Retention and Risk Factors for Attrition in a Large Public Health ART Program in Myanmar: A Retrospective Cohort Analysis

Thida, Aye; Tun, Sai Thein Than; Zaw, Sai Ko Ko; Lover, Andrew A.; Cavailler, Philippe; Chunn, Jennifer; Aye, Mar Mar; Par, Par; Naing, Kyaw Win; Zan, Kaung Nyunt; Shwe, Myint; Kyaw, Thar Tun; Waing, Zaw Htoon; Clevenbergh, Philippe

doi:10.1371/journal.pone.0108615

Cited by 34 publications

(53 citation statements)

References 38 publications

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“…High attrition in the initial 100 days was similar to this previous study where attrition was significantly higher in the initial 180 days [14]. Time to ART (after excluding the delay in eligibility and/or time interval in pre-ART care) was not associated with attrition.…”

Section: Discussionsupporting

confidence: 84%

“…Studies from Myanmar have documented low retention in pre-ART care and high retention once on ART [14–16]. PLHIV initiated on ART had low CD4 counts at baseline indicating delays before ART initiation [14–16].…”

Section: Introductionmentioning

confidence: 99%

“…PLHIV initiated on ART had low CD4 counts at baseline indicating delays before ART initiation [14–16]. Hence, there was a need for systematic assessment of time to ART and associated factors which has not been studied in the National AIDS Programme (NAP) setting.…”

Section: Introductionmentioning

confidence: 99%

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

Linn

Shewade

Htet³

et al. 2018

Global Health Action

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Background: Among people living with HIV (PLHIV) enrolled into care, time to anti-retroviral therapy (ART) has not been studied in Myanmar. To inform progress, we conducted this operational research among treatment-naive PLHIV (≥18 years) enrolled during a period of three years (2014–2016) at Pyin Oo Lwin, Myanmar. Objectives: To determine (i) the time from HIV diagnosis to ART initiation (time to ART) and associated factors and (ii) the association between time to ART and attrition (loss to follow-up and death) from ART care. Methods: This was a retrospective cohort study involving a record review of secondary programme data. The PLHIV were followed up to 5 December 2017 for ART initiation and up to 31 March 2018 (date of censoring) for attrition during ART. Results: Of 543 enrolled, 373 (69%) were found to be eligible and initiated on ART. Of 373, 245 (67%) were initiated within 6 weeks of enrolment. The median enrolment delay (from diagnosis) was 4 (IQR: 1, 14) days and median ART initiation delay (from ART eligibility) was 20 (IQR: 13, 36) days. The median time to ART (excluding the time interval in pre-ART care) was 29 (IQR: 18, 55) days and was significantly long in those with prevalent TB and CD4 count ≥ 500/mm3 at enrolment. Among 373, the annual incidence density of attrition was 12.8% (0.95 CI: 10.2, 15.7). Attrition was common in first 100 days. Time to ART (after excluding time interval in pre-ART care) was not significantly associated with attrition. Conclusion: The programme appears to be on track to initiate ART as soon as possible in a ‘test and treat’ scenario (implemented since September 2017) subject to interventions to reduce ART initiation delay.

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Section: Discussionsupporting

confidence: 84%

Section: Introductionmentioning

confidence: 99%

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

Linn

Shewade

Htet³

et al. 2018

Global Health Action

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“…Studies among private GPs in urban and rural South Africa found relatively high rates of loss to follow-up, ranging from 15% at 12 or 24 months [23,24] to 50% at 36 months [25]. In Myanmar, other providers of ART have also reported higher loss to follow-up rates of rates ranging from 6.5 to 7% [26,27]. The strong community component that facilitated active tracing of those who missed appointments and provision of psychosocial support to all patients through CBOs may have contributed to low loss to follow-up, despite a strict definition of loss to follow-up being used in the programme whereby a cutoff of four weeks was used, a time that is shorter than the commonly used 60 days [28] and the recommended 180 days [29].…”

Section: Discussionmentioning

confidence: 99%

Retention and mortality outcomes from a community‐supported public–private HIV treatment programme in Myanmar

Mburu

Paing

Myint

et al. 2016

Journal of the International AIDS Society

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IntroductionThere is a growing interest in the potential contribution the private sector can make towards increasing access to antiretroviral therapy (ART) in low- and middle-income settings. This article describes a public–private partnership that was developed to expand HIV care capacity in Yangon, Myanmar. The partnership was between private sector general practitioners (GPs) and a community-based non-governmental organization (International HIV/AIDS Alliance).MethodsRetrospective analysis of 2119 patient records dating from March 2009 to April 2015 was conducted. Outcomes assessed were immunological response, loss to follow-up, all-cause mortality, and alive and retained in care. Follow-up time was calculated from the date of registration to the date of death, loss to follow-up, transfer out, or if still alive and known to be in care, until April 2015. Cox proportional hazards model was used to identify predictors of loss to follow-up and mortality. Kaplan–Meier survival analysis was used to estimate survival function of being alive and retained in care.ResultsThe median number of patients for each of the 16 GPs was 42 (interquartile range (IQR): 25–227), and the median follow-up period was 13 months. The median patient age was 35 years (IQR: 30–41); 56.6% were men, 62 and 11.8% were in WHO Stage III and Stage IV at registration, respectively; median CD4 count at registration was 177 cells/mm3; and 90.7% were on ART in April 2015. The median CD4 count at registration increased from 122 cells/mm3 in 2009 to 194 cells/mm3 in 2014. Among patients on ART, CD4 counts increased from a median of 187 cells/mm3 at registration to 436 cells/mm3 at 36 months. The median time to initiation of ART among eligible patients was 29 days, with 93.8% of eligible patients being initiated on ART within 90 days. Overall, 3.3% patients were lost to follow-up, 4.2% transferred out to other health facilities, and 8.3% died during the follow-up period. Crude mortality rate was 48.6/1000 person-years; 42% (n=74) of deaths occurred during the pre-ART period and 39.8% (n=70) occurred during the first six months of ART. Of those who died during the pre-ART period, 94.5% were eligible for ART. In multivariate regression, baseline CD4 count and ART status were independent predictors of mortality, whereas ART status, younger age and patient volumes per provider were predictors of loss to follow-up. Probability of being alive and retained in care at six months was 96.8% among those on ART, 38.5% among pre-ART but eligible patients, and 20.0% among ART-ineligible patients.ConclusionsEffectively supported private sector GPs successfully administered and monitored ART in Myanmar, suggesting that community-supported private sector partnerships can contribute to expansion of HIV treatment and care capacity. To further improve patient outcomes, early testing and initiation of ART, combined with close clinical monitoring and support during the initial periods of enrolling in treatment and care, are required.

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“…Studies from India and Africa show that pre-ART care attrition could be as high as 40% at 1 year after registration (5–8). Anecdotal evidence suggests that this could be similar in Myanmar, although prior to this study there was no clear evidence of this.…”

Section: Introductionmentioning

confidence: 99%

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

Gupta

Aung

et al. 2016

Global Health Action

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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.

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Retention and Risk Factors for Attrition in a Large Public Health ART Program in Myanmar: A Retrospective Cohort Analysis

Cited by 34 publications

References 38 publications

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

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

Retention and mortality outcomes from a community‐supported public–private HIV treatment programme in Myanmar

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

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