Original Research

Estimating qualification and factors associated with third-line antiretroviral therapy referral in the Western Cape

Sadiyya Sheik, Bart Willems
Southern African Journal of HIV Medicine | Vol 22, No 1 | a1184 | DOI: https://doi.org/10.4102/sajhivmed.v22i1.1184 | © 2021 Sadiyya Sheik, Bart Willems | This work is licensed under CC Attribution 4.0
Submitted: 22 October 2020 | Published: 28 January 2021

About the author(s)

Sadiyya Sheik, Department of Global Health, Faculty of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa
Bart Willems, Department of Global Health, Faculty of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa


Background: South Africa’s ART programme is the largest globally and the universal test-and-treat policy is expected to increase the numbers on ART. This may have implications for treatment failure rates implying a greater future need for third-line regimens.

South Africa initiated a third-line programme in 2013. However, there is little evidence quantifying the third-line need in this setting and the programme itself has not been formally evaluated.

Objectives: The study undertook to evaluate the third-line ART referral process in the Western Cape.

Method: Routinely collected data were analysed to derive an estimate of patients meeting criteria for third-line referral and compared with patients who were referred. Factors associated with referral were identified.

Results: In the study period, 947 patients met criteria for third-line referral and 167 patients were actually referred. Comparison revealed a poor overlap of only 42 patients. In multivariate analysis, factors associated with referral included receiving care at a hospital rather than a primary health care facility (aOR=2.15, 95% CI 1.1-4.2), a higher number of VLs ≥1000 copies/ml whilst on a PI (aOR=1.2, 95%CI 1.01-1.42) and a greater number of years on a PI (aOR=1.25, 95% CI 1.07-1.46). Patients with a six-month gap in dispensing were less likely to be referred (aOR=0.37, 95% CI 0.17-0.81).

Conclusion: This study adds to a limited body of knowledge regarding third-line ART programmes. The findings indicate missed opportunities for and inappropriate referral of patients. Factors associated with referral were largely health system related. Clinician awareness and compliance with referral remain unknown and may be contributory.


Third-Line ART; Resistance; Public Health; HIV; Western Cape


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