Acceptance of anti-retroviral therapy among patients infected with HIV and tuberculosis in rural Malawi is low and associated with cost of transport

Risk factors for late-stage HIV disease presentation at initial HIV diagnosis in Durban, South Africa

Background

After observing persistently low CD4 counts at initial HIV diagnosis in South Africa, we sought to determine risk factors for late-stage HIV disease presentation among adults.

Methods

We surveyed adults prior to HIV testing at four outpatient clinics in Durban from August 2010 to November 2011. All HIV-infected adults were offered CD4 testing, and late-stage HIV disease was defined as a CD4 count <100 cells/mm³. We used multivariate regression models to determine the effects of sex, emotional health, social support, distance from clinic, employment, perceived barriers to receiving healthcare, and foregoing healthcare to use money for food, clothing, or housing (“competing needs to healthcare”) on presentation with late-stage HIV disease.

Results

Among 3,669 adults screened, 830 were enrolled, newly-diagnosed with HIV and obtained a CD4 result. Among those, 279 (33.6%) presented with late-stage HIV disease. In multivariate analyses, participants who lived ≥5 kilometers from the test site [adjusted odds ratio (AOR) 2.8, 95% CI 1.7–4.7], reported competing needs to healthcare (AOR 1.7, 95% CI 1.2–2.4), were male (AOR 1.7, 95% CI 1.2–2.3), worked outside the home (AOR 1.5, 95% CI 1.1–2.1), perceived health service delivery barriers (AOR 1.5, 95% CI 1.1–2.1), and/or had poor emotional health (AOR 1.4, 95% CI 1.0–1.9) had higher odds of late-stage HIV disease presentation.

Conclusions

Independent risk factors for late-stage HIV disease presentation were from diverse domains, including geographic, economic, demographic, social, and psychosocial. These findings can inform various interventions, such as mobile testing or financial assistance, to reduce the risk of presentation with late-stage HIV disease.

Early uptake of HIV clinical care after testing HIV-positive during home-based testing and counseling in western Kenya

Home-based HIV testing and counseling (HBTC) has the potential to increase access to HIV testing. However, the extent to which HBTC programs successfully link HIV-positive individuals into clinical care remains unclear. To determine factors associated with early enrollment in HIV clinical care, adult residents (aged ≥13 years) in the Health and Demographic Surveillance System in Kisumu, Kenya were offered HBTC. All HIV-positive residents were referred to nearby HIV clinical care centers. Two to four months after HBTC, peer educators conducted home visits to consenting HIV-positive residents. Overall, 9,895 (82 %) of 12,035 residents accepted HBTC; 1,087 (11 %) were HIV-positive; and 737 (68 %) received home visits. Of those receiving home visits, 42 % reported HIV care attendance. Factors associated with care attendance included: having disclosed, living with someone attending HIV care, and wanting to seek care after diagnosis. Residents who reported their current health as excellent or who doubted their HBTC result were less likely to report care attendance. While findings indicate that HBTC was well-received in this setting, less than half of HIV-positive individuals reported current care attendance. Identification of effective strategies to increase early enrollment and retention in HIV clinical care is critical and will require coordination between testing and treatment program staff and systems.

Barriers and facilitators to linkage to ART in primary care: a qualitative study of patients and providers in Blantyre, Malawi

Introduction

Linkage from HIV testing and counselling (HTC) to initiation of antiretroviral therapy (ART) is suboptimal in many national programmes in sub-Saharan Africa, leading to delayed initiation of ART and increased risk of death. Reasons for failure of linkage are poorly understood.

Methods

Semi-structured qualitative interviews were undertaken with health providers and HIV-positive primary care patients as part of a prospective cohort study at primary health centres in Blantyre, Malawi. Patients successful and unsuccessful in linking to ART were included.

Results

Progression through the HIV care pathway was strongly influenced by socio-cultural norms, particularly around the perceived need to regain respect lost during a period of visibly declining health. Capacity to call upon the support of networks of families, friends and employers was a key determinant of successful progression. Over-busy clinics, non-functioning laboratories and unsuitable tools used for ART eligibility assessment (WHO clinical staging system and centralized CD4 count measurement) were important health systems determinants of drop-out.

Conclusions

Key interventions that could rapidly improve linkage include guarantee of same-day, same-clinic ART eligibility assessments; utilization of the support offered by peer-groups and community health workers; and integration of HTC and ART programmes.

Short and long term retention in antiretroviral care in health facilities in rural Malawi and Zimbabwe

Background

Despite the successful scale-up of ART services over the past years, long term retention in ART care remains a major challenge, especially in high HIV prevalence and resource-limited settings. This study analysed the short (<12 months) and long (>12 months) term retention on ART in two ART programmes in Malawi (Thyolo district) and Zimbabwe (Buhera district).

Methods

Retention rates at six-month intervals are reported separately among (1) patients since ART initiation and (2) patients who had been on ART for at least 12 months, according to the site of ART initiation and follow-up, using the Kaplan Meier method. ‘Retention’ was defined as being alive on ART or transferred out, while ‘attrition’ was defined as dead, lost to follow-up or stopped ART.

Results

In Thyolo and Buhera, a total of 12,004 and 9,721 patients respectively were included in the analysis. The overall retention among the patients since ART initiation was 84%, 80% and 77% in Thyolo and 88%, 84% and 82% in Buhera at 6, 12 and 18 months, respectively. In both programmes the largest drop in ART retention was found during the initial 12 months on ART, mainly related to a high mortality rate in the health centres in Thyolo and a high loss to follow-up rate in the hospital in Buhera. Among the patients who had been on ART for at least 12 months, the retention rates leveled out, with 97%, 95% and 94% in both Thyolo and Buhera, at 18, 24 and 30 months respectively. Loss to follow-up was identified as the main contributor to attrition after 12 months on treatment in both programmes.

Conclusions

To better understand the reasons of attrition and adapt the ART delivery care models accordingly, it is advisable to analyse short and long term retention separately, in order to adapt intervention strategies accordingly. During the initial months on ART more medical follow-up, especially for symptomatic patients, is required to reduce mortality. Once stable on ART, however, the ART care delivery should focus on regular drug refill and adherence support to reduce loss to follow up. Hence, innovative life-long retention strategies, including use of new communication technologies, community based interventions and drug refill outside the health facilities are required.

Quantifying and addressing losses along the continuum of care for people living with HIV infection in sub-Saharan Africa: a systematic review

Introduction

Recent years have seen an increasing recognition of the need to improve access and retention in care for people living with HIV/AIDS. This review aims to quantify patients along the continuum of care in sub-Saharan Africa and review possible interventions.

Methods

We defined the different steps making up the care pathway and quantified losses at each step between acquisition of HIV infection and retention in care on antiretroviral therapy (ART). We conducted a systematic review of data from studies conducted in sub-Saharan Africa and published between 2000 and June 2011 for four of these steps and performed a meta-analysis when indicated; existing data syntheses were used for the remaining two steps.

