Page 282 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 8 of 10 Original Research

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2003 to 2011. Reasons for the disparity are likely to include delivery of CPT to clients with low baseline CD4 counts
reluctance of men to seek HIV care because of attitudinal and/or advanced clinical disease are warranted.
barriers, HIV stigma, perceptions of masculinity and cultural
practices, 45,46 as well as the scale-up of prevention of mother- The urban and rural districts analysed in this study had
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to-child transmission (PMTCT) services, which have comparable findings in terms of overall trends in population
increasingly engaged women in care. This study found that a CD4 counts, the proportion of clients initiating ART with
3
higher proportion of pregnant women aged 15–50 years had CD4 < 200 cells/mm in 2017 and characteristics of clients
baseline CD4 counts ≥ 200 cells/mm compared to women with low baseline CD4 counts. However, mortality was
3
who were not pregnant during ART initiation, suggesting markedly higher in rural Mopani than in Johannesburg.
that PMTCT services play a role in linking women to timely This highlights the inferior quality of care in the rural
HIV treatment. This is supported by findings of an association district, likely because of poor access to doctors as has
between PMTCT services and higher cohort median CD4 been previously described in rural settings, as well as the
count, as well as reduced risk of ART initiation with advanced deficit in specialist medical care in rural provinces of
disease. 41,42,48 In addition, late presentation for ART initiation South Africa. 55,56,57 In addition, characteristics of rural
was found to be linked with older age in this study. Mixed settings, such as lower levels of formal education, are also
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findings regarding the association between age and late known to be associated with higher mortality. While urban
presentation for care have been reported in the literature, settings need to be aware of the rate of programme
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with one study finding no significant association, others expansion owing to the increased risk of attrition associated
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finding a decreased risk of late presentation for HIV care in with rapid expansion of ART services, efforts in rural
older clients 41,42 and yet others demonstrating an increased settings need to focus on quality of care, perhaps by
risk of initiating ART with low CD4 in older clients. 25,40 The employing mobile units that are staffed by doctors or by
finding of this study that older age is linked to late providing training for primary healthcare staff.
presentation for care is supported by a recent study of South
Africans aged over 50 years who reported seeking HIV This study demonstrated the rich source of data available in
testing only once they were symptomatic and referred by a TIER.Net. The analysis was performed using data spanning
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provider or if a partner was diagnosed as infected. over a decade during which there were substantial guideline
changes in the ART programme, producing a robust and
Furthermore, older men in sub-Saharan Africa have been realistic analysis. On the other hand, this study has a number
found to be less aware of and knowledgeable about HIV
prevention compared to younger men, with increased risk of limitations. Firstly, TIER.Net was introduced in South Africa
in 2010, necessitating the back-capture of data from the ART
behaviours in some settings. Educational initiatives and programme prior to this time. There may have been challenges
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HIV testing strategies that focus on men and the older with the quality of the back-captured data, which may have
population are thus required.
led to an underestimation of the absolute numbers of clients on
ART, including those who died, although we believe that the
An additional intervention to improve outcomes of the HIV proportions are representative. Secondly, not all clients in
programme is delivery of CPT to high-risk clients presenting TIER.Net could be included in the analysis because of missing
for HIV care with low baseline CD4 counts, as recommended baseline CD4 counts. Thirdly, the study was not designed to
by the WHO. It has been well established that CPT follow up clients who were LTFU from the ART programme
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significantly reduces mortality in clients with low baseline and it is therefore unclear how many of these clients died. The
CD4 counts, 52,53 and it is therefore concerning that delivery of Kaplan–Meier analyses may therefore underestimate mortality.
this intervention appears to be declining over time, possibly Finally, although these data are representative of urban and
reflecting competing demands on healthcare providers as the rural areas in South Africa, they should be generalised to other
ART programme expands. Interestingly, a consistently higher settings with caution, particularly because only two districts
proportion of clients with WHO stage III or IV disease were included in the analysis.
received CPT compared to clients presenting with WHO
stage I or II disease, indicating that healthcare providers are Conclusion
more likely to give CPT to clients who appear ill. This is
concerning, as clients with immunosuppression who require In conclusion, this study of routine programme data
CPT may not present with advanced disease, as seen in this demonstrates rapid expansion of South Africa’s adult ART
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and other studies, and delivery of CPT may therefore be programme since 2004. Although median CD4 count has
missed in these clients. This is likely exacerbated in the era of increased over time, this population measure is masking a
UTT, as baseline CD4 counts which would alert healthcare high-risk group of clients who present late for HIV care with
providers to the need for CPT are not required at the time of low baseline CD4 counts. Despite improvements in mortality
ART initiation; delivery of CPT therefore relies on the over time, these clients are still at risk of increased mortality,
healthcare provider later checking the CD4 results and particularly in rural settings. Therefore, targeted interventions
subsequently initiating CPT if required, increasing the chance are urgently warranted to improve early engagement in care
that CPT may be overlooked. Interventions to increase and clinical management, with a specific focus on men, older
awareness of the importance of baseline CD4 testing and clients and those presenting at hospitals. Ongoing monitoring

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