47 results on '"Beverly S Musick"'
Search Results
2. Outcomes of retained and disengaged pregnant women living with HIV in Uganda.
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Agnes N Kiragga, Ellon Twinomuhwezi, Grace Banturaki, Marion Achieng, Juliet Nampala, Irene Bagaya, Joanita Kigozi, Barbara Castelnuovo, Beverly S Musick, Rohan Hazra, Constantin T Yiannoutsos, and Kara K Wools-Kaloustian
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Medicine ,Science - Abstract
IntroductionLoss-to-follow-up among women living with HIV (WLWHIV) may lead to unfavorable outcomes for both mother and exposed infant. This study traced WLWHIV disengaged from care and their infants and compared their outcomes with those retained in care.MethodsThe study included WLWHIV who initiated ART during pregnancy at six public clinics in Uganda. A woman was defined as disengaged (DW) if she had not attended her 6-week post-partum visit by 10 weeks after her estimated date of delivery. DW were matched with retained women (RW) by age and duration on ART. Nurse counselors traced all selected DW via telephone and community visits to assess vital status, infant HIV sero-status and maternal HIV viral load through blood draws.ResultsBetween July 2017 and July 2018, 734 women (359 DW and 375 RW) were identified for the study. Tracing was attempted on 349 DW and 160 (44.6%) were successfully located and enrolled in the study. They were matched with 162 RW. Among DW, 52 (32.5%) transferred to another health facility. Very few DW, 39.0% were HIV virally suppressed (ConclusionPregnant and breastfeeding WLWHIV who disengage from care are difficult to find in urban environments. Many have detectable viral loads, leading to the potential for an increased risk of MTCT. Efforts to reduce disengagement from care are critical for the successful elimination of MTCT in resource-limited settings.
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- 2021
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3. Lower rates of ART initiation and decreased retention among ART-naïve patients who consume alcohol enrolling in HIV care and treatment programs in Kenya and Uganda.
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Ioannis Patsis, Suzanne Goodrich, Constantin T Yiannoutsos, Steven A Brown, Beverly S Musick, Lameck Diero, Jayne L Kulzer, Mwembesa Bosco Bwana, Patrick Oyaro, and Kara K Wools-Kaloustian
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Medicine ,Science - Abstract
ObjectivesAlmost 13 million people are estimated to be on antiretroviral therapy in Eastern and Southern Africa, and their disease course and program effectiveness could be significantly affected by the concurrent use of alcohol. Screening for alcohol use may be important to assess the prevalence of alcohol consumption and its impact on patient and programmatic outcomes.MethodsAs part of this observational study, data on patient characteristics and alcohol consumption were collected on a cohort of 765 adult patients enrolling in HIV care in East Africa. Alcohol consumption was assessed with the AUDIT questionnaire at enrollment. Subjects were classified as consuming any alcohol (AUDIT score >0), hazardous drinkers (AUDIT score ≥8) and hyper drinkers (AUDIT score ≥16). The effects of alcohol consumption on retention in care, death and delays in antiretroviral therapy (ART) initiation were assessed through competing risk (Fine & Gray) models.ResultsOf all study participants, 41.6% consumed alcohol, 26.7% were classified as hazardous drinkers, and 16.0% as hyper drinkers. Depending on alcohol consumption classification, men were 3-4 times more likely to consume alcohol compared to women. Hazardous drinkers (median age 32.8 years) and hyper drinkers (32.7 years) were slightly older compared to non-hazardous drinkers (30.7 years) and non-hyper drinkers (30.8 years), (p-values = 0.014 and 0.053 respectively). Median CD4 at enrollment was 330 cells/μl and 16% were classified World Health Organization (WHO) stage 3 or 4. There was no association between alcohol consumption and CD4 count or WHO stage at enrollment. Alcohol consumption was associated with significantly lower probability of ART initiation (adjusted sub-distribution hazard ratio aSHR = 0.77 between alcohol consumers versus non-consumers; p-value = 0.008), and higher patient non-retention in care (aSHR = 1.77, p-value = 0.023).DiscussionAlcohol consumption is associated with significant delays in ART initiation and reduced retention in care for patients enrolling in HIV care and treatment programs in East Africa. Consequently, interventions that target alcohol consumption may have a significant impact on the HIV care cascade.
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- 2020
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4. Increased prevalence of pregnancy and comparative risk of program attrition among individuals starting HIV treatment in East Africa.
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Charles B Holmes, Constantin T Yiannoutsos, Batya Elul, Elizabeth Bukusi, John Ssali, Andrew Kambugu, Beverly S Musick, Craig Cohen, Carolyn Williams, Lameck Diero, Nancy Padian, and Kara K Wools-Kaloustian
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Medicine ,Science - Abstract
The World Health Organization now recommends initiating all pregnant women on life-long antiretroviral therapy (ART), yet there is limited information about the characteristics and program outcomes of pregnant women already on ART in Africa. Our hypothesis was that pregnant women comprised an increasing proportion of those starting ART, and that sub-groups of these women were at higher risk for program attrition.We used the International Epidemiology Databases to Evaluate AIDS- East Africa (IeDEA-EA) to conduct a retrospective cohort study including HIV care and treatment programs in Kenya, Uganda, and Tanzania. The cohort consecutively included HIV-infected individuals 13 years or older starting ART 2004-2014. We examined trends over time in the proportion pregnant, their characteristics and program attrition rates compared to others initiating and already receiving ART. 156,474 HIV-infected individuals (67.0% women) started ART. The proportion of individuals starting ART who were pregnant women rose from 5.3% in 2004 to 12.2% in 2014. Mean CD4 cell counts at ART initiation, weighted for annual program size, increased from 2004 to 2014, led by non-pregnant women (annual increase 20 cells/mm3) and men (17 cells/mm3 annually), with lower rates of change in pregnant women (10 cells/mm3 per year) (p
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- 2018
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5. Adherence to antiretroviral therapy in a clinical cohort of HIV-infected children in East Africa.
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Rachel C Vreeman, Samuel O Ayaya, Beverly S Musick, Constantin T Yiannoutsos, Craig R Cohen, Denis Nash, Deo Wabwire, Kara Wools-Kaloustian, and Sarah E Wiehe
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Medicine ,Science - Abstract
To describe antiretroviral therapy (ART) adherence and associated factors for a large HIV-infected pediatric cohort followed by sites of the East Africa International Epidemiologic Databases to Evaluate AIDS (IeDEA) consortium.This study utilized prospectively collected clinical data from HIV-infected children less than 13 years of age who initiated ART within 4 clinical care programs (with 26 clinical sites) in Kenya, Uganda, and Tanzania and were followed for up to 6 years. Programs used one of 3 adherence measures, including 7-day quantitative recall, 7-day categorical recall, and clinician pill assessments. We fit a hierarchical, three-level, logistic-regression model to examine adherence, with observations nested within patient, and patients within the 26 sites providing pediatric HIV data to this analysis.In East Africa, 3,304 children, 52.0% male, were enrolled in care and were subsequently observed for a median of 92 weeks (inter-quartile range [IQR] 50.3-145.0 weeks). Median age at ART initiation was 5.5 years ([IQR] 3.0-8.5 years). "Good" adherence, as reported by each clinic's measures, was extremely high, remaining on average above 90% throughout all years of follow-up. Longer time on ART was associated with higher adherence (adjusted Odds Ratio-aOR-per log-transformed week on ART: 1.095, 95% Confidence Interval-CI-[1.052-1.150].) Patients enrolled in higher-volume programs exhibited higher rates of clinician-assessed adherence (aOR per log-500 patients: 1.174, 95% CI [1.108-1.245]). Significant site-level variability in reported adherence was observed (0.28), with even higher variability among patients (0.71). In a sub-analysis, being an orphan at the start of ART was strongly associated with lower ART adherence rates (aOR: 0.919, 95% CI [0.864-0.976]).Self-reported adherence remained high over a median of 1.8 years in HIV care, but varied according to patient-level and site-level factors. Consistent adherence monitoring with validated measures and attention to vulnerable groups is recommended.
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- 2018
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6. CD4 trajectory adjusting for dropout among HIV‐positive patients receiving combination antiretroviral therapy in an East African HIV care centre
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Agnes N Kiragga, Judith J Lok, Beverly S Musick, Ronald J Bosch, Ann Mwangi, Kara K Wools‐Kaloustian, Constantin T Yiannoutsos, and for the East Africa IeDEA Regional Consortium
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HIV/AIDS ,IPCW ,Resource‐limited setting ,CD4 count ,Mathematical modeling ,sub‐Saharan Africa ,Immunologic diseases. Allergy ,RC581-607 - Abstract
Objective Estimates of CD4 response to antiretroviral therapy (ART) obtained by averaging data from patients in care, overestimate population CD4 response and treatment program effectiveness because they do not consider data from patients who are deceased or not in care. We use mathematical methods to assess and adjust for this bias based on patient characteristics. Design We examined data from 25,261 HIV‐positive patients from the East Africa IeDEA Consortium. Methods We used inverse probability of censoring weighting (IPCW) to represent patients not in care by patients in care with similar characteristics. We address two questions: What would the median CD4 be “had everyone starting ART remained on observation?” and “were everyone starting ART maintained on treatment?” Results Routine CD4 count estimates were higher than adjusted estimates even under the best‐case scenario of maintaining all patients on treatment. Two years after starting ART, differences between estimates diverged from 30 cells/µL, assuming similar mortality and treatment access among dropouts as patients in care, to over 100 cells/µL assuming 20% lower survival and 50% lower treatment access among dropouts. When considering only patients in care, the proportion of patients with CD4 above 350 cells/µL was 50% adjusted to below 30% when accounting for patients not in care. One‐year mortality diverged 6–14% from the naïve estimates depending on assumptions about access to care among lost patients. Conclusions Ignoring mortality and loss to care results in over‐estimation of ART response for patients starting treatment and exaggerates the efficacy of treatment programs administering it.
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- 2014
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7. Active tuberculosis is associated with worse clinical outcomes in HIV-infected African patients on antiretroviral therapy.
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Abraham M Siika, Constantin T Yiannoutsos, Kara K Wools-Kaloustian, Beverly S Musick, Ann W Mwangi, Lameck O Diero, Sylvester N Kimaiyo, William M Tierney, and Jane E Carter
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Medicine ,Science - Abstract
This cohort study utilized data from a large HIV treatment program in western Kenya to describe the impact of active tuberculosis (TB) on clinical outcomes among African patients on antiretroviral therapy (ART).We included all patients initiating ART between March 2004 and November 2007. Clinical (signs and symptoms), radiological (chest radiographs) and laboratory (mycobacterial smears, culture and tissue histology) criteria were used to record the diagnosis of TB disease in the program's electronic medical record system.We assessed the impact of TB disease on mortality, loss to follow-up (LTFU) and incident AIDS-defining events (ADEs) through Cox models and CD4 cell and weight response to ART by non-linear mixed models.We studied 21,242 patients initiating ART-5,186 (24%) with TB; 62% female; median age 37 years. There were proportionately more men in the active TB (46%) than in the non-TB (35%) group. Adjusting for baseline HIV-disease severity, TB patients were more likely to die (hazard ratio--HR = 1.32, 95% CI 1.18-1.47) or have incident ADEs (HR = 1.31, 95% CI: 1.19-1.45). They had lower median CD4 cell counts (77 versus 109), weight (52.5 versus 55.0 kg) and higher ADE risk at baseline (CD4-adjusted odds ratio = 1.55, 95% CI: 1.31-1.85). ART adherence was similarly good in both groups. Adjusting for gender and baseline CD4 cell count, TB patients experienced virtually identical rise in CD4 counts after ART initiation as those without. However, the overall CD4 count at one year was lower among patients with TB (251 versus 269 cells/µl).Clinically detected TB disease is associated with greater mortality and morbidity despite salutary response to ART. Data suggest that identifying HIV patients co-infected with TB earlier in the HIV-disease trajectory may not fully address TB-related morbidity and mortality.
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- 2013
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8. Sampling-based approaches to improve estimation of mortality among patient dropouts: experience from a large PEPFAR-funded program in Western Kenya.
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Constantin T Yiannoutsos, Ming-Wen An, Constantine E Frangakis, Beverly S Musick, Paula Braitstein, Kara Wools-Kaloustian, Daniel Ochieng, Jeffrey N Martin, Melanie C Bacon, Vincent Ochieng, and Sylvester Kimaiyo
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Medicine ,Science - Abstract
Monitoring and evaluation (M&E) of HIV care and treatment programs is impacted by losses to follow-up (LTFU) in the patient population. The severity of this effect is undeniable but its extent unknown. Tracing all lost patients addresses this but census methods are not feasible in programs involving rapid scale-up of HIV treatment in the developing world. Sampling-based approaches and statistical adjustment are the only scaleable methods permitting accurate estimation of M&E indices.In a large antiretroviral therapy (ART) program in western Kenya, we assessed the impact of LTFU on estimating patient mortality among 8,977 adult clients of whom, 3,624 were LTFU. Overall, dropouts were more likely male (36.8% versus 33.7%; p = 0.003), and younger than non-dropouts (35.3 versus 35.7 years old; p = 0.020), with lower median CD4 count at enrollment (160 versus 189 cells/ml; p
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- 2008
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9. The IeDEA Data Exchange Standard: a common data model for global HIV cohort collaboration
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Constantin T. Yiannoutsos, Mary-Ann Davies, Brenna C. Hogan, Kara Wools-Kaloustian, Cam Ha Dao Ostinelli, Bruno Ledergerber, Erik V. Hansen, Ruth L. Goodall, Catherine C. McGowan, Stephany N. Duda, Dennis Karsten Kristensen, Karen Malateste, Carolyn Williams, Nicola Maxwell, Judith T. Lewis, Qiuhu Shi, Beverly S. Musick, Annette H. Sohn, and Azar Kariminia
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Protocol (science) ,Data collection ,Data model ,Data exchange ,Computer science ,Informatics ,Best practice ,Observational study ,Data science ,Data modeling - Abstract
ObjectiveTo describe content domains and applications of the IeDEA Data Exchange Standard, its development history, governance structure, and relationships to other established data models, as well as to share open source, reusable, scalable, and adaptable implementation tools with the informatics community.MethodsIn 2012, the International Epidemiology Databases to Evaluate AIDS (IeDEA) collaboration began development of a data exchange standard, the IeDEA DES, to support collaborative global HIV epidemiology research. With the HIV Cohorts Data Exchange Protocol as a template, a global group of data managers, statisticians, clinicians, informaticians, and epidemiologists reviewed existing data schemas and clinic data procedures to develop the HIV data exchange model. The model received a substantial update in 2017, with annual updates thereafter.FindingsThe resulting IeDEA DES is a patient-centric common data model designed for HIV research that has been informed by established data models from US-based electronic health records, broad experience in data collection in resource-limited settings, and informatics best practices. The IeDEA DES is inherently flexible and continues to grow based on the ongoing stewardship of the IeDEA Data Harmonization Working Group with input from external collaborators. Use of the IeDEA DES has improved multiregional collaboration within and beyond IeDEA, expediting over 95 multiregional research projects using data from more than 400 HIV care and treatment sites across seven global regions. A detailed data model specification and REDCap data entry templates that implement the IeDEA DES are publicly available on GitHub.ConclusionsThe IeDEA common data model and related resources are powerful tools to foster collaboration and accelerate science across research networks. While currently directed towards observational HIV research and data from resource-limited settings, this model is flexible and extendable to other areas of health research.HighlightsThe IeDEA Data Exchange Standard is a data model for HIV epidemiology research.The model has expedited 95 projects using data from >400 HIV clinics worldwide.A browsable and adaptable version and data collection templates are available online.
