Patient Retention In HIV Care Research Articles

Barriers and Enablers for Adherence to Antiretroviral Therapy Among People Living With HIV/AIDS in the Era of COVID-19: A Qualitative Study From Pakistan.

Background: With the increased availability of safe antiretroviral therapy (ART) in recent years, achieving optimal adherence and patient retention is becoming the biggest challenge for people living with HIV (PLWH). Care retention is influenced by several socioeconomic, socio-cultural, and government policies during the COVID-19 pandemic. Therefore, we aim to explore barriers and facilitators to adherence to ART among PLWH in Pakistan in general and COVID-19 pandemic related in particular. Methods: Semi-structured interviews were conducted among 25 PLWH from December 2020 to April 2021 in the local language (Urdu) at the ART centre of Pakistan Institute of Medical Sciences, Islamabad, Pakistan. Interviews were audio-recorded in the local Urdu language, and bilingual expert (English, Urdu) transcribed verbatim, coded for themes and sub-themes, and analyzed using a phenomenological approach for thematic content analysis. Results: Stigma and discrimination, fear of HIV disclosure, economic constraints, forgetfulness, religion (Ramadan, spiritual healing), adverse drug reactions, lack of social support, alternative therapies, and COVID-19-related lock-down and fear of lesser COVID-19 care due to HIV associated stigma were identified as barriers affecting the retention in HIV care. At the same time, positive social support, family responsibilities, use of reminders, the beneficial impact of ART, and initiation of telephone consultations, courier delivery, and long-term delivery of antiretrovirals during COVID-19 were identified as facilitators of HIV retention. Conclusion: Improving adherence and retention is even more challenging due to COVID-19; therefore, it requires the integration of enhanced access to treatment with improved employment and social support. HIV care providers must understand these reported factors comprehensively and treat patients accordingly to ensure the continuum of HIV care. A coordinated approach including different stakeholders is required to facilitate patient retention in HIV care and consequently improve the clinical outcomes of PLWH.

Factors Predicting Retention In Care and Health Outcomes Among HIV Patients

Factors Predicting Retention In Care and Health Outcomes Among HIV Patients

Point of Diagnosis and Patient Retention in HIV Care in Western Kenya.

Home-based counseling and testing (HBCT) achieves earlier HIV diagnosis than other testing modalities; however, retention in care for these healthier patients is unknown. The objective of this study was to determine the association between point of HIV testing and retention in care and mortality. Academic Model Providing Access to Healthcare (AMPATH) has provided HIV care in western Kenya since 2001. AMPATH initiated HBCT in 2007. This retrospective analysis included individuals 13 years and older, enrolled in care between January 2008 and September 2016, with data on point of testing. Discrete-time multistate models were used to estimate the probability of transition between the following states: engaged, disengaged, transfer, and death, and the association between point of diagnosis and transition probabilities. Among 77,358 patients, 67% women, median age: 35 years and median baseline CD4: 248 cells/mm. Adjusted results demonstrated that patients from HBCT were less likely to disengage [relative risk ratio (RRR) = 0.87, 95% CI: 0.83 to 0.91] and die (RRR = 0.65, 95% CI: 0.55 to 0.75), whereas those diagnosed through provider-initiated counseling and testing were more likely to disengage (RRR = 1.09, 95% CI: 1.07 to 1.12) and die (RRR = 1.13, 95% CI: 1.06 to 1.20), compared with patients from voluntary counseling and testing. Once disengaged, patients from HBCT were less likely to remain disengaged, compared with patients from voluntary counseling and testing. Patients entering care from different HIV-testing programs demonstrate differences in retention in HIV care over time beyond disease severity. Additional research is needed to understand the patient and system level factors that may explain the associations between testing program, retention, and mortality.

Ethical issues in the use of SMS messaging in HIV care and treatment in low- and middle-income countries: case examples from Mozambique.

