South Africa has experienced a number of changes in its threshold for ART eligibility, from an initial CD4+ threshold of ≤200 cells/μl to all people infected with HIV from September 2016. The authors were interested in the association of these programmatic changes in ART eligibility with loss from care, both prior to ART initiation and within the first 16 weeks of starting treatment, during a period of programmatic expansion to ART treatment at CD4+ ≤350 cells/μl. They performed a retrospective cohort study of 4025 treatment-eligible, non-pregnant patients accessing care in a community health centre. Median age was 34 years, 62% were female and the median CD4+ count was 173 cells/μl. Patients were stratified into two cohorts: an early cohort (enrolled into care from 2009 to 2011 when ART initiation required CD4 count ≤200 cells/μl, pregnancy, advanced clinical symptoms or comorbidity) and a later cohort (enrolled 2011 to 2013 when the treatment threshold was CD4 count ≤350 cells/μl). The authors found that compared with patients in the later cohort, patients in the earlier cohort had significantly more advanced disease: median CD4 cell count 146 cells/μl vs. 214 cells/μl, 61.1% WHO stage 3/4 disease vs. 42.8%, and pre-ART mortality of 34.2% vs. 16.7%. In total, 385 ART-eligible patients (9.6%) failed to initiate ART, of whom 25.7% died before ever starting treatment. Of the 3640 people who started treatment, 1.6% died within the first 16 weeks in care and an additional 17.7% were lost to care within 16 weeks of starting ART. Patients who started treatment in the later cohort were significantly more likely to discontinue care in <16 weeks (19.8% vs. 15.8%). After controlling for baseline CD4 count, WHO stage and age, this effect remained significant (adjusted odds ratio [aOR] 1.30, 95%CI 1.09–1.55). It was not clear if this early attrition was due to a “healthy cohort” effect or to overcrowding as programs expanded to accommodate the new treatment guidelines. Therefore over one-quarter of this ART-eligible cohort did not achieve the long-term benefits of treatment due to early mortality, ART non-initiation or early ART discontinuation.
Read more here