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Treatment guidelines and early loss from care for people living with HIV in Cape Town, South Africa: A retrospective cohort study
- Source :
- PLoS Medicine, e1002434-177, PLoS Medicine, Vol 14, Iss 11, p e1002434 (2017)
- Publication Year :
- 2017
- Publisher :
- Public Library of Science (PLoS), 2017.
-
Abstract
- Background South Africa has undergone multiple expansions in antiretroviral therapy (ART) eligibility from an initial CD4+ threshold of ≤200 cells/μl to providing ART for all people living with HIV (PLWH) as of September 2016. We evaluated the association of programmatic changes in ART eligibility with loss from care, both prior to ART initiation and within the first 16 weeks of starting treatment, during a period of programmatic expansion to ART treatment at CD4+ ≤ 350 cells/μl. Methods and findings We performed a retrospective cohort study of 4,025 treatment-eligible, non-pregnant PLWH accessing care in a community health center in Gugulethu Township affiliated with the Desmond Tutu HIV Centre in Cape Town. The median age of participants was 34 years (IQR 28–41 years), almost 62% were female, and the median CD4+ count was 173 cells/μl (IQR 92–254 cells/μl). Participants were stratified into 2 cohorts: an early cohort, enrolled into care at the health center from 1 January 2009 to 31 August 2011, when guidelines mandated that ART initiation required CD4+ ≤ 200 cells/μl, pregnancy, advanced clinical symptoms (World Health Organization [WHO] stage 4), or comorbidity (active tuberculosis); and a later cohort, enrolled into care from 1 September 2011 to 31 December 2013, when the treatment threshold had been expanded to CD4+ ≤ 350 cells/μl. Demographic and clinical factors were compared before and after the policy change using chi-squared tests to identify potentially confounding covariates, and logistic regression models were used to estimate the risk of pre-treatment (pre-ART) loss from care and early loss within the first 16 weeks on treatment, adjusting for age, baseline CD4+, and WHO stage. Compared with participants in the later cohort, participants in the earlier cohort had significantly more advanced disease: median CD4+ 146 cells/μl versus 214 cells/μl (p < 0.001), 61.1% WHO stage 3/4 disease versus 42.8% (p < 0.001), and pre-ART mortality of 34.2% versus 16.7% (p < 0.001). In total, 385 ART-eligible PLWH (9.6%) failed to initiate ART, of whom 25.7% died before ever starting treatment. Of the 3,640 people who started treatment, 58 (1.6%) died within the first 16 weeks in care, and an additional 644 (17.7%) were lost from care within 16 weeks of starting ART. PLWH who did start treatment in the later cohort were significantly more likely to discontinue care in<br />In a retrospective cohort study, Ingrid Katz and colleagues report on the continuity of care for people with HIV in Gugulethu Township, South Africa<br />Author summary Why was this study done? Global HIV treatment initiatives have focused on increasing access to antiretroviral therapy, with the goal of creating an “AIDS-free generation.” In line with guidelines put forth by the World Health Organization, the focus is on starting newly diagnosed people on immediate treatment and maintaining long-term retention in care. There is growing evidence, however, that treatment availability alone is insufficient to stop the spread of the disease. In countries where HIV is hyperendemic such as South Africa, it remains unclear if expanding treatment eligibility to all individuals living with HIV will have an impact on patients’ engagement in care and early retention on treatment. We performed this study in a large, urban community HIV treatment site in Cape Town to understand the association of South Africa’s expanding treatment program with pre-treatment loss from care and early loss from care during treatment. What did the researchers do and find? We performed a retrospective study of 2 cohorts (which included over 4,000 treatment-eligible people living with HIV in total) who entered care at a community health center in Cape Town: an early cohort, enrolled into care from January 2009 to August 2011, when guidelines mandated that ART initiation required a CD4+ cell count of ≤200 cells/μl, pregnancy, advanced clinical symptoms (World Health Organization stage 4), or comorbidity (active tuberculosis), and a later cohort, enrolled September 2011 to December 2013, when the treatment threshold had been expanded to CD4+ ≤ 350 cells/μl. We determined the risk of pre-treatment and early losses (
- Subjects :
- Male
RNA viruses
0301 basic medicine
Pediatrics
Health Care Providers
Nurses
lcsh:Medicine
HIV Infections
Global Health
Pathology and Laboratory Medicine
Chi Square Tests
Geographical locations
Cohort Studies
South Africa
Mathematical and Statistical Techniques
0302 clinical medicine
Immunodeficiency Viruses
Antiretroviral Therapy, Highly Active
Health care
Medicine and Health Sciences
Public and Occupational Health
Medical Personnel
030212 general & internal medicine
General Medicine
Overcrowding
Vaccination and Immunization
3. Good health
Professions
Treatment Outcome
Anti-Retroviral Agents
Research Design
Medical Microbiology
Viral Pathogens
Physical Sciences
Practice Guidelines as Topic
Viruses
Cohort
Female
Pathogens
Statistics (Mathematics)
Research Article
Cohort study
Adult
medicine.medical_specialty
Immunology
Antiretroviral Therapy
Research and Analysis Methods
Microbiology
03 medical and health sciences
Antiviral Therapy
Retroviruses
medicine
Humans
Statistical Methods
Statistical Hypothesis Testing
Microbial Pathogens
Retrospective Studies
Treatment Guidelines
Health Care Policy
business.industry
lcsh:R
Lentivirus
Organisms
Biology and Life Sciences
HIV
Retrospective cohort study
Community Health Centers
Odds ratio
medicine.disease
030112 virology
Comorbidity
Discontinuation
Health Care
Africa
HIV-1
Population Groupings
Patient Care
Preventive Medicine
People and places
business
Mathematics
Subjects
Details
- ISSN :
- 15491676
- Volume :
- 14
- Database :
- OpenAIRE
- Journal :
- PLOS Medicine
- Accession number :
- edsair.doi.dedup.....4adc01d4454702e305f0d56fa7c950a5
- Full Text :
- https://doi.org/10.1371/journal.pmed.1002434