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Who starts ART in Durban, South Africa?...Not everyone who should!
Presented by Ingrid Bassett (United States).
I. Bassett1,2, S. Regan1, S. Chetty3, J. Giddy3, L. Uhler1, H. Holst3, D. Ross4, R. Walensky1,2, K. Freedberg1,2, E. Losina5,6
1Massachusetts General Hospital, General Medicine, Boston, United States, 2Harvard Medical School, Boston, United States, 3McCord Hospital, Durban, South Africa, 4St. Mary's Hospital, Durban, South Africa, 5Brigham and Women's Hospital, Boston, United States, 6Boston University School of Public Health, Boston, United States
Background: Although loss to follow-up after antiretroviral therapy (ART) initiation is well-described in resource-limited settings, little is known about entry into care following an HIV test. Our objective was to evaluate rates of ART initiation within 12 months of a positive HIV test in South Africa.
Methods: We prospectively enrolled adults (>18 years old) prior to HIV testing at two outpatient clinics in Durban. Both sites offer comprehensive HIV care. We collected HIV test results, CD4 counts, dates of ART initiation and dates of death from medical records and 12-month patient/family interviews. Minimum observation time was 6 months. ART-eligible patients had CD4 < 200/ml or an AIDS-defining condition. The primary endpoint was starting ART, and predictors of failing to initiate ART were evaluated.
Results: From Nov. 2006 - Nov. 2007, 896 HIV-infected patients were enrolled, 649 (72%) of who underwent CD4 count testing. Of 574 (88%) patients who obtained CD4 counts with results available, 367 (64%) had CD4 < 200/ml; an additional 19 patients (3%) were ART-eligible based on an AIDS-defining condition. Of 386 ART-eligible patients, only 213 (55%) were known to have initiated ART within 12 months. Median time from CD4 count to ART initiation was 3.5 months (IQR 2.0-5.5 months). There were 68 known deaths (18% of ART-eligible cohort); 52 (76%) occurred prior to ART initiation. Controlling for age, CD4 count and distance from clinic, patients who did not start ART were more likely to be male (RR 1.3, 95% CI 1.0-1.7).
Conclusions: There is substantial attrition from care and mortality following HIV diagnosis and prior to ART initiation in Durban, South Africa. Although patients are often severely immunosuppressed at HIV diagnosis, only half of eligible patients started ART within 12 months. Major efforts directed at earlier HIV diagnosis and linking HIV-infected people to care are urgently needed.
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