Paul Nambala 1 , Shinsuke Miyano 2 , Kenichi Komada 2,3 ,
description
Transcript of Paul Nambala 1 , Shinsuke Miyano 2 , Kenichi Komada 2,3 ,
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Urgent need to strengthen active tracing of lost to follow up cases: a prospective cohort study of newly diagnosed HIV clients in rural districts, Zambia
Paul Nambala1, Shinsuke Miyano2, Kenichi Komada2,3, Francis Hadunka1, Vincent Chipeta4, Kenneth Chibwe4, Albert Mwango5
1 Kazungula District Community Medical Office, Zambia2 National Center for Global Health and Medicine, Japan3 SHIMA project, JICA, Lusaka, Zambia4 Kalomo District Community Medical Office, Zambia5 Ministry of Health, Lusaka, Zambia
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Background: HIV in Zambia• Zambia has a population of 13.2
million (2010)
• New infection rate in 2011 - 0.96% among males - 1.25% among females
• HIV Prevalence in adults: 14.3% (2007 ZDHS)
- Rural 10.3 % - Urban 19.7%
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Kazungula and Kalomo District
• 480 & 360km south west of Lusaka (Capital city)
• Share borders with Zimbabwe, Namibia, Botswana by the Zambezi river.
• Total population: 396,390 (2013)
• Area: 30,000 km2
• The mainstay is agriculture and animal husbandly with few industry.
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HIV in Kazungula/Kalomo • Adult HIV prevalence rate -13.4%.
• ART services started in a few selected health facilities in 2005 and have been scaling up.
• Number of HIV infected adults on ARVs – 8200.
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Objectives
• To assess the retention among HIV testing, care and treatment.
• To evaluate active tracing for lost to follow up cases in rural districts in Zambia.
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Methods• A Prospective Cohort Study
• Newly diagnosed HIV clients from April 2012 to March 2013 in 8 health facilities in Kazungula and Kalomo has been enrolled.
• The data have been collected through clients’ records and interviews
• Assessed at June 2013
• The retention rates were estimated by Kaplan-Meier method
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ResultTable 1. Baseline characteristics of enrolled cases
Number %
Study site
District Hospital 404 49.1
Rural Health Centres 418 50.9
HIV test entry points
OPD/IPD 253 30.8
VCT 320 38.9
ANC/MCH 99 12.0
TB 12 1.5
Others 138 16.8
ART eligibility at base line
Eligible (ART) 414 63.3
Not eligible (Pre-ART) 240 36.7
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Number %
Gender
Male 309 41.1
Female 442 58.9
WHO stage
Stage Ⅰ 422 65.8
Stage Ⅱ 127 19.8
Stage Ⅲ 86 13.4
Stage Ⅳ 6 1.0
Discordant couples
Known as discordant 69 8.4
Median IQR
Age (years) 33 26 - 40
CD4 cell count (cells/mm3) 286 158 - 444
Table 1. Baseline characteristics of enrolled cases (cont’d)
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Result
Figure 1. Continuum of HIV care in enrolled cases
Pre-ART240 clients
(36.7%)
ART 414 clients
(63.3%)
No access to HIV care168 / 822 clients
(20.4%)
LTFU at 12 months139 / 654 clients
(21.3%)
HIV Positive
Total 822 clients
OPD/IPD 253
VCT 320
ANC/MCH 99
TB 12
Others 138
Enrolled in HIV CareTotal 654 clients (79.6%)
OPD/IPD 221 (87.4%)
VCT 266 (83.1%)
ANC/MCH 74 (74.7%)
TB 12 (100%)
Others 81 (58.7%)
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Result
Figure 2. Pre-ART and ART retention rate (Kaplan-Meier estimates)
12 months retentionART 75.4% Pre-ART 75.9%
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Result
Figure 3. The LTFU cases traced by phone
Lost to Follow up at 12 months n = 139
Have phone number 53 / 139 ( 38.1%)
No phone number 86 / 139 ( 61.9%)
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Figure 3. The LTFU cases traced by phone
Lost to Follow up at 12 months n = 139
Have phone number 53 / 139 ( 38.1%)
No phone number 86 / 139 ( 61.9%)
Reachable to Clients17 / 53 (32.1%)
Not Reachable14 / 53 (26.4%)
Invalid/Wrong number22 / 53 (41.5%)
Result
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Figure 3. The LTFU cases traced by phone
Lost to Follow up at 12 months n = 139
Have phone number 53 / 139 ( 38.1%)
No phone number 86 / 139 ( 61.9%)
Reachable to Clients17 / 53 (32.1%)
Not Reachable14 / 53 (26.4%)
Invalid/Wrong number22 / 53 (41.5%)
Returned to the original facility3 / 17 (17.6%)
Self transfer out to other facility
4 / 17 (23.5%)
Not returned on the care
10 /17 (58.9%)
Result
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Figure 3. The LTFU cases traced by phone
Lost to Follow up at 12 months n = 139
Have phone number 53 / 139 ( 38.1%)
No phone number 86 / 139 ( 61.9%)
Reachable to Clients17 / 53 (32.1%)
Not Reachable14 / 53 (26.4%)
Invalid/Wrong number22 / 53 (41.5%)
Returned to the original facility3 / 17 (17.6%)
Self transfer out to other facility
4 / 17 (23.5%)
Not returned on the care
10 /17 (58.9%)
122 / 139 (87.8%) needphysical follow-up
Result
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Discussions (1)• The reasons for Many LTFU cases were maybe; - long distances to access ART services. - bad road condition in the rainy season. - not enough attention by staff and supporters. - still have some stigma among HIV clients. - many seasonal migrants (fishermen) in some sites.
• The linkage between diagnosis and care should be strengthened.
• There is need to conduct adequate counseling soon after HIV diagnosis
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Discussions (2)• Tracing LTFU case by phone is not feasible in rural area of
Zambia because, - most clients do not have Mobile phones - some clients give wrong phone numbers - poor accessibility of phone networks in rural area
• Adherence counseling at every visit and physical tracing should be strengthened.
• Need to consider how to motivate treatment supporters.
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Conclusions
• Despite having successful scaled up HIV services to many rural health facilities, we still have a big number of LTFU cases.
• There is urgent need to strengthen active tracing of LTFU cases.
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Acknowledgement
• Our patients• Treatment supporters• District Community Medical Offices• JICA-SHIMA project• NCGM• MCDMCH- Zambia• MOH- Zambia