Competing risk of mortality on loss to follow-up outcome among patients with HIV on ART: a retrospective cohort study from the Zimbabwe national ART programme

Abstract

ObjectiveTo determine the loss to follow-up (LTFU) rates at different healthcare levels after antiretroviral therapy (ART) services decentralisation among ART patients who initiated ART between 2004 and 2017 using the competing risk model in addition to the Kaplan-Meier and Cox regressions analysis.DesignA retrospective cohort study.SettingThe study was done in Zimbabwe using a nationwide routinely collected HIV patient-level data from various health levels of care facilities compiled through the electronic patient management system (ePMS).ParticipantsWe analysed 390 771 participants aged 15 years and above from 538 health facilities.OutcomesThe primary endpoint was LTFU defined as a failure of a patient to report for drug refill for at least 90 days from last appointment date or if the patient missed the next scheduled visit date and never showed up again. Mortality was considered a secondary outcome if a patient was reported to have died.ResultsThe total exposure time contributed was 1 544 468 person-years. LTFU rate was 5.75 (95% CI 5.71 to 5.78) per 100 person-years. Adjustment for the competing event independently increased LTFU rate ratio in provincial and referral (adjusted sub-HRs (AsHR) 1.22; 95% CI 1.18 to 1.26) and district and mission (AsHR 1.47; 95% CI 1.45 to 1.50) hospitals (reference: primary healthcare); in urban sites (AsHR 1.61; 95% CI 1.59 to 1.63) (reference: rural); and among adolescence and young adults (15–24 years) group (AsHR 1.19; 95% CI 1.16 to 1.21) (reference: 35–44 years). We also detected overwhelming association between LTFU and tuberculosis-infected patients (AsHR 1.53; 95% CI 1.45 to 1.62) (reference: no tuberculosis).ConclusionsWe have observed considerable findings that ‘leakages’ (LTFU) within the ART treatment cascade persist even after the decentralisation of health services. Risk factors for LTFU reflect those found in sub-Saharan African studies. Interventions that retain patients in care by minimising any ‘leakages’ along the treatment cascade are essential in attaining the 90–90–90 UNAIDS fast-track targets.

Undernutrition increased the risk of loss to follow-up among adults living with HIV on ART in Northwest Ethiopia: a retrospective cohort study

“…The overall incidence of LTFU in our study (5.3 per 100 person-years) is consistent with a study conducted in Zimbabwe (5.75 per 100 person-years) 36 . However, our finding is lower than studies conducted in Uganda www.nature.com/scientificreports/ (7.5 per 100 person-years) 22 and Ethiopia (10.9 per 100 person-years) 10 .…”

Predictors of loss to follow up among adults on antiretroviral therapy before and after the start of treat-all strategy in public health facilities of Hawassa city, Ethiopia: A Competing risk regression

“…This study investigated the incidence and predictors of LTFU in HIV-positive adults initiated on ART before and after the implementation of a test-and-treat strategy. As illustrated in Fig 3, the cumulative incidence function estimates the valid rate of LTFU, adjusting for mortality's competing effect, as those who die are no longer at risk, which is in line with other similar studies [42,43]. The estimated rate of LTFU in this study was 4.92 and 8.67 per 100 personyears in the pre-treat-all and treat-all cohorts, respectively.…”

Incidence and predictors of attrition among adults receiving first line anti-retroviral therapy at public health facility in Adea Berga district, Oromia, Ethiopia

“…However, finding was also higher when compared to studies done in Zimbabwe (AHR = 0.74), Kenya (AHR = 0.232), and Adama (AHR = 0.42),. 5 , 12 , 22 , 23 Patients with advanced WHO clinical stages III or IV also underwent more attrition from the treatment as compared to those in stage I. Early HIV diagnosis and initiation of treatment could increase survival rates; this might be due to the “Test and Treat” approach.…”

“… 12 This high risk of attrition is higher when compared to studies conducted in Zimbabwe (1.19) and could be attributed to a high loss to follow-up as a result of stigma and discrimination, as well as a lack of psychosocial support during a health facility visit to pick up ART medication, and Zimbabwe. 16 , 22 This could be due to social stigma, the fact that they forgot and felt better, the fact that they are naturally sexually active in this age group, the burden of pills with the presence of opportunistic infection, or the religious factor (holy water), which resulted in a high viral load, treatment failure, and an increased likelihood of contracting OIs, and they would have died. Furthermore, this high hazard of attrition might be due to substance use.…”