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Retaining PWH in Care; Mortality
Increased with ART Interruptions >6 months
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'There needs to be a much greater focus on retaining people in care, and this focus must be maintained throughout the time that people are on ART, not just early on'
The steep cost of HIV treatment interruptions
Filip, Iulia
The impact of poor retention in care on HIV-related mortality has been previously documented [2,3]. New findings from a large South African cohort paint an even bleaker picture: PWH who discontinue antiretroviral therapy (ART) may pay the ultimate penalty even if they later resume treatment. Data collected between 2004 and 2019 from more than 63 000 PWH showed that patients who stopped treatment for periods longer than 6 months and later resumed therapy had a two- to threefold higher mortality risk than those who remained engaged in care.
A quarter of the 35% PWH who experienced care interruptions resumed ART within a year. Nevertheless, their mortality risk remained higher compared with patients who never fell out of care. Moreover, the penalty was steeper for PWH who stopped ART within the first 6 months after initiation than for those who interrupted therapy later. 'This is most likely due to early interrupters achieving a smaller increase in CD4+ cell count and lower rates of viral suppression, because they were on ART for a shorter period, leading to poorer health outcomes in the long term,' according to lead author Haroon Moolla, MD, of the University of Cape Town in South Africa. Low baseline CD4+ cell count (<200 cells/μl) and male sex were also harbingers of poorer outcomes for those who interrupted care. 'Males typically have greater mortality than females, so the fact that they had greater mortality in our study is not surprising', Moolla explained in a presentation at the 12th International AIDS Society Conference on HIV Science in Brisbane, Australia. 'That said, the effect is larger than one would expect'. The authors said they intend to further explore this effect in their study, which is pending publication.
Tracing and re-engaging PWH who fall out of care before they become critically ill require overcoming obstacles related to housing, income levels, mental illness, substance use disorders, and underinsurance, among other factors. 'There needs to be a much greater focus on retaining people in care, and this focus must be maintained throughout the time that people are on ART, not just early on', Moolla added. 'What the retention strategies look like will vary based on the local context'.
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