title: Who starts antiretroviral therapy in Durban, South Africa?... not everyone who should.
abstract: OBJECTIVE
  To evaluate rates of antiretroviral therapy (ART) initiation within 12 months of a new HIV diagnosis in Durban, South Africa.
  
  
  METHODS
  Prospective observational cohort.
  
  
  METHODS
  Adults (>or=18 years) were enrolled before HIV testing at two outpatient clinics into the South African Test, Identify and Link cohort. Both sites offer comprehensive HIV care. HIV test results, CD4 cell counts, dates of ART initiation and dates of death were collected from medical records and 12-month patient/family interviews were conducted. ART eligibility was defined as a CD4 cell count less than 200 cells/microl within 90 days of HIV diagnosis. The primary endpoint was ART initiation within 12 months for ART-eligible subjects.
  
  
  RESULTS
  From November 2006 to October 2008, 1474 newly diagnosed HIV-infected outpatients were enrolled, 1012 (69%) of whom underwent CD4 cell count testing within 90 days. The median CD4 cell count was 159 cells/microl (interquartile range 65-299). Of those who underwent CD4 cell count testing, 538 (53%) were ART-eligible. Only 210 (39%) eligible enrollees were known to have initiated ART within 12 months. Among ART-eligible subjects, there were 108 known deaths; 82% occurred before ART initiation or with unknown ART initiation status. Men [rate ratio (RR) 1.3, 95% confidence interval (CI) 1.1-1.5] and subjects without an HIV-infected family member/friend (RR 1.3, 95% CI 1.1-1.7) were more likely not to start ART.
  
  
  CONCLUSIONS
  Less than half of ART-eligible subjects started ART within 12 months. Substantial attrition and mortality follow HIV diagnosis before ART initiation in Durban, South Africa. Major efforts directed towards earlier HIV diagnosis, effective linkage to care and timely ART initiation are urgently needed.
authors.affiliation: Division of Infectious Disease, Massachusetts General Hospital, Boston, MA 02114, USA. ibassett@partners.org
authors.forename: Ingrid V
authors.initials: IV
authors.lastname: Bassett
authors.forename: Susan
authors.initials: S
authors.lastname: Regan
authors.forename: Senica
authors.initials: S
authors.lastname: Chetty
authors.forename: Janet
authors.initials: J
authors.lastname: Giddy
authors.forename: Lauren M
authors.initials: LM
authors.lastname: Uhler
authors.forename: Helga
authors.initials: H
authors.lastname: Holst
authors.forename: Douglas
authors.initials: D
authors.lastname: Ross
authors.forename: Jeffrey N
authors.initials: JN
authors.lastname: Katz
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods / Q000706:statistics & numerical data*; D018791:CD4 Lymphocyte Count; D016001:Confidence Intervals; D004333:Drug Administration Routes; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D008297:Male; D008498:Medical Record Linkage / Q000592:standards; D013019:South Africa / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents