A clinician-nurse model to reduce early mortality and increase clinic retention among high-risk HIV-infected patients initiating combination antiretroviral treatment

Paula Braitstein, Abraham Siika, Joseph Hogan, Rose Kosgei, Edwin Sang, John Sidle, Kara Wools-Kaloustian, Alfred Keter, Joseph Mamlin, Sylvester Kimaiyo

Research output: Contribution to journalArticle

18 Citations (Scopus)

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.

Original languageEnglish
Article number7
JournalJournal of the International AIDS Society
Volume15
Issue number1
DOIs
StatePublished - 2012

Fingerprint

Nurse Clinicians
HIV
Mortality
CD4 Lymphocyte Count
Therapeutics
Nurses
United States Agency for International Development
Safety Management
Propensity Score
Kenya
Sulfamethoxazole Drug Combination Trimethoprim
Tuberculosis
Confidence Intervals

Keywords

  • Adherence
  • Africa
  • Antiretrovirals
  • Losses to follow up
  • Models of care
  • Mortality

ASJC Scopus subject areas

  • Infectious Diseases
  • Public Health, Environmental and Occupational Health

Cite this

A clinician-nurse model to reduce early mortality and increase clinic retention among high-risk HIV-infected patients initiating combination antiretroviral treatment. / Braitstein, Paula; Siika, Abraham; Hogan, Joseph; Kosgei, Rose; Sang, Edwin; Sidle, John; Wools-Kaloustian, Kara; Keter, Alfred; Mamlin, Joseph; Kimaiyo, Sylvester.

In: Journal of the International AIDS Society, Vol. 15, No. 1, 7, 2012.

Research output: Contribution to journalArticle

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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.",
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AU - Kosgei, Rose

AU - Sang, Edwin

AU - Sidle, John

AU - Wools-Kaloustian, Kara

AU - Keter, Alfred

AU - Mamlin, Joseph

AU - Kimaiyo, Sylvester

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KW - Models of care

KW - Mortality

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