More than two-thirds of people who tested positive for HIV but weren't yet eligible for treatment when diagnosed were lost from care,
according to a systematic review of pre-antiretroviral (pre-ART) care in sub-Saharan Africa, published this month in PLoS Medicine.
included in the review report a substantial loss of patients at every step of
care, starting with patients who do not return for their initial CD4 count
results and ending with those who do not initiate ARVs despite eligibility,
according to Sydney Rosen and Matthew Fox of the Center for
Global Health and Development at Boston University, who conducted the review.
The study was conducted in order to evaluate the extent to which patients diagnosed with HIV are being lost before starting treatment.
studies which reported 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 were included. Results were
categorised into stages of pre-ART care with ranges reported for the proportions of patients
retained in each stage.
Stages were categorised as follows:
- Stage 1: from HIV testing to receipt of CD4 count results or
- Stage 2: from receipt of CD4 count results or clinical staging
to ARV eligibility
- Stage 3: from ARV eligibility to ARV initiation
The review found that the median proportion of
patients retained in Stage 1 was 59% (ranging from 35%–88%); Stage 2, 46%
(31%–95%); and Stage 3, 68% (14%–84%). 'Loss to
care' was defined as failing to reach the next step in the care sequence for
any reason (death or discontinuation), but each study’s own criteria for
determining which patients died or discontinued care were also included.
There are several key reasons for the poor
retention of pre-ART care patients. As most patients are asymptomatic during
the pre-ART period, they may not perceive themselves as requiring medical care.
Patients may also not come to the clinic for monitoring and may choose to
‘‘wait and see what happens’’ if they
"lack resources for transport, risk losing employment by taking time off work,
or fear being recognised as a client of an HIV clinic," write the authors. Those presenting with a
low CD4 count are likely to have died before reaching stage 3. Patient mobility
may also be a factor contributing to low retention rates.
According to the researchers the use of
point-of-care CD4 count technology, currently being evaluated in several
settings, to reduce the number of visits to the clinic in Stage 1 may be a
method of retaining patients in pre-ART care.
Another promising strategy identified by the researchers is to dispense
prophylaxis for opportunistic infections, such as cotrimoxazole and isoniazid,
more actively to pre-ART patients as a means of keeping pre-ART patients within
the health system. A study in Kenya
reported that retention of pre-ART patients 12 months after enrolment improved
from 63% to 84% after provision of cotrimoxazole was introduced.
Reports containing primary, patient- or
facility-level data from routine health-care delivery settings were included in the review but
data from studies where patients were solely in care to prevent mother-to-child transmission
of HIV, and daya from paediatric patients, were not used. Studies containing modelled
estimates without primary data, qualitative studies, and clinical trials that
did not take place under routine care conditions were also excluded from the
The review included three studies taken from
Ethiopia, Kenya, Uganda and Malawi each, one from Tanzania and Mozambique each
and 14 from South Africa. Most (18 of the 28) studies were designed as
retrospective cohorts using routinely collected patient-level data with the
remaining studies reporting on program
evaluations, trials of procedural changes, and a prospective cohort.
The results of the review were limited by the
fact that none of the studies followed a cohort of patients through all three
stages of pre-ART care, with most studies reporting on only one stage.
Aggregations of results were also difficult across the studies reviewed as
enrolment criteria, terminology, end points, follow-up, and outcomes varied
widely and were often poorly defined.
“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 standardise
the terminology, definitions, and time periods reported,” concluded the