Results

The World Health Organization estimates that only 39% of HIV-positive individuals are aware of their status. Among patients who know their HIV-positive status, just 57% (95% CI, 48 to 66%) completed assessment of ART eligibility. Of eight studies using an ART eligibility threshold of≤200 cells/µL, 41% of patients (95% CI, 27% to 55%) were eligible for treatment, while of six studies using an ART eligibility threshold of≤350 cells/µL, 57% of patients (95% CI, 50 to 63%) were eligible. Of those not yet eligible for ART, the median proportion remaining in pre-ART care was 45%. Of eligible individuals, just 66% (95% CI, 58 to 73%) started ART and the proportion remaining on therapy after three years has previously been estimated as 65%. However, recent studies highlight that this is not a simple linear pathway, as patients cycle in and out of care. Published studies of interventions have mainly focused on reducing losses at HIV testing and during ART care, whereas few have addressed linkage and retention during the pre-ART period.

Conclusions

Losses occur throughout the care pathway, especially prior to ART initiation, and for some patients this is a transient event, as they may re-engage in care at a later time. However, data regarding interventions to address this issue are scarce. Research is urgently needed to identify effective solutions so that a far greater proportion of infected individuals can benefit from long-term ART.

Risk factors, barriers and facilitators for linkage to antiretroviral therapy care: a systematic review

OBJECTIVE

To characterize patient and programmatic factors associated with retention in care during the pre-antiretroviral therapy (ART) period and linkage to ART care.

DESIGN

Systematic literature review.

METHODS

An electronic search was conducted on MEDLINE, Global Health, Google Scholar and conference databases to identify studies reporting on predictors, barriers and facilitators of retention in care in the pre-ART period, and linkage to care at three steps: ART-eligibility assessment, pre-ART care and ART initiation. Factors associated with attrition were then divided into areas for intervention.

RESULTS

Seven hundred and sixty-eight citations were identified. Forty-two studies from 12 countries were included for review, with the majority from South Africa (16). The most commonly cited category of factors was transport costs and distance. Stigma and fear of disclosure comprised the second most commonly cited category of factors followed by staff shortages, long waiting times, fear of drug side effects, male sex, younger age and the need to take time off work.

CONCLUSION

This review highlights the importance of investigating interventions that could reduce transport difficulties. Decentralization, task-shifting and integration of services need to be expedited to alleviate health system barriers. Patient support groups and strategic posttest counselling are essential to assist patients deal with stigma and disclosure. Moreover, well tolerated first-line drugs and treatment literacy programmes are needed to improve acceptance of ART. This review suggests a combination of interventions to retain specific groups at risk for attrition such as workplace programmes for employed patients, dedicated clinic and support programmes for men and younger individuals.

Antiretroviral treatment uptake in patients with HIV-associated TB attending co-located TB and ART services

BACKGROUND

Delivery of integrated care for patients with HIV-associated TB is challenging. We assessed the uptake and timing of antiretroviral treatment (ART) among eligible patients attending a primary care service with co-located ART and TB clinics.

METHODS

In a retrospective cohort study, all HIV-associated TB patients (≥18 years old) who commenced TB treatment in 2010 were included. Data were analysed using basic descriptive statistics and log-binomial regression analysis.

RESULTS

Of a total of 497 patients diagnosed with HIV-associated TB, 274 were eligible to start ART for the first time (median CD4 count, 159 cells/µl). ART was started during TB treatment by 220 (80.3%) patients. Among the 54 (19.7%) who did not start ART, 23 (42.6%) were either lost to follow-up (LTFU) or died before enrolling for ART; 12 (22.2%) were either LTFU or died after enrolling but before starting ART; 5 (9.3%) were transferred out; and 14 (25.9%) only started ART after completion of TB treatment. The median delay between starting TB treatment and starting ART was 51 days (IQR 29 - 77). Overall, only 58.6% of patients started ART within 8 weeks of TB treatment, and 12.7% of those with CD4 counts <50 cells/µl started ART within 2 weeks.

CONCLUSIONS

In a setting with co-located TB and ART clinics, delays to starting ART were substantial, and one-fifth of eligible patients did not start ART during TB treatment. Co-location of services alone is insufficient to permit timely initiation of ART; further measures need to be implemented to facilitate integrated treatment.

ART uptake, its timing and relation to anti-tuberculosis treatment outcomes among HIV-infected TB patients

SETTING

All public health facilities in two provinces of Zimbabwe.

OBJECTIVE

To determine, among tuberculosis (TB) patients with human immunodeficiency virus (HIV) registered in 2010, 1) the proportion started on antiretroviral treatment (ART), 2) the timing of ART in relation to the start of anti-tuberculosis treatment, and 3) whether timing of ART influenced anti-tuberculosis treatment outcomes.

DESIGN

Retrospective cohort study.

RESULTS

Of the 2655 HIV-positive TB patients, 1115 (42%) were documented as receiving ART. Of these, 178 (16%) started ART prior to anti-tuberculosis treatment. Of those who started after anti-tuberculosis treatment, 17% started within 2 weeks, 43% between 2 and 8 weeks and 40% after 8 weeks. Treatment success in the cohort was 82%, with 14% deaths before completion of anti-tuberculosis treatment. Not receiving ART during anti-tuberculosis treatment was associated with lower anti-tuberculosis treatment success (adjusted RR 0.70, 95%CI 0.53-0.91) and more deaths (adjusted RR 3.43, 95%CI 2.2-5.36). There were no differences in TB treatment outcomes by timing of ART initiation.

CONCLUSION

ART uptake is low given the improved treatment outcomes in those put on ART during anti-tuberculosis treatment. Better integration of HIV and TB services is needed to ensure increased coverage and earlier ART uptake.

Loss to programme between HIV diagnosis and initiation of antiretroviral therapy in sub-Saharan Africa: systematic review and meta-analysis

OBJECTIVES

To assess the proportion of patients lost to programme (died, lost to follow-up, transferred out) between HIV diagnosis and start of antiretroviral therapy (ART) in sub-Saharan Africa, and determine factors associated with loss to programme.

METHODS

Systematic review and meta-analysis. We searched PubMed and EMBASE databases for studies in adults. Outcomes were the percentage of patients dying before starting ART, the percentage lost to follow-up, the percentage with a CD4 cell count, the distribution of first CD4 counts and the percentage of eligible patients starting ART. Data were combined using random-effects meta-analysis.

RESULTS

Twenty-nine studies from sub-Saharan Africa including 148,912 patients were analysed. Six studies covered the whole period from HIV diagnosis to ART start. Meta-analysis of these studies showed that of the 100 patients with a positive HIV test, 72 (95% CI 60-84) had a CD4 cell count measured, 40 (95% CI 26-55) were eligible for ART and 25 (95% CI 13-37) started ART. There was substantial heterogeneity between studies (P < 0.0001). Median CD4 cell count at presentation ranged from 154 to 274 cells/μl. Patients eligible for ART were less likely to become lost to programme (25%vs. 54%, P < 0.0001), but eligible patients were more likely to die (11%vs. 5%, P < 0.0001) than ineligible patients. Loss to programme was higher in men, in patients with low CD4 cell counts and low socio-economic status and in recent time periods.

