Retention & Risk Factors for Attrition among Adults in Antiretroviral Treatment Programs in Tanzania, Uganda & Zambia

OBJECTIVES

We assessed retention and predictors of attrition (recorded death or loss to follow-up) in antiretroviral treatment (ART) clinics in Tanzania, Uganda and Zambia.

METHODS

We conducted a retrospective cohort study among adults (≥18 years) starting ART during 2003–2010. We purposefully selected six health facilities per country and randomly selected 250 patients from each facility. Patients who visited clinics at least once during the 90 days before data abstraction were defined as retained. Data on individual and programme level risk factors for attrition were obtained through chart review and clinic manager interviews. Kaplan–Meier curves for retention across sites were created. Predictors of attrition were assessed using a multivariable Cox-proportional hazards model, adjusted for site-level clustering.

RESULTS

From 17 facilities, 4147 patients were included. Retention ranged from 52.0% to 96.2% at 1 year to 25.8%–90.4% at 4 years. Multivariable analysis of ART initiation characteristics found the following independent risk factors for attrition: younger age [adjusted hazard ratio (aHR) and 95% confidence interval (95%CI) = 1.30 (1.14–1.47)], WHO stage 4 ([aHR (95% CI): 1.56 (1.29–1.88)], >10% bodyweight loss [aHR (95%CI) = 1.17 (1.00–1.38)], poor functional status [ambulatory aHR (95%CI) = 1.29 (1.09–1.54); bedridden aHR1.54 (1.15–2.07)], and increasing years of clinic operation prior to ART initiation in government facilities [aHR (95%CI) = 1.17 (1.10–1.23)]. Patients with higher CD4 cell count were less likely to experience attrition [aHR (95%CI) = 0.88 (0.78–1.00)] for every log (tenfold) increase. Sites offering community ART dispensing [aHR (95% CI) = 0.55 (0.30–1.01) for women; 0.40 (0.21–0.75) for men] had significantly less attrition.

CONCLUSIONS

Patient retention to an individual programme worsened over time especially among males, younger persons and those with poor clinical indicators. Community ART drug dispensing programmes could improve retention.

Below:  Kaplan-Meier estimates by site in Tanzania, Uganda and Zambia

Below:  Kaplan-Meier estimates by Community-Based Distribution (CBD) of ARVs in Tanzania, Uganda and Zambia

Full article at:   http://goo.gl/f62sCn

By:  Olivier Koole,1,2 Sharon Tsui,3,4 Fred Wabwire-Mangen,5 Gideon Kwesigabo,6 Joris Menten,2 Modest Mulenga,7Andrew Auld,8 Simon Agolory,8 Ya Diul Mukadi,3 Robert Colebunders,2,9 David R. Bangsberg,10,11 Eric van Praag,3Kwasi Torpey,3 Seymour Williams,8 Jonathan Kaplan,8 Aaron Zee,8 and Julie Denison3,4

¹Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK

²Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium

³FHI 360, Durham, NC, USA

⁴Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

⁵Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda

⁶Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania

⁷Tropical Diseases Research Centre, Ndola, Zambia

⁸Division of Global AIDS, United States Centers for Disease Control and Prevention, Atlanta, GA, USA

⁹Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium

¹⁰Massachusetts General Hospital, Boston, MA, USA

¹¹Harvard Medical School, Boston, MA, USA

Corresponding Author Olivier Koole, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Tel.: +265 997 680 108; Email: ku.ca.mthsl@elook.reivilo

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