Are there differences in HIV retention in care between female and male patients in Indonesia? A multi-state analysis of a retrospective cohort study

Abstract

Background: Little is known about HIV treatment outcomes in Indonesia, which has one of the most rapidly growing HIV epidemics worldwide.

Methods: We examined possible differences in loss to follow-up (LTFU) and survival between HIV-infected females and males over a 7-year period in an HIV clinic in Bandung, West Java. Data imputation was performed on missing covariates and a multi-state Cox regression was used to investigate the effects of sex and other covariates on patient transitions among four states: (1) clinic enrollment with HIV, (2) initiation/continuation/re-initiation of antiretroviral therapy (ART), (3) LTFU, and (4) death.

Results: We followed 3215 patients (33% females), for a total of 8430 person-years. ART was used by 59% of patients at some point. One-year retention was 73% for females and 77% for males (p = 0.06). One-year survival was 98% for both females and males (p = 0.15). Females experienced a higher relative hazard to transition from HIV to LTFU (adjusted hazard ratio 1.21; 95% confidence interval 1.00-1.45), but this decreased after adjustments for clinical variables (aHR 0.94; 95% CI 0.79-1.11). Similarly, a lower relative hazard in females to transition from ART to death (aHR 0.59; 95% CI 0.35-0.99) decreased after adjustments for demographic variables.

Conclusion: This Indonesian cohort has low ART uptake and poor overall pre- and post-ART retention. Female-male differences in survival and retention were gone after adjusting for clinical and sociodemographic factors such as CD4 count and education level. Efforts should be made to improve retention among patients with lower education.

Fig 1. Multi-state model to assess LTFU.

State definitions: (1) HIV state–started at the earliest recorded date of contact with the clinic for HIV testing, HIV test confirmation, or baseline interview; (2) ART state–started on the recorded ART start date or–when this information is missing–the earliest date in the pharmacy record of medicine pick-up. Individuals who received ART on the day they entered the clinic were modeled as starting directly in the ART state; (3) Death state–patients entered this state if their status is ‘Dead’ and the date of transition is the recorded date of death; (4) LTFU state–patients entered this state if the status is neither ‘Dead’ nor ‘Transferred.’ For patients who transitioned to LTFU from the HIV state, the date of LTFU is calculated as 90 days after the day the patient is expected to come back, i.e. 6 months or 183 days after the last recorded visit, so the date of LTFU is the date of the last recorded visit plus 273. For patients who transitioned to LTFU from the ART state, the date of LTFU is calculated as 60 days after the day the patient is expected to come back, i.e. 30 days after the last recorded visit (the LTFU date is the date of the last recorded visit plus 90 days); in cases where patients experienced multiple interruptions of 180 days or more, the date of LTFU is the date of the first interruption plus 90 days.

Fig 2. Subject flow.

Fig 3. Events in the multistate model.