CONCLUSIONS

Monitoring and care in the pre-ART time period need improvement, with greater emphasis on patients not yet eligible for ART.

Determinants and consequences of failure of linkage to antiretroviral therapy at primary care level in Blantyre, Malawi: a prospective cohort study

BACKGROUND

Poor rates of linkage from HIV diagnosis to ART initiation are a major barrier to universal coverage of ART in sub-Saharan Africa, with reasons for failure poorly understood. In the first study of this kind at primary care level, we investigated the pathway to care in the Malawian National Programme, one of the strongest in Africa.

METHODS AND FINDINGS

A prospective cohort study was undertaken at two primary care clinics in Blantyre, Malawi. Newly diagnosed HIV-positive adults (>15 years) were followed for 6-months to assess completion of eligibility assessments, initiation of ART and death. Two hundred and eighty participants were followed for 82.6 patient-years. ART eligibility assessments were problematic: only 134 (47.9%) received same day WHO staging and 121 (53.2%) completed assessments by 6-months. Completion of CD4 measurement (stage 1/2 only) was 81/153 (52.9%). By 6-months, 87/280 (31.1%) had initiated ART with higher uptake in participants who were ART eligible (68/91, 74.7%), and among participants who received same-day staging (52/134 [38.8%] vs. 35/146 [24.0%] p = 0.007). Non-completion of ART eligibility assessments (adjusted hazard ratio: 0.11, 95% CI: 0.06-0.21) was associated with failure to initiate ART. Retention in pre-ART care for non-ART initiators was low (55/193 [28.5%]). Of the 15 (5.4%) deaths, 11 (73.3%) occurred after ART initiation.

CONCLUSIONS

Although uptake of ART was high and prompt for patients with known eligibility, there was frequent failure to complete eligibility assessment and poor retention in pre-ART care. HIV care programmes should urgently evaluate the way patients are linked to ART. In particular, there is a critical need for simplified, same-day ART eligibility assessments, reduced requirements for hospital visits, and active defaulter follow-up.

Distance from home to study clinic and risk of follow-up interruption in a cohort of HIV-1-discordant couples in Nairobi, Kenya

BACKGROUND

Longitudinal studies of HIV-1-infected individuals or those at risk of infection are subject to missed study visits that may have negative consequences on the care of participants and can jeopardize study validity due to bias and loss of statistical power. Distance between participant residence and study clinic, as well as other socioeconomic and demographic factors, may contribute to interruptions in patient follow-up.

METHODS

HIV-1-serodiscordant couples were enrolled between May 2007 and October 2009 and followed for two years in Nairobi, Kenya. At baseline, demographic and home location information was collected and linear distance from each participant's home to the study clinic was determined. Participants were asked to return to the study clinic for quarterly visits, with follow-up interruptions (FUI) defined as missing two consecutive visits. Cox proportional hazards regression was used to assess crude and adjusted associations between FUI and home-to-clinic distance, and other baseline characteristics.

RESULTS

Of 469 enrolled couples, 64% had a female HIV-1-infected partner. Overall incidence of FUI was 13.4 per 100 person-years (PY), with lower incidence of FUI in HIV-1-infected (10.8 per 100 PY) versus -uninfected individuals (16.1 per 100 PY) (hazard ratio [HR] = 0.66; 95% confidence interval [CI]: 0.50, 0.88). Among HIV-1-infected participants, those living between 5 and 10 kilometers (km) from the study clinic had a two-fold increased rate of FUI compared to those living <5 km away (HR = 2.17; 95% CI: 1.09, 4.34). Other factors associated with FUI included paying higher rent (HR = 1.67; 95% CI: 1.05, 2.65), having at least primary school education (HR = 1.96; 95% CI: 1.02, 3.70), and increased HIV-1 viral load (HR = 1.23 per log(10) increase; 95% CI: 1.01, 1.51).

CONCLUSIONS

Home-to-clinic distance, indicators of socioeconomic status, and markers of disease progression may affect compliance with study follow-up schedules. Retention strategies should focus on participants at greatest risk of FUI to ensure study validity.

Access to, and uptake of, antiretroviral therapy in a developing country with high HIV prevalence: a population-based cohort study in rural Uganda, 2004-2008

OBJECTIVES

To investigate antiretroviral therapy (ART) uptake after its introduction in 2004 in a longitudinal population-based cohort and its nested clinical cohort in rural Uganda.

METHODS

A HIV serosurvey of all adults aged ≥ 15 years is conducted annually. Two intervals were selected for analysis. Interval 1 (November 2004-October 2006) provided 2 years of follow-up to prospectively evaluate access to HIV services. Interval 2 (November 2007-October 2008) was used to evaluate current coverage of services. Logistic regression was used to identify sociodemographic factors associated with ART screening within 2 years of diagnosis. ART coverage was assessed using Weibull survival models to estimate the numbers needing ART.

RESULTS

In Interval 1, 636 HIV-positive adults were resident and 295 (46.4%) knew their status. Of those, 248 (84.1%) were screened for ART within 2 years of diagnosis. After adjusting for age, those who were widowed, separated or never married were more likely to be screened than those who were married. In Interval 2, 575 HIV-positive adults were residents, 322 (56.0%) knew their status, 255 (44.3%) had been screened for ART and 189 (32.9%) had started ART. Estimated ART coverage was 66%.

CONCLUSIONS

In this cohort, ART access and uptake is very high once people are diagnosed. Owing to intensive screening in the study clinic, nearly all participants who were eligible initiated ART. However, this is unlikely to reflect coverage in the general population, intensified efforts are needed to promote HIV testing, and ART screening and uptake are needed among those found to be HIV-positive.

Social constraints to TB/HIV healthcare: accounts from coinfected patients in South Africa

There is a growing imperative to improve the coordination and collaboration of tuberculosis (TB) and HIV healthcare services in response to escalating rates of TB/HIV coinfection. Patient-specific challenges associated with the delivery of TB/HIV care have been minimally explored in this regard. As part of a larger study conducted in South Africa, this article highlights coinfected patients' experiences with TB and HIV healthcare in light of their broader social environments. Qualitative, in-depth interviews were conducted with 40 adult, coinfected patients (24 women and 16 men) and eight key-informant healthcare workers at three urban/peri-urban, ambulatory, public health clinics in the high-burden province of KwaZulu-Natal. Transcribed interviews were analyzed under a modified grounded theory approach to capture subjective meanings of healthcare experience subsequent to patients' codiagnosis with TB and HIV. Emerging analytic themes highlighted critical sociomedical constraints to TB/HIV care in relation to patients' income and employment, eligibility for social assistance and antiretroviral treatment, fears around illness disclosure, social and material support, and treatment adherence. Patients' healthcare experiences were bound by their poor access to essential resources, multiple life responsibilities, disparate gender roles, limits within the healthcare system, and the stigmatizing social symbolism of their illness. Overlapping social inequalities perpetuated coinfected patients' experiences with stigma and collectively mediated their health decisions around disclosure, adherence, and retention in medical care. The study urges a contextualized understanding of the social challenges associated with TB/HIV healthcare and helps inform more patient-sensitive and socially responsive interventions against the co-epidemic.

