Free cotrimoxazole improves retention in care among adults not yet eligible for ART

Providing free cotrimoxazole prophylaxis to adults not yet eligible for antiretroviral treatment in Nairobi, Kenya, improved retention in care by over 20% after one year when compared with retention before 2006, Pamela K Kohler and colleagues reported in a study published in the current edition of AIDS.

The retention rate improved significantly from 63% to 84% (p<0.001), and was comparable to the retention rate of those on ART.

The study was carried out at the Coptic Hope Center, a comprehensive HIV treatment facility,

Rapid scale-up of antiretroviral treatment services in resource-poor settings has led to over 5 million people with access to ART. Free provision of ART significantly increased enrolment and a corresponding high level of retention and adherence has resulted in decreased morbidity and mortality.

Starting treatment late is associated with early death and a poor response to treatment. Those ineligible for ART are not offered routine care. In contrast to the high retention rates among those on ART those ineligible or pre ART have significantly lower retention rates.

Between 2000 and 2007 mean retention rates in ART programmes in sub-Saharan Africa were estimated to be 75%, In contrast a recent meta-analysis of studies looking at retention of patients not yet eligible for treatment found that more two-thirds of patients became lost to follow-up. This means that many may not return for care until they are already quite sick so missing the opportunity for a timely start of ART.

In 2006 the World Health Organization (WHO) in 2006 recommended the use of cotrimoxazole prophylaxis (CTXP) for all adults diagnosed with HIV infection with CD4 cell counts below 500 cells/mm³, to protect against bacterial infections and pneumocystis carinii pneumonia (PCP).

In late 2006 CTXP became routine in many HIV programmes following revised Ministry of Health guidelines.

The authors of the new study believed that providing CTXP free might improve retention so they chose to compare retention among ART-ineligible clients in a treatment programme in Kenya before and after provision of free CTXP.

The Coptic Hope Center provides basic HIV care and free ART to adults and children. From September 2006 CTXP was provided free of charge to all ART-ineligible clients according to national guidelines (CD4 cell count above 250 cells/mm³ and WHO clinical stage 1 or 2). ART patients returned to the clinic every 1-2 months for a medical or pharmacy visit. Before free CTXP provision ART-ineligible patients were scheduled to return every six months. After CTXP was introduced they were asked to return every 1-2 months for a pharmacy visit.

To see whether clinic retention was affected by programme changes over time, retention of ART clients before and after September 2006 was also compared.

Among the 5175 clients with a baseline CD4 cell count enrolled at the Hope Center from 2005 to 2007, 62% started ART in the first year of care. Of the 1941 clients who did not start ART within the first year 53% (1024) were ineligible for ART.

Among ART-ineligible clients there were no significant differences in age sex, TB status or body mass index before or after provision of free CTXP.  Median baseline CD4 cell counts were similar before and after, 412 cells/mm³ and 441 cells/mm³, respectively.

In multivariate analysis adjusted for age, sex and CD4 cell count, ART-ineligible clients prior to the introduction of free CTXP were more than twice as likely to be lost to follow-up compared to those enrolled after free CTXP (AHR = 2.64, 95% CI: 1.95-3.57, p<0.001).

The authors note their findings are consistent with other studies. Before free CTXP retention rates in those ART-ineligible are considerably lower than those on ART. And, conversely other studies have shown provision of free treatment improves retention in HIV care.

Cotrimoxazole is one of the most cost-effective interventions in HIV treatment and is associated with improved individual and family health benefits.

The authors note their findings “suggest that the cost of CTX is likely to be outweighed by benefit, not only in terms of improved prevention of infections, but also as an incentive to maintain clinical monitoring that can ensure timely initiation of ART.”

Strengths of the study include adjusting for disease status, CD4 cell count and a comparison group of ART clients in a parallel analysis where retention remained unchanged.

Limitations include possible misclassifications of enrolment during, before or after free CTXP periods.

Improved retention may have been a result of improved monitoring with the provision of free CTXP.

The authors conclude “retention and CD4 monitoring of pre-ART clients are essential to promptly identify ART eligibility and start treatment. Implementation of free CTX may improve retention in sub-Saharan Africa and through increasingly timely ART start provide survival benefit.”

Kohler PK et al. Implementation of free cotrimoxazole prophylaxis improves clinic retention among antiretroviral therapy-ineligible clients in Kenya. AIDS 25:1657-1661, doi: 10.1097/QAD.0b013e32834957fd, 2011.