In this study, 69% of patients enrolled in pre-ART care failed to return for their first medical visit within 1 year of enrolment. This highlights the need for greater investment in patient retention from the beginning of HIV care, not just after ART begins.
Our data, combined with a previous analysis of post-voluntary counseling and testing (VCT) rates of CD4 testing at the same site (Larson et al. 2009
), paint a striking picture. First, very few patients (13%) who learn their HIV status prior to ART eligibility return to the clinic to obtain their CD4 counts (Larson et al. 2009
). Second, we showed only a small proportion of pre-ART care patients return for their first medical visit on time; less than 1/3 of these patients return within 1 year of enrolment.
According to the HIV/AIDS and STI Strategic Plan for South Africa, 2007–2011
(South African National Department of Health
), South Africa aims to ‘provide an appropriate package of treatment, care and support services to 80% of HIV positive people and their families by 2011 in order to reduce morbidity and mortality as well as other impacts of HIV/AIDS’ (South African National Department of Health, p. 57). One of the main goals of pre-ART care is to monitor disease progression to ensure as early a start on ART as possible, hopefully before the patient develops serious clinical illness. The low rate of retention we observed at the very beginning of the HIV care program does not bode well for achieving the country's stated goal. Patients who do not even return for their first medical visit may have benefited by being made aware of their status and from the counselling that accompanied the HIV test and CD4 count, but they are still at risk of becoming late presenters. Pre-ART care thus remains a broken link in the chain that should connect HIV testing to ART through pre-ART care. This link must be repaired if the problem of late presentation for treatment is to be solved and South Africa is to meet its national policy goals.
This study had several limitations. It was conducted at only one facility in South Africa, albeit one of the largest, so it is possible that experience differs at other sites. Importantly, there is no medical information system in South Africa that allows patients to be tracked from one facility to another. We cannot therefore rule out the possibility that some of our subjects transferred to a care program elsewhere, though this is unlikely to explain more than a fraction of the high level of attrition we observed. Finally, we do not know why the subjects in our study did or did not return. It is possible that some patients with low CD4 counts who should have returned within 3 months but instead waited 9–10 months, returned because they were sick and needed medical care. Patients like these, who can no longer accurately be labelled ‘early presenters,’ may cause our results to overestimate the proportion of patients who adhered to the program schedule.
None of these limitations is sufficient to alter the core finding of this study, which is that the majority of patients are lost from pre-ART care between enrolment and their first return visit. Future research is needed to examine why patients are LTF in pre-ART care and what interventions are feasible and effective for reducing such losses. We suspect that barriers to returning for pre-ART program visits are similar to barriers to ART adherence in general, which include, but are not limited to, costs and/or time for transport, lost earnings, lack of financial resources, stigma, lack of family support, perceived need and psychological issues (Jones 2005
; Mshana et al. 2006
; Horne et al. 2007
; Kinsler et al. 2007
; Makombe et al. 2007
; Muula et al. 2007
; Wilson & Blower 2007
). Employed patients were substantially more likely to complete their return medical visit within one year than unemployed patients, which is consistent with the literature on barriers to ART adherence in general. Future research should focus on identifying these barriers for particular patient populations and seeking strategies for overcoming them.