Loss to programme between HIV diagnosis and initiation of antiretroviral therapy in sub-Saharan Africa: systematic review and meta-analysis

Abstract

Objectives: To assess the proportion of patients lost to programme (died, lost to follow-up, transferred out) between HIV diagnosis and start of antiretroviral therapy (ART) in sub-Saharan Africa, and determine factors associated with loss to programme.

Methods: Systematic review and meta-analysis. We searched PubMed and EMBASE databases for studies in adults. Outcomes were the percentage of patients dying before starting ART, the percentage lost to follow-up, the percentage with a CD4 cell count, the distribution of first CD4 counts and the percentage of eligible patients starting ART. Data were combined using random-effects meta-analysis.

Results: Twenty-nine studies from sub-Saharan Africa including 148,912 patients were analysed. Six studies covered the whole period from HIV diagnosis to ART start. Meta-analysis of these studies showed that of the 100 patients with a positive HIV test, 72 (95% CI 60-84) had a CD4 cell count measured, 40 (95% CI 26-55) were eligible for ART and 25 (95% CI 13-37) started ART. There was substantial heterogeneity between studies (P < 0.0001). Median CD4 cell count at presentation ranged from 154 to 274 cells/μl. Patients eligible for ART were less likely to become lost to programme (25%vs. 54%, P < 0.0001), but eligible patients were more likely to die (11%vs. 5%, P < 0.0001) than ineligible patients. Loss to programme was higher in men, in patients with low CD4 cell counts and low socio-economic status and in recent time periods.

Conclusions: Monitoring and care in the pre-ART time period need improvement, with greater emphasis on patients not yet eligible for ART.

Keywords: Afrique subsaharienne; liens avec les soins; linkage to care; loss to follow‐up; mortalidad; mortality; mortalité; nexo con atención médica; perte au suivi; pre‐ART; pre‐TAR; pré‐ART; pérdida durante el seguimiento; sub‐Saharan Africa; África subsahariana.

Figure 1

Routes from HIV testing to start of antiretroviral therapy. Shaded boxes show the different pre-ART care points, and shaded circles show the number of studies included in the systematic review (number of studies included in the meta-analysis in parentheses) at each of these stages. The three areas (number 1 to 3) represent the different stages in the cascade which are described in more detail in the text (i.e. stage 1: From HIV to CD4 testing; stage 2: eligibility assessment; stage 3: from eligibility to start of ART). ^#Completed: the patient was informed about the CD4 test result or the CD4 test was done within a certain time period after the HIV test; *LTP: loss to programme

Figure 2

Percentage of HIV positive patients completing different stages between testing positive for HIV infection and start of antiretroviral therapy (ART). Results from meta-analysis of six studies covering the period from HIV testing to start of ART. The six studies include 58,746 patients (Bassett et al. 2010, Ingle et al. 2010, Kohler et al. 2011, Kranzer et al. 2010, Micek et al. 2009, Tayler-Smith et al. 2010).

Figure 3

Meta-analysis of loss to programme, mortality and loss to follow-up during the pre-ART phase, according to whether patients were or were not eligible for ART. Panel A/B: Percentage of ART eligible/ineligible patients becoming loss to programme (LTP) before ART start. LTP includes mortality, loss to follow-up, transfer out and alive but not in programme. Panel C/D: Percentage of ART eligible/ineligible patients dying before ART start. Panel E/F: Percentage of ART eligible/ineligible patients becoming lost to follow-up before ART start.