Status of HIV-infected patients classified as lost to follow up from a large antiretroviral program in southwest Nigeria

Incidence and predictors of loss to follow-up among adult patients receiving antiretroviral therapy in Central Ethiopia: a multi-center retrospective cohort study

Background

Globally, loss to follow-up (LTFU) remains a significant public health concern despite the rapid expansion of antiretroviral medication programs. It is a significant cause of treatment failure and threatens the enhancement of HIV treatment outcomes among patients on antiretroviral therapy (ART). However, there is a paucity of evidence on its incidence and predictors in Ethiopia. Thus, this study aimed to examine the incidence and predictors of LTFU among adult HIV patients receiving ART at hospitals in Central Ethiopia.

Methods

A multi-centered facility-based retrospective cohort study was conducted among 432 randomly selected adult patients who received antiretroviral therapy. Data were entered into EpiData version 3.1 and exported to Stata version 14 for analysis. The Kaplan-Meier failure function was employed to determine the overall failure estimates, and the log-rank test was used to compare the probability of failure among the different categories of variables. The Cox proportional hazard model was used to identify independent predictors of LTFU.

Results

Overall, 172 (39.8%) study participants were lost to follow-up over the 10-year follow-up period with an incidence rate of 8.12 (95% CI: 7.11, 9.09) per 1,000 person-months. Undisclosed HIV status (AHR: 1.96, 95% CI: 1.14, 3.36), not able to work (AHR: 1.84, 95% CI: 1.13, 2.22), opportunistic infections (AHR: 3.13, 95% CI: 2.17, 4.52), CD4 < 200 cell/mL (AHR: 1.95, 95% CI: 1.18, 3.21), not receiving isoniazid preventive therapy (IPT) (AHR: 2.57, 95% CI: 1.62, 4.06), not participating in clubs (AHR: 1.68, 95% CI: 1.10, 2.22), side effects of drugs (AHR: 1.44, 95% CI: 1.02, 2.04), and high viral load (AHR: 3.15, 95% CI: 1.81, 5.47) were identified as significant predictors of loss to follow-up.

Conclusion

In this study, the incidence of LTFU was high. The focus should be on creating awareness and prevention programs that aim to reduce loss to follow-up by continuing counseling, especially on the negative effects of loss to follow-up and the benefits of ART care.

Predictors of treatment interruption among patients on antiretroviral therapy in Akwa Ibom, Nigeria: outcomes after 12 months

Understanding the characteristics of people living with HIV who interrupt antiretroviral therapy (ART) is critical for designing client-centered services to ensure optimal outcomes. We assessed predictors of treatment interruption in 22 HIV clinics in Nigeria. We reviewed records of HIV-positive patients aged ≥15 years who started ART 1 January and 31 March 2019. We determined treatment status over 12 months as either active, or interrupted treatment (defined as interruption in treatment up to 28 days or longer). Potential predictors were assessed using Cox hazard regression models. Overall, 1185 patients were enrolled on ART, 829 (70%) were female, and median age was 32 years. Retention at 1, 3, 6, 9, and 12 months was 85%, 80%, 76%, 72%, and 68%, respectively. Predictors of treatment interruption were post-secondary education (p = 0.04), diagnosis through voluntary counseling and testing (p < 0.001), receiving care at low-volume facilities (p < 0.001), lack of access to a peer counselor (p < 0.001), and residing outside the clinic catchment area (p = 0.03). Treatment interruption was common but can be improved by focusing on lower volume health facilities, providing peer support especially to those with higher education, and client-centered HIV services for those who live further from clinics..

A Qualitative Study Exploring Factors Associated with Retention in HIV Care among Women with HIV in a Large HIV Clinic in Lagos, Nigeria, after Implementing the Test and Treat Policy

Background

In Nigeria, various sociocultural and economic factors may prevent women from being retained in HIV care. This study explores the factors associated with retention in care among women with HIV in a large HIV clinic in Lagos, Nigeria, under the Test and Treat policy.

Methods

Women living with HIV/AIDS (n = 24) enrolled in an HIV study at the AIDS Prevention Initiative in Nigeria (APIN) clinic in Lagos, Nigeria, were interviewed from April 1 to October 31, 2021, using a semistructured interview guide. Interviews were audio-taped, transcribed verbatim, and the themes were analyzed using the framework of Andersen and Newman's Behavioural Model for Healthcare Utilization.

Results

The mean age of the respondents was 37.4 ± 9.27 years. The identified themes were as follows: being aware of the antiretroviral medications and their benefits, the household's awareness of the respondents' HIV status, and the presence of social support. Other themes were the presence of a dependable source of income and the ability to overcome the challenges encountered in obtaining income, ease of travel to and from the clinic (length of travel time and transportation costs), securing support from the clinic, challenges encountered in the process of accessing care at the clinic, and the ability to overcome these challenges. Also mentioned were self-perception of being HIV positive, motivation to remain in care, linkage to care, and intention to stay in care.

Conclusion

Several deterring factors to retention in HIV care, such as nondisclosure of status, absence of social support, and clinic barriers, persist under the Test and Treat policy. Therefore, to achieve the "treatment as prevention" for HIV/AIDS, especially in sub-Saharan Africa, it is essential to employ strategies that address these barriers and leverage the facilitators for better health outcomes among women with HIV/AIDS.

