1. gesine.meyer-rath@lshtm.ac.uk Getting people to the pills: Transport costs, socio-economic status and reasons for defaulting from antiretroviral treatment in public sector clinics in South Africa Gesine Meyer-Rath HIVTools Working Group London School of Hygiene and Tropical Medicine, UK and Reproductive Health and HIV Research Unit University of the Witwatersrand, South Africa

2. gesine.meyer-rath@lshtm.ac.uk The sites Urban tertiary care hospital in Johannesburg with ~5000 pts. on ART (JGH) Semi-rural secondary care hospital in North West province with ~6500 pts. on ART (TWC) both started ART provision in April 2004

3. gesine.meyer-rath@lshtm.ac.uk Defaulting: The scope of the problem Defaulting at JGH

4. gesine.meyer-rath@lshtm.ac.uk Defaulting at TWC

5. gesine.meyer-rath@lshtm.ac.uk Defaulting timeframe on ART

6. gesine.meyer-rath@lshtm.ac.uk Defaulting timeframe before ART

7. gesine.meyer-rath@lshtm.ac.uk Systematic review: Retention in ART clinics in sub-Saharan Africa (Rosen 2007) 33 cohorts, 17,942 patients, 13 countries, 2000 to 2007 weighted mean follow-up period 9.9 months 78% of patients retained weighted mean retention rates were 79%, 75% and 62% at 6, 12, and 24 months, resp. after 24 months of follow-up, retention between 85% and 46% monthly weighted mean attrition rates of 3.3%/month, 1.9%/month, and 1.6%/month for studies reporting to 6, 12, and 24 months loss to follow-up and death accounted for 56% and 40% of attrition, resp.

8. gesine.meyer-rath@lshtm.ac.uk Methods Between 04/06 and 03/07 (JGH) and 01/07 and 03/07 (TWC) prospective enrollment of 600 eligible patients about to start ART Questionnaire-based interviews on socio-economic status and mode and cost of transport to ART clinic and any other HIV-related health care at enrollment, and 6 and 12 months after ART initiation Analysis with STATA for descriptive stats

9. gesine.meyer-rath@lshtm.ac.uk Results: Modes of transport at baseline ART clinic JGHART clinic TWC Other clinics JGHOther clinics TWC

10. gesine.meyer-rath@lshtm.ac.uk Results: Transport cost and time JGH: –mean transport cost R21.20 (US$ 3.42) –mean travel time 2.18 hrs TWC: –mean transport cost R16.82 (US$2.12) –mean travel time 1.64 hrs

11. gesine.meyer-rath@lshtm.ac.uk Transport cost distribution: Deciles

12. gesine.meyer-rath@lshtm.ac.uk Default rates at 12 months both clinics: mean default rate 19% TWC: –30% in same location* –17% in location 5 km away* –36% in location 10 km away* –40% in location 20 km away* * p<0.02

13. gesine.meyer-rath@lshtm.ac.uk Reasons for defaulting Part of prospective defaulter tracer activity at TWC: 57% lack of finances 31% went to work elsewhere 11% went to funerals elsewhere 1.3% denial, peer pressure, long queues at clinic

14. gesine.meyer-rath@lshtm.ac.uk Discussion Mean transport cost is lower in semi-rural setting, but likelihood of defaulting is dependent on distance travelled In this setting, 10% walk to clinic (mean walking time 1.5 hours) for lack of cash Lower socio-economic status: 87% in lowest socio-economic quintile in semi-rural site (as compared to 35% in urban setting)

15. gesine.meyer-rath@lshtm.ac.uk Conclusion Reduce number of required medication pick-up visits Introduce hospital-based transport schemes (buses, vouchers) Increase down-referral and ART initiation at primary health care level

16. gesine.meyer-rath@lshtm.ac.uk Thanks to JGH: Francois Venter Onica Khumalo Jeff Wings Kgomotso Thloaele Albertina Dambuza Belinda Dambuza LSHTM: Lilani Kumaranayake TWC: Ebrahim Variava Motlalepule Letsapa Clarina Pondo and all the patients who gave their time and information for this study