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Attrition From HIV Testing to Antiretroviral Therapy Initiation Among Patients Newly Diagnosed With HIV in Haiti

Noel, Edva MD*; Esperance, Morgan MD; Mclaughlin, Megan MPH; Bertrand, Rachel MD*; Devieux, Jessy PhD; Severe, Patrice MD*; Decome, Diessy*; Marcelin, Adias BS*; Nicotera, Janet RN, BSN§; Delcher, Chris MS; Griswold, Mark MSc; Meredith, Genevive MPH; Pape, Jean William MD*,¶; Koenig, Serena P. MD, MPH

JAIDS Journal of Acquired Immune Deficiency Syndromes: March 1st, 2013 - Volume 62 - Issue 3 - p e61–e69
doi: 10.1097/QAI.0b013e318281e772
Implementation and Operational Research: Clinical Science

Objective: We report rates and risk factors for attrition in the first cohort of patients followed through all stages from HIV testing to antiretroviral therapy (ART) initiation.

Design: Cohort study of all patients diagnosed with HIV between January and June 2009.

Methods: We calculated the proportion of patients who completed CD4 cell counts and initiated ART or remained in pre-ART care during 2 years of follow-up and assessed predictors of attrition.

Results: Of 1427 patients newly diagnosed with HIV, 680 (48%) either initiated ART or were retained in pre-ART care for the subsequent 2 years. One thousand eighty-three patients (76%) received a CD4 cell count, and 973 (90%) returned for result; 297 (31%) had CD4 cell count <200 cells per microliter, and of these, 256 (86%) initiated ART. Among 429 patients with CD4 >350 cells per microliter, 215 (50%) started ART or were retained in pre-ART care. Active tuberculosis was associated with not only lower odds of attrition before CD4 cell count [odds ratio (OR): 0.08; 95% confidence interval (CI): 0.03 to 0.25] but also higher odds of attrition before ART initiation (OR: 2.46; 95% CI: 1.29 to 4.71). Lower annual income (≤US $125) was associated with higher odds of attrition before CD4 cell count (OR: 1.65; 95% CI: 1.25 to 2.19) and before ART initiation among those with CD4 cell count >350 cells per microliter (OR: 1.74; 95% CI: 1.20 to 2.52). After tracking patients through a national database, the retention rate increased to only 57%.

Conclusions: Fewer than half of patients newly diagnosed with HIV initiate ART or remain in pre-ART care for 2 years in a clinic providing comprehensive services. Additional efforts to improve retention in pre-ART are critically needed.

*Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections, Port-au-Prince, Haiti

Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA

AIDS Prevention Program, Florida International University, Miami, FL

§Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, TN

National Alliance of State and Territorial AIDS Directors, Washington, D.C.

Center for Global Health, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medical College, New York, NY.

Correspondence to: Serena P. Koenig, MD, MPH, Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115 (e-mail: skoenig@partners.org).

All authors were involved in the conceptualization of the study and the manuscript. E. Noel, R. Bertrand, P. Severe, and J. W. Pape were directly involved in patient care at GHESKIO. All authors were involved in data collection or management. E. Noel, M. McLaughlin, M. Esperance, P. Severe, C. Delcher, J. W. Pape, and S. P. Koenig were involved in the study analysis. M. Esperance and S. P. Koenig wrote the first draft, and all authors reviewed and edited the manuscript.

Supported in part by the National Institutes of Health Fogarty International Center International Clinical, Operational, and Health Services Research and Training Award Grant Number 3 U2R TW006896-04S1 and the Fogarty International Center Grant Number K01 TW007142. Pape obtained funding for this study.

The authors have no conflicts of interest to disclose.

Received April 23, 2012

Accepted December 06, 2012

© 2013 Lippincott Williams & Wilkins, Inc.