HIV care need not hamper maternity care: a descriptive analysis of integration of services in rural Malawi

OBJECTIVE

To evaluate the use of reproductive health care and incidence of paediatric HIV infection during the expansion of antiretroviral therapy and services for the prevention of mother-to-child transmission in rural Malawi, and the influence of integration of these HIV-related services into general health services.

DESIGN

Descriptive analysis.

SETTING

Thyolo District, with a population of 600,000, an HIV prevalence of 21% and a total fertility rate of 5.7 in 2004.

POPULATION

Women attending reproductive health services care in 2005 and 2010.

METHODS

Review of facility records and databases for routine monitoring.

MAIN OUTCOME MEASURES

Use of antenatal, intrapartum, postpartum, family planning and sexually transmitted infection services; incidence of HIV infection in infants born to mothers who received prevention of mother-to-child transmission care.

RESULTS

There was a marked increase in the uptake of perinatal care: pregnant women in 2010 were 50% more likely to attend at least one antenatal visit (RR 1.50, 95% CI 1.48-1.51); were twice as likely to deliver at a healthcare facility (RR 2.05, 95% CI 2.01-2.08); and were more than four times as likely to present for postpartum care (RR 4.40, 95% CI 4.25-4.55). Family planning consultations increased by 40% and the number of women receiving treatment for sexually transmitted infections doubled. Between 2007 and 2010, the number of HIV-exposed infants who underwent testing for HIV went up from 421 to 1599/year, and the proportion testing positive decreased from 13.3 to 5.0%; infants were 62% less likely to test HIV positive (RR 0.38, 95% CI 0.27-0.52).

CONCLUSIONS

During the expansion and integration of HIV care, the use of reproductive health services increased and the outcomes of infants born to HIV-infected mothers improved. HIV care may be successfully integrated into broader reproductive health services.

Introduction and evaluation of a 'pre-ART care' service in Swaziland: an operational research study

OBJECTIVE

To implement and evaluate a formal pre-antiretroviral therapy (ART) care service at a district hospital in Swaziland.

DESIGN

Operational research.

SETTING

District hospital in Southern Africa.

PARTICIPANTS

1171 patients with a previous diagnosis of HIV. A baseline patient group consisted of the first 200 patients using the service. Two follow-up groups were defined: group 1 was all patients recruited from April to June 2009 and group 2 was 200 patients recruited in February 2010.

INTERVENTION

Introduction of pre-ART care-a package of interventions, including counselling; regular review; clinical staging; timely initiation of ART; social and psychological support; and prevention and management of opportunistic infections, such as tuberculosis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportion of patients assessed for ART eligibility, proportion of eligible patients who were started on ART and proportion receiving defined evidence-based interventions (including prophylactic co-trimoxazole and tuberculosis screening).

RESULTS

Following the implementation of the pre-ART service, the proportion of patients receiving defined interventions increased; the proportion of patient being assessed for ART eligibility significantly increased (baseline: 59%, group 1: 64%, group 2: 76%; p=0.001); the proportion of ART-eligible patients starting treatment increased (baseline: 53%, group 1: 81%, group: 2, 81%; p<0.001) and the median time between patients being declared eligible for ART and initiation of treatment significantly decreased (baseline: 61 days, group 1: 39 days, group 2: 14 days; p<0.001).

CONCLUSIONS

This intervention was part of a shift in the model of care from a fragmented acute care model to a more comprehensive service. The introduction of structured pre-ART was associated with significant improvements in the assessment, management and timeliness of initiation of treatment for patients with HIV.

Antiretroviral therapy refusal among newly diagnosed HIV-infected adults

OBJECTIVE

To determine rates and predictors of treatment refusal in newly identified HIV-infected individuals in Soweto, South Africa.

DESIGN

It is designed as a cross-sectional study.

METHODS

We analyzed data from adult clients (>18 years) presenting for voluntary counseling and testing (VCT) at the Zazi Testing Center, Perinatal HIV Research Unit to determine rates of antiretroviral therapy (ART) refusal among treatment-eligible, HIV-infected individuals (CD4(+) cell count < 200 cells/μl or WHO stage 4). Multiple logistic regression models were used to investigate factors associated with refusal.

RESULTS

From December 2008 to December 2009, 7287 adult clients were HIV tested after counseling. Two thousand, five hundred and sixty-two (35%) were HIV-infected, of whom 743 (29%) were eligible for immediate ART. One hundred and forty-eight (20%) refused referral to initiate ART, most of whom (92%) continued to refuse after 2 months of counseling. The leading reason for ART refusal was given as 'feeling healthy' (37%), despite clients having a median CD4(+) cell count of 110 cells/μl and triple the rate of active tuberculosis as seen in nonrefusers. In adjusted models, single clients [adjusted odds ratio (AOR) 1.80, 95% confidence interval (CI) 1.06-3.06] and those with active tuberculosis (AOR 3.50, 95% CI 1.55-6.61) were more likely to refuse ART.

CONCLUSION

Nearly one in five treatment-eligible HIV-infected individuals in Soweto refused to initiate ART after VCT, putting them at higher risk for early mortality. 'Feeling healthy' was given as the most common reason to refuse ART, despite a suppressed CD4(+) count and comorbidities such as tuberculosis. These findings highlight the urgent need for research to inform interventions targeting ART refusers.

Effect of point-of-care CD4 cell count tests on retention of patients and rates of antiretroviral therapy initiation in primary health clinics: an observational cohort study

BACKGROUND

Loss to follow-up of HIV-positive patients before initiation of antiretroviral therapy can exceed 50% in low-income settings and is a challenge to the scale-up of treatment. We implemented point-of-care counting of CD4 cells in Mozambique and assessed the effect on loss to follow-up before immunological staging and treatment initiation.

METHODS

In this observational cohort study, data for enrolment into HIV management and initiation of antiretroviral therapy were extracted retrospectively from patients' records at four primary health clinics providing HIV treatment and point-of-care CD4 services. Loss to follow-up and the duration of each preparatory step before treatment initiation were measured and compared with baseline data from before the introduction of point-of-care CD4 testing.

FINDINGS

After the introduction of point-of-care CD4 the proportion of patients lost to follow-up before completion of CD4 staging dropped from 57% (278 of 492) to 21% (92 of 437) (adjusted odds ratio [OR] 0·2, 95% CI 0·15-0·27). Total loss to follow-up before initiation of antiretroviral treatment fell from 64% (314 of 492) to 33% (142 of 437) (OR 0·27, 95% CI 0·21-0·36) and the proportion of enrolled patients initiating antiretroviral therapy increased from 12% (57 of 492) to 22% (94 of 437) (OR 2·05, 95% CI 1·42-2·96). The median time from enrolment to antiretroviral therapy initiation reduced from 48 days to 20 days (p<0·0001), primarily because of a reduction in the median time taken to complete CD4 staging, which decreased from 32 days to 3 days (p<0·0001). Loss to follow-up between staging and antiretroviral therapy initiation did not change significantly (OR 0·84, 95% CI 0·49-1·45).

