A patient-centred, fast tracking, TB-integrated approach to ART preparation and initiation counselling in a primary care clinic in Khayelitsha, South Africa.
Suhair Solomon1, Gabriela Patten1, Shariefa Abrahams2, Saar Baert1, Lena Anderson3, Lynne Wilkinson1 1 Medecins
Sans Frontières, 2 City of Cape Town, 3 University of Cape Town Background
A sub-Saharan African systematic review found losses to care exceeding 40% between ART eligibility and initiation1. Most ART programmes require ART eligible patients to complete several counselling sessions prior to initiation. There is little evidence demonstrating additional adherence benefits, while potentially increasing loss to care prior to initiation. We implemented a revised ART preparation counselling model limiting preinitiation preparation and strengthening support post initiation in a primary care facility in Khayelitsha, South Africa. Losses to care prior to ART initiation before the implementation of this model, calculated using routine data from a sample of eligible patients at the facility is estimated to be 35%.
Results Enrolled in programme in study period: n=292
Missing Folders: n=46 Study population: n=245 Initiated ART: 238 (97%)*
Returned for care after ART start: 234 (98%)
Did not initiate ART: 7 (3%)
Did not return after ART start: 4(2%)
In care for at least 28 days: 226 (96%)
In care and due for VL test at 4 months on ART: 166*
VL test taken: 135 (81%)**
No VL taken: 31 (19%)
Aims VL<400cells/µl: 126(93%)***
Reduce losses to care prior to ART initiation without compromising retention post ART initiation.
Methods From August 2012, all patients diagnosed with HIV and found to be eligible for ART at the facility were enrolled in the piloted ART preparation counselling model.
VL: Viral load * Initiated ART by 31/03/2013 **Study participants enrolled prior to 1/12/2012 were due for VL by 31/3/2013
Figure 1 Flow Diagram showing outcomes of a ART preparation and initiation programme implemented at a primary care clinic in Khayelitsha, South Africa in 2012
Among 245 patients enrolled, 63% were female and 27% were co-infected with TB. Median age at enrolment was 31. Median baseline CD4 count was 234 (95% CI: 211-251) and 15% of patients initiated with a baseline CD4 count of less than 100 cells/uL.
A lay counsellor provided one session before ART initiation, one session on date of initiation and two sessions post initiation. These four sessions cover treatment education and 14 structured adherence steps to support patients in overcoming common barriers to adherence, including substance use and annual migration. The structured approach to each session requires limited problem solving skills from lay staff. Patients self-declared readiness to initiate ART.
3% of patients eligible to initiate ART were lost from care prior to ART initiation.
An observational study was conducted using routinely-collected data on all ART eligible patients enrolled from 1 August to 31 December 2012 to assess loss to care prior to ART initiation, time to initiation and 28 day retention in care. Loss to pre-ART follow up was defined as not initiating ART within 3 months from enrolment. Viral load data was used to determine suppression rates.
There was no association between time to ART initiation and retention in care following ART initiation (hazard ratio 1.11, 95%CI 0.95 – 1.30).
To determine whether the rapid initiation approach negatively impacted short term retention post ART initiation, a cox proportional hazards model was used for all patients enrolled in the study to ascertain any association between time to initiation and retention in care when controlling for TB, age, sex and CD4 count.
Median time to ART initiation for patients without TB co-infection was 4 days (95% CI: 3-4.2 ). For TB co-infected patients it was 16 days (95%CI: 14-19.1). 96% of those initiated on ART were retained in short term care post ART initiation for at least 28 days.
93% of newly initiated ART patients suppressed at their first viral load.
Conclusions Preliminary results of this pilot indicate that limiting pre-initiation counselling and strengthening support after ART initiation has the potential to reduce pre-ART attrition, without impacting on short-term retention. Short time to initiation demonstrated patients' willingness to initiate ART quickly after eligibility ascertainment, including those co-infected with TB that were required to start TB treatment prior to ART initiation. 1Rosen S, Fox MP. Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review. PLoS Med 2011;8(7):e1001056
Acknowledgements HIV positive patients at Kuyasa clinic, Khayelitsha City of Cape Town Health Department TB/HIV Care Association MSF staff supporting this pilot, specifically Leticia Mdani Dedicated staff at Kuyasa clinic, Khayelitsha TB/HIV Care Association counsellors and supervisor at Kuyasa clinic Counsellor completes adherence step with client