Browsing by Author "Rosen S"

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Attrition from HIV treatment after enrollment in a differentiated service delivery model: A cohort analysis of routine care in Zambia.
(2023) Jo Y; Jamieson L; Phiri B; Grimsrud A; Mwansa M; Shakwelele H; Haimbe P; Mukumbwa-Mwenechanya M; Mulenga PL; Nichols BE; Rosen S; Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA, United States of America.; HIV Programmes and Advocacy, International AIDS Society, Cape Town, South Africa.; Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, Netherlands.; Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.; Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America.; Clinton Health Access Initiative, Lusaka, Zambia.; Ministry of Health, Lusaka, Zambia.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Many sub-Saharan Africa countries are scaling up differentiated service delivery (DSD) models for HIV treatment to increase access and remove barriers to care. We assessed factors associated with attrition after DSD model enrollment in Zambia, focusing on patient-level characteristics. METHODS: We conducted a retrospective record review using electronic medical records (EMR) of adults (≥15 years) initiated on antiretroviral (ART) between 01 January 2018 and 30 November 2021. Attrition was defined as lost to follow-up (LTFU) or died by November 30, 2021. We categorized DSD models into eight groups: fast-track, adherence groups, community pick-up points, home ART delivery, extended facility hours, facility multi-month dispensing (MMD, 4-6-month ART dispensing), frequent refill care (facility 1-2 month dispensing), and conventional care (facility 3 month dispensing, reference group). We used Fine and Gray competing risk regression to assess patient-level factors associated with attrition, stratified by sex and rural/urban setting. RESULTS: Of 547,281 eligible patients, 68% (n = 372,409) enrolled in DSD models, most commonly facility MMD (n = 306,430, 82%), frequent refill care (n = 47,142, 13%), and fast track (n = 14,433, 4%), with <2% enrolled in the other DSD groups. Retention was higher in nearly all DSD models for all dispensing intervals, compared to the reference group, except fast track for the ≤2 month dispensing group. Retention benefits were greatest for patients in the extended clinic hours group and least for fast track dispensing. CONCLUSION: Although retention in HIV treatment differed by DSD type, dispensing interval, and patient characteristics, nearly all DSD models out-performed conventional care. Understanding the factors that influence the retention of patients in DSD models could provide an important step towards improving DSD implementation.
Changes in HIV treatment differentiated care uptake during the COVID-19 pandemic in Zambia: interrupted time series analysis.
(2021-Oct) Jo Y; Rosen S; Sy KTL; Phiri B; Huber AN; Mwansa M; Shakwelele H; Haimbe P; Mwenechanya MM; Lumano-Mulenga P; Nichols BE; The Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, 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.; Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA.; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA.; Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands.; Clinton Health Access Initiative, Lusaka, Zambia.; Ministry of Health, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
INTRODUCTION: Differentiated service delivery (DSD) models aim to improve the access of human immunodeficiency virus treatment on clients and reduce requirements for facility visits by extending dispensing intervals. With the advent of the COVID-19 pandemic, minimising client contact with healthcare facilities and other clients, while maintaining treatment continuity and avoiding loss to care, has become more urgent, resulting in efforts to increase DSD uptake. We assessed the extent to which DSD coverage and antiretroviral treatment (ART) dispensing intervals have changed during the COVID-19 pandemic in Zambia. METHODS: We used client data from Zambia's electronic medical record system (SmartCare) for 737 health facilities, representing about three-fourths of all ART clients nationally. We compared the numbers and proportional distributions of clients enrolled in DSD models in the 6 months before and 6 months after the first case of COVID-19 was diagnosed in Zambia in March 2020. Segmented linear regression was used to determine whether the outbreak of COVID-19 in Zambia further accelerated the increase in DSD scale-up. RESULTS AND DISCUSSION: Between September 2019 and August 2020, 181,317 clients aged 15 or older (81,520 and 99,797 from 1 September 2019 to 1 March 2020 and from 1 March to 31 August 2020, respectively) enrolled in DSD models in Zambia. Overall participation in all DSD models increased over the study period, but uptake varied by model. The rate of acceleration increased in the second period for home ART delivery (152%), CONCLUSIONS: Participation in DSD models for stable ART clients in Zambia increased after the advent of COVID-19, but dispensing intervals diminished. Eliminating obstacles to longer dispensing intervals, including those related to supply chain management, should be prioritized to achieve the expected benefits of DSD models and minimize COVID-19 risk.
Emerging priorities for HIV service delivery.
