Lost opportunities to complete CD4+lymphocyte testing among patients who tested positive for HIV in South Africa

Center for Global Health and Development, Boston University School of Public Health, MA 02118, United States of America.
Bulletin of the World Health Organisation (Impact Factor: 5.09). 09/2010; 88(9):675-80. DOI: 10.2471/BLT.09.068981
Source: PubMed


To estimate rates of completion of CD4+ lymphocyte testing (CD4 testing) within 12 weeks of testing positive for human immunodeficiency virus (HIV) at a large HIV/AIDS clinic in South Africa, and to identify clinical and demographic predictors for completion.
In our study, CD4 testing was considered complete once a patient had retrieved the test results. To determine the rate of CD4 testing completion, we reviewed the records of all clinic patients who tested positive for HIV between January 2008 and February 2009. We identified predictors for completion through multivariate logistic regression.
Of the 416 patients who tested positive for HIV, 84.6% initiated CD4 testing within the study timeframe. Of these patients, 54.3% were immediately eligible for antiretroviral therapy (ART) because of a CD4 cell count ≤ 200/µl, but only 51.3% of the patients in this category completed CD4 testing within 12 weeks of HIV testing. Among those not immediately eligible for ART (CD4 cells > 200/µl), only 14.9% completed CD4 testing within 12 weeks. Overall, of HIV+ patients who initiated CD4 testing, 65% did not complete it within 12 weeks of diagnosis. The higher the baseline CD4 cell count, the lower the odds of completing CD4 testing within 12 weeks.
Patient losses between HIV testing, baseline CD4 cell count and the start of care and ART are high. As a result, many patients receive ART too late. Health information systems that link testing programmes with care and treatment programmes are needed.

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    • "Although comparing retention in preantiretroviral care across sites and countries is complicated by varying definitions and methods of measurement [2], it is clear that a large percentage of people testing HIV-positive at HCT sites do not return to collect CD4 test results, do not return on schedule for pre-ART monitoring and care, and/or do not initiate ART as soon as they become eligible [1, 3–6]. At Themba Lethu Clinic, which is a public-sector HIV/AIDS treatment facility at the Helen Joseph Hospital in Johannesburg, South Africa, for example, a retrospective review of patient records demonstrated that 65% of HIV-positive walk-in patients to the HCT program did not return for their CD4 test results within 12 weeks [3]. Among this cohort, nearly two-thirds (64%) of them were already eligible for ART on the day of HCT, based on having a CD4 count ≤ 200 cells/mm AIDS Research and Treatment providers and to reduce the number of visits required of patients, who would no longer have to make a second clinic visit just to receive test results. "
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    ABSTRACT: Background. We evaluated whether a pilot program providing point-of-care (POC), but not rapid, CD4 testing (BD FACSCount) immediately after testing HIV-positive improved retention in care. Methods. We conducted a retrospective record review at the Themba Lethu Clinic in Johannesburg, South Africa. We compared all walk-in patients testing HIV-positive during February, July 2010 (pilot POC period) to patients testing positive during January 2008–February 2009 (baseline period). The outcome for those with a cells/mm3 when testing HIV-positive was initiating ART weeks after HIV testing. Results. 771 patients had CD4 results from the day of HIV testing (421 pilots, 350 baselines). ART initiation within 16 weeks was 49% in the pilot period and 46% in the baseline period. While all 421 patients during the pilot period should have been offered the POC test, patient records indicate that only 73% of them were actually offered it, and among these patients only 63% accepted the offer. Conclusions. Offering CD4 testing using a point-of-care, but not rapid, technology and without other health system changes had minor impacts on the uptake of HIV care and treatment. Point-of-care technologies alone may not be enough to improve linkage to care and treatment after HIV testing.
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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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    • "Of these HIV-positive clients, two-thirds would be eligible for treatment as per guidelines (n = 535 patients). Of the 268 patients left, three quarters (n = 201) would be eligible for early treatment [46] and approached to participate. If the first participants were to be recruited during the third quarter of 2013, the project timeline detailing related activities would resemble Figure 3. "
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