Do loss to follow-up and death rates from ART care vary across primary health care facilities and hospitals in south Ethiopia? A retrospective follow-up study

Abstract

BackgroundDecentralization and task shifting has significantly improved access to antiretroviral therapy (ART). Many studies conducted to determine the attrition rate in Ethiopia have not compared attrition rates between hospitals and health centers in a relatively recent cohort of patients. This study compared death and loss to follow-up (LTFU) rates among ART patients in hospitals and health centers in south Ethiopia.MethodsData routinely collected from patients aged older than 15 years who started ART between July 2011 and August 2012 in 20 selected health facilities (12 being hospitals) were analyzed. The outcomes of interest were LTFU and death. The data were entered, cleaned, and analyzed using Statistical Package for the Social Sciences version 20.0 and Stata version 12.0. Competing-risk regression models were used.ResultsThe service years of the facilities were similar (median 8 and 7.5 for hospitals and health centers, respectively). The mean patient age was 33.7±9.6 years. The median baseline CD4 count was 179 (interquartile range 93–263) cells/mm3. A total of 2,356 person-years of observation were made with a median follow-up duration of 28 (interquartile range 22–31) months; 24.6% were either dead or LTFU, resulting in a retention rate of 75.4%. The death rates were 3.0 and 1.5 and the LTFU rate were 9.0 and 10.9 per 100 person-years of observation in health centers and hospitals, respectively. The competing-risk regression model showed that the gap between testing and initiation of ART, body mass index, World Health Organization clinical stage, isoniazid prophylaxis, age, facility type, and educational status were independently associated with LTFU. Moreover, baseline tuberculous disease, poor functional status, and follow-up at a health center were associated with an elevated probability of death.ConclusionWe observed a higher death rate and a lower LTFU rate in health centers than in hospitals. Most of the associated variables were also previously documented. Higher LTFU was noticed for patients with a smaller gap between testing and initiation of treatment.

Discontinuation from Antiretroviral Therapy: A Continuing Challenge among Adults in HIV Care in Ethiopia: A Systematic Review and Meta-Analysis

“…All studies had relatively high sample size and the total sample size was 62,156. The studies were analytical in type including: three case control studies[7,9,23], five retrospective cohort studies[8,10,29,30,39] and one prospective cohort study[28]. The majority of the studies (n = 7)[8–10,28–30,39] assessed factors associated with LTFU and the remaining two studies[7,23] assessed defaulting.…”

“…Four studies[10,28,29,39] considered LTFU when HIV positive patients on ART treatment had missed three or more monthly clinical appointments and not yet been classified as “dead” or “transferring out”. One study[8] measured LTFU when adult patients were one month late for their appointment to pick-up their antiretroviral drugs whereas one other study[9] defined LTFU when patients had missed two or more clinical appointments.…”

“…Two[23,39] of the four studies[7,9,23,39] that assessed the association between place of residence and discontinuation reported a significant association. Out of the six studies[7–9,23,29,30] that assessed correlation between marital status and discontinuation, only Melaku and colleagues [30] reported significant association. Seven studies[7–9,23,28–30] assessed the association between educational status and discontinuation, and only Melaku and colleagues [30] found statistical association.…”

“…Two [7,23] of the three studies [7,9,23] that assessed association of partner’s HIV status and discontinuation observed significant association. Dessalegn and colleagues [9] and Teshome and colleagues [29] studied the association of HIV disclosure status with discontinuation, however both found non-statistical association.…”

“…A study from five East African countries revealed the existence of 14 different definitions of ART defaulting were in use[26]. Currently, the definition of LTFU in Ethiopia is also not uniform, and has included a patient discontinuing from ART for more than one[8], two[9], three[10,27–29] or twelve[30] months. Additional studies have considered a ‘defaulter’ when a patient discontinues from ART for more than two months [7,23].…”