Browsing by Author "Nash D"

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Changes in rapid HIV treatment initiation after national "treat all" policy adoption in 6 sub-Saharan African countries: Regression discontinuity analysis.
(2019-Jun) Tymejczyk O; Brazier E; Yiannoutsos CT; Vinikoor M; van Lettow M; Nalugoda F; Urassa M; Sinayobye JD; Rebeiro PF; Wools-Kaloustian K; Davies MA; Zaniewski E; Anderegg N; Liu G; Ford N; Nash D; Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, United States of America.; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.; Global Hepatitis Programme, HIV/AIDS Department, World Health Organization, Geneva, Switzerland.; Department of Medicine, University of Alabama, Birmingham, Alabama, United States of America.; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.; Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America.; Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America.; Rakai Health Sciences Program, Kalisizo and Entebbe, Uganda.; Rwanda Military Hospital, Kigali, Rwanda.; Dignitas International, Zomba, Malawi.; Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, United States of America.; Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Most countries have formally adopted the World Health Organization's 2015 recommendation of universal HIV treatment ("treat all"). However, there are few rigorous assessments of the real-world impact of treat all policies on antiretroviral treatment (ART) uptake across different contexts. METHODS AND FINDINGS: We used longitudinal data for 814,603 patients enrolling in HIV care between 1 January 2004 and 10 July 2018 in 6 countries participating in the global International epidemiology Databases to Evaluate AIDS (IeDEA) consortium: Burundi (N = 11,176), Kenya (N = 179,941), Malawi (N = 84,558), Rwanda (N = 17,396), Uganda (N = 96,286), and Zambia (N = 425,246). Using a quasi-experimental regression discontinuity design, we assessed the change in the proportion initiating ART within 30 days of enrollment in HIV care (rapid ART initiation) after country-level adoption of the treat all policy. A modified Poisson model was used to identify factors associated with failure to initiate ART rapidly under treat all. In each of the 6 countries, over 60% of included patients were female, and median age at enrollment ranged from 32 to 36 years. In all countries studied, national adoption of treat all was associated with large increases in rapid ART initiation. Significant increases in rapid ART initiation immediately after treat all policy adoption were observed in Rwanda, from 44.4% to 78.9% of patients (34.5 percentage points [pp], 95% CI 27.2 to 41.7; p < 0.001), Kenya (25.7 pp, 95% CI 21.8 to 29.5; p < 0.001), Burundi (17.7 pp, 95% CI 6.5 to 28.9; p = 0.002), and Malawi (12.5 pp, 95% CI 7.5 to 17.5; p < 0.001), while no immediate increase was observed in Zambia (0.4 pp, 95% CI -2.9 to 3.8; p = 0.804) and Uganda (-4.2 pp, 95% CI -9.0 to 0.7; p = 0.090). The rate of rapid ART initiation accelerated sharply following treat all policy adoption in Malawi, Uganda, and Zambia; slowed in Kenya; and did not change in Rwanda and Burundi. In post hoc analyses restricted to patients enrolling under treat all, young adults (16-24 years) and men were at increased risk of not rapidly initiating ART (compared to older patients and women, respectively). However, rapid ART initiation following enrollment increased for all groups as more time elapsed since treat all policy adoption. Study limitations include incomplete data on potential ART eligibility criteria, such as clinical status, pregnancy, and enrollment CD4 count, which precluded the assessment of rapid ART initiation specifically among patients known to be eligible for ART before treat all. CONCLUSIONS: Our analysis indicates that adoption of treat all policies had a strong effect on increasing rates of rapid ART initiation, and that these increases followed different trajectories across the 6 countries. Young adults and men still require additional attention to further improve rapid ART initiation.
Gone But Not Lost: Implications for Estimating HIV Care Outcomes When Loss to Clinic Is Not Loss to Care.
(2020-Jul) Edwards JK; Lesko CR; Herce ME; Murenzi G; Twizere C; Lelo P; Anastos K; Tymejczyk O; Yotebieng M; Nash D; Adedimeji A; Edmonds A; From the Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.; Kalembelembe Pediatric Hospital, Kinshasa, Democratic Republic of the Congo.; Departments of Medicine and Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY.; Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC.; Rwanda Military Hospital, Kigali, Rwanda.; Centre Hospitalo, Universitaire de Kamenge, Bujumbura, Burundi.; Institute for Implementation Science in Population Health, City University of New York, New York, NY.; Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY.; Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
BACKGROUND: In some time-to-event analyses, it is unclear whether loss to follow up should be treated as a censoring event or competing event. Such ambiguity is particularly common in HIV research that uses routinely collected clinical data to report the timing of key milestones along the HIV care continuum. In this setting, loss to follow up may be viewed as a censoring event, under the assumption that patients who are "lost" from a study clinic immediately enroll in care elsewhere, or a competing event, under the assumption that people "lost" are out of care all together. METHODS: We illustrate an approach to address this ambiguity when estimating the 2-year risk of antiretroviral treatment initiation among 19,506 people living with HIV who enrolled in the IeDEA Central Africa cohort between 2006 and 2017, along with published estimates from tracing studies in Africa. We also assessed the finite sample properties of the proposed approach using simulation experiments. RESULTS: The estimated 2-year risk of treatment initiation was 69% if patients were censored at loss to follow up or 59% if losses to follow up were treated as competing events. Using the proposed approach, we estimated that the 2-year risk of antiretroviral therapy initiation was 62% (95% confidence interval: 61, 62). The proposed approach had little bias and appropriate confidence interval coverage under scenarios examined in the simulation experiments. CONCLUSIONS: The proposed approach relaxes the assumptions inherent in treating loss to follow up as a censoring or competing event in clinical HIV cohort studies.