(2020-Feb) Ford N; Geng E; Ellman T; Orrell C; Ehrenkranz P; Sikazwe I; Jahn A; Rabkin M; Ayisi Addo S; Grimsrud A; Rosen S; Zulu I; Reidy W; Lejone T; Apollo T; Holmes C; Kolling AF; Phate Lesihla R; Nguyen HH; Bakashaba B; Chitembo L; Tiriste G; Doherty M; Bygrave H; Ministry of Health and Child Care Zimbabwe, Harare, Zimbabwe.; Department HIV & Global Hepatitis Programme, World Health Organization, Geneva, Switzerland.; Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa.; ICAP, Columbia University Mailman School of Public Health, New York, New York, United States of America.; International AIDS Society, Cape Town, South Africa.; Ministry of Health, Lilongwe, Malawi.; Treatment and Care Department, Viet Nam Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam.; National AIDS Control Programme, Ministry of Health, Maseru, Lesotho.; National AIDS Control Programme, Ministry of Health, Accra, Ghana.; Department HIV, World Health Organization, Addis Ababa, Ethiopia.; Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.; SolidarMed, Swiss Organization for Health in Africa, Butha-Buthe, Lesotho.; Department HIV, World Health Organization Lusaka, Zambia.; The AIDS Support Organization (TASO), Kampala, Uganda.; Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America.; Department of Medicine, Faculty of Health Sciences, Cape Town, South Africa.; Department of Surveillance, Prevention and Control of STIs, HIV/AIDS and Viral Hepatitis, Ministry of Health, Brasilia, Brazil.; Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America.; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.; Bill and Melinda Gates Foundation, Seattle, Washington, United States of America.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; Georgetown University, Washington, DC, United States of America.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Nathan Ford and co-authors discuss global priorities in the provision of HIV prevention and treatment services.
How soon should patients be eligible for differentiated service delivery models for antiretroviral treatment? Evidence from a retrospective cohort study in Zambia.
(2022-Dec-22) Jamieson L; Rosen S; Phiri B; Grimsrud A; Mwansa M; Shakwelele H; Haimbe P; Mukumbwa-Mwenechanya M; Lumano-Mulenga P; Chiboma I; Nichols BE; Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, the Netherlands.; International AIDS Society, Cape Town, South Africa.; Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA.; Implementation Science Unit, Center for Infectious Disease Research in Zambia, Lusaka, Zambia.; Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa sbrosen@bu.edu.; Health Economics and Epidemiology Research Office, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa.; Clinton Health Access Initiative, Lusaka, Zambia.; Ministry of Health, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
OBJECTIVES: Patient attrition is high the first 6 months after antiretroviral therapy (ART) initiation. Patients with <6 months of ART are systematically excluded from most differentiated service delivery (DSD) models, which are intended to support retention. Despite DSD eligibility criteria requiring ≥6 months on ART, some patients enrol earlier. We compared loss to follow-up (LTFU) between patients enrolling in DSD models early with those enrolled according to guidelines, assessing whether the ART experience eligibility criterion is necessary. DESIGN: Retrospective cohort study using routinely collected electronic medical record data. SETTING: PARTICIPANTS: Adults (≥15 years) who initiated ART between 1 January 2019 and 31 December 2020. OUTCOMES: LTFU (>30 days late for scheduled visit) at 18 months for 'early enrollers' (DSD enrolment after <6 months on ART) and 'established enrollers' (DSD enrolment after ≥6 months on ART). We used a log-binomial model to compare LTFU risk, adjusting for age, sex, location, ART refill interval and DSD model. RESULTS: For 6340 early enrollers and 25 857 established enrollers, there were no differences in sex (61% female), age (median 37 years) or location (65% urban). ART refill intervals were longer for established versus early enrollers (72% vs 55% were given 4-6 months refills). LTFU at 18 months was 3% (192 of 6340) for early enrollers and 5% (24 646 of 25 857) for established enrollers. Early enrollers were 41% less likely to be LTFU than established patients (adjusted risk ratio 0.59, 95% CI 0.50 to 0.68). CONCLUSIONS: Patients enrolled in DSD after <6 months of ART were more likely to be retained than patients established on ART prior to DSD enrolment. A limitation is that early enrollers may have been selected for DSD due to providers' and patients' expectations about future retention. Offering DSD models to ART patients soon after ART initiation may help address high attrition during the early treatment period. TRIAL REGISTERATION NUMBER: NCT04158882.
Preferences for services in a patient's first six months on antiretroviral therapy for HIV in South Africa and Zambia (PREFER): research protocol for a prospective observational cohort study.
