Abstract
We aimed to examine the correlates of antiretroviral therapy (ART) deferral to inform ART demand creation and retention interventions for patients diagnosed with HIV during the Universal Test and Treat (UTT) policy in South Africa. We conducted a cohort study enrolling newly diagnosed HIV-positive adults (≥ 18 years), at four primary healthcare clinics in Johannesburg between October 2017 and August 2018. Patients were interviewed immediately after HIV diagnosis, and ART initiation was determined through medical record review up to six-months post-test. ART deferral was defined as not starting ART six months after HIV diagnosis. Participants who were not on ART six-months post-test were traced and interviewed telephonically to determine reasons for ART deferral. Modified Poisson regression was used to evaluate correlates of six-months ART deferral. We adjusted for baseline demographic and clinical factors. We present crude and adjusted risk ratios (aRR) associated with ART deferral. Overall, 99/652 (15.2%) had deferred ART by six months, 20.5% men and 12.2% women. Baseline predictors of ART deferral were older age at diagnosis (adjusted risk ratio (aRR) 1.5 for 30–39.9 vs 18–29.9 years, 95% confidence intervals (CI): 1.0–2.2), disclosure of intentions to test for HIV (aRR 2.2 non-disclosure vs disclosure to a partner/spouse, 95% CI: 1.4–3.6) and HIV testing history (aRR 1.7 for > 12 months vs < 12 months/no prior test, 95% CI: 1.0–2.8). Additionally, having a primary house in another country (aRR 2.1 vs current house, 95% CI: 1.4–3.1) and testing alone (RR 4.6 vs partner/spouse support, 95% CI: 1.2–18.3) predicted ART deferral among men. Among the 43/99 six-months interviews, women (71.4%) were more likely to self-report ART initiation than men (RR 0.4, 95% CI: 0.2–0.8) and participants who relocated within SA (RR 2.1 vs not relocated, 95% CI: 1.2–3.5) were more likely to still not be on ART. Under the treat-all ART policy, nearly 15.2% of study participants deferred ART initiation up to six months after the HIV diagnosis. Our analysis highlighted the need to pay particular attention to patients who show little social preparation for HIV testing and mobile populations.
Highlights
South Africa is home to nearly eight million persons living with HIV, with about 4.6 million of these individuals receiving antiretroviral therapy (ART) [1,2,3]
The ART program in South Africa has historically suffered from significant patient losses throughout the care cascade with nearly twothirds of patients losses occurring between HIV diagnosis and ART initiation [14,15,16]
Of the 708 patients who tested positive during the study period,703 (99.3%) newly diagnosed patients were successfully referred and screened, 652 (92.7%) were eligible and agreed to participate in the study (Fig. 1)
Summary
South Africa is home to nearly eight million persons living with HIV, with about 4.6 million of these individuals receiving antiretroviral therapy (ART) [1,2,3]. While this represents an impressive scale-up effort, ART coverage is still below the targeted 90% by 2020, with about 60% of HIV accessing ART in 2019 [3,4,5]. The ART program in South Africa has historically suffered from significant patient losses throughout the care cascade with nearly twothirds of patients losses occurring between HIV diagnosis and ART initiation [14,15,16]. In particular, are historically less likely to seek health care or test for HIV, and often enter the care cascade at late stages of the disease, with low retention in care [17,18,19]
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