Featured news from NHIVNA
HIV-related news from NAM
Significant attrition at each stage of HIV care cascade in South Africa
Michael Carter, 2016-06-06 07:00:00
significant attrition at each stage of the HIV care continuum in South Africa,
according to a study published in the online edition of the Journal of Acquired Immune Deficiency
Syndromes. The population-based research was conducted in North West Province
and revealed that of those with HIV, only 48% of men and 76% of women were
aware they were infected. Patients were then lost at each stage in the cascade
of HIV care. Overall, just 22% of HIV-positive men and 56% of HIV-positive
women had viral suppression, liberally defined as a viral load below 5000
provide a comprehensive picture of engagement with HIV care from diagnosis to
viral suppression in a geographic area with little previous research but
extremely high burden of disease,” write the investigators. “Based on the full
HIV-positive population, it is quite clear that the greatest gap in engagement
occurs at HIV diagnosis, indicating a critical need for improving case
detection, particularly among men.”
South Africa has
the largest ART delivery programme in the world. Yet despite a massive scale-up
in the delivery of antiretroviral therapy, approximately 200,000 South Africans
still die of AIDS each year and only half of those eligible for
antiretroviral treatment are receiving appropriate treatment.
currently very limited data on engagement of patients in South Africa with the
HIV care continuum. Population-based evidence is especially scarce.
A team of
investigators therefore conducted a population-based study involving adults
aged between 18 and 49 years in a rural districts of North West Province. The
area is known to have a high HIV prevalence (in excess of 20%).
Data were gathered
between January and March 2014 in Lewka-Teemane and Greater Taung sub-districts.
A total of 1044
individuals were included in the household-based survey and provided blood
samples for rapid HIV testing, point of care CD4 cell monitoring and dried
blood spots for viral load assessment. Participants were asked if they had ever
tested for HIV, if they knew if they were HIV-positive, and if so, whether they had
ever been linked to care, if they were retained in care, if they were taking
ART and if they were adherent to ART.
defined the HIV care continuum as follows:
- Undiagnosed or newly diagnosed
– HIV-positive patients with no reported previous test or a prior negative
- Linked to care – reported ever
seeing a doctor/nurse for HIV care.
- Ideal linkage to care – saw a
healthcare provider and had a CD4 count within three months of diagnosis.
- Retained in care – if eligible
for ART, reported being on therapy and seeing a healthcare provider every three
months in the past year; if not ART eligible, reported seeing a care provider
and receiving a CD4 count in the past year.
- Adherent to ART – reported
taking 90% or more of prescribed doses and no treatment interruptions.
- Viral suppression – viral load
below 5,000 copies/ml.
Overall, 20% of
men and 27% of women were HIV positive. Over half (52%) of men and a quarter of
men diagnosed with HIV were previously unaware of their infection status.
Of those with HIV,
only 44% of men and 75% of women reported ever linking to HIV care, and 40% of women and 29% of men had been linked to care and received a CD4 cell count within three months of diagnosis. Just
one-third of men and 58% of women were retained in care, the majority of whom
had started ART.
Although 33% of
ART-treated men and 53% of women taking HIV therapy reported being fully
adherent to their treatment, just 22% of men and 50% of women had a viral load
below 5,000 copies/ml.
Then investigators focused on engagement with the care continuum among patients who already
knew they were HIV-positive.
The majority (99%
of women and 91% of men) was ever linked to care, but only 60% connected with
care within three months of their diagnosis. Of those linked to care, 75% of
men and 78% of women were retained in care. The majority of ART-treated
patients (97% of men and 92% of women) reported being adherent to their
therapy, but only 29% of men and 60% of women had a viral load below 5,000
copies/ml. Only 26% had viral suppression when a threshold of 1,000 copies/ml
demonstrate high reported adherence, but low rates of viral suppression,
indicating a potential bias in self-reporting adherence data, which could be
due to social desirability bias or over-reporting of medication adherence, as
well as medication failure,” suggest the researchers.
They conclude that
their data “provide a comprehensive picture of the HIV care continuum in the
North West province and should be utilized to inform targeted programming.”
Although noting that attrition occurs at every stage of the care continuum, the
investigators suggest the most urgent need “is for improved HIV detection,
particularly among men.”