Predictors of antiretroviral therapy initiation in eThekwini (Durban), South Africa: Findings from a prospective cohort study

Abstract

Despite expanded antiretroviral therapy (ART) eligibility in South Africa, many people diagnosed with HIV do not initiate ART promptly, yet understanding of the reasons is limited. Using data from an 8-month prospective cohort interview study of women and men newly-diagnosed with HIV in three public-sector primary care clinics in the eThekwini (Durban) region, South Africa, 2010–2014, we examined if theoretically-relevant social-structural, social-cognitive, psychosocial, and health status indicators were associated with time to ART initiation. Of 459 diagnosed, 350 returned to the clinic for their CD4+ test results (linkage); 153 (33.3%) were ART-eligible according to treatment criteria at the time; 115 (75.2% of those eligible) initiated ART (median = 12.86 weeks [95% CI: 9.75, 15.97] after linkage). In adjusted Cox proportional hazard models, internalized stigma was associated with a 65% decrease in the rate of ART initiation (Adjusted hazard ratio [AHR] 0.35, 95% CI: 0.19–0.80) during the period less than four weeks after linkage to care, but not four or more weeks after linkage to care, suggesting that stigma-reduction interventions implemented shortly after diagnosis may accelerate ART uptake. As reported by others, older age was associated with more rapid ART initiation (AHR for 1-year age increase: 1.04, 95% CI: 1.01–1.07) and higher CD4+ cell count (≥300μL vs. <150μL) was associated with a lower rate of initiation (AHR 0.38, 95% CI: 0.19–0.80). Several other factors that were assessed prior to diagnosis, including stronger belief in traditional medicine, higher endorsement of stigma toward people living with HIV, food insecurity, and higher psychological distress, were found to be in the expected direction of association with ART initiation, but confidence intervals were wide and could not exclude a null finding.

ART initiation among women newly diagnosed with HIV in a contraceptive trial in sub-Saharan Africa

“…Recent population-level surveys have found that 30% of South Africans and ∼12% of people living with HIV in Eswatini, Kenya, and Zambia who know their HIV diagnosis are not using ART (Human Sciences Research Council, 2018;Ministry of Health, Zambia, 2017;NASCOP, 2020;Swaziland Ministry of Health, 2017). In these and similar settings, factors influencing the decision to delay ART include feeling healthy, feeling unprepared to start lifelong ART, HIV stigma, a lack of social support, difficulties translating intentions into actions, costs incurred to access ART, concerns about confidentiality, low-quality health services, and incomplete understanding about the benefits of ART (Ahmed et al, 2018;Nhassengo et al, 2018;Sy et al, 2021). Provider-based factors, such as a lack of urgency to prescribe ART, particularly in people with higher CD4 counts, have also resulted in delayed or non-initiation of ART (Lee et al, 2019).…”

An agricultural livelihood intervention is associated with reduced HIV stigma among people with HIV

“…Among the most pervasive barriers to HIV care and treatment is HIV stigma, which is associated with poor outcomes along the HIV treatment cascade. This includes lower rates of testing [6]; poor linkage to, engagement with, and retention in care [7]; suboptimal ART uptake [8]; delayed treatment initiation [9]; worse treatment adherence [10]; and unsuppressed viral load [11]. HIV stigma is conceptualized to act through behavioral and biological pathways, including interpersonal factors, worsened mental health, weakened psychological resources, and physiological stress processes, to undermine HIV treatment and care outcomes [12].…”

HIV Care Profiling and Delivery Status in the Mobile Health Clinics of eThekwini District in KwaZulu Natal, South Africa: A Descriptive Evaluation Study

“…Despite having the largest antiretroviral therapy (ART) rollout program globally [4], evidence in the country suggests that not all people living with HIV (PLHIV) needing HIV care are actually receiving it, due to various challenges [5,6]. This dampens HIV care and support services' desire to reach universal coverage [7]. However, the offer of extended HIV care through various modalities such as mobile health clinics (MHCs) in SA proves to improve and increase access to HIV care services.…”