The ‘‘ART’’ of Linkage: Pre-Treatment Loss to Care after
HIV Diagnosis at Two PEPFAR Sites in Durban, South
Elena Losina1,4,5,6,8*, Ingrid V. Bassett1,2,8, Janet Giddy10, Senica Chetty10, Susan Regan1,8, Rochelle P.
Walensky1,2,3,7,8,9, Douglas Ross11, Callie A. Scott1, Lauren M. Uhler1, Jeffrey N. Katz4,5,9, Helga Holst10,
Kenneth A. Freedberg1,2,6,7,8,9
1Division of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America, 2Division of Infectious Disease, Massachusetts General
Hospital, Boston, Massachusetts, United States of America, 3Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America,
4Department of Orthopedics, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America, 5Division of Rheumatology, Brigham and Women’s
Hospital, Boston, Massachusetts, United States of America, 6Departments of Biostatistics and Epidemiology, Boston University School of Public Health, Boston,
Massachusetts, United States of America, 7Center for AIDS Research, Harvard Medical School, Boston, Massachusetts, United States of America, 8Department of Medicine,
Harvard Medical School, Boston, Massachusetts, United States of America, 9Departments of Epidemiology and Health Policy and Management, Harvard School of Public
Health, Boston, Massachusetts, United States of America, 10Department of Medicine, McCord Hospital, Durban, South Africa, 11Department of Medicine, St. Mary’s
Hospital, Durban, South Africa
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 $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.
Citation: Losina E, Bassett IV, Giddy J, Chetty S, Regan S, et al. (2010) The ‘‘ART’’ of Linkage: Pre-Treatment Loss to Care after HIV Diagnosis at Two PEPFAR Sites in
Durban, South Africa. PLoS ONE 5(3): e9538. doi:10.1371/journal.pone.0009538
Editor: Cesar Augusto Ugarte-Gil, Instituto de Medicina Tropical Alexander Von Humboldt, Peru
Received September 3, 2009; Accepted February 11, 2010; Published March 4, 2010
Copyright: ? 2010 Losina et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was supported by the US National Institute of Allergy and Infectious Diseases (R01 AI058736, K24 AI062476, K23 AI068458), the Harvard
University Center for AIDS Research P30 AI42851, National Institutes of Health K24 AR 02123, the Doris Duke Charitable Foundation (Clinical Scientist
Development Award), and the Harvard University Program on AIDS (HUPA). The funders had no role in study design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: email@example.com
While the AIDS epidemic continues to devastate sub-Saharan
Africa, where it remains the leading cause of death , substantial
progress has been made in efforts to provide HIV care and
treatment to those in need. In South Africa, antiretroviral therapy
(ART) rollout began in 2004, and by December 2006, ART had
reached 32% of those eligible for treatment . The South African
Department of Health made access to care a top priority in its
National Strategic Plan for HIV/AIDS that was unveiled in March
2007 . In addition to reducing the number of new infections, the
primary aim of this plan is expanding access to treatment and
support services to reach 80% of HIV-infected people in need .
Maximal effectiveness of ART depends on timely HIV
diagnosis, linkage to care, treatment initiation, and retention in
care. The success of ART programs in South Africa depends in
large part on the ability to identify HIV-infected individuals, to
determine ART eligibility and monitor those not yet eligible for
ART to facilitate timely transition to treatment, to initiate care
among those eligible, and to ensure sustainable access to care over
time. High rates of loss to follow-up (LTFU) following ART
initiation have been reported from many sites [4–6]. A recent
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review of ART programs in sub-Saharan Africa found rates of
LTFU ranging from 20% at 6 months to nearly 40% at 2 years
after ART initiation . While these studies describe the rates of
LTFU after ART initiation, there is a paucity of data on loss to
care after HIV diagnosis, but prior to initiating ART. Our
objective was to examine the rates of pre-treatment loss to care
(PTLC) and to determine factors associated with a higher
likelihood of PTLC for newly diagnosed HIV-infected persons.
