Abstract
Despite expanded antiretroviral therapy (ART) eligibility in South Africa, many people diagnosed with HIV do not initiate ART promptly, yet understanding of the reasons is limited. Using data from an 8-month prospective cohort interview study of women and men newly-diagnosed with HIV in three public-sector primary care clinics in the eThekwini (Durban) region, South Africa, 2010–2014, we examined if theoretically-relevant social-structural, social-cognitive, psychosocial, and health status indicators were associated with time to ART initiation. Of 459 diagnosed, 350 returned to the clinic for their CD4+ test results (linkage); 153 (33.3%) were ART-eligible according to treatment criteria at the time; 115 (75.2% of those eligible) initiated ART (median = 12.86 weeks [95% CI: 9.75, 15.97] after linkage). In adjusted Cox proportional hazard models, internalized stigma was associated with a 65% decrease in the rate of ART initiation (Adjusted hazard ratio [AHR] 0.35, 95% CI: 0.19–0.80) during the period less than four weeks after linkage to care, but not four or more weeks after linkage to care, suggesting that stigma-reduction interventions implemented shortly after diagnosis may accelerate ART uptake. As reported by others, older age was associated with more rapid ART initiation (AHR for 1-year age increase: 1.04, 95% CI: 1.01–1.07) and higher CD4+ cell count (≥300μL vs. <150μL) was associated with a lower rate of initiation (AHR 0.38, 95% CI: 0.19–0.80). Several other factors that were assessed prior to diagnosis, including stronger belief in traditional medicine, higher endorsement of stigma toward people living with HIV, food insecurity, and higher psychological distress, were found to be in the expected direction of association with ART initiation, but confidence intervals were wide and could not exclude a null finding.
Highlights
In response to compelling evidence demonstrating that timely antiretroviral therapy (ART) initiation substantially decreases morbidity and mortality in people living with HIV (PLHIV) [1,2,3] and prevents onward transmission, World Health Organization (WHO) guidelines were revised in 2015 to recommend expanding ART eligibility to all individuals regardless of CD4+ count or WHO clinical stage
A 2018 multi-country analysis demonstrated that the incidence of ART initiation within 6 months increased after ART eligibility expansions between 2007 and 2015, in younger adults [6]
The median time from linkage to care to ART initiation estimated from the Kaplan-Meier curve was 12.86 weeks (Fig 1)
Summary
In response to compelling evidence demonstrating that timely antiretroviral therapy (ART) initiation substantially decreases morbidity and mortality in people living with HIV (PLHIV) [1,2,3] and prevents onward transmission, World Health Organization (WHO) guidelines were revised in 2015 to recommend expanding ART eligibility to all individuals regardless of CD4+ count or WHO clinical stage. UNAIDS set new HIV diagnosis and treatment targets, with the goal that by 2020, 90% of all PLHIV will know their HIV status, 90% of those diagnosed with HIV will receive sustained antiretroviral therapy, and 90% of those on ART will have viral suppression. In 2016, South Africa formally adopted these new WHO guidelines [4] and implemented a strategy of immediate ART initiation regardless of CD4+ count [5]. In the rural subdistrict of Hlabisa in KwaZulu-Natal, the same South African province where our study was conducted, found that expansion of ART eligibility resulted in an 85% increase in ART initiation among newly-eligible patients and a 32% increase in the number of patients starting ART overall [7]
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