Sydney Rosen from the Center for Global Health and Development at Boston University provided a thoughtful overview of the evidence and the key issues relevant to linkage to and continuity in care for HIV infected persons during the pre-antiretroviral therapy (ART) period. She presented Wednesday at the 18th Conference on Retroviruses and Opportunistic Infections (CROI) in Boston.
Rosen noted that little progress has been made in earlier treatment initiation in sub-Saharan Africa, with most reported median CD4 counts remaining well below 200.
There is not much evidence about loss to patients dropping out of care at some point during the process, but what is available is very concerning, Rosen said. In reviewing reports of the percentage of patients tested who return for test results, the median was 55 percent. Reports about the percentage of patients who presented for at least one clinic appointment after diagnosis, the median is 46 percent. In general, about half of those who enroll in care stay in care until ART is initiated.
Rosen suggested that we need to make it less expensive and less daunting to obtain care, and consider increasing benefits or providing more or better services, or improving patients’ understanding of the benefits of remaining in care. One obvious strategy is to provide multiple services at the same site, to provide CD4 counts at point of care, and to use incentives including conditional cash transfers to improve retention.
Several participants responded to the presentation by noting that it is important to look at system bottlenecks and not simply to focus on patients. It was also pointed out that providing prevention services during this period could reduce transmission and increase retention in care.