Kate Clouse

Patient retention from HIV diagnosis through one year on antiretroviral therapy at a primary health care clinic in Johannesburg, South Africa.

Objective:To compare patient retention at 3 stages of pre-antiretroviral (ART) care and 2 stages of post-ART care to identify when greatest attrition occurs. Design:An observational cohort study. Methods:We reviewed files of all adult nonpregnant individuals testing HIV-positive January 1–June 30, 2010, at a primary health clinic in Johannesburg, South Africa (N = 842). We classified retention in pre-ART stage 1 (HIV diagnosis to CD4 results notification in ⩽3 months), pre-ART stage 2 (initially ineligible for ART with repeat CD4 test ⩽1 year of prior CD4), pre-ART stage 3 (initiating ART ⩽3 months after first eligible CD4 result), and at 0–6 and 6–12 months post-ART. Results:Retention among all patients during pre-ART stage 1 was 69.8% [95% confidence interval (CI): 66.7% to 72.9%]. For patients initially ART ineligible (n = 221), 57.4% (95% CI: 49.5% to 65.0%) returned for a repeat CD4 during pre-ART stage 2. Among those who were ART eligible (n = 589), 73.5% (95% CI: 69.0% to 77.6%) were retained during pre-ART stage 3. Retention increased with time on ART, from 80.2% (95% CI: 75.3% to 84.5%) at 6 months to 95.3% (95% CI: 91.7% to 97.6%) between 6 and 12 months. Cumulative retention from diagnosis to 12 months on ART was 36.9% (95% CI: 33.0% to 41.1%) for those ART eligible and 43.0% (95% CI: 36.4% to 49.8%) from diagnosis to repeat CD4 testing within one year among those ART ineligible. Conclusions:Patient attrition in the first year after HIV diagnosis was greatest before ART initiation: more than 25% at each of 3 pre-ART stages. As countries expand HIV testing and ART programs, success will depend on linkage to care, especially before ART eligibility and initiation.

What they wanted was to give birth; nothing else: barriers to retention in option B+ HIV care among postpartum women in South Africa.

Background:Women initiating antiretroviral therapy during pregnancy have high rates of dropout, particularly after delivery. We aimed to identify challenges to postpartum retention in care under Option B+, which expands antiretroviral therapy access to all HIV-positive pregnant women regardless of CD4 count. Methodology:We performed 2 semi-structured interviews (SSI, n = 50) and 1 focus group discussion (n = 8) with HIV-positive women at Witkoppen Health and Welfare Centre, a primary care facility in Johannesburg, South Africa, that is one of the only clinics offering Option B+ in South Africa. Results:Fifty women completed the SSI before delivery, and 48 (96%) completed the second SSI within 3 months of delivery. Median age was 28 years (interquartile range: 26–34); most women worked (62%) or had worked in the previous year (18%). Postpartum women attending HIV care perceived that barriers to HIV care after delivery among other women included the belief that mothers care more about the babys health than their own (29.2%, 14/48), women were “ignorant” or “irresponsible” (16.7%, 8/48), negative clinic staff treatment (12.5%, 6/48), and denial or lack of disclosure of HIV status (10.4% each, 5/48). Experienced barriers included lack of money (18.0%, 9/50), work conflict (6.0%, 3/50), and negative staff treatment (6.0%, 3/50). During the focus group discussion, 3 main themes emerged: conflict with work commitment, negative treatment from health-care workers, and lack of disclosure related to stigma. Conclusions:We identified a complex set of interconnected barriers to retaining postpartum women in HIV care under Option B+, including structural, personal, and societal barriers. The importance of postpartum HIV care for the mothers own health must be embraced by health-care workers and public health programs.

Loss to follow-up before and after delivery among women testing HIV positive during pregnancy in Johannesburg, South Africa.

HIV‐positive pregnant women are at heightened risk of becoming lost to follow‐up (LTFU) from HIV care. We examined LTFU before and after delivery among pregnant women newly diagnosed with HIV.

Time to treatment and patient outcomes among TB suspects screened by a single point-of-care xpert MTB/RIF at a primary care clinic in Johannesburg, South Africa.

Introduction In December 2010, the World Health Organization recommended a single Xpert MTB/RIF assay as the initial diagnostic in people suspected of HIV-associated or drug resistant tuberculosis. Few data are available on the impact of this recommendation on patient outcomes. We describe the diagnostic follow-up, clinical characteristics and outcomes of a cohort of tuberculosis suspects screened using a single point-of-care Xpert. Methods Consecutive tuberculosis suspects at a primary care clinic in Johannesburg, South Africa were assessed for tuberculosis using point-of-care Xpert. Sputum smear microscopy and liquid culture were performed as reference standards. Xpert-negatives were evaluated clinically, and further assessed at the discretion of clinicians. Participants were followed for six months. Results From July-September 2011, 641 tuberculosis suspects were enrolled, of whom 69% were HIV-infected. Eight percent were positive by a single Xpert. Among 116 individuals diagnosed with TB, 66 (57%) were Xpert negative, of which 44 (67%) were empirical or radiological diagnoses and 22 (33%) were Xpert negative/culture-positive. The median time to tuberculosis treatment was 0 days (IQR: 0–0) for Xpert positives, 14 days (IQR: 5–35) for those diagnosed empirically, 14 days (IQR: 7–29) for radiological diagnoses, and 144 days (IQR: 28–180) for culture positives. Xpert negative tuberculosis cases were clinically similar to Xpert positives, including HIV status and CD4 count, and had similar treatment outcomes including mortality and time to antiretroviral treatment initiation. Conclusions In a high HIV-burden setting, a single Xpert identified less than half of those started on tuberculosis treatment, highlighting the complexity of TB diagnosis even in the Xpert era. Xpert at point-of-care resulted in same day treatment initiation in Xpert-positives, but had no impact on tuberculosis treatment outcomes or mortality.

