RESUMO
OBJECTIVE: To identify factors associated with antiretroviral therapy (ART) attrition among patients initiating therapy in 2005-2011 at two large, public-sector department-level hospitals, and to inform interventions to improve ART retention. METHODS: This retrospective cohort study used data from the iSanté electronic medical record (EMR) system. The study characterized ART attrition levels and explored the patient demographic, clinical, temporal, and service utilization factors associated with ART attrition, using time-to-event analysis methods. RESULTS: Among the 2 023 patients in the study, ART attrition on average was 17.0 per 100 person-years (95% confidence interval (CI): 15.8-18.3). In adjusted analyses, risk of ART attrition was up to 89% higher for patients living in distant communes compared to patients living in the same commune as the hospital (hazard ratio: 1.89, 95%CI: 1.54-2.33; P < 0.001). Hospital site, earlier year of ART start, spending less time enrolled in HIV care prior to ART initiation, receiving a non-standard ART regimen, lacking counseling prior to ART initiation, and having a higher body mass index were also associated with attrition risk. CONCLUSIONS: The findings suggest quality improvement interventions at the two hospitals, including: enhanced retention support and transportation subsidies for patients accessing care from remote areas; counseling for all patients prior to ART initiation; timely outreach to patients who miss ART pick-ups; "bridging services" for patients transferring care to alternative facilities; routine screening for anticipated interruptions in future ART pick-ups; and medical case review for patients placed on non-standard ART regimens. The findings are also relevant for policymaking on decentralization of ART services in Haiti.
OBJETIVO: Determinar los factores asociados con el abandono del tratamiento antirretrovírico en los pacientes que iniciaron el tratamiento en el período del 2005 al 2011 en dos grandes hospitales públicos de nivel departamental, y fundamentar las intervenciones necesarias para mejorar la retención de los pacientes en el tratamiento. MÉTODOS: Este estudio retrospectivo de cohortes empleó los datos del sistema de registro médico electrónico iSanté. Se describieron los niveles de abandono del tratamiento y se exploraron los factores demográficos, clínicos, temporales y de utilización de los servicios que se asociaban con su abandono, usando métodos de análisis del tiempo trascurrido hasta un evento. RESULTADOS: El abandono del tratamiento entre los 2 023 pacientes incluidos en el estudio fue en promedio de 17,0 por 100 personas-años (intervalo de confianza (IC) de 95%: 15,8-18,3). En los análisis ajustados, el riesgo de abandono del tratamiento fue de hasta 89% mayor en los pacientes que vivían en comunas distantes, en comparación con los pacientes que vivían en la misma comuna en que se ubicaba el hospital (razón de riesgo: 1,89; IC de 95%: 1,54-2,33; P < 0,001). La ubicación del hospital, el inicio del tratamiento en un año calendario anterior, un menor tiempo de inclusión en el programa de atención a la infección por el VIH antes de iniciar el tratamiento, la administración de un régimen terapéutico no estándar, la falta de orientación antes de iniciar el tratamiento y un mayor índice de masa corporal también se asociaron con un riesgo más elevado de abandono. CONCLUSIONES: Los resultados sugieren algunas intervenciones de mejora de la calidad en ambos hospitales, entre ellas: un mayor apoyo a la retención y subsidios de transporte para los pacientes que acuden desde zonas remotas para ser atendidos; la orientación a todos los pacientes antes del inicio del tratamiento antirretrovírico; el contacto oportuno de los servicios con los pacientes que omiten alguna recogida de medicación; "servicios de conexión" para transferir la atención de los pacientes a otros establecimientos alternativos; el tamizaje sistemático de las interrupciones previstas en las próximas recogidas de medicación; y la revisión médica de los casos de pacientes que siguen un tratamiento no estándar. Estos hallazgos son también pertinentes en materia de formulación de políticas de descentralización de los servicios de tratamiento antirretrovírico en Haití.
