Initiation of HIV Therapy in KwaZulu-Natal , South Africa : Improving Outcomes of Care
Over 20% of the adult population in South Africa is infected with HIV, with rates among women presenting for antenatal care of over 26%. These statistics amount to between 5.3 and 5.6 million infected South Africans. KwaZulu-Natal (KZN), on South Africa 's northeast coast, is consistently the worst affected province, with an antenatal seroprevalence of over 37%. The severity of the HIV/AIDS epidemic has led the South African government to approve a plan for universal access to ART, and to make significant strides in establishing traditional voluntary counseling and testing (VCT) centers to identify infected people, including pregnant women and children, and facilitate their entry into care.
Patients who are determined to be ART-eligible still face numerous barriers to accessing care, however. While antiretroviral initiation in KZN requires a 3-week formal work-up process, many HIV-infected patients have still not initiated therapy 6-12 weeks after being diagnosed as eligible to receive ART. Even pregnant women who are given facilitated access may experience delays in starting treatment. The cause for this “waiting period” is unknown but likely multifactorial. As many as 50% of patients who are booked to start on the ART program do not arrive for their first appointment because they either die in the interim, are ambivalent about the benefits of ART and the toxicity of ART, decide to use traditional medication, access care at another site, lack money to return, or have social/disclosure problems. Identification of reasons for failure to access care after qualifying for an ART program would offer valuable information about how efforts may be targeted to decrease treatment barriers.
In this context, an experienced and multidisciplinary research team at Massachusetts General Hospital , Brigham and Women's Hospital and Harvard Medical School in Boston , MA and McCord Hospital and St. Mary's Hospital in Durban, South Africa, has developed a research study which combines a retrospective study examining delays in receiving ART and predictors of mortality in ART eligible patients with a population-based, observational cohort. This unique prospective cohort enrolls patients just prior to HIV testing, allowing for evaluation of the many point of attrition along the care path from HIV testing to effective therapy.
McCord Hospital has been treating patients with ART since 1999; St. Mary's Hospital since 2003. While both hospitals are located in the metropolitan Durban area, the largest city in KZN, McCord serves a more urban population while St. Mary's has a larger, rural catchment area. At present, McCord Hospital has started more than 1,000 patients on ART, and St. Mary's more than 400. Both hospitals have been awarded President's Emergency Plan for AIDS Relief (PEPFAR) funding to continue to scale up the numbers of patients on ART. Together these sites have more patients on treatment and more years of experience in treating patients on ART than any other sites in the KZN public sector. Combined data from these sites, both retrospectively and prospectively, will provide powerful insight on clinical outcomes associated with the antiretroviral therapy roll-out.
This research will inform a ntiretroviral therapy distribution strategies that will provide maximum benefit to HIV-infected individuals in KwaZulu-Natal , South Africa . Ultimately, these efforts will serve to inform South African policy makers and drive future research questions regarding the opportunities and challenges involved in the scaling up of HIV treatment in resource limited settings.
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