Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review

Sydney Rosen, Matthew P Fox, Sydney Rosen, Matthew P Fox

Abstract

Background: Improving the outcomes of HIV/AIDS treatment programs in resource-limited settings requires successful linkage of patients testing positive for HIV to pre-antiretroviral therapy (ART) care and retention in pre-ART care until ART initiation. We conducted a systematic review of pre-ART retention in care in Africa.

Methods and findings: We searched PubMed, ISI Web of Knowledge, conference abstracts, and reference lists for reports on the proportion of adult patients retained between any two points between testing positive for HIV and initiating ART in sub-Saharan African HIV/AIDS care programs. Results were categorized as Stage 1 (from HIV testing to receipt of CD4 count results or clinical staging), Stage 2 (from staging to ART eligibility), or Stage 3 (from ART eligibility to ART initiation). Medians (ranges) were reported for the proportions of patients retained in each stage. We identified 28 eligible studies. The median proportion retained in Stage 1 was 59% (35%-88%); Stage 2, 46% (31%-95%); and Stage 3, 68% (14%-84%). Most studies reported on only one stage; none followed a cohort of patients through all three stages. Enrollment criteria, terminology, end points, follow-up, and outcomes varied widely and were often poorly defined, making aggregation of results difficult. Synthesis of findings from multiple studies suggests that fewer than one-third of patients testing positive for HIV and not yet eligible for ART when diagnosed are retained continuously in care, though this estimate should be regarded with caution because of review limitations.

Conclusions: Studies of retention in pre-ART care report substantial loss of patients at every step, starting with patients who do not return for their initial CD4 count results and ending with those who do not initiate ART despite eligibility. Better health information systems that allow patients to be tracked between service delivery points are needed to properly evaluate pre-ART loss to care, and researchers should attempt to standardize the terminology, definitions, and time periods reported.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1. Stages of pre-ART care.
Figure 1. Stages of pre-ART care.
Figure 2. Flow chart of literature search…
Figure 2. Flow chart of literature search on pre-ART retention in care.
Adherence conference, 5th International Conference on HIV Treatment Adherence; CROI, Conference on Retroviruses and Opportunistic Infections; IAS, International AIDS Society; Implementers conference, HIV Implementers Meetings.
Figure 3. Forest plot of the ten…
Figure 3. Forest plot of the ten studies reporting on the proportion of patients completing Stage 1 or steps within Stage 1.
Bars indicate 95% confidence intervals. Studies shown in the plot report to differing end points; refer to Table 2 for details.
Figure 4. Forest plot of the 14…
Figure 4. Forest plot of the 14 studies reporting on the proportion of patients completing Stage 2 or steps within Stage 2.
Bars indicate 95% confidence intervals. Studies shown in the plot report to differing end points; refer to Table 3 for details.
Figure 5. Forest plot of the 14…
Figure 5. Forest plot of the 14 studies reporting on the proportion of patients completing Stage 3 or steps within Stage 3.
Bars indicate 95% confidence intervals. Studies shown in the plot report to differing end points; refer to Table 4 for details.
Figure 6. Summary of proportions of patients…
Figure 6. Summary of proportions of patients completing steps within each stage of pre-ART care in the studies reviewed.

