Approved By:
Sandra Greene, DrPH Ned Brooks, DrPH, MBA Suzanne Havala Hobbs, DrPH Bruce Fried, PhD
RETENTION OF PATIENTS ON ANTIRETROVIRAL THERAPY IN THE HIGHLANDS OF PAPUA NEW GUINEA
Sarthak Das, MPH
A dissertation submitted to the faculty of the University of North Carolina at Chapel Hill LQ SDUWLDO IXO¿OOPHQW RI WKH UHTXLUHPHQWV IRU WKH GHJUHH RI 'RFWRU RI 3XEOLF +HDOWK LQ
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ABSTRACT
Over 4 million HIV positive people are on antiretroviral therapy (ART) worldwide;; WKH JDS LQ DFFHVV UHPDLQV VWHHS ZLWK RYHU PLOOLRQ LQ QHHG RI OLIH VDYLQJ WUHDWPHQW :LWK SURSHU DFFHVV WR +,9 FDUH DQG WUHDWPHQW VHUYLFHV +,9 LV QR ORQJHU D OLIH HQGLQJ FRQGLWLRQ DQG FDQ EH PDQDJHG DV D FKURQLF LOOQHVV 7KLV KRZHYHU UHTXLUHV D KLJK OHYHO RI DGKHUHQFH WR DQ$57 UHJLPHQ IRU WKH UHVW RI D SDWLHQW¶V OLIH PDNLQJ UHWHQWLRQ LQ$57 SURJUDPV RI FULWLFDO LPSRUWDQFH :KLOH D P\ULDG RI SURJUDPV H[LVW WR LPSURYH SDWLHQW UHWHQWLRQ LQ WKH GHYHORSLQJ ZRUOG YHU\ OLWWOH UHVHDUFK KDV EHHQ XQGHUWDNHQ WR H[DPLQH WKH HIIHFWLYHQHVV RI FDVH PDQDJHPHQW WR DGGUHVV SDWLHQW ORVW WR IROORZXS ,Q 3DSXD 1HZ *XLQHD 31* WKH HSLFHQWHU RI +,9 LQ WKH$VLD 3DFL¿F 5HJLRQ WKHUH LV D GHDUWK RI UHVHDUFK UHODWHG WR +,9 VHUYLFHV GHVSLWH RYHU SHRSOH FXUUHQWO\ RQ$57 7KURXJK D comprehensive chart review of patient data from two Government operated ART clinics, WKLV VWXG\ H[DPLQHG WKH HI¿FDF\ RI D &DVH 0DQDJHPHQW V\VWHP LQ WKH +LJKODQGV RI 31* 7KH (DVWHUQ +LJKODQGV KDYH EHHQ LPSOHPHQWLQJ &DVH 0DQDJHPHQW IRU$57 SDWLHQWV VLQFH ZKLOH &DVH 0DQDJHPHQW LV QRW EHLQJ LPSOHPHQWHG WKH :HVWHUQ +LJKODQGV
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SARTHAK DAS: Retention of Patients On Antiretroviral Therapy ,Q WKH +LJKODQGV RI 3DSXD 1HZ *XLQHD
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This dissertation is dedicated to my wife Andy Carmone, ZKRVH FRXUDJHRXV FRPPLWPHQW WR WKH UXUDO SRRU RI 31* DQG
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It is also dedicated to the late Mary Drua,
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ACKNOWLEDGEMENTS
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PREFACE
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TABLE OF CONTENTS
LIST OF TABLES [L LIST OF FIGURES [LL LIST OF ABBREVIATIONS [LLL Chapter
, ,1752'8&7,21 1
Statement of the Issue 1
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Goal 6
Key Criteria 7
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Study Aims 21
Study Location 22
Data Collection Methods 23
Data Analysis Methods 27
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Patient Characteristics 34
Data Analysis 36
9 ',6&866,21 43
Decentralization of ART Services 44
Limitations of this Study 47
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LIST OF TABLES
Table
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Retained After 90 Days by Province 38 0XOWLYDULDEOH$QDO\VLV RI WKH 5HODWLRQVKLS EHWZHHQ 3URYLQFH
and Attrition from Treatment 39
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LIST OF FIGURES
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LIST OF ABBREVIATIONS
ADB Asian Development Bank
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ANC Antenatal Clinic
