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Shi F, Zhang J, Hung P, Sun X, Yang X, Olatosi B, Weissman S, Li X. Travel Burden and Timely Linkage to Care Among People Newly Diagnosed with HIV Infection in South Carolina from 2005 to 2020. AIDS Behav 2024:10.1007/s10461-024-04411-1. [PMID: 38884666 DOI: 10.1007/s10461-024-04411-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2024] [Indexed: 06/18/2024]
Abstract
This retrospective study explored the association between travel burden and timely linkage to care (LTC) among people with HIV (PWH) in South Carolina. HIV care data were derived from statewide all-payer electronic health records, and timely LTC was defined as having at least one viral load or CD4 count record within 90 days after HIV diagnosis before the year 2015 and 30 days after 2015. Travel burden was measured by average driving time (in minutes) to any healthcare facility visited within six months before and one month after the initial HIV diagnosis. Multivariable logistic regression models with the least absolute shrinkage and selection operator were employed. From 2005 to 2020, 81.2% (3,547 out of 4,366) of PWH had timely LTC. Persons who had longer driving time (adjusted Odds Ratio (aOR): 0.37, 95% CI: 0.14-0.99), were male versus female (aOR: 0.73, 95% CI: 0.58-0.91), had more comorbidities (aOR: 0.73, 95% CI: 0.57-0.94), and lived in counties with a higher percentage of unemployed labor force (aOR: 0.21, 95% CI: 0.06-0.71) were less likely to have timely LTC. However, compared to those aged between 18 and 24 years old, those aged between 45 and 59 (aOR:1.47, 95% CI: 1.14-1.90) or older than 60 (aOR:1.71, 95% CI: 1.14-2.56) were more likely to have timely LTC. Concentrated and sustained interventions targeting underserved communities and the associated travel burden among newly diagnosed PWH who are younger, male, and have more comorbidities are needed to improve LTC and reduce health disparities.
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Affiliation(s)
- Fanghui Shi
- Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA.
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA.
| | - Jiajia Zhang
- Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
| | - Peiyin Hung
- Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
| | - Xiaowen Sun
- Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
| | - Xueying Yang
- Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
| | - Bankole Olatosi
- Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
| | - Sharon Weissman
- Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
- Department of Internal Medicine, School of Medicine, University of South Carolina, Columbia, SC, 29208, USA
| | - Xiaoming Li
- Arnold School of Public Health, South Carolina SmartState Center for Healthcare Quality, University of South Carolina, 915 Greene Street, Columbia, SC, 29208, USA
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
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Kebede HK, Mwanri L, Ward P, Gesesew HA. Predictors of lost to follow up from antiretroviral therapy among adults in sub-Saharan Africa: a systematic review and meta-analysis. Infect Dis Poverty 2021; 10:33. [PMID: 33743815 PMCID: PMC7981932 DOI: 10.1186/s40249-021-00822-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 03/08/2021] [Indexed: 01/14/2023] Open
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.