Attrition through multiple stages of pre-treatment and ART HIV care in South Africa.

Introduction While momentum for increasing treatment thresholds is growing, if patients cannot be retained in HIV care from the time of testing positive through long-term adherence to antiretroviral therapy (ART), such strategies may fall short of expected gains. While estimates of retention on ART exist, few cohorts have data on retention from testing positive through long-term ART care. Methods We explored attrition (loss or death) at the Themba Lethu HIV clinic, Johannesburg, South Africa in 3 distinct cohorts enrolled at HIV testing, pre-ART initiation, and ART initiation. Results Between March 2010 and August 2012 we enrolled 380 patients testing HIV+, 206 initiating pre-ART care, and 185 initiating ART. Of the 380 patients enrolled at testing HIV-positive, 38.7% (95%CI: 33.9–43.7%) returned for eligibility staging within ≤3 months of testing. Of the 206 enrolled at pre-ART care, 84.5% (95%CI: 79.0–88.9%) were ART eligible at their first CD4 count. Of those, 87.9% (95%CI: 82.4–92.2%) initiated ART within 6 months. Among patients not ART eligible at their first CD4 count, 50.0% (95%CI: 33.1–66.9%) repeated their CD4 count within one year of the first ineligible CD4. Among the 185 patients in the ART cohort, 22 transferred out and were excluded from further analysis. Of the remaining 163, 81.0% (95%CI: 74.4–86.5%) were retained in care through two years on treatment. Conclusions Our findings from a well-resourced clinic demonstrate continual loss from all stages of HIV care and strategies to reduce attrition from all stages of care are urgently needed.

Initiating antiretroviral therapy when presenting with higher CD4 cell counts results in reduced loss to follow-up in a resource-limited setting.

Objective:In August 2011, South Africa expanded its adult antiretroviral therapy (ART) guidelines to allow treatment initiation at CD4 cell values 350 cells/&mgr;l or less. Mortality and morbidity are known to be reduced when initiating at higher CD4 levels; we explored the impact on patient loss to follow-up. Design:An observational cohort study. Methods:We analyzed routine data of 1430 adult patients initiating ART from April to December 2010 from a Johannesburg primary healthcare clinic offering ART initiation at CD4 cell count 350 cells/&mgr;l or less since 2010. We compared loss to follow-up (≥3 months late for the last scheduled visit), death, and incident tuberculosis within 1 year of ART initiation for those initiating at CD4 cell values 200 or less versus 201–350 cells/&mgr;l. Results:Half (52.0%) of patients presented in the lower CD4 cell group [⩽200 cells/&mgr;l, median: 105 cells/&mgr;l, interquartile range (IQR): 55–154] and initiated ART, and 48.0% in the higher group (CD4 cell count 201–350 cells/&mgr;l, median: 268 cells/&mgr;l, IQR: 239–307). The proportion of women and pregnant women was greater in the high CD4 cell group; the lower CD4 cell group included more patients with prevalent tuberculosis. Among men and nonpregnant women, initiating at 201–350 cells/&mgr;l was associated with 26–42% reduced loss to follow-up compared to those initiating 200 cells/&mgr;l or less. We found no CD4 cell effect among pregnant women. Risk of mortality [adjusted hazard ratio (aHR) 0.34, 95% confidence interval (CI) 0.13–0.84] and incident tuberculosis (aHR 0.44, 95% CI 0.23–0.85) was lower among the higher CD4 cell group. Conclusion:This is one of the first studies from a routine clinical setting to demonstrate South Africas 2011 expansion of ART treatment guidelines can be enacted without increasing program attrition.

Point-of-care Xpert® MTB/RIF for smear-negative tuberculosis suspects at a primary care clinic in South Africa

OBJECTIVE To assess the clinical utility and cost of point-of-care Xpert® MTB/RIF for the diagnosis of smear-negative tuberculosis (TB). DESIGN Cohort study of smear-negative TB suspects at a South African primary care clinic. Participants provided one sputum sample for fluorescent smear microscopy and culture and an additional sample for Xpert. Outcomes of interest were TB diagnosis, linkage to care, patient and provider costs. RESULTS Among 199 smear-negative TB suspects, 16 were positive by Xpert, 15 by culture and 7 by microscopy. All cases identified by Xpert began anti-tuberculosis treatment the same or next day; only one of five Xpert-negative culture-positive cases started treatment after 34 days. Xpert at point of care offered similar diagnostic yield but a faster turnaround time than smear and culture performed at a centralized laboratory. Compared to smear plus culture, Xpert (at US

The patient impact of point-of-care vs. laboratory placement of Xpert® MTB/RIF

9.98 per cartridge) was US

High mobile phone ownership, but low Internet and email usage among pregnant, HIV-infected women attending antenatal care in Johannesburg

3 less expensive per valid result (US

Mobility and Clinic Switching Among Postpartum Women Considered Lost to HIV Care in South Africa.

21 vs. US