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
HIV continuum of care
HIV
testing
Pre-ART care
ART care
Not in
care
Not in
care
eligible
HIV
infection
HIV
test
Assessment for
ART eligibility:
• Clinical staging
• CD4 count
not yet eligible
ART
initiation
Continuous
lifelong ART
Retention in preART care until
eligible
Kranzer et al 2012
HIV continuum of care
HIV
testing
Pre-ART care
ART care
Not in
care
Not in
care
eligible
HIV
infection
HIV
test
Assessment for
ART eligibility:
• Clinical staging
• CD4 count
not yet eligible
ART
initiation
Continuous
lifelong ART
Retention in preART care until
eligible
Kranzer et al 2012
Systematic review
18
16
14
12
10
8
6
4
2
0
Search limited to sub-Saharan Africa
studies published before May 2011
Total number of studies: 42
Semi-qualitative studies: 19
Quantitative 17
Qualitative 6
Barriers to retention in pre-ART care
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
Govindasamy, Ford, Kranzer 2012
Predictors of attrition
Economic
• Transport cost
• Distance
Health systems
• Shortage of HCWs
Medical
• TB treatment
• Pregnancy
• Advanced immunodeficiency
• Severe malnutrition
Other
• Male sex
• Younger age
• Lower levels of education
Govindasamy, Ford, Kranzer 2012
Predictors of attrition
Economic
• Transport cost
• Distance
Health systems
• Shortage of HCWs
Medical
• TB treatment
• Pregnancy
• Advanced immunodeficiency
• Severe malnutrition
Other
• Male sex
• Younger age
• Lower levels of education
Govindasamy, Ford, Kranzer 2012
Men
• Lower test uptake
• Lower ART coverage
• More advanced immunodeficiency at diagnosis and ART initiation
• Higher mortality
on ART
• Lower adherence
• Higher risk of loss to follow-up
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
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)
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)
24 studies retained for analysis
(19 published articles + 1 unpublished article from experts + 2 conference
abstracts + 2 conference abstracts from experts)
Govindasamy, Kranzer 2013
Intervention studies - design and populations
 Before after studies: n=11
Observational studies with control group(s): n=6
Individuals randomized controlled trials: n=4
Cluster randomized controlled trials: n=3
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





Adults: n=11
Children: n=1
Adolescents: n=1
Pregnant women: n=8
Inpatients: n=1
TB patients: n=1
IVDU: n=1
Govindasamy, Kranzer 2013
Intervention studies - design and populations
 Before after studies: N=11
Observational studies with control group(s): n=6
Individuals randomized controlled trials: n=4
Cluster randomized controlled trials: n=3







Few studies
with rigorous
design
Adults: n=11
Children: n=1
Adolescents: n=1
Pregnant women: n=8
Inpatients: n=1
TB patients: n=1
IVDU: n=1
Govindasamy, Kranzer 2013
Intervention studies - design and populations
 Before after studies: N=11
Observational studies with control group(s): n=6
Individuals randomized controlled trials: n=4
Cluster 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
Govindasamy, Kranzer 2013
Pregnant women
No of studies
Design
Control - outcome
Intervention: Integration
Proportion of ART eligible women initiating ART
Pfeiffer
Observational Not presented
Tsague
studies
22/26 (85%)
Stinson
61/130 (47%)
Killam
103/716 (14%)
Myer
58/271 (21%)
Time to initiation of ART
Van der
Observational 56 days (30-103)
Merwe
studies
Intervention: Health system intervention
Proportion of ART-eligible women initiating ART
Weigel
Observational 2006 9/14 (64%)
studies
Youngleson
124/1243 (10%)
Interventionoutcome
Not presented
105/134 (78%)
124/227 (45%)
278/846 (33%)
183/214 (85%)
Relative
(95%CI)
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)
Absolute
-0.08 (-0.23; 0.08)
0.01 (-0.09; 0.11)
0.18 (0.14; 0.23)
0.64 (0.57; 0.71)
29 days (12-45)
2007 94/119 (79%) 1.23 (0.83; 1.84)
2008 84/101 (83%) 1.29 (0.87; 1.93)
2009 99/110 (90%) 1.40 (0.94; 2.08)
0.14 (-0.11;0.41)
0.19 (-0.07; 0.45)
0.26 (-0.0; 0.51)
122/486 (25%)
0.15 (0.11; 0.19)
2.52 (2.00; 3.16)
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 study
1 Individual RCT
1 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
Psychosocial
• Stigma
• Fear of disclosure
• Fear of drug toxicities
• Perceived good health
Economic
• Transport cost
• Distance
• Food shortage
• Unable to take time of work
Health systems
• Long waiting times
• Shortage of HCWs
Medical
• TB treatment
Interventions addressing the barriers
Psychosocial
• Stigma
• Fear of disclosure
• Fear of drug toxicities
• Perceived good health
Economic
• Transport cost
• Distance
• Food shortage
• Unable to take time of work
Health systems
• Long waiting times
• Shortage of HCWs
Medical
• TB treatment
Thank you!