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. 2014 Dec;19(12):1397-410.
doi: 10.1111/tmi.12386. Epub 2014 Sep 17.

Retention and risk factors for attrition among adults in antiretroviral treatment programmes in Tanzania, Uganda and Zambia

Olivier Koole  1 , Sharon Tsui, Fred Wabwire-Mangen, Gideon Kwesigabo, Joris Menten, Modest Mulenga, Andrew Auld, Simon Agolory, Ya Diul Mukadi, Robert Colebunders, David R Bangsberg, Eric van Praag, Kwasi Torpey, Seymour Williams, Jonathan Kaplan, Aaron Zee, Julie Denison
Affiliations

Retention and risk factors for attrition among adults in antiretroviral treatment programmes in Tanzania, Uganda and Zambia

Olivier Koole et al. Trop Med Int Health. 2014 Dec.

Abstract

Objectives: We assessed retention and predictors of attrition (recorded death or loss to follow-up) in antiretroviral treatment (ART) clinics in Tanzania, Uganda and Zambia.

Methods: We conducted a retrospective cohort study among adults (≥18 years) starting ART during 2003-2010. We purposefully selected six health facilities per country and randomly selected 250 patients from each facility. Patients who visited clinics at least once during the 90 days before data abstraction were defined as retained. Data on individual and programme level risk factors for attrition were obtained through chart review and clinic manager interviews. Kaplan-Meier curves for retention across sites were created. Predictors of attrition were assessed using a multivariable Cox-proportional hazards model, adjusted for site-level clustering.

Results: From 17 facilities, 4147 patients were included. Retention ranged from 52.0% to 96.2% at 1 year to 25.8%-90.4% at 4 years. Multivariable analysis of ART initiation characteristics found the following independent risk factors for attrition: younger age [adjusted hazard ratio (aHR) and 95% confidence interval (95%CI) = 1.30 (1.14-1.47)], WHO stage 4 ([aHR (95% CI): 1.56 (1.29-1.88)], >10% bodyweight loss [aHR (95%CI) = 1.17 (1.00-1.38)], poor functional status [ambulatory aHR (95%CI) = 1.29 (1.09-1.54); bedridden aHR1.54 (1.15-2.07)], and increasing years of clinic operation prior to ART initiation in government facilities [aHR (95%CI) = 1.17 (1.10-1.23)]. Patients with higher CD4 cell count were less likely to experience attrition [aHR (95%CI) = 0.88 (0.78-1.00)] for every log (tenfold) increase. Sites offering community ART dispensing [aHR (95%CI) = 0.55 (0.30-1.01) for women; 0.40 (0.21-0.75) for men] had significantly less attrition.

Conclusions: Patient retention to an individual programme worsened over time especially among males, younger persons and those with poor clinical indicators. Community ART drug dispensing programmes could improve retention.

Keywords: ART; Afrique subsaharienne; HIV; TAR; VIH; retención; retention; rétention; sub-Saharan Africa; África sub-Sahariana.

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Figures

Figure 1
Figure 1
Kaplan-Meier estimates by site in Tanzania, Uganda and Zambia.
Figure 2
Figure 2
Kaplan-Meier estimates by Community-Based Distribution (CBD) of ARVs in Tanzania, Uganda and Zambia.
See this image and copyright information in PMC

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