Disaggregating programmatic outcomes by documentation of citizenship in South Africa

Abstract 

Background: In many resource-limited settings, people in rural areas often migrate to urban hubs in search of w ork. As such, public-sector HIV clinics in urban areas of South Africa often include local residents and patients from outside of the province or other African countries. This analysis compares programmic outcomes by documentation of citizenship status in the urban resouce-limited setting. Methods: We included all adult ART-naïve patients who initiated treatment from April 2004-May 2012 at a public-sector HIV clinic in Johannesburg. Patients w ere follow ed from ART initiation until death, transfer, lost to follow -up (LTF; ≥3 months late for a scheduled visit), or completion of 12 months of follow -up. We describe attrition as mortality and LTF using proportions stratified by possession of a SA national ID number, as an indicator of SA citizenship. An ID number also allow s linkage w ith the National Vital Registration System to improve mortality ascertainment. We modeled the risk of attrition using a log-binomial model. Results: Of the 18237 patients w ho initiated ART betw een April 2004-May 2012, 66.2% had an ID, 61.2% w ere female, median (IQR) age w as 36.8 (31.4-43.4), and median (IQR) baseline CD4 count w as 100 (37-174) cells/mm3. Baseline clinical characteristics w ere similar across ID groups. Patients were followed for a median (range) of 12 (0.03-12) months each. After 1 year of follow -up, 13.6% of patients w ith an ID had either died or left care compared to 31.1% of patients w ithout an ID. Patients w ith an ID w ere slightly more likely to have died (9.1%) than patients w ithout an ID (6.6%), likely due to better ascertainment of mortality among patients w ith an ID. How ever, patients w ithout an ID w ere far more likely to be LTF (24.4%) compared to patients w ith an ID (4.6%),resulting in an overall increased risk of attrition (aRR:1.83; 95% CI:1.69-1.97). Conclusions: Patients w ithout an ID were more likely to drop out of care w ithin 12 months of ART initiation than patients with an ID. Further research is needed to determine whether such patients self-transfer to another HIV clinic for further care as such high rates of attrition pose challenges for the success of potential test-and-treat programs

Conference: International AIDS conference 2014, Melbourne, Australia