INTERPRETATION

Point-of-care CD4 testing enabled clinics to stage patients rapidly on-site after enrolment, which reduced opportunities for pretreatment loss to follow-up. As a result, more patients were identified as eligible for and initiated antiretroviral treatment. Point-of-care testing might therefore be an effective intervention to reduce pretreatment loss to follow-up.

FUNDING

Absolute Return for Kids and UNITAID.

Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review

BACKGROUND

Improving the outcomes of HIV/AIDS treatment programs in resource-limited settings requires successful linkage of patients testing positive for HIV to pre-antiretroviral therapy (ART) care and retention in pre-ART care until ART initiation. We conducted a systematic review of pre-ART retention in care in Africa.

METHODS AND FINDINGS

We searched PubMed, ISI Web of Knowledge, conference abstracts, and reference lists for reports 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. Results were categorized as Stage 1 (from HIV testing to receipt of CD4 count results or clinical staging), Stage 2 (from staging to ART eligibility), or Stage 3 (from ART eligibility to ART initiation). Medians (ranges) were reported for the proportions of patients retained in each stage. We identified 28 eligible studies. The median proportion retained in Stage 1 was 59% (35%-88%); Stage 2, 46% (31%-95%); and Stage 3, 68% (14%-84%). Most studies reported on only one stage; none followed a cohort of patients through all three stages. Enrollment criteria, terminology, end points, follow-up, and outcomes varied widely and were often poorly defined, making aggregation of results difficult. Synthesis of findings from multiple studies suggests that fewer than one-third of patients testing positive for HIV and not yet eligible for ART when diagnosed are retained continuously in care, though this estimate should be regarded with caution because of review limitations.

CONCLUSIONS

Studies of retention in pre-ART care report substantial loss of patients at every step, starting with patients who do not return for their initial CD4 count results and ending with those who do not initiate ART despite eligibility. Better health information systems that allow patients to be tracked between service delivery points are needed to properly evaluate pre-ART loss to care, and researchers should attempt to standardize the terminology, definitions, and time periods reported.

Inadequate coordination of maternal and infant HIV services detrimentally affects early infant diagnosis outcomes in Lilongwe, Malawi

OBJECTIVE

To assess the continuity of care and outcome of pediatric HIV prevention, testing, and treatment services, focusing on early infant diagnosis with DNA polymerase chain reaction (PCR).

DESIGN

A retrospective observational cohort.

METHODS

Maternal HIV antibody, infant HIV DNA PCR test results, and outcome data from HIV-infected infants from the prevention of mother-to-child transmission, early infant diagnosis, and pediatric HIV treatment programs operating in Lilongwe, Malawi, between 2004 and 2008 were collected, merged, and analyzed.

RESULTS

Of the 14,669 pregnant women who tested HIV antibody positive, 7875 infants (53.7%) received HIV DNA PCR testing. One thousand eighty-four infants (13.8%) were HIV infected. Three hundred twenty (29.5%) children enrolled into pediatric HIV care, with 202 (63.1%) at the Baylor Center of Excellence. Among these, antiretroviral therapy was initiated on 110 infants (54.5%) whose median age was 9.1 months (interquartile range, 5.4-13.8) and a median of 2.5 months (interquartile range, 1.4-5.2) after HIV clinic registration. Sixty-nine HIV-infected infants (34.2%) died or were lost by December 2008. Initiation of antiretroviral therapy increased the likelihood of survival 7-fold (odds ratio, 7.1; 95% confidence interval, 3.68 to 13.70).

CONCLUSIONS

Separate programs for maternal and infant HIV prevention and care services demonstrated high attrition rates of HIV-exposed and HIV-infected infants, elevated levels of mother-to-child transmission, late infant diagnosis, delayed pediatric antiretroviral therapy initiation, and high HIV-infected infant mortality. Antiretroviral therapy increased HIV-infected infant survival, emphasizing the urgent need for improved service coordination and strategies that increase access to infant HIV diagnosis, improve patient retention, and reduce antiretroviral therapy initiation delays.

User fees and access to ARV treatment for persons living with HIV/AIDS: implementation and challenges in Burkina Faso, a limited-resource country

Access to antiretroviral (ARV) treatment remains a crucial problem for patients living with HIV/AIDS (PLWHA) in limited-resources countries. Some African countries have adopted the principle of providing ARV free of charge, but Burkina Faso opted for a direct out-of-pocket payment at the point of care delivery, with subsidized payments and mechanisms for the poorest populations to receive these services free of charge. Our objectives were to determine the proportion of PLWHA who pay for ARV and to identify the factors associated with ARV access in Burkina Faso. A cross-sectional study was performed in 13 public health facilities, 10 Nongovernmental Organizations and association health facilities, and three faith-based health facilities. In each facility, 20 outpatients receiving ARV were interviewed during a routine clinic visit. A multivariate analysis by logistic regression was performed. Among the expected 520 patients receiving ARV, 499 (96.0%) were surveyed. The majority of patients (79%) did not pay for their ARV treatment, thereby limiting cost recovery from patient payments. In a multivariate analysis, level of education and income were associated with free access to ARV. Patients with no education more frequently received free ARV than those who had received some level of education (OR 2.7, 95% CI [1.3-5.6]). Patients without any income or with less than US$10 per month were more likely to receive free ARV (OR 2.6 [95% CI 1.3-5.2]) than those who earned more than US$10 per month. However, 16% of patients without any income and 21% of those without employment paid for ARV, and the costs of drugs for opportunistic infections, food, and transport remained a burden for 85%, 91%, and 74%, respectively, of those who did not pay for ARV. Free access to a minimum care package for every PLWHA would enhance access to ARV.

Barriers to antiretroviral treatment in ethiopia: a qualitative study

OBJECTIVE

Ethiopia has made meaningful headway in improving access to HIV care and treatment but client attrition remains a daunting challenge. The objective of this study was to describe the major reasons of patient attrition from treatment at hospital and health center levels in Oromia region of Ethiopia.

METHODS

This qualitatively designed study was based on semistructured interview with antiretroviral therapy (ART) service providers and focus group discussions with ART clients. The participants were recruited purposively to obtain robust and programmatically important information on in retention HIV care and treatment.

FINDINGS

The analysis identified four major themes: antiretroviral (ARV) medications as ''long-term life support,'' free ART as ''expensive,'' regular follow up as ''devotion to a life-long crisis management,'' and expansion of free ART as ''sharing the new hope,''

CONCLUSION

The finding clearly illustrated that while financial constraints and some sociocultural factors impede adherence, disclosure, community support, and decentralization of ART to primary health care units enhance retention in care and treatment.

Impact of household food insecurity on the nutritional status and the response to therapeutic feeding of people living with human immunodeficiency virus

BACKGROUND

The role of household food security (HFS) in the occurrence of wasting and the response to food-based intervention in people living with human immunodeficiency virus (PLHIV), especially adults, is still controversial and needs investigation.

