Comparing Different Measures of Retention in Care Among a Cohort of Adolescents and Young Adults Living with Behaviorally-Acquired HIV.

Young people living with HIV (YLWH) have some of the lowest rates of retention in HIV care, putting them at risk for negative health outcomes. To better understand retention in care in this age group, we conducted a retrospective cohort analysis of YLWH initiating care at a multidisciplinary, adolescent-focused HIV clinic (N = 344). Retention was calculated using a variety of definitions, and relationships between different definitions were assessed. During the 1-year study period, on average YLWH missed two scheduled appointments, and attended 80% of appointments, usually at least once every 3 months. About one-quarter experienced a 6-month gap in care and about two-thirds met the Health Resources and Services Administration's retention criteria. Although most retention definitions were significantly correlated, not all were. Researchers, clinicians, and policymakers should consider the impact of varying definitions of retention, in order to optimally measure this outcome in YLWH, a key vulnerable population.

Reasons for disengagement from antiretroviral care in the era of "Treat All" in low- or middle-income countries: a systematic review.

INTRODUCTION: Disengagement from antiretroviral therapy (ART) care is an important reason why people living with HIV do not achieve viral load suppression become unwell. METHODS: We searched two databases and conference abstracts from January 2015 to December 2022 for studies which reported reasons for disengagement from ART care. We included quantitative (mainly surveys) and qualitative (in-depth interviews or focus groups) studies conducted after "treat all" or "Option B+" policy adoption. We used an inductive approach to categorize reasons: we report how often reasons were reported in studies and developed a conceptual framework for reasons. RESULTS: We identified 21 studies which reported reasons for disengaging from ART care in the "Treat All" era, mostly in African countries: six studies in the general population of persons living with HIV, nine in pregnant or postpartum women and six in selected populations (one each in people who use drugs, isolated indigenous communities, men, women, adolescents and men who have sex with men). Reasons reported were: side effects or other antiretroviral tablet issues (15 studies); lack of perceived benefit of ART (13 studies); psychological, mental health or drug use (13 studies); concerns about stigma or confidentiality (14 studies); lack of social or family support (12 studies); socio-economic reasons (16 studies); health facility-related reasons (11 studies); and acute proximal events such as unexpected mobility (12 studies). The most common reasons for disengagement were unexpected events, socio-economic reasons, ART side effects or lack of perceived benefit of ART. Conceptually, studies described underlying vulnerability factors (individual, interpersonal, structural and healthcare) but that often unexpected proximal events (e.g. unanticipated mobility) acted as the trigger for disengagement to occur. DISCUSSION: People disengage from ART care for individual, interpersonal, structural and healthcare reasons, and these reasons overlap and interact with each other. While HIV programmes cannot predict and address all events that may lead to disengagement, an approach that recognizes that such shocks will happen could help. CONCLUSIONS: Health services should focus on ways to encourage clients to engage with care by making ART services welcoming, person-centred and more flexible alongside offering adherence interventions, such as counselling and peer support.

Association Between Time to Antiretroviral Therapy and Loss to Care Among Newly Diagnosed Rwandan People Living with Human Immunodeficiency Virus.

Despite improved clinical outcomes of initiating antiretroviral therapy (ART) soon after diagnosis, conflicting evidence exists regarding the impact of same-day ART initiation on subsequent clinical outcomes. We aimed to characterize the associations of time to ART initiation with loss to care and viral suppression in a cohort of newly diagnosed people living with HIV (PLHIV) entering care after Rwanda implemented a national "Treat All" policy. We conducted a secondary analysis of routinely collected data of adult PLHIV enrolling in HIV care at 10 health facilities in Kigali, Rwanda. Time from enrollment to ART initiation was categorized as same day, 1-7 days, or >7 days. We examined associations between time to ART and loss to care (>120 days since last health facility visit) using Cox proportional hazards models, and between time to ART and viral suppression using logistic regression. Of 2,524 patients included in this analysis, 1,452 (57.5%) were women and the median age was 32 (interquartile range: 26-39). Loss to care was more frequent among patients who initiated ART on the same day (15.9%), compared with those initiating ART 1-7 days (12.3%) or >7 days (10.1%), p < .001. In multivariable analyses, same-day ART initiation was associated with a greater hazard of loss to care compared with initiating >7 days after enrollment (adjusted hazard ratio 1.39, 95% confidence interval: 1.04-1.85). A total of 1,698 (67.3%) had available data on viral load measured within 455 days after enrollment. Of these, 1,476 (87%) were virally suppressed. A higher proportion of patients initiating ART on the same day were virally suppressed (89%) compared with those initiating 1-7 days (84%) or >7 days (88%) after enrollment. This association was not statistically significant. Our findings suggest that ensuring adequate, early support for PLHIV initiating ART rapidly may be important to improve retention in care for newly diagnosed PLHIV in the era of Treat All.

The Convergence of Disclosure Concerns and Poverty Contributes to Loss to HIV Care in India: A Qualitative Study.

In India, there is little evidence on reasons for high rates of loss to HIV care. We conducted a clinic-based qualitative study at the YR Gaitonde Centre for AIDS Research and Education to explore factors that influence loss to care. In all, 17 men and 14 women were interviewed; median age was 42 (interquartile range [IQR], 36-48) and median CD4 count was 448 (IQR, 163-609). A majority reported avoiding treatment freely available at nearby government facilities because of disclosure concerns and perceptions of poor quality. As a result, participants sought care in the private sector where they were subjected to medication and transport costs. Life circumstances causing lost wages or unexpected expenditures therefore prevented participants from attending clinic, resulting in loss to care. Improving perceptions of quality of care in the public sector, addressing disclosure concerns, and reducing economic hardships among people living with HIV may be important in reducing loss to HIV care in India.

Factors associated with loss to clinic among HIV patients not yet known to be eligible for antiretroviral therapy (ART) in Mozambique.

INTRODUCTION: Retention in HIV care prior to ART initiation is generally felt to be suboptimal, but has not been well-characterized. METHODS: We examined data on 37,352 adult pre-ART patients (ART ineligible or unknown eligibility) who enrolled in care during 2005-2008 with >1 clinical visit at 23 clinics in Mozambique. We defined loss to clinic (LTC) as >12 months since the last visit among those not known to have died/transferred. Cox proportional-hazards models were used to examine factors associated with LTC, accounting for clustering within sites. RESULTS: Of 37,352 pre-ART patients, 61% had a CD4 count within three months of enrolment (median CD4: 452, IQR: 345-611). 17,598 (47.1%) were ART ineligible and 19,754 (52.9%) were of unknown eligibility status at enrolment because of missing information on CD4 count and/or WHO stage. Kaplan-Meier estimates for LTC at 12 months were 41% (95% CI: 40.2-41.8) and 48% (95% CI: 47.2-48.8), respectively. Factors associated with LTC among ART ineligible patients included male sex (AHR(men_vs_non-pregnant women): 1.5; 95% CI: 1.4-1.6) and being pregnant at enrolment (AHR(pregnant_vs_non-pregnant women): 1.3; 95% CI: 1.1-1.5). Older age, more education, higher weight and more advanced WHO stage at enrolment were independently associated with lower risks of LTC. Similar findings were observed among patients whose ART eligibility status was unknown at enrolment. CONCLUSIONS: Substantial LTC occurred prior to ART initiation among patients not yet known to be eligible for ART, including nearly half of patients without documented ART eligibility assessment. Interventions are needed to target pre-ART patients who may be at higher risk for LTC, including pregnant women and patients with less advanced HIV disease.