Lighthouse Trust operates two, public, integrated HIV clinics, Lighthouse (LH) and Martin Preuss Center (MPC), in Lilongwe, Malawi. Approximately 20% of patients eligible for antiretroviral therapy (ART) do not start ART. We explore individual and geographic factors that influence whether ART-eligible patients initiate ART.
Adult patients eligible for ART between 2008–2011 were included. Analysis was stratified by clinic. Using logistic regression, we evaluated factors associated with initiating ART including gender, age, body mass index (BMI), employment, tuberculosis (TB), eligible at initial registration, WHO stage, CD4, months in pre-ART care (from initial registration to eligibility date), and patient neighborhood distance to clinic.
Of 14,216 study patients, 4841 were from LH; 9285 were from MPC. At LH and MPC, respectively, median age was 34.2 and 33.8 years; median BMI was 22.0 and 20.6; and median distance was 5.6 and 4.9 Km. In multivariate models, odds of starting ART was highest among those older than 35 years and those eligible for ART based on WHO stages 3–4 vs. those in WHO stages 1–2 with CD4<250. Patients with 1–12 months in pre-ART were at least 11 times more likely to start ART than peers with less pre-ART time. At LH, living 2.5–5 Km from the clinic increased the likelihood of starting ART over patients living closer.
Citation: Feldacker C, Johnson D, Hosseinipour M, Phiri S, Tweya H (2012) Who Starts? Factors Associated with Starting Antiretroviral Therapy among Eligible Patients in Two, Public HIV Clinics in Lilongwe, Malawi. PLoS ONE 7(11): e50871. https://doi.org/10.1371/journal.pone.0050871
Editor: Sarah Pett, University of New South Wales, Australia
Received: June 14, 2012; Accepted: October 25, 2012; Published: November 30, 2012
Copyright: © 2012 Feldacker et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: Derek Johnson was funded by a Fogarty Fellowship of the National Institutes of Health and worked on this project in partial fulfillment of the requirements of the funding (http://www.fic.nih.gov/Programs/Pages/fulbright-fellowships.aspx). Funding for other authors was not associated with any grants. The development of this paper was supported by the University of Washington and I-TECH with funding from Cooperative Agreement U91HA06801 from the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA). The funders played no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
As access to life-sustaining antiretroviral therapy (ART) increases throughout much of sub-Saharan Africa, attention is needed to improve quality services throughout the continuum of HIV-related care, including the period before ART initiation. Previous studies from sub-Saharan Africa examine loss to follow up (LTFU) among HIV-infected patients who were not yet eligible to start ART , , ,  and factors that influence LTFU after ART initiation , , , , , . However, the period between ART eligibility and ART initiation, during pre-ART care, is a time of high vulnerability , . In sub-Saharan Africa, pre-ART program attrition or discontinuation of care for any reason including LTFU and death, ranges from 14%–84% , illustrating a sizeable gap in the continuum of ART services. Patients who are lost to attrition after becoming eligible may eventually enter care later and sicker , , , decreasing the overall effectiveness, and increasing the costs, of HIV treatment programs . Hence, greater understanding of the drivers of attrition during this critical stage would strengthen efforts to retain patients during this transition.
In Malawi, program attrition across the continuum of HIV-related care is of concern. By 2011, the Ministry of Health reported national ART program coverage at 67% , indicating both great progress in ART scale up as well as lingering weaknesses moving ART-eligible patients into life-long treatment. National adult HIV prevalence remains high at approximately 12%; the majority of HIV-infected persons seek HIV-related care at public clinics . Lighthouse Trust, the largest provider of HIV-related services including ART in Lilongwe, Malawi and a flagship public provider of HIV-related services , runs two high-burden, integrated ART clinics: Lighthouse clinic (LH) on the campus of Kamuzu Central Hospital and the Martin Preuss Center (MPC) on the campus of Bwaila Hospital. Although national-level pre-ART attrition is unknown, approximately 20% of eligible patients do not start ART at LH and MPC, likely indicative of a similarly sized gap in the continuum of care at other public clinics.
In this study we explore the individual and geographic factors that influence whether ART-eligible patients at LH and MPC initiate ART. Increasing knowledge of the drivers of, and impediments to, ART initiation among eligible patients will help inform programmatic and policy efforts to reduce attrition during this critical period of entry to ART care.
