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Failure to initiate HIV treatment in patients with high CD 4 counts: evidence from demographic surveillance in rural South Africa
Author(s) -
Bor Jacob,
Chiu Calvin,
Ahmed Shahira,
Katz Ingrid,
Fox Matthew P.,
Rosen Sydney,
Yapa Manisha,
Tanser Frank,
Pillay Deenan,
Bärnighausen Till
Publication year - 2018
Publication title -
tropical medicine and international health
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.056
H-Index - 114
eISSN - 1365-3156
pISSN - 1360-2276
DOI - 10.1111/tmi.13013
Subject(s) - medicine , proportional hazards model , hazard ratio , demography , human immunodeficiency virus (hiv) , population , immunology , environmental health , confidence interval , sociology
Objectives To assess the relationship between CD 4 count at presentation and ART uptake and assess predictors of timely treatment initiation in rural KwaZulu‐Natal, South Africa. Methods We used Kaplan‐Meier and Cox proportional hazards models to assess the association between first CD 4 count and time from first CD 4 to ART initiation among all adults presenting to the Hlabisa HIV Treatment and Care Programme between August 2011 and December 2012 with treatment‐eligible CD4 counts (≤ 350 cells/mm 3 ). For a subset of healthier patients (200 < CD 4 ≤ 350 cells) residing within the population surveillance of the Africa Health Research Institute, we assessed sociodemographic, economic and geographic predictors hypothesised to influence ART uptake. Results A total of 4739 patients presented for care with eligible CD 4 counts. The proportion initiating ART within six months of diagnosis was 67% (95% CI 63, 71) in patients with CD 4 ≤ 50, 59% (0.55, 0.63) in patients with CD 4 151–200 and 48% (95% CI 44, 51) in patients with CD 4 301–350. The hazard of starting ART fell by 17% (95% CI 14, 20) for every 100‐cell increase in baseline CD 4 count. Among healthier patients under demographic surveillance ( n = 193), observable sociodemographic, economic and geographic predictors did not add discriminatory power beyond CD 4 count, age and sex to identify patients at high risk of non‐initiation. Conclusions Individuals presenting for HIV care at higher CD 4 counts were less likely to initiate ART than patients presenting at low CD 4 counts. Overall, ART uptake was low. Under new guidelines that establish ART eligibility regardless of CD 4 count, patients with high CD 4 counts may require additional interventions to encourage treatment initiation.