Alarming attrition rates among HIV-infected individuals in pre-antiretroviral therapy care in Myanmar, 2011–2014

Abstract

BackgroundHigh retention rates have been documented among patients receiving antiretroviral therapy (ART) in Myanmar. However, there is no information on human immunodeficiency virus (HIV)-infected individuals in care before initiation of ART (pre-ART care). We assessed attrition (loss-to-follow-up [LTFU] and death) rates among HIV-infected individuals in pre-ART care and their associated factors over a 4-year period.DesignIn this retrospective cohort study, we extracted routinely collected data of HIV-infected adults (>15 years old) entering pre-ART care (June 2011–June 2014) as part of an Integrated HIV Care (IHC) programme, Myanmar. Attrition rates per 100 person-years and cumulative incidence of attrition were calculated. Factors associated with attrition were examined by calculating hazard ratios (HRs).ResultsOf 18,037 HIV-infected adults enrolled in the IHC programme, 11,464 (63%) entered pre-ART care (60% men, mean age 37 years, median cluster of differentiation 4 (CD4) cell count 160 cells/µL). Of the 11,464 eligible participants, 3,712 (32%) underwent attrition of which 43% were due to deaths and 57% were due to LTFU. The attrition rate was 78 per 100 person-years (95% CI, 75–80). The cumulative incidence of attrition was 70% at the end of a 4-year follow-up, of which nearly 90% occurred in the first 6 months. Male sex (HR 1.5, 95% CI 1.4–1.6), WHO clinical Stage 3 and 4, CD4 count <200 cells/µL, abnormal BMI, and anaemia were statistically significant predictors of attrition.ConclusionsPre-ART care attrition among persons living with HIV in Myanmar was alarmingly high – with most attrition occurring within the first 6 months. Strategies aimed at improving early HIV diagnosis and initiation of ART are needed. Suggestions include comprehensive nutrition support and intensified monitoring to prevent pre-ART care attrition by tracking patients who do not return for pre-ART care appointments. It is high time that Myanmar moves towards a ‘test and treat’ approach and ultimately eliminates the need for pre-ART care.

Early Success With Retention in Care Among People Living With HIV at Decentralized ART Satellite Sites in Yangon, Myanmar, 2015–2016

“…First, despite the higher rates of retention in care, most of the attrition happened during the first year after ART initiation. This finding is consistent with the studies reported previously in Myanmar and in other settings (7, 9–11). Attrition was also found to be significantly associated with the expected risk factors, a CD4 count ≤ 50 cells/mm 3 and having baseline weight ≤ 50 kg.…”

Time to anti-retroviral therapy among people living with HIV enrolled into care in Myanmar: how prepared are we for ‘test and treat’?

“…It was related to a policy of assessment for eligibility for ART initiation during the study period. Though we do not know the status of those not on ART, a previous study in Myanmar has detected alarmingly high attrition during pre-ART care [15]. There is evidence that PLHIV often encountered barriers in accessing ART-related services (both before and after ART uptake) even in contexts where these services are freely available [6,23].…”

Attrition among HIV positive children enrolled under integrated HIV care programme in Myanmar: 12 years cohort analysis

“…A couple of studies using adult HIV seropositive patient data (aged ≥ 15 years of age) from IHC programme have shown that the attrition rates in pre-ART care and ART care is 32% and 16%, respectively (5-year cohort analysis with 13.7 months median duration of follow-up) [5,11]. Compared to these results, private sector adult ART cohort in Myanmar had a relatively higher attrition rate of 20% during 5-years follow-up [12].…”