Discontinuation from Antiretroviral Therapy: A Continuing Challenge among Adults in HIV Care in Ethiopia: A Systematic Review and Meta-Analysis

Abstract

Background: Discontinuation of antiretroviral therapy (ART) reduces the immunological benefit of treatment and increases complications related to human immune-deficiency virus (HIV). However, the risk factors for ART discontinuation are poorly understood in developing countries particularly in Ethiopia. This review aimed to assess the best available evidence regarding risk factors for ART discontinuation in Ethiopia.

Methods: Quantitative studies conducted in Ethiopia between 2002 and 2015 that evaluated factors associated with ART discontinuation were sought across six major databases. Only English language articles were included. This review considered studies that included the following outcome: ART treatment discontinuation, i.e. 'lost to follow up', 'defaulting' and 'stopping medication'. Meta- analysis was performed with Mantel Haenszel method using Revman-5 software. Summary statistics were expressed as pooled odds ratio with 95% confidence intervals at a p-value of <0.05.

Results: Nine (9) studies met the criteria of the search. Five (5) were retrospective studies, 3 were case control studies, and 1 was a prospective cohort study. The total sample size in the included studies was 62,156. Being rural dweller (OR = 2.1, 95%CI: 1.5-2.7, I2 = 60%), being illiterate (OR = 1.5, 95%CI: 1.1-2.1), being not married (OR = 1.4, 95%CI: 1.1-1.8), being alcohol drinker (OR = 2.9, 95%CI: 1.9-4.4, I2 = 39%), being tobacco smoker (OR = 2.6, 95%CI: 1.6-4.3, I2 = 74%), having mental illness (OR = 2.7, 95%CI: 1.6-4.6, I2 = 0%) and being bed ridden functional status (OR = 2.3, 95%CI: 1.5-3.4, I2 = 37%) were risk factors for ART discontinuation. Whereas, having HIV positive partner (OR = 0.4, 95%CI: 0.3-0.6, I2 = 69%) and being co-infected with Tb/HIV (OR = 0.6, 95%CI: 0.4-0.9, I2 = 0%) were protective factors.

Conclusion: Demographic, behavioral and clinical factors influenced ART treatment discontinuation. Hence, we recommend strengthening decentralization of HIV care services in remote areas, strengthening of ART task shifting, application of seek-test-treat-succeed model, and integration of smoking cession strategies and mental health care into the routine HIV care program.

Fig 1. PRISMA 2009 flow diagram.

This figure presents the results of the systematic search and reasons of exclusion.

Fig 2. Forest plot of meta-analytic association between age and discontinuation from ART.

It shows that the risk of ART discontinuation is not different by age.

Fig 3. Forest plot of meta-analytic association between sex and discontinuation from ART.

It shows that the risk of ART discontinuation is not different by sex.

Fig 4. Forest plot of meta-analytic association between residence and discontinuation from ART.

It shows that the risk of ART discontinuation is higher for rural than urban.

Fig 5. Forest plot of meta-analytic association between level of education and discontinuation from ART.

It shows that the risk of ART discontinuation is higher for patients with no literacy status than literates.

Fig 6. Forest plot of meta-analytic association between marital status and discontinuation from ART.

It shows that the risk of ART discontinuation is higher for not-married than married.

Fig 7. Forest plot of meta-analytic association between partners’ HIV status and discontinuation from ART.

It shows that the risk of ART discontinuation is lower for patients with HIV positive partner than HIV negative/unknown partner.

Fig 8. Forest plot of meta-analytic association between alcohol drinking and discontinuation from ART.

It shows that the risk of ART discontinuation is higher for alcohol drinkers than non-drinkers.

Fig 9. Forest plot of meta-analytic association between tobacco smoking and discontinuation from ART.

It shows that the risk of ART discontinuation is higher for cigarette smokers than non-smokers.

Fig 10. Forest plot of meta-analytic association between Tb/HIV co-infection and discontinuation from ART.

It shows that the risk of ART discontinuation is lower for Tb/HIV co-infected patients than HIV alone.

Fig 11. Forest plot of meta-analytic association between baseline functional status and discontinuation from ART.

It shows that the risk of ART discontinuation is higher for patients with bedridden than working functional status.

Fig 12. Forest plot of meta-analytic association between mental status and discontinuation from ART.

It shows that the risk of ART discontinuation is higher for patients with mental status than their comparator.

Fig 13. Forest plot of meta-analytic association between cotrimoxazole or opportunistic infections prophylaxis and discontinuation from ART.

It shows that the risk of ART discontinuation is not different by the status of cotrimoxazole or opportunistic infections prophylaxis.