Predictors of loss to follow up among adults on antiretroviral therapy before and after the start of treat-all strategy in public health facilities of Hawassa city, Ethiopia: A Competing risk regression

Abstract

Background Treat-all strategies improved patient outcomes, despite higher rates of loss to follow-up compared to the pre-treat era. Patients in Ethiopia experienced a higher rate of LTFU during the treat-all strategy period; however, studies did not identify contributing factors in comparison with previous strategies. This study aimed to assess the incidence and predictors of loss to follow-up before and after the start of the treat-all strategy among adults on anti-retroviral therapy in public health facilities in Hawassa City, Ethiopia. Methods An institution-based retrospective follow-up study was conducted among 1190 randomly selected adults on antiretroviral therapy in public health facilities in Hawassa City. Using the Open Data Kit (ODK), data were collected from medical records and exported to Stata version 16 and R 4.2.1 for analysis. A Grays test and cumulative incidence curve were used to compare the cumulative incidence function of loss to follow-up. Bivariable and multivariable competing risk regression were fitted to identify predictors of LTFU and variables with a p-value <0.05 were considered significant. Results The cumulative incidence of lost-to-follow-up was 4.92(3.84,6.3) and 8.67(7.26,10.3) per 100 person-years (PY) in pre-treat all and treat all cohorts, respectively. The cumulative incidence of mortality was 5.86(4.67,7.35) and 3(2.26,4.12) per 100 PY in pre-treat and treat all cohorts, respectively. Fair/poor adherence (aSHR:5.17; (95% CI 1.97, 13.51), underweight (aSHR:2.13; 95% CI: 1.15–3.93) and WHO stage III/IV (aSHR:2.69; 95% CI: 1.27, 5.71) were predictors of loss up in pre—treat all, whereas fair/poor adherence (aSHR = 2.07; 95% CI: 1.18, 3.68), underweight (aSHR:1.71; 95% CI: 1.13, 2.56), and CD4 cell >350 cell/m3 (aSHR: 1.67; 95% CI: 1.05, 2.65) predicts of loss up in treat all cohorts. Conclusion This study demonstrated that the incidence of loss to follow-up was considerably higher in the treat-all period as compared to the pre-treat-all era. Poor medication compliance, underweight, and a CD4 level >350 cells/m3 contributed to the higher rate of LTFU in the treat-all strategy. Targeted interventions, such as nutritional support and strengthening medication adherence counseling, should be implemented to maintain treatment retention and reduce antiretroviral therapy dropout rates.