Determinants of alcohol use among people living with HIV initiating isoniazid preventive therapy in Ethiopia.

BACKGROUND: Hepatotoxicity, an adverse effect of isoniazid preventative therapy (IPT), is exacerbated by alcohol consumption. Although the WHO recommends IPT for people living with HIV (PLHIV), it is contraindicated in regular alcohol users. The objective of this study was to identify the prevalence and determinants of alcohol use among PLHIV initiating IPT in Ethiopia. METHODS: Baseline data (July 2013-May 2015) from 316 participants in the Enhance Initiation and Retention in IPT Care for HIV (ENRICH) study were used to assess the prevalence of alcohol use. Multinomial logistic regression was used to identify determinants of non-hazardous and hazardous alcohol use, compared to no alcohol use. RESULTS: Overall, 41.8% of participants reported alcohol use, of which 45.5% reported hazardous use. Compared to non-alcohol users, hazardous users were younger (adjusted odds ratio [AOR]: 1.06; 95% confidence interval [95% CI]: 1.02, 1.11), more likely to be male (AOR: 6.40; 95% CI: 3.17, 12.93), Orthodox (AOR: 3.96; 95% CI: 1.74, 9.00), have larger support networks (AOR: 3.82; 95% CI: 1.61, 9.06), and report greater amount (AOR: 14.80; 95% CI: 5.76, 38.02) and frequency (AOR: 5.91; 95% CI: 2.75, 12.67) of khat use. CONCLUSIONS: Alcohol use was prevalent in this population, and current WHO guidelines would exclude a substantial proportion of the population from receiving IPT. PLHIV in this region would benefit from routine screening for alcohol and khat use, and from substance use education and counseling while receiving IPT until it can be determined whether alcohol users can safely receive IPT.

Psychosocial Factors Associated with Food Insufficiency Among People Living with HIV/AIDS (PLWH) Initiating ART in Ethiopia.

Food insufficiency is associated with suboptimal HIV treatment outcomes. Less is known about psychosocial correlates of food insufficiency among PLWH. This sample includes 1176 adults initiating antiretroviral therapy at HIV clinics in Ethiopia. Logistic regression modeled the association of psychological distress, social support, and HIV-related stigma with food insufficiency. Among respondents, 21.4% reported frequent food insufficiency. Psychological distress [adjusted odds ratio (aOR) 2.61 (95% CI 1.79, 3.82)], low social support [aOR 2.20 (95% CI 1.57, 3.09)] and enacted stigma [aOR 1.69 (95% CI 1.26, 2.25)] were independently associated with food insufficiency. Food insufficiency interventions should address its accompanying psychosocial context.

HIV-Related Stigma, Social Support, and Psychological Distress Among Individuals Initiating ART in Ethiopia.

Recent World Health Organization HIV treatment guideline expansion may facilitate timely antiretroviral therapy (ART) initiation. However, large-scale success of universal treatment strategies requires a more comprehensive understanding of known barriers to early ART initiation. This work aims to advance a more comprehensive understanding of interrelationships among three known barriers to ART initiation: psychological distress, HIV-related stigma, and low social support. We analyzed cross-sectional interview data on 1175 adults initiating ART at six HIV treatment clinics in Ethiopia. Experience of each form of HIV-related stigma assessed (e.g., anticipatory, internalized, and enacted) was associated with increased odds of psychological distress. However, among those who reported enacted HIV-related stigma, there was no significant association between social support and psychological distress. Interventions to improve mental health among people living with HIV should consider incorporating components to address stigma, focusing on strategies to prevent or reduce the internalization of stigma, given the magnitude of the relationship between high internalized stigma and psychological distress. Interventions to increase social support may be insufficient to improve the mental health of people living with HIV who experienced enacted HIV-related stigma. Future research should examine alternative strategies to manage the mental health consequences of enacted HIV-related stigma, including coping skills training.

Psychological distress, health and treatment-related factors among individuals initiating ART in Oromia, Ethiopia.