We obtained written, informed consent from all study
participants. The protocol, questionnaires, and consent forms
were approved by the McCord Hospital Ethics Committee, the
Ethics Committee of St. Mary’s Hospital Mariannhill, and the
Partners HealthCare Human Research Committee in Boston,
We conducted a prospective cohort study in two sites in
KwaZulu-Natal, the province with the highest HIV prevalence in
South Africa . McCord Hospital, located in Durban, is a
Christian, 142-bed state-aided (public/private partnership) general
hospital serving a predominantly urban population from the
greater Durban area, as well as more distant parts of KwaZulu-
Natal. McCord charges subsidized fees for services and treatment.
ART has been available since 2001, but prior to the President’s
Emergency Plan for AIDS Relief (PEPFAR)-funded scale-up of
ART in 2004, patients had to pay the full cost of their treatment,
which averaged 900-1500 Rand per month ($125-$210 US, 2007),
because of the high cost of ARV drugs. Gross national income per
capita in South Africa was $5,730 US in 2007 . Since PEPFAR
implementation in 2004, HIV-infected patients pay a subsidized,
inclusive monthly fee of 140 Rand ($20 US, 2007), which covers all
clinic visits, laboratory testing, and medications. Currently over
10,000 people have enrolled in the HIV program at McCord, of
which over 6,800 have begun ART. Throughout this report,
McCord Hospital is referred to as the ‘urban hospital.’
St. Mary’s Hospital Mariannhill, located 20 kilometers west of
Durban, is a Catholic, state-aided, 200-bed general district
hospital serving a poorer population from a defined catchment
area in the surrounding communities. St. Mary’s Hospital serves
primarily to the healthcare needs of the ‘‘poorest of the poor’’
living in rural and peri-urban areas of the Durban Metropolitan
area. A higher state subsidy enables St. Mary’s to charge lower fees
for all services than McCord. The iThemba Family Care Centre,
based at St. Mary’s, began offering ART in February 2003, and is
free of charge to patients. Since then, over 3,900 people have had
access to ART there. In this report we refer to St. Mary’s as the
Comprehensive care services at both hospitals include
outpatient medical care, social work, psychological services,
pastoral care, and training and income generation projects for
support group members. Both hospitals have been awarded
PEPFAR funding to expand the number of patients on ART.
Other sources of funding include the KwaZulu-Natal Provincial
Department of Health and subsidized patient fees for McCord
Hospital and the Department of Health and hospital-raised
funds for St. Mary’s Hospital. Together these sites have more
patients on treatment and more years of experience in treating
patients on ART than any other sites in the KwaZulu-Natal,
South Africa public sector.
HIV Testing Protocols
The urban hospital offered HIV testing, counseling, and
referral, using rapid HIV tests. Patients eligible for the study were
offered testing in the outpatient department. Patients generally
received HIV test results within 30 minutes of testing. Those with
a positive initial rapid HIV test underwent confirmatory testing
with a rapid HIV test from a second manufacturer. Patients
diagnosed with HIV were referred to the HIV clinic in an adjacent
building, approximately 300 meters away. There, CD4 testing via
venipuncture was offered to patients who registered and paid the
clinic registration fee of 90 Rand ($12 US, 2007). Venipuncture
specimens were sent to the National Health Laboratory Service or
Global Laboratories (both located in Durban) for flow cytometry.
The rural hospital’s protocol for HIV testing was based on a
venipuncture for a standard ELISA (Centaur XP, Siemens
Healthcare Diagnostics, Deerfield, IL, USA or Roche E170,
Roche, Basel, Switzerland). Patients eligible for the study were
offered HIV testing at the primary health care clinic. Patients were
asked to return for HIV test results within two weeks of HIV
testing. Positive results were confirmed with a Western Blot. CD4
testing for HIV-infected patients was offered at the same site free
of charge to the patients immediately after they received an HIV-
positive test result. Venipuncture specimens were sent to the
National Health Laboratory Service or Lancet Laboratories (both
located in Durban) for flow cytometry, and patients had to return
for the results after one month.
