Includes bibliographical references / Over the past decade, antiretroviral therapy (ART) programmes have rapidly expanded in resource-limited settings. Access to ART has been accelerated through a public health approach to reduce morbidity and mortality, thereby transforming HIV from a humanitarian crisis to a chronic disease. However, the benefits of ART to patients and communities are dependent on patients being retained in care. This thesis investigates loss to follow-up (LTFU) after ART initiation, in the context of scale-up and limited resources and evaluates models of ART delivery to improve retention. After a brief introduction that offers orientation to the key issues and concepts in the field, Chapter 2 provides a comprehensive literature review discussing the public health concerns related to LTFU in ART programmes, as well as the methodological concerns encountered in studying LTFU. Six results chapters (Chapters 3-8) are presented using complementary cohort data from two collaborative datasets (one from programmes in resource-limited settings and one including only South African cohorts) and from a single ART programme at a community health centre. How to define LTFU is the focus of Chapter 3, demonstrating that definitions can have an appreciable impact on estimates of LTFU. In Chapter 4, temporal factors related to the expansion of ART programmes are investigated, with evidence that the risk of patient LTFU increases with each successive calendar year of ART initiation, and that the rate of programme expansion has a stronger association with the risk of LTFU than absolute programme size. Analyses in Chapter 5 suggest that patients initiating ART at higher CD4 cell counts, above 300 cells/μl, may have an increased risk of LTFU compared to patients initiating ART with lower CD4 cell counts. Taken together, these findings underscore the notion that LTFU is a burgeoning threat to the long-term successes of ART programmes in South Africa and other resource-limited settings. Chapters 6-8 report on the implementation and outcomes from innovative models of ART delivery for stable ART patients. Patient outcomes from (i) a nurse-managed ART service and then (ii) community-based 'Adherence Clubs' highlight that comparable and, in some cases, favourable patient outcomes may be achieved when ART delivery is decentralised. This thesis concludes that LTFU is a significant challenge faced by ART programmes. In the context of ambitious targets and evidence of the potential benefits of ART for individuals and communities, concurrent changes to the health system are necessary to support retention in care. The successes of ART programmes in treating a chronic condition in resource-limited settings can be built upon by expanding community-based ART provision and potentially integrating management of other adulthood illnesses.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:uct/oai:localhost:11427/14578 |
| Date | January 2015 |
| Creators | Grimsrud, Anna Thora |
| Contributors | Myer, Landon |
| Publisher | University of Cape Town, Faculty of Health Sciences, Department of Public Health and Family Medicine |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Doctoral Thesis, Doctoral, PhD |
| Format | application/pdf |
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