Despite the dramatic increase in VCT in South Africa in the past few years, with more than half of all South African adults having been tested at least once, [13
] expansion of testing has not translated into earlier treatment initiation [14
]. This is supported by our finding that 70% of VCT clients presenting to Zazi had been previously tested for HIV, yet nearly one in five ART-eligible adults refused treatment within two months of diagnosis, leaving them at risk for early mortality. These findings are consistent with rates of pre-ART attrition found at other sites in sub-Saharan Africa [15
]. Despite VCT being traditionally viewed as an entry point to treatment and care, [17
] these data underscore the importance of a new and unappreciated challenge in the cascade of HIV testing to sustained antiretroviral treatment.
While ART eligible patients not yet in treatment have traditionally been difficult to monitor, we were able to document both rates and reasons for refusal in this VCT population. We found that over 35% of clients who refused ART stated they were “too healthy” to initiate treatment, despite a median CD4+
count of 110 cells/mm3
. In addition, those with active TB were three times more likely to refuse ART. Prior studies in sub-Saharan Africa have found similar associations between TB positivity and low acceptability of ART [18
]. Early ART initiation, particularly in patients with co-morbidities such as TB, clearly remains a priority [19
]. A recent South African study showing early ART initiation in conjunction with TB therapy in co-infected patients reduced mortality by 56% [20
Despite 92% of VCT clients initially reporting they would be willing to disclose their status, over 20% of those who refused ultimately stated they were “unable to disclose.” These results show that the inability to disclose one’s status has behavioral consequences and may be more pronounced than initially acknowledged by the general population. Given patients who self-identified as being single were more likely to refuse treatment, the risk for non-disclosure remains concerning among sexually active individuals. This is particularly relevant in light of increasing evidence of the importance of ART treatment in HIV-infected individuals as a form of prevention to uninfected partners [21
This study has a critical limitation - specifically these data were not collected to examine factors associated with ART refusal. Rather, basic clinical and demographic variables were collected concurrently on patients who accessed VCT. At the time these data were collected, the phenomenon of treatment refusal had not been identified or well understood. Given that, we have no data on clients’ understanding of HIV and AIDS and their interpretation of their test results.
As South Africa continues to expand its ART coverage, efforts will need to be made beyond simply testing and counseling to the reach the estimated 2 million people currently in need of treatment. This will require marketing the concept of ART as a life saving intervention, even for people who report feeling healthy. We have added to the growing literature on understanding factors driving treatment refusal after VCT in South Africa, [22
] by identifying a critical barrier to ramping up accelerated treatment coverage beyond cost reductions, [24
] willingness to test, and ART availability. To ensure the success of HIV treatment scale-up in South Africa, it will be essential to understand the reasons for ART refusal in individuals willing to undergo VCT, ultimately enabling the development of effective targeted interventions.