Liberia adherence and loss-to-follow-up in HIV and AIDS care and treatment: A retrospective cohort of adolescents and adults from 2016–2019

Author:

Gray Keith L.ORCID,Kiazolu MurphyORCID,Jones Janjay,Konstantinova AnnaORCID,Zawolo Jethro S. W.ORCID,Gray Wahdae-Mai HarmonORCID,Walker Naomi F.ORCID,Garbo Julia T.,Caldwell Samretta,Odo MichaelORCID,Bhadelia NahidORCID,DeMarco JeanORCID,Skrip Laura A.

Abstract

Background Antiretroviral therapy (ART) is a lifesaving intervention for people living with HIV infection, reducing morbidity and mortality; it is likewise essential to reducing transmission. The “Treat all” strategy recommended by the World Health Organization has dramatically increased ART eligibility and improved access. However, retaining patients on ART has been a major challenge for many national programs in low- and middle-income settings, despite actionable local policies and ambitious targets. To estimate retention of patients along the HIV care cascade in Liberia, and identify factors associated with loss-to-follow-up (LTFU), death, and suboptimal treatment adherence, we conducted a nationwide retrospective cohort study utilizing facility and patient-level records. Patients aged ≥15 years, from 28 facilities who were first registered in HIV care from January 2016 –December 2017 were included. We used Cox proportional hazard models to explore associations between demographic and clinical factors and the outcomes of LTFU and death, and a multinomial logistic regression model to investigate factors associated with suboptimal treatment adherence. Among the 4185 records assessed, 27.4% (n = 1145) were males and the median age of the cohort was 37 (IQR: 30–45) years. At 24 months of follow-up, 41.8% (n = 1751) of patients were LTFU, 6.6% (n = 278) died, 0.5% (n = 21) stopped treatment, 3% (n = 127) transferred to another facility and 47.9% (n = 2008) were retained in care and treatment. The incidence of LTFU was 46.0 (95% CI: 40.8–51.6) per 100 person-years. Relative to patients at WHO clinical stage I at first treatment visit, patients at WHO clinical stage III [adjusted hazard ratio (aHR) 1.59, 95%CI: 1.21–2.09; p <0.001] or IV (aHR 2.41, 95%CI: 1.51–3.84; p <0.001) had increased risk of LTFU; whereas at registration, age category 35–44 (aHR 0.65, 95%CI: 0.44–0.98, p = 0.038) and 45 years and older (aHR 0.60, 95%CI: 0.39–0.93, p = 0.021) had a decreased risk. For death, patients assessed with WHO clinical stage II (aHR 2.35, 95%CI: 1.53–3.61, p<0.001), III (aHR 2.55, 95%CI: 1.75–3.71, p<0.001), and IV (aHR 4.21, 95%CI: 2.57–6.89, p<0.001) had an increased risk, while non-pregnant females (aHR 0.68, 95%CI: 0.51–0.92, p = 0.011) and pregnant females (aHR 0.42, 95%CI: 0.20–0.90, p = 0.026) had a decreased risk when compared to males. Suboptimal adherence was strongly associated with the experience of drug side effects–average adherence [adjusted odds ratio (aOR) 1.45, 95% CI: 1.06–1.99, p = 0.02) and poor adherence (aOR 1.75, 95%CI: 1.11–2.76, p = 0.016), and attending rural facility decreased the odds of average adherence (aOR 0.01, 95%CI: 0.01–0.03, p<0.001) and poor adherence (aOR 0.001, 95%CI: 0.0004–0.003, p<0.001). Loss-to-follow-up and poor adherence remain major challenges to achieving viral suppression targets in Liberia. Over two-fifths of patients engaged with the national HIV program are being lost to follow-up within 2 years of beginning care and treatment. WHO clinical stage III and IV were associated with LTFU while WHO clinical stage II, III and IV were associated with death. Suboptimal adherence was further associated with experience of drug side effects. Active support and close monitoring of patients who have signs of clinical progression and/or drug side effects could improve patient outcomes.

Funder

Global Fund to Fight AIDS, Tuberculosis and Malaria

Boston University-University of Liberia Partnership to Enhance Emerging Epidemic Virus Research in Liberia

Publisher

Public Library of Science (PLoS)

Reference59 articles.

1. https://www.who.int/news-room/fact-sheets/detail/hiv-aids. Accessed 3 December, 2021.

2. https://cdn.who.int/media/docs/default-source/hq-hiv-hepatitis-and-stis-library/key-facts-hiv-2020.pdf?sfvrsn=582c3f6e_13. Accessed 3 December 2021.

3. UNAIDS. Fact Sheet 2021 Global HIV Statistics. End AIDS epidemic. 2021;(June):1–3.

4. Retention and predictors of attrition among patients who started antiretroviral therapy in Zimbabwe’s national antiretroviral therapy programme between 2012 and 2015.;R Makurumidze;PLoS One,2020

5. Incorporating Loss to Follow-up in Estimates of Survival Among HIV-Infected Individuals in Sub-Saharan Africa Enrolled in Antiretroviral Therapy Programs Linked references are available on JSTOR for this article: Incorporating Loss to Follow-up in Estima.;S Verguet,2019

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