Who starts antiretroviral therapy in Durban, South Africa?… not everyone who should

Division of Infectious Disease, Massachusetts General Hospital, Boston, MA 02114, USA.
AIDS (London, England) (Impact Factor: 6.56). 01/2010; 24 Suppl 1(Suppl 1):S37-44. DOI: 10.1097/01.aids.0000366081.91192.1c
Source: PubMed

ABSTRACT To evaluate rates of antiretroviral therapy (ART) initiation within 12 months of a new HIV diagnosis in Durban, South Africa.
Prospective observational cohort.
Adults (>or=18 years) were enrolled before HIV testing at two outpatient clinics into the South African Test, Identify and Link cohort. Both sites offer comprehensive HIV care. HIV test results, CD4 cell counts, dates of ART initiation and dates of death were collected from medical records and 12-month patient/family interviews were conducted. ART eligibility was defined as a CD4 cell count less than 200 cells/microl within 90 days of HIV diagnosis. The primary endpoint was ART initiation within 12 months for ART-eligible subjects.
From November 2006 to October 2008, 1474 newly diagnosed HIV-infected outpatients were enrolled, 1012 (69%) of whom underwent CD4 cell count testing within 90 days. The median CD4 cell count was 159 cells/microl (interquartile range 65-299). Of those who underwent CD4 cell count testing, 538 (53%) were ART-eligible. Only 210 (39%) eligible enrollees were known to have initiated ART within 12 months. Among ART-eligible subjects, there were 108 known deaths; 82% occurred before ART initiation or with unknown ART initiation status. Men [rate ratio (RR) 1.3, 95% confidence interval (CI) 1.1-1.5] and subjects without an HIV-infected family member/friend (RR 1.3, 95% CI 1.1-1.7) were more likely not to start ART.
Less than half of ART-eligible subjects started ART within 12 months. Substantial attrition and mortality follow HIV diagnosis before ART initiation in Durban, South Africa. Major efforts directed towards earlier HIV diagnosis, effective linkage to care and timely ART initiation are urgently needed.