References

    1. World Health Organization, Joint United Nations Programme on HIV/AIDS, United Nations Children's Fund. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector; progress report 2010. Geneva: World Health Organization; 2010. Available: . Accessed 13 June 2011.
    1. Fox MP, Rosen S. Patient retention in antiretroviral therapy programs up to three years on treatment in sub-Saharan Africa, 2007–2009: systematic review. Trop Med Int Health. 2010;15(Suppl 1):1–15.
    1. Brinkhof MW, Dabis F, Myer L, Bangsberg DR, Boulle A, et al. Early loss of HIV-infected patients on potent antiretroviral therapy programmes in lower-income countries. Bull World Health Organ. 2008;86:559–567.
    1. Leisegang R, Cleary S, Hislop M, Davidse A, Regensberg L, et al. Early and late direct costs in a Southern African antiretroviral treatment programme: a retrospective cohort analysis. PLoS Med. 2009;6:e1000189. doi: .
    1. Alcorn K. South Africa to launch mass HIV testing drive in April, to test 15 million in one year. 2010. Mar 25, AIDSMap News, NAM Publications. Available: . Accessed 13 June 2011.
    1. Cornell M, Grimsrud A, Fairall L, Fox MP, van Cutsem G, et al. Temporal changes in programme outcomes among adult patients initiating antiretroviral therapy across South Africa, 2002–2007. AIDS. 2010;24:2263–2270.
    1. Keiser O, Anastos K, Schechter M, Balestre E, Myer L, et al. Antiretroviral therapy in resource-limited settings 1996 to 2006: patient characteristics, treatment regimens and monitoring in sub-Saharan Africa, Asia and Latin America. Trop Med Int Health. 2008;13:870–879.
    1. Geng EH, Nash D, Kambugu A, Zhang Y, Braitstein P, et al. Retention in care among HIV-infected patients in resource-limited settings: emerging insights and new directions. Curr HIV/AIDS Rep. 2010;7:234–244.
    1. Jani I, Sitoe N, Alfai E, Chongo P, Lehe J, et al. Point-of-care CD4 improves patient retention and time-to-initiation of ART in Mozambique [abstract]. 2010. Abstract FRLBE101. XVIII International AIDS Conference; 18–23 July 2010; Vienna, Austria.
    1. Faal M, Naidoo N, Makgamatha L, Venter F, Osih R. Effect of an immediate CD4 result during VCT on patient retention in ART [abstract]. 2010. Abstract TUPE0113. XVIII International AIDS Conference; 18–23 July 2010; Vienna, Austria.
    1. Mtapuri-Zinyowera S, Chideme M, Mangwanya D, Mugurungi O, Gudukeya S, et al. Evaluation of the PIMA point-of-care CD4 analyzer in VCT clinics in Zimbabwe. J Acquir Immune Defic Syndr. 2010;55:1–7.
    1. Larson BA, Ndibongo B, Brennan A, Bistline K, Xulu T, et al. Point-of-care CD4 testing after HIV diagnosis to reduce losses to initiation of antiretroviral therapy: an evaluation of a pilot program at the Themba Lethu Clinic, Johannesburg, South Africa [abstract]. 2011. South African AIDS Conference; 7–10 June 2011; Durban, South Africa.
    1. Larson BA, Bistline K, Ndibongo B, Xulu T, Brennan A, et al. Rapid point-of-care CD4 testing at mobile HIV testing sites to increase linkage to care: an evaluation of a pilot program in South Africa [abstract]. 2011. South African AIDS Conference; 7–10 June 2011; Durban, South Africa.
    1. Kohler P, Chung M, Benki-Nugent S, McGrath C, Attwa M, et al. Free CTX substantially improves retention among ART-ineligible clients in a Kenyan HIV treatment program [abstract]. 2011. Abstract 1018. 18th Conference on Retroviruses and Opportunistic Infections; 28 February–3 March 2011; Boston, Massachusetts, United States of America.
    1. Fraser HS, Allen C, Bailey C, Douglas G, Shin S, et al. Information systems for patient follow-up and chronic management of HIV and tuberculosis: a life-saving technology in resource-poor areas. J Med Internet Res. 2007;9:e29.
    1. Assefa Y, Van D, Mariam DH, Kloos H. Toward universal access to HIV counseling and testing and antiretroviral treatment in Ethiopia: looking beyond HIV testing and ART initiation. AIDS Patient Care STDS. 2010;24:521–525.
    1. Berhanu AL. Confirmed referral for pre-ART and ART services: best practices from USAID/PSP-Ethiopia mobile HIV counseling and testing [abstract]. 2009. Abstract 1462. HIV Implementers Conference; 10–14 June 2009; Windhoek, Namibia.
    1. Mulissa Z, Jerene D, Lindtjørn B. Patients present earlier and survival has improved, but pre-ART attrition is high in a six-year HIV cohort data from Ethiopia. PLoS ONE. 2010;5:e13268. doi: .
    1. Karcher H, Omondi A, Odera J, Kunz A, Harms G. Risk factors for treatment denial and loss to follow-up in an antiretroviral treatment cohort in Kenya. Trop Med Int Health. 2007;12:687–694.
    1. Amolloh M, Medley A, Owuor P, Audi B, Sewe M, et al. Factors associated with early uptake of HIV care and treatment services after testing HIV+ during home-based testing and counseling in rural Western Kenya [abstract]. 2011. Abstract 1077. 18th Conference on Retroviruses and Opportunistic Infections; 28 February–3 March 2011; Boston, Massachusetts, United States of America.
    1. Gareta D, Tweya H, Weigel R, Phiri S, Chiwoko J, et al. Linking HIV-infected pregnant women to antiretroviral therapy: experience from Lilongwe, Malawi [abstract]. 2010. Abstract MOPE0277. XVIII International AIDS Conference; 18–23 July 2010; Vienna, Austria.
