Patient-mix, programmatic characteristics, retention and predictors of attrition among patients starting antiretroviral therapy (ART) before and after the implementation of HIV "Treat All" in Zimbabwe

Richard Makurumidze; Jozefien Buyze; Tom Decroo; Lutgarde Lynen; Madelon de Rooij; Trevor Mataranyika; Ngwarai Sithole; Kudakwashe C Takarinda; Tsitsi Apollo; James Hakim; Wim Van Damme; Simbarashe Rusakaniko

doi:10.1371/journal.pone.0240865

Patient-mix, programmatic characteristics, retention and predictors of attrition among patients starting antiretroviral therapy (ART) before and after the implementation of HIV "Treat All" in Zimbabwe

PLoS One. 2020 Oct 19;15(10):e0240865. doi: 10.1371/journal.pone.0240865. eCollection 2020.

Authors

Richard Makurumidze^{1

2

3}, Jozefien Buyze², Tom Decroo^{2

4}, Lutgarde Lynen², Madelon de Rooij¹, Trevor Mataranyika⁵, Ngwarai Sithole⁵, Kudakwashe C Takarinda^{5

6}, Tsitsi Apollo⁵, James Hakim¹, Wim Van Damme^{2

3}, Simbarashe Rusakaniko¹

Affiliations

¹ College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe.
² Institute of Tropical Medicine, Antwerp, Belgium.
³ Gerontology, Faculty of Medicine & Pharmacy, Free University of Brussels (VUB), Brussels, Belgium.
⁴ Research Foundation of Flanders, Brussels, Belgiums.
⁵ AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe.
⁶ International Union Against Tuberculosis and Lung Disease, Paris, France.

Abstract

Background: Since the scale-up of the HIV "Treat All" recommendation, evidence on its real-world effect on predictors of attrition (either death or lost to follow-up) is lacking. We conducted a retrospective study using Zimbabwe ART program data to assess the association between "Treat All" and, patient-mix, programmatic characteristics, retention and predictors of attrition.

Methods: We used patient-level data from the electronic patient monitoring system (ePMS) from the nine districts, which piloted the "Treat All" recommendation. We compared patient-mix, programme characteristics, retention and predictors of attrition (lost to follow-up, death or stopping ART) in two cohorts; before (April/May 2016) and after (January/February 2017) "Treat All". Retention was estimated using survival analysis. Predictors of attrition were determined using a multivariable Cox regression model. Interactions were used to assess the change in predictors of attrition before and after "Treat All".

Results: We analysed 3787 patients, 1738 (45.9%) and 2049 (54.1%) started ART before and after "Treat All", respectively. The proportion of men was higher after "Treat All" (39.4.% vs 36.2%, p = 0.044). Same-day ART initiation was more frequent after "Treat All" (43.2% vs 16.4%; p<0.001) than before. Retention on ART was higher before "Treat All" (p<0.001). Among non-pregnant women and men, the adjusted hazard ratio (aHR) of attrition after compared to before "Treat All" was 1.73 (95%CI: 1.30-2.31). The observed hazard of attrition for women being pregnant at ART initiation decreased by 17% (aHR: 1.73*0.48 = 0.83) after "Treat All". Being male (vs female; aHR: 1.45; 95%CI: 1.12-1.87) and WHO Stage IV (vs WHO Stage I-III; aHR: 2.89; 95%CI: 1.16-7.11) predicted attrition both before and after "Treat All" implementation.

Conclusion: Attrition was higher after "Treat All"; being male, WHO Stage 4, and pregnancy predicted attrition in both before and after Treat All. However, pregnancy became a less strong risk factor for attrition after "Treat All" implementation.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adult
Anti-HIV Agents / therapeutic use*
Antiretroviral Therapy, Highly Active
CD4 Lymphocyte Count
Cohort Studies
Female
HIV Infections / drug therapy*
Humans
Lost to Follow-Up
Male
Medication Adherence / statistics & numerical data*
Pregnancy
Proportional Hazards Models
Retrospective Studies
Risk Factors
Sex Factors
Survival Analysis
Zimbabwe

Substances

Anti-HIV Agents

Grants and funding

Richard Makurumidze receives a PhD scholarship grant from the Institute of Tropical Medicine, funded by the Belgian Development Cooperation (DGD). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.