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Community-based support aids retention, adherence and treatment response
Lesley Odendal, 2012-07-26 13:50:00
Patient retention and linkage throughout the cascade of HIV care remains very low, placing the concept of ‘test and treat’ as part of the solution to ending the AIDS epidemic in question, but community-based support can play an important role in improving retention in care, the 19th International AIDS Conference (AIDS 2012) in Washington DC heard this week.
Dr Matthew Fox of the Center for Global Health and Development at Boston University noted that systematic review shows that the median retention of patients prior to starting antiretroviral (ARV) treatment in sub-Saharan Africa is only 29%. From HIV-positive diagnosis to CD4 results being obtained, only 59% remain in care, while only 46% of patients remain in care from this point until reaching eligibility for ARVs. Once patients are declared eligible for ARVs, only 68% reach the point of ARV initiation. On average, only between 60 to 70% of patients remain on ARVs for two years after initiation.
Dr Rachel Baggaley of the World Health Organisation (WHO) presented findings of an electronic survey of more than twenty countries to determine the main reasons for patients being lost along the 'cascade' of HIV care. The survey found that people were unlikely to access HIV testing due to a lack of perceived benefits, stigma, discrimination, fear and denial. From the point of positive diagnosis to enrolment in care, patients were lost mostly due to stigma, denial of positive status, poor links and referrals from testing sites to health services, or due to poor post-test counselling.
Once enrolled in care, patients were likely to be lost due to delays in receiving CD4 results, or due to lack of CD4 testing, crowded clinics or far distances to clinics. Once patients are determined to be eligible for ARV initiation, they are often lost in care due to fear of ARV side-effects or disbelief in the effectiveness of ARVs, or due to drug stock-outs. For those patients on ARV treatment, the main causes for leaving care were found to be due to the high pill burden, high number of appointments and transportation costs and time burden, or patients stopping ARVs because they feel better.
Dr Florian Scheibe of the Institute of Public Health, Heidelberg University, Germany, showed high rates of loss to follow up during the first year of pre-ARV care at four rural health centres in Inganga district in Uganda. In this study, 81% (1634 of 2024) of the pre-ARV patients were lost-to-follow-up. More than 93% of those patients who dropped out of care did so after their first visit to the clinic. This retrospective cohort analysis reviewed pharmacy registers of all HIV-care-enrolled patients from February 2005 to August 2009. In all, 26% (521 of 2024) of the pre-ARV patient files were missing.
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