Variation in attrition at subnational level: review of the Botswana National HIV/AIDS Treatment (Masa) programme data (2002–2013)

Abstract

Objective To evaluate the variation in all-cause attrition (mortality and loss to follow-up (LTFU)) among HIV-infected individuals in Botswana by health district during the rapid and massive scale-up of the National Treatment Program. Methods Analysis of routinely collected longitudinal data from 226,030 patients who received ART through the Botswana National HIV/AIDS Treatment Program across all 24 health districts from 2002 to 2013. A time-to-event analysis was used to measure crude mortality and loss to follow-up rates (LTFU). A marginal structural model was used to evaluate mortality and LTFU rates by district over time, adjusted for individual-level risk factors (e.g., age, gender, baseline CD4, year of treatment initiation, and antiretroviral regimen). Results Mortality rates in the districts ranged from the lowest 1.0 (95% CI 0.9–1.1) in Selibe-Phikwe, to the highest 5.0 (95% CI 4.0–6.1), in Mabutsane. There was a wide range of overall LTFU across districts, including rates as low as 4.6 (95% CI 4.4–4.9) losses per 100 person-years in Ngamiland, and 5.9 (95% CI 5.6–6.2) losses per 100 person-years in South East, to rates as high as 25.4 (95% CI 23.08–27.89) losses per 100 person-years in Mabutsane and 46.3 (95% CI 43.48–49.23) losses per 100 person-years in Okavango. Even when known risk factors for mortality and LTFU were adjusted for, district was a significant predictor of both mortality and LTFU rates Conclusion We found statistically significant variation in attrition (mortality and LTFU) and data quality among districts. These findings suggest that district-level contextual factors affect retention in treatment. Further research needs to investigate factors that can potentially cause this variation.

Attrition from antiretroviral treatment services among pregnant and non-pregnant patients following adoption of Option B+ in Haiti

“…The overall attrition level in our study – 36.7% attrition at 12 months among all clients – was higher than those reported in the early days of ART programs in Haiti [10,12]. Most striking was the markedly elevated level of attrition among Option B+ clients, 50.4% at 12 months, compared with other adults.…”

“…Early reports from both urban and rural health facilities demonstrate moderate to high levels of sub-national retention [10,12,13]. However, data from other LMICs have shown that as ART programs mature, and the number of people initiating ART increases over time, incidence of loss to follow-up (LTFU) may increase as well [8].…”

Outcomes after antiretroviral therapy during the expansion of HIV services in Haiti

“…The marked heterogeneity in outcomes across facilities has been reported in other multi-country cohort studies [8, 9, 11, 36]. Differences could in part be explained by differences in undocumented deaths among patients categorized as lost.…”

Retention Throughout the HIV Care and Treatment Cascade: From Diagnosis to Antiretroviral Treatment of Adults and Children Living with HIV—Haiti, 1985–2015

“…However, the ≤ 40% threshold was chosen as an example to indicate the approximately 25% of arrondissements with the lowest linkage-to-care cumulative incidence percentages by database closure; the MOH would need to decide on the criteria for geographic focus as well as the thresholds involved based on perceived need for programmatic change and the availability of financial and human resources. 42 , 43 Investing in interventions to improve linkage-to-care could yield significant additional benefit in reducing HIV incidence. For example, in the U.S., it is estimated that 61% of new HIV transmissions are from patients with known HIV status but not linked to care.…”

“… 22 Variations in cumulative ART retention by database closure by arrondissement of residence from 30% to 88% suggest there may be local factors affecting attrition (LTFU or death) rates. 42 There are many causes for LTFU, including difficulties affording transport to the clinic, 57 work and childcare responsibilities, 57 overcrowded clinics, 58 , 59 and long wait times due to increased patient-to-provider ratios, with shortages of pharmacists or pharmacy assistants being a common cause for long wait times. 22 , 58 Therefore, LTFU prevention interventions may need to be tailored to the arrondissement in question to address main drivers of LTFU by arrondissement.…”