Retention of Adult Patients on Antiretroviral Therapy in Low- and Middle-Income Countries: Systematic Review and Meta-analysis 2008-2013

Abstract

Background: We previously published systematic reviews of retention in care after antiretroviral therapy initiation among general adult populations in sub-Saharan Africa. We estimated 36-month retention at 73% for publications from 2007 to 2010. This report extends the review to cover 2008-2013 and expands it to all low- and middle-income countries.

Methods: We searched PubMed, Embase, Cochrane Register, and ISI Web of Science from January 1, 2008, to December 31, 2013, and abstracts from AIDS and IAS from 2008-2013. We estimated retention across cohorts using simple averages and interpolated missing times through the last time reported. We estimated all-cause attrition (death, loss to follow-up) for patients receiving first-line antiretroviral therapy in routine settings in low- and middle-income countries.

Results: We found 123 articles and abstracts reporting retention for 154 patient cohorts and 1,554,773 patients in 42 countries. Overall, 43% of all patients not retained were known to have died. Unweighted averages of reported retention were 78%, 71%, and 69% at 12, 24, and 36 months, after treatment initiation, respectively. We estimated 36-month retention at 65% in Africa, 80% in Asia, and 64% in Latin America and the Caribbean. From lifetable analysis, we estimated retention at 12, 24, 36, 48, and 60 months at 83%, 74%, 68%, 64%, and 60%, respectively.

Conclusions: Retention at 36 months on treatment averages 65%-70%. There are several important gaps in the evidence base, which could be filled by further research, especially in terms of geographic coverage and duration of follow-up.

Figure 1

Average retention at specified time points, by region* * Note: Y axis starts at 40%

Figure 2

– Forest plots of retention by time period reported to at 12, 24, 36 and 48 months on ART* * Figure of 48 month retention includes 48 month retention (sometimes interpolated) for all cohorts reporting beyond 48 months

Figure 2

– Forest plots of retention by time period reported to at 12, 24, 36 and 48 months on ART* * Figure of 48 month retention includes 48 month retention (sometimes interpolated) for all cohorts reporting beyond 48 months

Figure 3

a–d Kaplan-Meir curves of time to attrition for all adults and stratified by region* * Kaplan Meir data use interpolated estimates