A study examining the first decade of HIV antiretroviral therapy (ART) scale-up in Mozambique revealed fewer people are dying from HIV in recent years, likely due to more patients starting treatment at earlier disease stages.
The study by researchers at the division of Global HIV and Tuberculosis, Centre for Global Health, Centres for Disease Control and Prevention, Atlanta, the Mozambique Ministry of Health and the division of global HIV and tuberculosis, Centre for Global Health, Centres for Disease Control and Prevention, Maputo, Mozambique, examining the first decade of HIV antiretroviral therapy (ART) scale-up in Mozambique, revealed fewer people are dying from HIV in recent years, likely due to more patients starting treatment at earlier disease stages.
The analysis also found that people who more recently began ART were less likely to remain engaged in HIV treatment and care over time. The analysis highlights participation in community ART support groups (CASGs), small groups of patients who support each other to remain on ART, as an effective strategy to significantly reduce loss to follow up. The study is the largest analysis of its kind focusing on a single country.
Researchers from CDC’s division of global HIV and tuberculosis and the Mozambique Ministry of Health reviewed over 300,000 individual records of HIV-positive adults enrolled in ART from 2004 to 2013 to evaluate trends and identify new ways to help increase access to treatment. Over the decade-long timeframe of the study, the number of people on treatment grew 37-fold, with an increase in health facility coverage and a decline in deaths during the first six months of treatment as more patients started ART at earlier disease stages.
Despite the significant scale-up of ART in Mozambique, CDC and its public health partners have encountered many real-world challenges to keeping patients on ART. The most concerning finding from the new study was that patients who began ART in more recent years were less likely to stay on treatment compared with patients who began treatment in 2004. This decreased retention was most notable among pregnant women, especially those starting treatment at very early disease stages.
In 2016, Mozambique, with support from CDC, began implementing the World Health Organisation’s recommended “test and start” treatment strategy to provide immediate treatment to everyone diagnosed with HIV. CDC’s work included successfully navigating various health system challenges, and evaluating trends and identifying new models of HIV treatment delivery are essential to ensure sustainable ART scale-up for the future.
The CDC study also analysed participants in CASGs from 2010 to 2013. CASGs are small groups of patients from the same community who each take turns collecting the group’s medications from the health facility and distributing the treatments at community locations convenient for group members to access. The study found that participation in these groups significantly reduced the risk of losing participants to follow up, suggesting that these groups may be an effective model to scale-up ART.
CASGs provide a support system and reduce the burden on patients by reducing travel costs and time spent at the clinic waiting for prescription refills. CASGs also relieve a strained healthcare system as fewer people need to visit the health facilities every month. These groups have become an important component of Mozambique’s HIV care and treatment strategy, and could be used to deliver treatment in other resource-constrained settings. CDC and partners are piloting these efforts in five countries around the world.
Countries are working to achieve the UN’s 90-90-90 targets by 2020, which call for 90% of people living with HIV to know their status, 90% of those diagnosed to start and stay on ART, and 90% of those on ART to have a suppressed viral load.
Today there are 17m people on treatment globally. Yet, despite this progress in scaling up ART, more than half of all people living with HIV worldwide still do not have access to treatment.
As an implementer of the US President’s Emergency Plan for AIDS Relief (PEPFAR), CDC is working in more than 50 countries to increase access to life-saving antiretroviral drugs for millions of people around the world. Through PEPFAR, CDC directly supported ART for 5.8m people living with HIV in 2015, which is roughly one out of every three people on treatment worldwide. CDC is working closely with Ministries of Health, community groups, and civil society organisations to reach the most vulnerable populations with effective HIV prevention and treatment, and help them remain in care.
Background: During 2004–2013 in Mozambique, 455,600 HIV-positive adults (≥15 years old) initiated antiretroviral therapy (ART). We evaluated trends in patient characteristics and outcomes during 2004–2013, outcomes of universal treatment for pregnant women (Option B+) implemented since 2013, and effect on outcomes of distributing ART to stable patients through Community ART Support Groups (CASG) since 2010.
Methods: Data for 306,335 adults starting ART during 2004–2013 at 170 ART facilities were analyzed. Mortality and loss to follow-up (LTFU) were estimated using competing risks models. Outcome determinants were estimated using proportional hazards models, including CASG participation as a time-varying covariate.
Results: Compared with ART enrollees in 2004, enrollees in 2013 were more commonly female (55% vs. 73%), more commonly pregnant if female (<1% vs. 30%), and had a higher median baseline CD4 count (139 vs. 235/μL). During 2004–2013, observed 6-month mortality declined from 7% to 2% but LTFU increased from 24% to 30%. Pregnant women starting ART with CD4 count >350/μL and WHO stage I/II under Option B+ guidelines in 2013 had low 6-month mortality (0.1%) but high 6-month LTFU (38%). During 2010–2013, 6766 patients joined CASGs. In multivariable analysis, compared with nonparticipation in CASG, CASG participation was associated with 35% lower LTFU but similar mortality.
Conclusions: Initiation of ART at earlier disease stages in later calendar years might explain observed declines in mortality. Retention interventions are needed to address trends of increasing LTFU overall and the high LTFU among Option B+ pregnant women specifically. Further expansion of CASG could help reduce LTFU.
Auld, Andrew F; Shiraishi, Ray W; Couto, Aleny; Mbofana, Francisco; Colborn, Kathryn; Alfredo, Charity; Ellerbrock, Tedd V; Xavier, Carla; Jobarteh, Kebba