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Fuge TG, Tsourtos G, Miller ER. Risk factors for late linkage to care and delayed antiretroviral therapy initiation amongst HIV infected adults in sub-Saharan Africa: a systematic review and meta-analyses. Int J Infect Dis 2022; 122:885-904. [PMID: 35843499 DOI: 10.1016/j.ijid.2022.07.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/11/2022] [Accepted: 07/11/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Late treatment initiation threatens the clinical and public health benefits of antiretroviral therapy (ART). Quantitative synthesises of the existing evidence related to this is lacking in sub-Saharan Africa (SSA), which would help ascertain the best evidence-based interventions. This review aimed to systematically synthesise the available literature on factors affecting linkage to care and ART initiation amongst HIV-infected adults in SSA. METHODS Systematic searches were undertaken on four databases to identify observational studies investigating factors affecting both HIV care outcomes amongst adults (age ≥19 years) in SSA, and were published between January 1, 2015 and June 1, 2021. RevMan-5 software was used to conduct meta-analyses and Mantel-Haenszel statistics to pool outcomes with 95% confidence interval and <0.05 level of significance. RESULTS Forty-six studies were included in the systematic review, of which 18 fulfilled requirements for meta-analysis. In both narrative review and meta-analyses, factors related to health care delivery, individual perception and sociodemographic circumstances were associated with late linkage to care and delays in ART initiation. CONCLUSION This review identified a range of risk factors for late linkage to care and delayed ART initiation amongst HIV-infected adults in SSA. We recommend implementation of patient-centred intervention approaches to alleviate these barriers.
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Affiliation(s)
- Terefe Gone Fuge
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - George Tsourtos
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Emma R Miller
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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Sy KTL, Tariq S, Ramjee G, Blanchard K, Leu CS, Kelvin EA, Exner TM, Gandhi AD, Lince-Deroche N, Mantell JE, O’Sullivan LF, Hoffman S. Predictors of antiretroviral therapy initiation in eThekwini (Durban), South Africa: Findings from a prospective cohort study. PLoS One 2021; 16:e0246744. [PMID: 33606712 PMCID: PMC7895397 DOI: 10.1371/journal.pone.0246744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 01/25/2021] [Indexed: 01/08/2023] Open
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.
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Affiliation(s)
- Karla Therese L. Sy
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
| | - Shema Tariq
- Institute for Global Health, University College London, London, United Kingdom
| | - Gita Ramjee
- South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa
| | - Kelly Blanchard
- Ibis Reproductive Health, Cambridge, Massachusetts and Johannesburg, South Africa
| | - Cheng-Shiun Leu
- Division of Gender, Sexuality, and Health, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Elizabeth A. Kelvin
- Department of Epidemiology & Biostatistics, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America
- CUNY Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
| | - Theresa M. Exner
- Division of Gender, Sexuality, and Health, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
| | - Anisha D. Gandhi
- Division of Gender, Sexuality, and Health, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
| | - Naomi Lince-Deroche
- Ibis Reproductive Health, Cambridge, Massachusetts and Johannesburg, South Africa
| | - Joanne E. Mantell
- Division of Gender, Sexuality, and Health, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
| | | | - Susie Hoffman
- Division of Gender, Sexuality, and Health, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
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