Among patients with CD4 cell count >350 cells per microliter, in multivariate analysis, attrition was more common among those with an annual income of US $125 or less compared with those earning more than US $125 per year (OR: 1.74; 95% CI: 1.20 to 2.52) (see Table 4). No other factors were significantly associated with attrition in the multivariable analysis.
We tracked the 747 patients who were lost to care before ART during the study period using the national HASS (described above) and the GHESKIO EMR. Fifty-one patients (7%) returned to GHESKIO after the study period ended, and 696 (93%) did not return. Among these 696 patients who were lost to care at GHESKIO, 690 (99%) were identified in the national HASS, meaning their HIV diagnosis and/or follow-up disease event was reported to the MSPP. Eighty-four of these patients (12%) received care in an outside clinic after being lost to care at GHESKIO; of these, 54 (64%) received care in only one other clinic after GHESKIO and 30 (36%) received care at more than one other clinic. Patient-level detail was not available on these patients because of confidentiality agreements with the HASS. If these patients were classified as in care, then the proportion of the total cohort (n = 1427) who started ART or remained in care would increase from 48% (n = 680) to 57% (n = 815).
We analyzed rates of attrition from HIV testing to ART initiation in a cohort of patients newly diagnosed with HIV and found that fewer than 50% of patients initiated ART or were retained in pre-ART care during 2 years of follow-up. High rates of attrition were observed at each stage from HIV testing to ART initiation, regardless of baseline CD4 cell count. Nearly one-quarter of patients newly diagnosed with HIV did not remain in care long enough to complete CD4 cell testing. Among those with a CD4 cell count <200 cells per microliter, nearly one-quarter of patients were not known to have initiated ART—in nearly half of these cases, the patients had not received their CD4 cell count results to confirm that they qualified for ART. Among patients with CD4 cell count >350 cells per microliter, only half initiated ART or were retained in pre-ART care in our clinic for the subsequent 2 years after HIV testing. We tracked patients who were lost to care using the GHESKIO EMR and Haiti's national HASS database and found that some patients either returned to GHESKIO after the study period ended or received care at another clinic; even with the inclusion of these patients, the retention rate increased to only 57%.
Though we report a high rate of pre-ART attrition, it is lower than those described in most published studies from other resource-poor settings. As described above, Rosen et al40 estimated that 17% of patients newly diagnosed with HIV remain in care to start ART. In their review of 28 African studies, 59% of patients were retained in care from HIV testing to completion of CD4 cell count or clinical staging, 46% from staging to ART eligibility, and 68% from ART eligibility to ART initiation. Studies from South Africa have reported that 39%–86% of eligible patients initiated ART.23,24,26,27,30,37 This proportion ranged from 31%–86% in reports from Mozambique, Uganda, Ethiopia, Kenya, and Malawi.16,19,33,35,39,45 The median time from staging to ART initiation among ART-eligible patients in these studies ranged from 16 days to 3.6 months, and all 4 sites with at least 30% attrition had median delays of at least 2 months.19,23,26,37 Among patients with CD4 cell counts >350 cells per microliter, rates of retention in care (with variable definitions) range from 4% to 60% in reports from Malawi, South Africa, and Cambodia.20,29,31,36 Reasons for this variation in retention rate have not been evaluated, and comparisons are limited by differing definitions, but it is likely that both structural and patient-level factors play a role.
