region (Paray and Seboche)

• Baseline characteristics compared with chi-squared and Mann-Whitney tests

• Kaplan-Meier curves for crude retention• Multivariable logistic regression models for no follow-up • Competing risk regression models for mortality and

LTFU and results shown in a Forest plot

Flow chart

ART start Jan 2008 - April 2011 N=3,969

ART start outside study areaN=222

ART start at hospital N=1,705

ART start at health center N=2,042

Paray N=832 Seboche N=873 Paray N=1,247 Seboche N=795

Resources for ART delivery

Hospitals   Health Centers4 Median number of physicians 03 Median number of nurse-clinicians 12 Median number of nurse-assistants 16 Median number of lay-counselors 2

Yes CD4 count on site NoYes Hemoglobin measurement on site InconsistentNo Viral Load measurement on site No

Baseline characteristics of patients

  Seboche (1,668)   Paray (2,079)

Hospitals Health Centers P-value Hospitals Health Centers P-value

Number of patients 873 795     832 1,247  

Number of women (%) 569 (65.2) 515 (64.8) 0.87   517 (62.1) 795 (63.8) 0.478

Median age in years (IQR)

37 (31-47) 39 (31-50) 0.028 

37 (30-47) 39 (32-48) 0.007

Median absolute CD4 count in cells/µl (IQR)

169 (86-278) 208 (119-287) <0.001 

157 (66-258) 215 (133-290) <0.001

Median hemoglobin level in g/dl (IQR)

11.4 (10-12.7) 12 (10.8-13.3) <0.001 

12.1 (10.5-13.6) 12.5 (11.5-13.7) 0.002

WHO stage (%)              

I/II 411 (47.1) 546 (68.7) <0.001   438 (52.6) 839 (67.4) <0.001

III/IV 462 (52.9) 249 (31.3)     394 (47.4) 405 (32.6)  

Overall retention in care: hospitals vs. HCs

50

100

60

70

80

90

1705 1009 583 245Hospitals2042 1284 677 128HCs

Number at risk

0 1 2 3

Health Centers Hospitals

Years after ART start

Pro

por

tion

of p

atie

nts

reta

ined

(%

)

Retention in care: hospitals vs. HCs by region

50

100

60

70

80

90

Pro

por

tion

of p

atie

nts

reta

ined

(%

)

832 501 289 114Hosp. Paray

873 508 294 131Hosp. Seboche

1247 794 395 56HCs Paray

795 490 282 72HCs Seboche

Number at risk

0 1 2 3

Years after ART start

HCs Seboche HCs Paray

Hospital Seboche Hospital Paray

Clinical outcomes, by region

All analyses are adjusted for gender, age, baseline CD4 cell count, WHO stage, ART regimen and region

Limitations

• Heterogeneity between two regions

• Tracing of patients LTFU not consistent across sites

• Limited death ascertainment

Conclusion

• In rural Lesotho, patients who started ART in health centers had less advanced HIV disease than those in hospitals

• Health centers: overall retention slightly better and early losses less likely compared to hospitals.

• However, the determinants of retention in care (mortality, LTFU) differed across regions, underlining the importance of tracing patients LTFU

All patients and staff of the participating sitesCollaborators from: • SolidarMed Lesotho (N. Labhardt, M. Sello, M.

A. Mohlaba)• SolidarMed, Lucerne, Switzerland (J. Ehmer, K.

Pfeiffer)• University of Bern, Switzerland (M. Egger, O.

Keiser)Financial support: NIH (NIAID, Grant U01AI069924)

Acknowledgments