title: Loss to programme between HIV diagnosis and initiation of antiretroviral therapy in sub-Saharan Africa: systematic review and meta-analysis.
abstract: OBJECTIVE
  To assess the proportion of patients lost to programme (died, lost to follow-up, transferred out) between HIV diagnosis and start of antiretroviral therapy (ART) in sub-Saharan Africa, and determine factors associated with loss to programme.
  
  
  METHODS
  Systematic review and meta-analysis. We searched PubMed and EMBASE databases for studies in adults. Outcomes were the percentage of patients dying before starting ART, the percentage lost to follow-up, the percentage with a CD4 cell count, the distribution of first CD4 counts and the percentage of eligible patients starting ART. Data were combined using random-effects meta-analysis.
  
  
  RESULTS
  Twenty-nine studies from sub-Saharan Africa including 148,912 patients were analysed. Six studies covered the whole period from HIV diagnosis to ART start. Meta-analysis of these studies showed that of the 100 patients with a positive HIV test, 72 (95% CI 60-84) had a CD4 cell count measured, 40 (95% CI 26-55) were eligible for ART and 25 (95% CI 13-37) started ART. There was substantial heterogeneity between studies (P < 0.0001). Median CD4 cell count at presentation ranged from 154 to 274 cells/μl. Patients eligible for ART were less likely to become lost to programme (25%vs. 54%, P < 0.0001), but eligible patients were more likely to die (11%vs. 5%, P < 0.0001) than ineligible patients. Loss to programme was higher in men, in patients with low CD4 cell counts and low socio-economic status and in recent time periods.
  
  
  CONCLUSIONS
  Monitoring and care in the pre-ART time period need improvement, with greater emphasis on patients not yet eligible for ART.
authors.affiliation: Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland  Department of Infectious Diseases, University Hospital Bern, Bern, Switzerland  School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Catrina
authors.initials: C
authors.lastname: Mugglin
authors.forename: Janne
authors.initials: J
authors.lastname: Estill
authors.forename: Gilles
authors.initials: G
authors.lastname: Wandeler
authors.forename: Nicole
authors.initials: N
authors.lastname: Bender
authors.forename: Matthias
authors.initials: M
authors.lastname: Egger
authors.forename: Thomas
authors.initials: T
authors.lastname: Gsponer
authors.forename: Olivia
authors.initials: O
authors.lastname: Keiser
mesh_terms: D015492:AIDS Serodiagnosis; D000328:Adult; D017954:Africa South of the Sahara; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D006301:Health Services Needs and Demand; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D017678:Sex Distribution
chemical_list: D019380:Anti-HIV Agents