Tuberculosis Preventative Therapy Initiation and Completion Among Adolescents and Young Adults Living With HIV in Kenya.

BACKGROUND: Tuberculosis is the leading cause of death among adolescents and young adults living with HIV (YWHIV) and their heightened risk warrants deeper understanding of utilization of tuberculosis-prevention measures within HIV care. SETTING: Retrospective study using clinic surveys and medical record data from 86 Kenyan HIV clinics. METHODS: Clinic surveys obtained information on tuberculosis preventive therapy (TPT) services. Medical records of YWHIV were abstracted. Bivariate and multivariate analyses used generalized linear models to determine individual-level and clinic-level cofactors of TPT initiation and completion. RESULTS: Among 10,328 eligible YWHIV, 4337 (42.0%) initiated TPT. Of 3295 with ≥6 months follow-up, 1774 (53.8%) completed TPT. A lower patient-to-staff ratio was a clinic-level cofactor of TPT initiation ( P = 0.044) and completion ( P = 0.004); designated adolescent areas were associated with TPT initiation {prevalence ratio 2.05 [95% confidence interval (CI): 1.46 to -2.88]}. Individual cofactors of TPT initiation included younger age at HIV-care enrollment [relative risk (RR) 0.85 (95% CI: 0.80 to 0.90)] and antiretroviral therapy (ART) duration [1-2 vs. <1 year RR 1.31 (95% CI: 1.18 to 1.45)]. TPT completion was associated with younger age [RR 0.91 (95% CI: 0.85 to 0.98)] and ART duration [2-5 vs. <1 year RR 1.27 (95% CI: 1.03 to 1.57)]. In multivariate models, TPT initiation was associated with younger age and ART duration [1-2 vs. 1 year; adjusted RR 1.30 (95% CI: 1.16 to 1.46)] and TPT completion with ART duration [2-5 vs. 1 year adjusted RR 1.23 (95% CI: 0.99 to 1.52)]. CONCLUSION: Over half of YWHIV did not initiate and >40% did not complete TPT, with distinct clinic-level and individual-level cofactors. Approaches to enhance adolescent-friendly infrastructure and support older YWHIV are necessary to improve TPT use.

Real-World Analysis of Treatment Patterns, Healthcare Utilization, Costs, and Mortality Among People with Biliary Tract Cancers in the USA.

INTRODUCTION: People with advanced biliary tract cancers (BTCs) have a 5-year survival of approximately 2% in the USA. Most cases are inoperable or require systemic treatment following surgery. This study adds to current literature by describing treatment patterns, healthcare resource utilization (HCRU), costs, and mortality among people with BTCs. METHODS: Adults diagnosed with BTCs were identified in the Merative MarketScan administrative claims databases from 1 January 2016 to 30 June 2020. Descriptive analysis was used to measure treatment patterns (i.e., regimen types, therapy duration) during three lines of therapy (LOT). All-cause and disease-related HCRU and costs were measured per-patient-per-month (PPPM) during the entire follow-up and in each LOT. Mortality was reported among the subset linked to the National Death Index (NDI). RESULTS: There were 2648 eligible people with BTCs [mean age 64.0 (standard deviation [SD] 12.4) years, 51.5% female, average follow-up 11.9 (SD 11.1) months]. Treatment was received by 56.3% (n = 1490), and 20.9% (n = 5534) and 7.1% (n = 187) moved on to a second and third LOT, respectively. The average treatment duration decreased across LOTs, from 3.8 (SD 3.1) months in LOT1 to 2.6 (SD 2.4) months in LOT3. Gemcitabine + cisplatin was the most common regimen in LOT1 (44.6%). Total all-cause mean healthcare costs PPPM increased after LOT1 (mean $21,517, $29,721, and $28,557, for LOT1, LOT2, and LOT3, respectively) and the majority (71.2%) were related to BTCs. Of people with BTCs linked to the NDI (n = 2168), 66.1% died and average time to death was 11.3 (SD 11.2) months. CONCLUSIONS: These findings, showing a high rate of mortality, a decrease in treatment duration, and an increase in costs as people progress after LOT1, add recent data to current literature highlighting the unmet need for more effective treatment options for people with BTCs.

