in five newly diagnosed ART eligible adults attending the Zazi Testing Center,
Perinatal HIV Research Unit (PHRU) in Soweto,
refused to start free ART, provided onsite, within two months of diagnosis.
Ingrid T. Katz and colleagues reported these findings in a cross-sectional analysis
comparing newly diagnosed ART eligible adults who refused to start treatment
with those who agreed to start from December 2008 to December 2009 published in
the advance online edition of AIDS.
of those presenting at the Zazi Center had been tested previously. “Too healthy”
was the most frequent reason given for refusing treatment in spite of a median
CD4 cell count of 110 cells/mm3 (IQR: 58-148), leaving them at risk
for early death.
sub-Saharan Africa has the greatest number of
people living with HIV. Studies have shown death rates during the first year on
ART range between 8 and 26% with most deaths happening within the first few
in South Africa
have shown those who present late for treatment with low CD4 cell counts at the
time of starting ART are at an increased risk for early death.
South Africa with close to
six million people living with HIV now has the largest antiretroviral treatment
programme in the world with an estimated one million on treatment by the end of
the dramatic increases in voluntary testing and counselling (VCT) with over
half of all South Africans having tested at least once has not resulted in more
people starting ART earlier. Approximately only half of those in need of
treatment get it. This raises concerns about the efficacy of VCT as the
traditional route to treatment and care.
authors note that most studies to date have focused appropriately on linkage to
care, especially loss to follow-up and where delay in starting ART has affected
pre-ART death rates. However, little is known about the reasons for delay in
starting ART they note, and in particular whether it is “due to failure to
present for treatment or actual treatment refusal.”
PHRU is in Soweto,
an urban area with one of the world’s highest HIV transmission rates. Free
comprehensive testing, treatment and care is provided. On-site VCT has been
provided since 2001 with funding from USAID and PEPFAR.
Zazi (VCT) Center provides HIV rapid testing to adults aged 18
and over as well as family planning, screening for TB and sexually transmitted
infections (STIs) monthly. Those who test HIV positive return for their CD4
cell counts a week later and are referred as appropriate. Following referral
the clients meet with social workers to discuss starting ART.
included in the analysis were HIV-positive and treatment eligible (with CD4
cell counts under 200 cells/mm3 or at WHO clinical stage 4). Free
onsite treatment was offered. Those who refused were further counselled for up
to two months by a social worker.
the 7287 adults presenting at the Zazi
Center from December 2008
to December 2009 35% were found to be HIV-positive.
the 2562 HIV-infected 29% (743) were eligible to start ART immediately. Of
these 20% (148) refused to start treatment upon referral of which 92% continued
to refuse treatment after two months of counselling.
authors note that while an overwhelming 92% of those tested said they would be
willing to disclose, over 20% of those who refused ART said they were “unable
adjusting for other factors those who were single were almost twice as likely
to refuse to start treatment compared to other marital status groups (AOR:
1.80; 95% CI: 1.06-3.06, p=<0.05).There was no gender difference between those who accepted and those who refused treatment; approximately one-third in each group were male.
the likelihood of non-disclosure, note the authors, is high and of concern
among single sexually active individuals. It is especially relevant, they add,
given the evidence that antiretroviral treatment in HIV-positive individuals prevents
transmission to uninfected regular partners.
with active tuberculosis (TB) were more than three times more likely to refuse
to start ART compared to those without (AOR: 3.20; 95% CI: 1.55-6.61). This
supports other findings of an association between having active TB and a low
acceptance of ART, the authors note.
authors highlight the importance of starting ART early especially in those with
co-morbidities. They cite a recent study in South Africa that showed early
start of ART together with TB treatment reduced mortality by 56%.
authors note a critical limitation. The data collected were not specific to
looking at factors associated with treatment refusal. At the time the concept
of treatment refusal had not been identified. As such there are no data on a
patient’s understanding of HIV and AIDS and what their test results might mean.
identified a critical barrier to improving coverage that goes beyond
availability, cost and a willingness to test the authors note the need to
“market the concept of ART as a life-saving intervention, even for people who
report feeling healthy.” They conclude “these finding highlight the urgent need
for research to inform interventions targeting ART refusers.”