The introduction of mobile communication technologies in health care in low- and middle-income countries offers an opportunity for increased efficiencies in provision of care, improved utilization of scarce resources, reductions in workload, and increased reach of services to a larger target population. Short message service (SMS) technologies offer promise, with several large-scale SMS-based implementations already under way. Still largely lacking in the research literature are evaluations of specific ethical issues that arise when SMS programs are implemented and studied in resource-limited settings. In this paper, we examine the ethical issues raised by the deployment of SMS messaging to support patient retention in HIV care and treatment and in the research conducted to evaluate that deployment. We use case studies that are based in Mozambique and ground our discussion in the ethical framework for international research proposed by Emanuel et al., highlighting ethical considerations needed to guide the design and implementation of future SMS-based interventions. Such guidance is increasingly needed in countries such as Mozambique, where the local capacity for ethical study design and oversight is still limited and the scale-up and study of mHealth initiatives are still driven predominantly by international collaborators. These issues can be complex and will need ongoing attention on a case-by-case basis to ensure that appropriate protections are in place, while simultaneously maximizing the potential benefit of new mHealth technologies.

Understanding data sources to measure patient retention in HIV care in sub-Saharan Africa.

Antiretroviral therapy (ART) programs in sub-Saharan Africa are moving towards universal treatment, yet the success of these programs is threatened by gaps within the continuum of HIV care. In this commentary, we seek to draw attention to the advantages and limitations of different data sources currently used for measuring retention in HIV care. Within the context of a piecemeal combination of imperfect data sources, selecting a gold standard of collecting retention data is difficult. Currently, our data systems for measuring retention provide an incomplete picture of the health of our national ART systems and, thus, the health of our patients.

Factors associated with long-term antiretroviral therapy attrition among adolescents in rural Uganda: a retrospective study.

IntroductionAs access to antiretroviral therapy (ART) increases, the success of treatment programmes depends on ensuring high patient retention in HIV care. We examined retention and attrition among adolescents in ART programmes across clinics operated by The AIDS Support Organization (TASO) in Uganda, which has operated both facility- and community-based distribution models of ART delivery since 2004.MethodsUsing a retrospective cohort analysis of patient-level clinical data, we examined attrition and retention in HIV care and factors associated with attrition among HIV-positive adolescents aged 10–19 years who initiated ART at 10 TASO clinics between January 2006 and December 2011. Retention in care was defined as the proportion of adolescents who had had at least one facility visit within the six months prior to 1 June 2013, and attrition was defined as the proportion of adolescents who died, were lost to follow-up, or stopped treatment. Descriptive statistics and Cox proportional hazards regression models were used to determine the levels of retention in HIV care and the factors associated with attrition following ART initiation.ResultsA total of 1228 adolescents began ART between 2006 and 2011, of whom 57% were female. The median duration in HIV care was four years (IQR=3–6 years). A total of 792 (65%) adolescents were retained in care over the five-year period; 36 (3%) had died or transferred out and 400 (32%) were classified as loss to follow-up. Factors associated with attrition included being older (adjusted hazard ratio (AHR)=1.38, 95% confidence interval (CI) 1.02–1.86), having a higher CD4 count (250+ cells/mm3) at treatment initiation (AHR=0.49, 95% CI 0.34–0.69) and HIV care site with a higher risk of attrition among adolescents in Gulu (AHR=2.26; 95% CI 1.27–4.02) and Masindi (AHR=3.30, 95% CI 1.87–5.84) and a lower risk of attrition in Jinja (AHR=0.24, 95% CI 0.08–0.70). Having an advanced WHO clinical stage at initiation was not associated with attrition.ConclusionsWe found an overall retention rate of 65%, which is comparable to rates achieved by TASO's adult patients and adolescents in other studies in Africa. Variations in the risk of attrition by TASO treatment site and by clinical and demographic characteristics suggest the need for early diagnosis of HIV infection, use of innovative approaches to reach and retain adolescents living with HIV in treatment and identifying specific groups, such as older adolescents, that are at high risk of dropping out of treatment for targeted care and support.