According to the Malawi National Health Science Research Committee (NHSRC) guidelines, retrospective reviews of existing programmatic data are exempt from formal consenting procedures. Lighthouse received approval from the NHSRC for this study in 2011 for analysis of routine programmatic data and publication of results from operations research.
The Lighthouse Trust partners with both the Malawi Ministry of Health (MoH) and the District Health Office (DHO) in Lilongwe to operate two integrated HIV clinics. Lighthouse (LH) Clinic opened in 2001. The Martin Preuss Center (MPC), located near the central bus station, opened in Dec 2006 as a purposeful TB/ART integration site . Combining patients at both clinics, the Lighthouse Trust is the largest public provider of free ART in the Central Region with over 22,000 patients in HIV-related care. From 2008 onwards, both LH and MPC used a real-time, touchscreen-based electronic data system (EDS) for patient management which improved clinic performance and reduced data errors . The EDS collects HIV testing details, residential location, demographics, and World Health Organization (WHO) stage at registration. The EDS also includes CD4 test results, opportunistic infections, reported side effects, and drug dispensing records. Pre-ART patient information is not stored longitudinally in the EDS; only registration, demographic, and most recent eligibility-relevant information is retained.
Although the MoH revised national ART guidelines in June, 2011 , Malawi’s 2008 National ART guidelines used at Lighthouse and all ART clinics defined ART eligibility for adults as meeting one of three criteria: 1) WHO stage 1 or 2 in combination with CD4 cell count of less than 250 cell/mm3; 2) WHO stage 3; or 3) WHO stage 4 . Pre-ART patients, HIV-infected individuals who have not started ART, are reviewed every 2 months to provide co-trimoxazole therapy (CPT) and to evaluate for any potential stage 3 or 4 defining conditions. Pre-ART patients should also undergo routine CD4 testing at 6-month intervals to monitor for ART eligibility; however, weaknesses in the laboratory system and problems with CD4 machines may delay or prevent CD4 testing or results provision. Also, patients who have an infection or condition indicative of a WHO 3 or WHO 4 condition, including TB, are immediately eligible for ART and may not have a CD4 test ordered or results recorded. Pre-ART patients may seek care between visits if they are sick.
Clinical procedures and hours of operation (Monday to Friday 7∶30am−4∶30pm, Saturday from 8am to 12pm) are identical at MPC and LH. At the first clinic visit and all subsequent pre-ART visits, patients are clinically staged and those with Stage 3 or 4 conditions are immediately informed of their ART eligibility by a clinician. Those who are stage 1 or 2 typically undergo CD4 testing to determine eligibility and are scheduled to return in 2 weeks for the result. Before an individual can begin ART, they are required to attend an ART education session with a guardian, usually a family member or friend. Eligible patients may start ART on the same day as the initial clinic visit or on the day of receiving their CD4 result if education and guardian requirements are met. Pregnant women are eligible for expedited start procedures  and were, therefore, excluded. Transfer patients were excluded due to incomplete data on eligibility criteria or pre-ART care prior to transfer.
Independent Variables and Covariate Definitions
Adult patients (>15 years) included in the study were informed of their eligibility for ART during a clinic visit between January 1, 2008–June 30, 2011. WHO stage 3 and 4 patients would be eligible and informed at a single visit; patients eligible by CD4 would require an additional visit before being informed. The binary outcome of interest was ART start or not as defined by the date of first ART drug dispensation. ART start dates were included through the study end date of September 30, 2011. Year of enrolment was categorized into 5 groups: 2007 or earlier; 2008; 2009; 2010; or from January 1 through June 30, 2011. Additional independent demographic variables included: sex; age at registration classified into 10 year age categories; body mass index (BMI) within 30 days of eligibility dichotomized as less than or equal to 18.5 or higher; and self-reported occupation classified as any current work vs. unemployment, including student or housewife status. Healthcare service related variables included ART eligibility at initial registration and diagnosis of TB at eligibility. Time in the pre-ART program was defined as months from initial clinic registration to the date a patient was informed of eligibility.
For location information, Euclidean distance in kilometers (Km) between LH or MPC clinic and patient village or Area locations was determined using Google Earth . Location information was available for 8447 MPC (91%) and 4138 LH (85%) patients.