All English or Zulu speaking adults ($18 years old) who
presented for HIV testing at each of the study hospitals between
November 2006 and May 2007 were eligible for enrollment in the
South African Test, Identify and Link (STIAL) Cohort, provided
they were able to give informed consent, were not pregnant, did
not present to care in a stretcher or wheelchair, were not already
known to be HIV-infected, and were willing to share HIV test
results with research staff. Those enrolled were asked to fill out a
voluntary baseline questionnaire, offered in English or Zulu by
trained study personnel. For study participants who were newly
identified as HIV-infected at the study visit, medical record review
was done within 12 weeks of study enrollment to document receipt
of HIV test results, presence of follow-up for CD4 count, and
results of the CD4 count test.
Patient level data were collected in the following four domains:
Demographic characteristics included age, gender, marital status,
primary language spoken at home, educational attainment,
employment status, and household composition.
Geographic characteristics included self-reported distance be-
tween the participant’s residence and the health center, time
spent traveling from home to the center, and mode of
transportation to reach the clinic.
Clinical characteristics were self-reported and included
reasons for visiting the hospital, means of referral for
HIV testing, history of tuberculosis (TB), frequency of
using health care services during the prior 6 months and
self-rated health. Self-rated health was ascertained using
one question asking about rating a person’s health
between ‘very good’, ‘good’, ‘fair’ and ‘poor’. The
‘excellent’ category from a standard 5-point self-rating
of health was omitted due to the lack of differentiation in
Zulu between ‘excellent’ and ‘very good’.
Loss after HIV Diagnosis
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Laboratory information obtained from clinic records included
dates and results of HIV test and CD4 count for those who
had CD4 tests.
1) Study outcomes.
pre-treatment loss to care (PTLC)—was defined by the authors as
failure to undergo a CD4 count within 8 weeks of receiving an
HIV-positive test result. Thus, PTLC was calculated as the
number of newly diagnosed HIV-infected study participants who
did not return for a CD4 test within 8 weeks of HIV diagnosis
divided by the total number of newly diagnosed HIV-infected
Bi-variate and multivariate analyses were
performed to determine the independent predictors of PTLC.
Variables exhibiting association with outcomes at a bi-variate risk
ratio (RR) of $1.5 or #0.60 or at a p-value of ,0.10 were
advanced into multivariate models to control for confounding and
to estimate the independent impact of each factor on PTLC. Log-
linear models were utilized for multivariate analysis to estimate risk
ratios (RR), since PTLC was not a rare outcome and odds ratios
would not accurately estimate risk ratios. We implemented a two-
level model building strategy. First, we built models within each of
3 domains: clinical, demographic, and geographic. Then, we
developeda series ofhierarchical
demographic+geographic, and demographic+geographic+clinical)
to determine the most parsimonious overall model.
Because patient factors associated with a higher likelihood of
PTLC may be inter-correlated, we combined them into a single
measure which we termed the ‘index of vulnerability for pre-
treatment loss to care.’ This measure was calculated as the sum of
the following characteristics, which emerged as predictors of
PTLC in multivariate analysis: $10 km distance between patient
residence and site of care, a history of treatment for TB, and
referral for HIV test by a medical care provider as opposed to self-
referral. The ‘index of vulnerability’ values could range from 0 (no
risk factors) to 3 (all 3 risk factors). We estimated a dose-response
relationship between the index of vulnerability and PTLC by
calculating a p-value for linear trend. We also estimated the risk
ratio of PTLC for persons with various numbers of risk factors
compared to persons who had none of the risk factors. All analyses
were carried out using Stata statistical software (Stata Statistical
Software Release 9, StataCorp, College Station, TX, USA).
