RISK FACTORS, BARRIERS AND FACILITATORS FOR LINKAGE AND RETENTION IN PRE-ART CARE Darshini Govindasamy Health Economics and Epidemiology Research Office, SA Katharina Kranzer London School of Hygiene and Tropical Medicine, UK
Feb 24, 2016
RISK FACTORS, BARRIERS AND FACILITATORS FOR LINKAGE AND RETENTION IN PRE-ART CARE
Darshini GovindasamyHealth Economics and Epidemiology Research Office, SA
Katharina KranzerLondon School of Hygiene and Tropical Medicine, UK
HIV continuum of care
HIV test
Continuous lifelong ARTAssessment for
ART eligibility:• Clinical
staging• CD4 count
ART initiation
Retention in pre-ART care until eligiblenot yet eligible
eligible
HIV infection
HIV testing
Pre-ART care ART care
Not in care
Not in care
Kranzer et al 2012
HIV continuum of care
HIV test
Continuous lifelong ARTAssessment for
ART eligibility:• Clinical
staging• CD4 count
ART initiation
Retention in pre-ART care until eligiblenot yet eligible
eligible
HIV infection
HIV testing
Pre-ART care ART care
Not in care
Not in care
Kranzer et al 2012
02468
1012141618
Search limited to sub-Saharan Africa studies published before May 2011
Total number of studies: 42Semi-qualitative studies: 19Quantitative 17 Qualitative 6
Systematic review
Barriers to retention in pre-ART care
Govindasamy, Ford, Kranzer 2012
Health systems• Long waiting
times• Shortage of HCWs
Economic• Transport cost• Distance• Food shortage• Unable to take time of
work
Medical• TB
treatment
Psychosocial• Stigma• Fear of disclosure• Fear of drug
toxicities• Perceived good
health
Predictors of attrition
Govindasamy, Ford, Kranzer 2012
Health systems• Shortage of HCWs
Economic• Transport cost• Distance
Medical• TB treatment• Pregnancy• Advanced immunodeficiency• Severe malnutrition
Other• Male sex• Younger age• Lower levels of education
Predictors of attrition
Govindasamy, Ford, Kranzer 2012
Health systems• Shortage of HCWs
Economic• Transport cost• Distance
Medical• TB treatment• Pregnancy• Advanced immunodeficiency• Severe malnutrition
Other• Male sex• Younger age• Lower levels of education
Men
• Lower test uptake• Lower ART coverage• More advanced immunodeficiency at diagnosis and ART initiation• Higher mortality• Lower adherence• Higher risk of loss to follow-up
on ART
Johnson 2013, Cornell 2012, Druyts 2013, Peltzer 2009, Kranzer 2013, Johnson 2012, Muula 2009, Remien 2009
How to address gender inequality
• Men do not become pregnant• Men are less health seeking• Health care staff are predominantly women• Health care services are targeted at women and
children
Health care services AIMED at men or "men friendly" health care services
Areas for interventions
Govindasamy, Ford, Kranzer 2012
Systematic review of interventions to improve linkage to and retention in pre-ART care
Govindasamy, Kranzer 2013
N=11129 potentially eligible citations identified through:Search strategy on electronic databases (n=11 048)
Keyword search on electronic conference abstract databases (n=45)References obtained from experts (n=36)
24 studies retained for analysis(19 published articles + 1 unpublished article from experts + 2 conference
abstracts + 2 conference abstracts from experts)
N=67 of full text articles assessed for eligibility(54 published articles + 1 unpublished article from experts + 10 conference
abstracts + 2 conference abstracts from experts)
Intervention studies - design and populations
Govindasamy, Kranzer 2013
Before after studies: n=11Observational studies with control group(s): n=6Individuals randomized controlled trials: n=4Cluster randomized controlled trials: n=3
Adults: n=11 Children: n=1 Adolescents: n=1 Pregnant women: n=8 Inpatients: n=1 TB patients: n=1 IVDU: n=1