Analysis was stratified by clinic, LH or MPC. Chi-square tests determined significant differences between eligible patients who started and those who did not, by clinic. Logistic regression models assessed factors associated with starting ART in univariate and multivariate models. T-tests determined significance of individual variables; alpha was set to 0.05. Age and gender were included in multivariate models a priori. Otherwise, significant factors at the p<0.05 level in univariate models were included in multivariate models. TB at eligibility, ART eligible at 1st visit, and CD4 cell count were not included in multivariate models because of their correlation with eligibility criteria. Analysis was conducted using STATA 11.0 .
At LH and MPC, respectively, 7 431 and 12 953 patients were presumed eligible for ART between January 1, 2008 and June 30th, 2011; 4 841 LH and 9 285 MPC patients were included in the study after removing pregnant women, transfers and other patients with incomplete or inaccurate records (Figure 1). At LH, 3 929 (81.2%) of 4 841 eligible patients started ART before September 30, 2011. Of 9 285 MPC patients, 7 212 (77.7%) started ART during the study period. Baseline characteristics of LH and MPC study patients were similar except MPC included a larger proportion with tuberculosis and patients eligible for ART at first visit (Table 1).
Table 2 describes differences in those who start ART and not, by clinic. At both clinics, those under 24 years of age, eligible for ART by CD4 criteria <250 cells, and without TB at baseline were less likely to begin ART. Patients who did not start ART as compared to those who started ART were more likely to be eligible at first visit (83.7% vs. 38.9% at LH and 92.1% vs. 53.3% at MPC) and have less than 1 month in the pre-ART period (85.2% vs 45.3% at LH and 93.8% vs. 57.2% at MPC). The proportion of eligible patients who initiated ART improved over time at MPC but decreased or remained stable at LH.
Univariate and multivariate models, stratified by clinic, are presented in Table 3 (columns 2, 3 for LH, columns 4, 5 for MPC). At both clinics, age plays a significant role. Patients ages 15–24 were less likely at LH (AOR 0.70; CI 0.53–0.93) and MPC (AOR 0.70; CI: 0. 0.59–0.84) to start ART while older patients, 35–45 years, were more likely to start at both LH (AOR 1.41; CI: 1.16–1.77) and MPC (AOR 1.22; CI: 1.06–1.40) than those ages 25–34 years. At both clinics, eligibility criteria were significantly associated with starting ART. Both LH patients in WHO stage 3 (AOR 5.14; CI: 4.12–6.36) or WHO stage 4 (AOR 4.99; CI: 3.82–6.51) and MPC patients in WHO stage 3 (AOR 14.1; CI: 11.9–16.6) or WHO stage 4 (AOR 11.9; CI: 973–14.8) were more likely to start than those eligible by CD4. At both clinics, time in pre-ART dramatically increased the odds of starting ART. Patients with 1–3 months in pre-ART were more than 28 (AOR 28.9; CI: 19.29–43.52) and 49 times (AOR 49.0; CI: 36.9–65.2) more likely at LH and MPC, respectively, to start ART than patients with less than one month in the pre-ART period. Patients with a year or more time in the pre-ART period at LH (AOR 12.69; CI: 7.15–23.0) and MPC (AOR 63.2; CI: 36.4–115.2) were also more likely to start ART than their peers with little pre-ART time. Distance was only included in the multivariate model at LH. LH patients who lived between 2.5–5 km (AOR 1.54; CI 1.12–2.16) were more likely to start ART than patients who lived closer.
Overall, 18.8% of LH and 22.4% of MPC patients informed of their ART eligibility still failed to start ART, similar to recent studies from Northern  and Southern  Malawi. Among demographic factors, the odds of starting ART were lowest among patients ages 15–24 and highest among patients older than 35 years. TB co-infection at eligibility, a WHO stage 3 condition, increased the likelihood of starting ART at both clinics. In multivariate models, patients eligible for ART based on WHO stage 3 or 4 were much more likely to start than patients with WHO stages 1–2 combined with CD4 criteria at both clinics. Increasing months in pre-ART dramatically increased a patient’s likelihood of ART initiation: patients with 1–12 months in the pre-ART period were at least 11 times more likely to start ART than their peers with less than a month in pre-ART. Lastly, distance from clinic LH increased the likelihood of starting ART at LH for some patients, but distance was not a significant influence at MPC. Previous research helps illuminate the findings.