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- 2020
10. Decreasing incidence of pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya between 2005 and 2017: A retrospective cohort study
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Edith Apondi, Alfred Keter, Katherine R. MacDonald, Beverly S. Musick, Juddy Wachira, Heather C. Millar, Rachel F. Spitzer, and Paula Braitstein
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Adult ,medicine.medical_specialty ,Referral ,Adolescent ,Reproductive medicine ,HIV Infections ,lcsh:Gynecology and obstetrics ,Cohort Studies ,03 medical and health sciences ,Young Adult ,0302 clinical medicine ,Family planning services ,Pregnancy ,medicine ,Humans ,030212 general & internal medicine ,Child ,Contraception Behavior ,lcsh:RG1-991 ,Reproductive health ,Retrospective Studies ,030219 obstetrics & reproductive medicine ,business.industry ,Research ,Incidence (epidemiology) ,Incidence ,Infant, Newborn ,Obstetrics and Gynecology ,HIV ,Retrospective cohort study ,medicine.disease ,Kenya ,Pregnancy in adolescence ,Contraception ,Reproductive Medicine ,Family planning ,Cohort ,Female ,business ,Demography - Abstract
Background The objective of this study was to estimate the prevalence, incidence and risk factors for pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya. Methods The Academic Model Providing Access to Healthcare (AMPATH) program is a partnership between Moi University, Moi Teaching and Referral Hospital and a consortium of 11 North American academic institutions. AMPATH currently provides care to 85,000 HIV-positive individuals in western Kenya. Included in this analysis were adolescents aged 10–19 enrolled in AMPATH between January 2005 and February 2017. Socio-demographic, behavioural, and clinical data at baseline and time-updated antiretroviral treatment (ART) data were extracted from the electronic medical records and summarized using descriptive statistics. Follow up time was defined as time of inclusion in the cohort until the date of first pregnancy or age 20, loss to follow up, death, or administrative censoring. Adolescent pregnancy rates and associated risk factors were determined. Results There were 8565 adolescents eligible for analysis. Median age at enrolment in HIV care was 14.0 years. Only 17.7% had electricity at home and 14.4% had piped water, both indicators of a high level of poverty. 12.9% (1104) were pregnant at study inclusion. Of those not pregnant at enrolment, 5.6% (448) became pregnant at least once during follow-up. Another 1.0% (78) were pregnant at inclusion and became pregnant again during follow-up. The overall pregnancy incidence rate was 21.9 per 1000 woman years or 55.8 pregnancies per 1000 women. Between 2005 and 2017, pregnancy rates have decreased. Adolescents who became pregnant in follow-up were more likely to be older, to be married or living with a partner and to have at least one child already and less likely to be using family planning. Conclusions A considerable number of these HIV-positive adolescents presented at enrolment into HIV care as pregnant and many became pregnant as adolescents during follow-up. Pregnancy rates remain high but have decreased from 2005 to 2017. Adolescent-focused sexual and reproductive health and ante/postnatal care programs may have the potential to improve maternal and neonatal outcomes as well as further decrease pregnancy rates in this high-risk group.
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- 2020
11. Mortality Among People With HIV Treated for Tuberculosis Based on Positive, Negative, or No Bacteriologic Test Results for Tuberculosis: The IeDEA Consortium
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Eugène Messou, Constantin T. Yiannoutsos, John M. Humphrey, E. Jane Carter, Beverly S. Musick, April C. Pettit, Brenda Crabtree-Ramírez, Marcel Yotebieng, Olivier Marcy, Kathryn Anastos, Lameck Diero, Philani Mpofu, Kara Wools-Kaloustian, Timothy R. Sterling, Bordeaux population health (BPH), and Université de Bordeaux (UB)-Institut de Santé Publique, d'Épidémiologie et de Développement (ISPED)-Institut National de la Santé et de la Recherche Médicale (INSERM)
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0301 basic medicine ,medicine.medical_specialty ,Tuberculosis ,[SDV.MHEP.PSR]Life Sciences [q-bio]/Human health and pathology/Pulmonology and respiratory tract ,IDLIC ,03 medical and health sciences ,0302 clinical medicine ,Acquired immunodeficiency syndrome (AIDS) ,[SDV.MHEP.MI]Life Sciences [q-bio]/Human health and pathology/Infectious diseases ,Internal medicine ,Epidemiology ,Major Article ,adults ,Medicine ,030212 general & internal medicine ,business.industry ,Proportional hazards model ,Hazard ratio ,HIV ,medicine.disease ,030112 virology ,mortality ,Confidence interval ,3. Good health ,Test (assessment) ,Infectious Diseases ,Oncology ,tuberculosis ,[SDV.SPEE]Life Sciences [q-bio]/Santé publique et épidémiologie ,epidemiology ,business ,Cohort study - Abstract
Background In resource-constrained settings, many people with HIV (PWH) are treated for tuberculosis (TB) without bacteriologic testing. Their mortality compared with those with bacteriologic testing is uncertain. Methods We conducted an observational cohort study among PWH ≥15 years of age initiating TB treatment at sites affiliated with 4 International epidemiology Databases to Evaluate AIDS consortium regions from 2012 to 2014: Caribbean, Central and South America, and Central, East, and West Africa. The exposure of interest was the TB bacteriologic test status at TB treatment initiation: positive, negative, or no test result. The hazard of death in the 12 months after TB treatment initiation was estimated using a Cox proportional hazard model. Missing covariate values were multiply imputed. Results In 2091 PWH, median age 36 years, 53% had CD4 counts ≤200 cells/mm3, and 52% were on antiretroviral therapy (ART) at TB treatment initiation. The adjusted hazard of death was higher in patients with no test compared with those with positive test results (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.08–2.26). The hazard of death was also higher among those with negative compared with positive tests but was not statistically significant (HR, 1.28; 95% CI, 0.91–1.81). Being on ART, having a higher CD4 count, and tertiary facility level were associated with a lower hazard for death. Conclusions There was some evidence that PWH treated for TB with no bacteriologic test results were at higher risk of death than those with positive tests. Research is needed to understand the causes of death in PWH treated for TB without bacteriologic testing.
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- 2020
12. A state transition framework for patient‐level modeling of engagement and retention in HIV care using longitudinal cohort data
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Ann Mwangi, Joseph W. Hogan, Xiaotian K. Wu, Paula Braitstein, Becky L. Genberg, Hana Lee, and Beverly S. Musick
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Adult ,Male ,0301 basic medicine ,Statistics and Probability ,Epidemiology ,media_common.quotation_subject ,HIV Infections ,Biostatistics ,Article ,Health Services Accessibility ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,Nursing ,Risk Factors ,Health care ,Humans ,Longitudinal Studies ,030212 general & internal medicine ,Disengagement theory ,media_common ,Estimation ,Models, Statistical ,Actuarial science ,business.industry ,Benchmarking ,Continuity of Patient Care ,Middle Aged ,Kenya ,030112 virology ,Markov Chains ,Disease Progression ,Conceptual model ,Regression Analysis ,Female ,Observational study ,business ,Psychology ,Cohort study - Abstract
The human immunodeficiency virus (HIV) care cascade is a conceptual model used to outline the benchmarks that reflects effectiveness of HIV care in the whole HIV care continuum. The models can be used to identify barriers contributing to poor outcomes along each benchmark in the cascade such as disengagement from care or death. Recently, the HIV care cascade has been widely applied to monitor progress towards HIV prevention and care goals in an attempt to develop strategies to improve health outcomes along the care continuum. Yet, there are challenges in quantifying successes and gaps in HIV care using the cascade models that are partly due to the lack of analytic approaches. The availability of large cohort data presents an opportunity to develop a coherent statistical framework for analysis of the HIV care cascade. Motivated by data from the Academic Model Providing Access to Healthcare, which has provided HIV care to nearly 200,000 individuals in Western Kenya since 2001, we developed a state transition framework that can characterize patient-level movements through the multiple stages of the HIV care cascade. We describe how to transform large observational data into an analyzable format. We then illustrate the state transition framework via multistate modeling to quantify dynamics in retention aspects of care. The proposed modeling approach identifies the transition probabilities of moving through each stage in the care cascade. In addition, this approach allows regression-based estimation to characterize effects of (time-varying) predictors of within and between state transitions such as retention, disengagement, re-entry into care, transfer-out, and mortality. Copyright © 2017 John Wiley & Sons, Ltd.
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- 2017
13. A qualitative study of the barriers and enhancers to retention in care for pregnant and postpartum women living with HIV
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Julia Songok, Constantin T. Yiannoutsos, Bett Kipchumba, Beverly S. Musick, Kara Wools-Kaloustian, Winfred Mwangi, Marsha Alera, Juddy Wachira, Elizabeth J. Pfeiffer, and John M. Humphrey
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medicine.medical_specialty ,Pregnancy ,business.industry ,Human immunodeficiency virus (HIV) ,Stigma (botany) ,medicine.disease ,medicine.disease_cause ,Acquired immunodeficiency syndrome (AIDS) ,Family medicine ,Health care ,Epidemiology ,Medicine ,Tracking (education) ,business ,Qualitative research - Abstract
Retention in care is a major challenge for pregnant and postpartum women living with HIV (PPHIV) in the prevention of mother-to-child HIV transmission (PMTCT) continuum. However, the factors influencing retention from the perspectives of women who have become lost to follow-up (LTFU) are not well described. We explored these factors within an enhanced sub-cohort of the East Africa International Epidemiology Databases to Evaluate AIDS Consortium. From 2018–2019, a purposeful sample of PPHIV ≥18 years of age were recruited from five maternal and child health clinics providing integrated PMTCT services in Kenya. Women retained in care were recruited at the facility; women who had become LTFU (last visit >90 days) were recruited through community tracking. Interview transcripts were analyzed thematically using a social-ecological framework. Forty-one PPHIV were interviewed. The median age was 27 years, 71% were pregnant, and 39% had become LTFU. In the individual domain, prior PMTCT experience and desires to safeguard infants’ health enhanced retention but were offset by perceived lack of value in PMTCT services following infants’ immunizations. In the peer/family domain, male-partner financial and motivational support enhanced retention. In the community/society domain, some women perceived social pressure to attend clinic while others perceived pressure to utilize traditional birth attendants. In the healthcare environment, long queues and negative provider attitudes were prominent barriers. HIV-related stigma and fear of disclosure crossed multiple domains, particularly for LTFU women, and were driven by perceptions of HIV as a fatal disease and fear of partner abandonment and abuse. Both retained and LTFU women perceived that integrated HIV services increased the risk of disclosure. Retention was influenced by multiple factors for PPHIV. Stigma and fear of disclosure were prominent barriers for LTFU women. Multicomponent interventions and refining the structure and efficiency of PMTCT services may enhance retention for PPHIV.
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- 2021
14. Brief Report: Pediatric Cancer Burden and Treatment Resources Within the Pediatric IeDEA Consortium
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Salma Abbas, Torsak Bunupuradah, Andrew Edmonds, Stephany N. Duda, Marcel Yotebieng, Catherine C. McGowan, Lorna Renner, Annette H. Sohn, Beverly S. Musick, Valériane Leroy, Lynne M. Mofenson, Mary-Ann Davies, Kara Wools-Kaloustian, Steven A. Brown, and Karl Technau
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medicine.medical_specialty ,education.field_of_study ,Pediatrics ,Modalities ,business.industry ,Population ,Health services research ,Cancer ,medicine.disease ,Pediatric cancer ,03 medical and health sciences ,0302 clinical medicine ,Infectious Diseases ,Acquired immunodeficiency syndrome (AIDS) ,030220 oncology & carcinogenesis ,Family medicine ,Epidemiology of cancer ,Epidemiology ,Medicine ,Pharmacology (medical) ,030212 general & internal medicine ,business ,education - Abstract
Introduction The incidence and treatment of cancer in HIV-infected children from resource-limited settings has not been extensively studied. Objectives Develop and implement a cross-sectional survey to evaluate pediatric cancer burden, diagnostic modalities in use, and treatment availability as perceived by HIV clinic staff at regional International Epidemiology Databases to Evaluate AIDS (IeDEA) sites. Methods IeDEA regional investigators developed a cross-sectional clinical site survey which included questions on the numbers and types of pediatric cancers observed, modalities used to treat identified cancers, and treatment options available at individual sites in the Asia-Pacific, Latin America, Central Africa, East Africa, West Africa, and Southern Africa regions. Results Kaposi sarcoma, non-Hodgkin lymphoma, and Burkitt lymphoma were reported by site personnel to be the most prevalent types of cancer in the pediatric HIV population. Survey results indicate that access to comprehensive cancer treatment modalities is very limited for children in these regions despite HIV care and treatment sites reporting that they diagnose pediatric cancers. Responses also showed that evaluating cancer in the pediatric HIV population is a challenge due to a lack of resources and varying treatment availability within regions. Conclusions Further study is needed to increase our understanding of the changing epidemiology of cancer in HIV-infected pediatric populations. Increased financial and technical resources are critical to aid in the advancement of health services to support treatment of these children in resource-constrained settings.
