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Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review.

Rosen S, Fox MP - PLoS Med. (2011)

Bottom Line: Improving the outcomes of HIV/AIDS treatment programs in resource-limited settings requires successful linkage of patients testing positive for HIV to pre-antiretroviral therapy (ART) care and retention in pre-ART care until ART initiation.Enrollment criteria, terminology, end points, follow-up, and outcomes varied widely and were often poorly defined, making aggregation of results difficult.Better health information systems that allow patients to be tracked between service delivery points are needed to properly evaluate pre-ART loss to care, and researchers should attempt to standardize the terminology, definitions, and time periods reported.

View Article: PubMed Central - PubMed

Affiliation: Center for Global Health and Development, Boston University, Boston, Massachusetts, USA. sbrosen@bu.edu

ABSTRACT

Background: Improving the outcomes of HIV/AIDS treatment programs in resource-limited settings requires successful linkage of patients testing positive for HIV to pre-antiretroviral therapy (ART) care and retention in pre-ART care until ART initiation. We conducted a systematic review of pre-ART retention in care in Africa.

Methods and findings: We searched PubMed, ISI Web of Knowledge, conference abstracts, and reference lists for reports on the proportion of adult patients retained between any two points between testing positive for HIV and initiating ART in sub-Saharan African HIV/AIDS care programs. Results were categorized as Stage 1 (from HIV testing to receipt of CD4 count results or clinical staging), Stage 2 (from staging to ART eligibility), or Stage 3 (from ART eligibility to ART initiation). Medians (ranges) were reported for the proportions of patients retained in each stage. We identified 28 eligible studies. The median proportion retained in Stage 1 was 59% (35%-88%); Stage 2, 46% (31%-95%); and Stage 3, 68% (14%-84%). Most studies reported on only one stage; none followed a cohort of patients through all three stages. Enrollment criteria, terminology, end points, follow-up, and outcomes varied widely and were often poorly defined, making aggregation of results difficult. Synthesis of findings from multiple studies suggests that fewer than one-third of patients testing positive for HIV and not yet eligible for ART when diagnosed are retained continuously in care, though this estimate should be regarded with caution because of review limitations.

Conclusions: Studies of retention in pre-ART care report substantial loss of patients at every step, starting with patients who do not return for their initial CD4 count results and ending with those who do not initiate ART despite eligibility. Better health information systems that allow patients to be tracked between service delivery points are needed to properly evaluate pre-ART loss to care, and researchers should attempt to standardize the terminology, definitions, and time periods reported.

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Forest plot of the 14 studies reporting on the proportion of patients completing Stage 3 or steps within Stage 3.Bars indicate 95% confidence intervals. Studies shown in the plot report to differing end points; refer to Table 4 for details.
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pmed-1001056-g005: Forest plot of the 14 studies reporting on the proportion of patients completing Stage 3 or steps within Stage 3.Bars indicate 95% confidence intervals. Studies shown in the plot report to differing end points; refer to Table 4 for details.

Mentions: The 14 studies reporting on Stage 3 are summarized in Table 4 and illustrated in Figure 5. Stage 3 has the most consistent and precise start and end points: from a clearly defined threshold, treatment eligibility, to a definite event, ART initiation. Across all the studies in Table 4, a median of 68% (range 14%–84%) of patients eligible for ART actually initiated treatment within the study periods of observation. As with Stage 1 and Stage 2, the time intervals allowed for the completion of Stage 3 varied widely and were in some cases unclear.


Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review.

Rosen S, Fox MP - PLoS Med. (2011)

Forest plot of the 14 studies reporting on the proportion of patients completing Stage 3 or steps within Stage 3.Bars indicate 95% confidence intervals. Studies shown in the plot report to differing end points; refer to Table 4 for details.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3139665&req=5

pmed-1001056-g005: Forest plot of the 14 studies reporting on the proportion of patients completing Stage 3 or steps within Stage 3.Bars indicate 95% confidence intervals. Studies shown in the plot report to differing end points; refer to Table 4 for details.
Mentions: The 14 studies reporting on Stage 3 are summarized in Table 4 and illustrated in Figure 5. Stage 3 has the most consistent and precise start and end points: from a clearly defined threshold, treatment eligibility, to a definite event, ART initiation. Across all the studies in Table 4, a median of 68% (range 14%–84%) of patients eligible for ART actually initiated treatment within the study periods of observation. As with Stage 1 and Stage 2, the time intervals allowed for the completion of Stage 3 varied widely and were in some cases unclear.

Bottom Line: Improving the outcomes of HIV/AIDS treatment programs in resource-limited settings requires successful linkage of patients testing positive for HIV to pre-antiretroviral therapy (ART) care and retention in pre-ART care until ART initiation.Enrollment criteria, terminology, end points, follow-up, and outcomes varied widely and were often poorly defined, making aggregation of results difficult.Better health information systems that allow patients to be tracked between service delivery points are needed to properly evaluate pre-ART loss to care, and researchers should attempt to standardize the terminology, definitions, and time periods reported.

View Article: PubMed Central - PubMed

Affiliation: Center for Global Health and Development, Boston University, Boston, Massachusetts, USA. sbrosen@bu.edu

ABSTRACT

Background: Improving the outcomes of HIV/AIDS treatment programs in resource-limited settings requires successful linkage of patients testing positive for HIV to pre-antiretroviral therapy (ART) care and retention in pre-ART care until ART initiation. We conducted a systematic review of pre-ART retention in care in Africa.

Methods and findings: We searched PubMed, ISI Web of Knowledge, conference abstracts, and reference lists for reports on the proportion of adult patients retained between any two points between testing positive for HIV and initiating ART in sub-Saharan African HIV/AIDS care programs. Results were categorized as Stage 1 (from HIV testing to receipt of CD4 count results or clinical staging), Stage 2 (from staging to ART eligibility), or Stage 3 (from ART eligibility to ART initiation). Medians (ranges) were reported for the proportions of patients retained in each stage. We identified 28 eligible studies. The median proportion retained in Stage 1 was 59% (35%-88%); Stage 2, 46% (31%-95%); and Stage 3, 68% (14%-84%). Most studies reported on only one stage; none followed a cohort of patients through all three stages. Enrollment criteria, terminology, end points, follow-up, and outcomes varied widely and were often poorly defined, making aggregation of results difficult. Synthesis of findings from multiple studies suggests that fewer than one-third of patients testing positive for HIV and not yet eligible for ART when diagnosed are retained continuously in care, though this estimate should be regarded with caution because of review limitations.

Conclusions: Studies of retention in pre-ART care report substantial loss of patients at every step, starting with patients who do not return for their initial CD4 count results and ending with those who do not initiate ART despite eligibility. Better health information systems that allow patients to be tracked between service delivery points are needed to properly evaluate pre-ART loss to care, and researchers should attempt to standardize the terminology, definitions, and time periods reported.

Show MeSH