The "ART" of linkage: pre-treatment loss to care after HIV diagnosis at two PEPFAR sites in Durban, South Africa
Elena Losina, Ingrid V Bassett, Janet Giddy, Senica Chetty, Susan Regan, Rochelle P Walensky, Douglas Ross, Callie A Scott, Lauren M Uhler, Jeffrey N Katz, Helga Holst, Kenneth A Freedberg, Elena Losina, Ingrid V Bassett, Janet Giddy, Senica Chetty, Susan Regan, Rochelle P Walensky, Douglas Ross, Callie A Scott, Lauren M Uhler, Jeffrey N Katz, Helga Holst, Kenneth A Freedberg
Abstract
Background: Although loss to follow-up after antiretroviral therapy (ART) initiation is increasingly recognized, little is known about pre-treatment losses to care (PTLC) after an initial positive HIV test. Our objective was to determine PTLC in newly identified HIV-infected individuals in South Africa.
Methodology/principal findings: We assembled the South African Test, Identify and Link (STIAL) Cohort of persons presenting for HIV testing at two sites offering HIV and CD4 count testing and HIV care in Durban, South Africa. We defined PTLC as failure to have a CD4 count within 8 weeks of HIV diagnosis. We performed multivariate analysis to identify factors associated with PTLC. From November 2006 to May 2007, of 712 persons who underwent HIV testing and received their test result, 454 (64%) were HIV-positive. Of those, 206 (45%) had PTLC. Infected patients were significantly more likely to have PTLC if they lived > or = 10 kilometers from the testing center (RR = 1.37; 95% CI: 1.11-1.71), had a history of tuberculosis treatment (RR = 1.26; 95% CI: 1.00-1.58), or were referred for testing by a health care provider rather than self-referred (RR = 1.61; 95% CI: 1.22-2.13). Patients with one, two or three of these risks for PTLC were 1.88, 2.50 and 3.84 times more likely to have PTLC compared to those with no risk factors.
Conclusions/significance: Nearly half of HIV-infected persons at two high prevalence sites in Durban, South Africa, failed to have CD4 counts following HIV diagnosis. These high rates of pre-treatment loss to care highlight the urgent need to improve rates of linkage to HIV care after an initial positive HIV test.
Conflict of interest statement
Competing Interests: The authors have declared that no competing interests exist.
Figures
References
- UNAIDS/WHO. AIDS epidemic update: December 2007. 2007.
- WHO/UNAIDS/Unicef. Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector. Progress Report. 2007.
- Department of Health SA. HIV and AIDS and STI Strategic Plan for South Africa. 2007. pp. 2007–2011.
- Braitstein P, Brinkhof MW, Dabis F, Schechter M, Boulle A, et al. Mortality of HIV-1-infected patients in the first year of antiretroviral therapy: comparison between low-income and high-income countries. Lancet. 2006;367:817–824.
- Dalal RP, Macphail C, Mqhayi M, Wing J, Feldman C, et al. Characteristics and outcomes of adult patients lost to follow-up at an antiretroviral treatment clinic in Johannesburg, South Africa. J Acquir Immune Defic Syndr. 2008;47:101–107.
- Rosen S, Fox MP, Gill CJ. Patient retention in antiretroviral therapy programs in sub-Saharan Africa: a systematic review. PLoS Med. 2007;4:e298.
- World Development Indicators database, April 2009.: World Bank. 2009.
- Micek MA, 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
- 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.
- Wools-Kaloustian K, Kimaiyo S, Diero L, Siika A, Sidle J, et al. Viability and effectiveness of large-scale HIV treatment initiatives in sub-Saharan Africa: experience from western Kenya. AIDS. 2006;20:41–48.
- Zachariah R, Teck R, Buhendwa L, Fitzerland M, Labana S, et al. Community support is associated with better antiretroviral treatment outcomes in a resource-limited rural district in Malawi. Trans R Soc Trop Med Hyg. 2007;101:79–84.
- Maskew M, MacPhail P, Menezes C, Rubel D. Lost to follow up: contributing factors and challenges in South African patients on antiretroviral therapy. S Afr Med J. 2007;97:853–857.
- Yu JK, Chen SC, Wang KY, Chang CS, Makombe SD, et al. True outcomes for patients on antiretroviral therapy who are “lost to follow-up” in Malawi. Bull World Health Organ. 2007;85:550–554.
- Krebs DW, Chi BH, Mulenga Y, Morris M, Cantrell RA, et al. Community-based follow-up for late patients enrolled in a district-wide programme for antiretroviral therapy in Lusaka, Zambia. AIDS Care. 2008;20:311–317.
- Bisson GP, Gaolathe T, Gross R, Rollins C, Bellamy S, et al. Overestimates of survival after HAART: implications for global scale-up efforts. PLoS ONE. 2008;3:e1725.
- 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.
- 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.
- Geng EH, Emenyonu N, Bwana MB, Glidden DV, Martin JN. Sampling-based approach to determining outcomes of patients lost to follow-up in antiretroviral therapy scale-up programs in Africa. JAMA. 2008;300:506–507.
- Bassett I, 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.
Source: PubMed