The primary outcome of the study—
Among 1,081 persons screened for the study between
November 2006 and May 2007 at the two hospitals, 827 were
eligible, and 767 (93%) of those eligible enrolled. The percent
eligible among those screened did not differ by site (76% at the
rural hospital vs. 77% at the urban hospital), but those eligible
were more likely to enroll at the rural hospital than at the urban
hospital (97% vs. 90%, p,0.001). The most common reasons for
ineligibility were having had a previous positive HIV test,
unwillingness to share test results with research staff, and age
,18 years (Figure 1). Almost all enrollees indicated Zulu as their
primary language. Eighty percent of enrollees were ,45 years of
age and 54% were male (Table 1). These characteristics were
similarly distributed among study participants from both centers.
Overall, 25% of study participants had primary school education
or no formal education and 34% had completed matric (equivalent
to completing high school in the US school system) or had received
higher education. The educational level varied between the sites,
with 30% of study participants at the urban hospital having had
primary education or less compared to 18% of study participants
at the rural hospital. Seventy-two percent of study participants
enrolled at the rural hospital reported living $10 km from the
center compared to 45% of study participants from the urban
Of 712 enrolled patients who were tested and received
conclusive results, 454 were HIV-infected, for an overall HIV
prevalence of 64% (95% CI: 60%-67%). HIV prevalence was
significantly higher among study subjects enrolled at the rural
hospital, with 243 of 330 enrollees HIV-infected (74%; 95% CI:
69–78%) compared to subjects enrolled at the urban center, with
211 of 382 enrollees HIV-infected (55%; 95% CI: 50%–60%).
HIV prevalence was similar between men and women, and no
significant association was found between prevalence of HIV and
level of education, employment status, or marital status. Among
study participants reporting a history of being treated for TB (9%
at the urban hospital vs. 19% at the rural hospital; 14% overall),
the prevalence of HIV was 65% in the urban center and 79% in
the rural center (74% overall). One hundred thirty-two (62%) of
those receiving CD4 counts and their results had CD4 counts
,200/ml (68% at the urban hospital and 60% at the rural hospital,
p=0.238; Figure 1).
Factors Associated with Pre-Treatment Loss to Care
Nearly half of the 454 newly diagnosed HIV-infected persons
(206; 45%) had PTLC (Table 2). In multivariate analysis, patients
who lived $10 km from the center (RR=1.37; 95% CI: 1.11–
1.71), patients with a history of being treated for TB (RR=1.26;
95% CI: 1.00–1.58), and patients referred for HIV testing by a
health care provider rather than self-referred (RR=1.61; 95% CI:
1.22–2.13) were more likely have PTLC. Notably, an additional
36 patients (15%) who had a CD4 count within 8 weeks did not
return for the results of that CD4 count (Figure 1).
The distribution of the index of vulnerability for PTLC was
similar across the two hospitals. Five percent of all HIV-infected
persons had all three risk factors ($10 km from the center, history
of TB treatment, and referral by a medical care provider), 36%
had two risk factors, 48% had one risk factor, and only 10% had
none of these risk factors. HIV-infected study participants with
one, two and three of these risk factors for PTLC were 1.88, 2.50
and 3.84 times more likely to have PTLC compared to study
participants with no risk factors (p-value for linear trend ,0.0001).
A greater number of risk factors led to a higher likelihood of PTLC
in both the urban and the rural center, as well as the two centers
combined (Figure 2).
In a population-based cohort presenting for HIV testing at two
South African HIV outpatient sites, we found that nearly half of
newly diagnosed HIV-infected persons had pre-treatment loss to
care (PTLC) as defined by not following up with a CD4 count.
Factors associated with higher rates of PTLC were: living $10 km
from the health center, a history of TB treatment, and referral for
HIV testing by a health care provider as opposed to self-referral.
However, even among patients with none of these risk factors, a
high proportion (21%) were still lost to care before initiating
treatment. Among those who did return for a CD4 count, 62%
had advanced HIV disease (CD4 count ,200/ml).
Loss after HIV Diagnosis
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We have found a small number of published studies that have
examined loss to care prior to starting ART among patients newly
diagnosed with HIV infection in resource-scarce settings [8,9].