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- 2017
15. SiZer Map to investigate significant features of body-weight profile changes in HIV infected patients in the IeDEA Collaboration
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Sasisopin Kiertiburanakul, Jaroslaw Harezlak, Constantin T. Yiannoutsos, Eric Balestre, Matthew P. Fox, Samiha Sarwat, Diana Huis in ‘t Veld, Michael Schomaker, Beverly S. Musick, Kara Wools-Kaloustian, and Matthew Law
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business.industry ,Weight change ,Body weight ,01 natural sciences ,010104 statistics & probability ,03 medical and health sciences ,Smoothing spline ,Regimen ,0302 clinical medicine ,Statistics ,medicine ,Biomarker (medicine) ,Hiv infected patients ,In patient ,030212 general & internal medicine ,0101 mathematics ,medicine.symptom ,business ,Weight gain - Abstract
ObjectivesWe extend the method of Significant Zero Crossings of Derivatives (SiZer) to address within-subject correlations of repeatedly collected longitudinal biomarker data and the computational aspects of the methodology when analyzing massive biomarker databases. SiZer is a powerful visualization tool for exploring structures in curves by mapping areas where the first derivative is increasing, decreasing or does not change (plateau) thus exploring changes and normalization of biomarkers in the presence of therapy.MethodsWe propose a penalized spline SiZer (PS-SiZer) which can be expressed as a linear mixed model of the longitudinal biomarker process to account for irregularly collected data and within-subject correlations. Through simulations we show how sensitive PS-SiZer is in detecting existing features in longitudinal data versus existing versions of SiZer. In a real-world data analysis PS-SiZer maps are used to map areas where the first derivative of weight change after antiretroviral therapy (ART) start is significantly increasing, decreasing or does not change, thus exploring the durability of weight increase after the start of therapy. We use weight data repeatedly collected from persons living with HIV initiating ART in five regions in the International Epidemiologic Databases to Evaluate AIDS (IeDEA) worldwide collaboration and compare the durability of weight gain between ART regimens containing and not containing the drug stavudine (d4T), which has been associated with shorter durability of weight gain.ResultsThrough simulations we show that the PS-SiZer is more accurate in detecting relevant features in longitudinal data than existing SiZer variants such as the local linear smoother (LL) SiZer and the SiZer with smoothing splines (SS-SiZer). In the illustration we include data from 185,010 persons living with HIV who started ART with a d4T (53.1%) versus non-d4T (46.9%) containing regimen. The largest difference in durability of weight gain identified by the SiZer maps was observed in Southern Africa where weight gain in patients treated with d4T-containing regimens lasted 52.4 weeks compared to 94.4 weeks for those with non-d4T-containing regimens. In the other regions, persons receiving d4T-containing regimens experienced weight gains lasting 51-61 weeks versus 59-77 weeks in those receiving non-d4T-based regimens.DiscussionPS-SiZer, a SiZer variant, can handle irregularly collected longitudinal data and within-subject correlations and is sensitive in detecting even subtle features in biomarker curves.
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- 2019
16. Mortality among adults living with HIV treated for tuberculosis based on positive, negative, or no bacteriologic test results for tuberculosis: the IeDEA consortium
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E. J. Carter, Marcel Yotebieng, John M. Humphrey, B. Crabtree-Ramirez, Kathryn Anastos, Beverly S. Musick, April C. Pettit, See S Table, E Messou, Lameck Diero, Timothy R. Sterling, Olivier Marcy, Philani Mpofu, Constantin T. Yiannoutsos, and Kara Wools-Kaloustian
- Subjects
medicine.medical_specialty ,Tuberculosis ,business.industry ,Proportional hazards model ,Human immunodeficiency virus (HIV) ,medicine.disease ,medicine.disease_cause ,Test (assessment) ,Acquired immunodeficiency syndrome (AIDS) ,Internal medicine ,Epidemiology ,medicine ,business ,Tb treatment ,Cohort study - Abstract
BackgroundIn resource-constrained settings, people living with HIV (PLWH) treated for tuberculosis (TB) despite negative bacteriologic tests have a higher mortality than those treated with positive tests. Many PLWH are treated without bacteriologic testing; their mortality compared to those with bacteriologic testing is uncertain.MethodsWe conducted an observational cohort study among PLWH ≥ 15 years of age who initiated TB treatment at clinical sites affiliated with four regions of the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium from 2012-2014: Caribbean, Central and South America, and Central, East, and West Africa. The primary exposure of interest was the TB bacteriologic test status at TB treatment initiation: positive, negative, or no test result. The hazard for death in the 12 months following TB treatment initiation was estimated using the Cox proportional hazard model, adjusted for patient- and site-level factors. Missing covariates were multiply imputed.ResultsAmong 2,091 PLWH included, the median age at TB treatment initiation was 36 years, 44% were female, 53% had CD4 counts ≤ 200 cells/mm3, and 52% were on antiretroviral treatment (ART). Compared to patients with positive bacteriologic tests, the adjusted hazard for death was higher among patients with no test results (HR 1.56, 95% CI 1.08-2.26) but not different than those with negative tests (HR 1.28, 95% CI 0.91-1.81). Older age was also associated with a higher hazard for death, while being on ART, having a higher CD4 count, West Africa region, and tertiary facility level were associated with lower hazards for death.ConclusionPLWH treated for TB with no bacteriologic test results were more likely to die than those treated with positive tests, underscoring the importance of TB bacteriologic diagnosis in resource-constrained settings. Research is needed to understand the causes of death among PLWH treated for TB in the absence of positive bacteriologic tests.
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- 2019
17. Untangling the Relationship Between Antiretroviral Therapy Use and Incident Pregnancy: A Marginal Structural Model Analysis Using Data From 47,313 HIV-Positive Women in East Africa
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Pius Okong, Andrew Kambugu, Beverly S. Musick, Constantin T. Yiannoutsos, Samuel Ayaya, Harriet Nuwagaba-Biribonwoha, Yingfeng Wu, Deo Wabwire, Elizabeth A. Bukusi, Kara Wools-Kaloustian, Batya Elul, Denis Nash, and Juliana A. Otieno
- Subjects
0301 basic medicine ,sub-Saharan Africa ,medicine.medical_specialty ,Population ,Context (language use) ,pregnancy incidence ,03 medical and health sciences ,0302 clinical medicine ,Acquired immunodeficiency syndrome (AIDS) ,medicine ,Pharmacology (medical) ,030212 general & internal medicine ,Young adult ,education ,Gynecology ,education.field_of_study ,Pregnancy ,business.industry ,Incidence (epidemiology) ,virus diseases ,Epidemiology and Prevention ,medicine.disease ,030112 virology ,Infectious Diseases ,ComputingMethodologies_DOCUMENTANDTEXTPROCESSING ,HIV/AIDS ,Observational study ,business ,ART ,Demography ,Cohort study - Abstract
Supplemental Digital Content is Available in the Text., Background: Scale-up of triple-drug antiretroviral therapy (ART) in Africa has transformed the context of childbearing for HIV-positive women and may impact pregnancy incidence in HIV programs. Methods: Using observational data from 47,313 HIV-positive women enrolled at 26 HIV clinics in Kenya and Uganda between 2001 and 2009, we calculated the crude cumulative incidence of pregnancy for the pre-ART and on-ART periods. The causal effect of ART use on incident pregnancy was assessed using inverse probability weighted marginal structural models, and the relationship was further explored in multivariable Cox models. Results: Crude cumulative pregnancy incidence at 1 year after enrollment/ART initiation was 4.0% and 3.9% during the pre-ART and on-ART periods, respectively. In marginal structural models, ART use was not significantly associated with incident pregnancy [hazard ratio = 1.06; 95% confidence interval (CI): 0.99 to 1.12]. Similarly, in Cox models, there was no significant relationship between ART use and incident pregnancy (cause-specific hazard ratio: 0.98; 95% CI: 0.91 to 1.05), but effect modification was observed. Specifically, women who were pregnant at enrollment and on ART had an increased risk of incident pregnancy compared to those not pregnant at enrollment and not on ART (cause-specific hazard ratio: 1.11; 95% CI: 1.01 to 1.23). Conclusions: In this large cohort, ART initiation was not associated with incident pregnancy in the general population of women enrolling in HIV care but rather only among those pregnant at enrollment. This finding further highlights the importance of scaling up access to lifelong treatment for pregnant women.
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- 2016
18. Lower rates of ART initiation and decreased retention among ART-naïve patients who consume alcohol enrolling in HIV care and treatment programs in Kenya and Uganda
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Constantin T. Yiannoutsos, Kara Wools-Kaloustian, Mwembesa Bosco Bwana, Jayne L Kulzer, Beverly S. Musick, Lameck Diero, Suzanne Goodrich, Ioannis Patsis, Patrick Oyaro, and Steven A. Brown
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Male ,RNA viruses ,0301 basic medicine ,Epidemiology ,Art initiation ,Human immunodeficiency virus (HIV) ,Psychological intervention ,Social Sciences ,HIV Infections ,Alcohol ,Pathology and Laboratory Medicine ,medicine.disease_cause ,Geographical Locations ,chemistry.chemical_compound ,0302 clinical medicine ,Immunodeficiency Viruses ,Surveys and Questionnaires ,Prevalence ,Medicine and Health Sciences ,Psychology ,Uganda ,Public and Occupational Health ,Prospective Studies ,030212 general & internal medicine ,Alcohol Consumption ,Multidisciplinary ,Hazard ratio ,HIV diagnosis and management ,Middle Aged ,Vaccination and Immunization ,Alcoholism ,Medical Microbiology ,Viral Pathogens ,Viruses ,Cohort ,Medicine ,Female ,Pathogens ,Research Article ,Adult ,Adolescent ,Alcohol Drinking ,Substance-Related Disorders ,Science ,Immunology ,Antiretroviral Therapy ,Addiction ,Audit ,Microbiology ,Young Adult ,03 medical and health sciences ,Antiviral Therapy ,Retroviruses ,Mental Health and Psychiatry ,medicine ,Humans ,Microbial Pathogens ,Nutrition ,business.industry ,Lentivirus ,Organisms ,Biology and Life Sciences ,HIV ,Patient Acceptance of Health Care ,Kenya ,030112 virology ,Diagnostic medicine ,Diet ,chemistry ,Medical Risk Factors ,People and Places ,Africa ,Observational study ,Preventive Medicine ,business ,Demography - Abstract
ObjectivesAlmost 13 million people are estimated to be on antiretroviral therapy in Eastern and Southern Africa, and their disease course and program effectiveness could be significantly affected by the concurrent use of alcohol. Screening for alcohol use may be important to assess the prevalence of alcohol consumption and its impact on patient and programmatic outcomes.MethodsAs part of this observational study, data on patient characteristics and alcohol consumption were collected on a cohort of 765 adult patients enrolling in HIV care in East Africa. Alcohol consumption was assessed with the AUDIT questionnaire at enrollment. Subjects were classified as consuming any alcohol (AUDIT score >0), hazardous drinkers (AUDIT score ≥8) and hyper drinkers (AUDIT score ≥16). The effects of alcohol consumption on retention in care, death and delays in antiretroviral therapy (ART) initiation were assessed through competing risk (Fine & Gray) models.ResultsOf all study participants, 41.6% consumed alcohol, 26.7% were classified as hazardous drinkers, and 16.0% as hyper drinkers. Depending on alcohol consumption classification, men were 3-4 times more likely to consume alcohol compared to women. Hazardous drinkers (median age 32.8 years) and hyper drinkers (32.7 years) were slightly older compared to non-hazardous drinkers (30.7 years) and non-hyper drinkers (30.8 years), (p-values = 0.014 and 0.053 respectively). Median CD4 at enrollment was 330 cells/μl and 16% were classified World Health Organization (WHO) stage 3 or 4. There was no association between alcohol consumption and CD4 count or WHO stage at enrollment. Alcohol consumption was associated with significantly lower probability of ART initiation (adjusted sub-distribution hazard ratio aSHR = 0.77 between alcohol consumers versus non-consumers; p-value = 0.008), and higher patient non-retention in care (aSHR = 1.77, p-value = 0.023).DiscussionAlcohol consumption is associated with significant delays in ART initiation and reduced retention in care for patients enrolling in HIV care and treatment programs in East Africa. Consequently, interventions that target alcohol consumption may have a significant impact on the HIV care cascade.
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- 2020
19. PS-SiZer map to investigate significant features of body-weight profile changes in HIV infected patients in the IeDEA Collaboration
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Constantin T. Yiannoutsos, Michael Schomaker, Sasisopin Kiertiburanakul, Eric Balestre, Matthew P. Fox, Samiha Sarwat, Matthew Law, Kara Wools-Kaloustian, Diana Huis in ‘t Veld, Beverly S. Musick, and Jaroslaw Harezlak
- Subjects
Male ,RNA viruses ,0301 basic medicine ,Physiology ,Human immunodeficiency virus (HIV) ,HIV Infections ,Weight Gain ,Pathology and Laboratory Medicine ,medicine.disease_cause ,Biochemistry ,Geographical Locations ,0302 clinical medicine ,Immunodeficiency Viruses ,Statistics ,Medicine and Health Sciences ,Medicine ,Public and Occupational Health ,Longitudinal Studies ,030212 general & internal medicine ,Multidisciplinary ,Simulation and Modeling ,Vaccination and Immunization ,Physiological Parameters ,Medical Microbiology ,Data Interpretation, Statistical ,Viral Pathogens ,Viruses ,Biomarker (medicine) ,Female ,Pathogens ,medicine.symptom ,Research Article ,Adult ,Computer and Information Sciences ,Anti-HIV Agents ,Science ,Immunology ,Antiretroviral Therapy ,Research and Analysis Methods ,Body weight ,Microbiology ,Africa, Southern ,03 medical and health sciences ,Smoothing spline ,Antiviral Therapy ,Retroviruses ,Humans ,Computer Simulation ,Microbial Pathogens ,business.industry ,Data Visualization ,Body Weight ,Lentivirus ,Weight change ,Organisms ,Biology and Life Sciences ,HIV ,030112 virology ,Antiretroviral therapy ,Regimen ,Africa ,People and Places ,Preventive Medicine ,business ,Weight gain ,Biomarkers - Abstract
ObjectivesWe extend the method of Significant Zero Crossings of Derivatives (SiZer) to address within-subject correlations of repeatedly collected longitudinal biomarker data and the computational aspects of the methodology when analyzing massive biomarker databases. SiZer is a powerful visualization tool for exploring structures in curves by mapping areas where the first derivative is increasing, decreasing or does not change (plateau) thus exploring changes and normalization of biomarkers in the presence of therapy.MethodsWe propose a penalized spline SiZer (PS-SiZer) which can be expressed as a linear mixed model of the longitudinal biomarker process to account for irregularly collected data and within-subject correlations. Through simulations we show how sensitive PS-SiZer is in detecting existing features in longitudinal data versus existing versions of SiZer. In a real-world data analysis PS-SiZer maps are used to map areas where the first derivative of weight change after antiretroviral therapy (ART) start is significantly increasing, decreasing or does not change, thus exploring the durability of weight increase after the start of therapy. We use weight data repeatedly collected from persons living with HIV initiating ART in five regions in the International Epidemiologic Databases to Evaluate AIDS (IeDEA) worldwide collaboration and compare the durability of weight gain between ART regimens containing and not containing the drug stavudine (d4T), which has been associated with shorter durability of weight gain.ResultsThrough simulations we show that the PS-SiZer is more accurate in detecting relevant features in longitudinal data than existing SiZer variants such as the local linear smoother (LL) SiZer and the SiZer with smoothing splines (SS-SiZer). In the illustration we include data from 185,010 persons living with HIV who started ART with a d4T (53.1%) versus non-d4T (46.9%) containing regimen. The largest difference in durability of weight gain identified by the SiZer maps was observed in Southern Africa where weight gain in patients treated with d4T-containing regimens lasted 59.9 weeks compared to 133.8 weeks for those with non-d4T-containing regimens. In the other regions, persons receiving d4T-containing regimens experienced weight gains lasting 38-62 weeks versus 55-93 weeks in those receiving non-d4T-based regimens.DiscussionPS-SiZer, a SiZer variant, can handle irregularly collected longitudinal data and within-subject correlations and is sensitive in detecting even subtle features in biomarker curves.
