Retention of pre-ART patients poor in sub-Saharan Africa

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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.

Studies 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.


retention in care

A patient’s regular and ongoing engagement with medical care at a health care facility. 

systematic review

A review of the findings of all studies which relate to a particular research question and which conform to pre-determined selection criteria. 


Qualitative research is used to explore and understand people’s beliefs, experiences, attitudes or behaviours. It asks questions about how and why. Qualitative research might ask questions about why people find it hard to use HIV prevention methods. It wouldn’t ask how many people use them or collect data in the form of numbers. Qualitative research methods include interviews, focus groups and participant observation.

mother-to-child transmission (MTCT)

Transmission of HIV from a mother to her unborn child in the womb or during birth, or to infants via breast milk. Also known as vertical transmission.


An antibiotic that works by stopping the growth of bacteria. It is used with other medications to treat active tuberculosis (TB) infections, and on its own to prevent active TB in people who may be infected with the bacteria without showing any symptoms (latent TB). 

28 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 clinical staging
  • 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 review .

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 researchers.

Kohler P et al. Free CTX substantially improves retention among ART-ineligible clients in a Kenyan HIV treatment program. 18th Conference on Retroviruses and Opportunistic Infections, Boston, abstract 1018, 2011.

Rosen S & Fox MP. Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review. PLoS Medicine 8 (7): e1001056, 2011.