Access to programmes providing highly active antiretroviral therapy (HAART) is recent in Africa. In Senegal, a national initiative was launched in 1998. The capacity of African patients to adhere to ...complex antiretroviral treatments (ARV) is largely unknown.
We assessed adherence and identified the main reasons for treatment interruption in a prospective observational cohort of patients participating in an ARV access programme in Dakar, Senegal. Adherence was estimated each month on the basis of the patients' stated consumption and on the proportion of the prescribed dose returned unused to the dispensing pharmacy. A total of 158 patients were studied between November 1999 and October 2001.
A cross-section analysis showed that the stated level of adherence was high: on average, over the study period, the patients said they had taken 91% of each monthly dose and that they had taken the full monthly dose during two-thirds of the months studied. Adherence tended to be better among patients who were required to make little or no contribution to the cost of their treatment, through an appropriate pricing structure. Adherence was also better with efavirenz-containing regimens than with indinavir-containing regimens.
These results show that adherence to HAART can be as high in Africa as that generally observed in industrialized countries, and that the cost and type of drug regimen must be taken into account when designing ARV access programmes for poor communities.
Assessed the difficulties encountered by general practitioners in the care of the elderly with complex medical and psycho-social conditions, their knowledge of the geriatric network, the interest ...engendered by setting-up mobile community based geriatric units.
The survey was both qualitative and quantitative and took the form of a telephone interview and a multimodal questionnaire (telephone interview, postal or email questionnaire) of general practitioners in the areas of Annecy, Grenoble and Roanne (France).
Sixty five per cent of the 129 GPs contacted by telephone said the survey interested them. One hundred and eleven physicians replied to the questionnaire. The first priority for intervention of the mobile geriatric unit should be the management of the elderly with cognitive disorders and behavioural symptoms (43 replies) that pose the most problems for physicians. The mobile team should be available, and easy to contact rapidly. The request for intervention should be made by the GP (69 replies, 72.6%), by telephone (95 replies, 86%) and the visit made within the following 48 - 72 hours (60 replies, 67.4%).
Our results confirm the existence of difficulties in the care the elderly people with complex conditions that justify experimentation of community mobile geriatric teams.
Background: among elderly patients, readmission in the month following hospital discharge is a frequent occurrence which involves a risk of functional decline, particularly among frail subjects. ...While previous studies have identified risk factors of early readmission, geriatric syndromes, as markers of frailty have not been assessed as potential predictors. Objective: to evaluate the risk of early unplanned readmission, and to identify predictors in inpatients aged 75 and over, admitted to medical wards through emergency departments. Design: prospective multi-centre study. Setting: nine French hospitals. Subjects: one thousand three hundred and six medical inpatients, aged 75 and older admitted through emergency departments (SAFES cohort). Methods: using logistic regressions, factors associated with early unplanned re-hospitalisation (defined as first unplanned readmission in the thirty days after discharge) were identified using data from the first week of hospital index stay obtained by comprehensive geriatric assessment. Results: data from a thousand out of 1,306 inpatients were analysed. Early unplanned readmission occurred in 14.2% of inpatients and was not related with sociodemographic characteristics, comorbidity burden or cognitive impairment. Pressure sores (OR = 2.05, 95% CI = 1.0–3.9), poor overall condition (OR = 2.01, 95% CI = 1.3–3.0), recent loss of ability for self-feeding (OR = 1.9, 95% CI = 1.2–2.9), prior hospitalisation during the last 3 months (OR = 1.6, 95% CI = 1.1–2.5) were found to be risk factors, while sight disorders appeared as negatively associated (OR = 0.5, 95% CI = 0.3–-0.8). Conclusions: markers of frailty (poor overall condition, pressure sores, prior hospitalisation) or severe disability (for self-feeding) were the most important predictors of early readmission among elderly medical inpatients. Early identification could facilitate preventive strategies in risk group.
Frail elderly patients during their hospitalization can benefit of a comprehensive geriatric assessment (CGA) by an inpatient geriatric consultation team (IGCT). This assessment yields ...recommendations aiming to improve medical and social management during the patient's hospital stay and after discharge.
This study examines the socio-demographic profile of patients assessed by the IGCT and describes the type of recommendations, their adherence rate at 3 months and their impact in terms of mortality, rehospitalization, and institutionalization.