Patients in the pre-ART period face many of the same barriers to attendance as patients on ART, including transportation, financial constraints, work, and child care responsibilities.15,16,19,21,32,33,35,45–55 Yet, the attrition rates reported during the pre-ART period—both at GHESKIO and in other resource-poor settings—are much higher than those reported among patients who have already initiated ART.7,8,56–63 Among patients who receive at least 1 month of ART at GHESKIO, only 6% are LTFU within the subsequent 2 years.41 Retention in care during the post-ART period is facilitated by the provision of transportation subsidies, phone calls for missed appointments, a dedicated ART clinic, and nutritional supplementation for those in need.64,65 In many clinics, including ours, these interventions are provided only after patients start ART because of budget limitations. Our findings suggest that interventions to decrease barriers to attendance will be most effective in the early period after HIV testing. Most patients who had not received a CD4 cell count within 2 weeks after HIV testing in our cohort were already LTFU. Furthermore, among those with CD4 cell count <200 cells per microliter, most patients who had not initiated ART within 6 weeks after CD4 cell testing were already lost to care. These findings are consistent with those of other studies finding a high rate of attrition in the early period after presentation and preventable delays in ART initiation.45,53,54
We attribute the association between annual income and retention in pre-ART care in our study to the greater ability of higher income patients to overcome financial barriers to clinic attendance. If additional funding was available, we could extend these services to patients in the pre-ART period. Such funding could have a major impact on mortality if it improved ART uptake among those who qualify for therapy, as detailed tracking studies have found that 28%–58% of ART-eligible patients who have defaulted in the pre-ART period have died, most within 2 months of attrition.33,35,38,49 We also found that higher education is associated with improved retention; we attribute this to a greater understanding of the importance of remaining in pre-ART care. Higher income and education have been associated with higher rates of ART initiation in other studies as well.18,45,54,55 It is also possible that these variables are surrogates for unstable residence. We measured residence zone (see Tables 2–4), but change in residence was not captured. It will be important to measure change in residence in future studies.
Though pregnant patients in our cohort received same-day HIV test results, over one-fourth did not complete a CD4 cell count. Of those who did complete CD4 cell testing, an additional fifth were LTFU during pregnancy or after delivery. These findings are similar to other reports from resource-poor settings.25,66 Point-of-care CD4 cell testing, which is becoming more widely available, may improve test completion rates. The new WHO guidelines for mother-to-child prevention, which now recommend consideration of lifetime therapy regardless of CD4 cell count, may improve retention in care among pregnant women.67
We found that active TB at HIV diagnosis was associated with completion of CD4 cell count; this finding has not been reported elsewhere. GHESKIO is the only site we are aware of that screens all patients for TB in the HIV VCT center and provides same-day TB testing and treatment. We attribute the high rate of CD4 cell completion to the immediate provision of services to patients who present with TB symptoms. Interestingly, a diagnosis of active TB was associated with a lower rate of ART initiation among patients with a CD4 cell count <200 cells per microliter, which we attribute to a high rate of mortality in this group of patients, as those who do not return for follow-up in the pre-ART period are not tracked to distinguish loss to care from death.
Younger patients were more likely to drop out of care before receiving a CD4 cell count. Other studies have suggested that adolescents have poorer ART treatment outcomes than adult patients.68,69,70 In response, GHESKIO opened an adolescent ART clinic in 2007 in a new facility with a specialized staff and the provision of patient incentives such as phone cards, transportation subsidies, scholarships and prizes, free dental care, peer counseling, and other psychosocial support. Waiting times decreased from 4 hours to 1 hour, and 1-year retention in care for adolescents on ART increased from 70% to 91%.71 If further studies confirm that adolescents also have poorer pre-ART outcomes, then additional interventions will be warranted to retain them in care.
Though we were able to track patients who were lost to care at GHESKIO using the National HIV/AIDS Surveillance System to determine if they sought care at another clinic, our study was limited by our inability to determine the outcome for those who did not seek further care. We suspect that many patients with advanced AIDS who do not return for care have died. Haiti also suffered a devastating earthquake on January 12, 2010, with the displacement of large numbers of people in Port-au-Prince. However, most attrition in our cohort occurred in the first year of follow-up, before the earthquake. Because GHESKIO provides comprehensive testing and treatment services, our study findings may not be generalizable to settings where patients receive VCT at stand-alone or mobile VCT clinics, where patients with positive test results face the additional barrier of referral to a separate clinic for HIV treatment services.
In summary, fewer than half of patients who were newly diagnosed with HIV in our cohort either started ART or were retained in pre-ART care for the subsequent 2 years. There are high rates of attrition at every step from HIV testing to ART initiation, regardless of baseline CD4 cell count. In the future, it will be important to determine the complete outcome for patients who are lost to care before ART initiation. Additional efforts to identify barriers and improve retention in pre-ART are critically needed.
The authors acknowledge Jean Benisson Dumas and Clemente Jacques for their generous assistance with data collection, and Sidney Atwood and Esther Iliones for their help with database management and statistical analysis.
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