This study evaluated the rate of ART initiation within 12 months of a new HIV diagnosis in the outpatient setting among ART-eligible patients in Durban, South Africa. Although a substantial proportion of study subjects had CD4 cell counts less than 200 cells/μl (53%, 538/1012), and were therefore eligible for ART according to South African guidelines [15
] at the time of study enrollment, only 39% (210/538) of eligible subjects were known to have started ART within 12 months. A substantial number of ART-eligible individuals died during the study period (20%, 108/538), with the vast majority of deaths (82%, 89/108) occurring before ART initiation or among subjects with unknown ART status. This study highlights the substantial losses from care and mortality that occur before entry into ART programmes, a time period for which limited data have previously been available.
Efforts are needed to improve entry into care following a new HIV diagnosis. There are multiple points in the HIV care trajectory from diagnosis to treatment initiation when patients may be lost; as has been seen in a retrospective study from routinely collected data in Mozambique [19
], a critical point of attrition is between HIV testing and obtaining a CD4 cell count to evaluate ART eligibility. This may reflect a physical or programmatic disconnect between HIV testing sites and ART treatment programmes.
We document a median 6.6 month interval from the time of HIV diagnosis to ART initiation. Although the delay to treatment initiation may be justified by the need for careful investigation and treatment for opportunistic infections and tuberculosis, as well as HIV literacy training and readiness, it has been identified as a period of substantial mortality [16
]. Providing CD4 cell count testing at the time of HIV diagnosis and allowing for ‘fast-tracking’, or prioritizing, of patients with the most advanced immune deficiency may help. Programmatic efforts to minimize delays are critical, particularly given the severe immune suppression seen in South African programmes at the time of ART programme entry [10
]. Both outpatient study sites now offer baseline CD4 cell count testing free of charge following a new HIV diagnosis to facilitate more rapid entry into care [16
]. McCord Hospital has also changed its ART literacy training from weekly sessions for 3 weeks to a shorter time frame to facilitate more rapid ART initiation [16
A major contribution of this study is the active patient follow-up following HIV diagnosis to ascertain vital status. Pre-treatment mortality among ART programme enrollees, particularly those with low baseline CD4 cell counts, has been seen in a model community-based programme in Cape Town [10
] as well as in Durban [16
]. This study shows the substantial burden of mortality occurring before ART programme entry that would otherwise go unaccounted for in PEPFAR statistics and standard ART programme monitoring and evaluation.
Concerns as to whether men are successfully accessing HIV prevention, testing and treatment in Africa have recently been raised [2
]. Men in this study were significantly less likely to start ART than women (70% men did not start versus 52% of women). These results echo findings from recent reviews of the sex distribution of HIV-infected adults receiving ART in resource-constrained settings [23
]. The Antiretroviral Treatment in Lower Income Countries (ART–LINC) collaboration pooled patient data from over 28 000 patients from 23 African cohorts and found that although men made up approximately 41% of infected patients, a significantly smaller proportion of ART recipients were men – 32% [22
]. Although women may have more opportunities to enter care and treatment through antenatal clinics, which may account for some of the observed sex differences [2
], the subjects in this study were diagnosed with HIV in a general medical outpatient setting and yet women were still accessing care faster and at higher rates. Innovative efforts are needed to obtain a better understanding of men’s health-seeking behaviours and to improve access to care for men.
Those who failed to start ART during the study period were less likely to have family or friends who they knew to be HIV infected. This finding supports the notion that disclosure within social networks promotes health-seeking behaviour [25
] and highlights the potential positive impact of disclosure to family and friends on linkage to HIV care for the index patient.
This study has several limitations. A large proportion (27%) of patients could not be reached by telephone during follow-up, and did not have health information available in the electronic medical record to ascertain their status at the 12-month time point. A systematic review and meta-analysis of the mortality among patients lost to follow-up in ART treatment programmes in sub-Saharan Africa found that mortality in this group was 46% [27
]. As a result, our mortality estimate of approximately 20% of ART-eligible patients dying during the study period is likely to be an underestimate. In addition, the study sites, which require a fee for patients to be seen in the outpatient department and to receive care in the on-site HIV clinic, may not be representative of public, wholly government-funded sites where patients with HIV may seek care. Ascertainment of ART initiation could be affected by this bias, as patients needed to initiate ART t the study sites to reach the primary outcome. Even when we performed a sensitivity analysis that included patients who self-reported ART initiation at non-study sites during the follow-up interview, the proportion of patients starting ART remained unacceptably low.
This study illustrates that less than half of ART-eligible individuals initiate treatment within the first year after a new HIV diagnosis in Durban, South Africa. Studies that have shown high rates of mortality and losses from ART programmes do not reflect the high burden of mortality in the community before ART programme entry. This study highlights the urgent need to devise interventions to facilitate earlier HIV diagnosis, CD4 cell count availability and rapid ART initiation in resource-limited settings.