Contemporary disengagement from antiretroviral therapy in Khayelitsha, South Africa: A cohort study

Abstract

BackgroundRetention in care is an essential component of meeting the UNAIDS “90-90-90” HIV treatment targets. In Khayelitsha township (population ~500,000) in Cape Town, South Africa, more than 50,000 patients have received antiretroviral therapy (ART) since the inception of this public-sector program in 2001. Disengagement from care remains an important challenge. We sought to determine the incidence of and risk factors associated with disengagement from care during 2013–2014 and outcomes for those who disengaged.Methods and findingsWe conducted a retrospective cohort study of all patients ≥10 years of age who visited 1 of the 13 Khayelitsha ART clinics from 2013–2014 regardless of the date they initiated ART. We described the cumulative incidence of first disengagement (>180 days not attending clinic) between 1 January 2013 and 31 December 2014 using competing risks methods, enabling us to estimate disengagement incidence up to 10 years after ART initiation. We also described risk factors for disengagement based on a Cox proportional hazards model, using multiple imputation for missing data. We ascertained outcomes (death, return to care, hospital admission, other hospital contact, alive but not in care, no information) after disengagement until 30 June 2015 using province-wide health databases and the National Death Registry. Of 39,884 patients meeting our eligibility criteria, the median time on ART to 31 December 2014 was 33.6 months (IQR 12.4–63.2). Of the total study cohort, 592 (1.5%) died in the study period, 1,231 (3.1%) formally transferred out, 987 (2.5%) were silent transfers and visited another Western Cape province clinic within 180 days, 9,005 (22.6%) disengaged, and 28,069 (70.4%) remained in care. Cumulative incidence of disengagement from care was estimated to be 25.1% by 2 years and 50.3% by 5 years on ART. Key factors associated with disengagement (age, male sex, pregnancy at ART start [HR 1.58, 95% CI 1.47–1.69], most recent CD4 count) and retention (ART club membership, baseline CD4) after adjustment were similar to those found in previous studies; however, notably, the higher hazard of disengagement soon after starting ART was no longer present after adjusting for these risk factors. Of the 9,005 who disengaged, the 2 most common initial outcomes were return to ART care after 180 days (33%; n = 2,976) and being alive but not in care in the Western Cape (25%; n = 2,255). After disengagement, a total of 1,459 (16%) patients were hospitalized and 237 (3%) died. The median follow-up from date of disengagement to 30 June 2015 was 16.7 months (IQR 11–22.4). As we included only patient follow-up from 2013–2014 by design in order to maximize the generalizability of our findings to current programs, this limited our ability to more fully describe temporal trends in first disengagement.ConclusionsTwenty-three percent of ART patients in the large cohort of Khayelitsha, one of the oldest public-sector ART programs in South Africa, disengaged from care at least once in a contemporary 2-year period. Fif...

Adolescent pregnancy at antiretroviral therapy (ART) initiation: a critical barrier to retention on ART

“…Individual and structural reasons for such LTFU identified in the literature could be amplified among OA due to limited autonomy and resources to independently continue ART. Our findings are in line with recent reports which suggest pregnancy at ART initiation is a significant risk factor for LTFU , and that postnatal disengagement from ART services is a significant programmatic challenge . Our observations imply that pregnant OA initiating ART should be one of the key populations targeted for interventions to reduce LTFU in prevention of mother‐to‐child HIV transmission (PMTCT) programmes.…”

“…Additionally, pregnancy at ART initiation is increasingly being associated with high LTFU after ART initiation in multiple cohorts, particularly as countries adopt lifelong ART for pregnant and breastfeeding women (Option B+) . Reasons for this may include individual factors related to child care, relationships with partners and family, migration postdelivery, stigma, and social barriers .…”

How accurately do routinely reported HIV viral load suppression proportions reflect progress towards the 90-90-90 target in the population on antiretroviral treatment in Khayelitsha, South Africa?

“…[3] Eligibility criteria have evolved in response to World Health Organization (WHO) recommendations, with universal test and treat adopted nationally in September 2016. [7]…”

HIV programmatic outcomes following implementation of the ‘Treat‐All’ policy in a public sector setting in Eswatini: a prospective cohort study

“…First, our estimates of ART retention are conservative. Previous studies showed that transient treatment interruptions and movements between clinics are common and many patients recorded with LTFU are retained [26,74,75]. Because of limitation in routine monitoring and limited tracking of patients lost to follow-up, this study was not able to adjust for silent transfer between treatment sites and silent return to care.…”