Diversity of patient preparation activities before initiation of antiretroviral therapy in Cape Town,South Africa

Objective  To investigate patient education and counseling activities prior to the initiation of antiretroviral therapy (ART) at public sector services across Cape Town, South Africa. Methods  Key informant interviews and programme reviews were conducted with government bodies and non‐governmental organisations involved in patient preparation activities. Results  All 11 organisations in Cape Town involved in training and managing personnel to prepare patients for ART during 2010 participated. Each organisation reported a different approach to patient preparation within public sector clinics and in each aspect of patient preparation activities. The number of patient education sessions ranged from 3 to 7, and the delays to ART initiation introduced by patient preparation ranged from 3 to 6 weeks. Different patient education materials (pamphlets, posters and flipcharts) were used by various programmes, and all programmes reported that shortages in materials meant that patient preparation often took place without any educational materials. Each programme also reported attention to mental illness and alcohol/substance use disorders, but none employed formal screening tools consistently, and the handling of patients with potential mental health‐ or substance‐related problems varied. Conclusion  Approaches to prepare patients before ART initiation are wide ranging in one part of South Africa. Their relative value requires investigation, as there is little evidence for the impact of varying approaches. Moreover, the risks associated with delayed ART initiation may outweigh any benefits of patient education before the start of treatment.     

Using vital registration data to update mortality among patients lost to follow‐up from ART programmes: evidence from the Themba Lethu Clinic,South Africa

Objective To estimate the rates of mortality in patients lost to follow‐up (LTFU) from a large urban public sector HIV clinic in South Africa. Methods We compared vital status using the clinic’s database to vital status verified against the Vital Registration system at the South African Department of Home Affairs. We compared rates of mortality before and after updating mortality data. Predictors of mortality were estimated using Kaplan–Meier curves and proportional hazard regression. Results Of the 7097 total patients who initiated highly active antiretroviral therapy at Themba Lethu Clinic by October 1st, 2008 and had an ID number, 6205 were included. 2453 patients (21%) were LTFU, of whom 1037 (42.3%) could be included in the analysis. After matching to the vital registration system, mortality more than doubled from 4.2% (258/6205) to 10.9% (676/6205). Overall 37% of those LTFU died by life‐table analysis the probability of survival amongst those LTFU was 69% (95% CI: 66–72%), 64% (95% CI: 61–67%) and 59% (95% CI: 55–62%) by years 1, 2 and 3 since being lost, respectively. Those at highest risk of death after being lost were patients with a history of tuberculosis, CD4 count < 100 cells/μl, BMI < 17.5, haemoglobin < 10 and on <6 months of treatment. Conclusion Mortality was substantially underestimated among patients lost from a South African HIV treatment programme despite limited active tracing. Linking to vital registration systems can provide more accurate assessments of programme effectiveness and target lost patients most at risk for mortality.