[email protected] Getting people to the pills: Transport costs, socio-economic status...
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[email protected] 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
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Transcript of [email protected] Getting people to the pills: Transport costs, socio-economic status...
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-RathHIVTools Working Group
London School of Hygiene and Tropical Medicine, UKand
Reproductive Health and HIV Research UnitUniversity of the Witwatersrand, South Africa
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
Defaulting: The scope of the problem
Patient status Johannesburg Hospital (Dec 2006, n=3679)
58%
16%
6%
18%
2%
Active
Clinic defaulter
Down referred
Treatment defaulter
Died
Defaulting at JGH
Defaulting at TWC
Patient status Tshepong Wellness Clinic (Aug 2006, n=5750)
41%
23%
19%
14% 2% 1%
Actively accessing carePre-ART DefaultersDown referredPost ART DefaultersDiedUnknown
Defaulting timeframe on ART
Patient defaulting times - post ART
0%
10%
20%
30%
40%
50%
60%
1-3 4-6 7-9 10-12 13-15 16-18 19-21 22-24 >24
Months
% o
f p
atie
nts
def
ault
ing
TshepongJHBTaung
Defaulting timeframe before ART
Time to defaulting before ART at Johannesburg Hospital
102
276
123
64
9
0
50
100
150
200
250
300
0 1 2 3 no data
No. of counselling sessions
No
. of
pat
ien
ts
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.
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
Results: Modes of transport at baseline
ART clinic JGH ART clinic TWC
Other clinics JGH Other clinics TWC
Modes of transport to other clinics (TWC, n=102)
32%
2%
1%65%
TaxiOwn carRented carWalking
Modes of transport to other clinics (JGH, n=70)
34%
2%
8%
54%
2%
Taxi
Bus
Own car
Walking
Train
Modes of transport to ART clinic (TWC, n=294)
83%
4%
9%
2%0.3%
0.7%1%
Taxi
Own car
Walking
Bike
Hitchhiking
Combinations
Hosp transport
Modes of transport to ART clinic (JGH, n=284)
1%
1%
61%
9% 17%2%
0.3%
9%Taxi
Bus
Own car
Rented car
Walking
Train
Meter taxi
Combinations
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
Transport cost distribution: Deciles
Mean transport cost to ART clinic per decile
0
10
20
30
40
50
60
70
80
0 1 2 3 4 5 6 7 8 9 10
Decile
Tran
spo
rt c
ost
per
vis
it [
ZA
R]
Mean cost JGH (n=284)
Mean cost TWC (n=294)
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
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
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)
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
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
