Date Published: June 11, 2018
Publisher: Public Library of Science
Author(s): Matthew P. Fox, Jacob Bor, Alana T. Brennan, William B. MacLeod, Mhairi Maskew, Wendy S. Stevens, Sergio Carmona, Marie-Louise Newell
Abstract: BackgroundSystematic reviews have described high rates of attrition in patients with HIV receiving antiretroviral therapy (ART). However, migration and clinical transfer may lead to an overestimation of attrition (death and loss to follow-up). Using a newly linked national laboratory database in South Africa, we assessed national retention in South Africa’s national HIV program.Methods and findingsPatients receiving care in South Africa’s national HIV program are monitored through regular CD4 count and viral load testing. South Africa’s National Health Laboratory Service has maintained a database of all public-sector CD4 count and viral load results since 2004. We linked individual laboratory results to patients using probabilistic matching techniques, creating a national HIV cohort. Validation of our approach in comparison to a manually matched dataset showed 9.0% undermatching and 9.5% overmatching. We analyzed data on patients initiating ART in the public sector from April 1, 2004, to December 31, 2006, when ART initiation could be determined based on first viral load among those whose treatment followed guidelines. Attrition occurred on the date of a patient’s last observed laboratory measure, allowing patients to exit and reenter care prior to that date. All patients had 6 potential years of follow-up, with an additional 2 years to have a final laboratory measurement to be retained at 6 years. Data were censored at December 31, 2012. We assessed (a) national retention including all laboratory tests regardless of testing facility and (b) initiating facility retention, where laboratory tests at other facilities were ignored. We followed 55,836 patients initiating ART between 2004 and 2006. At ART initiation, median age was 36 years (IQR: 30–43), median CD4 count was 150 cells/mm3 (IQR: 81–230), and 66.7% were female. Six-year initiating clinic retention was 29.1% (95% CI: 28.7%–29.5%). After allowing for transfers, national 6-year retention was 63.3% (95% CI: 62.9%–63.7%). Results differed little when tightening or relaxing matching procedures. We found strong differences in retention by province, ranging from 74.2% (95% CI: 73.2%–75.2%) in Western Cape to 52.2% (95% CI: 50.6%–53.7%) in Mpumalanga at 6 years. National attrition was higher among patients initiating at lower CD4 counts and higher viral loads, and among patients initiating ART at larger facilities. The study’s main limitation is lack of perfect cohort matching, which may lead to over- or underestimation of retention. We also did not have data from KwaZulu-Natal province prior to 2010.ConclusionsIn this study, HIV care retention was substantially higher when viewed from a national perspective than from a facility perspective. Our results suggest that traditional clinical cohorts underestimate retention.
Partial Text: In 2015, the World Health Organization (WHO) recommended removing CD4 count thresholds for HIV treatment eligibility  based on clinical trial evidence showing benefits to patients [2,3] and reduced transmission to uninfected partners . It is hoped this recommendation will increase the number of patients on antiretroviral therapy (ART) and reduce new infections [5–9]. However, WHO specifically noted that the expected gains of such an approach could only be achieved if improvements were made in retaining patients on ART.
The NHLS cohort contained 55,836 people who initiated ART in South Africa between 2004 and 2006 (Table 1). The population was predominately female (66.7%) with a median age of 36 years (IQR: 30–43) at ART initiation. Gauteng province contributed the largest share of patients, at 29.0%, while Northern Cape had the smallest, at 3.1% (KwaZulu-Natal was excluded from all analyses). Median CD4 count at ART initiation (closest to first viral load but no more than 12 months before and more than 90 days after) was 150 cells/mm3 (IQR: 81–230).
In this national assessment of retention in South Africa’s HIV program, we found that among patients starting ART in 2004–2006, national retention was 63.3% (95% CI: 62.9%–63.7%) at 6 years, more than twice the proportion retained at the initiating clinic (29.1%; 95% CI: 28.7%–29.5%). This 34.2 percentage point difference suggests that considering retention only from the perspective of the initiating clinic, the approach most commonly used to estimate retention in clinical cohort studies, strongly overstates attrition.