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Retention in HIV Care for Individuals Not Yet Eligible for Antiretroviral Therapy: Rural KwaZulu-Natal, South Africa

Lessells, Richard J MBChB; Mutevedzi, Portia C MSc; Cooke, Graham S PhD; Newell, Marie-Louise PhD

JAIDS Journal of Acquired Immune Deficiency Syndromes: March 1st, 2011 - Volume 56 - Issue 3 - p e79-e86
doi: 10.1097/QAI.0b013e3182075ae2
Implementation and Operational Research: Clinical Science

Objectives: To determine retention in HIV care for individuals not yet eligible for antiretroviral therapy (ART) and to explore factors associated with retention in a rural public health HIV program.

Methods: HIV-infected adults (≥16 years) not yet eligible for ART, with CD4 cell count >200 cells per microliter from January 2007 to December 2007 were included in the analysis. Retention was defined by repeat CD4 count within 13 months. Factors associated with retention were assessed using logistic regression with clustering at clinic level.

Results: Four thousand two hundred twenty-three were included in the analysis (83.9% female). Overall retention was 44.9% with median time to return 201 days [interquartile range (IQR): 127-274]. Retention by initial CD4 count 201-350, 351-500, and >500 cells per microliter was 51.6% [95% confidence interval (CI): 49.1 to 54.0], 43.2% (95% CI: 40.5 to 45.9), and 34.9% (95% CI: 32.4 to 37.4), respectively. Compared with CD4 201-350 cells per microliter, higher initial CD4 count was significantly associated with lower odds of retention [CD4: 351-500 cells/μL adjusted odds ratio (aOR): 0.72, 95% CI: 0.62 to 0.84; CD4 >500 cells/μL aOR: 0.51, 95% CI: 0.44 to 0.60]. Male sex was independently associated with lower odds (aOR: 0.80, 95% CI: 0.67 to 0.96), and older age with higher odds of retention (for each additional year of age aOR: 1.03, 95% CI: 1.03 to 1.04).

Conclusions: Retention in HIV care before eligibility for ART is poor, particularly for younger individuals and those at an earlier stage of infection. Further work to optimize and evaluate care and monitoring strategies is required to realize the full benefits of the rapid expansion of HIV programs in sub-Saharan Africa.

From the *Africa Centre for Health and Population Studies, University of KwaZulu-Natal, South Africa; †Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom; ‡UCL Department of Infection and Population Health, London, United Kingdom; §Department of Infectious Diseases, Imperial College, London, United Kingdom; and ‖UCL Institute of Child Health, London, United Kingdom.

Received for publication August 12, 2010; accepted November 16, 2010.

Supported by Wellcome Trust (grant numbers 050534 & 075393). The Hlabisa HIV Treatment and Care Programme receives support through the United States Agency for International Development (USAID) and the President's Emergency Plan (PEPFAR) under the terms of Award No. 674-A-00-08-00001-00.

The opinions expressed herein are those of the authors and do not necessarily reflect the view of the USAID or the United States Government.

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the article.

Data presented in part as poster at 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention, 2009, Cape Town, South Africa. Abstract WEPED181.

Correspondence to: Dr. Richard J. Lessells, MBChB, Africa Centre for Health and Population Studies, PO Box 198, Mtubatuba, KwaZulu-Natal 3935, South Africa (e-mail:

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