Who starts antiretroviral therapy in Durban, South Africa?... not everyone who should

Abstract

Objective: To evaluate rates of antiretroviral therapy (ART) initiation within 12 months of a new HIV diagnosis in Durban, South Africa.

Design: Prospective observational cohort.

Methods: Adults (>or=18 years) were enrolled before HIV testing at two outpatient clinics into the South African Test, Identify and Link cohort. Both sites offer comprehensive HIV care. HIV test results, CD4 cell counts, dates of ART initiation and dates of death were collected from medical records and 12-month patient/family interviews were conducted. ART eligibility was defined as a CD4 cell count less than 200 cells/microl within 90 days of HIV diagnosis. The primary endpoint was ART initiation within 12 months for ART-eligible subjects.

Results: From November 2006 to October 2008, 1474 newly diagnosed HIV-infected outpatients were enrolled, 1012 (69%) of whom underwent CD4 cell count testing within 90 days. The median CD4 cell count was 159 cells/microl (interquartile range 65-299). Of those who underwent CD4 cell count testing, 538 (53%) were ART-eligible. Only 210 (39%) eligible enrollees were known to have initiated ART within 12 months. Among ART-eligible subjects, there were 108 known deaths; 82% occurred before ART initiation or with unknown ART initiation status. Men [rate ratio (RR) 1.3, 95% confidence interval (CI) 1.1-1.5] and subjects without an HIV-infected family member/friend (RR 1.3, 95% CI 1.1-1.7) were more likely not to start ART.

Conclusion: Less than half of ART-eligible subjects started ART within 12 months. Substantial attrition and mortality follow HIV diagnosis before ART initiation in Durban, South Africa. Major efforts directed towards earlier HIV diagnosis, effective linkage to care and timely ART initiation are urgently needed.

Fig. 1

Cohort flow diagram showing study enrollment, HIV test results, CD4 cell count test results and antiretroviral therapy initiation ART, Antiretroviral therapy.

Fig. 2

Kaplan–Meier estimate of time from HIV diagnosis to antiretroviral therapy start for patients antiretroviral therapy eligible at baseline enrollment, stratified by sex ART, Anti-retroviral therapy.

Fig. 3

Mortality among antiretroviral therapy-eligible subjects, based on ART initiation status (NU108 deaths among 536 ART-eligible subjects) □ On ART; unknown ART status; ■ pre-ART. ART, Antiretroviral therapy.