Patient Enrolment into HIV Care and Treatment within 90 Days of HIV Diagnosis in Eight Rwandan Health Facilities: A Review of Facility-Based Registers

INTRODUCTION: Access to antiretroviral therapy (ART) has increased greatly in sub-Saharan Africa. However many patients do not enrol timely into HIV care and treatment after HIV diagnosis. We studied enrolment into care and treatment and determinants of non-enrolment in Rwanda. METHODS: Data were obtained from routine clinic registers from eight health facilities in Rwanda on patients who were diagnosed with HIV at the antenatal care, voluntary counselling-and-testing, outpatient or tuberculosis departments between March and May 2009. The proportion of patients enrolled into HIV care and treatment was calculated as the number of HIV infected patients registered in ART clinics for follow-up care and treatment within 90 days of HIV diagnosis divided by the total number of persons diagnosed with HIV in the study period. RESULTS: Out of 482 patients diagnosed with HIV in the study period, 339 (70%) were females, and the median age was 29 years (interquartile range [IQR] 24-37). 201 (42%) enrolled into care and treatment within 90 days of HIV diagnosis. The median time between testing and enrolment was six days (IQR 2-14). Enrolment in care and treatment was not significantly associated with age, sex, or department of testing, but was associated with study site. None of those enrolled were in WHO stage 4. The median CD4 cell count among adult patients was 387 cells/mm(3) (IQR: 242-533 cells/mm(3)); 81 of 170 adult patients (48%) were eligible to start ART (CD4 count<350 cells/mm(3) or WHO stage 4). Among those eligible, 45 (56%) started treatment within 90 days of HIV diagnosis. CONCLUSION: Less than 50% of diagnosed HIV patients from eight Rwandan health facilities had enrolled into care and treatment within 90 days of diagnosis. Improving linkage to care and treatment after HIV diagnosis is needed to harness the full potential of ART

Routine flow of patients after HIV diagnosis, Rwanda, 2009.

<p>Routine flow of patients after HIV diagnosis, Rwanda, 2009.</p

Enrolment into HIV care & treatment, WHO stage, median CD4 count, ART-eligibility and start of ART by study site, department, age and sex, Rwanda, 2009.

<p>N.A. Not Applicable; TB Tuberculosis; ANC Antenatal care; HIV Human immunodefiency virus; OPD Outpatient department; VCT Voluntary counselling and testing; ART antiretroviral treatment; IQR interquartile range; WHO World Health Organization.</p>a<p>WHO stage was available for 179. Data provided are for the 176 patients aged 15 years or above.</p>b<p>Patients with pulmonary TB and HIV infection are by definition in WHO stage 3; however not all patients diagnosed at TB clinics were confirmed TB cases.</p>c<p>CD4 count results were available for 188/201. Data provided are on the 185 patients aged 15 years or above.</p>d<p>ART eligibility was based on CD4 count (CD4<350 cells/mm³) and WHO stage (stage 4). Data provided are on the 170 patients aged 15 years or above.</p>e<p>Among those who were eligible for ART. Data provided are on the 81 patients aged 15 years or above.</p>f<p>The <i>p</i>-values are based on chi-squared test, Fisher's exact test or Kruskal-Wallis test, as appropriate.</p

Figure 3

<p><b>a</b>. Time to enrolment among 482 HIV patients. <b>b</b>. Time to start of ART among 81 eligible HIV patients, from date of HIV diagnosis. <b>c</b>. Time to start of ART among 81 eligible HIV patients, from date of CD4 test.</p

Number of newly diagnosed HIV infected patients, by department, sex, age and study site, Rwanda, March-May 2009.

<p>NA = Not Applicable; TB Tuberculosis; ANC Antenatal care; HIV Human immunodefiency virus; OPD Outpatient department; VCT Voluntary counselling and testing.</p

Factors associated with non-enrolment, high WHO stage and CD4 count <350 cells/mm³ among adult HIV patients diagnosed in eight Rwanda health facilities, 2009: logistic regression.

<p>Those aged <15 years were excluded from these analyses. NA = Not Applicable; TB Tuberculosis; ANC Antenatal care; HIV Human immunodefiency virus; OPD Outpatient department; VCT Voluntary counselling and testing; WHO World Health Organization.</p

Flow of HIV positive patients' enrolment into HIV care and treatment, Rwanda, 2009.

<p>Flow of HIV positive patients' enrolment into HIV care and treatment, Rwanda, 2009.</p