METHODS

Face-to-face interviews to collect data for Coping Strategies Index score and Dietary Diversity Score estimation were conducted during a noncontrolled and nonrandomized study assessing the effectiveness of ready-to-use therapeutic food in the treatment of wasting in adults with HIV. Coping Strategies Index score and Dietary Diversity Score were used to determine HFS, and the participants and tertiles of Coping Strategies Index score were used to categorize HFS.

RESULTS

The study showed that most participants were from food insecure households at admission, only 2.7% (5/187) ate food from six different food groups the day before enrolment, and 93% (180/194) were applying forms of coping strategy. Acute malnutrition was rare among <5-year-old children from participants' households, but the average (standard deviation) mid-upper arm circumference of other adults in the same households were 272.7 (42.1) mm, 254.8 (33.8) mm, and 249.8 (31.7) mm for those from the best, middle, and worst tertile of HFS, respectively (P = 0.021). Median weight gain was lower in participants from the worst HFS tertile than in those from the other two tertiles combined during therapeutic feeding phase (0.0 [-2.1 to 2.6] kg versus 1.9 [-1.7 to 6.0] kg; P = 0.052) and after ready-to-use therapeutic food discontinuation (-1.9 [-5.2 to 4.2] kg versus 1.8 [-1.4 to 4.7] kg; P = 0.098). Being on antiretroviral therapy influenced the response to treatment and nutritional status after discontinuation of ready-to-use therapeutic food supplementation.

CONCLUSION

Food insecurity is an important contributing factor to the development of wasting in PLHIV and its impact on therapeutic feeding response outlines the importance of food-based intervention in the management of wasting of PLHIV.

What happens to ART-eligible patients who do not start ART? Dropout between screening and ART initiation: a cohort study in Karonga, Malawi

Background

Routine ART programme statistics generally only provide information about individuals who start treatment. We aimed to investigate the outcome of those who are eligible but do not start ART in the Malawi programme, factors associated with this dropout, and reasons for not starting treatment, in a prospective cohort study.

Methods

Individuals having a first screening visit at the ART clinic at Karonga District Hospital, northern Malawi, between September 2005 and July 2006 were interviewed. Study follow-up to identify treatment outcomes was conducted at the clinic and in the community. Logistic regression models were used to identify factors associated with dropout before ART initiation among participants identified as clinically eligible for ART.

Results

88 participants eligible for ART at their first screening visit (out of 633, 13.9%) defaulted before starting ART. Participants with less education, difficulties in dressing, a more delayed ART initiation appointment, and mid-upper arm circumference (MUAC) < 22 cm were significantly less likely to have visited the clinic subsequently. Thirty-five (58%) of the 60 participants who defaulted and were tracked at home had died, 21 before their ART initiation appointment.

Conclusions

MUAC and reported difficulties in dressing may provide useful screening indicators to identify sicker ART-eligible individuals at high risk of dropping out of the programme who might benefit from being brought back quickly or admitted to hospital for observation. Individuals with less education may need adapted health information at screening. Deaths of ART-eligible individuals occurring prior to ART initiation are not included in routine programme statistics. Considering all those who are eligible for ART as a denominator for programme indicators would help to highlight this vulnerable group, in order to identify new opportunities for further improving ART programmes.

The risk and timing of tuberculosis diagnosed in smear-negative TB suspects: a 12 month cohort study in Harare, Zimbabwe

Background

Cases of smear-negative TB have increased dramatically in high prevalence HIV settings and pose considerable diagnostic and management challenges.

Methods and Findings

Between February 2006 and July 2007, a cohort study nested within a cluster-randomised trial of community-based case finding strategies for TB in Harare, Zimbabwe was undertaken. Participants who had negative sputum smears and remained symptomatic of TB were follow-up for one year with standardised investigations including HIV testing, repeat sputum smears, TB culture and chest radiography. Defaulters were actively traced to the community. The objectives were to investigate the incidence and risk factors for TB. TB was diagnosed in 218 (18.2%) participants, of which 39.4% was bacteriologically confirmed. Most cases (84.2%) were diagnosed within 3 months, but TB incidence remained high thereafter (111.3 per 1000 person-years, 95% CI: 86.6 to 146.3). HIV prevalence was 63.3%, and HIV-infected individuals had a 3.5-fold higher risk of tuberculosis than HIV-negative individuals.

Conclusion

We found that diagnosis of TB was insensitive and slow, even with early radiography and culture. Until more sensitive and rapid diagnostic tests become widely available, a much more proactive and integrated approach towards prompt initiation of ART, ideally from within TB clinics and without waiting for TB to be excluded, is needed to minimise the risk and consequences of diagnostic delay.

Strategies to improve patient retention on antiretroviral therapy in sub-Saharan Africa

The scale-up of antiretroviral therapy (ART) has been one of the success stories of sub-Saharan Africa, where coverage has increased from about 2% in 2003 to more than 40% 5 years later. However, tempering this success is a growing concern about patient retention (the proportion of patients who are alive and remaining on ART in the health system). Based on the personal experience of the authors, 10 key interventions are presented and discussed that might help to improve patient retention. These are (1) the need for simple and standardized monitoring systems to track what is happening, (2) reliable ascertainment of true outcomes of patients lost to follow-up, (3) implementation of measures to reduce early mortality in patients both before and during ART, (4) ensuring uninterrupted drug supplies, (5) consideration of simple, non-toxic ART regimens, (6) decentralization of ART care to health centres and the community, (7) a reduction in indirect costs for patients particularly in relation to transport to and from clinics, (8) strengthening links within and between health services and the community, (9) the use of ART clinics to deliver other beneficial patient or family-orientated packages of care such as insecticide-treated bed nets, and (10) innovative (thinking 'out of the box') interventions. High levels of retention on ART are vital for individual patients, for credibility of programmes and for on-going resource and financial support.

The financial burden of HIV care, including antiretroviral therapy, on patients in three sites in Indonesia

This paper assesses the extent of the financial burden due to out-of-pocket payments for health care incurred by people living with HIV (PLHIV) and the effect of this burden on their financial capacity. Data were collected in a cross-sectional survey of 353 PLHIV from three cities in Indonesia (Jakarta, Jogjakarta and Merauke). Respondents in Jakarta were sampled from one hospital and one non-governmental organization working with PLHIV. In Jogjakarta and Merauke, all HIV patients on antiretroviral therapy (ART) who came to selected hospitals during the interview period were asked to participate in the survey. The survey collected data on the frequency and extent of payments for HIV-related care, with answers cross-checked against medical records. Results show that PLHIV had different burdens of payments in the different geographical areas. On average, respondents in Jogjakarta spent 68%, and PLHIV on ART in Jakarta spent 96%, of monthly expenditure for HIV-related care, indicating a substantial financial burden for many ART patients. These patients depended on several sources of finance to cover the costs of their care, with donations from their immediate family being the most common method, selling assets and payments from personal income being the second most common method in Jakarta and Jogjakarta, respectively. Most PLHIV in these two areas did not have insurance. In Merauke, there were little observed out-of-pocket payments because the government covers medical costs via the local budget and health insurance for the poor. The results of this study confirm previous findings that providing subsidized ART drugs alone does not ensure financial accessibility to HIV care. Thus, the government of Indonesia at central and local levels should consider covering HIV care additional to providing antiretroviral drugs free of charge. Social health insurance should also be encouraged.

