title: Continuum in HIV care from entry to ART initiation in rural KwaZulu-Natal, South Africa.
abstract: OBJECTIVE
  To quantify time from entry in HIV care until Antiretroviral therapy (ART) initiation and identify factors associated with ART initiation in rural KwaZulu-Natal, South Africa.
  
  
  METHODS
  Adults ≥16 years entering the decentralised Hlabisa ART programme between 2007 and 2011 were followed until June 2013. Median survival times to ART initiation from date of programme entry and from date of ART eligibility were estimated with Kaplan-Meier methods. Associated factors were evaluated in Cox regressions, censoring for deaths.
  
  
  RESULTS
  Of 37 749 adults (71.6% female), 17 638 (46.7%) initiated ART. Nearly half (46.9%) met the CD4 criteria for treatment eligibility at programme entry. Among the 20 039 individuals not yet ART-eligible at entry, only 62.5% were retained in care with at least one further CD4 measurement, of whom 6688 subsequently became ART-eligible. Overall, 65.5% of the 24 398 ART-eligible individuals initiated ART over the study period. ART initiation was more likely in women (P < 0.001), in individuals ≥ 25 years old (P < 0.001) and in patients with low CD4 count (P < 0.001). Patients who became eligible during follow up were significantly more likely to initiate ART than those eligible at programme entry (72.6% vs. 62.9%, Adjusted Hazard Ratio = 1.46; 95% Confidence Interval [1.41-1.51]), adjusting for sex, age, year and CD4 count at eligibility.
  
  
  CONCLUSIONS
  In this rural programme, continuation of care remains challenging, especially in men and younger adults. ART initiation is more likely in those engaged prior eligibility than in those entering HIV care only late in their HIV disease.
authors.affiliation: Centre de recherche Inserm U897 Epidémiologie et Biostatistique, Université Bordeaux, Bordeaux, France.|Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université Bordeaux, Bordeaux, France.
authors.forename: Mélanie
authors.initials: M
authors.lastname: Plazy
authors.affiliation: Epidemiology of Occupational and Social Determinants of Health-Center for Research in Epidemiology and Population Health, Villejuif, France.|Université Versailles Saint-Quentin en Yvelines, Villejuif, France.
authors.forename: Rosemary
authors.initials: R
authors.lastname: Dray-Spira
authors.affiliation: Centre de recherche Inserm U897 Epidémiologie et Biostatistique, Université Bordeaux, Bordeaux, France.|Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université Bordeaux, Bordeaux, France.
authors.forename: Joanna
authors.initials: J
authors.lastname: Orne-Gliemann
authors.affiliation: Centre de recherche Inserm U897 Epidémiologie et Biostatistique, Université Bordeaux, Bordeaux, France.|Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université Bordeaux, Bordeaux, France.
authors.forename: François
authors.initials: F
authors.lastname: Dabis
authors.affiliation: Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa.|Faculty of Medicine, University of Southampton, Southampton, UK.
authors.forename: Marie-Louise
authors.initials: ML
authors.lastname: Newell
keywords: 
  HIV
  ; 
  VIH
  ; Adultos; Afrique du Sud; Antirretrovirales /uso terapéutico; Continuidad de cuidados en el paciente; South Africa; Sudáfrica; adultes; adults; antiretroviral agents/therapeutic use; antirétroviraux; continuity of patient care; continuité des soins aux patients; rural health services; services de santé en milieu rural; servicios sanitarios rurales; usage thérapeutique