- Published
- 2020
20. Trends Over Time for Adolescents Enrolling in HIV Care in Kenya, Tanzania, and Uganda From 2001-2014
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Fred Nalugoda, Alfred Keter, Ann Mwangi, John Ssali, Constantin T. Yiannoutsos, John M. Humphrey, Kara Wools-Kaloustian, Elizabeth A. Bukusi, Edwin Sang, Samuel Ayaya, Edith Apondi, and Beverly S. Musick
- Subjects
0301 basic medicine ,Male ,Adolescent ,Anti-HIV Agents ,Human immunodeficiency virus (HIV) ,HIV Infections ,medicine.disease_cause ,Tanzania ,Article ,03 medical and health sciences ,Young Adult ,0302 clinical medicine ,Environmental health ,parasitic diseases ,medicine ,East africa ,Humans ,Pharmacology (medical) ,Uganda ,030212 general & internal medicine ,Prospective Studies ,Child ,Retrospective Studies ,biology ,business.industry ,virus diseases ,Retrospective cohort study ,biology.organism_classification ,030112 virology ,Antiretroviral therapy ,Kenya ,Infectious Diseases ,Female ,business - Abstract
BACKGROUND: The data needed to understand the characteristics and outcomes, over time, of adolescents enrolling in HIV care in East Africa are limited. SETTING: Six HIV care programs in Kenya, Tanzania, and Uganda. METHODS: This retrospective cohort study included individuals enrolling in HIV care as younger adolescents (10–14 years) and older adolescents (15–19 years) from 2001–2014. Descriptive statistics were used to compare groups at enrollment and antiretroviral therapy (ART) initiation over time. The proportion of adolescents was compared with the total number of individuals aged 10 years and older enrolling over time. Competing-risk analysis was used to estimate 12-month attrition after enrollment/pre-ART initiation; post-ART attrition was estimated by Kaplan-Meier method. RESULTS: A total of 6344 adolescents enrolled between 2001 and 2014. The proportion of adolescents enrolling among all individuals increased from 2.5% (2001–2004) to 3.9% (2013–2014, P< 0.0001). At enrollment, median CD4 counts in 2001–2004 compared with 2013–2014 increased for younger (188 vs. 379 cells/ mm(3), P< 0.0001) and older (225 vs. 427 cells/mm(3), P< 0.0001) adolescents. At ART initiation, CD4 counts increased for younger (140 vs. 233 cells/mm(3), P< 0.0001) and older (64 vs. 323 cells/ mm(3), P< 0.0001) adolescents. Twelve-month attrition also increased for all adolescents both after enrollment/pre-ART initiation (4.7% vs. 12.0%, P< 0.001) and post-ART initiation (18.7% vs. 31.2%, P< 0.001). CONCLUSIONS: Expanding HIV services and ART coverage was likely associated with earlier adolescent enrollment and ART initiation but also with higher attrition rates before and after ART initiation. Interventions are needed to promote retention in care among adolescents.
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- 2018
21. Diagnostic and Prognostic Value of JC Virus DNA in Plasma in Progressive Multifocal Leukoencephalopathy
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Constantin T. Yiannoutsos, Simonetta Gerevini, Laura Passeri, Arabella Bestetti, Simona Bossolasco, Adriano Lazzarin, Diego Franciotta, Beverly S. Musick, Francesca Ferretti, Antonio Boschini, and Paola Cinque
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0301 basic medicine ,Microbiology (medical) ,Adult ,Male ,medicine.medical_specialty ,viruses ,JC virus ,HIV Infections ,medicine.disease_cause ,Gastroenterology ,Polymerase Chain Reaction ,Leukoencephalopathy ,03 medical and health sciences ,0302 clinical medicine ,Natalizumab ,Cerebrospinal fluid ,Internal medicine ,Demyelinating disease ,medicine ,Humans ,Clinical significance ,Survival analysis ,Aged ,Retrospective Studies ,business.industry ,Clinical Laboratory Techniques ,Progressive multifocal leukoencephalopathy ,Leukoencephalopathy, Progressive Multifocal ,virus diseases ,Middle Aged ,medicine.disease ,Prognosis ,JC Virus ,Survival Analysis ,030104 developmental biology ,Infectious Diseases ,nervous system ,Anti-Retroviral Agents ,DNA, Viral ,Disease Progression ,Female ,business ,030217 neurology & neurosurgery ,medicine.drug - Abstract
Background Progressive multifocal leukoencephalopathy (PML) is a severe demyelinating disease caused by the polyomavirus JC (John Cunningham; JCV) that affects patients with impaired immune systems. While JCV-DNA detection in cerebrospinal fluid (CSF) is diagnostic of PML, the clinical significance of plasma JCV-DNA is uncertain. Methods We retrospectively analyzed plasma samples from PML patients that were drawn close to disease onset and from controls without PML. In PML patients, we compared plasma JCV-DNA detection and levels to clinical and laboratory parameters, and patient survival. Results JCV-DNA was detected in plasma of 49/103 (48%) patients with PML (20/24, 83%, human immunodeficiency virus [HIV] negative; 29/79, 37%, HIV-positive) and of 4/144 (3%) controls without PML (0/95 HIV-negative; 4/49, 8%, HIV-positive), yielding a diagnostic sensitivity and specificity of 48% and 97% (83% and 100% in HIV-negative; 37% and 92% in HIV-positive), respectively. Among 16 PML patients with undetectable CSF JCV-DNA, 4 (25%) had detectable plasma JCV-DNA. Plasma JCV-DNA levels were independently associated with CSF levels (P < .0001) and previous corticosteroid treatment (P = .012). Higher plasma JCV-DNA levels were associated with disease progression in HIV-negative patients (P = .005); in HIV-positive patients, there was an increased risk of progression only in those treated with combination antiretroviral therapy (cART; P < .0001). Conclusions Testing JCV-DNA in plasma might complement PML diagnosis, especially when CSF is unavailable or JCV-DNA not detectable in CSF. In addition, JCV-DNA plasma levels could be useful as a marker of disease progression in both HIV-negative and cART-treated, HIV-positive PML patients.
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- 2017
22. Increased prevalence of pregnancy and comparative risk of program attrition among individuals starting HIV treatment in East Africa
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Constantin T. Yiannoutsos, Charles B. Holmes, Lameck Diero, Craig R. Cohen, Carolyn Williams, John Ssali, Batya Elul, Nancy Padian, Andrew Kambugu, Beverly S. Musick, Elizabeth A. Bukusi, Kara Wools-Kaloustian, and Yotebieng, Marcel
- Subjects
0301 basic medicine ,RNA viruses ,Epidemiology ,medicine.medical_treatment ,Maternal Health ,lcsh:Medicine ,HIV Infections ,Reproductive health and childbirth ,Eastern ,Pathology and Laboratory Medicine ,Assisted Reproductive Technology ,Tanzania ,Geographical Locations ,0302 clinical medicine ,Immunodeficiency Viruses ,Pregnancy ,Prevalence ,Medicine and Health Sciences ,Cumulative incidence ,Public and Occupational Health ,030212 general & internal medicine ,Pregnancy Complications, Infectious ,lcsh:Science ,Public health ,Multidisciplinary ,Infectious ,Obstetrics and Gynecology ,Africa, Eastern ,Vaccination and Immunization ,Infectious Diseases ,Medical Microbiology ,Viral Pathogens ,Cohort ,Viruses ,HIV/AIDS ,Female ,Pathogens ,Infection ,Research Article ,Adult ,medicine.medical_specialty ,Patient Dropouts ,General Science & Technology ,Anti-HIV Agents ,Immunology ,Antiretroviral Therapy ,Microbiology ,03 medical and health sciences ,Young Adult ,HIV infections--Treatment ,Acquired immunodeficiency syndrome (AIDS) ,Antiviral Therapy ,Clinical Research ,Retroviruses ,medicine ,Humans ,Management of High-Risk Pregnancies ,Microbial Pathogens ,Assisted reproductive technology ,business.industry ,Pregnant women ,Prevention ,lcsh:R ,Lentivirus ,Organisms ,Biology and Life Sciences ,HIV ,Retrospective cohort study ,medicine.disease ,030112 virology ,Antiretroviral agents ,Kenya ,Pregnancy Complications ,Good Health and Well Being ,People and Places ,Africa ,Patient Compliance ,Women's Health ,lcsh:Q ,Preventive Medicine ,business ,Demography - Abstract
Author(s): Holmes, Charles B; Yiannoutsos, Constantin T; Elul, Batya; Bukusi, Elizabeth; Ssali, John; Kambugu, Andrew; Musick, Beverly S; Cohen, Craig; Williams, Carolyn; Diero, Lameck; Padian, Nancy; Wools-Kaloustian, Kara K | Abstract: BackgroundThe World Health Organization now recommends initiating all pregnant women on life-long antiretroviral therapy (ART), yet there is limited information about the characteristics and program outcomes of pregnant women already on ART in Africa. Our hypothesis was that pregnant women comprised an increasing proportion of those starting ART, and that sub-groups of these women were at higher risk for program attrition.Methods and findingsWe used the International Epidemiology Databases to Evaluate AIDS- East Africa (IeDEA-EA) to conduct a retrospective cohort study including HIV care and treatment programs in Kenya, Uganda, and Tanzania. The cohort consecutively included HIV-infected individuals 13 years or older starting ART 2004-2014. We examined trends over time in the proportion pregnant, their characteristics and program attrition rates compared to others initiating and already receiving ART. 156,474 HIV-infected individuals (67.0% women) started ART. The proportion of individuals starting ART who were pregnant women rose from 5.3% in 2004 to 12.2% in 2014. Mean CD4 cell counts at ART initiation, weighted for annual program size, increased from 2004 to 2014, led by non-pregnant women (annual increase 20 cells/mm3) and men (17 cells/mm3 annually), with lower rates of change in pregnant women (10 cells/mm3 per year) (pl0.0001). There was no significant difference in the cumulative incidence of program attrition at 6 months among pregnant women starting ART and non-pregnant women. However, healthy pregnant women starting ART (WHO stage 1/2) had a higher rate of attrition rate (9.6%), compared with healthy non-pregnant women (6.5%); in contrast among women with WHO stage 3/4 disease, pregnant women had lower attrition (8.4%) than non-pregnant women (14.4%). Among women who initiated ART when healthy and remained in care for six months, subsequent six-month attrition was slightly higher among pregnant women at ART start (3.5%) compared to those who were not pregnant (2.4%), (absolute difference 1.1%, 95% CI 0.7%-1.5%).ConclusionsPregnant women comprise an increasing proportion of those initiating ART in Africa, and pregnant women starting ART while healthy are at higher risk for program attrition than non-pregnant women. As ART programs further expand access to healthier pregnant women, further studies are needed to better understand the drivers of loss among this high risk group of women to optimize retention.
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- 2017
23. Observational Study of the Effect of Patient Outreach on Return to Care: The Earlier the Better
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Beverly S. Musick, Paula Braitstein, Giorgos Bakoyannis, Fatma Some, Constantin T. Yiannoutsos, Peter F Rebeiro, Winstone M. Nyandiko, Kara Wools-Kaloustian, and Ronald Scott Braithwaite
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0301 basic medicine ,Adult ,Male ,medicine.medical_specialty ,No-Show Patients ,Patient Dropouts ,Adolescent ,Anti-HIV Agents ,MEDLINE ,HIV Infections ,Sensitivity and Specificity ,Article ,03 medical and health sciences ,Young Adult ,0302 clinical medicine ,Nursing ,Antiretroviral Therapy, Highly Active ,Health care ,Medicine ,Humans ,Pharmacology (medical) ,030212 general & internal medicine ,Lost to follow-up ,Young adult ,Retrospective Studies ,business.industry ,Retrospective cohort study ,Middle Aged ,030112 virology ,CD4 Lymphocyte Count ,Outreach ,Infectious Diseases ,Family medicine ,Patient Compliance ,Observational study ,Female ,Lost to Follow-Up ,business - Abstract
The burden of HIV remains heaviest in resource-limited settings, where problems of losses to care, silent transfers, gaps in care, and incomplete mortality ascertainment have been recognized.Patients in care at Academic Model Providing Access to Healthcare (AMPATH) clinics from 2001-2011 were included in this retrospective observational study. Patients missing an appointment were traced by trained staff; those found alive were counseled to return to care (RTC). Relative hazards of RTC were estimated among those having a true gap: missing a clinic appointment and confirmed as neither dead nor receiving care elsewhere. Sample-based multiple imputation accounted for missing vital status.Among 34,522 patients lost to clinic, 15,331 (44.4%) had a true gap per outreach, 2754 (8.0%) were deceased, and 837 (2.4%) had documented transfers. Of 15,600 (45.2%) remaining without active ascertainment, 8762 (56.2%) with later RTC were assumed to have a true gap. Adjusted cause-specific hazard ratios (aHRs) showed early outreach (a ≤8-day window, defined by grid-search approach) had twice the hazard for RTC vs. those without (aHR = 2.06; P0.001). HRs for RTC were lower the later the outreach effort after disengagement (aHR = 0.86 per unit increase in time; P0.001). Older age, female sex (vs. male), antiretroviral therapy use (vs. none), and HIV status disclosure (vs. none) were also associated with greater likelihood of RTC, and higher enrollment CD4 count with lower likelihood of RTC.Patient outreach efforts have a positive impact on patient RTC, regardless of when undertaken, but particularly soon after the patient misses an appointment.