Early Child Development Assessments and Their Associations with Long-Term Academic and Economic Outcomes: A Systematic Review.

Developmental screening instruments were designed as diagnostic tools, but there is growing interest in understanding whether select tools can also be used systematically in research to examine intervention impacts on long-term outcomes. As such, this systematic review aims to examine associations between child development assessment tools and educational attainment, academic achievement, or wealth. We included studies identified in PubMed, PsycINFO, and Educational Resources Information Center if they reported an association between at least one tool from a pre-established list and one outcome of interest after age 10. Of 597 studies identified, 11 met inclusion criteria; three examined educational attainment as the outcome of interest, six examined academic achievement, one wealth, and one both educational attainment and wealth. Intelligence tests were utilized in five of the included studies, neuropsychological/executive function or behavior tools were used in five, and one study used tools across the domains. High-quality studies were identified across all three of the domains, but educational attainment and wealth had the greatest proportion of high-quality studies, as compared to academic achievement. Our review demonstrates the potential for certain child development assessment tools to adequately assess long-term outcomes of interest, but additional prospective studies using validated, culturally appropriate tools are needed. PROSPERO registration number: CRD42018092292.

The Economic Burden of End-Organ Damage Among Medicaid Patients with Sickle Cell Disease in the United States: A Population-Based Longitudinal Claims Study.

BACKGROUND: The management of sickle cell disease (SCD), an inherited, chronic, and multifaceted condition, is associated with considerable health care resource utilization (HRU) and costs, especially for Medicaid. Anemia affects most patients with SCD and correlates with end-organ damage (EOD), such as stroke, chronic kidney disease (CKD), end-stage renal disease (ESRD), and pulmonary hypertension (PH). Limited research has been conducted to quantify the economic burden of EOD among patients with SCD. OBJECTIVE: To estimate the effect of EOD on HRU and direct costs and productivity loss incurred by patients with SCD on Medicaid. METHODS: Patients with ≥ 3 nondiagnostic SCD ICD-9-CM/ICD-10-CM codes in ≤ 5 years (January 1, 2013-December 31, 2017) were identified in the MarketScan Medicaid claims database. The earliest SCD diagnosis date was the index date. Continuous enrollment at least 3 months before and 1 month after the index date were required. Patients' post-index periods were divided into 3-month intervals (referred to as "intervals"). History of stroke, CKD, ESRD, and PH were identified in patients' claims histories from January 1, 2008. Intervals within 1 year and more than 1 year after an acute stroke event were also defined. All-cause HRU, direct costs, and productivity losses were summed across intervals and stratified by EOD type. Multivariate regression models were used to estimate the effect of stroke, CKD, ESRD, and PH on annual total cost, inpatient days, and number of emergency department visits by controlling for patients' demographic characteristics and other SCD complications. RESULTS: In total, 10,784 Medicaid patients with SCD (average age: 18.5 years; female: 54.5%) contributed to 152,455 intervals. Approximately 12% of the intervals had EOD. Patients with EOD had higher all-cause health care costs and more inpatient days, emergency department visits, outpatient visits, laboratory tests, and outpatient pharmacy claims than patients without EOD. After controlling for patient characteristics, among Medicaid patients with SCD annual costs within 1 year after stroke were 4.68-fold versus patients with no EOD (more than 1 year after stroke: 2.08-fold; CKD: 2.19-fold; ESRD: 3.40-fold; PH: 2.32-fold). Adjusted mean annual costs for adult patients with SCD on Medicaid were $285,816 and $127,393 within 1 year and more than 1 year after stroke and $135,493, $209,172, and $148,174 for CKD, ESRD, and PH, respectively. Patients with multiple SCD complications had even higher costs. The mean annual time patients with SCD spent receiving health care services ranged from 56 to 62 days for those with EOD versus 21 to 25 days among those without EOD, which created additional economic burden. CONCLUSIONS: When Medicaid patients with SCD experience EOD, the economic burden is significantly increased through direct costs to the health care system and indirect costs from productivity loss to society. SCD management strategies that potentially reduce the risk of EOD offer clinical and economic value to patients and society. DISCLOSURES: Funding for this study was provided by Global Blood Therapeutics (GBT). Campbell is a consultant for GBT, Bluebird Bio, and Cyclerion and receives research funding from Novartis, GBT, and Cyclerion. Cong and Agodoa are employees of and have equity ownership in GBT. Song, Martinez, Black, Lew, Varker, and Chan are employees of IBM Watson Health, which received research funding from GBT for this study. Lanzkron receives research funding from GBT, Pfizer, Ironwood, HRSA, and NIH. A poster based on this study was presented at the 61st ASH Annual Meeting and Exposition; December 7-10, 2019; Orlando, FL.