Baseline and Process Factors of Anti-Retroviral Therapy That Predict Loss to Follow-up Among People Living with HIV/AIDS in China: A Retrospective Cohort Study

We explored the predictors and predictive models of loss to follow-up (LTFU) during the first year of anti-retroviral therapy (ART). LTFU was defined as the failure to visit the clinic for antiretroviral drugs for ≥ 90 days after the last missed scheduled visit. Based on the electronic medical records of 5953 patients who were HIV positive and began ART between 2016 and 2019 in China, the LTFU rate was 7.24 (95% confidence interval 6.49-7.97) per 100 person-years during the first year of ART. ART baseline factors were associated with LTFU, but were non-optimal predictors. A model including ART process-related factors such as follow-up behaviors and physical health status had an area under the receiver operating characteristic curve of 73.4% for predicting LTFU. Therefore, the medical records of follow-up visits can be used to identify patients with a high risk of LTFU and allow interventions to be implemented proactively.

Retention in Care among Patients Attending a Large HIV Clinic in Nigeria Who Were Treated for Tuberculosis

A retrospective study of 2764 patients was conducted at an HIV clinic in Nigeria to evaluate retention in care in patients treated for TB. At 6 and 12 months after commencement of TB treatment, 1842(66.6%) and 1624(58.8%) participants remained in care. Of the 922 and 1140 not in care at 6 and 12 months, 814(88.3%) and 1006(88.2%) respectively were lost to follow-up (LTFU). VL < 1000copies/ml was associated with higher odds of retention in care at 6 and 12 months (OR  =  2.351 and 2.393) than VL > 1000 copies/ml. HAART use was associated with high likelihood of being in care at 12 months (OR  =  3.980). CD4 counts of 200–350 and >350 cells/mm³ were associated with increased odds of remaining in care at 12 months compared with CD4 < 200 cells/mm³ (p  =  0.005 and p  =  0.001). Targeted interventions such as early HAART and close follow-up for high risk groups are likely to improve retention in care.

Failure to return pillbox is a predictor of being lost to follow-up among people living with HIV on antiretroviral therapy in rural Tanzania

Objectives

Pill count is used to assess drug adherence in people living with HIV (PLHIV). Carrying a pillbox is associated with fear of concealment and stigma and might indicate poor adherence and predict someone who will be lost to follow‐up (LTFU). We therefore assessed the association between pillbox return and being LTFU in rural Tanzania.

Methods

This is a nested study of the Kilombero and Ulanga Antiretroviral Cohort (KIULARCO). We included PLHIV aged ≥ 18 years enrolled in KIULARCO between January 2013 and March 2019 with follow‐up through January 2020, who were on antiretroviral treatment (ART) for ≥ 6 months. Baseline was defined as the latest ART initiation or KIULARCO enrolment. We determined the association between time‐dependent failed pillbox return updated at every visit and LTFU using Kaplan–Meier estimation and Cox models.

Results

Among 2552 PLHIV included in the study, 1735 (68.0%) were female, 959 (40.3%) had a WHO stage III/IV and 1487 (66.4%) had a CD4 cell count < 350 cells/µL. The median age was 38.4 years [interquartile range (IQR): 31.7–46.2]. During a median follow‐up of 33.1 months (IQR: 17.5–52.4), 909 (35.6%) participants were LTFU, 43 (1.7%) died and 194 (7.6%) had transferred to another clinic. The probability of being LTFU was higher among PLHIV with failed pillbox return than among those who returned their pillbox [30.0%, 95% confidence interval (CI): 26.8–33.2% vs. 19.4%, 95% CI: 17.4–21.6%, respectively, at 24 months (hazard ratio = 1.67, 95% CI: 1.46–1.90; p < 0.001)].

Conclusions

Failed pillbox return was associated with a higher risk of being LTFU and could be used as a simple tool to identify PLHIV for appropriate interventions to reduce their chance of being LTFU.

Factors associated with an interruption in treatment of people living with HIV in USAID-supported states in Nigeria: a retrospective study from 2000-2020

Background

Patient interruption of antiretroviral therapy (ART) continues to limit HIV programs’ progress toward epidemic control. Multiple factors have been associated with client interruption in treatment (IIT)— including age, gender, CD4 count, and education level. In this paper, we explore the factors associated with IIT in people living with HIV (PLHIV) in United States Agency for International Development (USAID)-supported facilities under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program in Nigeria.

Methods

We conducted cross-sectional analyses on data obtained from Nigeria’s National Data Repository (NDR), representing a summarized record of 573 630 ART clients that received care at 484 PEPFAR/USAID-supported facilities in 16 states from 2000–2020. IIT was defined as no clinical contact for 28 days or more after the last expected clinical contact. Univariate and multivariate logistic regression models were computed to explore the factors associated with IIT. The variables included in the analysis were sex, age group, zone, facility level, regimen line, multi-month dispensing (MMD), and viral load category.

