How do you keep people living with HIV in care before they can get antiretroviral treatment? Cotrimoxazole helps.

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Free cotrimoxazole improves retention in care among adults not yet
eligible for ART
Carole Leach-Lemens
Published: 18 August 2011

Providing free cotrimoxazole prophylaxis to adults not yet eligible
for antiretroviral treatment in Nairobi, Kenya, improved retention in
care by over 20% after one year when compared with retention before
2006, Pamela K Kohler and colleagues reported in a study published in
the current edition of AIDS.

The retention rate improved significantly from 63% to 84% (p<0.001),
and was comparable to the retention rate of those on ART.

The study was carried out at the Coptic Hope Center, a comprehensive
HIV treatment facility,

Rapid scale-up of antiretroviral treatment services in resource-poor
settings has led to over 5 million people with access to ART. Free
provision of ART significantly increased enrolment and a corresponding
high level of retention and adherence has resulted in decreased
morbidity and mortality.

Starting treatment late is associated with early death and a poor
response to treatment. Those ineligible for ART are not offered
routine care. In contrast to the high retention rates among those on
ART those ineligible or pre ART have significantly lower retention
rates.

Between 2000 and 2007 mean retention rates in ART programmes in
sub-Saharan Africa were estimated to be 75%, In contrast a recent
meta-analysis of studies looking at retention of patients not yet
eligible for treatment found that more two-thirds of patients became
lost to follow-up. This means that many may not return for care until
they are already quite sick so missing the opportunity for a timely
start of ART.

In 2006 the World Health Organization (WHO) in 2006 recommended the
use of cotrimoxazole prophylaxis (CTXP) for all adults diagnosed with
HIV infection with CD4 cell counts below 500 cells/mm3, to protect
against bacterial infections and pneumocystis carinii pneumonia (PCP).

In late 2006 CTXP became routine in many HIV programmes following
revised Ministry of Health guidelines.

The authors of the new study believed that providing CTXP free might
improve retention so they chose to compare retention among
ART-ineligible clients in a treatment programme in Kenya before and
after provision of free CTXP.

The Coptic Hope Center provides basic HIV care and free ART to adults
and children. From September 2006 CTXP was provided free of charge to
all ART-ineligible clients according to national guidelines (CD4 cell
count above 250 cells/mm3 and WHO clinical stage 1 or 2). ART patients
returned to the clinic every 1-2 months for a medical or pharmacy
visit. Before free CTXP provision ART-ineligible patients were
scheduled to return every six months. After CTXP was introduced they
were asked to return every 1-2 months for a pharmacy visit.

To see whether clinic retention was affected by programme changes over
time, retention of ART clients before and after September 2006 was
also compared.

Among the 5175 clients with a baseline CD4 cell count enrolled at the
Hope Center from 2005 to 2007, 62% started ART in the first year of
care. Of the 1941 clients who did not start ART within the first year
53% (1024) were ineligible for ART.

Among ART-ineligible clients there were no significant differences in
age sex, TB status or body mass index before or after provision of
free CTXP.  Median baseline CD4 cell counts were similar before and
after, 412 cells/mm3 and 441 cells/mm3, respectively.

In multivariate analysis adjusted for age, sex and CD4 cell count,
ART-ineligible clients prior to the introduction of free CTXP were
more than twice as likely to be lost to follow-up compared to those
enrolled after free CTXP (AHR = 2.64, 95% CI: 1.95-3.57, p<0.001).

The authors note their findings are consistent with other studies.
Before free CTXP retention rates in those ART-ineligible are
considerably lower than those on ART. And, conversely other studies
have shown provision of free treatment improves retention in HIV care.

Cotrimoxazole is one of the most cost-effective interventions in HIV
treatment and is associated with improved individual and family health
benefits.

The authors note their findings “suggest that the cost of CTX is
likely to be outweighed by benefit, not only in terms of improved
prevention of infections, but also as an incentive to maintain
clinical monitoring that can ensure timely initiation of ART.”

Strengths of the study include adjusting for disease status, CD4 cell
count and a comparison group of ART clients in a parallel analysis
where retention remained unchanged.

Limitations include possible misclassifications of enrolment during,
before or after free CTXP periods.

Improved retention may have been a result of improved monitoring with
the provision of free CTXP.

The authors conclude “retention and CD4 monitoring of pre-ART clients
are essential to promptly identify ART eligibility and start
treatment. Implementation of free CTX may improve retention in
sub-Saharan Africa and through increasingly timely ART start provide
survival benefit.”

http://www.aidsmap.com/Free-cotrimoxazole-improves-retention-in-care-among-adults-not-yet-eligible-for-ART/page/2047903/