HIV diagnosis may be a source of psychological distress. Late initiation of antiretroviral therapy (ART) and treatment-related beliefs may intensify psychological distress among those recently diagnosed. This analysis describes the prevalence of psychological distress among people living with HIV (PLWH) and examines the association of recent HIV diagnosis, late ART initiation and treatment-related beliefs with psychological distress. The sample includes 1175 PLWH aged 18 or older initiating ART at six HIV clinics in Ethiopia. Psychological distress was assessed with Kessler Psychological Distress Scale. Scores ≥ 29 were categorized as severe psychological distress. Individuals who received their first HIV diagnosis in the past 90 days were categorized as recently diagnosed. Multivariable logistic regression modeled the association of recent diagnosis, late ART initiation and treatment-related beliefs on severe psychological distress, controlling for age, sex, education, area of residence, relationship status, and health facility. Among respondents, 29.5% reported severe psychological distress, 46.6% were recently diagnosed and 31.0% initiated ART late. In multivariable models, relative to those who did not initiate ART late and had longer time since diagnosis, odds of severe psychological distress was significantly greater among those with recent diagnosis and late ART initiation (adjusted OR [aOR]: 1.9 [95% CI 1.4, 2.8]). Treatment-related beliefs were not associated with severe psychological distress in multivariable models. Severe psychological distress was highly prevalent, particularly among those who were recently diagnosed and initiated ART late. Greater understanding of the relationship between psychological distress, recent diagnosis, and late ART initiation can inform interventions to reduce psychological distress among this population. Mental health screening and interventions should be incorporated into routine HIV clinical care from diagnosis through treatment.

Household decision-making power and the mental health and well-being of women initiating antiretroviral treatment in Oromia, Ethiopia.

Low decision-making power (DMP) has been associated with HIV seropositivity among women in sub-Saharan Africa. As treatment accessibility and life expectancy for HIV-positive individuals increase, greater attention to the mental health and well-being of HIV-positive women is needed. This study examined whether low DMP was associated with psychological distress, social support or health-related quality of life (HRQoL) among women initiating ART. The sample included 722 women aged 18 or older initiating ART during 2012-2013 at six HIV clinics in Oromia, Ethiopia. DMP was assessed with five questions about household resource control and decision-making. Psychological distress was assessed with the Kessler Psychological Distress Scale (K10). HRQoL was assessed with the overall subscale of the HIV/AIDS-Targeted Quality of Life instrument. Multivariable logistic regression analyses controlled for age, education, and location (urban/rural). Most respondents (63%) reported high DMP, followed by medium (27%) and low (10%) DMP. More than half (57%) reported psychological distress. Compared to medium DMP, low DMP among married or cohabitating women was associated with greater odds of low social support (aOR: 1.9 [1.3, 2.9]; high DMP among women not in a relationship was associated with greater odds of low social support (aOR: 4.4 [2.4, 8.1]) and psychological distress (aOR: 1.7 [1.1, 2.6]). Interventions to reduce psychological distress among women initiating ART should consider the familial context, as high DMP among women not in a relationship was associated with psychological distress. High DMP may indicate weak social ties and fewer material resources, particularly among women not in a relationship.

"Testing, Testing": Multiple HIV-Positive Tests among Patients Initiating Antiretroviral Therapy in Ethiopia.