Clinic-level and individual-level factors that influence HIV viral suppression in adolescents and young adults: a national survey in Kenya.

OBJECTIVES: To determine clinic-level and individual-level correlates of viral suppression among HIV-positive adolescents and young adult (AYA) aged 10-24 years receiving antiretroviral treatment (ART). DESIGN: Multilevel cross-sectional analysis using viral load data and facility surveys from HIV treatment programs throughout Kenya. METHODS: We abstracted medical records of AYA in HIV care, analyzed the subset on ART for more than 6 months between January 2016 and December 2017, and collected information on services at each clinic. Multilevel logistic regression models were used to determine correlates of viral suppression at most recent assessment. RESULTS: In 99 HIV clinics, among 10 096 AYA on ART more than 6 months, 2683 (27%) had unsuppressed viral load at last test. Among 16% of clinics, more than 80% of AYA were virally suppressed. Clinic-level correlates of individual viral suppression included designated adolescent spaces [aOR: 1.32, 95% CI (1.07-1.63)] and faster viral load turnaround time [aOR: 1.06 (95% CI 1.03-1.09)]. Adjusting for clinic-level factors, AYA aged 10-14 and 15-19 years had lower odds of viral suppression compared with AYA aged 20-24 years [aOR: 0.61 (0.54-0.69) and 0.59 (0.52-0.67], respectively. Compared with female patients, male patients had lower odds of viral suppression [aOR: 0.69 (0.62-0.77)]. Compared with ART duration of 6-12 months, ART for 2-5, above 5-10 or more than 10 years was associated with poor viral suppression (P < 0.001). CONCLUSION: Dedicated adolescent space, rapid viral load turnaround time, and tailored approaches for male individuals and perinatally infected AYA may improve viral suppression. Routine summarization of viral load suppression in clinics could provide benchmarking to motivate innovations in clinic-AYA and individual-AYA care strategies.

What happens at adolescent and young adult HIV clinics? A national survey of models of care, transition and disclosure practices in Kenya.

OBJECTIVE: Tailored services for adolescents and young adults (AYA) living with HIV may improve treatment outcomes. We surveyed HIV clinics throughout Kenya to determine AYA clinic practices, disclosure and transition services. METHODS: We deployed a mobile team to conduct surveys in a random sample of 102 public HIV clinics with> 300 total clients. Data were collected from healthcare workers offering AYA services who had >6 months of experience delivering AYA care. RESULTS: Of 102 surveyed HIV clinics, almost all (101/102) had the same staff to provide services to all age groups. AYA-specific services included dedicated clinic days (91%), the majority being on weekends (57%) and designated clinic spaces (20%). Activities to support AYA retention and adherence were common (support groups [97%] and HIV literacy meetings [93%]). Fewer clinics offered more holistic care, including psychosocial support (16%) and career education (2%), posted additional staff during the AYA day (17%), provided food (17%) or had sporting activities (10%) as incentives. Tracking of disclosure of HIV status to AYA was common (87%). In 40% of clinics, disclosure discussions with caregivers or AYA occurred a median of 2 years later in practice than stated in clinic policy. Transition was not routinely tracked, and definitions were heterogeneous. Median age at transition was reported as 20 years (range: 14-30 years). CONCLUSION: HIV programmes have implemented varied approaches to enhance AYA services that could be leveraged to support transition to adult services. Research on the impact of these services on health outcomes is needed.

