RISK FACTORS, BARRIERS AND FACILITATORS FOR LINKAGE AND RETENTION IN PRE-ART CARE

Darshini GovindasamyHealth Economics and Epidemiology Research Office, SA

Katharina KranzerLondon School of Hygiene and Tropical Medicine, UK

HIV continuum of care

HIV test

Continuous lifelong ARTAssessment for

ART eligibility:• Clinical

staging• CD4 count

ART initiation

Retention in pre-ART care until eligiblenot yet eligible

eligible

HIV infection

HIV testing

Pre-ART care ART care

Not in care

Not in care

Kranzer et al 2012

HIV continuum of care

HIV test

Continuous lifelong ARTAssessment for

ART eligibility:• Clinical

staging• CD4 count

ART initiation

Retention in pre-ART care until eligiblenot yet eligible

eligible

HIV infection

HIV testing

Pre-ART care ART care

Not in care

Not in care

Kranzer et al 2012

02468

1012141618

Search limited to sub-Saharan Africa studies published before May 2011

Total number of studies: 42Semi-qualitative studies: 19Quantitative 17 Qualitative 6

Systematic review

Barriers to retention in pre-ART care

Govindasamy, Ford, Kranzer 2012

Health systems• Long waiting

times• Shortage of HCWs

Economic• Transport cost• Distance• Food shortage• Unable to take time of

work

Medical• TB

treatment

Psychosocial• Stigma• Fear of disclosure• Fear of drug

toxicities• Perceived good

health

Predictors of attrition

Govindasamy, Ford, Kranzer 2012

Health systems• Shortage of HCWs

Economic• Transport cost• Distance

Medical• TB treatment• Pregnancy• Advanced immunodeficiency• Severe malnutrition

Other• Male sex• Younger age• Lower levels of education

Predictors of attrition

Govindasamy, Ford, Kranzer 2012

Health systems• Shortage of HCWs

Economic• Transport cost• Distance

Medical• TB treatment• Pregnancy• Advanced immunodeficiency• Severe malnutrition

Other• Male sex• Younger age• Lower levels of education

Men

• Lower test uptake• Lower ART coverage• More advanced immunodeficiency at diagnosis and ART initiation• Higher mortality• Lower adherence• Higher risk of loss to follow-up

on ART

Johnson 2013, Cornell 2012, Druyts 2013, Peltzer 2009, Kranzer 2013, Johnson 2012, Muula 2009, Remien 2009

How to address gender inequality

• Men do not become pregnant• Men are less health seeking• Health care staff are predominantly women• Health care services are targeted at women and

children

Health care services AIMED at men or "men friendly" health care services

Areas for interventions

Govindasamy, Ford, Kranzer 2012

Systematic review of interventions to improve linkage to and retention in pre-ART care

Govindasamy, Kranzer 2013

N=11129 potentially eligible citations identified through:Search strategy on electronic databases (n=11 048)

Keyword search on electronic conference abstract databases (n=45)References obtained from experts (n=36)

24 studies retained for analysis(19 published articles + 1 unpublished article from experts + 2 conference

abstracts + 2 conference abstracts from experts)

N=67 of full text articles assessed for eligibility(54 published articles + 1 unpublished article from experts + 10 conference

abstracts + 2 conference abstracts from experts)

Intervention studies - design and populations

Govindasamy, Kranzer 2013

Before after studies: n=11Observational studies with control group(s): n=6Individuals randomized controlled trials: n=4Cluster randomized controlled trials: n=3

Adults: n=11 Children: n=1 Adolescents: n=1 Pregnant women: n=8 Inpatients: n=1 TB patients: n=1 IVDU: n=1

Intervention studies - design and populations

Govindasamy, Kranzer 2013

Before after studies: N=11Observational studies with control group(s): n=6Individuals randomized controlled trials: n=4Cluster randomized controlled trials: n=3