Repeat HIV testing after receiving a positive result has never been studied systematically and may give insight into reasons for delayed linkage to care. Among 831 adults in 6 secondary facilities in Oromia, Ethiopia, who completed an interviewer-administered structured questionnaire within 2 weeks of initiating antiretroviral therapy in 2012 to 2013, 110 (13.2%) reported having retested after an HIV-positive result. The odds of repeat (versus single) HIV-positive testing were higher among those who had doubted their HIV status (adjusted odds ratio [AOR]ref=nodoubt = 6.5; 95% confidence interval [CI]: 3.7-11.4) and those who initially tested at another facility, whether another secondary facility (AOR ref=studyfacility = 22.7; 95% CI: 11.0-46.9) or a lower-level facility (AORref=studyfacility = 19.1; 95% CI: 10.5-34.5). The odds of repeat (versus single) HIV-positive testing were lower among those who initially tested because of symptoms (AORref=not a reason = 0.40; 95% CI: 0.24-0.66). Median time between initial diagnosis and enrollment in care was 12.3 versus 1.0 month for repeat and single HIV-positive testers, respectively ( P < .001). Repeat HIV-positive testing-not a rare occurrence-appears to stem from doubt, seeking care at a facility other than where diagnosed, and testing for a reason other than having symptoms. Because repeat HIV-positive testing is associated with delay in linkage to care, providers should be aware of this potential when counseling those who test HIV positive.

Reaching the end of the line: Operational issues with implementing phone-based unannounced pill counts in resource-limited settings.

INTRODUCTION: Accurate measurement of adherence is necessary to ensure that therapeutic outcomes can be attributed to the recommended treatment. Phone-based unannounced pill counts were shown to be feasible and reliable measures of adherence in developed settings; and have been further used as part of medication adherence interventions. However, it is not clear whether this method can be implemented successfully in resource-limited settings, where cellular network and mobile phone coverage may be low. Our objective is to describe operational issues surrounding the use of phone-based unannounced pill counts in Lesotho and Ethiopia. METHODS: Phone-based monthly unannounced pill counts, using an adaptation of a standardized protocol from previous US-based studies, were utilized to measure anti-TB and antiretroviral medication adherence in two implementation science studies in resource-limited settings, START (Lesotho) and ENRICH (Ethiopia). RESULTS: In START, 19.6% of calls were completed, with 71.9% of participants reached at least once; majority of failed call attempts were due to phones not being available (54.8%) or because participants were away from the pills (32.7%). In ENRICH, 33.5% of calls were completed, with 86.7% of participants reached at least once; the main reasons for failed call attempts were phones being switched off (31.5%), participants not answering (27.3%), participants' discomfort speaking on the phone (15.4%), and network problems (13.2%). Structural, facility-level, participant-level, and data collection challenges were encountered in these settings. DISCUSSION: Phone-based unannounced pill counts were found to be challenging, and response rates suboptimal. While some of these challenges were specific to local contexts, most of them are generalizable to resource-limited settings. In a research study context, a possible solution to ease operational challenges may be to focus phone-based unannounced pill count efforts on a randomly selected sample from participants who are provided with study phones and rigorously ensure that call attempts are made for these participants.

Brief Report: Stigma and HIV Care Continuum Outcomes Among Ethiopian Adults Initiating ART.

BACKGROUND: Stigma harms the mental health of HIV-positive individuals and reduces adherence to antiretroviral therapy (ART), but less is known about stigma and other outcomes across the HIV care continuum. METHODS: Among 1180 Ethiopian adults initiating ART at 6 urban HIV clinics, we examined the relationship of internalized, anticipated, and enacted stigma to HIV care-related outcomes ascertained by interview (repeat HIV-positive testing, provider vs. self-referred testing, missed clinic visit before ART initiation, eagerness to begin ART), and by abstraction of routinely collected clinical data (late ART initiation, 3-month gap in care following ART initiation). Logistic regression was used to assess the association of each type of stigma with each outcome, adjusting for potential confounders. RESULTS: Scoring higher on each stigma domain was associated with 50%-90% higher odds of repeat HIV-positive testing. High internalized stigma was associated with higher odds of provider vs. self-referred test [adjusted odds ratio (aOR)high vs. low: 1.7; 95% confidence interval (CI): 1.3 to 2.2]. Higher anticipated stigma was associated with lower eagerness to begin ART (aORhigh vs. low: 0.55; 0.35-0.87; aORmedium vs. low: 0.45; 95% CI: 0.30 to 0.69). Any enacted stigma was associated with higher odds of a missed visit (aORany vs. none 1.8; 1.2-2.8). Stigma was not associated with late ART-initiation or with a subsequent gap in care. DISCUSSION AND CONCLUSIONS: These findings provide further evidence of the importance of measuring and addressing stigma across the entire care continuum. Future work should test hypotheses about specific stigma domains and outcomes in prospective intervention or observational studies.

