Mapping Pathways is a multi-national project to develop and nurture a research-driven, community-led global understanding of the emerging evidence base around the adoption of antiretroviral-based prevention strategies to end the HIV/AIDS epidemic. The evidence base is more than results from clinical trials - it must include stakeholder and community perspectives as well.

31 July 2011

Retention of pre-ART patients poor in sub-Saharan Africa

Via AIDSMap, by Lesley Odendal.

 More than two-thirds of people who tested positive for HIV but weren't yet eligible for treatment when diagnosed were lost from care, according to a systematic review of pre-antiretroviral (pre-ART) care in sub-Saharan Africa, published this month in PLoS Medicine.

Studies included in the review report a substantial loss of patients at every step of care, starting with patients who do not return for their initial CD4 count results and ending with those who do not initiate ARVs despite eligibility, according to Sydney Rosen and Matthew Fox of the Center for Global Health and Development at Boston University, who conducted the review.

The study was conducted in order to evaluate the extent to which patients diagnosed with HIV are being lost before starting treatment.

28 studies which reported on the proportion of adult patients retained between any two points between testing positive for HIV and initiating ART in sub-Saharan African HIV/AIDS care programs were included. Results were categorised into stages of pre-ART care with ranges  reported for the proportions of patients retained in each stage.

Stages were categorised as follows:
  • Stage 1: from HIV testing to receipt of CD4 count results or clinical staging
  • Stage 2: from receipt of CD4 count results or clinical staging to ARV eligibility
  • Stage 3: from ARV eligibility to ARV initiation
The review found that the median proportion of patients retained in Stage 1 was 59% (ranging from 35%–88%); Stage 2, 46% (31%–95%); and Stage 3, 68% (14%–84%).  'Loss to care' was defined as failing to reach the next step in the care sequence for any reason (death or discontinuation), but each study’s own criteria for determining which patients died or discontinued care were also included.

There are several key reasons for the poor retention of pre-ART care patients. As most patients are asymptomatic during the pre-ART period, they may not perceive themselves as requiring medical care. Patients may also not come to the clinic for monitoring and may choose to ‘‘wait and see what happens’’  if they "lack resources for transport, risk losing employment by taking time off work, or fear being recognised as a client of an HIV clinic," write the authors. Those presenting with a low CD4 count are likely to have died before reaching stage 3. Patient mobility may also be a factor contributing to low retention rates.

 Read the rest here.

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