Low retention among HIV-positive adults not yet eligible for antiretroviral therapy

Impact of systematic HIV testing on case finding and retention in care at a primary care clinic in South Africa.

Clouse K, Hanrahan CF, Bassett J, Fox MP, Sanne I, Van Rie A. Trop Med Int Health. 2014 Sep 22. doi: 10.1111/tmi.12387. [Epub ahead of print]

Objective: Systematic, opt-out HIV counselling and testing (HCT) may diagnose individuals at lower levels of immunodeficiency but may impact loss to follow-up (LTFU) if healthier people are less motivated to engage and remain in HIV care. We explored LTFU and patient clinical outcomes under two different HIV testing strategies.

Methods: We compared patient characteristics and retention in care between adults newly diagnosed with HIV by either voluntary counselling and testing (VCT) plus targeted provider-initiated counselling and testing (PITC) or systematic HCT at a primary care clinic in Johannesburg, South Africa.

Results: One thousand one hundred and forty-four adults were newly diagnosed by VCT/PITC and 1124 by systematic HCT. Two-thirds of diagnoses were in women. Median CD4 count at HIV diagnosis (251 vs. 264 cells/µl, P = 0.19) and proportion of individuals eligible for antiretroviral therapy (ART) (67.2% vs. 66.7%, P = 0.80) did not differ by HCT strategy. Within 1 year of HIV diagnosis, half were LTFU: 50.5% under VCT/PITC and 49.6% under systematic HCT (P = 0.64). The overall hazard of LTFU was not affected by testing policy (aHR 0.98, 95%CI: 0.87-1.10). Independent of HCT strategy, males, younger adults and those ineligible for ART were at higher risk of LTFU.

Conclusions: Implementation of systematic HCT did not increase baseline CD4 count. Overall retention in the first year after HIV diagnosis was low (37.9%), especially among those ineligible for ART, but did not differ by testing strategy. Expansion of HIV testing should coincide with effective strategies to increase retention in care, especially among those not yet eligible for ART at initial diagnosis.

Abstract access 

Editor’s notes: Systematic, opt-out HIV counselling and testing of all individuals presenting to care facilities is recommended by World Health Organization in generalized HIV epidemics.

This study describes the results of a before and after study where the clinic switched from focussed, provider-initiated HIV testing to clinic-wide systematic HIV testing. The authors compare the number of people newly-diagnosed with HIV, their level of immunosuppression, and retention in care one year after HIV testing. They compared them to the focussed provider initiated HIV testing to systematic testing. Interestingly, they did not find any significant differences in these outcomes between the testing strategies. The switch to systematic HIV counselling and testing did not automatically increase HIV case finding nor identify cases at earlier stages of HIV disease. Loss to follow-up one year after HIV diagnosis was high (50%), but did not differ by testing strategy.

As the authors note, expansion of HIV testing strategies need to be combined with effective strategies to retain people in HIV care if the benefits of wider testing are to be fully realised.

South Africa
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