The ENRICH Study to evaluate the effectiveness of a combination intervention package to improve isoniazid preventive therapy initiation, adherence and completion among people living with HIV in Ethiopia: rationale and design of a mixed methods cluster randomized trial.

BACKGROUND: Isoniazid preventive therapy (IPT) prevents tuberculosis among HIV-positive individuals, however implementation is suboptimal. Implementation science studies are needed to identify interventions to address this evidence-to-program gap. OBJECTIVE: The ENRICH Study is a mixed methods cluster randomized trial aimed at evaluating the effectiveness and acceptability of a combination intervention package (CIP) to improve IPT implementation in Ethiopia. DESIGN: Ten health centers were randomized to receive the CIP or standard of care. The CIP includes: nurse training and mentorship using a clinical algorithm, tool to identify IPT-eligible family members, and data review at multidisciplinary team meetings; patient transport reimbursement; and adherence support using peer educators and interactive voice response messages. Routine data were abstracted for all newly-enrolled IPT-eligible HIV-positive patients; anticipated sample size was 1400 individuals. A measurement cohort of patients initiating IPT was recruited; target enrollment was 500 individuals, to be followed for the duration of IPT (6-9 months). Inclusion criteria were: HIV-positive; initiated IPT; age ≥18; Amharic-, Oromiffa-, Harari-, or Somali-speaking; and capable of informed consent. Three groups were recruited from CIP health centers for in-depth interviews: IPT initiators; IPT non-initiators; and health care providers. Primary outcomes are: IPT initiation; and IPT completion. Secondary outcomes include: retention; adherence; change in CD4+ count; adverse events; and acceptability. Follow-up is complete. DISCUSSION: The ENRICH Study evaluates a CIP targeting barriers to IPT implementation. If the CIP is found effective and acceptable, this study has the potential to inform TB prevention strategies for HIV patients in resource-limited countries in sub-Saharan Africa.

Outcomes among HIV-infected children initiating HIV care and antiretroviral treatment in Ethiopia.

OBJECTIVE: To describe pediatric ART scale-up in Ethiopia, one of the 21 global priority countries for elimination of pediatric HIV infection. METHODS: A descriptive analysis of routinely collected HIV care and treatment data on HIV-infected children (<15 years) enrolled at 70 health facilities in four regions in Ethiopia, January 2006-September 2013. Characteristics at enrollment and ART initiation are described along with outcomes at 1 year after enrollment. Among children who initiated ART, cumulative incidence of death and loss to follow-up (LTF) were estimated using survival analysis. RESULTS: 11 695 children 0-14 years were enrolled in HIV care and 6815 (58.3%) initiated ART. At enrollment, 31.2% were WHO stage III and 6.3% stage IV. The majority (87.9%) were enrolled in secondary or tertiary facilities. At 1 year after enrollment, 17.9% of children were LTF prior to ART initiation. Among children initiating ART, cumulative incidence of death was 3.4%, 4.1% and 4.8%, and cumulative incidence of LTF was 7.7%, 11.8% and 16.6% at 6, 12 and 24 months, respectively. Children <2 years had higher risk of LTF and death than older children (P < 0.0001). Children with more advanced disease and those enrolled in rural settings were more likely to die. Children enrolled in more recent years were less likely to die but more likely to be LTF. CONCLUSIONS: Over the last decade large numbers of HIV-infected children have been successfully enrolled in HIV care and initiated on ART in Ethiopia. Retention prior to and after ART initiation remains a major challenge.

