Patients who present late to HIV care and associated risk factors in Nigeria.

OBJECTIVES: Our objectives were to assess trends in late presentation and advanced HIV disease (AHD) and determine associated risk factors. METHODS: We conducted a retrospective cohort analysis of patients who had received care and treatment at the AIDS Prevention Initiative Nigeria Plus (APIN)/Harvard School of Public Health-President's Emergency Plan for AIDS Relief (PEPFAR) programme at the Jos University Teaching Hospital, Jos, Nigeria from 2005 to 2010. We used the European Consensus Definition to assess trends in late presentation (CD4 count < 350 cells/µL or AIDS-defining illness) and AHD (CD4 count < 200 cells/µL or AIDS-defining illness) and evaluated associated risk factors using logistic regression methods. RESULTS: Among 14,487 eligible patients, 12,401 (85.6%) were late presenters and 9127 (63.0%) presented with AHD. Late presentation decreased from 88.9% in 2005 to 80.1% in 2010 (P < 0.001). Similarly, AHD decreased from 67.8% in 2005 to 53.6% in 2010 (P < 0.001). In logistic regression models adjusting for sociodemographic and biological variables, male sex [adjusted odds ratio (aOR) = 1.80; 95% confidence interval (CI) 1.60-2.04], older age (aOR = 1.37; 95% CI 1.22-1.54), civil service employment (aOR = 1.48; 95% CI 1.00-2.21), referral from out-patient (aOR = 2.18; 95% CI 1.53-3.08) and in-patient (aOR = 1.55; 95% CI 1.11-2.17) services, and hepatitis B virus (aOR = 1.43; 95% CI 1.26-1.63) and hepatitis C virus (aOR = 1.18; 95% CI 1.02-1.37) coinfections were associated with late presentation. Predictors of AHD were male sex (aOR = 1.67; 95% CI 1.54-1.82), older age (aOR = 1.26; 95% CI 1.16-1.36), unemployment (aOR = 1.34; 95% CI 1.00-1.79), referral from out-patient (aOR = 2.40; 95% CI 1.84-3.14) and in-patient (aOR = 1.97; 95% CI 1.51-2.57) services and hepatitis B virus coinfection (aOR = 1.30; 95% CI 1.19-1.42). CONCLUSIONS: Efforts to reduce the proportion of patients who first seek care at late stages of disease are needed. The identified risk factors should be utilized in formulating targeted public health interventions to improve early diagnosis and presentation for HIV care.

Treatment Discontinuation in Adult HIV-Infected Patients on First-Line Antiretroviral Therapy in Nigeria.

BACKGROUND: Retention in care and treatment services is critical to health outcomes of individuals diagnosed and living with HIV. We evaluated the incidence of and risk factors for treatment discontinuation (TD) in a large adult HIV population on ART in Nigeria. METHOD: A retrospective cohort study of adult HIV patients initiated on first-line ART between 2004 and 2011 at the Jos University Teaching Hospital (JUTH) in Nigeria. Follow up information of participants was retrieved from various sources (patient visit database, pharmacy data and patients charts) up to the end of 2012. The primary study endpoint was TD, defined as discontinuation of ART for any reason, including death or loss to follow-up (lack of pharmacy pick-up for periods≥12 months). The Incidence and hazard for TD were estimated by Kaplan-Meier and Cox proportional regression analysis, respectively. RESULT: Overall, 3,362 (28%) patients discontinued treatment during 49,436 person-years (py) of follow-up (incidence rate (IR) 6.8 TD per 100 py). The hazard of treatment discontinuation decreased with increasing age (adjusted hazard ratio (aHR 0.99; 95% CI 0.98-0.99). Other independent risk factors for treatment discontinuation were: being unmarried (aHR 1.24; 95% CI: 1.12-1.38), having primary or secondary level of education as compared to tertiary level education (aHR 1.24; 95% CI: 1.12-1.40) and average percent adherence to drug refill visits<95% (adjusted hazard ratio (aHR) 2.13; 95% CI: 1.9-2.40). Compared to tenofovir, greater hazard of TD was noted in patients initiated on ART containing didanosine (aHR) 1.73; 95% CI: 1.03-2.91), but lower in those initiated on zidovudine containing regimen (aHR 0.77; 95% CI: 0.69-0.86). CONCLUSION: Long-term treatment discontinuation rate in this study was comparable to estimates in resource-rich countries. Younger patients, as well as patients with lower educational levels and those with poor adherence had significant hazards for treatment discontinuation and should be the target of interventions to reduce treatment discontinuation and improve retention, especially within the first year of ART.