1. Retention and risk factors for attrition among adults in antiretroviral treatment programs in Tanzania, Uganda and Zambia Olivier Koole Institute of Tropical Medicine, Antwerp ICRH-Mozambique AIDS 2012 - Turning the Tide Together

2. Study Team Family Health International (FHI 360) Muhimbili University of Health and Allied Sciences, Tanzania Infectious Diseases Institute, Makerere University Medical School, Uganda Tropical Diseases Research Centre, Zambia Institute of Tropical Medicine, Belgium Massachusetts General Hospital, USA Centers for Disease Control and Prevention, USA Gideon Kwesigabo Fred Wabwire-Mangen Modest Mulenga David Bangsberg Joris Menten Robert Colebunders Sharon Tsui Eric Van Praag Kwasi Torpey Ya Diul Mukadi Leine Stuart Julie Denison Andrew Auld Simon Agolory Seymour Williams Jonathan Kaplan Aaron Zee

3. Context Massive scale-up of ART: worldwide 8 million people on ART, 6.5 in sub-Saharan Africa Greatest increase in coverage in SSA Importance of retention and adherence for good clinical outcomes Retention: critical determinant of adherence and key indicator of quality of ART programs

4. Objectives Primary To characterise the current level of retention of patients on ART across multiple programme settings Secondary To identify important predictors of retention in care, including both individual risk factors and programme characteristics

5. Study Population & Sites Retrospective cohort study Study Population – 18 years and older at ART initiation at study site – Initiated 3 ARVs at least 6 months prior to data collection Study sites – 3 countries – 6 sites per country, purposively selected UGANDA TANZANIA ZAMBIA

6. Source of data Retrospective cohort study – medical chart review – April to August 2010, 250 medical charts/site randomly selected and reviewed: clinical records, laboratory register and pharmacy logbook – June to July 2011, Health Care Manager questionnaire at 18 sites for program characteristics

7. Sampling Sampling frame: all patients ever started on ART at that site Random sample of 250 medical charts/site Replacement strategy for ineligible patients Screening logs: – eligible and abstracted – ineligible – missing

8. Methods Retained patient: visit to one of the following services during the 90 days prior to data abstraction – Clinic – Laboratory – Pharmacy Kaplan-Meier analysis Attrition (=event): death or LTFU – transfer-outs censored at the time of transfer Predictor analysis: Cox proportional hazard model, shared frailty effect

9. Patient accounting Number of files randomly selected7,755 Number of ineligible files1,951 Number of missing files1,310 Number of files extracted4,494 Number of duplicate files extracted84 Number of files with missing start date of ART19 Number of ineligible charts (<18 years or abstraction date not within 6 months of first ART): 3 Number in the analysis-set4,388 Number in the analysis-set with one site (241 patients) dropped 4,147 CountryNumber of sitesNumber of patients Tanzania61,458 Uganda61,472 Zambia51,217

10. Selected characteristics at baseline (ART initiation) Characteristicn (%) Total number patients4,147 (100.0) Age (year), mean (SD)36.9 (9.4) Gender, n (%) Female2,670 (64.4) Calendar year of start ART, n (%) < 2004141 (3.7) 2005646 (15.6) 2006785 (18.9) 2007960 (23.2) 2008868 (20.9) 2009-2010747 (18.0) Characteristicn (%) CD4 cell count: median (IQR) 134 (63-206) Missing1,006 (24.3) WHO stage, n (%) I & II1,334 (32.2) III1,600 (38.6) IV597 (14.4) Missing616 (14.9) Functional status, n (%) Working2,140 (51.6) Ambulatory686 (16.5) Bedridden115 (2.8) Missing1,206 (29.1)

11. Selected program characteristics (1) Characteristic n, % Total number of facilities 18 Level health facility National referral 4 (22) Provincial/Regional 4 (22) District 6 (33) Primary or community based 4 (22) Type health facility Government 9 (50) Mission 5 (28) Non-religious NGO 4 (22) Characteristicn, % Number of adults on ART < 2000 8 (44) 2000-4000 6 (33) > 4000 4 (22) Setting Rural/peri-urban 8 (44) Urban 10 (56)

