Factors associated with pre-ART loss-to-follow up in adults in rural KwaZulu-Natal, South Africa: a prospective cohort study.
Timely initiation of antiretroviral treatment (ART) requires sustained engagement in HIV care before treatment eligibility. We assessed loss to follow-up (LTFU) correlates in HIV-positive adults accessing HIV treatment and care, not yet ART-eligible (CD4 >500 cells/mm(3)).



This was a sub-study of a prospective cohort study (focusing on sexual behaviour) in an area of high HIV prevalence and widespread ART availability in rural KwaZulu-Natal, South Africa. Psychosocial, clinical and demographic data were collected at recruitment from individuals with CD4 >500 cells/mm(3). LTFU was defined as not attending clinic within 13 months of last visit or before death. Individuals starting ART were censored at ART initiation. Data were collected between January 2009 and January 2013. Analysis used Competing Risks regression.



Two hundred forty-seven individuals (212 females) were recruited (median follow-up 2.13 years, total follow-up 520.15 person-years). 86 remained in pre-ART care (34.8 %), 94 were LTFU (38.1 %), 58 initiated ART (23.5 %), 7 died (2.8 %), 2 transferred out (0.8 %). The LTFU rate was 18.07 per 100 person-years (95 % CI 14.76-21.12). LTFU before a competing event was 13.5 % at one and 34.4 % at three years. Lower LTFU rates were significantly associated with age (>37 versus ≤37 years: adjusted sub-Hazard ratio (aSHR) 0.51, 95 % CI 0.30-0.87), openness with family/friends (a little versus not at all, aSHR 0.81, 95 % CI 0.45-1.43; a lot versus not at all, aSHR 1.57, 95 % CI 0.94-2.62), children (0 versus 4+, aSHR 0.68, 95 % CI 0.24-1.87; 1 versus 4+, aSHR 2.05 95 % CI 1.14-3.69, 2 versus 4+; aSHR 1.71, 95 % CI 0.94-3.09; 3 versus 4a, aSHR 1.14, 95 % CI 0.57-2.30), previous CD4 counts (1 versus 0, aSHR 0.81, 95 % CI 0.45-1.43; 2+ versus 0, aSHR 0.43, 95 % CI 0.25-0.73), and most recent partner HIV status (not known versus HIV-positive, aSHR 0.77, 95 % CI 0.50-1.19; HIV-negative versus HIV-positive, aSHR 2.40, 95 % CI 1.18-4.88). The interaction between openness with family/friends and HIV partner disclosure was close to significance (p = 0.06). Those who had neither disclosed to partners nor were open with family/friends had lowest LTFU rates.



Strategies to retain younger people in pre-ART care are required. How openness with others, partner HIV status and disclosure, and children relate to LTFU needs further exploration.
Department of Psychology, Royal Holloway University of London, Egham Hill, Egham, Surrey, London, TW20 0EX, UK. michael.evangeli@rhul.ac.uk.
Michael
M
Evangeli
Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa.|Academic Unit of Health and Development, Faculty of Medicine, University of Southampton, Southampton, UK.
Marie-Louise
ML
Newell
Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa.|Academic Unit of Primary Care and Population Sciences and Department of Social Statistics and Demography, University of Southampton, Southampton, UK.
Nuala
N
McGrath
D000328:Adult; D018791:CD4 Lymphocyte Count; D003266:Continuity of Patient Care; D003695:Delivery of Health Care; D030881:Disclosure; D005190:Family; D005260:Female; D005500:Follow-Up Studies; D033062:Friends; D015658:HIV Infections / Q000188:drug therapy; D006268:Health Facilities; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012424:Rural Population; D012747:Sexual Partners; D012944:Social Support; D013019:South Africa; D055815:Young Adult
HIV; Loss-to-follow up; Pre-ART; Psychosocial; South Africa