Effect of point of care CD4 cell count tests on retention of patients and rates of antiretroviral therapy initiation in sub-Saharan African countries: a systematic review

Abstract

Background: A point of care (PoC) CD4 test is a CD4 test performed in the immediate vicinity of a patient to provide a rapid same-day result outside the conventional laboratory environment, in order to facilitate immediate clinical decision-making, including initiation and adjustment of anti-retroviral therapy. Objectives: The objective of this review was to determine the effect of point of care CD4 cell count tests on retention of patients and rates of antiretroviral therapy initiation. Inclusion Criteria: Types of participants: Adults living with HIV were included. Types of intervention: Point of care CD4 testing Types of studies: Both experimental and epidemiological study designs were included. Types of outcomes: The primary outcomes were: attending a wellness program, initiation of antiretroviral treatment of enrolled patients, loss to follow up before attending pre-ART care, loss to follow up before ART initiation. Search strategy: The search strategy aimed to find both published and unpublished studies reported from 2004 to July, 2013. After an initial search for articles in MEDLINE and CINAHL and after an analysis of the text words contained in the title and abstract, and of the index terms used to describe article, the references of the studies were also searched. The search for unpublished studies included: Mednar, Google Scholar, and ProQuest Dissertations and Theses. Methodological quality: Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Data collection: Data were extracted independently by the two reviewers using the standardized data extraction tool from JBI-MAStARI. Data synthesis: Data were pooled in statistical meta-analysis using JBI-MAStARI. All results were subjected to double data entry. Before conducting meta-analyses, heterogeneity was assessed. Results: The initial search identified 55 articles out which 11 articles were retrieved. After critical appraisal, three articles were accepted to be included in data abstraction. Providing PoC CD4 tests had a significant effect on increasing treatment initiation. It did not decrease loss to follow up before treatment initiation. Providing PoC CD4 tests did not have effect on increasing the attendance of Pre-ART care and on decreasing follow up from Pre- ART care. Conclusions: The review of primary studies conducted from 2004 to 2013 indicated that providing point of care CD4 tests had significant effect on increasing ART initiation among adults living with HIV in sub-Saharan Africa. Therefore, there is a need to equip health institutions with the necessary laboratory facilities so that the CD4 test results will be provided immediately after the test without further appointment. Providing PoC CD4 tests did not have significant effect on decreasing loss to follow up before initiating ART and on decreasing loss to follow up before pre-ART care. The fact that the number of studies is small and the analyses method employed was a random effect model reduced the power, masking the effect on loss before ART care and loss before pre-ART care. Further primary studies are needed. © the authors 2014.