Prevalence and perinatal outcomes of non-communicable diseases in pregnancy in a regional hospital in Haiti: A prospective cohort study.

BACKGROUND: The prevalence of non-communicable diseases (NCDs) is rising in low and middle-income countries (LMIC). We aimed to report on the prevalence of NCDs in pregnancy and their associated perinatal outcomes in a regional hospital in Haiti. METHODS: We conducted the "Diabète et hYpertension Artéerielle et leurs issues MAternelles et Néonatales" (DYAMAN) prospective cohort study in a regional hospital in Haiti. Pregnant women presenting to care at 24-28 weeks were screened and treated for diabetes (DM) and hypertensive disorders of pregnancy (HDP) using setting-adapted protocols. Prevalence of NCDs and associated maternal-neonatal outcomes were described. RESULTS: 715 women were included, of which 51 (7.1%) had DM, 90 (12.6%) had HDP, and 30 (4.2%) had both DM and HDP (DM/HDP). Of 422 (59%) women delivered in hospital, 58 (13.7%) had preeclampsia, including 5 (8.6%) with eclampsia. Preterm birth <32 weeks was more common in the HDP than the control, DM, and DM/HDP groups. More low birth weight babies (n = 20, 25.6%) were born to the HDP group than to the control (n = 20, 7.1%), DM (n = 1, 2.7%), and DM/HDP (n = 3, 12%) groups (P < 0.001). Macrosomia and hypoglycemia affected 5 (8%) neonates of women with DM. Perinatal mortality, affecting 36/1000 births, was mainly driven by maternal NCDs. CONCLUSIONS: NCDs in pregnancy led to adverse maternal and perinatal outcomes. This study will help to prepare future refinements aimed at optimizing the management of NCDs in pregnancy in LMIC. Research is required to understand barriers to patient attendance at antenatal follow-up, treatment escalation for hyperglycemia, and in-hospital delivery.

Capacity Building and Innovation in Caring for Non-communicable Diseases in Maternal Global Health: The Example of Haiti.

Non-communicable diseases (NCDs) are important contributors to maternal morbidity and mortality worldwide. Yet, data on their prevalence and related outcomes in low-income countries are currently lacking. Additionally, screening and treatment protocols adapted for resource-limited settings are urgently required. This collaborative research initiative on the screening and management of hypertensive disorders of pregnancy and gestational diabetes was conducted in Saint-Nicolas Hospital in Saint-Marc, Haiti. The report discusses methods used to overcome several local challenges to implementation of care for NCDs. It also describes how collaborative research initiatives are efficient strategies to innovate and build research capacity for NCD care delivery during pregnancy in low-income countries.

Plasmodium falciparum K76T pfcrt Gene Mutations and Parasite Population Structure, Haiti, 2006-2009.

Hispaniola is the only Caribbean island to which Plasmodium falciparum malaria remains endemic. Resistance to the antimalarial drug chloroquine has rarely been reported in Haiti, which is located on Hispaniola, but the K76T pfcrt (P. falciparum chloroquine resistance transporter) gene mutation that confers chloroquine resistance has been detected intermittently. We analyzed 901 patient samples collected during 2006-2009 and found 2 samples showed possible mixed parasite infections of genetically chloroquine-resistant and -sensitive parasites. Direct sequencing of the pfcrt resistance locus and single-nucleotide polymorphism barcoding did not definitively identify a resistant population, suggesting that sustained propagation of chloroquine-resistant parasites was not occurring in Haiti during the study period. Comparison of parasites from Haiti with those from Colombia, Panama, and Venezuela reveals a geographically distinct population with highly related parasites. Our findings indicate low genetic diversity in the parasite population and low levels of chloroquine resistance in Haiti, raising the possibility that reported cases may be of exogenous origin.

Development of an electronic medical record based alert for risk of HIV treatment failure in a low-resource setting.

