Evaluation of the impact of PEPFAR transition on retention in care in South Africa's Western Cape.

Background:Research on the impact of the PEPFAR transition in South Africa (SA) in 2012 found varying results in retention in care (RIC) of people living with HIV (PLWH). Objectives:We investigated the factors that impacted RIC during the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) transition in Western Cape, South Africa in 2012. Methods:We used aggregate data from 61 facilities supported by four non-governmental organizations from to 2007-2015. The main outcome was RIC at 12-months after antiretroviral therapy initiation for two time periods. We used quantile regression to estimate the effect of the PEPFAR pull-out and other predictors on RIC. The models were adjusted for various covariates. Results:Regression models (50th quantile) for 12-month RIC showed a 4.6% (95%CI: -8.4, -0.8%) decline in RIC post direct service. Facilities supported by Anova/Kheth'impilo fared worst post PEFPAR; a decline in RIC of (-5.8%; 95% CI: -9.7, -1.8%), while that'sit fared best (6.3% increase in RIC; 95% CI:2.5,10.1%). There was a decrease in RIC when comparing urban to rural areas (-5.8%; 95% CI: -10.1, -1.5%). City of Cape town combined with Western Cape Government Health facilities showed a substantial decrease (-9.1%; 95% CI: -12.3, -5.9%), while community health clinic (vs. primary health clinic) declined slightly (-4.4; 95% CI: -9.6, 0.9%) in RIC. We observed no RIC difference by facility size and a slight increase when two or more human resources transitioned from PEPFAR to the government. Conclusions:When PEPFAR funding decreased in 2012, there was a decrease in RIC. To ensure the continuity of HIV care when a major funder withdraws sufficient and stable transition resources, investment in organizations that understand the local context, joint planning, and coordination are required.