Although risk factors identified for loss to follow-up (LTFU) from
studies in Africa include male sex  and lack of community
support , the current study may not be directly comparable to
studies on LTFU, since there may be different reasons for loss to
care prior to and after initiation of treatment. Loss to care prior to
ART initiation could be due to a number of causes, including
stigma and denial of HIV diagnosis, perceived need for repeat
testing, transfer to another clinic, or death.
Several studies in Africa have tracked patients who failed to
keep clinic appointments and ascertained their reasons for
nonattendance. Detailed tracking has revealed high rates of
mortality among those considered lost, with 27–59% mortality in
patients whose status could be determined [5,12–15]. Of those still
alive who could be reached, the most commonly reported reasons
for nonattendance at clinic appointments were transfer to another
clinic [5,13,16,17] as well as financial reasons, including the high
cost of transportation and the cost of the visit itself [12,16,18]. The
current study, showing a greater risk of PTLC for patients living
$10 km from the hospital, supports findings from studies that
have tracked missing patients and found that the logistics of getting
to a distant clinic are a major reason why patients fail to return to
their site of care [12,13,18]. Following receipt of their HIV-
positive test result, patients may have chosen to pursue HIV care
at a center other than one of the study sites. There are
approximately 20 alternative accredited ART initiation centers
in the greater Durban area, with a denser distribution around the
urban hospital. The greater number of alternative locations to
initiate HIV care may contribute to the higher rate of PTLC we
observed at the urban hospital.
Previous research has also shown that cost to the patient is a
deterrent to continuing in HIV care [12,16,18]. Our findings are
consistent with these studies, as we saw higher rates of PTLC when
a fee for CD4 testing was charged at the urban center, compared
to the rural center, which did not impose charges for CD4 testing.
The differential rates of PTLC persisted between centers, even
after adjusting for differences in demographic, clinical, or
geographic factors; the difference may be due to structural
features at the clinics, such as the cost of the CD4 test. In a
recent review of retention in ART programs in sub-Saharan
Africa, programs that did not require any payment from patients
had higher retention rates at six months compared to those
requiring partial or full payment . Furthermore, investigators
from the ART-LINC Collaboration examining mortality after one
year in 18 ART programs in low-income countries found that
access to treatment free of charge to the patient was associated
with lower mortality .
Our finding that patients self-referred for HIV testing have lower
rates of PTLC compared to patients referred by health care providers
suggest that patients referring themselves for an HIV test are likely
Figure 1. Study enrollment, HIV testing and CD4 testing flow chart. PTLC: Pre-treatment loss to care.
Loss after HIV Diagnosis
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moremotivated to follow-up with subsequent care. Those referred by
therefore less prepared to deal with the consequences of knowing
their HIV-positive status in the short term. These findings suggest
that physicians referring patients for HIV testing should consider
effective. In addition to possibly being less motivated, patients
referred for HIV testing by a physician may be sicker than self-
Table 1. Site-stratified and overall characteristics of a cohort of persons presenting for HIV testing in two PEPFAR sites, Durban,
FactorUrban Rural Overall
Total 382 (100)211 (55) 330 (100)243 (74) 712 (100) 454 (64)
Under 45 299 (78)176 (59)267 (82) 205 (77)566 (80)381 (67)
