Predictors of attrition among adults in a rural HIV clinic in southern Mozambique: 18-year retrospective study

Abstract

HIV remains a major cause of morbidity and mortality for people living in many low-income countries. With an HIV prevalence of 12.4% among people aged over 15 years, Mozambique was ranked in 2019 as one of eight countries with the highest HIV rates in the world. We analyzed routinely collected data from electronical medical records in HIV-infected patients aged 15 years or older and enrolled at Carmelo Hospital of Chokwe in Chokwe from 2002 to 2019. Attrition was defined as individuals who were either reported dead or lost to follow-up (LTFU) (≥ 90 days since the last clinic visit with missed medical pick-up after 3 days of failed calls). Kaplan–Meier survival curves and Cox regression analyses were used to model the incidence and predictors of time to attrition. From January 2002 to December 2019, 16,321 patients were enrolled on antiretroviral therapy (ART): 59.2% were women, and 37.9% were aged 25–34 years old. At the time of the analysis, 7279 (44.6%) were active and on ART. Overall, the 16,321 adults on ART contributed a total of 72,987 person-years of observation. The overall attrition rate was 9.46 per 100 person-years. Cox regression showed a higher risk of attrition in those following an inpatient regimen (hazard ratio [HR] 3.18, 95% confidence interval [CI] 2.89–3.50; p < 0.001), having CD4 counts under 50 cells/µL (HR 1.91, 95% CI 1.63–2.24, p < 0.001), receiving anti-TB treatment within 90 days of ART initiation (HR 6.53, 95% CI 5.72–7.45; p < 0.001), classified as WHO clinical stage III (HR 3.75, 95% CI 3.21–4.37; p < 0.001), and having Kaposi’s sarcoma (HR 1.99, 95% CI 1.65–2.39, p < 0.001). Kaplan–Meier analysis showed that patients with CD4 counts of less than 50 cells/µL on ART initiation had a 40% lower chance of survival at 18 years. Low CD4 cell counts, ART initiation as an inpatient, WHO clinical stage III, and anti-tuberculosis treatment within 90 days of ART initiation were strongly associated with attrition. Strengthening HIV testing and ART treatment, improving the diagnosis of tuberculosis before ART initiation, and guaranteed psychosocial support systems are the best tools to reduce patient attrition after starting ART.

Extrapulmonary tuberculosis mortality according to clinical and point of care ultrasound features in Mozambique

“…Our research showed that the use of ART for more than three months was associated with a higher risk of death, particularly in those with immunovirological failure or immunological non-responders to ART. These findings are in keeping with studies from other low-income settings, which report the negative impact that a low CD4 cell count during the TB treatment initiation period has on mortality outcomes 32 . This is why early detection of viral load and initial CD4 counts are recommended for all TB/HIV co-infected patients, along with urgent switching to second-line ART in those with immunovirological failure 39 .…”

“…Those who had an optimal immunovirological response to ART in our hospitalized cohort showed a lower risk of death. This result highlights the critical importance of adhering to ART and strengthening psychosocial support systems for HIV testing and ART treatment 32 .…”

Long-term survival analysis of HIV patients on antiretroviral therapy in Congo: a 14 years retrospective cohort analysis, 2003-2017

“…We used the Cox model to identify prognostic factors associated with patient death. In univariate analysis, each relevant explanatory variable identified in the review of the literature (sex, viral load, WHO clinical stage of the disease, CD4 number) was crossed with the explanatory variable "vital status" (1 = death; 0 = survival) [17][18][19]. The endpoint was death.…”

Attrition and its predictors among adults enrolled in cART programs in two referral hospitals in the northern coastal areas of Eritrea: 16-year retrospective study

“…One such concern is the quality of decentralised cART programs in Low and Middle (LMICs) income countries in sub-Saharan Africa (SSA). In particular, patient retention and minimisation of loss to follow-up (LTFU) at the disparate stages of the HIV continuum of care has been described as one of the most important challenges (4,5). According to some reports, the rate of attrition can be used to evaluate HIV/AIDS programme performance and /or quality, and to pin-point gaps and opportunities for contextualised interventions directed at maximisation of retention and improvement of clinical outcomes (6).…”