(2023) Maskew M; Ntjikelane V; Juntunen A; Scott N; Benade M; Sande L; Hasweeka P; Haimbe P; Lumano-Mulenga P; Shakewelele H; Mukumbwa-Mwenechanya M; Rosen S; Global Health, Boston University, Boston, MA, 02118, USA.; Department of Medical Microbiology, Amsterdam University Medical Center, Amstersdam, The Netherlands.; Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand Johannesburg, Johannesburg, Gauteng, South Africa.; Center for Infectious Disease Research in Zambia, Lusaka, Lusaka Province, Zambia.; CHAI-Zambia, Clinton Health Access Initiative, Lusaka, Zambia.; MOH Zambia, Ministry of Health, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: For patients on HIV treatment in sub-Saharan Africa, the highest risk for loss from care remains the first six months after antiretroviral (ART) initiation, when patients are not yet eligible for differentiated service delivery (DSD) models that offer lower-burden, patient-centred care and thus improve treatment outcomes. To reduce early disengagement from care, the PREFER study will use a sequential mixed-methods approach to describe the characteristics, needs, concerns, and preferences of patients in South Africa and Zambia 0-6 months after ART initiation or re-initiation. PROTOCOL: PREFER is an observational, prospective cohort study of adults on ART for ≤6 months at 12 public healthcare facilities in Zambia and 18 in South Africa. Its objective is to describe and understand the needs and preferences of initiating and re-initiating ART clients to inform the design of DSD models for the early HIV treatment period, improve early treatment outcomes, and distinguish the barriers encountered by naïve patients from those facing re-initiators. It has four components: 1) survey of clients 0-6 months after ART initiation (identify characteristics and preferences of clients starting ART); 2) follow up through routinely collected medical records for <24 months after enrollment (describe resource utilization and patterns and predictors of engagement in care); 3) focus group discussions and discrete choice experiment (explore reported barriers to and facilitators of retention); and 4) in South Africa only, collection of blood samples (assess the prevalence of ARV metabolites indicating prior ART use). CONCLUSIONS: PREFER aims to understand why the early treatment period is so challenging and how service delivery can be amended to address the obstacles that lead to early disengagement from care. It will generate information about client characteristics and preferences to help respond to patients' needs and design better strategies for service delivery and improve resource allocation going forward.
Resource Utilization and Costs of Care prior to ART Initiation for Pediatric Patients in Zambia.
(2014) Iyer HS; Scott CA; Lembela Bwalya D; Meyer-Rath G; Moyo C; Bolton Moore C; Larson BA; Rosen S; Zambia Center for Applied Health Research and Development, 10100 Lusaka, Zambia.; Center for Global Health and Development, Boston University, Boston, MA 02118, USA ; Health Economics and Epidemiology Research Office, Wits Health Consortium, Department of Clinical Medicine, School of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2198, South Africa.; Center for Global Health and Development, Boston University, Boston, MA 02118, USA ; Department of International Health, School of Public Health, Boston University, Boston, MA 02118, USA.; Zambia Center for Applied Health Research and Development, 10100 Lusaka, Zambia ; Center for Global Health and Development, Boston University, Boston, MA 02118, USA.; Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA ; Centre for Infectious Disease Research in Zambia, 101000 Lusaka, Zambia.; Zambian Ministry of Health, 10100 Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Objective. We estimated time to initiation, outpatient resource use, and costs of outpatient care during the 6 months prior to ART initiation for HIV-infected pediatric patients in Zambia. Methods. We enrolled 1,102 children who initiated ART at <15 years of age between 2006 and 2011 at 5 study sites. Of these, 832 initiated ART ≤6 months after first presenting to care at the study sites. Data on time in care and resources utilized during the 6 months prior to ART initiation were extracted from patient medical records. Costs were estimated from the provider's perspective and are reported in 2011 USD. Results. For the patients who initiated ART ≤6 months after presenting to care, median age at presentation to care was 3.9 years; median CD4 percentage was 13%. Median time to ART initiation was 26 days. Patients made, on average, 2.38 clinic visits prior to ART initiation and received 0.81 CD4 tests, 0.74 full blood count tests, and 0.49 blood chemistry tests. The mean cost of pre-ART care was $20 per patient. Conclusions. Zambian pediatric patients initiating ART ≤6 months after presenting to care do so quickly, utilize fewer resources than mandated by national guidelines, and accrue low costs.
The revolving door of HIV care: Revising the service delivery cascade to achieve the UNAIDS 95-95-95 goals.
(2021-May) Ehrenkranz P; Rosen S; Boulle A; Eaton JW; Ford N; Fox MP; Grimsrud A; Rice BD; Sikazwe I; Holmes CB; Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America.; Global Health, Bill & Melinda Gates Foundation, Seattle, WA, United States of America.; Center for Innovation in Global Health, Georgetown University, Washington, DC, United States of America.; Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom.; 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.; School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.; Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America.; MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom.; HIV & Global Hepatitis Programme, World Health Organization, Geneva, Switzerland.; HIV Programmes & Advocacy Department, International AIDS Society, Cape Town, South Africa.; Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Peter Ehrenkranz and co-authors present a cyclical cascade of care for people with HIV infection, aiming to facilitate assessment of outcomes.