Patient retention from HIV diagnosis through one year on antiretroviral therapy at a primary health care clinic in Johannesburg, South Africa

Abstract

Objective: To compare patient retention at 3 stages of pre-antiretroviral (ART) care and 2 stages of post-ART care to identify when greatest attrition occurs.

Design: An observational cohort study.

Methods: We reviewed files of all adult nonpregnant individuals testing HIV-positive January 1-June 30, 2010, at a primary health clinic in Johannesburg, South Africa (N = 842). We classified retention in pre-ART stage 1 (HIV diagnosis to CD4 results notification in ≤3 months), pre-ART stage 2 (initially ineligible for ART with repeat CD4 test ≤1 year of prior CD4), pre-ART stage 3 (initiating ART ≤3 months after first eligible CD4 result), and at 0-6 and 6-12 months post-ART.

Results: Retention among all patients during pre-ART stage 1 was 69.8% [95% confidence interval (CI): 66.7% to 72.9%]. For patients initially ART ineligible (n = 221), 57.4% (95% CI: 49.5% to 65.0%) returned for a repeat CD4 during pre-ART stage 2. Among those who were ART eligible (n = 589), 73.5% (95% CI: 69.0% to 77.6%) were retained during pre-ART stage 3. Retention increased with time on ART, from 80.2% (95% CI: 75.3% to 84.5%) at 6 months to 95.3% (95% CI: 91.7% to 97.6%) between 6 and 12 months. Cumulative retention from diagnosis to 12 months on ART was 36.9% (95% CI: 33.0% to 41.1%) for those ART eligible and 43.0% (95% CI: 36.4% to 49.8%) from diagnosis to repeat CD4 testing within one year among those ART ineligible.

Conclusions: Patient attrition in the first year after HIV diagnosis was greatest before ART initiation: more than 25% at each of 3 pre-ART stages. As countries expand HIV testing and ART programs, success will depend on linkage to care, especially before ART eligibility and initiation.

Figures

Figure 1. Study profile of completion of key stages of early HIV care among 842 newly diagnosed HIV-positive patients at an HIV treatment program in South Africa

Stage completion is dependent on completing the prior stage in the time period specified. Patients eligible for ART per CD4 value at the time of HIV testing skip Pre-ART Stage 2 and move directly to Pre-ART Stage 3. *12 month ART retention data not available by the end of data collection.

Figure 2. Cumulative patient retention from HIV diagnosis through one year on ART for 544 HIV-positive patients eligible for ART, and one year after initial CD4 staging for 207 HIV-positive patients ineligible for ART

Error bars indicate 95% confidence intervals on the proportions. Stage completion is dependent on completing the prior stage in the time period specified. *Patients eligible for ART at the time of HIV testing skip pre-ART stage 2 and proceed directly to pre-ART stage 3. Patients who transferred during the stages shown were excluded from this analysis (n=59).