Giving Voice to Patients in Rural Haiti: An Assessment of Retention in HIV Care

Objective: Initiatives aimed at improving patient retention in HIV care in Haiti have focused on a wide range of tactics for identifying individuals who are lost to follow-up yet the patient perspective is often missing from efforts to understand and address the root causes of lost to follow-up. Methods: As part of a routine quality control audit of the HIV program, structured interviews were conducted with 100 patients who had returned to care after previously being lost to follow-up at three rural health centers in the Lower Artibonite region of Haiti supported by the non-governmental organization Zanmi Lasante. These interviews uncovered factors that contributed to patients’ previous lack of follow up and elucidated factors that influenced their return to care. The interviews sought to capture the patients’ preferred communication methods and their suggestions for improvements in HIV care at the health facility. Results: As part of a quality of care audit, 100 patients were interviewed in November and December 2014, and their reasons for loss to follow-up were identified. The common factors noted were socio-economic barriers to remaining in care, challenges affecting case management at both provider and the facility level, and patient perceptions of good health. 74% of the respondents identified increased communication by health care professionals through telephone calls and home visits as the reason they chose to return to care. Respondents suggested increase in economic and transportation support, improved communication between providers and patients, improved clinic experience, and increased medication management as factors that would decrease lost to follow up in the future. Conclusion: Reasons for loss to follow-up in this rural Haitian population reflect similar social and structural barriers common to lost to follow-up populations globally, however patients participating in these interviews reported unique barriers in communication as inhibiting factors to remaining in care. By utilizing this feedback from end users of the health system as an essential component in the design and implementation of service improvements, health systems can more effectively diminish loss to follow-up.

Outcomes of a Clinic-Based Surveillance-Informed Intervention to Relink Patients to HIV Care

Improving patient retention in HIV care is crucial to improving the HIV care continuum. We instituted and evaluated a relinkage program that uses clinical data to identify potentially out-of-care patients, matches those data to public health surveillance, and employs a linkage specialist (LS) to coordinate care relinkage. The intervention began November 1, 2012, in the largest HIV clinic in Washington State. We evaluated program outcomes and compared patient outcomes in the year after initiation of the intervention to a historical control cohort of patients. Cox proportional hazard ratios were used to compare time to relinkage to care between cohorts, and regression models using generalized estimated equations were preformed to examine secondary outcomes of relinkage to care, engagement in care, and viral suppression. A total of 753 patients were identified as "out of care" on November 1, 2012. Matching with surveillance data and initial LS investigations found that 596 (79%) of these patients had moved, transferred care, or were incarcerated. Of the 157 remaining patients, 40 (25%) relinked to care before LS contact, and the LS successfully contacted 38 (24%). A total of 116 (15%) patients in the intervention cohort relinked to care and 24 (20%) were contacted by the LS. Compared with the historical cohort, the time to relinkage was shorter among patients in the intervention cohort [adjusted hazard ratio = 1.7 (1.2-2.3)] and a greater proportion relinked (15% vs. 10%). This clinic-based surveillance-informed relinkage intervention showed statistically significant but modest effectiveness in returning out-of-care patients to HIV care compared with historical controls.

Barriers and facilitators to patient retention in HIV care.

BackgroundRetention in HIV care improves survival and reduces the risk of HIV transmission to others. Multiple quantitative studies have described demographic and clinical characteristics associated with retention in HIV care. However, qualitative studies are needed to better understand barriers and facilitators.MethodsSemi-structured interviews were conducted with 51 HIV-infected individuals, 25 who were retained in care and 26 not retained in care, from 3 urban clinics. Interview data were analyzed for themes using a modified grounded theory approach. Identified themes were compared between the two groups of interest: patients retained in care and those not retained in care.ResultsOverall, participants identified 12 barriers and 5 facilitators to retention in HIV care. On average, retained individuals provided 3 barriers, while persons not retained in care provided 5 barriers. Both groups commonly discussed depression/mental illness, feeling sick, and competing life activities as barriers. In addition, individuals not retained in care commonly reported expensive and unreliable transportation, stigma, and insufficient insurance as barriers. On average, participants in both groups referenced 2 facilitators, including the presence of social support, patient-friendly clinic services (transportation, co-location of services, scheduling/reminders), and positive relationships with providers and clinic staff.ConclusionsIn our study, patients not retained in care faced more barriers, particularly social and structural barriers, than those retained in care. Developing care models where social and financial barriers are addressed, mental health and substance abuse treatment is integrated, and patient-friendly services are offered is important to keeping HIV-infected individuals engaged in care.