12. Program characteristics (2) Characteristicn Total number of facilities18 Refill frequency after 6 months on ART Monthly6 (33) Every 2 months8 (44) Every 3 months4 (22) Three counseling sessions required before ART initiation No4 (22) Yes14 (78) Physician based care No3 (17) Yes15 (83) Characteristicn Buddy required to initiate ART No3 (17) Yes15 (83) Home based care No8 (44) Yes10 (56) ARV dispensing in community (= any dispensing outside the clinic) No13 (72) Yes5 (28)

13. Levels of retention

14. Model building - risk factors for attrition Individual characteristics Significant and selected (p<0.1)Significant and not selected -Lower age -Male gender -Increasing years since program active -Increasing WHO stage -Weight loss > 10% body mass -Fever > 1 month -Lower CD4 count -Poorer functional status -Higher distance to clinic -Lower TLC count -Lower Hb level -Candidiasis -Wasting Program characteristics (p<0.2) -Level of health facility -Type of health facility -Dispensing of ARVs at community level -Buddy needed for ART initiation

15. Risk factors of attrition - Multivariable analysis (1) Patient baseline characteristicsAdjusted Hazard Ratio (95% CI) Age at start 18-29 years1 ≥ 30 years0.77 (0.67 – 0.88) Gender Women1 Men1.28 (1.14 – 1.43) Year of start ART since program active ( / year) 1.13 (1.08 – 1.19) WHO stage at start ART I & II1 III1.10 (0.94 – 1.29) IV1.60 (1.32 – 1.93) Missing1.29 (1.10 – 1.58)

16. Risk factors of attrition - Multivariable analysis (2) Patient baseline characteristicsAdjusted Hazard Ratio (95% CI) Absolute values CD4 cell count (cells/µl) 51.30 (1.11 – 1.53) 201.15 (1.06 – 1.26) 501.06 (1.02 – 1.10) 100 (average value)1 2000.94 (0.91 – 0.98) Missing 1.14 (1.01 – 1.30)

17. Risk factors of attrition - Multivariable analysis (3) Patient baseline characteristicsAdjusted Hazard Ratio (95% CI) Weight loss > 10% No1 Yes1.17 (1.00 – 1.37) Functional status Working1 Ambulatory1.50 (1.28 – 1.75) Bedridden2.08 (1.58 – 2.74) Missing1.23 (1.04 – 1.45) Program characteristicsAdjusted Hazard Ratio (95% CI) ARV dispensing in community No1 Yes0.61 (0.42 – 0.88)

18. Lower retention amongst men in programs without community dispensing but similar in programs with ARV dispensing More difficult for men to come to clinic for drug pick-up? Hazard Ratio (95% CI) Female – no community distribution1 Male – no community distribution1.36 (1.20 – 1.54) Female – with community distribution0.68 (0.47 – 1.02) Male – with community distribution0.66 (0.43 – 1.00)

19. Conclusion Wide variability in retention rates among different models of care Importance of community ARV dispensing – Mobile clinics? – Community pharmacies? – Community ART groups? Particularily needed for – Men – Younger persons – The very sick

20. Special thanks to our funders and partners :

21. Extra-Selected characteristics at baseline (ART initiation) (2) Opportunistic infectionsn (%) Total number patients4,147 (100.0) Weight loss > 10%841 (20.3) Fever > 1 month613 (14.8) Pulmonary TB491 (11.8) Chronic diarrhoea > 1 month482 (11.6) Oral candidiasis269 (6.5) Wasting syndrome209 (5.0)

22. Percentage of selected numbers not found NumberRetention rate SitesPatients1 Yr2 Yr3 YrHR (95% CI)P-value <10% 61,46563.653.545.61<0.001 ≥10% - <20% 61,47588.182.478.60.31 (0.21-0.54) ≥20% 61,20785.178.373.70.37(0.22-0.62) Extra-Correction for sampling