Results

Of the 573 630 clients analysed in this study, 32% have been recorded as having interrupted treatment. Of the clients investigated, 66% were female (32% had interrupted treatment), 39% were aged 25–34 at their last ART pick-up date (with 32% of them interrupted treatment), 59% received care at secondary level facilities (37% interrupted treatment) and 38% were last receiving between three- to five-month MMD (with 10% of these interrupted treatment). Those less likely to interrupt ART were males (aOR = 0.91), clients on six-month MMD (aOR = 0.01), adults on 2^nd line regimen (aOR = 0.09), and paediatrics on salvage regimen (aOR = 0.02). Clients most likely to interrupt ART were located in the South West Zone (aOR = 1.99), received treatment at a tertiary level (aOR = 12.34) or secondary level facilities (aOR = 4.01), and had no viral load (VL) on record (aOR =10.02). Age group was not significantly associated with IIT.

Conclusions

Sex, zone, facility level, regimen line, MMD, and VL were significantly associated with IIT. MMD of three months and longer (especially six months) had better retention on ART than those on shorter MMD. Not having a VL on record was associated with a considerable risk of IIT.

Adolescence and the risk of ART non-adherence during a geographically focused public health intervention: an analysis of clinic records from Nigeria

The risk of poor antiretroviral therapy (ART) adherence among adolescents is a challenge to controlling HIV. This study aims to provide guidance for geographically focussed public health interventions to improve adherence. Through clinic records, it investigates adolescents' non-adherence risk and clinic-level differences in regions of Nigeria which were part of PEPFAR's geographical pivot. Records (n = 26,365) were selected using systematic random sampling from all PEPFAR-supported facilities (n = 175) in targeted Local Government Areas across three regions in Nigeria. Adolescents' risk of non-adherence was estimated using region-specific random-effects models accounting for clinic-level variation. These were adjusted for sex, whether a patient had to travel to a different region, clinic location (urban/rural), clinic type (primary, secondary, tertiary). Despite regional variations, adolescents were at higher risk of non-adherence compared to adults. A similar, but weaker, association was found for children. Patients attending tertiary facilities for ART in the South-South region exhibited very high risk of non-adherence. Adolescents and children are at an increased risk of poor ART adherence in rural regions of Nigeria. Regional differences and facility type are critical factors. Future public health programmes focused on the risk of poor adherence targeting "high-prevalence areas" should be sensitive to contextual differences and age-appropriate care.

Determinants of loss to follow-up among people living with HIV on antiretroviral therapy in Nigeria

Background: Considerable success has been recorded in the global fight against the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). Retention in care is the key to the attainment of set goals in the fight against the disease. We aim to determine the factors associated with loss to follow-up (LTFU) among people living with HIV on antiretroviral therapy (ART) in a limited resource setting.Method: This was a retrospective cohort study that included adult patients who accessed ART at the study site between January 2005 and October 2018. A multivariate logistic regression model was used to obtain adjusted odds ratios and 95% confidence intervals of independent determinants of LTFU.Results: Of the 8 679 patients included in the study, 3 716 (43%) were males, 4 009 (46%) were enrolled during the years 2005 to 2008, 8 421 (97%) spent less than two hours travelling from their residence to the treatment centre, and 3 523 (41%) had their first-line ART regimen changed. Among the characteristics that determine LTFU were male patients (OR = 1.167, 95% CI: 1.071-1.272), and World Health Organization clinical stage 3 (OR = 2.091, 95% CI: 1.485-2.944).Conclusion: In our study, male gender, enrolment year 2005 to 2008, no change in first-line ART and nevirapine-based therapy were more likely to be associated with LTFU.

Risk factors for loss to follow-up from antiretroviral therapy programmes in low-income and middle-income countries

INTRODUCTION

Loss to follow-up (LTFU) rates from antiretroviral treatment (ART) programmes in low- and middle-income countries (LMIC) are high, leading to poor treatment outcomes and onward transmission of HIV. Knowledge of risk factors is required to address LTFU. In this systematic review, risk factors for LTFU are identified and meta-analyses performed.

METHODS

PubMed, Embase, Psycinfo and Cochrane were searched for studies that report on potential risk factors for LTFU in adults who initiated ART in LMICs. Meta-analysis was performed for risk factors evaluated by at least five studies. Pooled effect estimates and their 95% confidence intervals (95% CI) were calculated using random effect models with inverse variance weights. Risk of bias was assessed and sensitivity analyses performed.

RESULTS

Eighty studies were included describing a total of 1 605 320 patients of which 87.4% from sub-Saharan Africa. The following determinants were significantly associated with an increased risk of LTFU in meta-analysis: male sex, older age, being single, unemployment, lower educational status, advanced WHO stage, low weight, worse functional status, poor adherence, nondisclosure, not receiving cotrimoxazole prophylactic therapy when indicated, receiving care at secondary level and more recent year of initiation. No association was seen for CD4 cell count, tuberculosis at baseline, regimen, and geographical setting.

CONCLUSION

There are several sociodemographic, clinical, patient behaviour, treatment-related and system level risk factors for LTFU from ART programs. Knowledge of risk factors should be used to better target retention interventions and develop tools to identify high-risk patients.