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- 2017
24. Incidence of World Health Organization Stage 3 and 4 Events, Tuberculosis and Mortality in Untreated, HIV-infected Children Enrolling in Care Before 1 Year of Age
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Samuel Ayaya, Andrea L. Ciaranello, Zhigang Lu, Rachel C. Vreeman, John Ssali, Elena Losina, Constantin T. Yiannoutsos, Elaine J. Abrams, Beverly S. Musick, Lisa Dillabaugh, Kara Wools-Kaloustian, Katie Doherty, and Kenneth A. Freedberg
- Subjects
Male ,Microbiology (medical) ,Pediatrics ,medicine.medical_specialty ,Tuberculosis ,Opportunistic infection ,Population ,HIV Infections ,World Health Organization ,computer.software_genre ,Article ,Cohort Studies ,Acquired immunodeficiency syndrome (AIDS) ,Case fatality rate ,Humans ,Medicine ,education ,education.field_of_study ,AIDS-Related Opportunistic Infections ,Database ,business.industry ,Incidence ,Mortality rate ,Incidence (epidemiology) ,Infant ,Africa, Eastern ,medicine.disease ,Infectious Diseases ,Pediatrics, Perinatology and Child Health ,Female ,business ,computer ,Cohort study - Abstract
Few studies have reported CD4%- and age-stratified rates of World Health Organization Stage 3 (WHO3) events, World Health Organization Stage 4 (WHO4) events, tuberculosis (TB) and mortality in HIV-infected infants before initiation of antiretroviral therapy.HIV-infected children enrolled before 1 year of age in the International Epidemiologic Databases to Evaluate AIDS East Africa region (October 1, 2002, to November, 2008) were included. We estimated incidence rates of earliest clinical event (WHO3, WHO4 and TB), before antiretroviral therapy initiation per local guidelines, stratified by current age (or ≥6 months) and current CD4% (15%, 15-24%, ≥25%). CD4%-stratified mortality rates were estimated separately for children who did not experience a clinical event ("background" mortality) and for children who experienced an event, including "acute" mortality (≤30 days post event) and "later" mortality (30 days post event).Among 847 children (median enrollment age: 4.8 months; median pre-antiretroviral therapy follow up: 10.8 months; 603 (71%) with ≥1 CD4% recorded), event rates were comparable for those aged6 and ≥6 months. Current CD4% was associated with risk of WHO4 events for children6 months of age and with all evaluated events for children ≥6 months old (P0.05). "Background" mortality was 3.7-8.4/100 person-years (PY). "Acute" mortality (≤30 days post event) was 33.8/100 PY (after TB) and 41.1/100 PY (after WHO3 or WHO4). "Later" mortality (30 days post event) ranged by CD4% from 4.7 to 29.1/100 PY.In treatment-naïve, HIV-infected infants, WHO3, WHO4 and TB events were common before and after 6 months of age and led to substantial increases in mortality. Early infant HIV diagnosis and treatment are critically important, regardless of CD4%.
- Published
- 2014
25. Evaluating the Impact of a HIV Low-Risk Express Care Task-Shifting Program: A Case Study of the Targeted Learning Roadmap
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Constantin T. Yiannoutsos, Mark J. van der Laan, Linh Tran, Kara Wools-Kaloustian, Sylvester Kimaiyo, Abraham Siika, Beverly S. Musick, and Maya L. Petersen
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Estimation ,Counterfactual thinking ,Epidemiology ,business.industry ,Applied Mathematics ,Human immunodeficiency virus (HIV) ,causal road map ,medicine.disease_cause ,causal estimation ,Triage ,Article ,R package ,Clinical Research ,Statistics ,medicine ,Population study ,semiparametric models ,Task shifting ,Lost to follow-up ,causal inference ,business ,Infection ,targeted learning ,Demography - Abstract
In conducting studies on an exposure of interest, a systematic roadmap should be applied for translating causal questions into statistical analyses and interpreting the results. In this paper we describe an application of one such roadmap applied to estimating the joint effect of both time to availability of a nurse-based triage system (low risk express care (LREC)) and individual enrollment in the program among HIV patients in East Africa. Our study population is comprised of 16,513 subjects found eligible for this task-shifting program within 15 clinics in Kenya between 2006 and 2009, with each clinic starting the LREC program between 2007 and 2008. After discretizing follow-up into 90-day time intervals, we targeted the population mean counterfactual outcome (i. e. counterfactual probability of either dying or being lost to follow up) at up to 450 days after initial LREC eligibility under three fixed treatment interventions. These were (i) under no program availability during the entire follow-up, (ii) under immediate program availability at initial eligibility, but non-enrollment during the entire follow-up, and (iii) under immediate program availability and enrollment at initial eligibility. We further estimated the controlled direct effect of immediate program availability compared to no program availability, under a hypothetical intervention to prevent individual enrollment in the program. Targeted minimum loss-based estimation was used to estimate the mean outcome, while Super Learning was implemented to estimate the required nuisance parameters. Analyses were conducted with the ltmle R package; analysis code is available at an online repository as an R package. Results showed that at 450 days, the probability of in-care survival for subjects with immediate availability and enrollment was 0.93 (95 % CI: 0.91, 0.95) and 0.87 (95 % CI: 0.86, 0.87) for subjects with immediate availability never enrolling. For subjects without LREC availability, it was 0.91 (95 % CI: 0.90, 0.92). Immediate program availability without individual enrollment, compared to no program availability, was estimated to slightly albeit significantly decrease survival by 4 % (95 % CI 0.03,0.06, p
- Published
- 2016
26. Frequency and impact of suboptimal immune recovery on first-line antiretroviral therapy within the International Epidemiologic Databases to Evaluate AIDS in East Africa
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Kara Wools-Kaloustian, Agnes Kiragga, John Ssali, Beverly S. Musick, Lameck Diero, Emanuel Lugina, Philippa Easterbrook, Patrick Oyaro, Constantin T. Yiannoutsos, Andrew Kambugu, and Damalie Nakanjako
- Subjects
0301 basic medicine ,Adult ,Male ,medicine.medical_specialty ,Adolescent ,Immunology ,HIV Infections ,Tanzania ,Article ,03 medical and health sciences ,Young Adult ,0302 clinical medicine ,Pharmacotherapy ,Immune Reconstitution ,Acquired immunodeficiency syndrome (AIDS) ,Interquartile range ,Internal medicine ,Antiretroviral Therapy, Highly Active ,medicine ,Prevalence ,Immunology and Allergy ,Humans ,Uganda ,030212 general & internal medicine ,Young adult ,Survival analysis ,Retrospective Studies ,Reverse-transcriptase inhibitor ,AIDS-Related Opportunistic Infections ,business.industry ,Incidence (epidemiology) ,Retrospective cohort study ,Middle Aged ,medicine.disease ,030112 virology ,Kenya ,CD4 Lymphocyte Count ,Infectious Diseases ,Anti-Retroviral Agents ,Female ,business ,medicine.drug - Abstract
OBJECTIVE To describe patterns of suboptimal immune recovery (SO-IR) and associated HIV-related-illnesses during the first 5 years following first-line antiretroviral therapy (ART) initiation across seven ART sites in East Africa. DESIGN Retrospective analysis of data from seven ART clinical sites (three Uganda, two Kenya and two Tanzania). METHODS SO-IR was described by proportions of ART-treated adults with CD4 cell counts less than 200, less than 350 and less than 500 cells/μl. Kaplan-Meier survival analysis techniques were used to assess predictors of SO-IR, and incident rates of HIV-related illnesses at CD4 cell counts less than 200, 200-350, 351-499, and >500 cells/μl, respectively. RESULTS Overall 80 843 adults initiated non-nucleoside reverse transcriptase inhibitor-based first-line ART; 65% were women and median CD4 cell count was 126 [interquartile range (IQR), 52-202] cells/μl. Cumulative probability of SO-IR
- Published
- 2016
27. Facility-Level Factors Influencing Retention of Patients in HIV Care in East Africa
- Author
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Paula Braitstein, Giorgos Bakoyannis, Constantin T. Yiannoutsos, Philippa Easterbrook, Becky L. Genberg, Kara Wools-Kaloustian, Craig R. Cohen, Elizabeth A. Bukusi, Ronald Scott Braithwaite, Beth Rachlis, Andrew Kambugu, Beverly S. Musick, Elvin Geng, Geoffrey Somi, Mwebesa Bwana, and Andrei, Graciela
- Subjects
RNA viruses ,Bacterial Diseases ,Male ,Pediatrics ,Databases, Factual ,Epidemiology ,Human immunodeficiency virus (HIV) ,lcsh:Medicine ,HIV Infections ,Kaplan-Meier Estimate ,Pathology and Laboratory Medicine ,medicine.disease_cause ,Tanzania ,Geographical Locations ,0302 clinical medicine ,Immunodeficiency Viruses ,Interquartile range ,Medicine and Health Sciences ,Public and Occupational Health ,Uganda ,030212 general & internal medicine ,Viral ,lcsh:Science ,Multidisciplinary ,biology ,Reverse Transcriptase Polymerase Chain Reaction ,HIV diagnosis and management ,Vaccination and Immunization ,3. Good health ,Infectious Diseases ,Medical Microbiology ,HIV epidemiology ,Viral Pathogens ,Viruses ,HIV/AIDS ,RNA, Viral ,Female ,Pathogens ,Infection ,Research Article ,Adult ,medicine.medical_specialty ,Tuberculosis ,Anti-HIV Agents ,General Science & Technology ,Immunology ,030231 tropical medicine ,Antiretroviral Therapy ,Microbiology ,03 medical and health sciences ,Databases ,Antiviral Therapy ,Acquired immunodeficiency syndrome (AIDS) ,Clinical Research ,Retroviruses ,medicine ,Humans ,Lost to follow-up ,Microbial Pathogens ,Factual ,Proportional Hazards Models ,business.industry ,Proportional hazards model ,Lentivirus ,lcsh:R ,Organisms ,Biology and Life Sciences ,HIV ,Tropical Diseases ,medicine.disease ,biology.organism_classification ,Kenya ,Diagnostic medicine ,Confidence interval ,CD4 Lymphocyte Count ,People and Places ,Africa ,RNA ,lcsh:Q ,Lost to Follow-Up ,Preventive Medicine ,Health Facilities ,business ,Delivery of Health Care ,Demography - Abstract
Losses to follow-up (LTFU) remain an important programmatic challenge. While numerous patient-level factors have been associated with LTFU, less is known about facility-level factors. Data from the East African International epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium was used to identify facility-level factors associated with LTFU in Kenya, Tanzania and Uganda. Patients were defined as LTFU if they had no visit within 12 months of the study endpoint for pre-ART patients or 6 months for patients on ART. Adjusting for patient factors, shared frailty proportional hazard models were used to identify the facility-level factors associated with LTFU for the pre- and post-ART periods. Data from 77,362 patients and 29 facilities were analyzed. Median age at enrolment was 36.0 years (Interquartile Range: 30.1, 43.1), 63.9% were women and 58.3% initiated ART. Rates (95% Confidence Interval) of LTFU were 25.1 (24.7-25.6) and 16.7 (16.3-17.2) per 100 person-years in the pre-ART and post-ART periods, respectively. Facility-level factors associated with increased LTFU included secondary-level care, HIV RNA PCR turnaround time >14 days, and no onsite availability of CD4 testing. Increased LTFU was also observed when no nutritional supplements were provided (pre-ART only), when TB patients were treated within the HIV program (pre-ART only), and when the facility was open ≤4 mornings per week (ART only). Our findings suggest that facility-based strategies such as point of care laboratory testing and separate clinic spaces for TB patients may improve retention.
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- 2016
28. Reply
- Author
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Kara Wools-Kaloustian, Constantin T. Yiannoutsos, Batya Elul, and Beverly S. Musick
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0301 basic medicine ,03 medical and health sciences ,0302 clinical medicine ,Infectious Diseases ,business.industry ,Medicine ,Pharmacology (medical) ,030212 general & internal medicine ,business ,030112 virology - Published
- 2017
29. Impact of Integrated Family Planning and HIV Care Services on Contraceptive Use and Pregnancy Outcomes
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James Kiarie, E. Jane Carter, Kara Wools-Kaloustian, Abraham Siika, Rose J. Kosgei, Beverly S. Musick, Hillary Mabeya, Ann Mwangi, Changyu Shen, and Kizito M. Lubano
- Subjects
Adult ,Pediatrics ,medicine.medical_specialty ,Population ,HIV Infections ,Pilot Projects ,Article ,law.invention ,Cohort Studies ,Condoms ,Contraceptive Agents ,Condom ,Pregnancy ,law ,medicine ,Humans ,Pharmacology (medical) ,education ,Contraception Behavior ,Retrospective Studies ,education.field_of_study ,Obstetrics ,business.industry ,Incidence (epidemiology) ,Pregnancy Outcome ,Retrospective cohort study ,medicine.disease ,Kenya ,Infectious Diseases ,Family planning ,Family Planning Services ,Attributable risk ,Female ,business ,Developed country - Abstract
OBJECTIVE: To determine the impact of routine care (RC) and integrated family planning and HIV care service (IFP) on family planning (FP) uptake and pregnancy outcomes. DESIGN: Retrospective cohort study conducted between 1-10-2005 and 28-02-2009. SETTING: United States Agency for International Development - Academic Model Providing Access To Healthcare (USAID-AMPATH) in western Kenya. SUBJECTS: Records of adult HIV-infected women. INTERVENTION: Integration of FP into one of the care teams. PRIMARY OUTCOMES MEASURES: Incidence of FP methods and pregnancy. RESULTS: Results: 4031 women (1453 IFP; 2578 RC) were eligible. Among the IFP group there was a: 16.7% increase (p
- Published
- 2011
30. Adherence to antiretroviral therapy in a clinical cohort of HIV-infected children in East Africa
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Samuel Ayaya, Constantin T. Yiannoutsos, Craig R. Cohen, Denis Nash, Sarah E. Wiehe, Rachel C. Vreeman, Beverly S. Musick, Kara Wools-Kaloustian, Deo Wabwire, and Belay, Mulugeta
- Subjects
RNA viruses ,Male ,0301 basic medicine ,Pediatrics ,Human immunodeficiency virus (HIV) ,Social Sciences ,lcsh:Medicine ,HIV Infections ,Eastern ,Pathology and Laboratory Medicine ,medicine.disease_cause ,Tanzania ,Geographical Locations ,Families ,0302 clinical medicine ,Immunodeficiency Viruses ,Sociology ,7.1 Individual care needs ,Consortia ,Medicine and Health Sciences ,Public and Occupational Health ,030212 general & internal medicine ,lcsh:Science ,Child ,Children ,Pediatric ,Multidisciplinary ,biology ,Africa, Eastern ,Vaccination and Immunization ,3. Good health ,Infectious Diseases ,Medical Microbiology ,Viral Pathogens ,Child, Preschool ,6.1 Pharmaceuticals ,Pill ,Viruses ,Cohort ,HIV/AIDS ,Female ,Pathogens ,Infection ,Research Article ,medicine.medical_specialty ,Adolescent ,Anti-HIV Agents ,General Science & Technology ,Immunology ,MEDLINE ,Antiretroviral Therapy ,Microbiology ,03 medical and health sciences ,Antiviral Therapy ,Acquired immunodeficiency syndrome (AIDS) ,Clinical Research ,Retroviruses ,medicine ,East africa ,Humans ,Preschool ,Microbial Pathogens ,business.industry ,Lentivirus ,lcsh:R ,Organisms ,Biology and Life Sciences ,HIV ,Evaluation of treatments and therapeutic interventions ,Infant ,biology.organism_classification ,medicine.disease ,Kenya ,030112 virology ,Antiretroviral therapy ,Age Groups ,People and Places ,Africa ,Patient Compliance ,Population Groupings ,lcsh:Q ,Preventive Medicine ,Management of diseases and conditions ,business - Abstract
Author(s): Vreeman, Rachel C; Ayaya, Samuel O; Musick, Beverly S; Yiannoutsos, Constantin T; Cohen, Craig R; Nash, Denis; Wabwire, Deo; Wools-Kaloustian, Kara; Wiehe, Sarah E | Abstract: ObjectiveTo describe antiretroviral therapy (ART) adherence and associated factors for a large HIV-infected pediatric cohort followed by sites of the East Africa International Epidemiologic Databases to Evaluate AIDS (IeDEA) consortium.MethodsThis study utilized prospectively collected clinical data from HIV-infected children less than 13 years of age who initiated ART within 4 clinical care programs (with 26 clinical sites) in Kenya, Uganda, and Tanzania and were followed for up to 6 years. Programs used one of 3 adherence measures, including 7-day quantitative recall, 7-day categorical recall, and clinician pill assessments. We fit a hierarchical, three-level, logistic-regression model to examine adherence, with observations nested within patient, and patients within the 26 sites providing pediatric HIV data to this analysis.ResultsIn East Africa, 3,304 children, 52.0% male, were enrolled in care and were subsequently observed for a median of 92 weeks (inter-quartile range [IQR] 50.3-145.0 weeks). Median age at ART initiation was 5.5 years ([IQR] 3.0-8.5 years). "Good" adherence, as reported by each clinic's measures, was extremely high, remaining on average above 90% throughout all years of follow-up. Longer time on ART was associated with higher adherence (adjusted Odds Ratio-aOR-per log-transformed week on ART: 1.095, 95% Confidence Interval-CI-[1.052-1.150].) Patients enrolled in higher-volume programs exhibited higher rates of clinician-assessed adherence (aOR per log-500 patients: 1.174, 95% CI [1.108-1.245]). Significant site-level variability in reported adherence was observed (0.28), with even higher variability among patients (0.71). In a sub-analysis, being an orphan at the start of ART was strongly associated with lower ART adherence rates (aOR: 0.919, 95% CI [0.864-0.976]).ConclusionsSelf-reported adherence remained high over a median of 1.8 years in HIV care, but varied according to patient-level and site-level factors. Consistent adherence monitoring with validated measures and attention to vulnerable groups is recommended.
