Incidence and predictors of attrition among patients receiving ART in eastern Zimbabwe before, and after the introduction of universal 'treat-all' policies: A competing risk analysis.

Malebogo Tlhajoane,Jeffrey W Eaton,Simon Gregson,Constance Nyamukapa,Freedom Dzamatira,Noah Kadzura,Godfrey N Musuka

doi:10.1371/journal.pgph.0000006

Abstract

As HIV treatment is expanded, attention is focused on minimizing attrition from care. We evaluated the impact of treat-all policies on the incidence and determinants of attrition amongst clients receiving ART in eastern Zimbabwe. Data were retrospectively collected from the medical records of adult patients (aged≥18 years) enrolled into care from July 2015 to June 2016-pre-treat-all era, and July 2016 to June 2017-treat-all era, selected from 12 purposively sampled health facilities. Attrition was defined as an absence from care >90 days following ART initiation. Survival-time methods were used to derive incidence rates (IRs), and competing risk regression used in bivariate and multivariable modelling. In total, 829 patients had newly initiated ART and were included in the analysis (pre-treat-all 30.6%; treat-all 69.4%). Incidence of attrition (per 1000 person-days) increased between the two time periods (pre-treat-all IR = 1.18 (95%CI: 0.90-1.56) versus treat-all period IR = 1.62 (95%CI: 1.37-1.91)). In crude analysis, patients at increased risk of attrition were those enrolled into care during the treat-all period, <34 years of age, WHO stage I at enrolment, and had initiated ART on the same day as HIV diagnosis. After accounting for mediating clinical characteristics, the difference in attrition between the pre-treat-all, and treat-all periods ceased to be statistically significant. In a full multivariable model, attrition was significantly higher amongst same-day ART initiates (aSHR = 1.47, 95%CI:1.05-2.06). Implementation of treat-all policies was associated with an increased incidence of ART attrition, driven largely by ART initiation on the same day as HIV diagnosis which increased significantly in the treat all period. Differentiated adherence counselling for patients at increased risk of attrition, and improved access to clinical monitoring may improve retention in care.

Highlights

Increasing empirical evidence has shown the clinical benefits of antiretroviral therapy (ART) for all people living with HIV (PLHIV) regardless of their immunological status [1, 2]
These include a reduction in rates of severe HIV-related illness and mortality, approximately 23% reported in Uganda and Kenya, improved levels of viral suppression at the population level, and a reduction in HIV incidence [3,4,5]
This is of concern amongst those with higher CD4 cell counts (>500 cells/mm3) who are eligible for ART and may be more likely to experience attrition [16]

Summary

Introduction

Increasing empirical evidence has shown the clinical benefits of antiretroviral therapy (ART) for all people living with HIV (PLHIV) regardless of their immunological status [1, 2]. In Botswana, Zambia and South Africa for example, reductions of 20% to 30% in HIV incidence were observed in the intervention arms of two clinical trials when compared to the control arms [4, 6, 7] These findings prompted the World Health Organization (WHO) to recommend immediate initiation of ART to all PLHIV through a policy initiative known as ‘treat-all’ [8]. Several studies have documented high rates of attrition ( 10%) amongst those receiving ART [12,13,14,15], a phenomenon that is of particular interest as treat-all policies are scaled-up, and more PLHIV are initiated onto treatment. Patient-level data were collected from a national electronic patient monitoring system (ePMS), more commonly used in high-volume health facilities which may differ from smaller primary care facilities in service provision [20]

Methods

Results

Discussion

Conclusion