The “ART” of Linkage: Pre-Treatment Loss to Care after HIV Diagnosis at Two PEPFAR Sites in Durban, South Africa

Abstract

BackgroundAlthough loss to follow-up after antiretroviral therapy (ART) initiation is increasingly recognized, little is known about pre-treatment losses to care (PTLC) after an initial positive HIV test. Our objective was to determine PTLC in newly identified HIV-infected individuals in South Africa.Methodology/Principal FindingsWe assembled the South African Test, Identify and Link (STIAL) Cohort of persons presenting for HIV testing at two sites offering HIV and CD4 count testing and HIV care in Durban, South Africa. We defined PTLC as failure to have a CD4 count within 8 weeks of HIV diagnosis. We performed multivariate analysis to identify factors associated with PTLC. From November 2006 to May 2007, of 712 persons who underwent HIV testing and received their test result, 454 (64%) were HIV-positive. Of those, 206 (45%) had PTLC. Infected patients were significantly more likely to have PTLC if they lived ≥10 kilometers from the testing center (RR = 1.37; 95% CI: 1.11–1.71), had a history of tuberculosis treatment (RR = 1.26; 95% CI: 1.00–1.58), or were referred for testing by a health care provider rather than self-referred (RR = 1.61; 95% CI: 1.22–2.13). Patients with one, two or three of these risks for PTLC were 1.88, 2.50 and 3.84 times more likely to have PTLC compared to those with no risk factors.Conclusions/SignificanceNearly half of HIV-infected persons at two high prevalence sites in Durban, South Africa, failed to have CD4 counts following HIV diagnosis. These high rates of pre-treatment loss to care highlight the urgent need to improve rates of linkage to HIV care after an initial positive HIV test.

Lost opportunities to complete CD4+ lymphocyte testing among patients who tested positive for HIV in South Africa

“…11,[13][14][15] In a semiprivate clinic in Durban with a high prevalence of HIV infection (63% of all patients tested), about 53% of the patients with newly-diagnosed HIV infection did not complete CD4 testing within 8 weeks. In a small community outside Cape Town, 62% of patients who tested positive for HIV infection completed CD4 testing within 6 months of testing positive.…”

Paper-based smart microfluidics for education and low-cost diagnostics

“…Similarly for environmental monitoring, the risk of the disease spreading is increased by the typically low rate of monitoring, which is affected by the high costs and time delays associated with sampling, sample transportation and specialised testing. [2][3][4][5] Point-of-care (PoC) tests are laboratory diagnostic assays performed at or near the site where clinical care is delivered and may therefore be used in both a first world laboratory and the most remote corner of the developing world. In the latter case, these tests have the ability to overcome many of the disadvantages of centralised testing facilities because they are low-cost, provide faster test results, and negate the need for samples/patients to be transported over long distances.…”

Mitigating intimate partner violence to promote safe linkage to care for South African women who test HIV positive during mobile counseling and testing.

“…Past research has helped refine HCT methods so that programs more effectively encourage a greater number of individuals to link to care and at a faster pace. Although it is difficult to find an average linkage rate in the literature due to variations in collection periods and classifications of "successful" linkage periods, rates ranged from only 10% (Bassett, Regan et al, 2014) to 47% (Losina et al, 2010), 53.4% (Krazner et al, 2010) and 51% in a large sample of South African youth (Van Zyl et al, 2015). While most of these numbers indicate mobile HCT can be effective in assisting many, the demand for more improvements with HCT is underscored.…”

“…This program also has empirical support for its use among South Africans (Van Zyl et al, 2015). While offering HCT through the mobile medium has assisted with testing uptake, most individuals living with HIV remain without needed medical care because they delay linkage to care (Lawn et al, 2006;Losina et al, 2010;Bassett et al, 2010;Kayigamba, Bakker, Fikse, Mugisha, & Asiimwe, 2012 As the most basic explanation, the health belief model demonstrates that individuals will act to avoid poor health. Individuals must first perceive themselves to be at risk and then discern the possibility for risk high enough that action should be taken to avoid harm.…”

“…An alternative but common practice is using CD4 cell stratum to guide and gauge linkage rates so that those with lower CD4 cell counts are advised to link to care sooner given the urgency of their need for care 54 (Krazner et al, 2012;Govindassamy et al, 2013). Linkage to care may refer to going to a clinic for CD4 cell results (Losina et al 2010) or may indicate linking to further medical care after CD4 cell results have been received. The latter is more often the case in studies using point of care CD4 testing, in which an individual receives both an HIV+ diagnosis and CD4 cell results in the same visit (Wynberg, Cooke, Shroufi, Reid & Ford, 2014).…”