Impact of Universal Antiretroviral Treatment Eligibility on Rapid Treatment Initiation Among Young Adolescents with Human Immunodeficiency Virus in Sub-Saharan Africa.
(2020-Aug-04) Tymejczyk O; Brazier E; Wools-Kaloustian K; Davies MA; Dilorenzo M; Edmonds A; Vreeman R; Bolton C; Twizere C; Okoko N; Phiri S; Nakigozi G; Lelo P; von Groote P; Sohn AH; Nash D; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.; Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA.; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.; Kenya Medical Research Institute (KEMRI), Nairobi, Kenya.; Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.; Kalembelembe Pediatric Hospital, Kinshasa, Democratic Republic of the Congo.; TREAT Asia, amfAR-The Foundation for AIDS Research, Bangkok, Thailand.; Lighthouse Trust, Lilongwe, Malawi.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Rakai Health Sciences Program, Kalisizo, Uganda.; Department of Epidemiology and Biostatistics, School of Public Health, City University of New York, New York, NY, USA.; Centre Hospitalo-Universitaire de Kamenge, Bujumbura, Burundi.; Indiana University School of Medicine, Indianapolis, Indiana, USA.; Boston Medical Center, Boston, Massachusetts, USA.; Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Young adolescents with perinatally acquired human immunodeficiency virus (HIV) are at risk for poor care outcomes. We examined whether universal antiretroviral treatment (ART) eligibility policies (Treat All) improved rapid ART initiation after care enrollment among 10-14-year-olds in 7 sub-Saharan African countries. METHODS: Regression discontinuity analysis and data for 6912 patients aged 10-14-years were used to estimate changes in rapid ART initiation (within 30 days of care enrollment) after adoption of Treat All policies in 2 groups of countries: Uganda and Zambia (policy adopted in 2013) and Burundi, Democratic Republic of the Congo, Kenya, Malawi, and Rwanda (policy adopted in 2016). RESULTS: There were immediate increases in rapid ART initiation among young adolescents after national adoption of Treat All. Increases were greater in countries adopting the policy in 2016 than in those adopting it in 2013: 23.4 percentage points (pp) (95% confidence interval, 13.9-32.8) versus 11.2pp (2.5-19.9). However, the rate of increase in rapid ART initiation among 10-14-year-olds rose appreciably in countries with earlier treatment expansions, from 1.5pp per year before Treat All to 7.7pp per year afterward. CONCLUSIONS: Universal ART eligibility has increased rapid treatment initiation among young adolescents enrolling in HIV care. Further research should assess their retention in care and viral suppression under Treat All.
Retention and mortality on antiretroviral therapy in sub-Saharan Africa: collaborative analyses of HIV treatment programmes.
(2018-Feb) Haas AD; Zaniewski E; Anderegg N; Ford N; Fox MP; Vinikoor M; Dabis F; Nash D; Sinayobye JD; Niyongabo T; Tanon A; Poda A; Adedimeji AA; Edmonds A; Davies MA; Egger M; Institut Supérieur des Sciences de la santé, Université Polytechnique de Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso.; Department of Epidemiology and Biostatistics, City University of New York, School of Public Health, New York, NY, USA.; Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA.; Department of Epidemiology and Population Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa.; ISPED, Centre Inserm U1219-Bordeaux Population Health, Université de Bordeaux, Bordeaux, France.; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.; Department of Global Health, Boston University School of Public Health, Boston, MA, USA.; Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.; World Health Organisation, Geneva, Switzerland.; Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.; Rwanda Military Hospital, Kigali, Rwanda.; Service de Maladies Infectieuses et Tropicales (SMIT), CHU de Treichville, Abidjan, Cote d'Ivoire.; Centre National de Reference en Matiere de VIH/SIDA (CNR), Bujumbura, Burundi.; School of Medicine, University of Zambia, Lusaka, Zambia.; Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland.; Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
INTRODUCTION: By 2020, 90% of all people diagnosed with HIV should receive long-term combination antiretroviral therapy (ART). In sub-Saharan Africa, this target is threatened by loss to follow-up in ART programmes. The proportion of people retained on ART long-term cannot be easily determined, because individuals classified as lost to follow-up, may have self-transferred to another HIV treatment programme, or may have died. We describe retention on ART in sub-Saharan Africa, first based on observed data as recorded in the clinic databases, and second adjusted for undocumented deaths and self-transfers. METHODS: We analysed data from HIV-infected adults and children initiating ART between 2009 and 2014 at a sub-Saharan African HIV treatment programme participating in the International epidemiology Databases to Evaluate AIDS (IeDEA). We used the Kaplan-Meier method to calculate the cumulative incidence of retention on ART and the Aalen-Johansen method to calculate the cumulative incidences of death, loss to follow-up, and stopping ART. We used inverse probability weighting to adjust clinic data for undocumented mortality and self-transfer, based on estimates from a recent systematic review and meta-analysis. RESULTS: We included 505,634 patients: 12,848 (2.5%) from Central Africa, 109,233 (21.6%) from East Africa, 347,343 (68.7%) from Southern Africa and 36,210 (7.2%) from West Africa. In crude analyses of observed clinic data, 52.1% of patients were retained on ART, 41.8% were lost to follow-up and 6.0% had died 5 years after ART initiation. After accounting for undocumented deaths and self-transfers, we estimated that 66.6% of patients were retained on ART, 18.8% had stopped ART and 14.7% had died at 5 years. CONCLUSIONS: Improving long-term retention on ART will be crucial to attaining the 90% on ART target. Naïve analyses of HIV cohort studies, which do not account for undocumented mortality and self-transfer of patients, may severely underestimate both mortality and retention on ART.