Retrospective, single center study including all patients assessed by the IGCT during the 4 first months of 2009. These 151 patients fulfilled criteria of either medical and/or social frailty or had been submitted to an inappropriate in-hospital trajectory. Hospital records and telephone follow-up (with informal and/or professional caregivers as well as primary care physicians) were used to monitor the implementation of recommendations up to three months after hospital discharge.
Mean age of the 151 patients was 85.6 years, 63% were women. 94% of patients lived at home, 70% had a non-supportive environment, 85% were frail and 11% had dementia. On admission, 64% of them had an acute functional loss. 93% of patients were admitted via the emergency room where 67% benefited from CGA. The median hospital duration stay was 14 days. At discharge, 76% of patients went back home, 12% were institutionalized and 12% had died. Three months after discharge, 18% of the 134 patients surviving hospitalization had been readmitted, 26% institutionalized and 12% had died. The CGA yielded an average of 7 recommendations (median value). The mean adherence rate was 78%. The majority of medical recommendations concerned ancillary care and standard medical management, showing high adherence rates (95%). Recommendations concerning the management of cognitive problems were less frequent and overall poorly adhered to (62%).
Mean adherence rate was maximal (97%) when the number of recommendations was limited to 4 and it dropped under 80% with more than 5 recommendations. The recommendations concerning management at home were generally followed (60-77%). Regarding to social outcomes, the main recommendation was to mobilize home assistance and its financial support. There was no significant difference between adherence rate in the hospital and in the community. The extent of adherence rate did not correlate with mortality or readmission at 3 months.
To evaluate survival and investigate causes of death among HIV-1 infected adults receiving HAART in Senegal.
An observational prospective cohort.
Mortality was assessed in the first patients enrolled ...between August 1998 and April 2002 in the Senegalese antiretroviral drug access initiative. First-line regimen combined two nucleoside reverse transcriptase inhibitors and either a non-nucleoside reverse transcriptase inhibitor or a protease inhibitor. The most likely causes of death were ascertained through medical records or post-mortem interviews (verbal autopsy).
Four hundred and four patients (54.7% women) were enrolled in the study and were followed for a median of 46 months (interquartile range: 32-57 months) after HAART initiation. At baseline, 5% were antiretroviral therapy (ART) non-naive, 39 and 55% were respectively at CDC stage B and C, median age, CD4 cell count and viral load were 37 years, 128 cells/microl and 5.2 log cp/ml, respectively. Ninety-three patients died during follow-up and the overall incidence rate of death was 6.3/100 person-years 95% confidence interval (CI), 5.2-7.7. During the first year after HAART initiation, 47 patients died and seven were lost to follow-up, yielding to a probability of dying of 11.7% (95% CI, 8.9-15.3%). The death rate, which was highest during the first year after HAART initiation, decreased with time yielding a cumulative probability of dying of 17.4% (95% CI, 13.9-21.5%) and 24.6% (95% CI, 20.4-29.4%) at 2 and 5 years. Causes of death were ascertained in 76 deaths. Mycobacterial infections, neurotropic infections and septicaemia were the most frequent likely causes of death.
This study underlines the early mortality pattern after HAART initiation and highlights the leading role of mycobacterial infections in the causes of death.
Adherence is one of the main predictors of antiretroviral treatment success. A governmental initiative was launched in 1998 for HIV-infected patients in Senegal to provide access to highly active ...antiretroviral therapy.
Between August 1998 and April 2002, 404 adult patients were enrolled. Adherence measurements, defined as pills taken/pills prescribed, were assessed between November 1999 and April 2009 using a pill count along with a questionnaire for 330 patients. Predictors of adherence were explored through a random-intercept Tobit model and a latent class analysis (LCA) was performed to identify adherence trajectories. We also performed a survival analysis taking into account gender and latent adherence classes.
Median treatment duration was 91 months (interquartile range, 84-101). On average, adherence declined by 7% every year, was 30% lower for patients taking indinavir, and 12% higher for those receiving cotrimoxazole prophylaxis. Based on the predicted probability of having an adherence ≥ 95%, LCA revealed 3 adherence behaviors and a better adherence for women. A quarter of patients had a high adherence trajectory over time and half had an intermediate one. Male gender and low adherence behavior over time were independently associated with a higher mortality rate.
This study shows that an overall good adherence can be obtained in the long term in Senegal. LCA suggests a better adherence for women and points out a large subsample of patients with intermediate level of adherence behavior who are at risk for developing resistance to antiretroviral drugs. This study warrants further research into gender issues.
The aim of this study was to identify factors predictive of nursing home admission (NHA) over a period of 1 year among elderly subjects with dementia.