Assuntos
Humanos , Masculino , Feminino , Gravidez , Adolescente , Adulto , Pessoa de Meia-Idade , Adulto Jovem , Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Pacientes Desistentes do Tratamento/estatística & dados numéricos , Comorbidade , Quimioterapia Combinada , Terremotos , Seguimentos , Infecções por HIV/epidemiologia , Haiti/epidemiologia , Acessibilidade aos Serviços de Saúde , Hospitais Públicos/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Serviço de Farmácia Hospitalar/estatística & dados numéricos , Complicações Infecciosas na Gravidez/epidemiologia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Risco , Fatores Socioeconômicos , Tuberculose/epidemiologiaRESUMO
BACKGROUND: On January 12, 2010, a devastating 7.0 magnitude earthquake struck the West Department of Haiti, killing more than 200,000 people and injuring or displacing many more. This disaster threatened continuity of HIV care and treatment services. OBJECTIVES: This case study examined the effect of the devastating 2010 earthquake in Haiti on attrition from the HIV antiretroviral therapy (ART) program. DESIGN: The study triangulated retrospective data from existing sources, including: 1) individual-level longitudinal patient data from an electronic medical record for ART patients at two large public sector departmental hospitals differently affected by the earthquake; and 2) aggregate data on the volume of HIV-related services delivered at the two hospitals before and after the earthquake. METHODS: The study compared ART attrition and service delivery in Jacmel, a site in the 'very strong' zone of earthquake impact, and in Jérémie, a site in the 'light' zone of earthquake impact. The analysis used time-to-event analysis methods for the individual-level patient data, and descriptive statistical methods for the aggregate service delivery data. RESULTS: Adjusted ART attrition risk was lower at the hospital in Jacmel after vs. before the earthquake (HR=0.51; p=0.03), and was lower in Jacmel vs. Jérémie both before (HR=0.55; p=0.01) and after the earthquake (HR=0.35; p=0.001). The number of new ART patient enrollments, new HIV patient registrations, and HIV clinical visits dropped notably in Jacmel immediately after the earthquake, but then rapidly rebounded. On average, there was no change in new ART enrollments per month after vs. before the earthquake at either site. CONCLUSION: These findings underscore the resilience of Haitian ART providers and patients, and contribute evidence that it is possible to maintain continuity of ART services even in the context of a complex humanitarian crisis.
Assuntos
Fármacos Anti-HIV/provisão & distribuição , Desastres , Terremotos , Infecções por HIV/tratamento farmacológico , Adulto , Fármacos Anti-HIV/uso terapêutico , Feminino , Haiti , Humanos , Masculino , Pessoa de Meia-Idade , Estudos de Casos Organizacionais , Administração em Saúde Pública , Estudos Retrospectivos , Adulto JovemRESUMO
OBJECTIVE: To identify factors associated with antiretroviral therapy (ART) attrition among patients initiating therapy in 2005-2011 at two large, public-sector department-level hospitals, and to inform interventions to improve ART retention. METHODS: This retrospective cohort study used data from the iSanté electronic medical record (EMR) system. The study characterized ART attrition levels and explored the patient demographic, clinical, temporal, and service utilization factors associated with ART attrition, using time-to-event analysis methods. RESULTS: Among the 2 023 patients in the study, ART attrition on average was 17.0 per 100 person-years (95% confidence interval (CI): 15.8-18.3). In adjusted analyses, risk of ART attrition was up to 89% higher for patients living in distant communes compared to patients living in the same commune as the hospital (hazard ratio: 1.89, 95%CI: 1.54-2.33; P < 0.001). Hospital site, earlier year of ART start, spending less time enrolled in HIV care prior to ART initiation, receiving a non-standard ART regimen, lacking counseling prior to ART initiation, and having a higher body mass index were also associated with attrition risk. CONCLUSIONS: The findings suggest quality improvement interventions at the two hospitals, including: enhanced retention support and transportation subsidies for patients accessing care from remote areas; counseling for all patients prior to ART initiation; timely outreach to patients who miss ART pick-ups; "bridging services" for patients transferring care to alternative facilities; routine screening for anticipated interruptions in future ART pick-ups; and medical case review for patients placed on non-standard ART regimens. The findings are also relevant for policymaking on decentralization of ART services in Haiti.