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Affiliation(s)
- Hafte Kahsay Kebede
- Clinical Pharmacy, College of Health Sciences, Defense University, Debrezeit, Ethiopia
| | - Lillian Mwanri
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Paul Ward
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Hailay Abrha Gesesew
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Epidemiology Department, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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Craig SL, Austin A, Levenson J, Leung VWY, Eaton AD, D'Souza SA. Frequencies and patterns of adverse childhood events in LGBTQ+ youth. CHILD ABUSE & NEGLECT 2020; 107:104623. [PMID: 32682145 DOI: 10.1016/j.chiabu.2020.104623] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/14/2020] [Accepted: 07/03/2020] [Indexed: 05/16/2023]
Abstract
BACKGROUND Trauma, specifically adverse childhood experiences (ACEs), predicts significant health and mental health disparities, yet there is a paucity of research with LGBTQ + youth. OBJECTIVE This study explored ACE prevalence in a large sample of LGBTQ+ youth; examined ACE patterns within and across subgroups; and compared results with the general population. PARTICIPANTS AND SETTING Participant (n = 3,508) ages ranged between 14-18 (x̄ = 16.02) and represented a range of sexual orientations: pansexual (33.9 %), bisexual (26.6 %), and queer (16.2 %), and gender identities: female (39.9 %), non-conforming (38 %), male (14.9 %), and transgender (16.6 %). METHODS An online cross-sectional survey was conducted with LGBTQ+ youth ages 14-18 that self-identified as LGBTQ+ and resided in the US or Canada. Descriptive statistics generated the prevalence of ACEs, and ANOVAs and post-hoc tests were run for comparisons. RESULTS Participants reported multiple ACEs (M = 3.14, SD = 2.44) with emotional neglect (58 %), emotional abuse (56 %), and living with a family member with mental illness (51 %) as the most prevalent. Notably, 43 % of participants experienced 4+ ACEs, considered to be a high level of trauma exposure. Compared to national samples, LGBTQ + youth demonstrated unique patterns of ACEs and were higher in 9 of 10 categories. Significantly high (all p < .001) ACEs were found in pansexual (t = 7.67), transgender and gender non-conforming (t = 5.19), American-Indian (t = 6.42), Latinx (t = 2.83) and rural youth (F = 12.12) while those with highly educated parents (F = 83.30, p < .001), lived with a parent (t = 6.02), and in Canada (t = 6.14) reported fewer ACEs. CONCLUSION LGBTQ+ youth experience significant childhood trauma with potential impact on their mental health. This study identifies implications for trauma-informed practice and research.
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Affiliation(s)
- Shelley L Craig
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor St. W., Toronto, ON, M5S 1V4, Canada.
| | - Ashley Austin
- Ellen Whiteside McDonnell Faculty of Social Work, Barry University, 11300 NE 2nd Ave., Miami Shores, FL, 33161-6695, USA.
| | - Jill Levenson
- Ellen Whiteside McDonnell Faculty of Social Work, Barry University, 11300 NE 2nd Ave., Miami Shores, FL, 33161-6695, USA.
| | - Vivian W Y Leung
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor St. W., Toronto, ON, M5S 1V4, Canada.
| | - Andrew D Eaton
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor St. W., Toronto, ON, M5S 1V4, Canada.
| | - Sandra A D'Souza
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor St. W., Toronto, ON, M5S 1V4, Canada.
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Woodward EN, Cunningham JL, Flynn AWP, Mereish EH, Banks RJ, Landes SJ, Kirchner JE, Pantalone DW. Sexual minority men want provider behavior consistent with attitudes and norms during patient-provider interactions regarding HIV prevention. PSYCHOL HEALTH MED 2019; 25:354-367. [PMID: 31429323 DOI: 10.1080/13548506.2019.1656338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
HIV is a health problem for sexual minority men in the United States. One factor among many that contributes to this HIV disparity is poor patient-provider interactions. We focused on specific provider behavior preferred by sexual minority men during patient-provider interactions about HIV prevention. We interviewed 20 HIV-negative sexual minority men who endorsed 1+ psychosocial HIV risk factor. We used follow up interviews and conventional content analysis. Among our sample, 55% identified as White; 50% as bisexual, (Mage = 28.45). Findings suggested even some providers knowledgeable about sexual minority health provided unhelpful care to sexual minority men (knowledge-behavior discrepancy). Some knowledgeable providers engaged in affirmative, tailored treatment (knowledge-behavior consistency). Specific behaviors of preferred patient-provider interactions regarding HIV prevention are reported. Our recommendations are based on patient perceptions, which is a limit and strength. We identified an important type of unhelpful patient-provider interaction for HIV-negative sexual minority men beyond discriminatory experiences. Patient-provider interaction efforts need to go beyond education to help providers practice skills. With increased focus on cultural competency for sexual minority patients, more providers may advertise their practice as affirmative, yet interactions will likely vary, may require lifelong practice of cultural humility, and impact HIV prevention.
