Retention and predictors of attrition among patients who started antiretroviral therapy in Zimbabwe’s National Antiretroviral Therapy Programme between 2012 and 2015

Abstract

21Background 22 The last evaluation to assess outcomes for patients receiving antiretroviral therapy (ART) 23 through the Zimbabwe public sector was conducted in 2011, covering the 2007-2010 cohorts. 24 The reported retention at 6, 12, 24 and 36 months were 90. 7%, 78.1%, 68.8% and 64.4%, 25 respectively. We report findings of a follow up evaluation for the 2012-2015 cohorts to assess 26 the implementation & impact of recommendations from this prior evaluation. 27 Methods 28A nationwide retrospective study was conducted in 2016. Multi-stage proportional sampling 29 was used to select health facilities and study participants records. The data extracted from 30 patient manual records included demographic, baseline clinical characteristics and patient 31 outcomes (active on treatment, died, transferred out, stopped ART and lost to follow-up 32 (LFTU)) at 6, 12, 24 and 36 months. The data were analysed using Stata/IC 14.2. Retention 33 was estimated using survival analysis. The predictors associated with attrition were determined 34 using a multivariate Cox regression model. 35 Results 36A total of 3,810 participants were recruited in the study. The median age in years was 35 (IQR: 37 28-42). Overall, retention increased to 92.4%, 86.5%, 79.2% and 74.4% at 6, 12, 24 and 36 38 months respectively. LFTU accounted for 98% of attrition. Being an adolescent or a young 39 adult (aHR 1.41; 95%CI:1.14-1.74), receiving care at primary health care facility (aHR 1.23; 40 95%CI:1.01-1.49), having initiated ART between 2014-2015 (aHR 1.45; 95%CI:1.24-1.69), 41 having WHO Stage 4 (aHR 2.06; 95%CI:1.51-2.81) and impaired functional status (aHR 1.24; 42 95%CI:1.04-1.49) predicted attrition.43 44 Conclusion 45 The overall retention was higher in comparison to the previous 2007--2010 evaluation. Further 46 studies to understand why attrition was found to be higher at primary health care facilities are 47 warranted. Implementation of strategies for managing patients with advanced HIV disease, 48 differentiated care for adolescents and young adults and tracking of LFTU should be prioritised 49 to further improve retention. 50 51 Key words 52 ART outcomes, implementation, low resource setting, differentiated care, Zimbabwe53 54 56 Globally by the end of 2018, there were 37.9 million [32.7 million-44.0 million] people living 57 with HIV (PLHIV) with 61% of these residing in Eastern and Southern Africa (ESA) [1]. Over 58 the past two to three decades, investments in the global HIV response have achieved 59 unprecedented results with the number of new HIV infections significantly reduced from 2.9 60 million [2.3 million-3.8 million] in 1997 to 1.7 million [1.6 million-2.3 million] new infections 61 by 2018 and 23.3 million PLHIV put on treatment globally [1]. Between 2010 and 2018 new 62 HIV infections and deaths decreased by 16% and 33%, respectively [2]. Despite these 63 remarkable achievements, patient attrition and losses to follow-up (LTFU) still remain 64 legitimate threats to the long-term success of antiretroviral ther...

Lost to follow up rate in the first year of ART in adults initiated in a universal test and treat programme: a retrospective cohort study in Ekurhuleni District, South Africa

“…Although there is overwhelming support for the UTT strategy, evident by the adoption of the strategy by most countries [ 35 ], the current study findings and those of others [ 31 , 40 ] suggest that a delay is required for individuals who test HIV positive to accept the diagnosis. There is need to provide psychosocial preparation and readiness assessment to newly diagnosed HIV-positive individuals before ART initiation under UTT [ 39 ]. This is necessary for individuals to make informed decision whether or not to attend a clinic.…”

“…We included variables that were associated with LFTU up in the bivariate analysis at p value of 0.05. We also included variables such as gender, age, and clinical data including CD4 count and WHO staging based on a documented association with loss to follow up in literature [ 25 , 39 ]. A p-value < 0.05 was considered statistically significant.…”

Models of service delivery for optimizing a patient’s first six months on antiretroviral therapy for HIV: an applied research agenda

“…Among patients who initiated ART in the last quarter of 2018 in South Africa, for example, 30% were reported as lost to follow up by six months 9 . In Zimbabwe, retention in care improved significantly between 2010 and 2015 except for patients in their first six months 10 . Beyond the impact on individual morbidity and mortality, early losses from care are associated with internalized stigma, leading to social isolation, fear of disclosure, and discrimination, which potentially compound the inherent challenges in returning to care 11 – 13 .…”

District-level strategies to control the HIV epidemic in Zimbabwe: a practical example of precision public health.

“…viral load suppression, was unavailable. Previous studies showed that the retention on ART was high, but that access to viral load monitoring and viral load suppression remained suboptimal [33][34][35].…”