Adults: n=11 Children: n=1 Adolescents: n=1 Pregnant women: n=8 Inpatients: n=1 TB patients: n=1 IVDU: n=1

Few studies with rigorous design

Intervention studies - design and populations

Govindasamy, Kranzer 2013

Before after studies: N=11Observational studies with control group(s): n=6Individuals randomized controlled trials: n=4Cluster randomized controlled trials: n=3

Adults: n=11 Children: n=1 Adolescents: n=1 Pregnant women: n=8 Inpatients: n=1 TB patients: n=1 IVDU: n=1

Few studies with rigorous design

Few studies in special risk groups

Pregnant women

No of studies Design Control - outcome Intervention- outcome

Relative (95%CI) Absolute

Intervention: Integration Proportion of ART eligible women initiating ART Pfeiffer Tsague Stinson Killam Myer

Observational studies

Not presented 22/26 (85%) 61/130 (47%) 103/716 (14%) 58/271 (21%)

Not presented 105/134 (78%) 124/227 (45%) 278/846 (33%) 183/214 (85%)

1.58 (1.17; 2.14) 0.90 (0.7; 1.1) 0.62 (0.37; 1.04) 2.01 (1.37; 2.95) 4.00 (3.16; 5.05)

-0.08 (-0.23; 0.08) 0.01 (-0.09; 0.11) 0.18 (0.14; 0.23) 0.64 (0.57; 0.71)

Time to initiation of ART Van der Merwe

Observational studies

56 days (30-103) 29 days (12-45)

Intervention: Health system intervention Proportion of ART-eligible women initiating ART Weigel Youngleson

Observational studies

2006 9/14 (64%) 124/1243 (10%)

2007 94/119 (79%) 2008 84/101 (83%) 2009 99/110 (90%) 122/486 (25%)

1.23 (0.83; 1.84) 1.29 (0.87; 1.93) 1.40 (0.94; 2.08) 2.52 (2.00; 3.16)

0.14 (-0.11;0.41) 0.19 (-0.07; 0.45) 0.26 (-0.0; 0.51) 0.15 (0.11; 0.19)

Interventions and outcomes in special groups

Intervention Number of studies

Participants Design Outcome

Food incentives 1 Children Before/after study

Improved clinic attendance (RR 2.9)

Health system intervention

1 TB patients Before/after study

Increased ART initiation (HR 2.6)

Food vouchers 1 IVDU RCT Time to initiation: 7 days (intervention) 58 days (control)

Point of care CD4 count testing

1 adolescents Before/after study

Time between HIV-testing and eligibility assessment: 14 days (control) and 0 days (intervention)

Interventions and outcomes in adults

Intervention No of studies

Design Outcome

Monthly visits with refill of cotrimoxazole

1 Before/after study Improved retention in pre-ART care (RR 2.6)

Health system intervention

1 Before/after study Increased ART initiation (HR 2.7)

Point of care or immediate CD4 count testing

3 1 before/after study1 Individual RCT1 Observation study with control group

Increased retention and ART initiation (RR 2)

PICT 1 Observation study with control group No effect on ART initiation (RR 0.9)

Task shifting and decentralisation

1 Cluster RCT No effect on retention (RR 1.0)

Intensive counselling 1 Individual RCT Increased pre-ART enrolment (RR 1.8)

Home-based ART initiation

1 Cluster RCT Increased ART initiation rate (RR 2.9)

Interventions addressing the barriers

Health systems• Long waiting times• Shortage of HCWs

Economic• Transport cost• Distance• Food shortage• Unable to take time of work

Medical• TB treatment

Psychosocial• Stigma• Fear of disclosure• Fear of drug toxicities• Perceived good health

Interventions addressing the barriers

Health systems• Long waiting times• Shortage of HCWs

Economic• Transport cost• Distance• Food shortage• Unable to take time of

work

Medical• TB treatment

Psychosocial• Stigma• Fear of disclosure• Fear of drug toxicities• Perceived good health

Thank you!