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    • "However, the majority of patients enter into care late both in developed and developing countries (Adler, Mounier-Jack & Coker, 2009; Althoff et al., 2010; Alvarez-Uria et al., 2012c; Girardi, Sabin & Monforte, 2007). One of the most important reasons for this late presentation is the poor linkage between healthcare centres performing HIV testing and ART centres (Bassett et al., 2010; Kranzer et al., 2010; Larson et al., 2010; Losina et al., 2010). "
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    ABSTRACT: Studies from sub-Saharan Africa have shown that a substantial proportion of patients diagnosed with HIV enter into HIV medical care late. However, data from low or middle-income countries outside Africa are scarce. In this study, we investigated risk factors associated with delayed entry into care stratified by gender in a large cohort study in India. 7701 patients were diagnosed with HIV and 5410 entered into care within three months of HIV diagnosis. Nearly 80% entered into care within a year, but most patients who did not enter into care within a year remained lost to follow up or died. Patient with risk factors related to having a low socio-economic status (poverty, being homeless, belonging to a disadvantaged community and illiteracy) were more likely to enter into care late. In addition, male gender and being asymptomatic at the moment of HIV infection were factors associated with delayed entry into care. Substantial gender differences were found. Younger age was found to be associated with delayed entry in men, but not in women. Widows and unmarried men were more likely to enter into care within three months. Women belonging to disadvantaged communities or living far from a town were more likely to enter into care late. The results of this study highlight the need to improve the linkage between HIV diagnosis and HIV treatment in India. HIV programmes should monitor patients diagnosed with HIV until they engage in HIV medical care, especially those at increased risk of attrition.
    PeerJ 06/2013; 1:e90. DOI:10.7717/peerj.90 · 2.10 Impact Factor
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    • "Figure 1 shows the number of studies that reported on different time periods between HIV diagnosis and ART start. Six studies, conducted in four different countries covered the whole time period (Micek et al. 2009; Bassett et al. 2010; Ingle et al. 2010; Kranzer et al. 2010; Tayler- Smith et al. 2010; Kohler et al. 2011) from HIV testing to start of ART. Most studies provided information for the time between ART eligibility and ART start (21 studies, 18 included in meta-analysis). "
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    ABSTRACT: Objectives  To assess the proportion of patients lost to programme (died, lost to follow-up, transferred out) between HIV diagnosis and start of antiretroviral therapy (ART) in sub-Saharan Africa, and determine factors associated with loss to programme. Methods  Systematic review and meta-analysis. We searched PubMed and EMBASE databases for studies in adults. Outcomes were the percentage of patients dying before starting ART, the percentage lost to follow-up, the percentage with a CD4 cell count, the distribution of first CD4 counts and the percentage of eligible patients starting ART. Data were combined using random-effects meta-analysis. Results  Twenty-nine studies from sub-Saharan Africa including 148 912 patients were analysed. Six studies covered the whole period from HIV diagnosis to ART start. Meta-analysis of these studies showed that of the 100 patients with a positive HIV test, 72 (95% CI 60-84) had a CD4 cell count measured, 40 (95% CI 26-55) were eligible for ART and 25 (95% CI 13-37) started ART. There was substantial heterogeneity between studies (P < 0.0001). Median CD4 cell count at presentation ranged from 154 to 274 cells/μl. Patients eligible for ART were less likely to become lost to programme (25%vs. 54%, P < 0.0001), but eligible patients were more likely to die (11%vs. 5%, P < 0.0001) than ineligible patients. Loss to programme was higher in men, in patients with low CD4 cell counts and low socio-economic status and in recent time periods. Conclusions  Monitoring and care in the pre-ART time period need improvement, with greater emphasis on patients not yet eligible for ART.
    Tropical Medicine & International Health 09/2012; 17(12). DOI:10.1111/j.1365-3156.2012.03089.x · 2.30 Impact Factor
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    • "In Malawi, this figure is 48% (World Health Organization 2010). In addition, most patients do not receive ART until they have advanced immunosuppression (Bassett et al. 2010), increasing the risk of early ART mortality (Lawn et al. 2008), treatment complications, opportunistic infections and transmission of HIV to partners (Granich et al. 2009). Provider-initiated HIV testing and counselling (PITC) is the main entry point to comprehensive HIV care (including ART) for individuals attending health facilities (World Health Organization 2007a). "
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    ABSTRACT: Objective To understand reasons for suboptimal and delayed uptake of antiretroviral therapy (ART) by describing the patterns of HIV testing and counselling (HTC) and outcomes of ART eligibility assessments in primary clinic attendees. Methods All clinic attendances and episodes of HTC were recorded at two clinics in Blantyre. A cohort of newly diagnosed HIV-positive adults (>15 years) was recruited and exit interviews undertaken. Logistic regression models were constructed to investigate factors associated with referral to start ART. Qualitative interviews were conducted with providers and patients. Results There were 2398 episodes of HTC during 18 021 clinic attendances (13.3%) between January and April 2011. The proportion of clinic attendees undergoing HTC was lowest in non-pregnant women (6.3%) and men (8.5%), compared with pregnant women (47.2%). Men had more advanced HIV infection than women (79.7% WHO stage 3 or 4 vs. 56.4%). Problems with WHO staging and access to CD4 counts affected ART eligibility assessments; only 48% completed ART eligibility assessment, and 54% of those reporting WHO stage 3/4 illnesses were not referred to start ART promptly. On multivariate analysis, HIV-positive pregnant women were significantly less likely to be referred directly for ART initiation (adjusted OR: 0.29, 95% CI: 0.13–0.63). Conclusions These data show that provider-initiated testing and counselling (PITC) has not yet been fully implemented at primary care clinics. Suboptimal ART eligibility assessments and referral (reflecting the difficulties of WHO staging in primary care) mean that simplified eligibility assessment tools are required to reduce unnecessary delay and attrition in the pre-ART period. Simplified initiation criteria for pregnant women, as being introduced in Malawi, should improve linkage to ART.
    Tropical Medicine & International Health 02/2012; 17(4):507-17. DOI:10.1111/j.1365-3156.2011.02946.x · 2.30 Impact Factor
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