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- 2018
31. Magnetic Resonance Imaging Findings in Children With a First Recognized Seizure
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Beverly S. Musick, Susan M. Perkins, Vincent P. Mathews, Andrew J. Kalnin, Ton J. deGrauw, John C. Egelhoff, Joan K. Austin, David W. Dunn, Cynthia S. Johnson, and Philip S. Fastenau
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Male ,medicine.medical_specialty ,Adolescent ,Neurological disorder ,Statistics, Nonparametric ,Article ,Cohort Studies ,Central nervous system disease ,Epilepsy ,Developmental Neuroscience ,Residence Characteristics ,Seizures ,Convulsion ,medicine ,Humans ,Gliosis ,Child ,Prospective cohort study ,Chi-Square Distribution ,medicine.diagnostic_test ,business.industry ,Brain ,Magnetic resonance imaging ,Cortical dysplasia ,medicine.disease ,Magnetic Resonance Imaging ,Surgery ,Neurology ,Pediatrics, Perinatology and Child Health ,Female ,Neurology (clinical) ,Radiology ,Abnormality ,medicine.symptom ,business - Abstract
This study characterized structural abnormalities associated with onset of seizures in children, using magnetic resonance imaging and a standardized classification system in a large prospective cohort. Two hundred eighty-one children aged 6-14 years completed magnetic resonance imaging within 6 months of their first recognized seizure. Most examinations were performed with a standardized, dedicated seizure protocol; all were scored using a standard scoring system. At least one magnetic resonance imaging abnormality was identified in 87 of 281 (31%) children with a first recognized seizure. Two or more abnormalities were identified in 34 (12%). The commonest abnormalities were ventricular enlargement (51%), leukomalacia/gliosis (23%), gray-matter lesions such as heterotopias and cortical dysplasia (12%), volume loss (12%), other white-matter lesions (9%), and encephalomalacia (6%). Abnormalities defined as significant, or potentially related to seizures, occurred in 40 (14%). Temporal lobe and hippocampal abnormalities were detected at a higher frequency than in previous studies (13/87). Magnetic resonance imaging and a standardized, reliable, valid scoring system demonstrated a higher rate of abnormal findings than previously reported, including findings formerly considered incidental. Practice parameters may need revision, to expand the definition of significant abnormalities and support wider use of magnetic resonance imaging in children with newly diagnosed seizures.
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- 2008
32. The Need for Double-Sampling Designs in Survival Studies: An Application to Monitor PEPFAR
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Constantin T. Yiannoutsos, Ming Wen An, Beverly S. Musick, and Constantine Frangakis
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Statistics and Probability ,Research design ,Human immunodeficiency virus (HIV) ,medicine.disease_cause ,Article ,General Biochemistry, Genetics and Molecular Biology ,Bias ,Acquired immunodeficiency syndrome (AIDS) ,medicine ,Humans ,Dropout (neural networks) ,Acquired Immunodeficiency Syndrome ,Models, Statistical ,Actuarial science ,Data collection ,General Immunology and Microbiology ,business.industry ,Applied Mathematics ,Emergency plan ,General Medicine ,medicine.disease ,Objective Evidence ,Survival Analysis ,Double sampling ,Research Design ,General Agricultural and Biological Sciences ,business - Abstract
In 2007, there were 33.2 million people around the world living with HIV/AIDS (UNAIDS/WHO, 2007). In May 2003, the U.S. President announced a global program, known as the President's Emergency Plan for AIDS Relief (PEPFAR), to address this epidemic. We seek to estimate patient mortality in PEPFAR in an effort to monitor and evaluate this program. This effort, however, is hampered by loss to follow-up that occurs at very high rates. As a consequence, standard survival data and analysis on observed nondropout data are generally biased, and provide no objective evidence to correct the potential bias. In this article, we apply double-sampling designs and methodology to PEPFAR data, and we obtain substantially different and more plausible estimates compared with standard methods (1-year mortality estimate of 9.6% compared to 1.7%). The results indicate that a double-sampling design is critical in providing objective evidence of possible nonignorable dropout and, thus, in obtaining accurate data in PEPFAR. Moreover, we show the need for appropriate analysis methods coupled with double-sampling designs.
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- 2008
33. Outcomes of HIV-Infected Orphaned and Non-Orphaned Children on Antiretroviral Therapy in Western Kenya
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Winstone M. Nyandiko, Samuel Ayaya, Beverly S. Musick, Kara Wools-Kaloustian, John E. Sidle, William M. Tierney, E. Nabakwe, Constance Tenge, and Constantin T. Yiannoutsos
- Subjects
Male ,Pediatrics ,medicine.medical_specialty ,Adolescent ,Anti-HIV Agents ,Population ,HIV Infections ,Foster Home Care ,Orphan drug ,Acquired immunodeficiency syndrome (AIDS) ,Humans ,Medicine ,Body Weights and Measures ,Pharmacology (medical) ,Child ,Sida ,education ,education.field_of_study ,biology ,business.industry ,Infant ,Retrospective cohort study ,biology.organism_classification ,medicine.disease ,Kenya ,CD4 Lymphocyte Count ,Treatment Outcome ,Infectious Diseases ,El Niño ,Child, Preschool ,Cohort ,HIV-1 ,Female ,Electronic data ,business - Abstract
The objectives were to determine outcome differences between orphaned and non-orphaned children receiving antiretroviral therapy (ART). Design: Retrospective review of prospectively recorded electronic data. Setting: Nine HIV clinics in western Kenya. Population: 279 children on ART enrolled between August 2002 and February 2005. Main Measures: Orphan status CD4% sex- and age-adjusted height (HAZ) and weight (WAZ) z scores ART adherence mortality. Median follow-up was 34 months. Cohort included 51% males and 54% orphans. At ART initiation (baseline) 71% of children had CDC clinical stage B or C disease. Median CD4% was 9% and increased dramatically the first 30 weeks of therapy then leveled off. Parents and guardians reported perfect adherence at every visit for 75% of children. Adherence and orphan status were not significantly associated with CD4% response. Adjusted for baseline age follow-up was significantly shorter among orphaned children (median 33 vs. 41 weeks P = 0.096). One-year mortality was 7.1% for orphaned and 6.6% for non-orphaned children (P = 0.836). HAZ and WAZ were significantly below norm in both groups. With ART HAZ remained stable while WAZ tended to increase toward the norm especially among non-orphans. Orphans showed identical weight gains as non-orphans the first 70 weeks after start of ART but experienced reductions afterwards. Good ART adherence is possible in western rural Kenya. ART for HIV-infected children produced substantial and sustainable CD4% improvement. Orphan status was not associated with worse short-term outcomes but may be a factor for long-term therapy response. ART alone may not be sufficient to reverse significant developmental lags in the HIV-positive pediatric population. (authors)
- Published
- 2006
34. Comprehensiveness of HIV care provided at global HIV treatment sites in the IeDEA consortium: 2009 and 2014
- Author
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Catherine C. McGowan, Meridith Blevins, Mary Lou Lindegren, Eugène Messou, Kelly Goodwin, Aimee M. Freeman, Dianne Addison, Cristin Q. Fritz, Denis Nash, Beverly S. Musick, Kara Wools-Kaloutsian, Armel Poda, Jean Claude Dusingize, Richard D. Moore, Stephany N. Duda, Morna Cornell, C. William Wester, and Matthew Law
- Subjects
Male ,0301 basic medicine ,Gerontology ,Complete data ,Financial Management ,Human immunodeficiency virus (HIV) ,HIV Infections ,medicine.disease_cause ,Cohort Studies ,0302 clinical medicine ,HIV care capacity ,030212 general & internal medicine ,Hiv treatment ,610 Medicine & health ,Child ,implementation science ,Middle Aged ,3. Good health ,Outreach ,Infectious Diseases ,Female ,Viral load ,360 Social problems & social services ,Research Article ,Adult ,medicine.medical_specialty ,Asia ,Adolescent ,resource-limited settings ,Anti-HIV Agents ,Article ,Young Adult ,03 medical and health sciences ,Acquired immunodeficiency syndrome (AIDS) ,medicine ,East africa ,Humans ,survey ,laboratory capacity ,business.industry ,Australia ,Public Health, Environmental and Occupational Health ,HIV ,Central africa ,medicine.disease ,030112 virology ,CD4 Lymphocyte Count ,comprehensive care ,Family medicine ,Africa ,North America ,business - Abstract
Introduction: An important determinant of the effectiveness of HIV treatment programs is the capacity of sites to implement recommended services and identify systematic changes needed to ensure that invested resources translate into improved patient outcomes. We conducted a survey in 2014 of HIV care and treatment sites in the seven regions of the International epidemiologic Database to Evaluate AIDS (IeDEA) Consortium to evaluate facility characteristics, HIV prevention, care and treatment services provided, laboratory capacity, and trends in the comprehensiveness of care compared to data obtained in the 2009 baseline survey. Methods: Clinical staff from 262 treatment sites in 45 countries in IeDEA completed a site survey from September 2014 to January 2015, including Asia-Pacific with Australia (n = 50), Latin America and the Caribbean (n = 11), North America (n = 45), Central Africa (n = 17), East Africa (n = 36), Southern Africa (n = 87), and West Africa (n = 16). For the 55 sites with complete data from both the 2009 and 2014 survey, we evaluated change in comprehensiveness of care. Results: The majority of the 262 sites (61%) offered seven essential services (ART adherence, nutritional support, PMTCT, CD4+ cell count testing, tuberculosis screening, HIV prevention, and outreach). Sites that were publicly funded (64%), cared for adults and children (68%), low or middle Human Development Index (HDI) rank (68%, 68%), and received PEPFAR support (71%) were most often fully comprehensive. CD4+ cell count testing was universally available (98%) but only 62% of clinics offered it onsite. Approximately two-thirds (69%) of sites reported routine viral load testing (44–100%), with 39% having it onsite. Laboratory capacity to monitor antiretroviral-related toxicity and diagnose opportunistic infections varied widely by testing modality and region. In the subgroup of 55 sites with two surveys, comprehensiveness of services provided significantly increased across all regions from 2009 to 2014 (5.7 to 6.5, p < 0.001). Conclusions: The availability of viral load monitoring remains suboptimal and should be a focus for site capacity, particularly in East and Southern Africa, where the majority of those initiating on ART reside. However, the comprehensiveness of care provided increased over the past 5 years and was related to type of funding received (publicly funded and PEPFAR supported). Keywords: HIV; HIV care capacity; comprehensive care; survey; laboratory capacity; resource-limited settings; implementation science To access the supplementary material to this article please see Supplementary Files in the column to the right (under Article Tools). (Published: 6 January 2017) Citation: Fritz CQ et al. Journal of the International AIDS Society 2017, 20 :20933 http://www.jiasociety.org/index.php/jias/article/view/20933 | http://dx.doi.org/10.7448/IAS.20.1.20933
- Published
- 2017
35. CD4 trajectory adjusting for dropout among HIV-positive patients receiving combination antiretroviral therapy in an East African HIV care centre
- Author
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Constantin T. Yiannoutsos, Beverly S. Musick, Judith J. Lok, Kara Wools-Kaloustian, Ann Mwangi, Ronald J. Bosch, and Agnes Kiragga
- Subjects
Adult ,CD4-Positive T-Lymphocytes ,Male ,sub-Saharan Africa ,medicine.medical_specialty ,Patient Dropouts ,Adolescent ,Population ,Dropout (communications) ,Human immunodeficiency virus (HIV) ,Patient characteristics ,HIV Infections ,CD4 count ,medicine.disease_cause ,01 natural sciences ,IPCW ,010104 statistics & probability ,03 medical and health sciences ,Young Adult ,0302 clinical medicine ,Acquired immunodeficiency syndrome (AIDS) ,medicine ,Humans ,030212 general & internal medicine ,Resource-limited setting ,0101 mathematics ,Young adult ,education ,education.field_of_study ,business.industry ,Public Health, Environmental and Occupational Health ,Africa, Eastern ,Models, Theoretical ,medicine.disease ,Antiretroviral therapy ,3. Good health ,Surgery ,CD4 Lymphocyte Count ,Infectious Diseases ,Treatment Outcome ,Anti-Retroviral Agents ,Censoring (clinical trials) ,HIV/AIDS ,Female ,Mathematical modeling ,business ,Demography ,Research Article - Abstract
Objective: Estimates of CD4 response to antiretroviral therapy (ART) obtained by averaging data from patients in care, overestimate population CD4 response and treatment program effectiveness because they do not consider data from patients who are deceased or not in care.We use mathematical methods to assess and adjust for this bias based on patient characteristics. Design: We examined data from 25,261 HIV-positive patients from the East Africa IeDEA Consortium. Methods: We used inverse probability of censoring weighting (IPCW) to represent patients not in care by patients in care with similar characteristics. We address two questions: What would the median CD4 be ''had everyone starting ART remained on observation?'' and ''were everyone starting ART maintained on treatment?'' Results: Routine CD4 count estimates were higher than adjusted estimates even under the best-case scenario of maintaining all patients on treatment. Two years after starting ART, differences between estimates diverged from 30 cells/mL, assuming similar mortality and treatment access among dropouts as patients in care, to over 100 cells/mL assuming 20% lower survival and 50% lower treatment access among dropouts. When considering only patients in care, the proportion of patients with CD4 above 350 cells/mL was 50% adjusted to below 30% when accounting for patients not in care. One-year mortality diverged 614% from the nao¨ve estimates depending on assumptions about access to care among lost patients. Conclusions: Ignoring mortality and loss to care results in over-estimation of ART response for patients starting treatment and exaggerates the efficacy of treatment programs administering it.