The study population was drawn from the SAFES ...cohort that was formed within a national research program into the recruitment of emergency departments in 9 teaching hospitals. Subjects were to have been hospitalized in a medical ward in the same hospital as the emergency department to which they were initially admitted. Subjects who experienced NHA before emergency department admission were excluded. Those with a confirmed diagnosis of dementia were considered in the present analysis. NHA has been defined as the incident admission into either a nursing home or other long term care facility within the follow-up period. Data obtained from a Comprehensive Geriatric Assessment were used in a Cox model to predict 1-year NHA.
The 425 subjects of the study were 86 ± 6 years old, and were mainly women (63%). NHA rate was 40% (n = 172). Four factors were identified to increase NHA risk: age 85 or older (hazard ratio HR = 1.5; 95% confidence interval CI = 1.1-2.1), inability to use the toilet (HR = 2.5; 95% CI = 1.5-4.2), balance disorders (HR = 1.5; 95% CI = 1.1-2.1), and living alone (HR = 1.5; 95% CI = 1.1-2.1). Three factors decreased this risk significantly: inability to transfer (HR = 0.5; 95% CI = 0.3-0.8), increased number of children (HR = 0.88; 95% CI = 0.96-0.99), and increased initial Mini-Mental State Examination score (HR = 0.97; 95% CI = 0.8-0.9).
NHA determinants in dementia are strongly linked to the patient's own characteristics but also to his or her physical or social environment. Interventions should target both members of the dyad "patient-caregiver" because both are affected by the disease.
To study the feasibility, effectiveness, adherence, toxicity and viral resistance in an African government HAART initiative.
A prospective observational cohort study started in Dakar in August 1998. ...Initial treatment consisted of two nucleoside reverse transcriptase inhibitors and one protease inhibitor. The patients attended monthly medical examinations. Plasma HIV-1 RNA and CD4 cell counts were determined at baseline and every 6 months. Intention-to-treat analyses were performed.
Fifty-eight treatment-naive patients, mostly infected by HIV-1 strain CRF02-AG, were enrolled. Most were at an advanced stage of HIV disease (86.2% had AIDS). Adherence was good in 87.9% of patients and treatment was effective in most of them. Thus, HIV-1 RNA was undetectable in 79.6, 71.2, 51.4 and 59.3% of patients at months 1, 6, 12 and 18, respectively and the median viral load reduction was approximately 2.5 log10 copies/ml. The CD4 cell count rose by a median of 82, 147 and 180 x 106 cells/l at months 6, 12 and 18, respectively. At the same time points, the cumulative probability of remaining alive or free of new AIDS-defining events was 94.8, 85.0 and 82.3%. Most adverse effects (80.8%) were mild or moderate and only two cases of drug resistance occurred.
This study shows that HAART is feasible and well tolerated in African patients. Clinical and biological results were comparable to those seen in western cohorts, despite differences in the HIV-1 subtype distribution and an advanced disease stage when the treatment was initiated. Contrary to other recent studies in Africa, viral resistance rarely emerged.
To assess the long-term survival, as well as the immunologic and virologic effectiveness, adherence, and drug resistance, in HIV-infected patients receiving highly active antiretroviral therapy ...(HAART) in one of the oldest and best-documented African cohorts.
A prospective observational cohort study included the first 176 HIV-1-infected adults followed in the Senegalese government-sponsored antiretroviral therapy initiative launched in August 1998. Patients were followed for a median of 30 months (interquartile range, 21-36 months). HAART comprised 2 nucleoside reverse transcriptase inhibitors and either 1 protease inhibitor or 1 nonnucleoside reverse transcriptase inhibitor.
At baseline, 92% of patients were antiretroviral naive and 82% had AIDS; the median CD4 count was 144 cells/mm, and median viral load was 202,368 copies/mL. The survival probability was high (0.81 at 3 years; 95% CI, 0.74-0.86) and was independently related to a baseline hemoglobin level <10 g/dL and a Karnofsky score <90%. Antiviral efficacy was consistently observed during the 3 years of treatment (-2.5 to -3.0 log10 copies/mL; 60-80% of patients with viral load <500 copies/mL) and the CD4 count increase reached a median of 225 cells/mm. Most patients reported good adherence (80-90%). The emergence of drug resistance was relatively rare (12.5%).
This study shows that clinical and biologic results similar to those seen in Western countries can be achieved and sustained during the long term in Africa.
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