Research in Mozambique has found that the introduction of rapid point-of-care CD4 testing* almost halved the number of patients who dropped out before starting antiretroviral therapy (ART), and nearly doubled the number beginning treatment. The findings, published Online First in The Lancet, also showed that patients began HIV treatment faster, suggesting that point-of-care tests have the potential to improve survival chances as well as increase access to treatment.
"Point-of-care CD4 testing enabled clinics to stage patients more rapidly on-site after enrolment**, which reduced opportunities for pre-treatment loss to follow-up. As a result, more patients were identified as eligible for and initiated antiretroviral treatment", explains Ilesh Jani from Instituto Nacional de Sáude, Maputo, Mozambique, a lead author on the study.
In low-income settings, loss to follow-up of HIV-positive patients is a major obstacle to the scale up of ART. Up to 45% of patients who begin antiretroviral therapy (ART) dropout during their first year of treatment, and as many as 80% of patients fail to return between their HIV diagnosis and starting treatment. Most losses happen between HIV diagnosis and initial CD4 count staging (to determine eligibility for treatment). But until now, few interventions to improve patient retention have been investigated.
In this study, the researchers investigated the effect of rapid point-of-care CD4 tests on loss to follow-up of HIV patients before starting ART from four primary health clinics in Mozambique. Loss to follow-up and time taken for patients to complete each stage before starting treatment were measured and compared before and after the launch of point-of-care CD4 testing.
After the introduction of point-of-care CD4 tests there was a significant reduction in the number of patients lost to follow-up. Total losses between enrolment and beginning treatment fell from 64% to 33%, and the proportion of patients who started ART increased from 12% to 22%.
Point-of-care CD4 testing also more than halved the median time from enrolment to beginning treatment (from 48 days to 20 days), mainly because of a reduction in the time taken to complete CD4 staging, which decreased from 1 month to 3 days.
The authors point out that in line with the revised (2010) WHO guidelines that recommend treatment earlier during disease progression: "Reduction of loss to follow-up with point-of-care CD4 might also help increase the likelihood that patients start treatment at higher CD4 cell counts, thereby reducing one of the largest causes of HIV-related mortality."
They conclude: "These results suggest that point-of-care CD4 tests should be more widely implemented as an important method to both increase access to treatment and improve the efficiency of ART delivery…[they] have the potential to bring substantial benefit to health systems in resource-limited settings.
Dr Ilesh Jani, Instituto Nacional de Sáude, Maputo, Mozambique.
T) +25 8827 453 820 E) ilesh.jani@gmail.com
Notes to editors:
*CD4 testing is a marker of immune function that, when it drops below a certain level, indicates that it is time to initiate ART.
**HIV-positive patients enrol in clinics and are monitored regularly to ensure that ART is started as soon as they become eligible for treatment.
Journal
The Lancet