Date of Award

Spring 12-2019

Degree Name

Doctor of Public Health (DrPH)

Advisor(s)

CASEY DURAND, PhD

Second Advisor

LU-YU HWANG, MD

Third Advisor

SHERYL MCCURDY, PhD

Abstract

Introduction: The maximum benefits of antiretroviral therapy (ART) are achieved when HIV patients follow through the HIV Care Continuum. Understanding the factors that impact the Care Continuum are key in minimizing late ART uptake while increasing treatment retention and adherence in sub-Saharan Africa. Objectives: To explore factors that impact the various phases of the HIV Care Continuum, we review trends in median CD4 cells count and presentation with HIV advanced disease stage between 2013 and 2017. We also examined treatment retention rates and the impact of food security on ART adherence. Methods: Two datasets were reviewed. One dataset consists of data abstracted from 1100 HIV clinic records of adults aged 15 who initiated ART between 2013 and 2017 at a comprehensive clinic in Nigeria. The other dataset was a cross-sectional study conducted among HIV patients aged 18 years in Uganda. Data analysis: We used Chi square tests to compare baseline median CD4 cell counts and HIV advanced disease stage among males and females initiating ART between 2013 and 2017. Logistic regression was used to determine retention rates over time as well as ART adherence. All data was analyzed using STATA version 15. Results: The overall median CD4 cell count was 243.5 cells/l. Men had a downward median CD4 cell count trend and presented late to treatment compared to females. Patients aged 36 and viii those with TB also presented with advanced HIV disease stage at ART initiation. Nigeria National HIV policy changes had no impact in late presentation to ART uptake. ART treatment retention was 71.39%, 79.50%, 74.01% and 62.67% at 6, 12, 24 and 36 months respectively. CD4 cell count <100 was inversely predictive of retention (AOR 0.55; 95% CI, 0.37-0.82) while female gender (AOR, 2.00; 95% CI, 1.02 – 3.89), older age (AOR, 1.88; 95% CI, 1.01-3.51), TB at start (AOR, 2.21; 95% CI, 1.02-4.75). and CD4 cell count 100-199 (AOR, 2.54; 95% CI, 1.046.20) were significantly associated with retention. Overall food security level in Uganda was 65.5%. HIV positive males reported higher food security levels compared to females (77.60% vs 61.90). Food security (AOR, 1.76; 95% CI, 1.03-3.01), income (AOR 2.69; 95% CI, 1.14-6.34) and nutrition counseling (AOR, 1.99; 95% CI, 1.12-3.54) were associated with good adherence. Conclusion: Various factors contribute gaps in the HIV Care Continuum and foster existing gender disparities in HIV care outcomes. Interventions targeting men for early ART uptake and treatment retention are needed. Promoting food security and treatment support programs may be effective in advancing HIV care in the sub-Saharan Africa. Further research is needed to examine the long -term impact of HIV policy and program changes.

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