Attrition From HIV Testing to Antiretroviral Therapy Initiation Among Patients Newly Diagnosed With HIV in Haiti

Abstract

Objective We report rates and risk factors for attrition in the first cohort of patients followed through all stages from HIV testing to ART initiation. Design Cohort study of all patients diagnosed with HIV between January and June, 2009. Methods We calculated the proportion of patients who completed CD4 cell counts and initiated ART or remained in pre-ART care during two years of follow-up, and assessed predictors of attrition. Results Of 1,427 patients newly diagnosed with HIV, 680 (48%) either initiated ART or were retained in pre-ART care for the subsequent two years. One thousand eighty-three patients (76%) received a CD4 cell count and 973 (90%) returned for result; 297 (31%) had CD4 cell count < 200 cells/μl and of these, 256 (86%) initiated ART. Among 429 patients with CD4 > 350 cells/μl, 215 (50%) started ART or were retained in pre-ART care. Active TB was associated with lower odds of attrition prior to CD4 cell count (OR: 0.08; 95% CI: 0.03–0.25) but also higher odds of attrition prior to ART initiation (OR: 2.46; 95% CI: 1.29–4.71). Lower annual income (≤ $US125) was associated with higher odds of attrition prior to CD4 cell count (OR 1.65; 95% CI: 1.25–2.19), and prior to ART initiation among those with CD4 cell count > 350 cells/μl (OR: 1.74; 95% CI: 1.20–2.52). After tracking patients through a national database, the retention rate increased to only 57%. Conclusion Fewer than half of patients newly diagnosed with HIV initiate ART or remain in pre-ART care for two years in a clinic providing comprehensive services. Additional efforts to improve retention in pre-ART are critically needed.

Impact of a youth‐friendly HIV clinic: 10 years of adolescent outcomes in Port‐au‐Prince, Haiti

“…Our results were similar to a study in Kenya, which reported that youth-friendly HIV services did not improve long-term retention [31]. In comparison to a study on retention among adults in HIV care at GHESKIO [32], a higher proportion of adolescents in our cohort were LTF at each step in the cascade. In the adult cohort, 91% returned for an HIV test result compared to 86% of adolescents; 84% of adults returned for a CD4 count compared to 69% of adolescents; and 94% of eligible adults initiated ART compared to 89% of adolescents.…”

Rapid initiation of antiretroviral therapy in those with newly diagnosed HIV infection in London, UK

“…We minimized the risk of coercion to start ART rapidly by deliberately setting out the potential disadvantages and benefits of early ART at the first medical appointment and, indeed, a quarter of patients declined to start at this appointment, suggesting that our anxiety was misplaced. There has been debate about the readiness of patients with newly diagnosed HIV infection to rapidly initiate ART and whether this may indeed impair long‐term retention in care, although other data suggest that this is not the case . Commenting further is beyond the scope of this report and requires longer follow‐up of bigger cohorts.…”

High Poverty and Hardship Financing Among Patients with Noncommunicable Diseases in Rural Haiti

“…In Haiti, there is a rich history of studies documenting the barriers to chronic care for human immunodeficiency virus. Patient factors include limited time to attend clinic, low income, food insecurity, poor social support, and cultural norms [31][32][33]. Environmental factors include transport costs [34], lack of healthcare facilities close to patients, road conditions, seasonal weather, and political disruptions.…”