First, we found pre-ART care, the time between ART registration and determination of ART eligibility, is the most significant predictor of starting ART among eligible patients. Patients who were immediately eligible at initial registration had lower odds of starting ART at both LH and MPC. However, patients who spent between 1–3 months in the pre-ART period were more than 28 times at LH and 49 times at MPC more likely to start ART, an effect that decreased slightly, but remained highly significant, even after more than 12 months in that transitional time. The larger effect of time in pre-ART at MPC over LH may be due to the location of MPC near a large hospital and transit center. Although MPC may see more patients due to easier access to services, more of those patients may be mobile and less prepared to start treatment thus increasing the effect of additional pre-ART time. We acknowledge that some eligible patients may have started ART elsewhere , , , died before they could initiate ART , , , , , or simply not wanted to start ART . However, our finding that pre-ART time increases the likelihood of ART initiation is consistent with regional findings on the individual- and service-level factors that influence patient retention during this period. Studies from Uganda  and Malawi  suggest that ART uptake is influenced by patient acceptance of their HIV-positive status, disclosure, and preparation for ART initiation. Among healthcare factors, patients from a South African clinic who returned for one or more routine, pre-ART visits had multiple exposures to care providers who appeared to increase patient motivation and refute prevalent myths about ART, ultimately reducing delays in ART initiation . A study from Kenya found that provision of other pre-ART services, including bi-annual CD4 testing and free prophylaxis therapy, reduced pre-ART attrition .
Second, as other studies from the region  and Malawi  note, healthier patients may not perceive the need to start ART. Both at LH and at MPC, patients who were younger, had higher BMI, or eligibility based on CD4, possibly reflecting better health, were less likely to start ART than those who were older, with lower BMI or eligible by WHO stages 3 or 4. Among younger and healthier patients, perceptions of health and wellness may combine with lack of preparation to start lifelong ART, adding additional barriers to ART initiation. Also, in contrast to studies that found increased barriers to ART initiation among TB co-infected patients , , including in our own clinic , we found that TB co-infection at eligibility increased the odds of starting ART. Although both LH and MPC provide TB treatment, a stronger, positive effect of TB co-infection at eligibility on ART initiation was evident at MPC, a purposefully integrated clinic that also serves as a national TB diagnosis, treatment, and follow-up facility. Possibly, sicker patients with easy access to comprehensive TB/ART care may be more likely to initiate ART, suggesting an additional benefit of service integration.
Furthermore, although socio-economic factors likely contribute to attrition among pre-ART patients, the two socio-economic variables available in our routine data, distance and employment status, were less influential than anticipated. Previous research from public clinics in the region noted transportation costs as a barrier to returning for subsequent visits , , , , , , . However, findings from this study suggest that employment and distance to clinic were not significant deterrents to ART initiation. Several factors may make our clinic cohorts different. First, LH was the first public clinic providing ART and serves as a center of excellence for the region; patients who started there may continue to seek care there despite transportation costs or distances. At MPC, distance may play a lesser role because of its heightened accessibly next to the bus station in the central business district. Moreover, lingering stigma, perceived or experienced, may still motivate patients to seek care far from their neighborhoods and nearby clinics. Lastly, it is possible that patients who took initiative or had resources to seek care from more distant places were also those more driven to continue care and initiate treatment.
