High rates of unplanned interruptions from HIV care early after antiretroviral therapy initiation in Nigeria

Abstract

BackgroundUnplanned care interruption (UCI) challenges effective HIV treatment. We determined the frequency and risk factors for UCI in Nigeria.MethodsWe conducted a retrospective-cohort study of adults initiating antiretroviral therapy (ART) between January 2009 and December 2011. At censor, patients were defined as in care, UCI, or inactive. Associations between baseline factors and UCI rates were quantified using Poisson regression.ResultsAmong 2,496 patients, 44 % remained in care, 35 % had ≥1 UCI, and 21 % became inactive. UCI rates were higher in the first year on ART (39/100PY), than the second (19/100PY), third (16/100PY), and fourth (14/100PY) years (p < 0.001). In multivariate analysis, baseline CD4 > 350/uL (IRR 3.21, p < 0.0001), being a student (IRR 1.95, p < 0.0001), and less education (IRR 1.58, p = 0.001) increased risk for UCI. Fifty-five percent of patients with UCI and viral load data had HIV viral load > 1,000 copies/ml upon return to care.DiscussionUCI were observed in over one-third of patients treated, and were most common in the first year on ART. High baseline CD4 count at ART initiation was the greatest predictor of subsequent UCI.ConclusionsInterventions focused on the first year on ART are needed to improve continuity of HIV care.

High Rates of Unplanned Care Interruption: Implications for Program Response

“…Our recent analysis was based in Nigeria, home to the second largest number of people in the world living with HIV after South Africa [1]. In our cohort, 35% of patients had UCI, and rates were highest in the first year after starting ART [3]. This study supports our experience in the field -that patients are likely to experience many episodes of UCI over the course of their care.…”

“…There are many potential measures of retention, and much of the retention literature has focused on patients who are lost to follow-up, despite its limitations [2]. Loss to follow-up (LTFU), as a measure, may be conflated with other poorly ascertained outcomes including undocumented transfers of care, death, or transient care interruptions [3].…”

“…Our group has recently published on unplanned care interruption (UCI) as a measure of retention, a less heterogeneous outcome that can be assessed at the program level without requiring resources to track patients who do not return to care [3]. Our recent analysis was based in Nigeria, home to the second largest number of people in the world living with HIV after South Africa [1].…”

“…In our analysis of one cohort in Northern Nigeria, we found that having a higher baseline CD4 count (>350 cells/µL) was associated with a 3-fold increased risk of UCI in the first year on ART. This may reflect a less robust commitment to care among patients who generally do not feel "sick" [2,3]. Indeed patients who do not feel ill may be less willing to invest in travelling to clinic (because of cost of transportation, potential lost wages, etc.)…”

Age Matters: Increased Risk of Inconsistent HIV Care and Viremia Among Adolescents and Young Adults on Antiretroviral Therapy in Nigeria

“…In our cohort, females were over-represented amongst AYA compared to older adults, and AYA had a higher median CD4 count at baseline than older adults. A prior analysis by our group showed that high baseline CD4 is an independent risk factor for UCI from HIV care suggesting that patients who initiate ART with higher CD4 counts may be less likely to comply with care because they do not feel “sick” (30–32). In our Nigerian cohort, it is possible that the high baseline CD4 in the younger population may be accounted for by a predominance of females, who tend to be diagnosed with higher CD4 counts than males (33, 34).…”