OBJECTIF: Des services taillés sur mesure pour les adolescents et les jeunes adultes (AJA) vivant avec le VIH peuvent améliorer les résultats du traitement. Nous avons mené une surveillance des cliniques VIH à travers le Kenya pour déterminer les pratiques, la divulgation et les services de transition dans les cliniques AJA. MÉTHODES: Nous avons déployé une équipe mobile pour mener des enquêtes sur un échantillon aléatoire de 102 cliniques publiques du VIH avec >300 patients au total. Les données ont été recueillies auprès d'agents de santé offrant des services AJA qui avaient >6 mois d'expérience dans la prestation de soins AJA. RÉSULTATS: Sur 102 cliniques VIH surveillées, presque toutes (101/102) avaient les mêmes personnels pour fournir des services à tous les groupes d'âge. Les services spécifiques AJA comprenaient des journées de clinique dédiées (91%), la majorité étant le week-end (57%) et des espaces de clinique désignés (20%). Les activités visant à soutenir la rétention et l'adhésion à l'AJA étaient courantes (groupes de soutien [97%] et réunions d'éducation sur le VIH [93%]). Peu de cliniques offraient de soins plus holistiques, y compris un soutien psychosocial (16%) et une formation professionnelle (2%), détachaient du personnel supplémentaire pendant la journée AJA (17%), fournissait de la nourriture (17%) ou pratiquaient des activités sportives (10%) comme des incitations. Le suivi de la divulgation du statut VIH aux AJA était courant (87%). Dans 40% des cliniques, les discussions de divulgation avec les soignants ou AJA ont eu lieu en moyenne 2 ans plus tard dans la pratique que ce qui est indiqué dans la politique de la clinique. La transition n'était pas systématiquement suivie et les définitions étaient hétérogènes. L'âge médian au moment de la transition était de 20 ans (intervalle: 14-30 ans). CONCLUSION: Les programmes de lutte contre le VIH ont mis en œuvre diverses approches pour améliorer les services AJA qui pourraient être exploitées pour soutenir la transition vers les services pour adultes. Des recherches sur l'impact de ces services sur les résultats de santé sont nécessaires.

Managing the transition from paediatric to adult care for HIV, Kenya.

Expansion of access to diagnosis and treatment for human immunodeficiency virus (HIV) and a high incidence of HIV infection in adolescence has resulted in a growing population of adolescents and young adults living with HIV. The prevalence of poor retention in care, insufficient viral suppression and loss to follow-up are higher among adolescents and young adults compared with other age groups. Poor outcomes could be attributed to psychosocial changes during adolescence, but also to poor transitional care from paediatric to adult HIV services. In many countries, transition processes remain poorly defined and unstructured, which may jeopardize treatment adherence and retention. We describe existing definitions of transition and transition frameworks, and key elements of transition as proposed by key national stakeholders in Kenya. Our consensus definition of transition is "a planned process by which adolescents and young adults living with HIV, and their caregivers, are empowered with knowledge and skills to enable them to independently manage their health." Transition should begin soon after disclosure of HIV status until an adolescent gains the necessary knowledge and skills and is willing to move to adult services, or by 25 years of age. Proposed key elements of transition are: target ages for milestone achievement; readiness assessment; caregiver involvement and communication with adult clinics; flexibility to return to adolescent or paediatric clinics; group transition; and considerations for adolescents with special needs. Retention in care, linkage to care and viral suppression are important markers of transition success. Proposed definitions and key elements could provide a framework for structuring transition programmes in other countries.