BACKGROUND: The adoption of electronic medical record systems in resource-limited settings can help clinicians monitor patients' adherence to HIV antiretroviral therapy (ART) and identify patients at risk of future ART failure, allowing resources to be targeted to those most at risk. METHODS: Among adult patients enrolled on ART from 2005-2013 at two large, public-sector hospitals in Haiti, ART failure was assessed after 6-12 months on treatment, based on the World Health Organization's immunologic and clinical criteria. We identified models for predicting ART failure based on ART adherence measures and other patient characteristics. We assessed performance of candidate models using area under the receiver operating curve, and validated results using a randomly-split data sample. The selected prediction model was used to generate a risk score, and its ability to differentiate ART failure risk over a 42-month follow-up period was tested using stratified Kaplan Meier survival curves. RESULTS: Among 923 patients with CD4 results available during the period 6-12 months after ART initiation, 196 (21.2%) met ART failure criteria. The pharmacy-based proportion of days covered (PDC) measure performed best among five possible ART adherence measures at predicting ART failure. Average PDC during the first 6 months on ART was 79.0% among cases of ART failure and 88.6% among cases of non-failure (p<0.01). When additional information including sex, baseline CD4, and duration of enrollment in HIV care prior to ART initiation were added to PDC, the risk score differentiated between those who did and did not meet failure criteria over 42 months following ART initiation. CONCLUSIONS: Pharmacy data are most useful for new ART adherence alerts within iSanté. Such alerts offer potential to help clinicians identify patients at high risk of ART failure so that they can be targeted with adherence support interventions, before ART failure occurs.

Patient attrition from the HIV antiretroviral therapy program at two hospitals in Haiti / Abandono del programa de tratamiento antirretrovírico de la infección por el VIH en pacientes de dos hospitales de Haití

OBJECTIVE: To identify factors associated with antiretroviral therapy (ART) attrition among patients initiating therapy in 2005-2011 at two large, public-sector department-level hospitals, and to inform interventions to improve ART retention. METHODS: This retrospective cohort study used data from the iSanté electronic medical record (EMR) system. The study characterized ART attrition levels and explored the patient demographic, clinical, temporal, and service utilization factors associated with ART attrition, using time-to-event analysis methods. RESULTS: Among the 2 023 patients in the study, ART attrition on average was 17.0 per 100 person-years (95% confidence interval (CI): 15.8-18.3). In adjusted analyses, risk of ART attrition was up to 89% higher for patients living in distant communes compared to patients living in the same commune as the hospital (hazard ratio: 1.89, 95%CI: 1.54-2.33; P < 0.001). Hospital site, earlier year of ART start, spending less time enrolled in HIV care prior to ART initiation, receiving a non-standard ART regimen, lacking counseling prior to ART initiation, and having a higher body mass index were also associated with attrition risk. CONCLUSIONS: The findings suggest quality improvement interventions at the two hospitals, including: enhanced retention support and transportation subsidies for patients accessing care from remote areas; counseling for all patients prior to ART initiation; timely outreach to patients who miss ART pick-ups; "bridging services" for patients transferring care to alternative facilities; routine screening for anticipated interruptions in future ART pick-ups; and medical case review for patients placed on non-standard ART regimens. The findings are also relevant for policymaking on decentralization of ART services in Haiti.

OBJETIVO: Determinar los factores asociados con el abandono del tratamiento antirretrovírico en los pacientes que iniciaron el tratamiento en el período del 2005 al 2011 en dos grandes hospitales públicos de nivel departamental, y fundamentar las intervenciones necesarias para mejorar la retención de los pacientes en el tratamiento. MÉTODOS: Este estudio retrospectivo de cohortes empleó los datos del sistema de registro médico electrónico iSanté. Se describieron los niveles de abandono del tratamiento y se exploraron los factores demográficos, clínicos, temporales y de utilización de los servicios que se asociaban con su abandono, usando métodos de análisis del tiempo trascurrido hasta un evento. RESULTADOS: El abandono del tratamiento entre los 2 023 pacientes incluidos en el estudio fue en promedio de 17,0 por 100 personas-años (intervalo de confianza (IC) de 95%: 15,8-18,3). En los análisis ajustados, el riesgo de abandono del tratamiento fue de hasta 89% mayor en los pacientes que vivían en comunas distantes, en comparación con los pacientes que vivían en la misma comuna en que se ubicaba el hospital (razón de riesgo: 1,89; IC de 95%: 1,54-2,33; P < 0,001). La ubicación del hospital, el inicio del tratamiento en un año calendario anterior, un menor tiempo de inclusión en el programa de atención a la infección por el VIH antes de iniciar el tratamiento, la administración de un régimen terapéutico no estándar, la falta de orientación antes de iniciar el tratamiento y un mayor índice de masa corporal también se asociaron con un riesgo más elevado de abandono. CONCLUSIONES: Los resultados sugieren algunas intervenciones de mejora de la calidad en ambos hospitales, entre ellas: un mayor apoyo a la retención y subsidios de transporte para los pacientes que acuden desde zonas remotas para ser atendidos; la orientación a todos los pacientes antes del inicio del tratamiento antirretrovírico; el contacto oportuno de los servicios con los pacientes que omiten alguna recogida de medicación; "servicios de conexión" para transferir la atención de los pacientes a otros establecimientos alternativos; el tamizaje sistemático de las interrupciones previstas en las próximas recogidas de medicación; y la revisión médica de los casos de pacientes que siguen un tratamiento no estándar. Estos hallazgos son también pertinentes en materia de formulación de políticas de descentralización de los servicios de tratamiento antirretrovírico en Haití.

Before and after the earthquake: a case study of attrition from the HIV antiretroviral therapy program in Haiti.

BACKGROUND: On January 12, 2010, a devastating 7.0 magnitude earthquake struck the West Department of Haiti, killing more than 200,000 people and injuring or displacing many more. This disaster threatened continuity of HIV care and treatment services. OBJECTIVES: This case study examined the effect of the devastating 2010 earthquake in Haiti on attrition from the HIV antiretroviral therapy (ART) program. DESIGN: The study triangulated retrospective data from existing sources, including: 1) individual-level longitudinal patient data from an electronic medical record for ART patients at two large public sector departmental hospitals differently affected by the earthquake; and 2) aggregate data on the volume of HIV-related services delivered at the two hospitals before and after the earthquake. METHODS: The study compared ART attrition and service delivery in Jacmel, a site in the 'very strong' zone of earthquake impact, and in Jérémie, a site in the 'light' zone of earthquake impact. The analysis used time-to-event analysis methods for the individual-level patient data, and descriptive statistical methods for the aggregate service delivery data. RESULTS: Adjusted ART attrition risk was lower at the hospital in Jacmel after vs. before the earthquake (HR=0.51; p=0.03), and was lower in Jacmel vs. Jérémie both before (HR=0.55; p=0.01) and after the earthquake (HR=0.35; p=0.001). The number of new ART patient enrollments, new HIV patient registrations, and HIV clinical visits dropped notably in Jacmel immediately after the earthquake, but then rapidly rebounded. On average, there was no change in new ART enrollments per month after vs. before the earthquake at either site. CONCLUSION: These findings underscore the resilience of Haitian ART providers and patients, and contribute evidence that it is possible to maintain continuity of ART services even in the context of a complex humanitarian crisis.

Patient attrition from the HIV antiretroviral therapy program at two hospitals in Haiti.

OBJECTIVE: To identify factors associated with antiretroviral therapy (ART) attrition among patients initiating therapy in 2005-2011 at two large, public-sector department-level hospitals, and to inform interventions to improve ART retention. METHODS: This retrospective cohort study used data from the iSanté electronic medical record (EMR) system. The study characterized ART attrition levels and explored the patient demographic, clinical, temporal, and service utilization factors associated with ART attrition, using time-to-event analysis methods. RESULTS: Among the 2 023 patients in the study, ART attrition on average was 17.0 per 100 person-years (95% confidence interval (CI): 15.8-18.3). In adjusted analyses, risk of ART attrition was up to 89% higher for patients living in distant communes compared to patients living in the same commune as the hospital (hazard ratio: 1.89, 95%CI: 1.54-2.33; P < 0.001). Hospital site, earlier year of ART start, spending less time enrolled in HIV care prior to ART initiation, receiving a non-standard ART regimen, lacking counseling prior to ART initiation, and having a higher body mass index were also associated with attrition risk. CONCLUSIONS: The findings suggest quality improvement interventions at the two hospitals, including: enhanced retention support and transportation subsidies for patients accessing care from remote areas; counseling for all patients prior to ART initiation; timely outreach to patients who miss ART pick-ups; "bridging services" for patients transferring care to alternative facilities; routine screening for anticipated interruptions in future ART pick-ups; and medical case review for patients placed on non-standard ART regimens. The findings are also relevant for policymaking on decentralization of ART services in Haiti.