Reduced loss to ART initiation among patients initiating cotrimoxazole prophylaxis therapy in Johannesburg, South Africa

Abstract

Background: Loss of patients eligible for ART prior to initiation is a major challenge for HIV care throughout sub-Saharan Africa, yet few effective interventions have been identified to mitigate the problem. Cotrimoxazole prophylaxis therapy has been shown to reduce HIV-related opportunistic infections and mortality on antiretroviral therapy, and limited research suggests it may be associated with improved patient retention. We investigated the effect of cotrimoxazole on ART initiation within the first year following initial CD4 staging at a primary healthcare clinic in Johannesburg, South Africa. Methods: South African HIV management guidelines recommend cotrimoxazole for patients with a CD4 ≤200 or WHO stages II/III/IV. We investigated rates of remaining alive, in care and initiating ART one year after CD4 staging by cotrimoxazole status among non-pregnant, newly-diagnosed HIV-positive, cotrimoxazole-eligible adults with a first CD4 test January 1-December 31, 2010, a CD4 staging visit 1 week-2 months later, and an initial CD4 value ≤200 cells/mm3. Patients were considered to have initiated cotrimoxazole if the drug was started within two months of CD4 staging. Results: 76.5% (491/642) of eligible patients initiated cotrimoxazole. Baseline demographic characteristics were similar among groups (Table 1). 96.5% (474/491) of those initiating cotrimoxazole later started ART, while 91.4% (138/151) of those who did not initiate cotrimoxazole failed to initiate ART (p< 0.0001). Of those who did not initiate ART, 76.8% (119/155) were lost to follow-up (no return ≥3 months after the last scheduled visit) within one year and 17.4% (27/155) were confirmed dead. Conclusions: Our results support prior findings that cotrimoxazole may improve retention and likelihood of initiating ART among eligible patients. In our study, we found far a far higher proportion of ART initiation among patients who first initiated cotrimoxazole prophylaxis therapy. These findings suggest cotrimoxazole may be an inexpensive and effective intervention to reduce loss to initiation among HIV-positive patients.

Conference: AIDS 2012, Washington DC, USA