title: Access to CD4 Testing for Rural HIV Patients: Findings from a Cohort Study in Zimbabwe.
abstract: BACKGROUND
  CD4 cell count measurement remains an important diagnostic tool for HIV care in developing countries. Insufficient laboratory capacity in rural Sub-Saharan Africa is frequently mentioned but data on the impact at an individual patient level are lacking. Urban-rural discrepancies in CD4 testing have not been quantified to date. Such evidence is crucial for public health planning and to justify new yet more expensive diagnostic procedures that could circumvent access constraints in rural areas.
  
  
  OBJECTIVE
  To compare CD4 testing among rural and urban HIV patients during the first year of treatment.
  
  
  METHODS
  Records from 2,145 HIV positive adult patients from a Médecins sans Frontières (Doctors without Borders) HIV project in Beitbridge, Zimbabwe, during 2011 and 2012 were used for a retrospective cohort analysis. Covariate-adjusted risk ratios were calculated to estimate the effects of area of residence on CD4 testing at treatment initiation, six and 12 months among rural and urban patients.
  
  
  RESULTS
  While the proportion of HIV patients returning for medical consultations at six and 12 months decreased at a similar rate in both patient groups, CD4 testing during consultations dropped to 21% and 8% for urban, and 2% and 1% for rural patients at six and 12 months, respectively. Risk ratios for missing CD4 testing were 0.8 (95% CI 0.7-0.9), 9.2 (95% CI 5.5-15.3), and 7.6 (95% 3.7-17.1) comparing rural versus urban patients at treatment initiation, six and 12 months, respectively.
  
  
  CONCLUSIONS
  CD4 testing was low overall, and particularly poor in rural patients. Difficulties with specimen transportation were probably a major factor underlying this difference and requires new diagnostic approaches. Our findings point to severe health system constraints in providing CD4 testing overall that need to be addressed if effective monitoring of HIV patients is to be achieved, whether by alternative CD4 diagnostics or newly-recommended routine viral load testing.
authors.affiliation: Operational Centre Barcelona, Médecins sans Frontières/Doctors without Borders, Barcelona, Spain.
authors.forename: Florian
authors.initials: F
authors.lastname: Vogt
authors.affiliation: Operational Research Unit Luxembourg, Médecins sans Frontières/Doctors without Borders, Luxembourg, Luxembourg.
authors.forename: Katie
authors.initials: K
authors.lastname: Tayler-Smith
authors.affiliation: Operational Centre Barcelona, Médecins sans Frontières/Doctors without Borders, Barcelona, Spain; Department of Field Epidemiology and Training, Epicentre, Paris, France.
authors.forename: Andrea
authors.initials: A
authors.lastname: Bernasconi
authors.affiliation: Laboratory Department, Beitbridge District Hospital, Ministry of Health and Child Welfare, Beitbridge, Zimbabwe.
authors.forename: Eliphas
authors.initials: E
authors.lastname: Makondo
authors.affiliation: Zimbabwe Mission, Médecins sans Frontières/Doctors without Borders, Harare, Zimbabwe.
authors.forename: Fabian
authors.initials: F
authors.lastname: Taziwa
authors.affiliation: Beitbridge Project, Médecins sans Frontières/Doctors without Borders, Beitbridge, Zimbabwe.
authors.forename: Buhlebenkosi
authors.initials: B
authors.lastname: Moyo
authors.affiliation: Beitbridge Project, Médecins sans Frontières/Doctors without Borders, Beitbridge, Zimbabwe.
authors.forename: Liberty
authors.initials: L
authors.lastname: Havazvidi
authors.affiliation: Centre for Operational Research, South-East Asia Regional Office, International Union against Tuberculosis and Lung Disease, New Delhi, India.
authors.forename: Srinath
authors.initials: S
authors.lastname: Satyanarayana
authors.affiliation: Operational Research Unit Luxembourg, Médecins sans Frontières/Doctors without Borders, Luxembourg, Luxembourg.
authors.forename: Marcel
authors.initials: M
authors.lastname: Manzi
authors.affiliation: Operational Research Unit Luxembourg, Médecins sans Frontières/Doctors without Borders, Luxembourg, Luxembourg.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Khogali
authors.affiliation: Operational Research Unit Luxembourg, Médecins sans Frontières/Doctors without Borders, Luxembourg, Luxembourg.
authors.forename: Anthony
authors.initials: A
authors.lastname: Reid
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000276:immunology*; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D012424:Rural Population / Q000706:statistics & numerical data*; D055815:Young Adult; D015030:Zimbabwe
chemical_list: D019380:Anti-HIV Agents