Attrition in HIV care following HIV diagnosis: a comparison of the pre‐UTT and UTT eras in South Africa

Abstract

Introduction Policies for Universal Test & Treat (UTT) and same‐day initiation (SDI) of antiretroviral therapy (ART) were instituted in South Africa in September 2016 and 2017 respectively. However, there is limited evidence on whether these changes have improved patient retention after HIV diagnosis. Methods We enrolled three cohorts of newly diagnosed HIV‐infected adults from two primary health clinics in Johannesburg from April to November 2015 (Pre‐UTT, N = 144), May‐September 2017 (UTT, N = 178) and October‐December 2017 (SDI, N = 88). A baseline survey was administered immediately after HIV diagnosis after which follow‐up using clinical records (paper charts, electronic health records and laboratory data) ensued for 12 months. The primary outcome was patient loss to follow‐up (being >90 days late for the last scheduled appointment) at 12 months post‐HIV diagnosis. We modelled attrition across HIV policy periods with Cox proportional hazard regression. Results Overall, 410 of 580 screened HIV‐positive patients were enrolled. Overall, attrition at 12 months was 30% lower in the UTT guideline period (38.2%) compared to pre‐UTT (47.2%, aHR 0.7, 95% CI: 0.5 to 1.0). However, the total attrition was similar between the SDI (47.7%) and pre‐UTT cohorts (aHR 1.0, 95% CI: 0.7 to 1.5). Older age at HIV diagnosis (aHR 0.5 for ≥40 vs. 25 to 29 years, 95% CI: 0.3 to 0.8) and being in a non‐marital relationship (aHR 0.5 vs. being single, 95% CI: 0.3 to 0.8) protected against LTFU at 12 months, whereas LTFU rates increased with longer travel time to the diagnosing clinic (aHR 1.8 for ≥30 minutes vs. ≤15 minutes, 95% CI: 1.1 to 3.1). In analyses adjusted for the time‐varying ART initiation status, compared to the pre‐ART period of care, the hazard of on‐ART LTFU was 90% higher among participants diagnosed under the SDI policy compared to pre‐UTT (aHR 1.9, 95% CI: 1.1 to 2.9). Conclusions Overall, nearly two‐fifths of HIV positive patients are likely to disengage from care by 12 months after HIV diagnosis under the new SDI policy. Furthermore, the increase in on‐ART patient attrition after the introduction of the SDI policy is cause for concern. Further research is needed to determine the best way for rapidly initiating patients on ART and also reducing long‐term attrition from care.

Impact of SMS and peer navigation on retention in HIV care among adults in South Africa: results of a three‐arm cluster randomized controlled trial

“…Importantly, the findings were driven by differences among participants on ART. Across study arms, those on ART were more likely to be retained than those who were pre‐ART, consistent with findings following UTT rollout [ 3 ]. Among participants on ART, retention was significantly higher when they had received the SMS+PN intervention.…”

“…A few contextual changes have occurred since this trial. Data were collected prior to UTT [ 3 ], however, our results remain highly relevant. The SMS+PN intervention worked most successfully among those qualifying for ART.…”

“…Recent national data from South Africa indicate that only 52% of people living with HIV (PLHIV) aged 15 or older are virally suppressed [ 2 ]. This comes despite improved medication access through policies for Universal Test & Treat (UTT), Same‐Day Initiation (SDI) of ART [ 3 ] and decentralized medication initiation and monitoring [ 4 ]. Although UTT has been associated with a 30% reduction in loss‐to‐follow‐up, nearly 40% of HIV patients continue to have suboptimal retention [ 3 ].…”

“…This comes despite improved medication access through policies for Universal Test & Treat (UTT), Same‐Day Initiation (SDI) of ART [ 3 ] and decentralized medication initiation and monitoring [ 4 ]. Although UTT has been associated with a 30% reduction in loss‐to‐follow‐up, nearly 40% of HIV patients continue to have suboptimal retention [ 3 ]. To further address barriers to care, countries are deploying personal support strategies, including short message service (SMS or text message) reminders [ 5 ] and in‐person support (e.g.…”

Predictors of attrition among adults in a rural HIV clinic in southern Mozambique: 18-year retrospective study

“…Known predictors of attrition include low initial CD4 T-cell lymphocyte counts, low baseline body mass index (BMI), history of hospitalization, advanced WHO clinical staging, older age at HIV diagnosis, and being a man 11 – 13 . Other studies from the region show anemia and decreased red blood cell counts and platelets as predictors of death during the first year of ART treatment 14 .…”