Featured news from NHIVNA
HIV-related news from NAM
Far fewer people drop out of HIV care in South Africa than previously thought
Roger Pebody, 2016-07-20 06:10:00
Previous research has considerably over-estimated the number
of people living with HIV who stop attending medical facilities, the 21st
International AIDS Conference (AIDS 2016) in Durban was told yesterday.
Previous estimates have been based on data from individual
clinics. As a result, people who stop attending one clinic have been assumed to
have dropped out of care entirely. A new analysis, based on data from across
the public health sector in South Africa, shows that many people who stop
attending one clinic go on to receive medical care elsewhere.
Ensuring that people living with HIV stay in medical care is
vital to achieving the individual and public health benefits of HIV treatment.
Retention in care is an important step on the treatment cascade. Nonetheless,
especially in resource-limited settings, there are many barriers to people
staying in care, including long waiting times, drug stock-outs and stigma.
studies from low and middle income countries suggest that, three years
after beginning HIV treatment, around 65% to 70% of patients remain in care.
The missing patients will include both individuals who have died and
individuals who have dropped out of care.
But the existing studies are based on individual clinics and
may provide an incomplete picture. Some patients who have stopped attending one
clinic may continue care at another clinic without the move having been
recorded. Other patients who had stopped attending return to their original
clinic but are inaccurately recorded as new patients.
Matthew Fox and colleagues looked at data from the country’s
National Health Laboratory Service. This is the main provider of laboratory
services for public sector clinics in South Africa - data on the vast majority
of patients in the country are included.
This cohort includes records for 9.2 million people,
including 3.1 million who are currently taking HIV treatment and having their
viral load monitored.
One limitation is that there is no wholly reliable way to
link laboratory samples with individual patients (unique patient identification
numbers are not used). The researchers used a process of probabilistic data matching
to link records which were likely to come from the same person, taking into
account the first name, last name, sex, date of birth and clinic that was
recorded. They think this is likely to be around 90% accurate.
The current analysis is not on the whole cohort but on the 66,865
people who began HIV treatment in 2004 or 2005. The researchers wanted to see
how many were still in care in 2013 to 2015 - a person who had their CD4 cell
count or viral load monitored during that period was judged to still be in
The researchers looked both at retention within their
original clinic and retention within the national programme.
Nine years after beginning therapy, just 17% were still
attending their original clinic. However 54% were still in care somewhere in
the health system.
Of note, the patients who were not retained in care include
individuals who have died as well as people who stopped attending care. In line
with this, retention was poorer for people who began treatment with a low CD4
cell count and older people.
Women were more likely to still be in care than men.
It’s also worth noting that an individual who attended care both
in 2004 and 2014 (and so considered ‘retained in care’ in this study) may well
have had gaps in care in between those two dates.
Nonetheless the study does show that patient migration and
transfer are common in South Africa. Previous studies, based on individual
clinics, are likely to have considerably under-estimated retention in care.