Abstract
ABSTRACT Background: Access to antiretroviral therapy (ART) has expanded in Haiti because of the adoption of Option B+ and the revision of treatment guidelines. Retention in care and treatment varies greatly and few studies have examined retention rates, particularly among women enrolled in Option B+. Objective: To assess attrition among pregnant and non-pregnant patients initiating ART following adoption of Option B+ in Haiti. Methods: Longitudinal data of adult patients initiated on ART from October 2012 through August 2014 at 73 health facilities across Haiti were analyzed using a survival analysis framework to determine levels of attrition. The Kaplan–Meier method and Cox proportional hazards regression were used to examine risk factors associated with attrition. Results: Among 17,059 patients who initiated ART, 7627 (44.7%) were non-pregnant women, 5899 (34.6%) were men, and 3533 (20.7%) were Option B+ clients. Attrition from the ART program was 36.7% at 12 months (95% CI: 35.9–37.5%). Option B+ patients had the highest level of attrition at 50.4% at 12 months (95% CI: 48.6–52.3%). While early HIV disease stage at ART initiation was protective among non-pregnant women and men, it was a strong risk factor among Option B+ clients. In adjusted analyses, key protective factors were older age (p < 0.0001), living near the health facility (p = 0.04), having another known HIV-positive household member (p < 0.0001), having greater body mass index (BMI) (p < 0.0001), pre-ART counseling (p < 0.0001), and Cotrimoxazole prophylaxis during baseline (p < 0.01). Higher attrition was associated with rapidly starting ART after enrollment (p < 0.0001), anemia (p < 0.0001), and regimen tenofovir+lamivudine+nevirapine (TDF+3TC+NVP) (p < 0.001). Conclusions: ART attrition in Haiti is high among adults, especially among Option B+ patients. Identifying newly initiated patients most at risk for attrition and providing appropriate interventions could help reduce ART attrition.
Highlights
Access to antiretroviral therapy (ART) has expanded in Haiti because of the adoption of Option B+ and the revision of treatment guidelines
Since the early phases of ART scaleup in low- and middle-income countries (LMICs), support for adherence and retention in care has been an important component of treatment programs
The objective of the analysis presented here is to determine the level of attrition in a large cohort of pregnant and non-pregnant adults initiating ART from October 2012 through August 2014 from 73 health facilities in Haiti: We assess the risk factors associated with ART attrition notably in the context of the nationwide rollout of ‘test and start’
Summary
Access to antiretroviral therapy (ART) has expanded in Haiti because of the adoption of Option B+ and the revision of treatment guidelines. Retention in care and treatment varies greatly and few studies have examined retention rates, among women enrolled in Option B+. Global expansion of access to HIV antiretroviral therapy (ART) has exceeded targets, with over 17 million patients receiving ART including 10.3 million in eastern and southern Africa and 1.1 million in Latin America and the Caribbean [1]. The adoption of the Option B+ policy which offers lifelong ART to all HIV-infected pregnant and breastfeeding women [4,5] and the revision of the treatment guidelines greatly contributed to that expansion. More than 80,000 patients are receiving ART including nearly 90% of HIV-infected pregnant and breastfeeding women [6]. Studies on ART retention have shown promising results, with many national and sub-national programs achieving average retention levels of ≥ 75% at 12 months
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