Determinants of mortality and loss to follow-up among adults enrolled in HIV care services in Rwanda.

BACKGROUND: Antiretroviral therapy (ART) improves morbidity and mortality in patients with HIV, however high rates of loss to follow-up (LTF) and mortality have been documented in HIV care and treatment programs. METHODS: We analyzed routinely-collected data on HIV-infected patients ≥ 15 years enrolled at 41 healthcare facilities in Rwanda from 2005 to 2010. LTF was defined as not attending clinic in the last 12 months for pre-ART patients and 6 months for ART patients. For the pre-ART period, sub-distribution hazards models were constructed to estimate LTF and death to account for competing risks. Kaplan-Meier (KM) and Cox proportional hazards models were used for patients on ART. RESULTS: 31,033 ART-naïve adults were included, 64% were female and 75% were WHO stage I or II at enrollment. 17,569 (56%) patients initiated ART. Pre-ART competing risk estimates of LTF at 2 years was 11.2% (95%CI, 10.9-11.6%) and 2.9% for death (95%CI 2.7-3.1%). Among pre-ART patients, male gender was associated with higher LTF (adjusted sub-hazard ratio (aSHR) 1.3, 95%CI 1.1-1.5) and death (aSHR 1.7, 95%CI 1.4-2.1). Low CD4 count (CD4<100 vs. ≥ 350 aSHR 0.2, 95%CI 0.1-0.3) and higher WHO stage (WHO stage IV vs. stage I aSHR 0.4, 95%CI 0.2-0.6) were protective against pre-ART LTF. KM estimates for LTF and death in ART patients at 2 years were 4.4% (95%CI 4.4-4.5%) and 6.3% (95%CI 6.2-6.4%). In patients on ART, male gender was associated with LTF (adjusted hazard ratio (AHR) 1.4, 95%CI 1.2-1.7) and death (AHR1.3, 95%CI 1.2-1.5). Mortality was higher for ART patients ≥ 40 years and in those with lower CD4 count at ART initiation. CONCLUSIONS: Low rates of LTF and death were founds among pre-ART and ART patients in Rwanda but greater efforts are needed to retain patients in care prior to ART initiation, particularly among those who are healthy at enrollment.

High retention among HIV-infected children in Rwanda during scale-up and decentralization of HIV care and treatment programs, 2004 to 2010.

BACKGROUND: Efforts to scale-up HIV treatment in high burden countries have resulted in wider access to care, improved survival and decreased morbidity for HIV-infected children. The country of Rwanda has made significant achievements in expanding coverage of pediatric HIV services. METHODS: We describe the extent of and factors associated with mortality and lost to follow-up (LTF) in children (<15 years) enrolled in HIV care at 39 ICAP-supported facilities across Rwanda from 2004 to 2010 by antiretroviral treatment (ART) status. We estimated the 1-year cumulative incidence of death and LTF among all children enrolled in care (pre-ART) and children on ART. Survival analysis was used to evaluate factors associated with death and LTF in both groups. RESULTS: Between January 2004 and June 2010, 3244 children with a median age of 5.7 years (interquartile range 2.8-9.6) enrolled in HIV care. One-year cumulative incidence for death and LTF among pre-ART children was 4% (95% confidence interval [CI]: 3-5%) and 5% (95% CI: 4-6%), respectively. Overall, 2035 (63%) children initiated ART, median age 6.3 years (interquartile range 3.3-10.4): 1-year Kaplan-Meier estimates of death and LTF were 3% (95% CI: 3-4%) and 1% (95% CI: 1-2%), respectively. Factors associated with an increased hazard for death among pre-ART children included being <18 months old versus ≥5 years (adjusted sub hazard ratio [aSHR] = 4.4, 95% CI: 2.9-6.8) and World Health Organization stage IV versus I (aSHR = 4.1, 95% CI: 2.0-8.4), whereas children entering care through prevention of mother-to-child transmission had lower hazard than those from voluntary counseling and testing (aSHR = 0.50, 95% CI: 0.25-1.0). Markers of advanced disease, including severe immunosuppression (aSHR = 0.25, 95% CI: 0.12-0.54), and enrollment in care in rural versus urban clinics (aSHR = 0.71, 95% CI: 0.53-0.97) were protective against LTF. For children on ART, factors associated with hazard of death included younger age (adjusted hazard ratio [aHR] <18 months versus ≥5 years = 2.1, 95% CI: 1.3-3.6), severe malnutrition versus not malnourished (aHR = 3.2, 95% CI: 1.3-8.1), advanced World Health Organization stage (aHR IV versus I = 9.8, 95% CI: 3.5-27.4) and severe immunodeficiency versus no evidence (aHR = 2.3, 95% CI: 1.7-3.3). No associations were observed with LTF among children on ART. CONCLUSIONS: The results demonstrate very high retention among children enrolled in HIV care in Rwanda. Younger children continue to be particularly vulnerable, underscoring the urgent need for early identification, rapid treatment initiation and long-term retention in care.