Risk factors, barriers and facilitators for linkage and retention in pre-ART care

1. Risk factors, barriers and facilitators for linkage and retention in pre-ART care Darshini Govindasamy Health Economics and Epidemiology Research Office, SA Katharina Kranzer London School of Hygiene and Tropical Medicine, UK

2. HIV continuum of care Not in care Not in care HIV testing Pre-ART care ART care HIV infection eligible ART initiation Continuous lifelong ART • Assessment for ART eligibility: • Clinical staging • CD4 count HIV test Retention in pre-ART care until eligible not yet eligible Kranzer et al 2012

3. HIV continuum of care Not in care Not in care HIV testing Pre-ART care ART care HIV infection eligible ART initiation Continuous lifelong ART • Assessment for ART eligibility: • Clinical staging • CD4 count HIV test Retention in pre-ART care until eligible not yet eligible Kranzer et al 2012

4. Systematic review • Search limited to sub-Saharan Africa studies published before May 2011 • Total number of studies: 42 • Semi-qualitative studies:19 • Quantitative 17 • Qualitative 6

5. Barriers to retention in pre-ART care • Medical • TB treatment • Health systems • Long waiting times • Shortage of HCWs • Economic • Transport cost • Distance • Food shortage • Unable to take time of work • Psychosocial • Stigma • Fear of disclosure • Fear of drug toxicities • Perceived good health Govindasamy, Ford, Kranzer 2012

6. Predictors of attrition • Economic • Transport cost • Distance • Health systems • Shortage of HCWs • Medical • TB treatment • Pregnancy • Advanced immunodeficiency • Severe malnutrition • Other • Male sex • Younger age • Lower levels of education Govindasamy, Ford, Kranzer 2012

7. Predictors of attrition • Economic • Transport cost • Distance • Health systems • Shortage of HCWs • Medical • TB treatment • Pregnancy • Advanced immunodeficiency • Severe malnutrition • Other • Male sex • Younger age • Lower levels of education Govindasamy, Ford, Kranzer 2012

8. Men • Lower test uptake • Lower ART coverage • More advanced immunodeficiency at diagnosis and ART initiation • Higher mortality • Lower adherence • Higher risk of loss to follow-up on ART Johnson 2013, Cornell 2012, Druyts 2013, Peltzer 2009, Kranzer 2013, Johnson 2012, Muula 2009, Remien 2009

9. How to address gender inequality • Men do not become pregnant • Men are less health seeking • Health care staff are predominantly women • Health care services are targeted at women and children Health care services AIMED at men or "men friendly" health care services

10. Areas for interventions Govindasamy, Ford, Kranzer 2012

11. Systematic review of interventions to improve linkage to and retention in pre-ART care N=11129 potentially eligible citations identified through: Search strategy on electronic databases (n=11 048) Keyword search on electronic conference abstract databases (n=45) References obtained from experts (n=36) N=67 of full text articles assessed for eligibility (54 published articles + 1 unpublished article from experts + 10 conference abstracts + 2 conference abstracts from experts) 24 studies retained for analysis (19 published articles + 1 unpublished article from experts + 2 conference abstracts + 2 conference abstracts from experts) Govindasamy, Kranzer 2013

12. Intervention studies - design and populations • Before after studies: n=11 • Observational studies with control group(s): n=6 • Individuals randomized controlled trials: n=4 • Cluster randomized controlled trials: n=3 • Adults: n=11 • Children: n=1 • Adolescents: n=1 • Pregnant women: n=8 • Inpatients: n=1 • TB patients: n=1 • IVDU: n=1 Govindasamy, Kranzer 2013

13. Intervention studies - design and populations • Before after studies: N=11 • Observational studies with control group(s): n=6 • Individuals randomized controlled trials: n=4 • Cluster randomized controlled trials: n=3 • Adults: n=11 • Children: n=1 • Adolescents: n=1 • Pregnant women: n=8 • Inpatients: n=1 • TB patients: n=1 • IVDU: n=1 Few studies with rigorous design Govindasamy, Kranzer 2013

14. Intervention studies - design and populations • Before after studies: N=11 • Observational studies with control group(s): n=6 • Individuals randomized controlled trials: n=4 • Cluster randomized controlled trials: n=3 • Adults: n=11 • Children: n=1 • Adolescents: n=1 • Pregnant women: n=8 • Inpatients: n=1 • TB patients: n=1 • IVDU: n=1 Few studies with rigorous design Few studies in special risk groups Govindasamy, Kranzer 2013

15. Pregnant women

16. Interventions and outcomes in special groups

17. Interventions and outcomes in adults

18. Interventions addressing the barriers • Psychosocial • Stigma • Fear of disclosure • Fear of drug toxicities • Perceived good health • Health systems • Long waiting times • Shortage of HCWs • Economic • Transport cost • Distance • Food shortage • Unable to take time of work • Medical • TB treatment

19. Interventions addressing the barriers • Psychosocial • Stigma • Fear of disclosure • Fear of drug toxicities • Perceived good health • Health systems • Long waiting times • Shortage of HCWs • Economic • Transport cost • Distance • Food shortage • Unable to take time of work • Medical • TB treatment

20. Thank you!