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Affiliation(s)
- Eva N Woodward
- Central Arkansas Veterans Healthcare System, VA Center for Mental Healthcare and Outcomes Research, North Little Rock, AR, USA.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Anthony W P Flynn
- Department of Psychology, University of Massachusetts Boston, Boston, MA, USA.,Department of Counseling Psychology, University of Wisconsin, Madison, WI, USA
| | - Ethan H Mereish
- Department of Health Studies, American University, Washington, DC, USA
| | - Regina J Banks
- Degree Completion Program, Fresno Pacific University, Fresno, CA, USA
| | - Sara J Landes
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,US Department of Veterans Affairs, VA QUERI for Team Based Behavioral Health, North Little Rock, AR
| | - Joann E Kirchner
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,US Department of Veterans Affairs, VA QUERI for Team Based Behavioral Health, North Little Rock, AR
| | - David W Pantalone
- Department of Psychology, University of Massachusetts Boston, Boston, MA, USA.,The Fenway Institute, Fenway Health, Boston, MA, USA
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Canoy N, Thapa S, Hannes K. Transgender persons' HIV care (dis)engagement: a qualitative evidence synthesis protocol from an ecological systems theory perspective. BMJ Open 2019; 9:e025475. [PMID: 30670527 PMCID: PMC6347901 DOI: 10.1136/bmjopen-2018-025475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION There seems to be little information on interactional patterns of enabling and constraining factors contributing to HIV care engagement across systems and across time. Understanding these patterns from a (micro-meso-macro-exo) systems perspective can provide rich insights on relevant social networks affecting transgender populations. In this review, we will synthesise the wealth of literature on transgender persons' engagement in the HIV care continuum. METHODS AND ANALYSIS We will perform a networked systems approach to qualitative evidence synthesis of relevant qualitative research data generated from primary qualitative, mixed-method and evaluation studies exploring HIV care engagement among diverse transgender populations. Studies not using qualitative methods and studies not published in English will be excluded from this review. Empirical studies will be identified via a search in major databases such as PubMed, Scopus, ERIC, Embase, Web of Science, Sociological Abstracts, PsychInfo and Social Services Abstract in January 2019. Two reviewers will independently screen the studies for inclusion, assess their quality and extract data. In case some of the system levels in the network are ill-covered by empirical studies, non-empirical studies will be considered for inclusion. The qualitative evidence synthesis includes a summary of descriptive data (first order), an exploration of relationships between system levels or their components (second order) and a structured summary of research evidence through narrative synthesis. The narrative synthesis will be extended with an overall social network analysis that visualises important nodes and links cutting across ecological systems. ETHICS AND DISSEMINATION Ethical approval is not required to conduct this review. Review findings will be disseminated via peer-reviewed academic journals and a targeted information campaign towards organisations that work with our population of interest. PROSPERO REGISTRATION NUMBER CRD42018089956.
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Affiliation(s)
- Nico Canoy
- Department of Psychology, Ateneo de Manila University, Quezon City, Manila, Philippines
| | - Subash Thapa
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Karin Hannes
- Social Research Methodology Group, Faculty of Social Sciences, Leuven, Belgium
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Reisner SL, Jadwin-Cakmak L, White Hughto JM, Martinez M, Salomon L, Harper GW. Characterizing the HIV Prevention and Care Continua in a Sample of Transgender Youth in the U.S. AIDS Behav 2017. [PMID: 29138982 DOI: 10.1007/s10461-017-1938-] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
In the U.S., transgender and other gender minority (TG) youth are an at-risk group understudied in HIV prevention and treatment. This study sought to characterize the HIV prevention and care continua in a diverse sample of 181 sexually-active TG ages 16-24 years (mean age = 20.7 years; 76.8% trans feminine; 69.1% youth of color) recruited July-December 2015 in 14 U.S. cities. Overall, 30.9% reported living with HIV, of which 71.4% were on antiretroviral therapy (ART) and 55.0% were medication adherent; 65.6% were known to be virally suppressed. In multivariable models, medical gender affirmation was associated with lower odds of viral suppression. Medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. Among at-risk TG youth not living with HIV, only 8.2% had accessed pre-exposure prophylaxis (PrEP). Early biobehavioral prevention and treatment interventions are needed for TG youth.
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Affiliation(s)
- Sari L Reisner
- Division of General Pediatrics, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA.
