Predictors of Dropout from Care among HIV-Infected Patients Initiating Antiretroviral Therapy at a Public Sector HIV Treatment Clinic in Sub-Saharan Africa
METHODS:
In a
cohort of HIV-infected patients initiating ART at a public sector clinic in
Uganda, we assessed predictors of dropout from care (a composite outcome
combining death and loss to follow-up). From a large set of socio-demographic,
clinical, and laboratory variables routinely collected at ART initiation, we
selected those predicting dropout at P <0.1 in unadjusted analyses for
inclusion into a multivariable proportional hazards regression model. We then
used a stepwise backward selection procedure to identify variables which
independently predicted dropout at P <0.05.
RESULTS:
Data from
5,057 patients were analyzed. The median age was 33 years (IQR 28 to 40)
and 27.4 % had CD4+ T-cell counts <100 cells/μL at ART initiation. The
median duration of follow-up was 24 months (IQR = 14 to 42, maximum
follow-up = 64 months). Overall dropout was 26.9 % (established
cumulative mortality = 2.3 %, loss to follow-up = 24.6 %), 5.6 %
were transferred to other service providers, and 67.5 % were retained in
care. A diagnosis of Kaposi's sarcoma (hazard ratio (HR) = 3.3, 95 % CI
2.5 to 4.5); HIV-associated dementia (HR = 2.6, 95 % CI 1.5 to 4.6);
history of cryptococcosis (HR = 2.2, 95 % CI 1.4 to 3.3); and reduced
hemoglobin concentration (<11 g/dl versus ≥13.8 g/dl (HR = 1.9,
95 % CI 1.6 to 2.2) were strong predictors of dropout. Other independent
predictors of dropout were: year of ART initiation; weight loss ≥10 %;
reduced total lymphocyte count; chronic diarrhea; male sex; young age
(≤28 years); and marital status.
CONCLUSIONS:
Among
HIV-infected patients initiating ART at a public sector clinic in SSA,
biological factors that usually predict death were especially predictive of
dropout. As most of the dropouts were lost to follow-up, this observation
suggests that many losses to follow-up may have died. Future studies are needed
to identify appropriate interventions that may improve both individual-level
patient outcomes and outcome ascertainment among HIV-infected ART initiators in
this setting.
- 1Department of Medicine, Mbarara Regional Referral Hospital, P.O Box 40, Mbarara, Uganda. asiimwesteve@gmail.com.
- 2Department of Epidemiology and Biostatistics, University of California San Francisco, California, USA. asiimwesteve@gmail.com.
- 3Department of Medicine, Mbarara Regional Referral Hospital, P.O Box 40, Mbarara, Uganda. mkanyesigye2010@gmail.com.
- 4Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda. mwebesa_bwana@yahoo.com.
- 5Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda. okello.samson@must.ac.ug.
- 6Department of Medicine, Mbarara Regional Referral Hospital, P.O Box 40, Mbarara, Uganda. wmuyindike@gmail.com.
- BMC Infect Dis. 2016 Feb 1;16(1):43. doi: 10.1186/s12879-016-1392-7.
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