The clock is ticking: the rate and timeliness of antiretroviral therapy initiation from the time of treatment eligibility in Kenya

Abstract

IntroductionUnderstanding the determinants of timely antiretroviral therapy (ART) initiation is useful for HIV programmes intent on developing models of care that reduce delays in treatment initiation while maintaining a high quality of care. We analysed patient- and facility-level determinants of time to ART initiation among patients who initiated ART in Kenya.MethodsWe collected facility-level information and conducted a retrospective chart review of adults initiating ART between 2007 and 2012 at 51 health facilities in Kenya. We evaluated the association between patient- and facility-level covariates at the time of ART eligibility and time to ART initiation. We also explored the determinants associated with timeliness of ART initiation.ResultsThe analysis included 11,942 patients. The median age at the time eligibility was first determined was 37 years (interquartile range [IQR] 31–45). Overall, 75% of patients initiated ART within two months of eligibility. The median CD4 cell count at the time eligibility was first determined rose from 132 (IQR 51–217) in 2007 to 195 (IQR 91–286) in 2011 to 2012 (p<0.001). The cumulative probability of ART initiation among treatment-eligible patients increased over time: 87.1% (95% confidence interval [CI] 85.1–89.0%) in 2007; 96.8% (96.0–97.5%) in 2008; 97.1% (96.3–97.7%) in 2009; 98.5% (98.0 −98.9%) in 2010; and 99.7% (95% CI 99.4 −99.8%) in 2011 to 2012 (p<0.0001). In multivariate analyses, attending a health facility with high ART patient volumes within two months of eligibility was considered the key facility-level determinant of ART initiation (adjusted odds ratio 0.57, 95% CI 0.45–0.72, p<0.001). Patient-level determinants included being eligible for ART in the years subsequent to 2007, advanced World Health Organization clinical stage and low CD4 cell count at the time eligibility was first determined.ConclusionsOverall, the time between treatment eligibility and ART initiation decreased substantially in Kenya between 2007 and 2012, with uniform gains across different types of health facilities. Our findings highlight the slow increase in CD4 cell counts at the time of ART eligibility over time, indicating that a large number of patients are still beginning ART with advanced HIV disease. Our findings also support the decentralisation of ART services at all health facilities that have the capacity to initiate treatment. Continued evaluation of programme- and country-level data is needed to monitor timeliness of ART initiation as countries continue to expand treatment access.

Timing and Predictors of Initiation on Antiretroviral Therapy Among Newly-Diagnosed HIV-Infected Persons in South Africa

“…However little variation was seen in ART initiation among patients by CD4 level or WHO staging. Similar results were seen in studies conducted in Kenya and Rwanda which found little or no variation in ART initiation WHO staging, however these studies saw variation by CD4 count category [21, 22]. It appears that prioritization for treatment initiation among HIV-positive persons is not currently occurring at a significantly different rate based on CD4 level within the selected facilities we studied in South Africa.…”

“…While not affecting timeliness of ART initiation, age influenced rate of ART initiation with adolescents initiating at a faster rate than adults of all ages. Similar studies in sub-Saharan Africa saw no variation in timeliness of ART initiation by age [21, 22]. While the present analysis is limited in scope to explain the differences in timeliness by age, this is likely partially explained by the high proportion of pregnant women falling in the 15–24 age category.…”

Failure to initiate HIV treatment in patients with high CD4 counts: evidence from demographic surveillance in rural South Africa

“…The relationship was approximately linear, precisely estimated and robust to adjustment for age, sex and other baseline covariates. This is some of the first quantitative evidence on the association between CD4 count at presentation and ART uptake , confirming evidence in qualitative studies .…”

“…Table 2 presents hazard ratios of ART initiation associated with each predictor in the full sample. The hazard of ART initiation fell by 17% (95% CI 14,20) for every 100-cell increase in baseline CD4 count, with CD4 count modelled continuously. These effects were robust to alternate specifications controlling for age, sex, age-sex interactions, year of first recorded CD4 count and clinic fixed effects.…”

Sustainability of the streamlined ART (START-ART) implementation intervention strategy among ART-eligible adult patients in HIV clinics in public health centers in Uganda: a mixed methods study

“…Despite increasing access to antiretroviral therapy (ART), the proportion of eligible patients initiated on treatment remains suboptimal [1,2]. The 90-90-90 targets aim for 90% of people living with HIV (PLHIV) to know their HIV status, 90% of PLHIV to be on ART, and 90% of patients on ART to attain virological suppression by 2020 [3].…”