title: Barriers to Care and 1-Year Mortality Among Newly Diagnosed HIV-Infected People in Durban, South Africa.
abstract: Prompt entry into HIV care is often hindered by personal and structural barriers. Our objective was to evaluate the impact of self-perceived barriers to health care on 1-year mortality among newly diagnosed HIV-infected individuals in Durban, South Africa.
  
  
  
  Before HIV testing at 4 outpatient sites, adults (≥18 years) were surveyed regarding perceived barriers to care including (1) service delivery, (2) financial, (3) personal health perception, (4) logistical, and (5) structural. We assessed deaths via phone calls and the South African National Population Register. We used multivariable Cox proportional hazards models to determine the association between number of perceived barriers and death within 1 year.
  
  
  
  One thousand eight hundred ninety-nine HIV-infected participants enrolled. Median age was 33 years (interquartile range: 27-41 years), 49% were females, and median CD4 count was 192/μL (interquartile range: 72-346/μL). One thousand fifty-seven participants (56%) reported no, 370 (20%) reported 1-3, and 460 (24%) reported >3 barriers to care. By 1 year, 250 [13%, 95% confidence interval (CI): 12% to 15%] participants died. Adjusting for age, sex, education, baseline CD4 count, distance to clinic, and tuberculosis status, participants with 1-3 barriers (adjusted hazard ratio: 1.49, 95% CI: 1.06 to 2.08) and >3 barriers (adjusted hazard ratio: 1.81, 95% CI: 1.35 to 2.43) had higher 1-year mortality risk compared with those without barriers.
  
  
  
  HIV-infected individuals in South Africa who reported perceived barriers to medical care at diagnosis were more likely to die within 1 year. Targeted structural interventions, such as extended clinic hours, travel vouchers, and streamlined clinic operations, may improve linkage to care and antiretroviral therapy initiation for these people.
authors.affiliation: *Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA; †Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA; ‡Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA; §Harvard Medical School, Boston, MA; ‖Harvard University Center for AIDS Research, Harvard University, Boston, MA; ¶Data Coordinating Center, Boston University School of Public Health, Boston, MA; #McCord Hospital, Durban, South Africa; **Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA; ††RAND Corporation, Santa Monica, CA; ‡‡St. Mary's Hospital, Durban, South Africa; §§Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA; ‖‖Department of Epidemiology, Boston University School of Public Health, Boston, MA; ¶¶Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA; ##Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA; and ***Department of Biostatistics, Boston University School of Public Health, Boston, MA.
authors.forename: Ingrid V
authors.initials: IV
authors.lastname: Bassett
authors.forename: Sharon M
authors.initials: SM
authors.lastname: Coleman
authors.forename: Janet
authors.initials: J
authors.lastname: Giddy
authors.forename: Laura M
authors.initials: LM
authors.lastname: Bogart
authors.forename: Christine E
authors.initials: CE
authors.lastname: Chaisson
authors.forename: Douglas
authors.initials: D
authors.lastname: Ross
authors.forename: Moses J E
authors.initials: MJ
authors.lastname: Flash
authors.forename: Tessa
authors.initials: T
authors.lastname: Govender
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D060085:Coinfection / Q000401:mortality*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000401:mortality*; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D010349:Patient Compliance; D016032:Randomized Controlled Trials as Topic; D012944:Social Support; D013019:South Africa / Q000453:epidemiology; D014376:Tuberculosis / Q000188:drug therapy / Q000401:mortality*
chemical_list: D019380:Anti-HIV Agents