Risk factors barriers and facilitators for linkage and retention in pre art care
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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. HIV continuum of care. Not in care. Not in care. HIV

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Risk factors barriers and facilitators for linkage and retention in pre art care

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


Hiv continuum of care
HIV continuum of care retention in

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


Hiv continuum of care1
HIV continuum of care retention in

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


Systematic review
Systematic review retention in

  • Search limited to sub-Saharan Africa studies published before May 2011

  • Total number of studies: 42

    • Semi-qualitative studies:19

    • Quantitative 17

    • Qualitative 6


Barriers to retention in pre art care
Barriers to retention in pre-ART care retention in

  • 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


Predictors of attrition
Predictors of attrition retention in

  • 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


Predictors of attrition1
Predictors of attrition retention in

  • 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


Men retention in

  • 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


How to address gender inequality
How to address gender inequality retention in

  • 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


Areas for interventions
Areas for interventions retention in

Govindasamy, Ford, Kranzer 2012


Systematic review of interventions to improve linkage to and retention in pre art care
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


Intervention studies design and populations
Intervention studies - design and populations retention in pre-ART care

  • 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


Intervention studies design and populations1
Intervention studies - design and populations retention in pre-ART care

  • 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


Intervention studies design and populations2
Intervention studies - design and populations retention in pre-ART care

  • 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


Pregnant women
Pregnant women retention in pre-ART care



Interventions and outcomes in adults
Interventions and outcomes in adults retention in pre-ART care


Interventions addressing the barriers
Interventions addressing the barriers retention in pre-ART care

  • 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


Interventions addressing the barriers1
Interventions addressing the barriers retention in pre-ART care

  • 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


Thank you

Thank you! retention in pre-ART care


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