title: Adults receiving HIV care before the start of antiretroviral therapy in sub-Saharan Africa: patient outcomes and associated risk factors.
abstract: BACKGROUND
  Gaining understanding of the period before antiretroviral therapy (ART) is needed to improve treatment outcomes and to reduce HIV transmission. This study describes the cascade of enrollment in HIV care, pre-ART follow-up, and predictors of mortality and lost to follow-up (LTFU) before ART initiation.
  
  
  METHODS
  We conducted a cohort study among HIV-infected adult patients not yet started on ART in 4 HIV Sub-Saharan African programs. Patient follow-up began at enrollment and ended at the earliest of death, transfer-out, ART initiation, last visit date, or 60 months postenrollment. Risk factors for death and LTFU were investigated during the periods 0-6 and 6-60 months.
  
  
  RESULTS
  A total of 55,789 patients (65.4% women) were included as follows: 44.2% in clinical stage 3 or 4, with median CD4 of 261 cells per microliter [interquartile range (IQR): 125-447]. Patient care started with a median of 3 days (IQR: 0-11) after HIV diagnosis, and 31,104 of 55,789 (55.8%) patients had CD4 counts performed within 1 month of enrollment. Of 47,283 patients with known ART eligibility status at enrollment, 36,969 (78.2%) patients required ART and 27,798 of 36,969 (75.7%) patients initiated therapy. Median follow-up was 2.5 months (IQR: 0.9-13.1). Mortality and LTFU rates were 3.9 per 100 person-years [95% confidence interval (CI): 3.7 to 4.1] and 28.3 per 100 person-years (95% CI: 27.8 to 28.8), respectively. Regardless of period, increased mortality and LTFU were associated with male, lower body mass index, advanced clinical stage, and lower CD4 cell count.
  
  
  CONCLUSIONS
  Short delays between HIV testing and care enrollment were observed in our HIV programs, but delays to determine ART eligibility were long. Interventions to initiate ART earlier, specifically targeted to men, are needed to improve patient retention in Africa.
authors.affiliation: *Clinical Research Department, Epicentre, Paris, France; †Médecins Sans Frontières, Medical Department, Paris, France; and ‡University College London, London, United Kingdom.
authors.forename: Mathieu
authors.initials: M
authors.lastname: Bastard
authors.forename: Nathalie
authors.initials: N
authors.lastname: Nicolay
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Szumilin
authors.forename: Suna
authors.initials: S
authors.lastname: Balkan
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Poulet
authors.forename: Mar
authors.initials: M
authors.lastname: Pujades-Rodriguez
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara / Q000453:epidemiology; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000628:therapy* / Q000635:transmission; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D005791:Patient Care / Q000379:methods*; D012307:Risk Factors; D016896:Treatment Outcome