1. Successfully enrolled in HIV Care but not linked to timely Treatment: Poor retention and Monitoring of Pre-ART patients who are not yet eligible for ART C. Sialubanje, S. Miyano, V. Chipeta, E. Ngalande, B. Ntentabunga, N Ishikawa, I Sikazwe, C. Moyo, G. Syakantu Kalomo District Medical Office, Zambia MOH-JICA SHIMA Project National Center for Global Health and Medicine, Japan (NCGM)

2. Background Scaling up of antiretroviral therapy(ART) services in Zambia - Hospital started providing free ART services in 2005 -Services have been scaled up to primary health facility level since 2007 Continuum of quality HIV care including testing, Pre-ART and ART is required for all PLHIV Retention in Pre- ART has received less attention than retention in ART care

3. Objectives To determine retention in Pre-ART for those patients who are not yet eligible for ART To explore the factors associated with lost to follow up in Pre-ART care

4. Methodology Study area: Kalomo District, Southern Province, 360km south of Lusaka Population: 250 808 HFs: 2 hospitals, 33 RHCs

5. Methodology Study type: Retrospective Cohort Research population: All adult HIV positive clients enrolled in Pre-ART care at Kalomo district Hospital between April 2009 and March 2010. Children and transfer in, excluded Data collection: Through national registers and client files Statistical analysis —Kaplan-Meier method to analyze retention in Pre-ART —Cox’s proportional hazard analysis to identify risk factors

6. Results

7. HIV (+) 875 clients VCT 416 PMTCT 90 TB 155 OPD/IPD 214 HIV care 656 clients * (75.0%) Pre-ART 145 clients (23.3%) ART 511 clients (76.7%) * Paediatric clients and clients transferred in were excluded No access to HIV care 219 clients (25.0%) HIV test 3138 clients VCT 1645 PMTCT 558 TB 253 OPD/IPD 682 Results: Patient flow Quality Care for the Community SHIMA Operational Research: Continuum of HIV Care

8. Baseline Characteristics (N=145) n (%) Age_ median32.0 (IQR: 26.0-41.0) GenderFemale Male 111 (76.6) 34 (23.4) EducationNone Primary (Grade 1-7) Basic ~ (Grade 8-) 13 (9.2) 69 (48.9) 59 (41.9) Income per month< 10USD 10-49 50-99 100< 29 (20.4) 54(38.0) 53 (37.3) 6 (4.3) Marital statusNever Married Married Divorced Widowed 19 (13.7) 89 (64.0) 19 (13.7) 12 (8.6)

9. Baseline Characteristics (N=145) n (%) Distance to the hospital (km)< 9 10-19 20- 61 (42.1) 13 (9.0) 71 (48.9) Disclose their HIV statusYes No 136 (97.8) 3 (2.2) Partner’s HIV statusPositive Negative Unknown 48 (47.1) 13 (12.7) 41 (40.2) WHO Clinical StageStage I Stage II 106 (73.1) 39 (26.9) CD4 cell count (cells/μl)Median 350-499 500-699 700- 522.0 (IQR: 417.5-661.0) 66 (45.5) 51 (35.2) 28 (19.3)

10. 3 months: 71.3% 12 months: 51.0 % 24 months: 39.9 % Overall Retention in Pre-ART Care

11. Factors associated with lost to follow up in Pre-ART Care VariableCrude HR (95% C.I.) Adjusted HR (95% C.I.) Age15-29 30< 2.14 (1.37-3.33)* 1 1.98 (1.27-3.01)* 1 GenderFemale Male 1 1.16 (0.70-1.90) Marital StatusNever married Married Divorced Widowed 1 0.71 (0.39-1.26) 0.40 (0.16-0.98)* 0.55 (0.20-1.50) EducationNone Primary (Grade1-7) Basic (Grade 8-9) Secondary (Grade 10-12) College/University 1 0.73 (0.35-1.54) 0.80 (0.36-1.78) 0.90 (0.39-2.01) 0.99 (0.22-4.62) Monthly Income< 10 USD 10-19 20-39 40-99 100- 1 0.65 (0.34-1.23) 0.67 (0.28-1.60) 0.74 (0.41-1.33) 1.70 (0.63-4.58)

12. Factors associated with lost to follow up in Pre-ART Care Variable Crude HR (95% C.I.) Adjusted HR (95% C.I.) Distance to the hospital (km)<20 20- 1.83 (1.17-2.88)* 1 1.66 (1.05-2.62)* 1 Partner’s HIV statusPositive Negative Unknown 1.90 (1.10-3.26)* 1.18 (0.47-2.92) 1 WHO Clinical StageStage I Stage II 1.62 (0.93-2.80) 1 CD4 cell count (cells/μl)350-499 cells/μl 500-699 700- 1 1.12 (0.67-1.86) 1.63 (0.94-2.82)

13. Discussion Only half of the clients enrolled in Pre-ART care were retained at 12 months Drastic decline in retention at 3 months Age and distance were found to be significantly associated with poor retention – Younger clients and clients living close to the hospital LTFU in Pre-ART: Public health concern – Asymptomatic, but more infectious than those on ART – Missed opportunity to get timely treatment might affect outcomes

14. Conclusion This study has demonstrated poor retention in Pre- ART care Strengthening of the continuum of care between Pre-ART and ART services is urgently required Activities such as client education as well as client tracing should be reinforced More innovative strategies such as early initiation of ART need to be considered

15. Thank you !!