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African studies identify strategies for improving treatment adherence, retention in care
Mara Kardas-Nelson, 2014-01-07 09:00:00
Getting people tested for HIV is one thing; getting them onto antiretrovirals (ARVs) another; and retaining them in care for a long period something else entirely. A session at the 17th International Conference on AIDS and STIs in Africa (ICASA) in Cape Town, South Africa, last month, considered which patients are least likely to be retained in care, and innovative strategies to keep patients in care in the long run, using limited resources.
By retrospectively analysing data from patient files between February 2002 and May 2013 at a clinic in Masaka, Uganda, Juan Gozalez-Perez of the AIDS Healthcare Foundation presented findings showing that patients were more likely to die and least likely to be retained in care in their first year after diagnosis; and that men, adolescents aged 15-29, and those with a CD4 under 100 were least likely to be retained.
The study considered 12,475 patients, with 'lost to follow-up' defined as a patient not presenting for care 90 days after the last missed appointment. In the cohort, 2216 patients were lost to follow-up, 971 died, and 1734 were transferred out. Of these, 61.1% were female with a median age of 32.2 years and a median CD4 baseline of 162. Of those lost to follow-up, one-third of patients could not be reached, 11% had died, 24% were transferred out or not documented, 19% were alive and not taking their ARVs, 6% self-referred out, and 4% had their files lost.
The greatest loss to follow-up occurred in the first year of treatment. After one year, retention rates were 82.4%. Thereafter the rate of attrition was relatively consistent, and 63% of patients treated for ten years remained in care. Female patients were more likely to be retained, with 83% of women, versus 81% of men, being retained in their first year, and 63% of women, versus 58% of men, retained at 10 years. People aged 15-19 fared worse, with retention rates of only 43% at five years, compared with 70% in the overall cohort.
While their study did not consider rates of retention of people not yet on ART, Gonzelez-Perez noted that patients in pre-ART care, such as those taking cotrimoxazole, are even harder to retain. "We need to work more on this, it's a completely different situation."
A retrospective analysis of routine patient data in Shiselweni district, Swaziland, presented by Kiran Jobanptura of Médecins Sans Frontières (MSF) Swaziland and Switzerland, found that children and adolescents were less likely to re-suppress when considering viral load for patients in the Shiselweni district of the country, indicating that this group of patients may need tailored adherence and genotyping support.
By considering records of patients who had a first detectable viral load attending Ministry of Health facilities in Shiselweni between May 2012 and July 2013, MSF also found that those with a viral load under 1000 copies/ml, with a CD4 under 350, and who did not receive counselling were more likely to re-suppress viral load after an adherence intervention. In total, 54% of patients observed achieved re-suppression. Surprised by results that counselling did not lead to re-suppression, Jobanptura notes that treatment literacy may offer an explanation. "Just receiving detectable results, without counselling, may enable patients to re-suppress," he said, also noting, "we cannot say that we're doing the counselling in the optimal way." Currently the project is using lay counsellors who receive limited training for counseling, as nurses are in short supply.
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