Research Article: Contemporary disengagement from antiretroviral therapy in Khayelitsha, South Africa: A cohort study

Date Published: November 7, 2017

Publisher: Public Library of Science

Author(s): Samantha R. Kaplan, Christa Oosthuizen, Kathryn Stinson, Francesca Little, Jonathan Euvrard, Michael Schomaker, Meg Osler, Katherine Hilderbrand, Andrew Boulle, Graeme Meintjes, Marie-Louise Newell

Abstract: BackgroundRetention in care is an essential component of meeting the UNAIDS “90-90-90” HIV treatment targets. In Khayelitsha township (population ~500,000) in Cape Town, South Africa, more than 50,000 patients have received antiretroviral therapy (ART) since the inception of this public-sector program in 2001. Disengagement from care remains an important challenge. We sought to determine the incidence of and risk factors associated with disengagement from care during 2013–2014 and outcomes for those who disengaged.Methods and findingsWe conducted a retrospective cohort study of all patients ≥10 years of age who visited 1 of the 13 Khayelitsha ART clinics from 2013–2014 regardless of the date they initiated ART. We described the cumulative incidence of first disengagement (>180 days not attending clinic) between 1 January 2013 and 31 December 2014 using competing risks methods, enabling us to estimate disengagement incidence up to 10 years after ART initiation. We also described risk factors for disengagement based on a Cox proportional hazards model, using multiple imputation for missing data. We ascertained outcomes (death, return to care, hospital admission, other hospital contact, alive but not in care, no information) after disengagement until 30 June 2015 using province-wide health databases and the National Death Registry. Of 39,884 patients meeting our eligibility criteria, the median time on ART to 31 December 2014 was 33.6 months (IQR 12.4–63.2). Of the total study cohort, 592 (1.5%) died in the study period, 1,231 (3.1%) formally transferred out, 987 (2.5%) were silent transfers and visited another Western Cape province clinic within 180 days, 9,005 (22.6%) disengaged, and 28,069 (70.4%) remained in care. Cumulative incidence of disengagement from care was estimated to be 25.1% by 2 years and 50.3% by 5 years on ART. Key factors associated with disengagement (age, male sex, pregnancy at ART start [HR 1.58, 95% CI 1.47–1.69], most recent CD4 count) and retention (ART club membership, baseline CD4) after adjustment were similar to those found in previous studies; however, notably, the higher hazard of disengagement soon after starting ART was no longer present after adjusting for these risk factors. Of the 9,005 who disengaged, the 2 most common initial outcomes were return to ART care after 180 days (33%; n = 2,976) and being alive but not in care in the Western Cape (25%; n = 2,255). After disengagement, a total of 1,459 (16%) patients were hospitalized and 237 (3%) died. The median follow-up from date of disengagement to 30 June 2015 was 16.7 months (IQR 11–22.4). As we included only patient follow-up from 2013–2014 by design in order to maximize the generalizability of our findings to current programs, this limited our ability to more fully describe temporal trends in first disengagement.ConclusionsTwenty-three percent of ART patients in the large cohort of Khayelitsha, one of the oldest public-sector ART programs in South Africa, disengaged from care at least once in a contemporary 2-year period. Fifty-eight percent of these patients either subsequently returned to care (some “silently”) or remained alive without hospitalization, suggesting that many who are considered “lost” actually return to care, and that misclassification of “lost” patients is likely common in similar urban populations.A challenge to meeting ART retention targets is developing, testing, and implementing program designs to target mobile populations and retain them in lifelong care. This should be guided by risk factors for disengagement and improving interlinkage of routine information systems to better support patient care across complex care platforms.

Partial Text: With the 2015 World Health Organization (WHO) guidelines recommending treatment for all HIV-infected individuals regardless of CD4 status and the continued high HIV incidence rates in endemic areas, there are increasing numbers of patients eligible for and starting lifelong antiretroviral therapy (ART). In order for health systems to meet the UNAIDS 90-90-90 treatment targets of patients receiving sustained ART and maintaining viral suppression, retention in care is an essential focus [1]. Viral suppression reduces HIV transmission [2], and in a modeling study has been shown to contribute to the public health goal of ending the HIV/AIDS epidemic [3]. Patients who disengage from care have an increased risk of poor health outcomes, transmitting HIV to others, and developing drug resistance, thereby undermining overall program impact as well as the global public health goal of ending the HIV epidemic. In Southern Africa, as of 2014, WHO-estimated ART retention rates after 5 years to be less than 50%, and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) countries in this region reported 77% retention at 12 months in 2015 [4,5].

In this study, we examined disengagement from ART care during 2013–2014 among patients of the large, peri-urban cohort in Khayelitsha—one of the oldest public-sector ART cohorts in South Africa. Roughly 1 in 5 patients disengaged from care, demonstrating a high rate of disengagement and a key challenge to reaching the UNAIDS 90-90-90 treatment targets. Factors associated with disengagement were age <30 years, male sex, pregnancy at ART initiation, and last CD4 count <350 cells/μl. Factors associated with retention were ART adherence club membership and baseline CD4 <350 cells/μl. However, despite the high incidence of disengagement, many of those who disengaged did not do so permanently. While 48% (n = 4,199) of patients could not be traced (either did not have a national identification number or had an ID number and/or medical record number but no additional data were found), and 16% (n = 1,459) were admitted to the hospital at some point after disengagement, roughly 1 in 3 patients returned to care within the province during the study period, and half were estimated to return to care within 2.5 years. Additionally, not included in the overall estimate of disengagement are the 2.5% of silent transfers who appeared to disengage from a clinic perspective but were actually in care elsewhere in the Western Cape province when province-wide data linkage was performed. These data indicate that a substantial proportion of patients are cycling in and out of care as well as transferring elsewhere in the province (often “silently”), and potentially to facilities outside of the Western Cape province (something that our study could not ascertain). Source: http://doi.org/10.1371/journal.pmed.1002407

 

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