Date of Award

Summer 5-2019

Degree Name

Doctor of Philosophy (PhD)

Advisor(s)

DR. SUJA S. RAJAN, PHD

Second Advisor

DR. MINJAE LEE, PHD

Third Advisor

DR. ROBERT MORGAN, PHD

Abstract

Introduction: Since the introduction of anti-retroviral therapy (ART), treatment initiation criteria have continually been revised to start these lifesaving drugs before onset of advanced disease and optimize ART benefits for people living with HIV. However, little is known about the effect of these changes on treatment outcomes among young people. We evaluated the effect of such a policy change on long term adherence and treatment outcomes among young people, aged 15-24 years.

Methods: We conducted a retrospective cohort analysis of young people, 15-24years old, who started ART from January 2012 – December 2016. We used administrative data from the District Health Information System (DHIS2) and the national referral hospital’s EMR. We compared young people who started ART in the period July 1st, 2014 to December 31st, 2016 to a historical cohort that was treated in January 1st, 2012 to 30th June 2014 before the policy change. Multivariable logistic regression was used to assess the effect of the 2014 policy change on ART adherence and opportunistic infections among those who started treatment before and after the guidelines changed. We also run a Cox Proportional Hazards regression to examine the effect of the policy change on survival.

Results: On average, the health facility providing ART and having an opportunistic infection at the start of ART, had an effect on ART adherence. The policy change did not have an effect on ART adherence. Young people who started ART after the policy change had lesser odds of having an OI compared to those who started ART before the policy at 3, 6 and 12 months on ART. Age, the health facility, weight, and WHO disease stage were also associated with having OIs, as well as duration in pre-ART care, ARV regimen and number of pills per day. There was no significant difference in the survival probabilities and the hazard ratios of young people who started ART before and those who started ART after the policy changed. Also, WHO disease stage, weight at ART start and ART adherence at the time of death had an effect on survival.

Conclusion: This study found that ART adherence among young people was mainly driven by differences between health facilities providing ART in Uganda and whether an individual had an OI at ART start and not by policy change. Furthermore, early ART initiation reduced the risk of OIs among this population. Young people who initiated ART after the policy change were less likely to have an OI after starting treatment. Young people were also more likely to survive longer after ART initiation regardless of whether they started ART before or after the policy change.

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