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- The Fenway Institute, Fenway Health, Boston, MA, USA.
| | - Laura Jadwin-Cakmak
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
- Center for Sexuality & Health Disparities, University of Michigan, Ann Arbor, MI, USA
| | - Jaclyn M White Hughto
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Miguel Martinez
- Division of Adolescent and Young Adult Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Liz Salomon
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Gary W Harper
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA.
- Center for Sexuality & Health Disparities, University of Michigan, Ann Arbor, MI, USA.
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Reisner SL, Jadwin-Cakmak L, White Hughto JM, Martinez M, Salomon L, Harper GW. Characterizing the HIV Prevention and Care Continua in a Sample of Transgender Youth in the U.S. AIDS Behav 2017; 21:3312-3327. [PMID: 29138982 PMCID: PMC5705332 DOI: 10.1007/s10461-017-1938-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In the U.S., transgender and other gender minority (TG) youth are an at-risk group understudied in HIV prevention and treatment. This study sought to characterize the HIV prevention and care continua in a diverse sample of 181 sexually-active TG ages 16-24 years (mean age = 20.7 years; 76.8% trans feminine; 69.1% youth of color) recruited July-December 2015 in 14 U.S. cities. Overall, 30.9% reported living with HIV, of which 71.4% were on antiretroviral therapy (ART) and 55.0% were medication adherent; 65.6% were known to be virally suppressed. In multivariable models, medical gender affirmation was associated with lower odds of viral suppression. Medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. Among at-risk TG youth not living with HIV, only 8.2% had accessed pre-exposure prophylaxis (PrEP). Early biobehavioral prevention and treatment interventions are needed for TG youth.
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Affiliation(s)
- Sari L Reisner
- Division of General Pediatrics, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA.
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- The Fenway Institute, Fenway Health, Boston, MA, USA.
| | - Laura Jadwin-Cakmak
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
- Center for Sexuality & Health Disparities, University of Michigan, Ann Arbor, MI, USA
| | - Jaclyn M White Hughto
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Miguel Martinez
- Division of Adolescent and Young Adult Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Liz Salomon
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Gary W Harper
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA.
- Center for Sexuality & Health Disparities, University of Michigan, Ann Arbor, MI, USA.
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Loss to Follow-up Trends in HIV-Positive Patients Receiving Antiretroviral Treatment in Asia From 2003 to 2013. J Acquir Immune Defic Syndr 2017; 74:555-562. [PMID: 28129256 DOI: 10.1097/qai.0000000000001293] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Over time, there has been a substantial improvement in antiretroviral treatment (ART) programs, including expansion of services and increased patient engagement. We describe time trends in, and factors associated with, loss to follow-up (LTFU) in HIV-positive patients receiving ART in Asia. METHODS Analysis included HIV-positive adults initiating ART in 2003-2013 at 7 ART programs in Asia. Patients LTFU had not attended the clinic for ≥180 days, had not died, or transferred to another clinic. Patients were censored at recent clinic visit, follow-up to January 2014. We used cumulative incidence to compare LTFU and mortality between years of ART initiation. Factors associated with LTFU were evaluated using a competing risks regression model, adjusted for clinical site. RESULTS A total of 8305 patients were included. There were 743 patients LTFU and 352 deaths over 26,217 person-years (pys), a crude LTFU, and mortality rate of 2.83 (2.64-3.05) per 100 pys and 1.34 (1.21-1.49) per 100 pys, respectively. At 24 months, the cumulative LTFU incidence increased from 4.3% (2.9%-6.1%) in 2003-05 to 8.1% (7.1%-9.2%) in 2006-09 and then decreased to 6.7% (5.9%-7.5%) in 2010-13. Concurrently, the cumulative mortality incidence decreased from 6.2% (4.5%-8.2%) in 2003-05 to 3.3% (2.8%-3.9%) in 2010-13. The risk of LTFU reduced in 2010-13 compared with 2006-09 (adjusted subhazard ratio = 0.73, 0.69-0.99). CONCLUSIONS LTFU rates in HIV-positive patients receiving ART in our clinical sites have varied by the year of ART initiation, with rates declining in recent years whereas mortality rates have remained stable. Further increases in site-level resources are likely to contribute to additional reductions in LTFU for patients initiating in subsequent years.
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