Disclosure History Among Persons Initiating Antiretroviral Treatment at Six HIV Clinics in Oromia, Ethiopia, 2012-2013.

HIV status disclosure can help patients obtain support which may influence treatment adherence and subsequent healthcare needs. We examined the extent of disclosure and correlates of non-disclosure among 1180 adults newly initiating antiretroviral treatment (ART). While 91 % of those in a relationship shared their status with their partners, 14 % of the overall sample had not disclosed to anyone. Non-disclosure was positively associated with older age; control over household resources; and concerns about unintended disclosure, life disruptions, and family reactions. Knowing other HIV-positive people and longer time since diagnosis were associated with lower odds of non-disclosure. Most respondents reporting disclosure experienced supportive responses, frequently including decision to get an HIV test by confidants who had not known their own status. Although HIV status disclosure prior to ART initiation was high, some individuals cited concerns about unintended disclosure, gossip, and partner violence, and may benefit from additional disclosure support.

A Qualitative Evaluation of the Acceptability of an Interactive Voice Response System to Enhance Adherence to Isoniazid Preventive Therapy Among People Living with HIV in Ethiopia.

Interactive voice response (IVR) is increasingly used to monitor and promote medication adherence. In 2014, we evaluated patient acceptability toward IVR as part of the ENRICH Study, aimed to enhance adherence to isoniazid preventive therapy for tuberculosis prevention among HIV-positive adults in Ethiopia. Qualitative interviews were completed with 30 participants exposed to 2867 IVR calls, of which 24 % were completely answered. Individualized IVR options, treatment education, and time and cost savings facilitated IVR utilization, whereas poor IVR instruction, network and power malfunctions, one-way communication with providers, and delayed clinic follow-up inhibited utilization. IVR acceptability was complicated by HIV confidentiality, mobile phone access and literacy, and patient-provider trust. Incomplete calls likely reminded patients to take medication but were less likely to capture adherence or side effect data. Simple, automated systems that deliver health messages and triage clinic visits appear to be acceptable in this resource-limited setting.

Factors associated with initiation of antiretroviral therapy in the advanced stages of HIV infection in six Ethiopian HIV clinics, 2012 to 2013.

INTRODUCTION: Most HIV-positive persons in sub-Saharan Africa initiate antiretroviral therapy (ART) with advanced infection (late ART initiation). Intervening on the drivers of late ART initiation is a critical step towards achieving the full potential of HIV treatment scale-up. This study aimed to identify modifiable factors associated with late ART initiation in Ethiopia. METHODS: From 2012 to 2013, Ethiopian adults (n=1180) were interviewed within two weeks of ART initiation. Interview data were merged with HIV care histories to assess correlates of late ART initiation (CD4+ count <150 cells/µL or World Health Organization Stage IV). RESULTS: The median CD4 count at enrollment in HIV care was 263 cells/µL (interquartile range (IQR): 140 to 390) and 212 cells/µL (IQR: 119 to 288) at ART initiation. Overall, 31.2% of participants initiated ART late, of whom 85.1% already had advanced HIV disease at enrollment. Factors associated with higher odds of late ART initiation included male sex (vs. non-pregnant females; adjusted odds ratio (aOR): 2.02; 95% CI: 1.50 to 2.73), high levels of psychological distress (vs. low/none, aOR: 1.96; 95% CI: 1.34 to 2.87), perceived communication barriers with providers (aOR: 2.42, 95% CI: 1.24 to 4.75), diagnosis via provider initiated testing (vs. voluntary counselling and testing, aOR: 1.47, 95% CI: 1.07 to 2.04), tuberculosis (TB) treatment prior to ART initiation (aOR: 2.16, 95% CI: 1.43 to 3.25) and a gap in care of six months or more prior to ART initiation (aOR: 2.02, 95% CI: 1.10 to 3.72). Testing because of partner illness/death (aOR: 0.64, 95% CI: 0.42 to 0.95) was associated with lower odds of late ART initiation. CONCLUSIONS: Programmatic initiatives promoting earlier diagnosis, engagement in pre-ART care, and integration of TB and HIV treatments may facilitate earlier ART initiation. Men and those experiencing psychological distress may also benefit from targeted support prior to ART initiation.

