Many South African patients not on ART are being lost to care

Fewer than 50% of patients diagnosed with HIV in a district of rural South Africa who are not yet eligible for antiretroviral therapy have been retained in care, a study published in the online edition of the Journal of Acquired Immune Deficiency Syndromes shows.

Men, individuals with higher CD4 cell counts and younger patients were the groups most likely to be lost to care.

“Retention in long-term care both before and after the initiation of ART [antiretroviral therapy] is important not only to reduce individual mortality and morbidity but also as a means to deliver ‘positive prevention,’” comment the investigators. They are therefore concerned that “in this large primary health care HIV programme under the existing model of care for individuals not yet eligible for ART, fewer than 50% returned within 13 months for repeat CD4 cell count.”

Access to antiretroviral therapy is increasing in South Africa. Eligibility to treatment is determined by a patient’s health or CD4 cell count, and timely initiation of therapy can reduce the risk of serious illness and death. It is therefore important that patients attend for regular follow-up appointments so that their suitability for treatment can be assessed.

However, little is currently known about the proportion of patients not yet eligible for antiretroviral therapy who are retained in care.

Investigators therefore conducted a retrospective analysis that included 4,223 HIV-positive adults living in the rural Hlabisa health district of KwaZulu-Natal. None of the patients were taking HIV therapy, and all had a baseline CD4 cell count above 200 cells/mm³, the then threshold for starting antiretroviral drugs.

Patients with a CD4 cell count below 500 cells/mm³ were advised to return to the clinic for follow-up appointments every six months. Those with a CD4 cell count above this level were counselled to attend every twelve months.

Retention in care was defined as attending for at least one follow-up CD4 cell count measurement within 13 months. Analyses were conducted to see if there were any factors associated with failure to return for clinic appointments.

Most of the patients (89%) lived within 5km of their nearest clinic and the majority were women  (84%), who had a significantly younger median age then men (31 vs. 37, p < 0.001). Baseline CD4 cell counts were higher in women (407 vs. 365 cells/mm³).

The patients were divided into three CD4 cell strata: 201-350 cells/mm³ (38%); 351-500 cells/mm³ (30%); and above 500 cells/mm³ (32%).

Overall, only 45% of patients returned for a repeat CD4 cell count. Of these, 72% returned only once, and 28% attended the clinic on more than one occasion.

The proportion of patients returning for repeat visits varied according to baseline CD4 cell count, and was highest for those with counts in the lowest strata (52% vs. 43% vs. 35%). The median interval between clinic visits was 201 days and was shortest for those with the weakest immune systems (175 vs. 206 vs. 230 days, p < 001).

A total of 27% of patients who returned to the clinic experienced a fall in their CD4 cell count to below 200 cells/mm³ and therefore became eligible to start HIV therapy.

Analysis showed that compared to patients with the weakest immune systems, individuals with a CD4 cell count between 350-500 cells/mm³ and above 500 cells/mm³ were less likely to be retained in care (adjusted odds ratio [AOR] 0.72; 95% CI, 0.62-0.84 and AOR 0.51; 95% CI 0.44-0.60 respectively).

“One plausible explanation for poor retention would be the lack of incentive for asymptomatic individuals to return for monitoring,” suggest the investigators.

Men were also more approximately 20% less likely to be retained in care than women (AOR 0.80; 95% CI 0.67-0.96). The researchers believe that this finding highlights the “need to explore health utilisation by men and to develop strategies to engage and retain men in HIV care, perhaps targeting work-based care.”

Younger age was associated with worse retention, which concerned the investigators, who stressed the role that care can play in bolstering prevention messages. They suggest that younger patients who are not returning to the clinic “may be responsible for a significant proportion of transmissions.”

The researchers call for “trials to evaluate different models of pre-ART care or wellness programmes” and caution, “if the substantial benefits of the massive scale-up of HIV treatment and care programmes are to be maintained then we need to build an evidence base with which to inform the design of programmes to offer comprehensive care throughout the continuum of HIV infection.”