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

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 Defaulting at JGH

Defaulting at TWC

Defaulting timeframe on ART

Defaulting timeframe before ART

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 JGHART clinic TWC Other clinics JGHOther clinics TWC

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

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