Retention on antiretroviral therapy during Universal Test and Treat implementation in Zomba district, Malawi: a retrospective cohort study

Abstract

IntroductionSince June 2016, the national HIV programme in Malawi has adopted Universal Test and Treat (UTT) guidelines requiring that all persons who test HIV positive will be referred to start antiretroviral therapy (ART). Although there is strong evidence from clinical trials that early initiation of ART leads to reduced morbidity and mortality, the impact of UTT on retention on ART in real‐life programmatic settings in Africa is not yet known.MethodsWe conducted a retrospective cohort study in Zomba district, Malawi to compare ART outcomes of patients who initiated ART under 2016 UTT guidelines and those who started ART prior to rollout of UTT (pre‐UTT). We analysed data from 32 rural and urban health facilities of various sizes. Cox proportional hazards modelling was used to determine the independent risk factors of attrition from ART at 12 months. All analyses were adjusted for clustering by health facility using a robust standard errors approach.ResultsAmong 1492 patients (mean age 34.4 years, 933 (63%) female) who initiated ART during the study period, 501 were enrolled in the pre‐UTT cohort and 911 during UTT. At 12 months, retention on ART in the UTT cohort was higher than in the pre‐UTT cohort 83.0% (95% confidence interval (CI): 81.0% to 85.0%) versus 76.2% (95% CI 73.9% to 78.5%). Adolescents, aged 10 to 19 years (adjusted hazard ratio (aHR) 1.53; 95% CI 1.01 to 2.32), and women who were pregnant or breastfeeding at ART initiation (aHR 1.87; 95% CI 1.30 to 2.38) were at higher risk of attrition in the combined pre‐UTT and UTT cohort.ConclusionsRetention on ART was nearly 6% higher after UTT introduction. Young adults and women who were pregnant or breastfeeding at the start of ART were at increased risk of attrition, emphasizing the need for targeted interventions for these groups to achieve the 90‐90‐90 UNAIDS targets in the UTT era.

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

“…We found that adolescents and young adults were more at risk of attrition when compared to adults. Our findings are consistent with other studies [49][50][51][52]. Adolescents and young adults have been shown to be at high risk of attrition due to several factors, which include lack of youth-friendly services, rigid scheduling not taking into account schooling, and unavailability of peer caregivers [53,54].…”

Early outcomes after implementation of treat all in Rwanda: an interrupted time series study

“…However, among patients enrolling in care in the Treat All period, retention in care among patients initiating ART within 30 days was significantly higher than those not initiating ART within 30 days after enrolment. These results are consistent with earlier studies that have described either no effect or improvement in retention in care associated with early ART initiation, including preliminary findings from the MaxART trial in eSwatini and from implementation of Treat All in Malawi [24][25][26][27][28]. In subgroup analyses, retention in care did not significantly worsen after Treat All implementation among those with more advanced HIV (as indicated by CD4 count) or among men and younger patients, who have traditionally been at risk of worse outcomes.…”

Determinants of loss to follow-up among HIV positive patients receiving antiretroviral therapy in a test and treat setting: A retrospective cohort study in Masaka, Uganda

“…Besides, our findings also show an elevated risk of LTFU among patients who started ART within seven days following diagnosis compared to those who started after 7 days following HIV diagnosis. This finding contrasts what has been reported previously [27]. One possibility for the differences could be methodological, especially in the determination of the outcomes across the studies, but also the fact that different study populations were considered.…”