These findings should be considered within the following limitations. First, patients who were eligible earlier in the study period had more time to start ART; some patients who became eligible closer to July 1, 2011 may have started ART after the study censure date of September 30, 2011. However, almost 70% of LH and MPC patients start ART within 2 weeks of eligibility, with median days between eligibility and ART start of 19 days and 21 days at LH and MPC, respectively, reducing the effect of this potential bias. Second, this study used only routine service statistics; other social, economic, or structural data was not available. Third, pre-ART data over multiple visits is not stored. Therefore, the number and type of visits between initial registration and eligibility cannot be determined, decreasing our ability to determine what service factors and visit frequency may be influential during that period. Fourth, patients who left pre-ART care before they were informed of their eligibility, a factor more likely to affect those who needed to return for at least one additional visit to receive CD4 results, were not included. Program attrition among patients who drop out of care earlier, including those not informed of their eligibility, merits further attention. Lastly, several groups of patients were excluded from this analysis (Table 1), including children, pregnant women, and those with incomplete data such as transfer-in patients, decreasing the sample size and reducing generalizability to other populations or clinics. Analysis of eligible patients who were excluded compared to those included [not shown] indicated that excluded patients at both LH and MPC were significantly different in sex, age, eligibility criteria, time in pre-ART, and starting ART; therefore, caution must be used in generalizing these results especially to transfer patients who comprise 68% and 54% of excluded patients at LH and MPC, respectively. Despite these limitations, LH and MPC are large, well-established, urban providers of public services, and information on the drivers and deterrents of program attrition among identified, ART- eligible patients is likely representative of similar groups of eligible, urban patients in Malawi.
The findings suggest several steps to reduce program attrition during this period at both Lighthouse clinics and in Malawi. First, as those with more time between registration and eligibility appear more likely to start. Therefore, testing and referral process that encourage early entry into pre-ART care coupled with improved counseling on both ART preparedness and transiting to lifelong treatment may decrease attrition. Second, pre-ART counseling guidelines should be revisited to resonate with those who are eligible by CD4 and younger patients, many of whom may not feel sick. Third, those eligible by CD4 appear less likely to start due, in part, because they have to return to be informed of eligibility. Implementation of point of care CD4 testing as tested in neighboring countries may prove beneficial to reduce ART initiation delays , . Lastly, although LH and MPC have a successful client follow-up program for patients on ART , this program should be extended to include pre-ART patients in this clinic setting and throughout Malawi, where possible. Adoption of one or more of these recommendations may help reduce systematic weaknesses in the continuum of HIV-related services, move more eligible patients swiftly onto ART, and improve patient health and outcomes over time.
- 1. Tayler-Smith K, Zachariah R, Massaquoi M, Manzi M, Pasulani O, et al. (2010) Unacceptable attrition among WHO stages 1 and 2 patients in a hospital-based setting in rural Malawi: can we retain such patients within the general health system? Transactions of the Royal Society of Tropical Medicine and Hygiene 104: 313–319.
- 2. Larson BA, Brennan A, McNamara L, Long L, Rosen S, et al. (2010) Early loss to follow up after enrolment in pre-ART care at a large public clinic in Johannesburg, South Africa. Tropical Medicine & International Health 15: 43–47.
- 3. Lessells RJ, Mutevedzi PC, Cooke GS, Newell ML (2011) Retention in HIV care for individuals not yet eligible for antiretroviral therapy: rural KwaZulu-Natal, South Africa. Journal of acquired immune deficiency syndromes (1999) 56: e79.
- 4. Kranzer K, Zeinecker J, Ginsberg P, Orrell C, Kalawe NN, et al. (2010) Linkage to HIV care and antiretroviral therapy in Cape Town, South Africa. PLoS One 5: e13801.
- 5. Fox MP, Rosen S (2010) Patient retention in antiretroviral therapy programs up to three years on treatment in sub-Saharan Africa, 2007–2009: systematic review. Tropical Medicine & International Health 15: 1–15.
- 6. Geng EH, Bangsberg DR, Musinguzi N, Emenyonu N, Bwana MB, et al. (2010) Understanding reasons for and outcomes of patients lost to follow-up in antiretroviral therapy programs in Africa through a sampling-based approach. JAIDS Journal of Acquired Immune Deficiency Syndromes 53: 405.
- 7. Brinkhof MWG, Dabis F, Myer L, Bangsberg DR, Boulle A, et al. (2008) Early loss of HIV-infected patients on potent antiretroviral therapy programmes in lower-income countries. Bulletin of the World Health Organization 86: 559–567.
- 8. Harries AD, Zachariah R, Lawn SD, Rosen S (2010) Strategies to improve patient retention on antiretroviral therapy in sub-Saharan Africa. Tropical Medicine & International Health 15: 70–75.
- 9. Brinkhof MWG, Pujades-Rodriguez M, Egger M (2009) Mortality of patients lost to follow-up in antiretroviral treatment programmes in resource-limited settings: systematic review and meta-analysis. PLoS One 4: e5790.
