The effect of HIV testing and instant antiretroviral therapy (ART) initiation on long term patients’ attrition: A retrospective cohort study in Masaka, Uganda

Abstract

Introduction: By June 2013, an estimated 35 million people were living with HIV/AIDS of which, about 13.6 million had been put on antiretroviral drugs (ART). The World Health Organization (WHO) through UNAIDS set the ambitious 90-90-90 campaign where 90% of all people living with HIV will know their HIV status (testing), 90% of those diagnosed HIV+ receive sustained antiretroviral therapy (enrolment) and 90% of people receiving ART to have viral suppression, by 2020. Currently however, a myriad of HIV treatment programs are plagued with the challenge of patient attrition from care. This study set out to determine the effects of a test and treat strategy on long term patients’ attrition. Methods: This was a retrospective cohort study of 600 patients drawn from routine patients’ data for HIV clients enrolled into HIV care from January 2012 to December 2014 at Masaka regional referral hospital –Uganda Cares clinic. Cumulative incidence of loss to follow up and incidence rate of mortality were determined and compared between patients who experienced tested and treat (T&T) to those who initiated ART later (deferred) using survival analysis. Multivariable Cox proportional hazards regression model was used to estimate adjusted hazard ratios of factors associated with time to LTFU. Analyses were done using STATA version 13.

Results: Of 600 patients in the sample, 64.67% in each study group were females with median (IQR) of 29.5 (22-37.6) years and 30.4 (24.9-36.5) years in the T&T and deferred groups respectively. In the T&T and deferred group, 54.91% and 53.69% of the patients had a baseline CD4 cell count of more than 350 cells respectively. The overall cumulative incidence of LTFU was 9.17%. At 12 months into HIV care, it was higher in the T&T group (12.26%, 95% CI=7.90- 17.5%) compared to the deferred group (5.89%, 95% CI=3.57-9.02%, p=0.023). The incidence rate for mortality was higher in the T&T group (7.96/100 person years of observation (pyo)) than

the deferred group (4.14/100 pyo), and these rates were statistically different (p=0.028). At multivariate level, T&T (aHR=2.49, 95% CI=1.07-5.78), WHO stage 3&4 (aHR=3.78, 95% CI=1.70-8.41), TB susceptibility (aHR=3.42, 95% CI=1.19-9.71) were associated with elevated risk of LFTU; whereas access to mobile phone (aHR=0.56, 95% CI=0.36-0.88) duration on ART 1-3 months (aHR=0.21, 95% CI=0.08-0.59), duration on ART 3-6 months (aHR=0.03, 95% CI=0.01-0.11) and duration on ART for more than six months (aHR=0.003, 95% CI=0.001-0.01) were independently associated with reduced risk of LTFU. Conclusion: This study identified cumulative incidence of LTFU being higher in the T&T group compared to the deferred group; and similarly a higher mortality rate was observed in the T&T group, as opposed to the deferred group. The 90-90-90 campaign for steep ART initiation should be backed by intensive pre-initiation and adherence counseling for better long term retention of patients.