L'accès élargi au diagnostic et au traitement du virus de l'immunodéficience humaine (VIH) et l'incidence élevée de l'infection par le VIH à l'adolescence ont entraîné une hausse de la population d'adolescents et de jeunes adultes atteints du VIH. La prévalence de mauvais continuums de soins, de suppressions virales insuffisantes et d'interruptions du suivi est plus élevée chez les adolescents et les jeunes adultes que dans d'autres groupes d'âge. Ces mauvais résultats peuvent être attribués aux changements psychosociaux qui interviennent à l'adolescence, mais aussi à la médiocrité de la transition entre les services de soins pédiatriques et adultes du VIH. En Afrique subsaharienne, les processus de transition sont mal définis et peu structurés, ce qui peut nuire au respect et à la poursuite des traitements. Nous décrivons ici les définitions existantes de la transition et des cadres de transition, ainsi que les éléments clés de la transition proposés par les principales parties prenantes nationales du Kenya. Notre définition consensuelle de la transition est: « processus planifié qui permet aux adolescents et aux jeunes adultes atteints du VIH, ainsi qu'à leurs aidants, de disposer des connaissances et compétences nécessaires pour gérer leur santé de manière autonome ¼. La transition devrait débuter peu après la communication de la séropositivité et durer jusqu'à ce que l'adolescent ait acquis les connaissances et compétences nécessaires et qu'il souhaite passer à des services pour adultes, ou jusqu'à l'âge de 25 ans. Les éléments clés proposés de la transition sont: âges cibles pour le franchissement de certaines étapes; évaluation de la maturité; implication des aidants et communication avec les services pour adultes; possibilité de revenir à des services pédiatriques ou pour adolescents; transition de groupe; prise en compte des adolescents ayant des besoins spéciaux. Le continuum de soins, le lien entre les soins et la suppression virale sont d'importants marqueurs de la réussite de la transition. Les définitions et éléments clés proposés peuvent offrir un cadre pour structurer les programmes de transition dans d'autres pays.

La ampliación del acceso al diagnóstico y tratamiento del virus de la inmunodeficiencia humana (VIH) y la alta incidencia de la infección por el VIH en la adolescencia han dado lugar a una población creciente de adolescentes y adultos jóvenes que viven con el VIH. La prevalencia de una retención inadecuada en la atención, la supresión viral insuficiente y la pérdida de seguimiento son mayores entre los adolescentes y los adultos jóvenes en comparación con otros grupos de edad. Los resultados negativos pueden atribuirse a cambios psicosociales durante la adolescencia, pero también a una atención de transición deficiente de los servicios pediátricos a los servicios para adultos con VIH. En África subsahariana, los procesos de transición siguen siendo mal definidos y desestructurados, lo que puede suponer un riesgo para el cumplimiento y la retención del tratamiento. Describimos las definiciones existentes de transición y los marcos de transición, así como los elementos clave de la transición propuestos por las principales partes interesadas a nivel nacional en Kenia. Nuestra definición consensuada de transición es "un proceso planificado mediante el cual los adolescentes y adultos jóvenes que viven con el VIH, y sus cuidadores, son capacitados con conocimientos y habilidades que les permiten manejar su salud de manera independiente". La transición debe comenzar poco después de la revelación del estado serológico respecto al VIH hasta que el adolescente adquiera el conocimiento y las habilidades necesarias y esté dispuesto a trasladarse a los servicios para adultos, o a la edad de 25 años. Los elementos clave de la transición propuestos son: edades objetivo para el logro de los hitos; evaluación de la preparación; participación de los cuidadores y comunicación con las clínicas para adultos; flexibilidad para regresar a las clínicas para adolescentes o pediátricas; transición de grupos; y consideraciones para los adolescentes con necesidades especiales. La retención en la atención, la vinculación a la atención y la supresión viral son marcadores importantes del éxito de la transición. Las definiciones propuestas y los elementos clave podrían proporcionar un marco para estructurar los programas de transición en otros países.

Symptom screening for active tuberculosis in pregnant women living with HIV.

This is a protocol for a Cochrane Review (Diagnostic test accuracy). The objectives are as follows: To assess the accuracy of the four-symptom screen (cough, fever, night sweats, or weight loss) for identifying active TB in pregnant PLHIV who are screened in an outpatient or community setting. To investigate potential sources of heterogeneity of the accuracy of the four-symptom screen between studies including: ART status, CD4 cell count, gestational age, pregnancy stage (pregnancy vs. postpartum), screening test definition of cough (any cough vs. cough greater than 2 weeks).To describe the accuracy of single symptoms included within the four-symptom screen, additioal symptoms or symptom combinations, for identifying active TB in pregnant PLHIV. For example, additional symptoms may include failure to gain weight or fatigue.