- Published
- 2013
36. Active tuberculosis is associated with worse clinical outcomes in HIV-infected African patients on antiretroviral therapy
- Author
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Ann Mwangi, Constantin T. Yiannoutsos, William M. Tierney, Jane Carter, Beverly S. Musick, Abraham Siika, Sylvester Kimaiyo, Kara Wools-Kaloustian, and Lameck Diero
- Subjects
CD4-Positive T-Lymphocytes ,Male ,Bacterial Diseases ,Health Screening ,HIV opportunistic infections ,lcsh:Medicine ,HIV Infections ,Comorbidity ,030312 virology ,Weight Gain ,Cohort Studies ,0302 clinical medicine ,030212 general & internal medicine ,lcsh:Science ,0303 health sciences ,education.field_of_study ,Multidisciplinary ,Mortality rate ,Hazard ratio ,3. Good health ,Treatment Outcome ,Anti-Retroviral Agents ,Medicine ,Infectious diseases ,Female ,Public Health ,Cohort study ,Research Article ,Adult ,medicine.medical_specialty ,Tuberculosis ,Medical Records Systems, Computerized ,Clinical Research Design ,Population ,Viral diseases ,Microbiology ,03 medical and health sciences ,Acquired immunodeficiency syndrome (AIDS) ,Population Metrics ,Internal medicine ,Virology ,Death Rate ,medicine ,Humans ,education ,Biology ,Proportional Hazards Models ,Retrospective Studies ,Population Biology ,business.industry ,lcsh:R ,Modeling ,HIV ,Retrospective cohort study ,Odds ratio ,medicine.disease ,Kenya ,Co-Infections ,Immunology ,lcsh:Q ,business ,Infectious Disease Modeling - Abstract
Objective This cohort study utilized data from a large HIV treatment program in western Kenya to describe the impact of active tuberculosis (TB) on clinical outcomes among African patients on antiretroviral therapy (ART). Design We included all patients initiating ART between March 2004 and November 2007. Clinical (signs and symptoms), radiological (chest radiographs) and laboratory (mycobacterial smears, culture and tissue histology) criteria were used to record the diagnosis of TB disease in the program’s electronic medical record system. Methods We assessed the impact of TB disease on mortality, loss to follow-up (LTFU) and incident AIDS-defining events (ADEs) through Cox models and CD4 cell and weight response to ART by non-linear mixed models. Results We studied 21,242 patients initiating ART–5,186 (24%) with TB; 62% female; median age 37 years. There were proportionately more men in the active TB (46%) than in the non-TB (35%) group. Adjusting for baseline HIV-disease severity, TB patients were more likely to die (hazard ratio – HR = 1.32, 95% CI 1.18–1.47) or have incident ADEs (HR = 1.31, 95% CI: 1.19–1.45). They had lower median CD4 cell counts (77 versus 109), weight (52.5 versus 55.0 kg) and higher ADE risk at baseline (CD4-adjusted odds ratio = 1.55, 95% CI: 1.31–1.85). ART adherence was similarly good in both groups. Adjusting for gender and baseline CD4 cell count, TB patients experienced virtually identical rise in CD4 counts after ART initiation as those without. However, the overall CD4 count at one year was lower among patients with TB (251 versus 269 cells/µl). Conclusions Clinically detected TB disease is associated with greater mortality and morbidity despite salutary response to ART. Data suggest that identifying HIV patients co-infected with TB earlier in the HIV-disease trajectory may not fully address TB-related morbidity and mortality.
- Published
- 2013
37. Frequency and factors associated with adherence to and completion of combination antiretroviral therapy for prevention of mother to child transmission in western Kenya
- Author
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Winstone M. Nyandiko, Beverly S. Musick, Hai Liu, PO Ayuo, Adrian Gardner, Paula Braitstein, Boaz Otieno-Nyunya, and Kara Wools-Kaloustian
- Subjects
Cart ,Adult ,Pediatrics ,medicine.medical_specialty ,combination antiretroviral therapy (CART) ,Adolescent ,Population ,Medication Adherence ,Cohort Studies ,03 medical and health sciences ,Young Adult ,0302 clinical medicine ,Acquired immunodeficiency syndrome (AIDS) ,Pregnancy ,Antiretroviral Therapy, Highly Active ,Medicine ,Humans ,030212 general & internal medicine ,adherence ,Young adult ,Disengagement theory ,Pregnancy Complications, Infectious ,education ,Retrospective Studies ,education.field_of_study ,Acquired Immunodeficiency Syndrome ,business.industry ,Public Health, Environmental and Occupational Health ,Infant, Newborn ,Gestational age ,HIV ,Odds ratio ,Middle Aged ,prevention of mother-to-child transmission (PMTCT) ,medicine.disease ,Kenya ,Infectious Disease Transmission, Vertical ,3. Good health ,Infectious Diseases ,Female ,business ,030217 neurology & neurosurgery ,Cohort study ,Research Article - Abstract
Introduction: The objective of this analysis was to identify points of disruption within the prevention of mother-to-child transmission (PMTCT) continuum from combination antiretroviral therapy (CART) initiation until delivery. Methods: To address this objective, the electronic medical records of all antiretroviral-nai¨ve adult pregnant women who were initiating CART for PMTCT between January 2006 and February 2009 within the Academic Model Providing Access To Healthcare (AMPATH), western Kenya, were reviewed. Outcomes of interest were clinician-initiated change or stop in regimen, disengagement from programme (any, early, late) and self-reported medication adherence. Disengagement was categorized as early disengagement (any interval of greater than 30 days between visits but returning to care prior to delivery) or late disengagement (no visit within 30 days prior to the date of delivery). The association between covariates and the outcomes of interest were assessed using bivariate (Kruskal-Wallis test for continuous variables and the Chi-square test for categorical variables) and multivariate logistic regression analysis. Results: A total of 4284 antiretroviral-nai¨ve pregnant women initiated CART between January 2006 and February 2009. The majority of women (89%) reported taking all of their medication at every visit. There were 18 (0.4%) deaths reported. Clinicians discontinued CART in 10 patients (0.7%) while 1367 (31.9%) women disengaged from care. Of those disengaging, 404 (29.6%) disengaged early and 963 (70.4%) late. In the multivariate model, the odds of disengagement decreased with increasing age (odds ratio [OR] 0.982; confidence interval [CI] 0.966-0.998) and increasing gestational age at CART initiation (OR 0.925; CI 0.9090.941). Women receiving care at a district hospital (OR 0.794; CI 0.644-0.980) or tuberculosis medication (OR 0.457; CI 0.202-0.935) were less likely to disengage. The odds of disengagement were higher in married women (OR 1.277; CI 1.034-1.584). The odds of early disengagement decreased with increasing age at CART initiation (OR 0.902; CI 0.881-0.924). The odds of late disengagement decreased with increasing age at CART initiation (OR 0.936; CI 0.917-0.956). While they increased with higher CD4 counts at CART-initiation (OR 1.001; CI 1.000-1001) and in married women (OR 1.297; CI 1.000-1.695) Conclusions: In a PMTCT programme embedded in an antiretroviral treatment programme with an active outreach department, the majority (67.4%) of women remained engaged and received uninterrupted prenatal CART. Keywords: HIV; pregnancy; combination antiretroviral therapy (CART); prevention of mother-to-child transmission (PMTCT); adherence. (Published: 2 January 2013) Citation: Ayuo P et al. Journal of the International AIDS Society 2013, 16 :17994 http://www.jiasociety.org/index.php/jias/article/view/17994 | http://dx.doi.org/10.7448/IAS.16.1.17994
- Published
- 2012
38. Impact of the Kenya post-election crisis on clinic attendance and medication adherence for HIV-infected children in western Kenya
- Author
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Sarah E. Wiehe, Beverly S. Musick, Rachel C. Vreeman, Paula Braitstein, Winstone M. Nyandiko, and Edwin Sang
- Subjects
medicine.medical_specialty ,Pediatrics ,Health (social science) ,business.industry ,Research ,Public health ,lcsh:RC952-1245 ,Humanitarian crisis ,lcsh:Special situations and conditions ,Health services research ,Attendance ,Public Health, Environmental and Occupational Health ,lcsh:Medical emergencies. Critical care. Intensive care. First aid ,Retrospective cohort study ,lcsh:RC86-88.9 ,Health(social science) ,Family medicine ,Health care ,Epidemiology ,Cohort ,medicine ,business - Abstract
Background Kenya experienced a political and humanitarian crisis following presidential elections on 27 December 2007. Over 1,200 people were killed and 300,000 displaced, with disproportionate violence in western Kenya. We sought to describe the immediate impact of this conflict on return to clinic and medication adherence for HIV-infected children cared for within the USAID-Academic Model Providing Access to Healthcare (AMPATH) in western Kenya. Methods We conducted a mixed methods analysis that included a retrospective cohort analysis, as well as key informant interviews with pediatric healthcare providers. Eligible patients were HIV-infected children, less than 14 years of age, seen in the AMPATH HIV clinic system between 26 October 2007 and 25 December 2007. We extracted demographic and clinical data, generating descriptive statistics for pre- and post-conflict antiretroviral therapy (ART) adherence and post-election return to clinic for this cohort. ART adherence was derived from caregiver-report of taking all ART doses in past 7 days. We used multivariable logistic regression to assess factors associated with not returning to clinic. Interview dialogue from was analyzed using constant comparison, progressive coding and triangulation. Results Between 26 October 2007 and 25 December 2007, 2,585 HIV-infected children (including 1,642 on ART) were seen. During 26 December 2007 to 15 April 2008, 93% (N = 2,398) returned to care. At their first visit after the election, 95% of children on ART (N = 1,408) reported perfect ART adherence, a significant drop from 98% pre-election (p < 0.001). Children on ART were significantly more likely to return to clinic than those not on ART. Members of tribes targeted by violence and members of minority tribes were less likely to return. In qualitative analysis of 9 key informant interviews, prominent barriers to return to clinic and adherence included concerns for personal safety, shortages of resources, hanging priorities, and hopelessness. Conclusion During a period of humanitarian crisis, the vulnerable, HIV-infected pediatric population had disruptions in clinical care and in medication adherence, putting children at risk for viral resistance and increased morbidity. However, unique program strengths may have minimized these disruptions.
- Published
- 2009
39. The impact of the President's Emergency Plan for AIDS Relief on expansion of HIV care services for adult patients in western Kenya
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Kara Wools-Kaloustian, Winstone M. Nyandiko, Beverly S. Musick, William M. Tierney, Abraham Siika, Robert Einterz, John E. Sidle, Silvester Kimaiyo, and Constantin T. Yiannoutsos
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Adult ,Male ,Pediatrics ,medicine.medical_specialty ,Anti-HIV Agents ,International Cooperation ,Immunology ,Medically Underserved Area ,HIV Infections ,Disease ,Health Services Accessibility ,Pharmacotherapy ,Acquired immunodeficiency syndrome (AIDS) ,Antiretroviral Therapy, Highly Active ,Health care ,Epidemiology ,medicine ,Immunology and Allergy ,Humans ,Sida ,Developing Countries ,biology ,business.industry ,Medical record ,biology.organism_classification ,medicine.disease ,Kenya ,CD4 Lymphocyte Count ,Infectious Diseases ,Female ,Emergencies ,business ,Delivery of Health Care ,Cohort study - Abstract
The President's Emergency Plan for AIDS Relief committed $15 billion to addressing HIV in resource-poor settings.To assess the impact of The President's Emergency Plan for AIDS Relief on the treatment services of an HIV care program.Cohort study utilizing computerized medical records of nonpregnant adults enrolled into the Academic Model for the Prevention and Treatment of HIV/AIDS system, in western Kenya between 27 November 2001 and 24 July 2006.Number of clinics and patients enrolled in Academic Model for the Prevention and Treatment of HIV/AIDS, as well as patient demographics, immunologic, and clinical characteristics during three periods defined by the availability of combination antiretroviral therapy (cART).Enrollment as of May 2006 was 23,539. Mean monthly enrollment increased from 64 to 815 between periods 1 and 3. The median CD4 cell count at enrollment during period 3 (172 cells/microl) was significantly higher than for period 2 (119 cells/microl; P0.001). World Health Organization stage at enrollment differed significantly between periods with 6.7% having stage 4 disease in period 3 compared with 13.8% during period 1 (P0.001). Significantly more patients had complete documentation of cART eligibility, during period 3 as compared with the previous periods. Time from enrollment to cART initiation decreased from a median of 64 weeks in period 1 to 12 weeks during period 3 (P0.001).The President's Emergency Plan for AIDS Relief funding has allowed Academic Model for the Prevention and Treatment of HIV/AIDS to significantly increase the number of individuals receiving HIV care and provided the ability to expand services allowing for identification of patients earlier in their disease process.