Intervention studies - design and populations
Govindasamy, Kranzer 2013
Before after studies: N=11Observational studies with control group(s): n=6Individuals randomized controlled trials: n=4Cluster randomized controlled trials: n=3
Adults: n=11 Children: n=1 Adolescents: n=1 Pregnant women: n=8 Inpatients: n=1 TB patients: n=1 IVDU: n=1
Few studies with rigorous design
Intervention studies - design and populations
Govindasamy, Kranzer 2013
Before after studies: N=11Observational studies with control group(s): n=6Individuals randomized controlled trials: n=4Cluster randomized controlled trials: n=3
Adults: n=11 Children: n=1 Adolescents: n=1 Pregnant women: n=8 Inpatients: n=1 TB patients: n=1 IVDU: n=1
Few studies with rigorous design
Few studies in special risk groups
Pregnant women
No of studies Design Control - outcome Intervention- outcome
Relative (95%CI) Absolute
Intervention: Integration Proportion of ART eligible women initiating ART Pfeiffer Tsague Stinson Killam Myer
Observational studies
Not presented 22/26 (85%) 61/130 (47%) 103/716 (14%) 58/271 (21%)
Not presented 105/134 (78%) 124/227 (45%) 278/846 (33%) 183/214 (85%)
1.58 (1.17; 2.14) 0.90 (0.7; 1.1) 0.62 (0.37; 1.04) 2.01 (1.37; 2.95) 4.00 (3.16; 5.05)
-0.08 (-0.23; 0.08) 0.01 (-0.09; 0.11) 0.18 (0.14; 0.23) 0.64 (0.57; 0.71)
Time to initiation of ART Van der Merwe
Observational studies
56 days (30-103) 29 days (12-45)
Intervention: Health system intervention Proportion of ART-eligible women initiating ART Weigel Youngleson
Observational studies
2006 9/14 (64%) 124/1243 (10%)
2007 94/119 (79%) 2008 84/101 (83%) 2009 99/110 (90%) 122/486 (25%)
1.23 (0.83; 1.84) 1.29 (0.87; 1.93) 1.40 (0.94; 2.08) 2.52 (2.00; 3.16)
0.14 (-0.11;0.41) 0.19 (-0.07; 0.45) 0.26 (-0.0; 0.51) 0.15 (0.11; 0.19)
Interventions and outcomes in special groups
Intervention Number of studies
Participants Design Outcome
Food incentives 1 Children Before/after study
Improved clinic attendance (RR 2.9)
Health system intervention
1 TB patients Before/after study
Increased ART initiation (HR 2.6)
Food vouchers 1 IVDU RCT Time to initiation: 7 days (intervention) 58 days (control)
Point of care CD4 count testing
1 adolescents Before/after study
Time between HIV-testing and eligibility assessment: 14 days (control) and 0 days (intervention)
Interventions and outcomes in adults
Intervention No of studies
Design Outcome
Monthly visits with refill of cotrimoxazole
1 Before/after study Improved retention in pre-ART care (RR 2.6)
Health system intervention
1 Before/after study Increased ART initiation (HR 2.7)
Point of care or immediate CD4 count testing
3 1 before/after study1 Individual RCT1 Observation study with control group
Increased retention and ART initiation (RR 2)
PICT 1 Observation study with control group No effect on ART initiation (RR 0.9)
Task shifting and decentralisation
1 Cluster RCT No effect on retention (RR 1.0)
Intensive counselling 1 Individual RCT Increased pre-ART enrolment (RR 1.8)
Home-based ART initiation
1 Cluster RCT Increased ART initiation rate (RR 2.9)
Interventions addressing the barriers
Health systems• Long waiting times• Shortage of HCWs
Economic• Transport cost• Distance• Food shortage• Unable to take time of work
Medical• TB treatment
Psychosocial• Stigma• Fear of disclosure• Fear of drug toxicities• Perceived good health
Interventions addressing the barriers
Health systems• Long waiting times• Shortage of HCWs
Economic• Transport cost• Distance• Food shortage• Unable to take time of
work
Medical• TB treatment
Psychosocial• Stigma• Fear of disclosure• Fear of drug toxicities• Perceived good health
Thank you!