Unacceptable attrition among WHO stages 1 and 2 patients in a hospital-based setting in rural Malawi: can we retain such patients within the general health system?

A study conducted among HIV-positive adults in WHO clinical stages 1 and 2 was followed up at Thyolo District Hospital (rural Malawi) to report on: (1) retention and attrition before and while on antiretroviral treatment (ART); and (2) the criteria used for initiating ART. Between June 2008 and January 2009, 1633 adults in WHO stages 1 and 2 were followed up for a total of 282 person-years. Retention in care at 1, 2, 3 and 6 months for those not on ART (n=1078) was 25, 18, 11 and 4% vs. 99, 97, 95 and 90% for patients who started ART (n=555, P=0.001). Attrition rates were 31 times higher among patients not started on ART compared with those started on ART (adjusted hazard ratio, 31.0, 95% CI 22-44). Ninety-two patients in WHO stage 1 or 2 were started on ART without the guidance of a CD4 count, and 11 were incorrectly started on ART with CD4 count > or = 250 cells/mm(3). In a rural district hospital setting in Malawi, attrition of individuals in WHO stages 1 and 2 is unacceptably high, and specific operational strategies need to be considered to retain such patients in the health system.

Strategies to reduce early morbidity and mortality in adults receiving antiretroviral therapy in resource-limited settings

PURPOSE OF REVIEW

We review recently published literature concerning early morbidity and mortality during antiretroviral therapy (ART) among patients in resource-limited settings. We focus on articles providing insights into this burden of disease and strategies to address it.

RECENT FINDINGS

In sub-Saharan Africa, mortality rates during the first year of ART are very high (8-26%), with most deaths occurring in the first few months. This figure compares with 3-13% in programmes in Latin America and the Caribbean and 11-13% in south-east Asia. Risk factors generally reflect late presentation with advanced symptomatic disease. Key causes of morbidity and mortality include tuberculosis (TB), acute sepsis, cryptococcal meningitis, malignancy and wasting syndrome/chronic diarrhoea. Current literature shows that the fundamental need is for much earlier HIV diagnosis and initiation of ART. In addition, further studies provide data on the role of screening and prophylaxis against opportunistic diseases (particularly TB, bacterial sepsis and cryptococcal disease) and the management of specific opportunistic diseases and complications of ART. Effective and sustainable delivery of these interventions requires strengthening of programmes.

SUMMARY

Strategies to address this disease burden should include earlier HIV diagnosis and ART initiation, screening and prophylaxis for opportunistic infections, optimized management of specific diseases and treatment complications, and programme strengthening.

From HIV diagnosis to treatment: evaluation of a referral system to promote and monitor access to antiretroviral therapy in rural Tanzania

Background

Individuals diagnosed with HIV in developing countries are not always successfully linked to onward treatment services, resulting in missed opportunities for timely initiation of antiretroviral therapy, or prophylaxis for opportunistic infections. In collaboration with local stakeholders, we designed and assessed a referral system to link persons diagnosed at a voluntary counselling and testing (VCT) clinic in a rural district in northern Tanzania with a government-run HIV treatment clinic in a nearby city.

Methods

Two-part referral forms, with unique matching numbers on each side were implemented to facilitate access to the HIV clinic, and were subsequently reconciled to monitor the proportion of diagnosed clients who registered for these services, stratified by sex and referral period. Delays between referral and registration at the HIV clinic were calculated, and lists of non-attendees were generated to facilitate tracing among those who had given prior consent for follow up.

Transportation allowances and a "community escort" from a local home-based care organization were introduced for patients attending the HIV clinic, with supportive counselling services provided by the VCT counsellors and home-based care volunteers. Focus group discussions and in-depth interviews were conducted with health care workers and patients to assess the acceptability of the referral procedures.

Results

Referral uptake at the HIV clinic averaged 72% among men and 66% among women during the first three years of the national antiretroviral therapy (ART) programme, and gradually increased following the introduction of the transportation allowances and community escorts, but declined following a national VCT campaign. Most patients reported that the referral system facilitated their arrival at the HIV clinic, but expressed a desire for HIV treatment services to be in closer proximity to their homes. The referral forms proved to be an efficient and accepted method for assessing the effectiveness of the VCT clinic as an entry point for ART.

Conclusion

The referral system reduced delays in seeking care, and enabled the monitoring of access to HIV treatment among diagnosed persons. Similar systems to monitor referral uptake and linkages between HIV services could be readily implemented in other settings.

Barriers to access to antiretroviral treatment in Mozambique, as perceived by patients and health workers in urban and rural settings

This study identifies, ranks, and compares factors perceived as barriers to accessing antiretroviral treatment (ART) in urban and rural settings in Mozambique. Data were collected between March and July 2008. It consisted of 13 focus group discussions and a structured questionnaire administered to 252 people living with HIV/AIDS (PLWHA) and 28 health workers in the districts of Beira and Buzi. Data analysis was performed using content analysis, factor analysis, and percentages of the maximum attainable scores. The data analysis revealed six clusters of factors, which were ranked according to the percentages of the maximum attainable scores between brackets: (1) patient resource availability, in which distance from home to the health facility, transportation and food availability were rated below 40%; (2) community information (47%), and (3) service availability (53%), in which the waiting time to receive the results of CD4 analysis and the sufficiency of doctors/nurses at the health facility were both rated at 45%; (4) patient information and attitudes toward treatment (74%); family support (77%) and health personnel confidentiality (79%). Policy makers, in efforts to further improve the access to ART may decide to target their attention in designing interventions to improve specific aspects of patient resource availability, community information, and service availability in both urban and rural settings.

Cost-effectiveness of preventing loss to follow-up in HIV treatment programs: a Côte d'Ivoire appraisal

BACKGROUND

Data from HIV treatment programs in resource-limited settings show extensive rates of loss to follow-up (LTFU) ranging from 5% to 40% within 6 mo of antiretroviral therapy (ART) initiation. Our objective was to project the clinical impact and cost-effectiveness of interventions to prevent LTFU from HIV care in West Africa.

METHODS AND FINDINGS

We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) International model to project the clinical benefits and cost-effectiveness of LTFU-prevention programs from a payer perspective. These programs include components such as eliminating ART co-payments, eliminating charges to patients for opportunistic infection-related drugs, improving personnel training, and providing meals and reimbursing for transportation for participants. The efficacies and costs of these interventions were extensively varied in sensitivity analyses. We used World Health Organization criteria of <3x gross domestic product per capita (3x GDP per capita = US$2,823 for Côte d'Ivoire) as a plausible threshold for "cost-effectiveness." The main results are based on a reported 18% 1-y LTFU rate. With full retention in care, projected per-person discounted life expectancy starting from age 37 y was 144.7 mo (12.1 y). Survival losses from LTFU within 1 y of ART initiation ranged from 73.9 to 80.7 mo. The intervention costing US$22/person/year (e.g., eliminating ART co-payment) would be cost-effective with an efficacy of at least 12%. An intervention costing US$77/person/year (inclusive of all the components described above) would be cost-effective with an efficacy of at least 41%.

