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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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Summary of proportions of patients completing steps within each stage of pre-ART care in the studies reviewed.
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pmed-1001056-g006: Summary of proportions of patients completing steps within each stage of pre-ART care in the studies reviewed.

Mentions: Our analysis of 24 studies documenting rates of retention of patients from testing positive for HIV infection to initiating ART suggests that patient management during this period poses serious challenges. Most studies reported a substantial reduction in patient numbers at every step of the process. This reduction in patient numbers is clearly illustrated in Figure 6, which summarizes findings from all the reports. Studies are few, however, and offering a definitive answer to our core question—what proportion of patients who test positive for HIV are staged, enroll and remain in pre-ART care until ART eligibility, and initiate ART—is not possible with the data available. Only a handful of countries are represented, and most by no more than one or two studies. No study provides all the information needed to answer this question, even for a single setting, and combining results from multiple studies appears ill-advised. To examine the implications of doing this, we multiplied the median proportions of patients achieving the study end point in each stage (Stage 1, 59%; Stage 2, 46%; Stage 3, 68%), and found that the information available suggests that only about 18% of patients who are not yet eligible for ART when they are diagnosed with HIV remain continuously in care until ART eligibility. When we instead multiplied all combinations of estimates from each of the three stages, we estimated a median completion of all three stages of 17%, with an interval from the 10th to the 90th percentile of 7%–32%.


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

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

Summary of proportions of patients completing steps within each stage of pre-ART care in the studies reviewed.
© Copyright Policy
Related In: Results  -  Collection

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

pmed-1001056-g006: Summary of proportions of patients completing steps within each stage of pre-ART care in the studies reviewed.
Mentions: Our analysis of 24 studies documenting rates of retention of patients from testing positive for HIV infection to initiating ART suggests that patient management during this period poses serious challenges. Most studies reported a substantial reduction in patient numbers at every step of the process. This reduction in patient numbers is clearly illustrated in Figure 6, which summarizes findings from all the reports. Studies are few, however, and offering a definitive answer to our core question—what proportion of patients who test positive for HIV are staged, enroll and remain in pre-ART care until ART eligibility, and initiate ART—is not possible with the data available. Only a handful of countries are represented, and most by no more than one or two studies. No study provides all the information needed to answer this question, even for a single setting, and combining results from multiple studies appears ill-advised. To examine the implications of doing this, we multiplied the median proportions of patients achieving the study end point in each stage (Stage 1, 59%; Stage 2, 46%; Stage 3, 68%), and found that the information available suggests that only about 18% of patients who are not yet eligible for ART when they are diagnosed with HIV remain continuously in care until ART eligibility. When we instead multiplied all combinations of estimates from each of the three stages, we estimated a median completion of all three stages of 17%, with an interval from the 10th to the 90th percentile of 7%–32%.

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