- Published
- 2008
40. Predicting poor outcome from acute upper gastrointestinal hemorrhage
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Faouzi Azzouz, Lynn P. Boes, Susan M. Perkins, Jason A. Dominitz, Jill C. Bowers, Beverly S. Musick, Dawn Provenzale, Thomas F. Imperiale, and Cynthia M. Rose
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Male ,Washington ,medicine.medical_specialty ,Gastrointestinal bleeding ,Indiana ,Severity of Illness Index ,Endoscopy, Gastrointestinal ,Esophageal varices ,Recurrence ,Risk Factors ,Internal medicine ,Severity of illness ,Internal Medicine ,medicine ,Humans ,Hospital Mortality ,Prospective Studies ,Intensive care medicine ,Prospective cohort study ,Survival rate ,Aged ,business.industry ,Length of Stay ,Middle Aged ,medicine.disease ,Prognosis ,Comorbidity ,Survival Rate ,Cohort ,Acute Disease ,Female ,Upper gastrointestinal bleeding ,business ,Gastrointestinal Hemorrhage ,Follow-Up Studies - Abstract
Background Uncertainty about the outcome of acute upper gastrointestinal bleeding often results in a longer-than-necessary hospital stay. Methods We derived and internally validated clinical prediction rules (CPRs) to predict outcome from upper gastrointestinal bleeding. This multisite, prospective cohort study involved consecutive patients admitted for acute upper gastrointestinal bleeding. Multivariate logistic regression was used to derive CPRs on two thirds of the cohort (derivation set) that predicted bleeding-specific outcomes (rebleeding, need for urgent surgery, or hospital death [poor outcome 1]) and bleeding-specific outcomes plus new or worsening comorbidity (poor outcome 2). Both CPRs were then tested on the remaining third of the cohort (validation set). Results A total of 391 individuals (99% men; mean age, 63.4 years) were enrolled, of which 4.6% rebled and 3.1% died. Independent predictors of poor outcome 1 were APACHE (Acute Physiology and Chronic Health Evaluation) II score of 11 or greater, esophageal varices, and stigmata of recent hemorrhage. Predictors of poor outcome 2 were these 3 factors plus unstable comorbidity on admission. Of patients with no risk factors, only 1 (1.1%) of 92 experienced poor outcome 1 and only 6 (6.2%) of 97 experienced poor outcome 2. Risks in the validation set were comparable. The CPRs identified 37.8% and 32.2% of patients in the derivation and validation sets, respectively, who were eligible for a shorter hospital stay. Conclusions Patients admitted with acute upper gastrointestinal bleeding were unlikely to have a poor outcome if these risk factors were absent. These CPRs might make hospital management more efficient by identifying low-risk patients for whom early hospital discharge is possible.
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- 2007
41. Risk factors for incident Alzheimer’s disease in African Americans and Yoruba
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F. W. Unverzagt, Adesola Ogunniyi, O Baiyewu, R. E. Evans, Hugh C. Hendrie, Jeanne Dickens, Valerie Smith-Gamble, Beverly S. Musick, Kathleen S. Hall, Sujuan Gao, and Oye Gureje
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Gerontology ,Male ,Indiana ,Protective factor ,Nigeria ,Disease ,Biochemistry ,Article ,Cohort Studies ,Cellular and Molecular Neuroscience ,Sex Factors ,Alzheimer Disease ,Risk Factors ,Medicine ,Humans ,Longitudinal Studies ,Family history ,Risk factor ,Life Style ,Aged ,Aged, 80 and over ,business.industry ,Incidence (epidemiology) ,Yoruba ,Age Factors ,language.human_language ,Black or African American ,Socioeconomic Factors ,language ,Female ,Neurology (clinical) ,Rural area ,business ,Cohort study - Abstract
Introduction: The incidence rate of Alzheimer's disease (AD) was found to be 2 times lower in Yoruba than in African Americans. This study was aimed at identifying the factors associated with increased risk of incident AD in the two communities. Methodology: A two-stage design with initial screening using the CSI'D followed by neuropsychological test battery, relations' interview and physician assessment in a sub- sample. NINCDS-ADRDA criteria were met for AD. The risk factor variables assessed included demographic, lifestyle, medical and family history items. Results: In the Yoruba, AD was associated with age (OR = 1.07) and female gender (OR = 2.93). In African Americans, age (OR = 1.09) and rural living (OR = 2.08) were the significant risk factors, while alcohol was protective (OR = 0.49). Discussion: Age was a significant risk factor for AD at both sites. The higher risk of incident AD in the Yoruba female, and in African Americans who resided in rural areas in childhood were similar with the prevalence cases. Alcohol emerged a protective factor in African Americans. More studies are required, including biological measurements, to adequately explain the differences in rates.
- Published
- 2006
42. Reduced renal function is associated with progression to AIDS but not with overall mortality in HIV-infected kenyan adults not initially requiring combination antiretroviral therapy
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Mitchell Goldman, Kara Wools-Kaloustian, Beverly S. Musick, Samir K. Gupta, Willis Owino Ong'or, and Changyu Shen
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Adult ,Male ,medicine.medical_specialty ,Kenya ,Anti-HIV Agents ,Renal function ,HIV Infections ,Disease ,Kidney Function Tests ,Acquired immunodeficiency syndrome (AIDS) ,Internal medicine ,Medicine ,Humans ,Risk factor ,Retrospective Studies ,Acquired Immunodeficiency Syndrome ,business.industry ,Public health ,Research ,Disease progression ,Public Health, Environmental and Occupational Health ,Retrospective cohort study ,medicine.disease ,Infectious Diseases ,Immunology ,Disease Progression ,Drug Therapy, Combination ,Female ,Kidney Diseases ,business ,Follow-Up Studies ,Glomerular Filtration Rate - Abstract
Background The World Health Organization (WHO) has recently recommended that antiretrovirals be initiated in all individuals with CD4 counts of less than 350 cells/mm3. For countries with resources too limited to expand care to all such patients, it would be of value to able to identify and target populations at highest risk of HIV progression. Renal disease has been identified as a risk factor for disease progression or death in some populations. Methods Times to meeting combination antiretroviral therapy (cART) initiation criteria (developing either a CD4 count < 200 cells/mm3 or WHO stage 3 or 4 disease) and overall mortality were evaluated in cART-naïve, HIV-infected Kenyan adults with CD4 cell counts ≥200/mm3 and with WHO stage 1 or 2 disease. Cox proportional hazard regression models were used to evaluate the associations between renal function and these endpoints. Results We analyzed data of 7383 subjects with a median follow-up time of 59 (interquartile range, 27-97) weeks. In Cox regression analyses adjusted for age, sex, WHO disease stage, CD4 cell count and haemoglobin, estimated creatinine clearance (CrCl) < 60 mL/min was significantly associated with shorter times to meeting cART initiation criteria (HR 1.34; 95% CI, 1.23-1.52) and overall mortality (HR 1.73; 95% CI, 1.19-2.51) compared with CrCl ≥60 mL/min. Estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 was associated with shorter times to meeting cART initiation criteria (HR 1.39; 95% CI, 1.22-1.58), but not with overall mortality. CrCl and eGFR remained associated with shorter times to cART initiation criteria, but neither was associated with mortality, in weight-adjusted analyses. Conclusions In this large natural history study, reduced renal function was strongly associated with faster HIV disease progression in adult Kenyans not initially meeting cART initiation criteria. As such, renal function measurement in resource-limited settings may be an inexpensive method to identify those most in need of cART to prevent progression to AIDS. The initial association between reduced CrCl, but not reduced eGFR, and greater mortality was explained by the low weights in this population.
- Published
- 2011
43. Alternative antiretroviral monitoring strategies for HIV-infected patients in east Africa: opportunities to save more lives?
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Lameck Diero, Constantin T. Yiannoutsos, Sylvester Kimaiyo, Melanie C. Bacon, Kara Wools-Kaloustian, Kimberly A. Nucifora, Beverly S. Musick, and R. Scott Braithwaite
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medicine.medical_specialty ,Anti-HIV Agents ,Cost effectiveness ,Cost-Benefit Analysis ,Human immunodeficiency virus (HIV) ,Developing country ,HIV Infections ,medicine.disease_cause ,Environmental health ,medicine ,East africa ,Humans ,Computer Simulation ,health care economics and organizations ,Cost–benefit analysis ,business.industry ,Research ,Public health ,Public Health, Environmental and Occupational Health ,virus diseases ,Africa, Eastern ,Viral Load ,Antiretroviral therapy ,CD4 Lymphocyte Count ,Treatment Outcome ,Infectious Diseases ,Immunology ,Drug Monitoring ,business ,Viral load - Abstract
Background Updated World Health Organization guidelines have amplified debate about how resource constraints should impact monitoring strategies for HIV-infected persons on combination antiretroviral therapy (cART). We estimated the incremental benefit and cost effectiveness of alternative monitoring strategies for east Africans with known HIV infection. Methods Using a validated HIV computer simulation based on resource-limited data (USAID and AMPATH) and circumstances (east Africa), we compared alternative monitoring strategies for HIV-infected persons newly started on cART. We evaluated clinical, immunologic and virologic monitoring strategies, including combinations and conditional logic (e.g., only perform virologic testing if immunologic testing is positive). We calculated incremental cost-effectiveness ratios (ICER) in units of cost per quality-adjusted life year (QALY), using a societal perspective and a lifetime horizon. Costs were measured in 2008 US dollars, and costs and benefits were discounted at 3%. We compared the ICER of monitoring strategies with those of other resource-constrained decisions, in particular earlier cART initiation (at CD4 counts of 350 cells/mm3 rather than 200 cells/mm3). Results Monitoring strategies employing routine CD4 testing without virologic testing never maximized health benefits, regardless of budget or societal willingness to pay for additional health benefits. Monitoring strategies employing virologic testing conditional upon particular CD4 results delivered the most benefit at willingness-to-pay levels similar to the cost of earlier cART initiation (approximately $2600/QALY). Monitoring strategies employing routine virologic testing alone only maximized health benefits at willingness-to-pay levels (> $4400/QALY) that greatly exceeded the ICER of earlier cART initiation. Conclusions CD4 testing alone never maximized health benefits regardless of resource limitations. Programmes routinely performing virologic testing but deferring cART initiation may increase health benefits by reallocating monitoring resources towards earlier cART initiation.
- Published
- 2011
44. T1042 Risk Factors for More Than One Upper Endoscopy During Hospitalization for Acute Upper Gastrointestinal Hemorrhage
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Faouzi Azzouz, Dawn Provenzale, Thomas F. Imperiale, Beverly S. Musick, Jason A. Dominitz, and Sofyan Radaideh
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medicine.medical_specialty ,Hepatology ,business.industry ,General surgery ,Upper endoscopy ,Gastroenterology ,medicine ,Acute upper gastrointestinal hemorrhage ,Intensive care medicine ,business - Published
- 2008
45. External validation of the Rockall scoring system for acute upper GI hemorrhage: A multisite VA study
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Beverly S. Musick, Dawn Provenzale, Cindy M. Rose, Lynn P. Boes, Thomas F. Imperiale, Jill C. Bowers, and Jason A. Dominitz
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medicine.medical_specialty ,Scoring system ,Hepatology ,business.industry ,Gastroenterology ,External validation ,Medicine ,business ,Acute upper GI hemorrhage ,Surgery - Published
- 2003
46. Decreasing incidence of pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya between 2005 and 2017: a retrospective cohort study
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Heather C. Millar, Alfred K. Keter, Beverly S. Musick, Edith Apondi, Juddy Wachira, Katherine R. MacDonald, Rachel F. Spitzer, and Paula Braitstein
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Pregnancy in adolescence ,Adolescent ,HIV ,Pregnancy ,Contraception ,Family planning services ,Gynecology and obstetrics ,RG1-991 - Abstract
Abstract Background The objective of this study was to estimate the prevalence, incidence and risk factors for pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya. Methods The Academic Model Providing Access to Healthcare (AMPATH) program is a partnership between Moi University, Moi Teaching and Referral Hospital and a consortium of 11 North American academic institutions. AMPATH currently provides care to 85,000 HIV-positive individuals in western Kenya. Included in this analysis were adolescents aged 10–19 enrolled in AMPATH between January 2005 and February 2017. Socio-demographic, behavioural, and clinical data at baseline and time-updated antiretroviral treatment (ART) data were extracted from the electronic medical records and summarized using descriptive statistics. Follow up time was defined as time of inclusion in the cohort until the date of first pregnancy or age 20, loss to follow up, death, or administrative censoring. Adolescent pregnancy rates and associated risk factors were determined. Results There were 8565 adolescents eligible for analysis. Median age at enrolment in HIV care was 14.0 years. Only 17.7% had electricity at home and 14.4% had piped water, both indicators of a high level of poverty. 12.9% (1104) were pregnant at study inclusion. Of those not pregnant at enrolment, 5.6% (448) became pregnant at least once during follow-up. Another 1.0% (78) were pregnant at inclusion and became pregnant again during follow-up. The overall pregnancy incidence rate was 21.9 per 1000 woman years or 55.8 pregnancies per 1000 women. Between 2005 and 2017, pregnancy rates have decreased. Adolescents who became pregnant in follow-up were more likely to be older, to be married or living with a partner and to have at least one child already and less likely to be using family planning. Conclusions A considerable number of these HIV-positive adolescents presented at enrolment into HIV care as pregnant and many became pregnant as adolescents during follow-up. Pregnancy rates remain high but have decreased from 2005 to 2017. Adolescent-focused sexual and reproductive health and ante/postnatal care programs may have the potential to improve maternal and neonatal outcomes as well as further decrease pregnancy rates in this high-risk group.
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- 2020
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47. Short-Term Rationing of Combination Antiretroviral Therapy: Impact on Morbidity, Mortality, and Loss to Follow-Up in a Large HIV Treatment Program in Western Kenya
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April J. Bell, Kara Wools-Kaloustian, Sylvester Kimaiyo, Hai Liu, Adrian Katschke, Changyu Shen, Gilbert Simiyu, Beverly S. Musick, John E. Sidle, Abraham Siika, and Paula Braitstein
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Immunologic diseases. Allergy ,RC581-607 - Abstract
Background. There was a 6-month shortage of antiretrovirals (cART) in Kenya. Methods. We assessed morbidity, mortality, and loss to follow-up (LTFU) in this retrospective analysis of adults who were enrolled during the six-month period with restricted cART (cap) or the six months prior (pre-cap) and eligible for cART at enrollment by the pre-cap standard. Cox models were used to adjust for potential confounders. Results. 9009 adults were eligible for analysis: 4,714 pre-cap and 4,295 during the cap. Median number of days from enrollment to cART initiation was 42 pre-cap and 56 for the cap (P
- Published
- 2012
- Full Text
- View/download PDF
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