Characteristics and outcomes of adult Ethiopian patients enrolled in HIV care and treatment: a multi-clinic observational study.
BACKGROUND
We describe trends in characteristics and outcomes among adults initiating HIV care and treatment in Ethiopia from 2006-2011.


METHODS
We conducted a retrospective longitudinal analysis of HIV-positive adults (≥ 15 years) enrolling at 56 Ethiopian health facilities from 2006-2011. We investigated trends over time in the proportion enrolling through provider-initiated counseling and testing (PITC), baseline CD4+ cell counts and WHO stage. Additionally, we assessed outcomes (recorded death, loss to follow-up (LTF), transfer, and total attrition (recorded death plus LTF)) before and after ART initiation. Kaplan-Meier techniques estimated cumulative incidence of these outcomes through 36 months after ART initiation. Factors associated with LTF and death after ART initiation were estimated using Hazard Ratios accounting for within-clinic correlation.


RESULTS
93,418 adults enrolled into HIV care; 53,300 (57%) initiated ART. The proportion enrolled through PITC increased from 27.6% (2006-2007) to 44.8% (2010-2011) (p < .0001). Concurrently, median enrollment CD4+ cell count increased from 158 to 208 cells/mm(3) (p < .0001), and patients initiating ART with advanced WHO stage decreased from 56.6% (stage III) and 15.0% (IV) in 2006-2007 to 47.6% (stage III) and 8.5% (IV) in 2010-2011. Median CD4+ cell count at ART initiation remained stable over time. 24% of patients were LTF before ART initiation. Among those initiating ART, attrition was 30% after 36 months, with most occurring within the first 6 months. Recorded death after ART initiation was 6.4% and 9.2% at 6 and 36 months, respectively, and decreased over time. Younger age, male gender, never being married, no formal education, low CD4+ cell count, and advanced WHO stage were associated with increased LTF. Recorded death was lower among younger adults, females, married individuals, those with higher CD4+ cell counts and lower WHO stage at ART initiation.


CONCLUSIONS
Over time, enrollment in HIV care through outpatient PITC increased and patients enrolled into HIV care at earlier disease stages across all HIV testing points. However, median CD4+ cell count at ART initiation remained steady. Pre- and post-ART attrition (particularly in the first 6 months) have remained major challenges in ensuring prompt ART initiation and retention on ART.
ICAP-Columbia University, Mailman School of Public Health, 722 West 168th Street, 13th floor, New York, NY, 10032, USA. zy2115@columbia.edu.
Zenebe
Z
Melaku
ICAP-Columbia University, Mailman School of Public Health, 722 West 168th Street, 13th floor, New York, NY, 10032, USA. mrl2013@columbia.edu.|Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA. mrl2013@columbia.edu.
Matthew R
MR
Lamb
ICAP-Columbia University, Mailman School of Public Health, 722 West 168th Street, 13th floor, New York, NY, 10032, USA. cw2551@columbia.edu.
Chunhui
C
Wang
ICAP-Columbia University, Mailman School of Public Health, 722 West 168th Street, 13th floor, New York, NY, 10032, USA. sl2883@columbia.edu.
Sileshi
S
Lulseged
ICAP-Columbia University, Mailman School of Public Health, 722 West 168th Street, 13th floor, New York, NY, 10032, USA. tg2244@columbia.edu.
Tsigereda
T
Gadisa
Centers for Disease Control and Prevention, Addis Ababa, Ethiopia. hnb2@cdc.gov.
Solomon
S
Ahmed
Oromia Regional Health Bureau, Addis Ababa, Ethiopia. zhabtamuj@yahoo.com.
Zelalem
Z
Habtamu
Oromia Regional Health Bureau, Addis Ababa, Ethiopia. ha2323@columbia.edu.
Hailubeza
H
Alemu
ICAP-Columbia University, Mailman School of Public Health, 722 West 168th Street, 13th floor, New York, NY, 10032, USA. ta2302@columbia.edu.
Tamrat
T
Assefa
ICAP-Columbia University, Mailman School of Public Health, 722 West 168th Street, 13th floor, New York, NY, 10032, USA. eja1@columbia.edu.|Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA. eja1@columbia.edu.|College of Physicians & Surgeons, Columbia University, New York, NY, USA. eja1@columbia.edu.
Elaine J
EJ
Abrams
D000293:Adolescent; D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count / Q000706:statistics & numerical data; D005002:Ethiopia / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000097:blood / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000379:methods* / Q000706:statistics & numerical data; D010352:Patient Dropouts / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012720:Severity of Illness Index; D055815:Young Adult