Incidence and predictors of attrition among patients receiving ART in eastern Zimbabwe before, and after the introduction of universal ‘treat-all’ policies: A competing risk analysis

Abstract

As HIV treatment is expanded, attention is focused on minimizing attrition from care. We evaluated the impact of treat-all policies on the incidence and determinants of attrition amongst clients receiving ART in eastern Zimbabwe. Data were retrospectively collected from the medical records of adult patients (aged≥18 years) enrolled into care from July 2015 to June 2016—pre-treat-all era, and July 2016 to June 2017—treat-all era, selected from 12 purposively sampled health facilities. Attrition was defined as an absence from care >90 days following ART initiation. Survival-time methods were used to derive incidence rates (IRs), and competing risk regression used in bivariate and multivariable modelling. In total, 829 patients had newly initiated ART and were included in the analysis (pre-treat-all 30.6%; treat-all 69.4%). Incidence of attrition (per 1000 person-days) increased between the two time periods (pre-treat-all IR = 1.18 (95%CI: 0.90–1.56) versus treat-all period IR = 1.62 (95%CI: 1.37–1.91)). In crude analysis, patients at increased risk of attrition were those enrolled into care during the treat-all period, <34 years of age, WHO stage I at enrolment, and had initiated ART on the same day as HIV diagnosis. After accounting for mediating clinical characteristics, the difference in attrition between the pre-treat-all, and treat-all periods ceased to be statistically significant. In a full multivariable model, attrition was significantly higher amongst same-day ART initiates (aSHR = 1.47, 95%CI:1.05–2.06). Implementation of treat-all policies was associated with an increased incidence of ART attrition, driven largely by ART initiation on the same day as HIV diagnosis which increased significantly in the treat all period. Differentiated adherence counselling for patients at increased risk of attrition, and improved access to clinical monitoring may improve retention in care.

Attrition rate and its predictors among adults receiving anti-retroviral therapy following the implementation of the “Universal Test and Treat strategy” at public health institutions in Northern Ethiopia. A retrospective follow-up study

“…This figure is higher than the previous study undertaken in Ethiopia prior to the commencement of the test and treat era [ 22 ]. On the other hand, it is consistent with the previous research findings conducted in Zimbabwe following UTT [ 14 , 16 ]. The likely explanation for this agreement could be the comparable socioeconomic status and HIV management protocol of the two countries, which indirectly increases the risk of early mortality and loss from ART treatment [ 26 ].…”

“…For instance, research in Zimbabwe that looked at predictors of attrition before and after the “test and treat era” found that patients who enrolled in ART after the test and treat era had a 73% higher risk of attrition than their peers [ 14 ]. Additionally, Studies in Nigeria [ 15 ], Uganda [ 2 , 14 ], Zimbabwe [ 16 ]and South Africa [ 17 ] revealed that rapid initiation of ART increases the incidence of attrition through enhancing early LTFU. In Nigeria and South Africa, nearly 34% and 33% of patients who commenced into ART under this era were immediately loss from their regular care [ 15 , 17 ].…”

“…High attrition rate from ART is the leading cause of morbidity, mortality, hospitalization, increasing transmission rate, treatment failure, increasing burden of opportunistic infections (OIs), and the emergence of drug resistance HIV-virus (HIVDR) [ 13 ]. The main factors contributing to the increased rate of attrition were sex, age, marital status, HIV-disclosure status, lack of social support, functional status, nutritional status, having opportunistic infections, WHO clinical stage, substance abuse status, residence, cotrimoxazole prophylaxis (CPT), drug adherence level, type of ART regimen, and side effects of ART [ 2 , 14 , 15 , 16 , 19 , 20 , 21 , 22 , 23 ].…”

Acceptability of a pilot motivational interviewing intervention at public health facilities to improve the HIV treatment cascade among people who inject drugs in Indonesia

“…Moreover, a growing number of reports on increasing trends in attrition during ART suggest that universal ART eligibility may attract more patients with low motivation to adhere. They would have likely dropped out of pre-ART care had eligibility been determined on the basis of immunological/clinical criteria [ 16 – 18 ]. Therefore, introducing MI following HIV diagnosis would be a promising strategy to motivate ART initiation and encourage adherence behaviours in PWID during early ART—the critical period in which the risk of mortality and treatment discontinuation peaks [ 19 ].…”

Attrition one year after starting antiretroviral therapy before and after the programmatic implementation of HIV “Treat All” in Sub-Saharan Africa: a systematic review and meta- analysis

“…Tlhajoane et al provided data for a few patients who had 12 months follow-up, while Makurumidze et al and Mayasi et al con rmed that none of the included participants had less than 12 months follow up [18,19,25]. None of the studies reported pre-ART attrition.…”