45 and over 83 (22)35 (42) 58 (18)34 (59)141 (20)69 (49)
Male 193 (51) 113 (59) 195 (59)142 (73)388 (54)255 (66)
Female 189 (49) 98 (52) 135 (41) 101 (75)324 (46) 199 (61)
Primary or none112 (30) 61 (54) 60 (18)43 (72)172 (25) 104 (60)
Some high school 108 (29)70 (65)184 (56)139 (76)292 (42) 209 (72)
Matriccor more 154 (41)76 (49) 83 (25)58 (70) 237 (34)134 (57)
No full-time job195 (52) 104 (53)190 (58) 141 (74) 385 (55)245 (64)
Full-time job183 (48) 105 (57)137 (42)100 (73) 320 (45)205 (64)
Unmarried/Lives alone 42 (12) 26 (62)51 (16)37 (73) 93 (14)63 (68)
Unmarried/Lives with others 204 (60)131 (64)224 (69) 170 (76)428 (64) 301 (70)
Married/With children83 (24) 29 (35)30 (9)18 (60)113 (17) 47 (42)
Married/No children12 (4) 5 (42)19 (6) 14 (74)31 (5)19 (61)
Distance from home to facility**
,10 kilometers211 (55)111 (53)90 (28)54 (60)301 (43)165 (55)
$10 kilometers171 (45)100 (58)232 (72)185 (80)403 (57)285 (71)
TB treatment history**
Yes34 (9)22 (65) 63 (19)50 (79)97 (14)72 (74)
No347 (91)189 (54)267 (81)193 (72)614 (86)382 (62)
Reason for HIV testing**
Referred by health care provider322 (85)181 (56)139 (42)103 (74)461 (65) 284 (62)
Self- or other referral57 (15)28 (49)191 (58) 140 (73)248 (35) 168 (68)
Self-rating of health**
Very good8 (2)3 (38)20 (6)8 (40)28 (4)11 (39)
Good237 (64)115 (49)123 (38)80 (65)360 (52)195 (54)
Fair117 (32)82 (70)124 (38) 96 (77)241 (35)178 (74)
Poor/bad7 (2)5 (71) 60 (18)57 (95)67 (10)62 (93)
a% of total at hospital or overall.
b% of total in category.
cEquivalent to completing high school in the US school system.
*denotes p-values 0.01,p,0.05 in comparing characteristics across two sites.
**denotes p-values p,0.001 in comparing characteristics across two sites.
Loss after HIV Diagnosis
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referred patients, and therefore more likely to have died or been
hospitalized at another site. Similarly, patients with a history of TB
treatment may have had greater PTLC because they were more
immune-compromised than other patients, and may have died or
been too sick to return to the care center.
This study has several limitations. We relied on several self-
reported measures, including distance from site of care and history
of TB treatment. While the findings of this study may apply to
settings similar to the two sites in Durban, it may not be possible to
generalize the findings to all of South Africa, or to other resource-
Table 2. Factors associated with pre-treatment loss to care after HIV diagnosis in a cohort of newly diagnosed HIV-infected
persons in two PEPFAR sites, Durban, South Africa, 2006–2007.
N (total) % PTLCCrude RR (95% CI) Adjusted RR (95% CI)
45 and over6936.2 1.00 1.00
Under 45 381 46.71.29 (0.93, 1.80)1.30 (0.95, 1.78)
Female199 43.2 1.001.00
Male25547.1 1.09 (0.89, 1.34) 1.13 (0.93, 1.38)
Primary or none 104 43.31.00
Some high school 209 45.9 1.06 (0.81, 1.38)
Matricaor more134 45.51.05 (0.79, 1.40)
No full-time job 245 43.31.00
Full-time job 205 47.81.10 (0.90, 1.35)
Unmarried/Lives alone 6346.0 1.00
Unmarried/Lives with others 301 45.9 1.00 (0.74, 1.34)
Married/With children47 51.1 1.11 (0.75,1.63)
Married/No children19 36.80.80 (0.42, 1.53)
N (total)% PTLC Crude RR (95% CI)Adjusted RR (95% CI)
Distance from home to facility
,10 kilometers 16540.6 1.00 1.00
$10 kilometers 285 48.81.20 (0.96, 1.50) 1.37 (1.11, 1.71)
Site of care
Rural hospital243 37.0 1.00 1.00
Urban hospital 211 55.0 1.48 (1.21, 1.82) 1.40 (1.12, 1.77)
TB treatment history
No 382 44.0 1.001.00
Yes72 52.8 1.20 (0.94, 1.54) 1.26 (1.00, 1.58)
Reason for testing
Self- or other referral16831.0 1.001.00
Referred by health care provider284 54.2 1.75 (1.36, 2.25)1.61 (1.22, 2.13)
Self-rating of health
Very good11 54.6 1.00
Good 19547.20.86 (0.49, 1.51)
Fair17843.30.79 (0.45, 1.40)
Poor/bad 62 41.90.77 (0.42, 1.42)
RR: risk ratio.
