Risk factors, barriers and facilitators for linkage to antiretroviral therapy care:  a systematic review.
OBJECTIVE
To characterize patient and programmatic factors associated with retention in care during the pre-antiretroviral therapy (ART) period and linkage to ART care.


METHODS
Systematic literature review.


METHODS
An electronic search was conducted on MEDLINE, Global Health, Google Scholar and conference databases to identify studies reporting on predictors, barriers and facilitators of retention in care in the pre-ART period, and linkage to care at three steps: ART-eligibility assessment, pre-ART care and ART initiation. Factors associated with attrition were then divided into areas for intervention.


RESULTS
Seven hundred and sixty-eight citations were identified. Forty-two studies from 12 countries were included for review, with the majority from South Africa (16). The most commonly cited category of factors was transport costs and distance. Stigma and fear of disclosure comprised the second most commonly cited category of factors followed by staff shortages, long waiting times, fear of drug side effects, male sex, younger age and the need to take time off work.


CONCLUSIONS
This review highlights the importance of investigating interventions that could reduce transport difficulties. Decentralization, task-shifting and integration of services need to be expedited to alleviate health system barriers. Patient support groups and strategic posttest counselling are essential to assist patients deal with stigma and disclosure. Moreover, well tolerated first-line drugs and treatment literacy programmes are needed to improve acceptance of ART. This review suggests a combination of interventions to retain specific groups at risk for attrition such as workplace programmes for employed patients, dedicated clinic and support programmes for men and younger individuals.
Médecins Sans Frontières, Cape Town, South Africa. gdarsh@gmail.com
Darshini
D
Govindasamy
Nathan
N
Ford
Katharina
K
Kranzer
D019380:Anti-HIV Agents / Q000008:administration & dosage* / Q000191:economics; D003219:Confidentiality; D003906:Developing Countries; D004334:Drug Administration Schedule; D016527:Drug Costs; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics / Q000453:epidemiology; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand; D006801:Humans; D008297:Male; D010349:Patient Compliance / Q000706:statistics & numerical data*; D015397:Program Evaluation; D012307:Risk Factors; D012944:Social Support; D013019:South Africa / Q000453:epidemiology
D019380:Anti-HIV Agents