Predictors for delayed initiation of antiretroviral therapy in HIV-infected patients admitted in Mulago Hospital
Ingabire, Prossie Merab
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Background: Over half of medical admissions at Mulago Hospital present with advanced HIV disease and have not yet initiated antiretroviral therapy (ART). There is increasing evidence from AIDS clinical trials and cohorts that earlier initiation of ART during treatment of opportunistic infections reduces morbidity and mortality. AIDS Clinical Trials Group (ACTG) 5164 showed that early ART resulted in less AIDS progression or death (14%) with no increase in adverse events or loss of virologic response compared to deferred ART (24%). In Uganda, it is not known what proportion of patients initiate ART within 2 weeks of being found eligible during hospitalization. There is need to understand the factors associated with delayed initiation of ART during hospitalization to increase access to HIV treatment among individuals hospitalized with advanced untreated HIV disease. Objectives: 1. To determine the proportion of HIV-infected, ART- naïve, ART-eligible adults who do not initiate ART within 2 weeks of being found eligible during hospitalization at Mulago Hospital medical wards (delayed initiation of ART). 2. To determine the factors associated with delayed initiation of ART among HIV-infected, ART-naïve, ART-eligible adults admitted on Mulago Hospital medical wards. Methods: A cross sectional study was conducted among hospitalized HIV-infected, ART-naïve, and ART-eligible adults on Mulago Hospital medical wards. HIV-infected patients were consecutively selected from the patients register on the wards. Patients who fulfilled the inclusion criteria were recruited. Patients or their attendants gave written consent, proxy consent or assent to take part in the study. A pre-tested questionnaire was administered. Patients were examined and date of eligibility for ART was determined. The hospital files were labeled with a study sticker. Three phone contacts were obtained from patients and their attendant to enable follow up at 2 weeks from date of eligibility for ART. At 2 weeks from date of eligibility, the study clinician reviewed the hospital files, either on the ward if the patient was still admitted or in the ward’s records office if the patients had been discharged or died. In the patients’ files, information from the attending clinicians’ notes about initiation of ART, referral notes, outcome at discharge was obtained. The study clinician called the study patients who had been discharged or died to determine whether they had initiated ART or not. Patients that had not initiated ART were asked why they had not. All data were analyzed using Stata version 12. Results: In this study we screened 473 hospitalized HIV-infected, ART-naïve, ART-eligible adults, 386 of whom were enrolled. Of the 386 participants, 193(50%) were females, 295(76%) were aware of their HIV positive diagnosis prior to admission, 219(57%) had attended 5 or more outpatient clinics in the year prior to admission and 142(37%) had an inpatient diagnosis of tuberculosis. Overall, 289(75%) of 386 patients had delayed initiation of ART. Mortality was reported in 96(25%) of 386 patients within the 2 weeks of being found eligible for ART. Patients who resided outside Kampala were about 2 times more likely to have delayed ART initiation (p-value 0.025) compared to those residing in Kampala district. Patients with a CD4 cell count above 50 were about 2 times more likely to have delayed initiation of ART (p-value 0.003) compared to those with CD4 cell count 50 and below. Conclusions and Recommendations: Up to 75% of HIV-infected, ART-naïve, ART-eligible patients admitted on Mulago Hospital medical wards do not initiate ART within 2 weeks of being found eligible. This is a missed opportunity for linkage to care and treatment of HIV in these patients, given known benefits of ART initiation within two weeks of eligibility. We recommend scale up of ART initiation during hospitalization and improvement of referral and linkage systems for HIV-infected, ART-naïve patients upon discharge from Mulago Hospital.