In sub-Saharan Africa, only about one third of patients who test positive for HIV but are not yet eligible for antiretroviral treatment remain in care until they become eligible and start treatment. Some patients never return for the results of their initial CD4 count (a prognostic and treatment eligibility biomarker); some disappear between having their initial CD4 count taken and becoming eligible for HIV treatment; and others with CD4 counts that indicate that they are eligible for treatment do not return to start receiving medications.
These findings from a study by Sydney Rosen and Matthew Fox, based at Boston University in the USA, highlight one of the challenges of improving outcomes for patients in HIV/AIDS programs in resource-limited settings. Earlier initiation of treatment, which is one of the most important ways to improve patient outcomes, requires that all individuals who test positive for HIV enroll and remain in pre-treatment care and be monitored regularly to ensure that antiretroviral therapy is initiated as soon as they become eligible for treatment.
The authors reviewed 28 relevant studies and found that on average, 59% of patients were retained between testing positive for HIV and completing their first CD4 count (defined by the authors as Stage 1), 46% were retained in pre-treatment care after their first CD4 count but before treatment eligibility (Stage 2), and 68% were retained between treatment eligibility and treatment initiation (Stage 3). Retention rates at each stage differed greatly between studies-- for example between 14% and 84% for Stage 3 of pre-treatment care. Nevertheless, the researchers estimate that, taking all the studies together, less than one third of patients testing positive for HIV but not eligible for antiretroviral treatment at diagnosis were continuously retained in pre-treatment care.
The authors conclude: "Studies of retention in pre-[treatment] 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 [antiretroviral therapy] despite eligibility."
They continue: "Better health information systems that allow patients to be tracked between service delivery points are needed to properly evaluate pre-[treatment] loss to care, and researchers should attempt to standardize the terminology, definitions, and time periods reported."
Funding: Funding was provided by the United States Agency for International Development (USAID) (http://www.usaid.gov/) under Award Number 674-A-00-09-00018-00 with Boston University and by the National Institute of Allergy and Infectious Diseases (http://www.niaid.nih.gov/Pages/default.aspx) under Award Number K01AI083097. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of USAID, the National Institute of Allergy and Infectious Diseases, the National Institutes of Health, or other parties.
Competing Interests: The authors have declared that no competing interests exist.
Citation: Rosen S, Fox MP (2011) Retention in HIV Care between Testing and Treatment in Sub-Saharan Africa: A Systematic Review. PLoS Med 8(7): e1001056. doi:10.1371/journal.pmed.1001056
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