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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. Study Team. Family Health International (FHI 360)

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Study team

Retention and risk factors for attrition among adults in antiretroviral treatment programs in Tanzania, Uganda and ZambiaOlivier KooleInstitute of Tropical Medicine, AntwerpICRH-Mozambique


Study team
Study antiretroviral treatment programs in Tanzania, Uganda and ZambiaTeam

  • Family Health International (FHI 360)

  • MuhimbiliUniversity 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

  • JorisMenten

  • Robert Colebunders

  • Sharon Tsui

  • Eric Van Praag

  • Kwasi Torpey

  • YaDiulMukadi

  • Leine Stuart

  • Julie Denison

  • Andrew Auld

  • Simon Agolory

  • Seymour Williams

  • Jonathan Kaplan

  • Aaron Zee


Context
Context antiretroviral treatment programs in Tanzania, Uganda and Zambia

  • Massive scale-up of ART: worldwide 8 million people on ART, 6.5 in sub-SaharanAfrica

  • Greatestincrease in coverage in SSA

  • Importance of retentionandadherenceforgoodclinicaloutcomes

  • Retention: critical determinant of adherenceand key indicator of quality of ART programs


Objectives
Objectives antiretroviral treatment programs in Tanzania, Uganda and Zambia

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 programmecharacteristics


Study population sites

TANZANIA antiretroviral treatment programs in Tanzania, Uganda and Zambia

ZAMBIA

Study Population & Sites

  • Retrospective cohort study

  • StudyPopulation

    • 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


Source of data
Source of data antiretroviral treatment programs in Tanzania, Uganda and Zambia

  • Retrospective cohort study – medicalchart review

    • April toAugust 2010, 250 medicalcharts/site randomlyselectedandreviewed: clinical records, laboratory register andpharmacylogbook

    • June to July 2011, Health Care Manager questionnaire at 18 sites for program characteristics


Sampling
Sampling antiretroviral treatment programs in Tanzania, Uganda and Zambia

  • Sampling frame: all patients ever started on ART at that site

  • Random sample of 250 medicalcharts/site

  • Replacement strategy for ineligible patients

  • Screening logs:

    • eligible and abstracted

    • ineligible

    • missing


Methods
Methods antiretroviral treatment programs in Tanzania, Uganda and Zambia

  • 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


Patient accounting
Patient accounting antiretroviral treatment programs in Tanzania, Uganda and Zambia


Selected characteristics at baseline art initiation
Selected characteristics antiretroviral treatment programs in Tanzania, Uganda and Zambiaat baseline (ART initiation)


Selected program characteristics 1
Selected program characteristics (1) antiretroviral treatment programs in Tanzania, Uganda and Zambia


Program characteristics 2
Program characteristics (2) antiretroviral treatment programs in Tanzania, Uganda and Zambia


L evels of retention
L antiretroviral treatment programs in Tanzania, Uganda and Zambiaevels of retention


Model building risk factors for attrition
Model building - antiretroviral treatment programs in Tanzania, Uganda and Zambiarisk factors for attrition


R isk factors of attrition multivariable analysis 1
R antiretroviral treatment programs in Tanzania, Uganda and Zambiaisk factors of attrition - Multivariable analysis (1)


Risk factors of attrition m ultivariable analysis 2
Risk antiretroviral treatment programs in Tanzania, Uganda and Zambiafactors of attrition - Multivariable analysis (2)


Risk factors of attrition multivariable analysis 3
Risk antiretroviral treatment programs in Tanzania, Uganda and Zambiafactors of attrition - Multivariable analysis (3)


Study team
Lower retention amongst men in programs without community dispensing but similar in programs with ARV dispensing

More difficultfor men tocometoclinicfor drug pick-up?


Conclusion
Conclusion dispensing but similar in programs with ARV dispensing

  • Wide variability in retentionratesamong different models of care

  • Importance of community ARV dispensing

    • Mobile clinics?

    • Community pharmacies?

    • Community ART groups?

  • Particularilyneeded for

    • Men

    • Younger persons

    • The very sick


Study team

Special thanks to our funders and partners dispensing but similar in programs with ARV dispensing:


Extra selected characteristics at baseline art initiation 2
Extra-Selected characteristics dispensing but similar in programs with ARV dispensingat baseline (ART initiation) (2)


Study team

Extra-Correction dispensing but similar in programs with ARV dispensingfor sampling


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