ART Antiretroviral Treatment ARV Antiretroviral
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CHAI Clinton Health Access Initiative
CST Care Support and Treatment (for HIV)
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MCH Maternal and Child Health
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NACS National AIDS Council Secretariat NDoH National Department of Health
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PMTCT Prevention of Mother to Child Transmission PNG Papua New Guinea
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UNAIDS United Nations AIDS
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CHAPTER 1 INTRODUCTION
Statement of the Issue
As the world approaches the fourth decade of the AIDS pandemic, an HIV vaccine UHPDLQV HOXVLYH PHDQZKLOH WKRXVDQGV PRVWO\ LQ WKH ZRUOG¶V SRRUHVW FRXQWULHV FRQWLQXH WR SHULVK IURP RQH RI PRVW SHUQLFLRXV SDWKRJHQV PRGHUQ KLVWRU\ KDV H[SHULHQFHG 6LQFH WKH HSLGHPLF EHJDQ PLOOLRQ SHRSOH KDYH EHHQ LQIHFWHG ZLWK PLOOLRQ GHDWKV IURP +,9 UHODWHG LOOQHVV ,Q 81$,'6 HVWLPDWHV WKHUH ZHUH PLOOLRQ GHDWKV IURP $,'6 JOREDOO\ RYHU SHUFHQW RI WKHVH RFFXUUHG LQ UHVRXUFHOLPLWHG VHWWLQJV 81$,'6
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6 CHAPTER 2 LITERATURE REVIEW
Goal
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Categorization of Studies
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Key Criteria
Inclusion
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Exclusion
8 Results
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Table 1: Search Terms
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Chapter 2 Endnotes
*ULQV]WHMQHW DOEffects of Early versus Delayed Initiation of Antiretroviral Therapy (ART) on HIV Clinical Outcomes: Results from the HPTN 052 Randomized Clinical Trial IAS Rome 2011
20 CHAPTER 3 METHODOLOGY
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Number of patients alive and on treatment at 12 months (or 24, 36, 48 months) ÷
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Potential Sources of Bias and Confounding Factors
30
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Chapter 3 Endnotes
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CHAPTER 4 RESULTS
Chapter Three outlined the main methods used to collect and analyze data from WKH FKDUW UHYLHZ 2I SDWLHQW FKDUWV UHYLHZHG LQ WKH (DVWHUQ +LJKODQGV SDWLHQWV ZHUH LQFOXGHG IRU DQDO\VLV LQ WKH :HVWHUQ +LJKODQGV RXW RI SDWLHQW FKDUWV UHYLHZHG ZHUH LQFOXGHG LQ WKLV VWXG\
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Review of Study Aims
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Patient Characteristics
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Multivariate Analysis and Kaplan Meier Estimates
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Table 6: Multivariable Analysis of the Relationship between Province and Attrition from Treatment* (N=2457)**
40 UHWDLQHG ZKHQ DGMXVWHG IRU DOO IDFWRUV
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Analysis of HIV Testing Data & Patient Retention
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42
Chapter 4 Endnotes
