Factors Influencing Retention in Care after Starting Antiretroviral Therapy in a Rural South African Programme

Abstract

IntroductionThe prognosis of patients with HIV in Africa has improved with the widespread use of antiretroviral therapy (ART) but these successes are threatened by low rates of long-term retention in care. There are limited data on predictors of retention in care, particularly from rural sites.MethodsProspective cohort analysis of outcome measures in adults from a rural HIV care programme in Madwaleni, Eastern Cape, South Africa. The ART programme operates from Madwaleni hospital and seven primary care feeder clinics with full integration between inpatient and outpatient services. Outreach workers conducted home visits for defaulters.Results1803 adults initiated ART from June 2005 to May 2009. At the end of the study period 82.4% were in active care or had transferred elsewhere, 11.1% had died and 6.5% were lost to follow-up (LTFU). Independent predictors associated with an increased risk of LTFU were CD4 nadir >200, initiating ART as an inpatient or while pregnant, and younger age, while being in care for >6 months before initiating ART was associated with a reduced risk. Independent factors associated with an increased risk of mortality were baseline CD4 count <50 and initiating ART as an inpatient, while being in care for >6 months before initiating ART and initiating ART while pregnant were associated with a reduced risk.ConclusionsServing a socioeconomically deprived rural population is not a barrier to successful ART delivery. Patients initiating ART while pregnant and inpatients may require additional counselling and support to reduce LTFU. Providing HIV care for patients not yet eligible for ART may be protective against being LTFU and dying after ART initiation.

The role of the Infectious Diseases unit at Groote Schuur Hospital in addressing South Africa’s greatest burden of disease

“…(A recent study from the Eastern Cape showed that retention in care was reduced if pregnant women were started on ART as inpatients, 9 perhaps because pregnant women view ART as primarily to protect their babies). Is HAI, as a cause of death in HIV-infected patients, peculiar to tertiary hospital inpatients or does it apply to all HIV-infected hospitalised patients?…”

Attendance at an outpatient follow-up clinic by HIV-positive psychiatric patients initiated on ART as inpatients

“…[5,6] It has previously been suggested that decreased time before initiation of treatment, resulting in a decreased number of preparation sessions might in part account for this finding. [5] Time from diagnosis to initiation of ART was not examined in the current study. There may be links between illness awareness, insight into risk of infection, insight into need for treatment and subsequent adherence to treatment.…”

“…[3,4] Research has also shown that medical patients initiated on ART as inpatients have poorer outcomes than those initiated as outpatients. [5,6] Negative perceptions with regard to rates of adherence, future clinic attendance and long-term outcome may affect the decision to initiate ART in HIV-positive psychiatric patients, especially in patients requiring hospitalisation, in effect depriving these patients of potentially lifesaving treatment. [7] With this in mind, the Luthando Neuropsychiatric HIV Clinic (Luthando Clinic) at Chris Hani Baragwanath Academic Hospital (CHBAH), Soweto, was established, providing specialised integrated treatment for HIV-positive psychiatric patients at a tertiary academic level.…”

Hopes interrupted: accessing and experiences of antiretroviral therapy in South Africa

“…Nonetheless, treatment scale-up in South Africa has succeeded in vastly increasing the numbers of people benefitting from ART. As the service evolves and expands, an additional challenge revolves around how best to retain patients over time 4 5…”