Retention in an antiretroviral program in the Democratic Republic of Congo Kalenga Lucien Koole Olivier Menten Joris Kiumbu Modeste Robin Ryder Mukumbi Henri Colebunders Robert ACS/ AMO- Congo

Background Retention remains an important challenge in sud- sahara africa Source: Rosen 2007, Brinkhoff 2009, WHO Mln HIV people on ART in the end of % of patients retained in care after 1 year 61% of patients retained in care after 2 years

Context DRC Prevalence of HIV: 1.3% 1.2 Mln of HIV positive ART eligible patients ART patients (<15%) Limited scaling up Decreased funding Source: PNLS 2009, UNGASS DRC report 2010, UNAIDS 2010 Retention: ??? MSF study: 76.8% -89% No large study with multiples sites No study on risk factors Lack of intervention Retention: ??? MSF study: 76.8% -89% No large study with multiples sites No study on risk factors Lack of intervention

Objectives To characterize the level of retention of patients in AmoCongo ART program across different sites in the Democratic Republic of Congo (DRC). Specifically by: – Determining the retention rate in ART program in DRC; – Identifying mains predictors and risk factors associated to retention in ART program;

Methods Retrospective cohort study Six ART treatment centers of ACS/ Amocongo Inclusion criteria: adults patients who initiated ART treatment at least six months prior to the data collection

Methods Data collection period: from September to December medical charts randomly selected in each site Non retention in the ART program was defined as patients who did not have any visit to the clinic in the 4 months prior to abstraction date and who were notified as dead, or stopped ART. Referred patients were excluded from the denominator.

Results and Discussion

Patients characteristics CharatericsN=1469% Sex Female97266,2 Male49733,8 Age median (IQR)40(34;46) Weight (KgMean(SD)5713,6 Stage I & II25117,1 III85758,3 IV1298,8 Missing23215,8 CD4Median (IQR)151(71;238)

Proportion of patients discontinuing from the AmoCongo ART Comparable to other studies in sub-Saharan Africa settings (Rosen, Tassie) But coverage of patients on ART still very low in DRC….

Risk factorsAjusted HR95% ICP-value Weight <50 Kg <0.001 ≥50 kg1 Missing WHO stage at start Stage 1&21 Stage Stage <0.001 Missing Gender Female 1 Male CD4 (cells/µL) CD4 < CD4 ≥ 50 < CD4 ≥ 2001 Missing Predictors/risk factors for attrition during the first year after ART initiation

Proportion of patients discontinuing during the first year by the 6 study sites Wide variability of retention rates between sites, (from 55.5% to 86.2% at 1 year) Poor retention in rural settings (Kananga, Mbandaka),

Probability of discontinuing during the first year by calendar year Rapid scaling-up may have compromised the organisation and quality of care

Risk factorsAjusted HR95% ICP-value Site Kasavubu1 Ndjili1,00,71,50,928 Lubumbashi0,70,51,10,144 Matadi1,00,61,50,876 Kananga1,30,92,00,200 Mbandaka2,61,73,9<0,001 Calendar year 2005 & ,91,42,5<0, ,22,44,3<0,001 Rural site: few number of health care providers, no access to CD4 cell count, lack of an electronic monitoring system and less supervisions. Calendar year: drop of quality of care Multivariate analysis of program predictors

Limitations of the study Retrospective chart review: incomplete data, poor quality data Possible confuding with risk factors not included in the study (social status, education) Results from a local NGO program, not representative of the situation in the public sector in the country

Implications of decreasing funding for ARV Poor coverage (interruptions of activities) Low initiation rates (later start) High attrition (high loss to follow up, transfert out, stock outs)

Conclusion First study on retention in the DRC in different sites Retention major challenge, specially in rural settings Risk factors for attrition: Gender, weight, WHO stage, CD4 baseline Rapid scaling-up may have reduced retention

Conclusion Decreasing funding towards DRC: Scaling up treatment or retaining in care? – Better system to trace patients – Early ART initiation – Improving of quality of care in scaling up – Laboratory if strictely necessary – More access to ARV, IO drugs and CD4 cell count

Acknowledgments ACS/Amocongo, Democratic Republic of Congo Institute of Tropical Medicine, Antwerp, Belgium School of Public Health, Kinshasa, Democratic Republic of Congo Programme National Multisectoriel de Lutte contre le Sida, Democratic Republic of Congo

Thank you