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Late HIV care enrollment remains problematic in sub-Saharan Africa
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ATLANTA — Late enrollment into care for HIV has declined in sub-Saharan Africa since 2006, but it is still a substantial issue among this population, according to data presented here.
“We know that late treatment initiation remains a problem in sub-Saharan Africa, despite the fact that treatment guidelines have been expanded internationally,” Susie Hoffman, DrPH, of the HIV Center for Clinical and Behavioral Studies of New York State Psychiatric Institute and Columbia University, said during a presentation at the 2013 Conference on Retroviruses and Opportunistic Infections. “Late enrollment into care is an important precursor of late initiation of treatment, since people who enroll into care after they are already eligible for treatment cannot, by definition, begin treatment on time. We found that late enrollment into care has improved over time, but it still remains an important challenge to scaling up HIV care and treatment in the region.”
Susie Hoffman
As part of the L-START study, which was funded by the National Institute of Mental Health and the US President’s Emergency Plan for AIDS Relief (PEPFAR) through the Identifying Optimal Models of HIV Care and Treatment Collaboration, the investigators are identifying determinants of late treatment initiation in sub-Saharan Africa. Hoffman and colleagues evaluated data from 302,777 adults who enrolled in HIV care from 2006 to 2011 at 142 HIV clinics supported by ICAP at Columbia University via PEPFAR in sub-Saharan Africa. They examined CD4+ counts at enrollment in 2006 and in 2011, defining late enrollment as CD4+ counts of 350 cells/mcL or less, or WHO clinical stage 3 or 4, regardless of CD4+ count.
The median CD4+ counts increased from 238 cells/mcL to 286 cells/mcL. The percentage of patients enrolling late decreased from 68.3% in 2006 to 54.8% in 2011 (RR=0.83; 95% CI, 0.79-0.88). When examining determinants of late enrollment into care in 2011, the researchers found that the risk for late enrollment was higher in men compared with women, and higher among nonpregnant women compared with pregnant women. Older patients were also at higher risk for late enrollment.
Hoffman said patients who enrolled in clinics that had more than 700 patients at the time were 20% more likely to enroll late. In addition, those from communities with higher HIV knowledge and where testing coverage was better were less likely to enroll late.
“These are important findings because this is one of few studies to look at late enrollment into care in sub-Saharan Africa,” Hoffman said. “Although there is still much work that needs to be done to address the problem, these data provide some direction as to where we must go. They provide additional empirical support that interventions to increase uptake of testing on a community-wide level may have great potential to reduce late enrollment into care and, consequently, late initiation of treatment.”
For more information:
Hoffman S. #94. Presented at: 2013 Conference on Retroviruses and Opportunistic Infections; March 3-6, 2013; Atlanta.
Susie Hoffman, DrPH, can be reached at: Associate Professor of Clinical Epidemiology, Mailman School of Public Health, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY; email: sh51@columbia.edu.
Disclosure: Hoffman reports no relevant financial disclosures.
Perspective
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Paul A. Volberding, MD
Starting HIV treatment early in the course of disease is important for personal and public health. Immune recovery is reduced with delayed treatment and untreated HIV allows the virus to be transmitted to others. While early treatment is now recommended by guidelines, patients continue to engage in care with regrettably late stage disease. This is a problem everywhere but particularly in resource limited settings where health care access is a challenge. Efforts are underway to reduce this problem by programs to encourage community-wide HIV testing. Progress is being made, but reports like this one show more work is still needed.Perspective
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Joel Gallant, MD, MPH
There has been some improvement over time in the timing of treatment enrollment. However, more than half of the patients in this study enrolled with CD4 counts that are below the threshold for ART eligibility in their countries, and 20% had CD4 counts below 200. This results in a higher risk of morbidity and mortality due to HIV, and it also puts the people who are starting therapy at greater risk for immune reconstitution inflammatory syndrome (IRIS), which is a cause of morbidity and mortality in resource limited settings. The researchers point out that the best improvements have been in pregnant women, which is the result of routine voluntary counseling and testing in that population. We still have a long way to go in terms of diagnosis and referral to care. As guidelines for initiation of ART evolve to recommend earlier initiation of therapy, it will become even more important for people to get diagnosed and enrolled into care quickly.
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