- 10. Rosen S, Fox MP, Gill CJ (2007) Patient Retention in Antiretroviral Therapy Programs in Sub-Saharan Africa: A Systematic Review. PLoS Medicine 4: e298.
- 11. Zachariah R, Tayler-Smith K, Manzi M, Massaquoi M, Mwagomba B, et al. (2011) Retention and attrition during the preparation phase and after start of antiretroviral treatment in Thyolo, Malawi, and Kibera, Kenya: implications for programmes? Transactions of the Royal Society of Tropical Medicine and Hygiene. Aug 105(8): 421–30.
- 12. Scott V, Zweigenthal V, Jennings K (2011) Between HIV diagnosis and initiation of antiretroviral therapy: assessing the effectiveness of care for people living with HIV in the public primary care service in Cape Town, South Africa. Tropical Medicine & International Health 16: 1384–1391.
- 13. Rosen S, Fox MP (2011) Retention in HIV Care between Testing and Treatment in Sub-Saharan Africa: A Systematic Review. Plos Medicine 8: 16.
- 14. Kitahata MM, Gange SJ, Abraham AG, Merriman B, Saag MS, et al. (2009) Effect of early versus deferred antiretroviral therapy for HIV on survival. New England Journal of Medicine 360: 1815–1826.
- 15. Keiser O, Anastos K, Schechter M, Balestre E, Myer L, et al. (2008) Antiretroviral therapy in resource-limited settings 1996 to 2006: patient characteristics, treatment regimens and monitoring in sub-Saharan Africa, Asia and Latin America. Tropical Medicine and International Health 13 (7): 870–9.
- 16. Lawn SD, Harries AD, Anglaret X, Myer L, Wood R (2008) Early mortality among adults accessing antiretroviral treatment programmes in sub-Saharan Africa. Aids 22: 1897–1908.
- 17. Government of Malawi Ministry of Health (2011) Quarterly HIV Progranmme Report,. Lilongwe, Malawi: HIV/AIDS Unit, Department of Clinical Services.
- 18. World Health Organization (2004) Perspectives and Practice in Antiretroviral Treatment: The Lighthouse, A centre for comprehensive HIV/AIDS treatment and care in Malawi. A case study. Case Study. Geneva: World Health Organization.
- 19. Phiri S, Khan PY, Grant AD, Gareta D, Tweya H, et al.. (2011) Integrated tuberculosis and HIV care in a resource limited setting: experience from the Martin Preuss centre, Malawi. Tropical Medicine & International Health 16 1397–1403.
- 20. Douglas GP, Gadabu OJ, Joukes S, Mumba S, McKay MV, et al. (2010) Using touchscreen electronic medical record systems to support and monitor national scale-up of antiretroviral therapy in Malawi. PLoS Medicine 7: e1000319.
- 21. Ministry of Health and National AIDS Commission, editor (2011) Malawi Integrated Guidelines for Clinical Management of HIV, 2011, First Edition. 3rd ed. Lilongwe: Government of Malawi.
- 22. Ministry of Health Malawi (2008) Treatment of AIDS: Guidelines for the use of antiretroviral therapy in Malawi.
- 23. Weigel R, Hosseinipour MC, Feldacker C, Gareta D, Tweya H, et al.. (2012) Ensuring HIV-infected pregnant women start antiretroviral treatment: an operational cohort study from Lilongwe, Malawi. Tropical Medicine & International Health: DOI: 10.1111/j.1365–3156.2012.02980.x.
- 24. Google Inc. (2011) Google Earth [Software]. Mountain View, CA., USA: Google Inc.
- 25. STATA (2010) 11.0. Stata Statistical Software: Release 12. College Station, TX: StataCorp LP.
- 26. McGrath N, Glynn JR, Saul J, Kranzer K, Jahn A, et al. (2010) What happens to ART-eligible patients who do not start ART? Dropout between screening and ART initiation: a cohort study in Karonga, Malawi. BMC Public Health 10: 601.
- 27. Lahuerta M, Lima J, Elul B, Okamura M, Alvim MF, et al. (2011) Patients Enrolled in HIV Care in Mozambique: Baseline Characteristics and Follow-Up Outcomes. Jaids-Journal of Acquired Immune Deficiency Syndromes 58: E75–E86.
