Increasing Transfers-Out from an Antiretroviral Treatment Service in South Africa: Patient Characteristics and Rates of Virological Non-Suppression

Mweete D Nglazi,Catherine Orrell,Landon Myer,Robin Wood,Stephen D Lawn,Richard Kaplan,Linda-Gail Bekker,Matthew P Fox

doi:10.1371/journal.pone.0057907

Abstract

ObjectivesTo determine the proportion, characteristics and outcomes of patients who transfer-out from an antiretroviral therapy (ART) service in a South African township.MethodsThis retrospective cohort study included all patients aged ≥15 years who enrolled between September 2002 and December 2009. Follow-up data were censored in December 2010. Kaplan-Meier survival analysis was used to describe time to transfer-out and cox proportional hazard analysis was used to determine associated risk factors.Results4511 patients (4003 ART-naïve and 508 non-naïve at baseline) received ART during the study period. Overall, 597 (13.2%) transferred out. The probability of transferring out by one year of ART steadily increased from 1.4% in 2002/2004 cohort to 8.9% for the 2009 cohort. Independent risk factors for transfer-out were more recent calendar year of enrolment, younger age (≤25 years) and being ART non-naïve at baseline (i.e., having previously transferred into this clinic from another facility). The proportions of patients transferred out who had a CD4 cell count <200 cells/µL and/or a viral load ≥1000 copies/mL were 19% and 20%, respectively.ConclusionsWith scale-up of ART over time, an increasing proportion of patients are transferring between ART services and information systems are needed to track patients. Approximately one-fifth of these have viral loads >1000 copies/mL around the time of transfer, suggesting the need for careful adherence counseling and assessment of medication supplies among those planning transfer.

Highlights

Increasing numbers of patients are receiving antiretroviral therapy (ART) at health facilities in sub-Saharan Africa and the World Health Organization (WHO) estimated that 5.1 million people had started ART in the region by the end of 2010
As scale-up has progressed, it has been reported that growing proportions of patients are not retained long-term within ART services with losses estimated at approximately 40% of patients during the first 2 years of therapy [2,3]
While many studies have reported on these two outcomes [2,3,4,5,6,7], few have characterised those who transfer-out to other ART services [7,8,9]

Summary

Introduction

Increasing numbers of patients are receiving antiretroviral therapy (ART) at health facilities in sub-Saharan Africa and the World Health Organization (WHO) estimated that 5.1 million people had started ART in the region by the end of 2010. We have previously reported from an ART service in South Africa that an increasing proportion of patients enrolling for ART subsequently transfer-out [7]. The characteristics, risk factors and immune and virological status of patients transferring out is unknown. We conducted this detailed analysis of patients transferring out from a large community based ART service in Cape Town, South Africa

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