CONCLUSIONS

Interventions that prevent LTFU in resource-limited settings would substantially improve survival and would be cost-effective by international criteria with efficacy of at least 12%-41%, depending on the cost of intervention, based on a reported 18% cumulative incidence of LTFU at 1 y after ART initiation. The commitment to start ART and treat HIV in these settings should include interventions to prevent LTFU.

Mortality of patients lost to follow-up in antiretroviral treatment programmes in resource-limited settings: systematic review and meta-analysis

Background

The retention of patients in antiretroviral therapy (ART) programmes is an important issue in resource-limited settings. Loss to follow up can be substantial, but it is unclear what the outcomes are in patients who are lost to programmes.

Methods and Findings

We searched the PubMed, EMBASE, Latin American and Caribbean Health Sciences Literature (LILACS), Indian Medlars Centre (IndMed) and African Index Medicus (AIM) databases and the abstracts of three conferences for studies that traced patients lost to follow up to ascertain their vital status. Main outcomes were the proportion of patients traced, the proportion found to be alive and the proportion that had died. Where available, we also examined the reasons why some patients could not be traced, why patients found to be alive did not return to the clinic, and the causes of death. We combined mortality data from several studies using random-effects meta-analysis. Seventeen studies were eligible. All were from sub-Saharan Africa, except one study from India, and none were conducted in children. A total of 6420 patients (range 44 to 1343 patients) were included. Patients were traced using telephone calls, home visits and through social networks. Overall the vital status of 4021 patients could be ascertained (63%, range across studies: 45% to 86%); 1602 patients had died. The combined mortality was 40% (95% confidence interval 33%–48%), with substantial heterogeneity between studies (P<0.0001). Mortality in African programmes ranged from 12% to 87% of patients lost to follow-up. Mortality was inversely associated with the rate of loss to follow up in the programme: it declined from around 60% to 20% as the percentage of patients lost to the programme increased from 5% to 50%. Among patients not found, telephone numbers and addresses were frequently incorrect or missing. Common reasons for not returning to the clinic were transfer to another programme, financial problems and improving or deteriorating health. Causes of death were available for 47 deaths: 29 (62%) died of an AIDS defining illness.

Conclusions

In ART programmes in resource-limited settings a substantial minority of adults lost to follow up cannot be traced, and among those traced 20% to 60% had died. Our findings have implications both for patient care and the monitoring and evaluation of programmes.

Reasons for loss to follow-up among mothers registered in a prevention-of-mother-to-child transmission program in rural Malawi

This study was conducted to identify reasons for a high and progressive loss to follow-up among HIV-positive mothers within a prevention-of-mother-to-child HIV transmission (PMTCT) program in a rural district hospital in Malawi. Three focus group discussions were conducted among a total of 25 antenatal and post-natal mothers as well as nurse midwives (median age 39 years, range 22-55 years). The main reasons for loss to follow-up included: (1) not being prepared for HIV testing and its implications before the antenatal clinic (ANC) visit; (2) fear of stigma, discrimination, household conflict and even divorce on disclosure of HIV status; (3) lack of support from husbands who do not want to undergo HIV testing; (4) the feeling that one is obliged to rely on artificial feeding, which is associated with social and cultural taboos; (5) long waiting times at the ANC; and (6) inability to afford transport costs related to the long distances to the hospital. This study reveals a number of community- and provider-related operational and cultural barriers hindering the overall acceptability of PMTCT that need to be addressed urgently. Mothers attending antenatal services need to be better informed and supported, at both community and health-provider level.

The World Health Organization's global strategy for prevention and assessment of HIV drug resistance

Antiretroviral treatment (ART) for HIV is being scaled up rapidly in resource-limited countries. Treatment options are simplified and standardized, generally with one potent first-line regimen and one potent alternate first-line regimen recommended. Widespread HIV drug resistance (HIVDR) was initially feared, but reports from resource-limited countries suggest that initial ART programmes are as effective as in resource-rich countries, which should limit HIV drug resistance if programme effectiveness continues during scale-up. ART interruptions must be minimized to maintain viral suppression on the first-line regimen for as long as possible. Lack of availability of appropriate second-line drugs is a concern, as is the additional accumulation of resistance mutations in the absence of viral load testing to determine failure. The World Health Organization (WHO) recommends a minimum-resource strategy for prevention and assessment of HIVDR in resource-limited countries. The WHO's Global Network HIVResNet provides standardized tools, training, technical assistance, laboratory quality assurance, analysis of results and recommendations for guidelines and public health action. National strategies focus on assessments to guide immediate public health action to improve ART programme effectiveness in minimizing HIVDR and to guide regimen selection. Globally, WHO HIVResNet collects and analyses data to support evidence-based international policies and guidelines. Financial support is provided by major international organizations and technical support from HIVDR experts worldwide. As of December 2007, 25 countries were planning or implementing the strategy; seven countries report results in this supplement.

Can the initial success of the Malawi ART scale-up programme be sustained? The example of Queen Elizabeth Central Hospital, Blantyre

The antiretroviral therapy clinic of Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi was established as a fee-paying clinic in 2000. In 2004 a successful transition to free-of-charge antiretroviral therapy (ART) provision was made with the introduction of the national ART scale-up programme. Despite the human resource crisis in the healthcare system, remarkable improvements in quantity and quality of care, a reduction of defaulters, favourable ART outcomes and better access to ART for the poor, women and children were achieved. A number of challenges need to be overcome to sustain the initial success of the national ART scale-up programme in QECH, the most important being the shortage of ART staff in relation to the ever-expanding patient population.

Identification of beneficiaries of free anti-retroviral drugs in Malawi: a community consensus process

Malawi is a southeastern Africa country that has been heavily affected by the AIDS pandemic. It is estimated that about 170,000 people were in need of highly active antiretroviral therapy (HAART) for the treatment of AIDS in 2006. At the end of 2006, at least 55,000 people in Malawi were on HAART treatment, mostly through the free public sector program. At the time the program was being initiated, an ethical question needed to be answered in respect to who would be targeted for free treatment in an environment where medications, human and other resources were not enough to cater for all who were clinically eligible to be on treatment. In this paper we report on a qualitative study that was carried out to obtain public perceptions and input as to which criteria ought to have been applied to identify persons or groups of persons to be targeted in the free HAART program. In general, there was no agreement as to who should be prioritised for HAART, whether treatment should be free to user or whether cost-sharing should be introduced. While it may have been relatively straightforward in obtaining consensus and agreement among medical practitioners on the clinical criteria for HART in Malawi, deciding on the social criteria was complex. The decision to start the nationwide HAART program was started with the understanding that virtually every social group could be justified as worth of free HAART.