- 28. Geng E, Nash D, Kambugu A, Zhang Y, Braitstein P, et al. (2010) Retention in care among HIV-infected patients in resource-limited settings: emerging insights and new directions. Current HIV/AIDS Reports 7: 234–244.
- 29. Yu JKL, Chen SCC, Wang KY, Chang CS, Makombe SD, et al. (2007) True outcomes for patients on antiretroviral therapy who are “lost to follow-up” in Malawi. Bulletin of the World Health Organization 85: 550–554.
- 30. Bassett IV, Wang B, Chetty S, Mazibuko M, Bearnot B, et al. (2009) Loss to care and death before antiretroviral therapy in Durban, South Africa. Journal of Acquired Immune Deficiency Syndromes (1999) 51: 135.
- 31. Katz IT, Essien T, Marinda ET, Gray GE, Bangsberg DR, et al. (2011) Antiretroviral therapy refusal among newly diagnosed HIV-infected adults. AIDS 25: 2177–2181.
- 32. Amuron B, Namara G, Birungi J, Nabiryo C, Levin J, et al. (2009) Mortality and loss-to-follow-up during the pre-treatment period in an antiretroviral therapy programme under normal health service conditions in Uganda. BMC Public Health 9: 290.
- 33. McGuire M, Munyenyembe T, Szumilin E, Heinzelmann A, Le Paih M, et al. (2010) Vital status of pre-ART and ART patients defaulting from care in rural Malawi. Tropical Medicine & International Health 15: 55–62.
- 34. Jarvis JN, Meintjes G, Wood R, Harrison TS (2010) Testing but not treating: missed opportunities and lost lives in the South African ART programme. AIDS (London, England) 24 (8): 1233–1235.
- 35. Kohler PK, Chung MH, McGrath CJ, Benki-Nugent SF, Thiga JW, et al. (2011) Implementation of free cotrimoxazole prophylaxis improves clinic retention among antiretroviral therapy-ineligible clients in Kenya. AIDS 25: 1657.
- 36. Pepper DJ, Marais S, Wilkinson RJ, Bhaijee F, De Azevedo V, et al. (2011) Barriers to Initiation of Antiretrovirals during Antituberculosis Therapy in Africa. PLoS One 6 (5): e19484.
- 37. Phiri S, Khan PY, Grant AD, Gareta D, Tweya H, et al. (2011) Integrated tuberculosis and HIV care in a resource-limited setting: experience from the Martin Preuss centre, Malawi. Tropical Medicine & International Health 16: 1397–1403.
- 38. Zachariah R, Harries K, Moses M, Manzi M, Line A, et al. (2009) Very early mortality in patients starting antiretroviral treatment at primary health centres in rural Malawi. Tropical Medicine & International Health 14: 713–721.
- 39. Maskew M, MacPhail P, Menezez C, Rubel D (2007) Lost to follow up - contributing factors and challenges in South African patients on antiretroviral therapy. South African Medical Journal 97 (9): 853–7.
- 40. Losina E, Bassett IV, Giddy J, Chetty S, Regan S, et al. (2010) The “ART” of Linkage: Pre-Treatment Loss to Care after HIV Diagnosis at Two PEPFAR Sites in Durban, South Africa. PLoS One 5 (3): e9538.
- 41. Jani IV, Sitoe NE, Alfai ER, Chongo PL, Quevedo JI, et al. (2011) Effect of point-of-care CD4 cell count tests on retention of patients and rates of antiretroviral therapy initiation in primary health clinics: an observational cohort study. The Lancet 378(9802): 1572–9.
- 42. Faal M, Naidoo N, Glencross DK, Venter WDF, Osih R (2011) Providing Immediate CD4 Count Results at HIV Testing Improves ART Initiation. Jaids-Journal of Acquired Immune Deficiency Syndromes 58: E54–E59.
- 43. Tweya H, Gareta D, Chagwera F, Ben-Smith A, Mwenyemasi J, et al. (2010) Early active follow-up of patients on antiretroviral therapy (ART) who are lost to follow-up: the ‘Back-to-Care’ project in Lilongwe, Malawi. Tropical Medicine & International Health 15: 82–89.