759 individuals attended the screening clinic for the first time during this period and 730 (96.2%) were interviewed and consented to participate. Twenty-two patients were missed by the study team during busy clinic sessions and seven refused. The median age of the participants at first presentation was 36.7 years, (IQR 30.9 - 44.3), with 9 <18 years old (median 14.9, range 13.3-15.8 years). Forty percent (40%) were male, 43% reported farming as their occupation, and 55% were assessed to be in WHO stage IV. Forty-eight percent (48%) were currently married and 28% were widowed. Only 27% had ever attended secondary school. Almost universally (>99%), participants reported having sought care within the last 6 months from a hospital/health centre or a traditional healer, a private practitioner or a combination of these.
Six hundred and thirty-three (633/730, 86.7%) were told they were clinically eligible for treatment (Figure ), including six individuals who were in WHO stage II but had a CD4 count < 250 cells/mm3 established through their participation in a research study. However, 17 of these participants were not ready to start treatment because they were too sick (N = 13) or had contra-indications (N = 4). Of the 616 participants identified as ready to start treatment, 532 (86.4%) did so, a median of 22 days (IQR 12-29 days) after the screening visit, with 10% starting after more than 40 days. In addition, 13 of the 17 clinically eligible participants initially advised not to start treatment started later (Figure ), a median of 22 days (IQR 13-27 days) after the screening visit. This leaves 88 (13.9%) individuals who were clinically eligible for ART after the first visit, but who did not return to clinic. Table shows the distribution of selected characteristics among those clinically eligible to start treatment at their first screening visit and odds ratio (OR) estimates of association between these factors and dropout before starting ART. In the final multivariate model, there was a significantly higher risk of dropout associated with lower education, grade 1 or higher chronic energy deficiency (CED), difficulty in dressing, a more delayed ART initiation appointment, and being screened in the later calendar periods of the study. A test for linear trend in calendar period was not statistically significant (χ2 test for trend was 3.27 on 1 degree freedom, p = 0.07). There was no significant association with age, sex, current marital status, distance of residence from clinic, or WHO stage, even in univariate models. In a univariate model, BMI < 18.5 was significantly associated with a significantly higher odds of dropout, however this did not remain significant in the multivariate model that included an indicator of CED using MUAC. An alternative model to the final model considered the composite indicator of difficulty in any daily functioning instead of difficulty in dressing and found the composite indicator not to be significantly associated with the odds of dropout (likelihood ratio test p = 0.65).
Outcome of first screening visit and ART initiation status.
Univariate and multivariate logistic regression models for odds of dropout after first screening visit despite being clinically eligible to start ART1
Forty-eight (49%) of the 97 individuals who were told that they were not yet clinically eligible on the first visit were invited by the clinician to return for a second screening, however the dates of these new screening visit appointments were not captured in the study database. Sixteen of these 48 returned for a second screening, a median of 61 days (IQR 25, 100) after their first screening. In contrast, 15 of the 49 participants asked to return when they had symptoms returned a median of 80 days (IQR (30, 173) after their first screening visit. Thus overall, 31 participants returned for a second screening, and 25 of them were eligible for ART. One of these 25 was too sick and one had contra-indications so were not started on ART immediately, and neither returned, and three other individuals did not return to the ART clinic. The remaining 20 started ART. Among the 6 who were not clinically eligible at their second visit to the screening clinic, 3 returned for a third visit at which time one was clinically eligible for ART and started treatment.
Combining the first, second and third screening visits, 93 eligible participants (out of 659, 14%) defaulted before starting ART. We tracked 60 (65%) of these at home, a median 55 days after they had missed their ART appointment (IQR: 35, 83). Thirty-five (58%) had died, 21 before their ART initiation appointment and the others soon after (median 19 days after appointment, IQR 7, 47). Three individuals had left the area and two could not be traced. Of the 20 individuals found alive at follow-up, 4 reported illness as the main reason for not attending, 8 reported lack of money for transport, 4 could not find a suitable guardian, 2 were too busy, one felt well after the screening visit, and one gave no reason. One of the individuals who reported ill health as the reason for not attending at the first follow-up visit, was found through a second home visit to have died soon after. Twenty one (64%) of the 33 not sought in the community had ART initiation appointments after mid-June 2006, i.e. shortly before the end of the study.