Correlates of Patient Retention in HIV Care and Treatment Programs in Nigeria.

Long-term retention is a crucial component of HIV care because treatment success can only be measured among retained patients. Understanding determinants of retention will inform retention strategies. We evaluated the correlates of retention in a large HIV program in Nigeria. We reviewed quality of care data for 5320 randomly selected HIV-positive adults aged ≥15 years enrolled in 37 treatment facilities in Nigeria between 2005 and 2009. Retention was described as having one or more clinic visits in the one year (2010) review period. Patient-related correlates of retention were determined using logistic regression. 144 patients exited the program through deaths or transferrals. Of the 5176 with no documented exits, 3231 (62.4%) were retained (65.6% female; median age: 35.6 years). 2938 (75.8%) patients on ART, and 286 (23.4%) pre-ART patients were retained. Being on ART (OR=10.3, p<0.001), Age 30-60 years (30 - 45 years: OR=1.36, p<0.001 and >45 - 60 years: OR=1.47, p<0.001) compared to patients <30 years; Female gender (OR=1.18, p=0.006), baseline CD4 cell count (100-350 cells/mm(3): OR=1.24, p=0.006) vs <100 cells/mm(3) and lower WHO stage at baseline (WHO Stage IV, III, II: OR=0.50,0.51,0.77 respectively) vs Stage I were associated with retention. Among patients on ART, recent ART initiation 2008-09 (OR=1.73, p<0.001) vs 2005-07, being on ART for >6 months (p<0.001) vs <6 month and initiating ART on non-Stavudine based regimen (p<0.001) were also associated with retention. 3 out of 4 pre-ART patients and 1-in-4 ART patients were not retained in 37 HIV treatment facilities in Nigeria. These findings provide insight that enables HIV programs integrate retention strategies at all stages of the HIV care continuum.

Barriers to HIV Care and Treatment Among Participants in a Public Health HIV Care Relinkage Program.

Improving patient retention in HIV care and use of antiretroviral therapy (ART) are key steps to improving the HIV care continuum in the US. However, contemporary quantitative data on barriers to care and treatment from population-based samples of persons poorly engaged in care are sparse. We analyzed the prevalence of barriers to clinic visits, ART initiation, and ART continuation reported by 247 participants in a public health HIV care relinkage program in King County, WA. We identified participants using HIV surveillance data (N=188) and referrals from HIV/STD clinics and partner services (N=59). Participants most commonly reported insurance (50%), practical (26-34%), and financial (30%) barriers to care, despite residing in a state with essentially universal access to HIV care. Perceived lack of need for medical care was uncommon (<20%), but many participants (58%) endorsed a perceived lack of need for medication as a reason for not initiating ART. Depression and substance abuse were both highly prevalent (69% and 54%, respectively), and methamphetamine was the most commonly abused substance. Barriers to HIV care and treatment may be amenable to intervention by health department outreach in coordination with existing HIV medical and support services.

Higher Quality Communication and Relationships Are Associated With Improved Patient Engagement in HIV Care

Patient retention in HIV care may be influenced by patient-provider interactions. In an urban, academic HIV clinic, 1363 patients rated the quality of communication and relationships with their providers on 5 domains. We used linear regressions to investigate associations between these 5 domains and appointment adherence. In multivariate analysis, patients kept more appointments if providers treated them with dignity and respect, listened carefully to them, explained in ways they could understand, and knew them as persons. Being involved in decisions was not significantly associated with appointment adherence. Enhancing providers' skills in effective communication and relationship building may improve patient retention in HIV care.