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CHAPTER 5 DISCUSSION
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Contextual Similarities: Eastern & Western Highlands Provinces
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Decentralization of ART Services
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The Impact of Decentralization on Analysis of Results
As previous sections have mentioned, a truer comparison to evaluate the HI¿FDF\ RI &DVH 0DQDJHPHQW ZRXOG KDYH LQYROYHG HLWKHU
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Aim 1: 7R DVVHVV WKH LPSDFW RI WKH &DVH 0DQDJHPHQW V\VWHP RQ SDWLHQW ORVW WR IROORZXS DPRQJ DGXOW$57 SDWLHQWV LQ WKH +LJKODQGV %DVHG RQ WKH PXOWL YDULDEOH DQDO\VLV WKDW DGMXVWHG IRU DOO IDFWRUV WKHUH ZDV LQGHHG D VWDWLVWLFDOO\ VLJQLI LFDQW DVVRFLDWLRQ EHWZHHQ OLNHOLKRRG RI UHWHQWLRQ DQG EHLQJ IURP WKH (DVWHUQ +LJK ODQGV$ NH\ LVVXH KRZHYHU LV WKDW WKH DFWXDO UHWHQWLRQ UDWH LWVHOI ZKHQ LQFOXVLYH RI DOO SDWLHQWV DQG QRW MXVW WKRVH UHWDLQHG DIWHU GD\V UHPDLQV EHORZ HLJKW\¿YH SHUFHQW
With respect to Aim 2, the most powerful association may be the link between +,9 WHVWLQJ GDWD IURP DQG WKH PXOWLYDULDWH DQDO\VLV WKDW UHYHDOV FRQQHFWLRQV EHWZHHQ EHLQJ IURP WKH (DVWHUQ +LJKODQGV LQLWLDWLRQ RI$57 LQ DQG OLNH OLKRRG RI UHWHQWLRQ ,Q RWKHU ZRUGV WKH VLJQL¿FDQWO\ KLJKHU QXPEHU RI +,9 WHVWV FRQGXFWHG LQ LQ (DVWHUQ +LJKODQGV PD\ LQGHHG PHDQ WKDW WKRVH SDWLHQWV ZHUH LGHQWL¿HG HDUOLHU DV +,9 SRVLWLYH OLQNHG WR WKH$57 SURJUDP WKURXJK &DVH 0DQ DJHPHQW DQG LQLWLDWHG RQ$57 DW D PRUH RSWLPDO WLPH WKHQ FRXQWHUSDUWV LQ VWXG\ SHULRG
Aim 3: ,I WKH GDWD \LHOG VXEVWDQWLYH HYLGHQFH RI WKH HI¿FDF\ RI &DVH 0DQ DJHPHQW LQ LPSURYLQJ UHWHQWLRQ DGYRFDWH IRU HYLGHQFH WR VXSSRUW WKH DGRSWLRQ RI an improved model of HIV service delivery national level policy in Papua New *XLQHD WKDW LQFOXGHV &DVH 0DQDJHPHQW
7KH LQÀXHQFH RI D P\ULDG RI FOLQLFDO GHPRJUDSKLF VRFLRHFRQRPLF DQG cultural factors coupled with issues of where services are physically located pose a FKDOOHQJH LQ GHWHUPLQLQJ ZKHWKHU &DVH 0DQDJHPHQW VHUYLFHV WUXO\ LQÀXHQFH UHWHQ WLRQ RU LI WKHUH DUH RWKHU FRYDULDWHV DW ZRUN %XW ZKLOH WKHUH LV URRP IRU LPSURYH PHQW LQ WKH &DVH 0DQDJHPHQW V\VWHP¶V DELOLW\ WR LPSURYH IXUWKHU RQ UHWHQWLRQ UDWHV HJ RU JUHDWHU DW PRQWKV LW QRQHWKHOHVV DSSHDUV WR EH D SURPLVLQJ LQWHUYHQWLRQ LQ D VHWWLQJ LQ QHHG RI VWUDWHJLHV IRU +,9 FDUH DQG WUHDWPHQW )XUWKHU WLPH DQG VWXG\ DUH QHHGHG WR DOORZ WKH IXOO SRWHQWLDO RI WKH PRGHO WR EH UHDOL]HG
Limitations of this Study
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Inability to accurately assess patients who may have transferred out of care and VRXJKW VHUYLFHV LQ DQRWKHU IDFLOLW\ EXW ZKR ZHUH UHFRUGHG DV ORVW WR IROORZXS LV DQRWKHU key limitation of this study, as these patients should have been recorded as transferred out LQVWHDG RI ORVW WR IROORZXS *LYHQ WKDW WKH YDVW PDMRULW\ RI SDWLHQW FKDUWV GLG QRW FRQ tain information that recorded if a patient had transferred care, these patients were always UHSRUWHG DV ORVW
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50
Chapter 5 Endnotes
CHAPTER 6 PLAN FOR CHANGE
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52
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