Ten-year survival of patients with aids receiving aniretroviral therapy in Haiti and lessons learned from the survivors

摘要

Background: Long-term outcomes of antiretroviral therapy (ART) in resource-poor settings are unknown. Understanding the psychosocial and contextual factors that enable patients living with HIV/AIDS to survive at least 10 years after the initiation of ART is necessary. Given Haiti's unique and fragile political and economic infrastructure, we describe the 10-year outcomes, characteristics of the first cohort of patients receiving ART in Haiti, and the experience of the 10-year survivors in the following chapters.;Methods: Data from 910 patients, age ≥ 13 years, who initiated ART from 2003-2004 were included. Lost-to follow-up (LTF) was defined as no clinic/pharmacy visit within 180 days of the date of censor. Kaplan Meier, contact tracing with inverse probability weighting, and multiple imputation methods were used to estimate survival. Cox modeling and logistic regression were used to identify characteristics associated with survival. Additionally, individual audiotaped in-depth interviews that lasted 45 to 60 minutes using a semi-structured open-ended format were conducted with 25 participants who survived at least 10 years with AIDS, in between January 2015 and August 2015. Grounded theory approach was used for data collection and analysis. Each interview was then transcribed verbatim and back-translated from Creole to English. Questions focused on understanding how participants survived in the midst of challenges faced by the 10-year survivors since starting ART, coping strategies used to overcome those challenges, accomplishments that they made during those 10 years, and their hopes.;Results: Among 910 adults who initiated ART, 55% were female, median age was 38 years, and median CD4+ was 131 cells/uL (IQR 57-212). Ten years after ART initiation, 53% were alive, 27% dead, 12% were LTF, and 8% transferred care. Ten-year survival estimates ranged from 63--71%. Forty-two percent of deaths occurred in the first 6 months; characteristics associated with early death were being male, age > 50 years, low weight, WHO Stage III/IV, and baseline TB. Characteristics associated with death after 6 months were age > 50 years, income < $1 per day, low weight, and low adherence. Among 10-year survivors, 58% were female, median age was 49 years (IQR43-55), and median CD4+ was 541 cells/uL. Seventy-three percent remained on first-line therapy and 38% had a chronic non-communicable disease. We integrated our core findings into an explanatory framework. The 25 participants described stressors aside from HIV, including poverty, sociopolitical challenges and stigmatization that are counterbalanced with positive outlook and the fact of having a goal. Psychosocial factors like caring for one's child, spirituality and faith, the role of providers and adherence to antiretroviral helped them to look past the disease and have another meaning to theirs lives in order to survive the 10 years of ART.;Conclusion: The 10-year survival of patients with AIDS receiving ART in Haiti is approximately 70%, which demonstrates the long-term sustainability of international efforts to provide ART in resource-poor settings. Aside the devastating health impacts of HIV itself, there was an underlying current of resilience, hope, and the desire to live. As described in the second study, women with children wanted to work and support their children's education. This study provides a portrait of Haiti that is not defined by death or hopelessness.