Patient Retention From HIV Diagnosis Through One Year on Antiretroviral Therapy at a Primary Health Care Clinic in Johannesburg, South Africa

Abstract

Objective To compare patient retention at three stages of pre-antiretroviral (ART) care and two stages of post-ART care to identify when greatest attrition occurs. Design An observational cohort study. Methods We reviewed files of all adult, non-pregnant individuals testing HIV-positive January 1 – June 30, 2010, at a primary health clinic in Johannesburg, South Africa (N=842). We classified retention in pre-ART stage 1 (HIV diagnosis to CD4 results notification in ≤3 months), pre-ART stage 2 (initially ineligible for ART with repeat CD4 test ≤1 year of prior CD4), pre-ART stage 3 (initiating ART ≤3 months after first eligible CD4 result), as well as at 0–6 and 6–12 months post-ART. Results Retention among all patients during pre-ART stage 1 was 69.8% (95%CI 66.7–72.9%). For patients initially ART-ineligible (n=221), 57.4% (95%CI 49.5–65.0%) returned for a repeat CD4 during pre-ART stage 2. Among those ART-eligible (n=589), 73.5% (95%CI 69.0–77.6%) were retained during pre-ART stage 3. Retention increased with time on ART, from 80.2% (95%CI 75.3–84.5%) at 6 months to 95.3% (95%CI 91.7–97.6%) between 6–12 months. Cumulative retention from diagnosis to 12 months on ART was 36.9% (95%CI 33.0–41.1%) for those ART-eligible and 43.0% (95%CI 36.4–49.8%) from diagnosis to repeat CD4 testing within one year among those ART-ineligible. Conclusions Patient attrition in the first year following HIV diagnosis was greatest prior to ART initiation: over 25% at each of three pre-ART stages. As countries expand HIV testing and ART programs, success will depend on linkage to care, especially prior to ART eligibility and initiation.

Linkage to and engagement in HIV care in western Kenya: an observational study using population-based estimates from home-based counselling and testing

“…The estimates of engaging in (or linking to) care following testing presented here are lower than what has been observed following other types of testing (i.e., VCT, PITC, mobile VCT) in other settings 3,20–23 . However, direct comparisons between these testing venues are inappropriate, as are direct comparisons of engagement in care between individuals previously diagnosed and those newly diagnosed.…”

Shame, Guilt, and Stress: Community Perceptions of Barriers to Engaging in Prevention of Mother to Child Transmission (PMTCT) Programs in Western Kenya

“…Persons et al describe a theoretical model in which HIV-related shame manifests as avoidant behavior, negative self-image, and poor mental health functioning; leading to avoidance of health care or other social support networks, decreased motivation for self-care, and feelings of inadequacy in managing one's own health. 26 This theoretical model is supported by literature demonstrating similar findings between shame and other HIV-related health behaviors such as condom use, 27 retention in care, 28,29 and adherence to medication. [30][31][32][33] This also suggests that shame, unlike more culturally or socially rooted values of stigma, is potentially modifiable and should be a target for intervention at the individual level.…”

Time to reduce CD4+ monitoring for the management of antiretroviral therapy in HIV-infected individuals

“…+ cell counts will therefore continue to be of value for pre-ART patients, but more efforts are required to make them more meaningful and reduce the currently high attrition rates (only 57% of SA patients initially determined as being not yet eligible for treatment return for repeat CD4 + testing and eventually ART, [15] and similar challenges are reported from the USA [16] ). Point-of-care CD4 + testing has been promoted as one way to improve linkage to care, and while there is evidence of reduced pre-ART attrition associated with the use of point-of-care CD4 + devices, [17] other efforts are also needed to ensure maintenance of linkage to care.…”