title: A clinician-nurse model to reduce early mortality and increase clinic retention among high-risk HIV-infected patients initiating combination antiretroviral treatment.
abstract: BACKGROUND
  In resource-poor settings, mortality is at its highest during the first 3 months after combination antiretroviral treatment (cART) initiation. A clear predictor of mortality during this period is having a low CD4 count at the time of treatment initiation. The objective of this study was to evaluate the effect on survival and clinic retention of a nurse-based rapid assessment clinic for high-risk individuals initiating cART in a resource-constrained setting.
  
  
  METHODS
  The USAID-AMPATH Partnership has enrolled more than 140,000 patients at 25 clinics throughout western Kenya. High Risk Express Care (HREC) provides weekly or bi-weekly rapid contacts with nurses for individuals initiating cART with CD4 counts of ≤100 cells/mm3. All HIV-infected individuals aged 14 years or older initiating cART with CD4 counts of ≤100 cells/mm3 were eligible for enrolment into HREC and for analysis. Adjusted hazard ratios (AHRs) control for potential confounding using propensity score methods.
  
  
  RESULTS
  Between March 2007 and March 2009, 4,958 patients initiated cART with CD4 counts of ≤100 cells/mm3. After adjusting for age, sex, CD4 count, use of cotrimoxazole, treatment for tuberculosis, travel time to clinic and type of clinic, individuals in HREC had reduced mortality (AHR: 0.59; 95% confidence interval: 0.45-0.77), and reduced loss to follow up (AHR: 0.62; 95% CI: 0.55-0.70) compared with individuals in routine care. Overall, patients in HREC were much more likely to be alive and in care after a median of nearly 11 months of follow up (AHR: 0.62; 95% CI: 0.57-0.67).
  
  
  CONCLUSIONS
  Frequent monitoring by dedicated nurses in the early months of cART can significantly reduce mortality and loss to follow up among high-risk patients initiating treatment in resource-constrained settings.
authors.affiliation: Indiana University, School of Medicine, 1001 West 10th Street, OPW-M200, Indianapolis, IN 46202, USA. pbraitstein@yahoo.com
authors.forename: Paula
authors.initials: P
authors.lastname: Braitstein
authors.forename: Abraham
authors.initials: A
authors.lastname: Siika
authors.forename: Joseph
authors.initials: J
authors.lastname: Hogan
authors.forename: Rose
authors.initials: R
authors.lastname: Kosgei
authors.forename: Edwin
authors.initials: E
authors.lastname: Sang
authors.forename: John
authors.initials: J
authors.lastname: Sidle
authors.forename: Kara
authors.initials: K
authors.lastname: Wools-Kaloustian
authors.forename: Alfred
authors.initials: A
authors.lastname: Keter
authors.forename: Joseph
authors.initials: J
authors.lastname: Mamlin
authors.forename: Sylvester
authors.initials: S
authors.lastname: Kimaiyo
mesh_terms: D000293:Adolescent; D000328:Adult; D000553:Ambulatory Care; D000554:Ambulatory Care Facilities; D019380:Anti-HIV Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000401:mortality* / Q000451:nursing; D006792:House Calls; D006801:Humans; D007630:Kenya; D008297:Male; D008875:Middle Aged; D016294:Models, Nursing; D009720:Nurse Clinicians; D010349:Patient Compliance; D011446:Prospective Studies; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents