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.
International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, Washington, United States of America; Department of Health Services, University of Washington, Seattle, Washington, United States of America.
Nancy
N
Puttkammer
Department of Health Services, University of Washington, Seattle, Washington, United States of America.
Steven
S
Zeliadt
International Training and Education Center for Health-Haiti, Port-au-Prince, Haiti.
Jean Gabriel
JG
Balan
Department of Epidemiology, University of Washington, Seattle, Washington, United States of America.
Janet
J
Baseman
International Training and Education Center for Health-Haiti, Port-au-Prince, Haiti.
Rodney
R
Destiné
Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Port-au-Prince, Haiti.
Jean Wysler
JW
Domerçant
Population Division, Ministry of Public Health and Population, Port-au-Prince, Haiti.
Garilus
G
France
International Training and Education Center for Health-Haiti, Port-au-Prince, Haiti.
Nathaelf
N
Hyppolite
Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Port-au-Prince, Haiti.
Valérie
V
Pelletier
International Training and Education Center for Health-Haiti, Port-au-Prince, Haiti.
Nernst Atwood
NA
Raphael
Health Alliance International, Department of Global Health, University of Washington, Seattle, Washington, United States of America.
Kenneth
K
Sherr
Center for AIDS Research, Department of Global Health, University of Washington, Seattle, Washington, United States of America.
Krista
K
Yuhas
International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, Washington, United States of America; Department of Medicine, University of Washington, Seattle, Washington, United States of America.
Scott
S
Barnhart
D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D019540:Area Under Curve; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D057286:Electronic Health Records; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006295:Health Resources; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D012372:ROC Curve; D012306:Risk; D017211:Treatment Failure; D055815:Young Adult
D019380:Anti-HIV Agents