Defining retention and attrition in pre-antiretroviral HIV care: proposals based on experience in Africa
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Fewer than 33% of those testing HIV-positive in sub-Saharan Africa are continuously retained in pre-antiretroviral therapy (ART) HIV care until ART initiation. Existing evidence is difficult to synthesize, however, due to unclear and inconsistent definitions of terms. We developed practical, standardized definitions for reporting retention for the three stages of pre-ART care: Stage 1, testing HIV-positive to initial ART eligibility assessment; Stage 2, initial assessment to ART eligibility; and Stage 3, ART eligibility to ART initiation. For each stage, negative outcomes include death, loss, or not being retained. Stage 1 retention is defined as the proportion of patients who complete initial ART eligibility assessment within 3 months of HIV testing, with reporting of cohort outcomes at 3 and 12 months after HIV testing. Patients who end Stage 1 eligible for ART move directly to Stage 3. Stage 2 retention is defined as the proportion of patients who either complete all possible ART eligibility re-assessments within 6 months of the site’s standard visit schedule or had an assessment within 1 year of the time reported to and were not ART eligible at the last assessment. Retention should be reported at 12-month intervals. Stage 3 retention is defined as the proportion of patients eligible for ART who initiate ART (i.e.ARVs dispensed) within 3 months of determining ART eligibility, with reporting at 3 months after eligibility and 3 monthly intervals thereafter. If pre-ART retention is to improve, consistent terminology is needed for collecting data, measuring and reporting outcomes, and comparing results across programs and countries. The definitions we propose offer a strategy for improving the consistency and comparability of future reports.
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