Gender Differences and Psychosocial Factors Associated with Quality of Life Among ART Initiators in Oromia, Ethiopia.

Health-related quality of life (HRQoL) is an important outcome to assess among persons living with HIV/AIDS, but few studies have been conducted in sub-Saharan Africa. We examined HRQoL among 1180 ART-initiating adults from six clinics in Ethiopia in 2012-2013, and compared the correlates of two subscale scores between women and men. Women scored significantly higher than men on both overall function (8.4 points higher) and life satisfaction (6.3 points higher). In multivariable models, psychological distress, low CD4+ count, unemployment, and food insecurity were associated with lower quality of life scores among women and men. Men whose last sexual encounter occurred 3 months to 1 year from the interview date had lower overall function and life satisfaction scores. Men between the ages of 30-39 had lower overall function scores. Protestant women and women in the low-middle social support category had lower life satisfaction scores. Assessment of HRQoL over time will help inform HIV care and treatment practices to ensure favorable patient outcomes.

HIV Care and Treatment Beliefs among Patients Initiating Antiretroviral Treatment (ART) in Oromia, Ethiopia.

To better understand patient beliefs, which may influence adherence to HIV care and treatment, we examined three dimensions of beliefs among Ethiopian adults (n = 1177) initiating antiretroviral therapy (ART). Beliefs about benefits of ART/HIV clinical care were largely accurate, but few patients believed in the ability of ART to prevent sexual transmission and many thought Holy Water could cure HIV. Factors associated with lower odds of accurate beliefs included advanced HIV, lack of formal education, and Muslim religion (benefits of ART/clinical care); secondary or university education and more clinic visits (ART to prevent sexual transmission); and pregnancy and Orthodox Christian religion (Holy Water). Assessment of patient beliefs may help providers identify areas needing reinforcement. In this setting, counselors also need to stress the benefits of ART as prevention and that Holy Water should not be used to the exclusion of HIV care and ART.

Identifying Perceived Barriers along the HIV Care Continuum: Findings from Providers, Peer Educators, and Observations of Provider-Patient Interactions in Ethiopia.

Increasing the proportion of HIV-positive individuals who link promptly to and are retained in care remains challenging in sub-Saharan Africa, but little evidence is available from the provider perspective. In 4 Ethiopian health facilities, we (1) interviewed providers and peer educators about their perceptions of service delivery- and patient-level barriers and (2) observed provider-patient interactions to characterize content and interpersonal aspects of counseling. In interviews, providers and peer educators demonstrated empathy and identified nonacceptance of HIV status, anticipated stigma from unintended disclosure, and fear of antiretroviral therapy as patient barriers, and brusque counseling and insufficient counseling at provider-initiated testing sites as service delivery-related. However, observations from the same clinics showed that providers often failed to elicit patients' barriers to retention, making it unlikely these would be addressed during counseling. Training is needed to improve interpersonal aspects of counseling and ensure providers elicit and address barriers to HIV care experienced by patients.

Burden of malaria among adult patients attending general medical outpatient department and HIV care and treatment clinics in Oromia, Ethiopia: a comparative cross-sectional study.

