The "ART" of linkage: pre-treatment loss to care after HIV diagnosis at two PEPFAR sites in Durban, South Africa

Division of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
PLoS ONE (Impact Factor: 3.23). 03/2010; 5(3):e9538. DOI: 10.1371/journal.pone.0009538
Source: PubMed


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.
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.
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.

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    • "New interventions such as PITC may be constrained by broader organisational barriers such as poor patient flow, poor monitoring and evaluation of patients and the absence of mechanisms for recalling HIV positive patients to ensure follow-up visits take place. This study did not investigate these and other components identified as requirements for successful linkage to care - such as for instance, strengthening service delivery and management capacity [18, 20, 35, 36]. "
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    ABSTRACT: BackgroundWe examined linkage to care for patients with sexually transmitted infection who were diagnosed HIV-positive via the provider-initiated HIV testing and counselling (PITC) approach, as compared to the voluntary counselling and testing (VCT) approach, as little is known about the impact of expanded testing strategies on linkage to care.MethodsIn a controlled trial on PITC (Cape Town, 2007), we compared HIV follow-up care for a nested cohort of 930 HIV-positive patients. We cross-referenced HIV testing and laboratory records to determine access to CD4 and viral load testing as primary outcomes. Secondary outcomes were HIV immune status and time taken to be linked to HIV care. Logistic regression was performed to analyse the difference between arms.ResultsThere was no difference in the main outcomes of patients with a record of CD4 testing (69.9% in the intervention, 65.2% in control sites, OR 0.82 (CI: 0.44-1.51; p = 0.526) and viral load testing (14.9% intervention versus 10.9% control arm; OR 0.69 (CI: 0.42-1.12; p = 0.131). In the intervention arm, ART-eligible patients (based on low CD4 test result), accessed viral load testing approximately 2.5 months sooner than those in the control arm (214 days vs. 288 days, HR: 0.417, 95% CI: 0.221-0.784; p = 0.007).ConclusionThe PITC intervention did not improve linkage to CD4 testing, but shortened the time to viral load testing for ART-eligible patients. Major gaps found in follow-up care across both arms, indicate the need for more effective linkage-to-HIV care strategies.Trial registrationCurrent Controlled Trials ISRCTN93692532Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6963-14-350) contains supplementary material, which is available to authorized users.
    BMC Health Services Research 08/2014; 14(1):350. DOI:10.1186/1472-6963-14-350 · 1.71 Impact Factor
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    • "The most important determinants of success in anti-retroviral treatment (ART) programs in South Africa rely on rapid HIV diagnosis, linkage to care, timely treatment initiation, and long-term retention of patients in care [1]. By 2012, South Africa had scaled up its ART services to access approximately 7.1 million people [2] and has 2.5 million people currently receiving treatment [3]. "
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    ABSTRACT: Point of Care testing (POCT) provides on-site, rapid, accessible results. With current South African anti-retroviral treatment guidelines, up to 4 fingersticks /patient/clinic visit could be required if utilizing POC. We determined the feasibility and accuracy of a nurse performing multiple POCT on multiple fingersticks followed by simplification of the process by performance of multiple POC on a single fingerstick. Random HIV positive adult patients presenting at a HIV treatment clinic in South Africa, for ART initiation/ monitoring, were approached to participate in the study between April-June 2012. Phase I: n=150 patients approached for multiple POCT on multiple fingersticks. Phase II: n=150 patients approached for multiple POCT on a single fingerstick. The following POC tests were performed by a dedicated nurse: PIMA (CD4), HemoCue (hemoglobin), Reflotron (alanine aminotransferase, creatinine). A venepuncture specimen was taken for predicate laboratory methodology. Normal laboratory ranges and Royal College of Pathologists Australasia (RCPA) allowable differences were used as guidelines for comparison. In 67% of participants, ≥3 tests were requested per visit. All POCT were accurate but ranged in variability. Phase I: Hemoglobin was accurate (3.2%CV) while CD4, alanine aminotransferase and creatinine showed increased variability (16.3%CV; 9.3%CV; 12.9%CV respectively). PIMA generated a misclassification of 12.4%. Phase II: Hemoglobin, alanine aminotransferase and creatinine showed good accuracy (3.2%CV, 8.7%CV, 6.4%CV respectively) with increased variability on CD4 (12.4%CV) but low clinical misclassification (4.1%). No trends were observed for the sequence in which POC was performed on a single fingerstick. Overall, PIMA CD4 generated the highest error rate (16-19%). Multiple POCT for ART initiation and/or monitoring can be performed practically by a dedicated nurse on multiple fingersticks. The process is as accurate as predicate methodology and can be simplified using a single fingerstick.
    PLoS ONE 12/2013; 8(12):e85265. DOI:10.1371/journal.pone.0085265 · 3.23 Impact Factor
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    • "Studies from Ethiopia, South Africa, Uganda, and Cambodia have demonstrated that there is a high rate of pre-ART mortality and LTFU [5-9]. However, compared to patients who have started ART, less emphasis has been given to the follow-up of pre-ART patients, making them a neglected population [5,10,11]. Unlike the follow-up of PLHIV who are taking ART, there is no standardized definition of LTFU and appointment system for pre-ART patients and this contributes to the challenges of tracing those LTFU in Ethiopia [5]. This gap highlights the need for greater focus upon retention of pre-ART patients from the beginning of HIV care, not just after patients have been initiated on ART. "
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    ABSTRACT: In Ethiopia, there is a growing concern about the increasing rates of loss to follow-up (LTFU) in HIV programs among people waiting to start HIV treatment. Unlike other African countries, there is little information about the factors associated with LTFU among pre-antiretroviral treatment (pre-ART) patients in Ethiopia. We conducted a case--control study to investigate factors associated with pre-ART LTFU in Ethiopia. Charts of HIV patients newly enrolled in HIV care at Gondar University Hospital (GUH) between September 11, 2008 and May 8, 2011 were reviewed. Patients who were "loss to follow-up" during the pre-ART period were considered to be cases and patients who were "in care" during the pre-ART period were controls. Logistic regression analysis was used to explore factors associated with pre-ART LTFU. In multivariable analyses, the following factors were found to be independently associated with pre-ART LTFU: male gender [Adjusted Odds Ratio (AOR) = 2.00 (95% CI: 1.15, 3.46)], higher baseline CD4 cell count (251--300 cells/mul [AOR = 2.64 (95% CI: 1.05, 6.65)], 301--350 cells/mul [AOR = 5.21 (95% CI: 1.94, 13.99)], and >350 cells/mul [AOR = 12.10 (95% CI: 6.33, 23.12)] compared to CD4 cell count of <=200 cells/mul) and less advanced disease stage (WHO stage I [AOR = 2.81 (95% CI: 1.15, 6.91)] compared to WHO stage IV). Married patients [AOR = 0.39 (95% CI: 0.19, 0.79)] had reduced odds of being LTFU. In addition, patients whose next visit date was not documented on their medical chart [AOR = 241.39 (95% CI: 119.90, 485.97)] were more likely to be LTFU. Our study identified various factors associated with pre-ART LTFU. The findings highlight the importance of giving considerable attention to pre-ART patients' care from the time that they learn of their positive HIV serostatus. The completeness of the medical records, the standard of record keeping and obstacles to retrieving charts also indicate a serious problem that needs due attention from clinicians and data personnel.
    BMC Public Health 09/2013; 13(1):867. DOI:10.1186/1471-2458-13-867 · 2.26 Impact Factor
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