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: 5.55). 01/2010; 24 Suppl 1(Suppl 1):S37-44. DOI: 10.1097/01.aids.0000366081.91192.1c
Source: PubMed


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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    • "In the present study, the median CD4 count at ART eligibility was low (128 cells/µL) and did not change substantially during the five years of the study. In accordance with Sub-Saharan African studies [16, 23–26], patients with lower CD4 counts were less likely to initiate ART and had a higher risk of death and loss to followup. Typically, preparation of ART requires two or three counselling sessions during 4–6 weeks before ART is started. "
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    ABSTRACT: Studies from Sub-Saharan Africa have shown that a substantial number of HIV patients eligible for antiretroviral therapy (ART) do not start treatment. However, data from other low- or middle-income countries are scarce. In this study, we describe the outcomes of 4105 HIV patients who became ART eligible from January 2007 to November 2011 in an HIV cohort study in India. After three years of ART eligibility, 78.4% started ART, 9.3% died before ART initiation, and 10.3% were lost to followup. Diagnosis of tuberculosis, being homeless, lower CD4 count, longer duration of pre-ART care, belonging to a disadvantaged community, being widowed, and not living near a town were associated with delayed ART initiation. Diagnosis of tuberculosis, being homeless, lower CD4 count, shorter duration of pre-ART care, belonging to a disadvantaged community, illiteracy, and age >45 years were associated with mortality. Being homeless, being single, not living near a town, having a CD4 count <150 cells/ μ L, and shorter duration of pre-ART care were associated with loss to followup. These results highlight the need to improve the timely initiation of ART in HIV programmes in India, especially in ART eligible patients with tuberculosis, low CD4 counts, living in rural areas, or having a low socioeconomic status.
    Full-text · Article · Oct 2013
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    • "Innovative strategies are urgently needed to improve linkage to TB and HIV care, so that South Africans can reap the maximum benefits from currently available life-saving therapies. Although HIV testing efforts have expanded recently in South Africa [26], a substantial proportion of people newly diagnosed with HIV are not retained in the care system [24,27-30]. While evidence supports that behavioral and cognitive interventions can be effective for improving ART adherence in sub-Saharan Africa [31,32], few studies have rigorously evaluated approaches for increasing linkage to HIV care in high-prevalence regions [31]. "
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    ABSTRACT: Despite increases in HIV testing, only a fraction of people newly diagnosed with HIV infection enter the care system and initiate antiretroviral therapy (ART) in South Africa. We report on the design and initial enrollment of a randomized trial of a health system navigator intervention to improve linkage to HIV care and TB treatment completion in Durban, South Africa. We employed a multi-site randomized controlled trial design. Patients at 4 outpatient sites were enrolled prior to HIV testing. For all HIV-infected participants, routine TB screening with sputum for mycobacterial smear and culture were collected. HIV-infected participants were randomized to receive the health system navigator intervention or usual care. Participants in the navigator arm underwent a baseline interview using a strengths-based case management approach to assist in identifying barriers to entering care and devising solutions to best cope with perceived barriers. Over 4 months, participants in the navigator arm received scheduled phone and text messages. The primary outcome of the study is linkage and retention in care, assessed 9 months after enrollment. For ART-eligible participants without TB, the primary outcome is 3 months on ART as documented in the medical record; participants co-infected with TB are also eligible to meet the primary outcome of completion of 6 months of TB treatment, as documented by the TB clinic. Secondary outcomes include mortality, receipt of CD4 count and TB test results, and repeat CD4 counts for those not ART-eligible at baseline. We hypothesize that a health system navigator can help identify and positively affect modifiable patient factors, including self-efficacy and social support, that in turn can improve linkage to and retention in HIV and TB care. We are currently evaluating the clinical impact of a novel health system navigator intervention to promote entry to and retention in HIV and TB care for people newly diagnosed with HIV. The details of this study protocol will inform clinicians, investigators, and policy makers of strategies to best support HIV-infected patients in resource-limited settings.Trial registration: unique identifier: NCT01188941.
    Full-text · Article · Aug 2013 · BMC Infectious Diseases
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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.
    Full-text · Article · Jun 2013 · PeerJ
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