Attrition from HIV testing to antiretroviral therapy initiation among patients newly diagnosed with HIV in Haiti.

OBJECTIVE: We report rates and risk factors for attrition in the first cohort of patients followed through all stages from HIV testing to antiretroviral therapy (ART) initiation. DESIGN: Cohort study of all patients diagnosed with HIV between January and June 2009. METHODS: We calculated the proportion of patients who completed CD4 cell counts and initiated ART or remained in pre-ART care during 2 years of follow-up and assessed predictors of attrition. RESULTS: Of 1427 patients newly diagnosed with HIV, 680 (48%) either initiated ART or were retained in pre-ART care for the subsequent 2 years. One thousand eighty-three patients (76%) received a CD4 cell count, and 973 (90%) returned for result; 297 (31%) had CD4 cell count <200 cells per microliter, and of these, 256 (86%) initiated ART. Among 429 patients with CD4 >350 cells per microliter, 215 (50%) started ART or were retained in pre-ART care. Active tuberculosis was associated with not only lower odds of attrition before CD4 cell count [odds ratio (OR): 0.08; 95% confidence interval (CI): 0.03 to 0.25] but also higher odds of attrition before ART initiation (OR: 2.46; 95% CI: 1.29 to 4.71). Lower annual income (≤US $125) was associated with higher odds of attrition before CD4 cell count (OR: 1.65; 95% CI: 1.25 to 2.19) and before ART initiation among those with CD4 cell count >350 cells per microliter (OR: 1.74; 95% CI: 1.20 to 2.52). After tracking patients through a national database, the retention rate increased to only 57%. CONCLUSIONS: Fewer than half of patients newly diagnosed with HIV initiate ART or remain in pre-ART care for 2 years in a clinic providing comprehensive services. Additional efforts to improve retention in pre-ART are critically needed.

Early versus standard antiretroviral therapy for HIV-infected adults in Haiti.

BACKGROUND: For adults with human immunodeficiency virus (HIV) infection who have CD4+ T-cell counts that are greater than 200 and less than 350 per cubic millimeter and who live in areas with limited resources, the optimal time to initiate antiretroviral therapy remains uncertain. METHODS: We conducted a randomized, open-label trial of early initiation of antiretroviral therapy, as compared with the standard timing for initiation of therapy, among HIV-infected adults in Haiti who had a confirmed CD4+ T-cell count that was greater than 200 and less than 350 per cubic millimeter at baseline and no history of an acquired immunodeficiency syndrome (AIDS) illness. The primary study end point was survival. The early-treatment group began taking zidovudine, lamivudine, and efavirenz therapy within 2 weeks after enrollment. The standard-treatment group started the same regimen of antiretroviral therapy when their CD4+ T-cell count fell to 200 per cubic millimeter or less or when clinical AIDS developed. Participants in both groups underwent monthly follow-up assessments and received isoniazid and trimethoprim-sulfamethoxazole prophylaxis with nutritional support. RESULTS: Between 2005 and 2008, a total of 816 participants--408 per group--were enrolled and were followed for a median of 21 months. The CD4+ T-cell count at enrollment was approximately 280 per cubic millimeter in both groups. There were 23 deaths in the standard-treatment group, as compared with 6 in the early-treatment group (hazard ratio with standard treatment, 4.0; 95% confidence interval [CI], 1.6 to 9.8; P=0.001). There were 36 incident cases of tuberculosis in the standard-treatment group, as compared with 18 in the early-treatment group (hazard ratio, 2.0; 95% CI, 1.2 to 3.6; P=0.01). CONCLUSIONS: Early initiation of antiretroviral therapy decreased the rates of death and incident tuberculosis. Access to antiretroviral therapy should be expanded to include all HIV-infected adults who have CD4+ T-cell counts of less than 350 per cubic millimeter, including those who live in areas with limited resources. (ClinicalTrials.gov number, NCT00120510.)