Abstract
Accurate reporting of antiretroviral therapy (ART) uptake is crucial for measuring the success of epidemic control. Programs without linked electronic medical records are susceptible to duplicating ART initiation events. We assessed the prevalence of undisclosed ART use at the time of treatment initiation and explored its correlates among people presenting to public ambulatory clinics in South Africa. Data were analyzed from the community-based delivery of ART (DO ART) clinical trial, which recruited people living with HIV who presented for ART initiation at two clinics in rural South Africa. We collected data on socioeconomic factors, clinical factors, and collected blood as part of study screening procedures. We estimated the proportion of individuals presenting for ART initiation with viral load suppression (< 20 copies/mL) and fitted regression models to identify social and clinical correlates of non-disclosure of ART use. We also explored clinical and national databases to identify records of ART use. Finally, to confirm surreptitious ART use, we measured tenofovir (TDF) and emtricitabine (FTC) levels in dried blood spots. A total of 193 people were screened at the two clinics. Approximately 60% (n = 114) were female, 40% (n = 78) reported a prior HIV test, 23% (n = 44) had disclosed to a partner, and 31% (n = 61) had a partner with HIV. We found that 32% (n = 62) of individuals presenting for ART initiation or re-initiation had an undetectable viral load. In multivariable regression models, female sex (AOR 2.16, 95% CI 1.08–4.30), having a prior HIV test and having disclosed their HIV status (AOR 2.48, 95% CI 1.13–5.46), and having a partner with HIV (AOR 1.94, 95% CI 0.95–3.96) were associated with having an undetectable viral load. In records we reviewed, we found evidence of ART use from either clinical or laboratory databases in 68% (42/62) and detected either TDF or FTC in 60% (37/62) of individuals with an undetectable viral load. Undisclosed ART use was present in approximately one in three individuals presenting for ART initiation or re-initiation at ambulatory HIV clinics in South Africa. These results have important implications for ART resource use and planning in the region. A better understanding of reasons for non-disclosure of ART at primary health care clinics in such settings is needed.
Highlights
South Africa has the highest number of people living with HIV (PLWH) in the world with an estimated 7.1 million PLWH [1]
Less is known about undisclosed antiretroviral therapy (ART) use from public health clinics (PHCs) as most studies have been reported from a community and randomised clinical trial setting
In this study in rural KwaZulu-Natal among individuals with HIV infection presenting for ART initiation, we found that undisclosed ART use with resulting undetectable viral loads were present in approximately one in three individuals
Summary
South Africa has the highest number of people living with HIV (PLWH) in the world with an estimated 7.1 million PLWH [1]. Methods used to measure these estimates include population-based demographic health surveys and health management information systems data from clinics [6] The validity of this data is crucial to the accurate estimation of HIV program success and gaps. According to Fogel et al undisclosed ART use is the use of “off study” antiretrovirals (ARVs) before enrolment into a clinical trial which may confound study outcomes [8]. This could have major implications if this practise is found in people initiating ART in public health settings. That study investigated ART denial from homebased testing, relatively little is known about this phenomenon in primary health care clinics, in which people are presenting for ART care initiation
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