Browsing by Author "Nichols, Brooke"

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Patterns of engagement in care during clients' first 12 months after HIV treatment initiation in Zambia: a retrospective cohort analysis using routinely collected data.
(2025-Aug-11) Benade, Mariet; Maskew, Mhairi; Chilembo, Phillip; Mwansa, Mwansa W.; Savory, Theodora; Nichols, Brooke; Bolton, Carolyn; Mulenga, Lloyd B ; Sivile, Suilanji; Zyambo, Khozya D. ; Rosen, Sydney
BACKGROUND: The first year after HIV treatment initiation or re-initiation is the period of highest risk of a treatment interruption or disengagement, yet little is known about the timing, patterns and effects of interruptions in the early treatment period. METHODS: Using routinely collected electronic medical record data from 543 Zambian facilities from 2018 to 2023, we described patterns of engagement during the first year of HIV treatment. We defined engagement patterns for months 0-6 and months 7-12 after initiation or reinitiation as (1) continuous (attended all scheduled clinic and medication pickup visits as planned; (2) cyclical (attended ≥1 visits late >28 days but returned to and remained in care) or (3) disengaged (missed a scheduled visit by >28 days and had no evidence of return). RESULTS: Our sample population comprised 159 429 adult participants (61% female, median age 33). Of the 513 322 interactions observed ≤12 months after initiation, 53% occurred as planned, 22% were late ≤28 days late, 9% were >28 days late, and 17% were scheduled but never attended. In 0-6 months after initiation, 51% clients were continuously engaged, 12% cyclically engaged and 33% disengaged. Two-thirds of disengagers (21% of cohort) did not return after the initiation visit. During months 7-12, most clients who had been continuously engaged in months 0-6 (54%) remained continuous, while 18% moved to cyclical engagement. Among cyclical engagers in months 0-6, nearly half (47%) moved to being continuously engaged by month 12. Only 34% of the study population remained engaged continuously by the end of the 12-month period. CONCLUSIONS: Fewer than 60% of clients initiating antiretroviral therapy care between 2018 and 2022 at Zambian facilities remained continuously engaged at month 6 and 34% at month 12. Cyclical engagement and frequent interruptions should be accepted as the norm and models of service delivery designed to accommodate them.
Sustainable HIV treatment in Africa through viral-load-informed differentiated care.
(2015-Dec-03) Phillips, Andrew; Shroufi, Amir; Vojnov, Lara; Cohn, Jennifer; Roberts, Teri; Ellman, Tom; Bonner, Kimberly; Rousseau, Christine; Garnett, Geoff; Cambiano, Valentina; Nakagawa, Fumiyo; Ford, Deborah; Bansi-Matharu, Loveleen; Miners, Alec; Lundgren, Jens D.; Eaton, Jeffrey W.; Parkes-Ratanshi, Rosalind; Katz, Zachary; Maman, David; Ford, Nathan; Vitoria, Marco; Doherty, Meg; Dowdy, David; Nichols, Brooke; Murtagh, Maurine; Wareham, Meghan; Palamountain, Kara M.; Chakanyuka, Christine M.; Stevens, Wendy; Katzenstein, David; Ciaranello, Andrea; Barnabas, Ruanne; Braithwaite, Scott R.; Bendavid, Eran; Nathoo, Kusum J.; van de Vijver, David; Wilson, David P.; Holmes, Charles; Bershteyn, Anna; Walker, Simon; Raizes, Elliot; Jani, Ilesh; Nelson, Lisa J.; Peeling, Rosanna; Terris-Prestholt, Fern; Murungu, Joseph; Mutasa-Apollo, Tsitsi ; Hallett, Timothy B.; Revill, Paul
There are inefficiencies in current approaches to monitoring patients on antiretroviral therapy in sub-Saharan Africa. Patients typically attend clinics every 1 to 3 months for clinical assessment. The clinic costs are comparable with the costs of the drugs themselves and CD4 counts are measured every 6 months, but patients are rarely switched to second-line therapies. To ensure sustainability of treatment programmes, a transition to more cost-effective delivery of antiretroviral therapy is needed. In contrast to the CD4 count, measurement of the level of HIV RNA in plasma (the viral load) provides a direct measure of the current treatment effect. Viral-load-informed differentiated care is a means of tailoring care so that those with suppressed viral load visit the clinic less frequently and attention is focussed on those with unsuppressed viral load to promote adherence and timely switching to a second-line regimen. The most feasible approach to measuring viral load in many countries is to collect dried blood spot samples for testing in regional laboratories; however, there have been concerns over the sensitivity and specificity of this approach to define treatment failure and the delay in returning results to the clinic. We use modelling to synthesize evidence and evaluate the cost-effectiveness of viral-load-informed differentiated care, accounting for limitations of dried blood sample testing. We find that viral-load-informed differentiated care using dried blood sample testing is cost-effective and is a recommended strategy for patient monitoring, although further empirical evidence as the approach is rolled out would be of value. We also explore the potential benefits of point-of-care viral load tests that may become available in the future.