    1. Tayler-Smith K, Zachariah R, Massaquoi M, Manzi M, Pasulani O, et al. Unacceptable attrition among WHO stages 1 and 2 patients in a hospital-based setting in rural Malawi: can we retain such patients within the general health system? Trans R Soc Trop Med Hyg. 2010;104:313–319.
    1. Zachariah R, Harries AD, Manzi M, Gomani P, Teck R, et al. Acceptance of anti-retroviral therapy among patients infected with HIV and tuberculosis in rural Malawi is low and associated with cost of transport. PLoS ONE. 2006;1:e121. doi: .
    1. Micek M, Gimbel-Sherr K, Baptista AJ, Matediana E, Montoya P, et al. Loss to follow-up of adults in public HIV care systems in central Mozambique: identifying obstacles to treatment. J Acquir Immune Defic Syndr. 2009;52:397–405.
    1. April MD, Walensky RP, Chang Y, Pitt J, Freedberg KA, et al. Testing rates and outcomes in a South African community, 2001–2006: implications for expanded screening policies. J Acquir Immune Defic Syndr. 2009;51:2001–2006.
    1. Bassett IV, Wang B, Chetty S, Mazibuko M, Bearnot B, et al. Loss to care and death before antiretroviral therapy in Durban, South Africa. J Acquir Immune Defic Syndr. 2009;51:135–139.
    1. Bassett IV, Regan S, Chetty S, Giddy J, Uhler LM, et al. Who starts antiretroviral therapy in Durban, South Africa?…not everyone who should. AIDS. 2010;24(Suppl 1):S37–S44.
    1. Ingle SM, May M, Uebel K, Timmerman V, Kotze E, et al. Outcomes in patients waiting for antiretroviral treatment in the Free State Province, South Africa: prospective linkage study. AIDS. 2010;24:2717–2725.
    1. Kaplan R, Orrell C, Zwane E, Bekker LG, Wood R. Loss to follow-up and mortality among pregnant women referred to a community clinic for antiretroviral treatment. AIDS. 2008;22:1679–1681.
    1. Kranzer K, Zeinecker J, Ginsberg P, Orrell C, Kalawe NN, et al. Linkage to HIV care and antiretroviral therapy in Cape Town, South Africa. PLoS ONE. 2010;5:e13801. doi: .
    1. Larson BA, Brennan A, McNamara L, Long L, Rosen S, et al. Lost opportunities to complete CD4+ lymphocyte testing among patients who tested positive for HIV in South Africa. Bull World Health Organ. 2010;88:675–680.
    1. Larson BA, Brennan A, McNamara L, Long L, Rosen S, et al. Early loss to follow up after enrolment in pre-ART care at a large public clinic in Johannesburg, South Africa. Trop Med Int Health. 2010;15(Suppl 1):43–47.
    1. Lawn SD, Myer L, Harling G, Orrell C, Bekker LG, et al. Determinants of mortality and nondeath losses from an antiretroviral treatment service in South Africa: implications for program evaluation. Clin Infect Dis. 2006;43:770–776.
    1. Lessells RJ, Mutevedzi PC, Cooke GS, Newell ML. Retention in HIV care for individuals not yet eligible for antiretroviral therapy: rural KwaZulu-Natal, South Africa. J Acquir Immune Defic Syndr. 2011;56:e79–e86.
    1. Losina E, Bassett IV, Giddy J, Chetty S, Regan S, et al. The “ART” of linkage: pre-treatment loss to care after HIV diagnosis at two PEPFAR sites in Durban, South Africa. PLoS ONE. 2010;5:8. doi: .
    1. Luseno W, Wechsberg W, Middlesteadt-Ellerson R, Gumula W. Linkages and barriers to care for high-risk South African women testing positive for HIV [abstract]. 2008. Abstract TUPE0209. XVII International AIDS Conference; 3–8 August 2008; Mexico City, Mexico.
    1. Naidoo NP, Faal M, Venter WDF, Osih R. Patient retention-reasons why patients do or do not come back for care after HIV testing [abstract]. 2010. Abstract THPE0798. XVIII International AIDS Conference; 18–23 July 2010; Vienna, Austria.
    1. Govindasamy D, van Schaik N, Kranzer K, Mpali M, Thuebus E, et al. Linkage to HIV care from a mobile testing unit in South Africa by different CD4 count strata [abstract]. 2011. Abstract 1076. 18th Conference on Retroviruses and Opportunistic Infections; 28 February–3 March 2011; Boston, Massachusetts, United States of America.
    1. Nsigaye R, Wringe A, Roura M, Kalluvya S, Urassa M, et al. From HIV diagnosis to treatment: evaluation of a referral system to promote and monitor access to antiretroviral therapy in rural Tanzania. J Int AIDS Soc. 2009;12:31.
    1. Amuron B, Namara G, Birungi J, Nabiryo C, Levin J, et al. Mortality and loss-to-follow-up during the pre-treatment period in an antiretroviral therapy programme under normal health service conditions in Uganda. BMC Public Health. 2009;9:290.
    1. Wanyenze RK, Hahn J, Liechty C, Ragland K, Ronald A, et al. Linkage to HIV care and survival following inpatient HIV counseling and testing. AIDS Behav. 2011;15:751–760.
    1. Geng E, Muyindike W, Glidden D, Bwana M, Yiannoutsos CT, et al. Failure to initiate ART, loss to follow-up and mortality among HIV-infected patients during the pre-ART period in Uganda: Understanding engagement in care in resource-limited settings [abstract]. 2011. Abstract 1017. 18th Conference on Retroviruses and Opportunistic Infections; 28 February–3 March 2011; Boston, Massachusetts, United States of America.

Source: PubMed

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