Predictors of lost to follow up from antiretroviral therapy among adults in sub-Saharan Africa: a systematic review and meta-analysis

Abstract

Background: It is known that 'drop out' from human immunodeficiency virus (HIV) treatment, the so called lost-to-follow-up (LTFU) occurs to persons enrolled in HIV care services. However, in sub-Saharan Africa (SSA), the risk factors for the LTFU are not well understood.

Methods: We performed a systematic review and meta-analysis of risk factors for LTFU among adults living with HIV in SSA. A systematic search of literature using identified keywords and index terms was conducted across five databases: MEDLINE, PubMed, CINAHL, Scopus, and Web of Science. We included quantitative studies published in English from 2002 to 2019. The Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used for methodological validity assessment and data extraction. Mantel Haenszel method using Revman-5 software was used for meta-analysis. We demonstrated the meta-analytic measure of association using pooled odds ratio (OR), 95% confidence interval (CI) and heterogeneity using I² tests.

Results: Thirty studies met the search criteria and were included in the meta-analysis. Predictors of LTFU were: demographic factors including being: (i) a male (OR = 1.2, 95% CI 1.1-1.3, I² = 59%), (ii) between 15 and 35 years old (OR = 1.3, 95% CI 1.1-1.3, I² = 0%), (iii) unmarried (OR = 1.2, 95% CI 1.2-1.3, I² = 21%), (iv) a rural dweller (OR = 2.01, 95% CI 1.5-2.7, I² = 40%), (v) unemployed (OR = 1.2, 95% CI 1.04-1.4, I² = 58%); (vi) diagnosed with behavioral factors including illegal drug use(OR = 13.5, 95% CI 7.2-25.5, I² = 60%), alcohol drinking (OR = 2.9, 95% CI 1.9-4.4, I² = 39%), and tobacco smoking (OR = 2.6, 95% CI 1.6-4.3, I² = 74%); and clinical diagnosis of mental illness (OR = 3.4, 95% CI 2.2-5.2, I² = 1%), bed ridden or ambulatory functional status (OR = 2.2, 95% CI 1.5-3.1, I² = 74%), low CD4 count in the last visit (OR = 1.4, 95% CI 1.1-1.9, I² = 75%), tuberculosis co-infection (OR = 1.2, 95% CI 1.02-1.4, I² = 66%) and a history of opportunistic infections (OR = 2.5, 95% CI 1.7-2.8, I² = 75%).

Conclusions: The current review identifies demographic, behavioral and clinical factors to be determinants of LTFU. We recommend strengthening of HIV care services in SSA targeting the aforementioned group of patients. Trial registration Protocol: the PROSPERO Registration Number is CRD42018114418.

Keywords: Antiretroviral therapy; Defaulting; Discontinuation; HIV; Lost to follow up; Meta-analysis; Sub-Sharan Africa; Systematic review.

Fig. 1

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flowchart detailing the identification and selection of studies for inclusion in the review. It describes the flowchart of search strategy

Fig. 2

Forest plot of the meta-analytic association between age and LTFU. It shows that the risk of loss to follow up is higher in younger patients relative to their older counterparts

Fig. 3

Forest plot of meta-analytic association between sex and LTFU. It shows that the risk of lost to follow up is higher among males than female patients

Fig. 4

Forest plot of meta-analytic association between marital status and LTFU. It shows that the risk of lost to follow up is higher among single or widowed or divorced than married

Fig. 5

Forest plot of meta-analytic association between residence and LTFU. It shows that the risk of lost to follow up is higher in rural than urban residents

Fig. 6

Forest plot of meta-analytic association between educational status and LTFU. It shows that the risk of lost to follow up is not associated with literacy level

Fig. 7

Forest plot of meta-analytic association between employment and LTFU. It shows that the risk of lost to follow up is higher in unemployed patients

Fig. 8

Forest plot of meta-analytic association between partners HIV status and LTFU. It shows that the studies show high heterogenicity

Fig. 9

Forest plot of meta-analytic association between hard drugs use and LTFU. It shows that the risk of lost to follow up is higher in patients who are hard drug uses

Fig. 10

Forest plot of meta-analytic association between tobacco smoking and LTFU. It shows that the risk of lost to follow up is higher in patient’s tobacco smokers

Fig. 11

Forest plot of meta-analytic association between alcohol drinking and LTFU. It shows that the risk of lost to follow up from ART is higher in patients who drink alcohol

Fig. 12

Forest plot of meta-analytic association between base line functional status and LTFU. It shows that the risk of lost to follow up is higher in bed ridden and ambulatory than working patients

Fig. 13

Forest plot of meta-analytic association between WHO clinical stage and LTFU. It shows that the studies show high heterogenicity

Fig. 14

Forest plot of meta-analytic association between base line CD4 count and LTFU. It shows that the risk of lost to follow up is higher in patients with low than high CD4 count

Fig. 15

Forest plot of meta-analytic association between having history of OI treatment and LTFU. It shows that the risk of lost to follow up is higher in patients with history of OI treatment

Fig. 16

Forest plot of meta-analytic association between mental status and LTFU. It shows that the risk of lost to follow up is higher in patients with mental illness than their counterparts

Fig. 17

Forest plot of meta-analytic association between TB coinfection and LTFU. It shows that the risk of lost to follow up is higher in patients co-infected with TB

Fig. 18

Forest plot of meta-analytic association between adherence status and LTFU. It shows that the studies show high heterogenicity

Fig. 19

Forest plot of meta-analytic association between drug toxicity experience and LTFU. It shows that the studies have high heterogenicity

Fig. 20

Forest plot of meta-analytic association between cotrimoxazole prophylaxis and LTFU. It shows that the studies have high heterogenicity