CI: confidence interval.
aEquivalent to completing high school in the US school system.
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limited settings. We also used data for patient CD4 follow up at the
site of the HIV test for only 8 weeks following receipt of a positive
HIV test result. If patients returned after more than 8 weeks, or
had a CD4 count done at another site, those results were not
reflected in this study.
Despite these limitations, this study also has several methodo-
logical strengths. The first lies in the unique nature of the cohort:
enrollment was offered at the time of HIV testing, prior to
knowledge of HIV status, and was therefore not biased by the HIV
test results. We enrolled patients consecutively, minimizing
selection bias. Data were collected by study staff not involved in
the care of patients. Finally, the study personnel recruiting patients
were bilingual in English and Zulu, ensuring clear communication
between study participants and staff.
The major finding of this study is that nearly half of newly
diagnosed HIV-infected patients at two sites in South Africa had
pre-treatment loss to care; they failed to obtain a CD4 count
within 8 weeks after initial HIV diagnosis. Since a CD4 count is
the first step toward linkage to effective HIV care and toward
determining eligibility for ART, these findings—and appropriate
remedies—are critical to ensure the success of HIV treatment
scale-up efforts in South Africa. Of those who did obtain a CD4
count and result, nearly two-thirds had advanced HIV disease
(CD4,200/ml) and thus met guidelines for beginning antiretro-
viral therapy. This high proportion of patients presenting with
advanced disease highlights the urgent need to identify HIV-
infected patients earlier in the course of their illness. One recent
study from South Africa reported 34% mortality in patients lost to
follow up prior to ART initiation . Another recent South
African study found rates of pre-treatment mortality of over 30 per
100 person-years and early treatment mortality rates of almost 20
per 100 person-years .
Understanding reasons for pre-treatment loss to care is critical
for the development of targeted interventions to increase the
number of people who access and remain in HIV care. This
significant rate of loss to care warrants the expansion of adherence
and retention efforts focused on those starting ART to all persons
from the time they receive an initial HIV-positive test result.
Strategies to increase pre-treatment linkage to care might include
providing reimbursement for transportation to the clinic, provid-
ing CD4 testing free of charge to the patient, and contacting
patients with reminders about appointments and test results. The
substantial loss of patients after their initial HIV-positive test
result, and prior to initiating HIV care, highlights the urgent need
for strategies to be developed to improve successful linkage to care
and retention in South Africa.
The authors thank the study’s research assistants: Nompumelelo Badumuti,
Success Mabunda, Aletta Maphasa, Yolisa Mgobhozi, and Lindeni
Sangweni. Presented in part at the XVII International AIDS Conference,
Mexico City, August 3–8, 2008.
Conceived and designed the experiments: EL IVB RPW KAF. Performed
the experiments: EL IVB SC. Analyzed the data: EL SR. Contributed
reagents/materials/analysis tools: IVB SC SR CAS LMU. Wrote the
paper: EL. Supervised study enrollment and follow-up at McCord
Figure 2. Likelihood of pre-treatment loss to care following an initial HIV-positive test, Durban, South Africa, 2006–2007.
Loss after HIV Diagnosis
PLoS ONE | www.plosone.org7 March 2010 | Volume 5 | Issue 3 | e9538
Hospital: JG HH. Coordinated study enrollment and follow-up at both Download full-text
South African sites: SC. Managed the database in Boston: SR. Contributed
to the design of the study: RPW JK. Supervised study enrollment and
follow-up at St. Mary’s Hospital: DR. Contributed to writing the paper:
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