Factors predictive of successful retention in care among HIV-infected men in a universal test-and-treat setting in Uganda and Kenya: A mixed methods analysis

Abstract

BackgroundPrevious research indicates clinical outcomes among HIV-infected men in sub-Saharan Africa are sub-optimal. The SEARCH test and treat trial (NCT01864603) intervention included antiretroviral care delivery designed to address known barriers to HIV-care among men by decreasing clinic visit frequency and providing flexible, patient-centered care with retention support. We sought to understand facilitators and barriers to retention in care in this universal treatment setting through quantitative and qualitative data analysis.MethodsWe used a convergent mixed methods study design to evaluate retention in HIV care among adults (age > = 15) during the first year of the SEARCH (NCT01864603) test and treat trial. Cox proportional hazards regression was used to evaluate predictors of retention in care. Longitudinal qualitative data from n = 190 in-depth interviews with HIV-positive individuals and health care providers were analyzed to identify facilitators and barriers to HIV care engagement.ResultsThere were 1,863 men and 3,820 women who linked to care following baseline testing. Retention in care was 89.7% (95% CI 87.0–91.8%) among men and 89.0% (86.8–90.9%) among women at one year. In both men and women older age was associated with higher rates of retention in care at one year. Additionally, among men higher CD4+ at ART initiation and decreased time between testing and ART initiation was associated with higher rates of retention. Maintaining physical health, a patient-centered treatment environment, supportive partnerships, few negative consequences to disclosure, and the ability to seek care in facilities outside of their community of residence were found to promote retention in care.ConclusionsFeatures of the ART delivery system in the SEARCH intervention and social and structural advantages emerged as facilitators to retention in HIV care among men. Messaging around the health benefits of early ART start, decreasing logistical barriers to HIV care, support of flexible treatment environments, and accelerated linkage to care, are important to men’s success in ART treatment programs. Men already benefit from increased social support following disclosure of their HIV-status. Future efforts to shift gender norms towards greater equity are a potential strategy to support high levels of engagement in care for both men and women.

What do the Universal Test and Treat trials tell us about the path to HIV epidemic control?

“…Prior cohort studies report a marked disparity in men's engagement in HIV testing and care in Africa due to a wide range of individual, structural and societal barriers. The UTT approach reached and quite successfully engaged men . The many factors that enabled and motivated men to access HIV testing and care included home testing, multi‐disease services and flexible clinic services.…”

Retention and predictors of attrition among patients who started antiretroviral therapy in Zimbabwe’s national antiretroviral therapy programme between 2012 and 2015

“…Another strategy that may have improved male ART uptake and retention was male involvement in PMTCT (Option B+), promoted during massive campaigns [19]. There is a need for further studies to assess whether this strategy suffices, or if other strategies targeting men are needed, such as flexible clinic hours to accommodate work, community-based ART delivery, and tracing of those who miss appointments [40,41].…”

Retention and predictors of attrition among patients who started antiretroviral therapy in Zimbabwe’s National Antiretroviral Therapy Programme between 2012 and 2015

“…Another strategy that may have improved male ART uptake and retention was male involvement in PMTCT (Option B+), promoted during massive campaigns [19]. There is a need for further studies to assess whether this strategy suffices, or if other strategies targeting men are needed, such as flexible clinic hours to accommodate work, community-based ART delivery, and tracing of those who miss appointments[39, 40].…”