BACKGROUND: Malaria and HIV/AIDS constitute major public health problems in Ethiopia, but the burden associated with malaria-HIV co-infection has not been well documented. In this study, the burden of malaria among HIV positive and HIV negative adult outpatients attending health facilities in Oromia National Regional State, Ethiopia was investigated. METHODS: A comparative cross-sectional study among HIV-positive patients having routine follow-up visits at HIV care and treatment clinics and HIV-seronegative patients attending the general medical outpatient departments in 12 health facilities during the peak malaria transmission season was conducted from September to November, 2011. A total of 3638 patients (1819 from each group) were enrolled in the study. Provider initiated testing and counseling of HIV was performed for 1831 medical outpatients out of whom 1819 were negative and enrolled into the study. Malaria blood microscopy and hemoglobin testing were performed for all 3638 patients. Data was analyzed using descriptive statistics, Chi square test and multivariate logistic regression. RESULTS: Of the 3638 patients enrolled in the study, malaria parasitaemia was detected in 156 (4.3%); malaria parasitaemia prevalence was 0.7% (13/1819) among HIV-seropositive patients and 7.9% (143/1819) among HIV-seronegative patients. Among HIV-seropositive individuals 65.4% slept under a mosquito bed net the night before data collection, compared to 59.4% of HIV-seronegative individuals. A significantly higher proportion of HIV-seropositive malaria-negative patients were on co-trimoxazole (CTX) prophylaxis as compared to HIV-malaria co-infected patients: 82% (1481/1806) versus 46% (6/13) (P = 0.001). HIV and malaria co-infected patients were less likely to have the classical symptoms of malaria (fever, chills and headache) compared to the HIV-seronegative and malaria positive counterparts. Multivariate logistic regression showed that HIV-seropositive patients who come for routine follow up were less likely to be infected by malaria (OR = 0.23, 95% CI = 0.09-0.74). CONCLUSION: The study documented lower malaria prevalence among the HIV-seropositive attendants who come for routine follow up. Clinical symptoms of malaria were more pronounced among HIV-seronegative than HIV-seropositive patients. This study also re-affirmed the importance of co-trimoxazole in preventing malaria symptoms and parasitaemia among HIV-positive patients.

Characteristics and outcomes of adult Ethiopian patients enrolled in HIV care and treatment: a multi-clinic observational study.

BACKGROUND: We describe trends in characteristics and outcomes among adults initiating HIV care and treatment in Ethiopia from 2006-2011. METHODS: We conducted a retrospective longitudinal analysis of HIV-positive adults (≥ 15 years) enrolling at 56 Ethiopian health facilities from 2006-2011. We investigated trends over time in the proportion enrolling through provider-initiated counseling and testing (PITC), baseline CD4+ cell counts and WHO stage. Additionally, we assessed outcomes (recorded death, loss to follow-up (LTF), transfer, and total attrition (recorded death plus LTF)) before and after ART initiation. Kaplan-Meier techniques estimated cumulative incidence of these outcomes through 36 months after ART initiation. Factors associated with LTF and death after ART initiation were estimated using Hazard Ratios accounting for within-clinic correlation. RESULTS: 93,418 adults enrolled into HIV care; 53,300 (57%) initiated ART. The proportion enrolled through PITC increased from 27.6% (2006-2007) to 44.8% (2010-2011) (p < .0001). Concurrently, median enrollment CD4+ cell count increased from 158 to 208 cells/mm(3) (p < .0001), and patients initiating ART with advanced WHO stage decreased from 56.6% (stage III) and 15.0% (IV) in 2006-2007 to 47.6% (stage III) and 8.5% (IV) in 2010-2011. Median CD4+ cell count at ART initiation remained stable over time. 24% of patients were LTF before ART initiation. Among those initiating ART, attrition was 30% after 36 months, with most occurring within the first 6 months. Recorded death after ART initiation was 6.4% and 9.2% at 6 and 36 months, respectively, and decreased over time. Younger age, male gender, never being married, no formal education, low CD4+ cell count, and advanced WHO stage were associated with increased LTF. Recorded death was lower among younger adults, females, married individuals, those with higher CD4+ cell counts and lower WHO stage at ART initiation. CONCLUSIONS: Over time, enrollment in HIV care through outpatient PITC increased and patients enrolled into HIV care at earlier disease stages across all HIV testing points. However, median CD4+ cell count at ART initiation remained steady. Pre- and post-ART attrition (particularly in the first 6 months) have remained major challenges in ensuring prompt ART initiation and retention on ART.