Low retention of HIV-infected patients on antiretroviral therapy in 11 clinical centres in West...

Low retention of HIV-infected patients on antiretroviral therapyin 11 clinical centers

Didier K. Ekouevi1,2, Eric Balestre1, Franck-Olivier Ba-Gomis3, Serge Paul Eholie4, MoussaMaiga5, Clarisse Amani-Bosse6, Albert Minga2,7, Eugène Messou8, Papa Salif Sow9,Charlotte Lewden1, Hamar Allassane Traoré10, Emmanuel Bissagnene4, François Dabis1,and IeDEA West Africa Collaboration1

1INSERM, U897, and ISPED, Université Bordeaux 2, Bordeaux, France2Programme PAC-CI, CHU de Treichville, Abidjan, Côte d'Ivoire3Centre Intégré de Recherche Bioclinique d'Abidjan (CIRBA), Abidjan, Côte d'Ivoire4Service de Maladies Infectieuses et Tropicales (SMIT), Centre Hospitalier Universitaire (CHU)de Treichville, Abidjan, Côte d'Ivoire5Service d'Hépato-Gastro-Entérologie, Hôpital Gabriel Touré, Bamako, Mali6MTCT+ Initiative, ACONDA, Abidjan, Côte d'Ivoire7Centre Médical de Suivi de Donneurs de Sang/CNTS/PRIMO-CI, Abidjan, Côte d'Ivoire8CePReF, ACONDA, Abidjan Côte d'Ivoire9SMIT, CHU de Fann, Dakar, Senegal10Service de Medecine interne, Hôpital du point G, Bamako, Mali

SummaryObjective—To study factors associated with the probability of retention in antiretroviral therapy(ART) programs in West Africa.

Methods—The International epidemiologic Databases to Evaluate AIDS (IeDEA) in West Africais a prospective, operational, observational cohort study based on collaboration between 11cohorts of HIV-infected adult patients in Benin, Côte d'Ivoire, Gambia, Mali and Senegal. Allpatients aged 16 and older at ART initiation, with documented gender and date of ART initiation,were included. For those with at least one day of follow-up, Kaplan-Meier method and Weibull

Corresponding author: Didier Koumavi Ekouevi, Programme PAC-CI, CHU de Treichville, Abidjan, Côte d’Ivoire. Phone + 225 2175 59 64, Cell phone +225 07 78 08 45, Fax: +225 21 24 90 69, ekouevi@aviso.ci, Website www.iedeawestafrica.org.1The IeDEA West Africa Adults Group is constituted as follows: Primary investigators: Pr François Dabis* (INSERM U897,ISPED, Bordeaux, France), Emmanuel Bissagnene* (SMIT, CHU de Treichville, Abidjan, Côte d'Ivoire); Co-investigators: ClarisseAmani-Bosse, Franck Olivier Ba-Gomis, Emmanuel Bissagnene*, Man Charurat*, Eric Delaporte, Joseph Drabo*, Serge-PaulEholie*, Serge-Olivier Koulé, Moussa Maiga*, Eugène Messou, Albert Minga, Kevin Peterson, Papa Salif Sow, Hamar Traoré,Marcel D Zannou*; Other members: Gérard Allou, Xavier Anglaret, Alain Azondékon, Eric Balestre, Jules Bashi, Ye-Diarra, DidierK Ekouévi*, Jean-François Eytard, Antoine Jaquet, Alain Kouakoussui, Valériane Leroy, Charlotte Lewden, Karen Malateste, LornaRenner, Annie Sasco, Haby Signaté Sy*, Rodolphe Thiebault, Marguerite Timité-Konan, Hapsatou Touré. Adult Clinical centers:Service de Médecine Interne et Tropicale (SMIT), CHU de Treichville, Abidjan, Côte d'Ivoire; Unité de Soins Ambulatoires et deConseil (USAC), Abidjan, Côte d'Ivoire; Centre Médical de Suivi de Donneurs de Sang/CNTS/PRIMO-CI, Abidjan, Côte d'Ivoire;ACONDA-MTCT-Plus, Abidjan, Côte d'Ivoire; ACONDA-CePReF, Abidjan Côte d'Ivoire; Centre Intégré de Recherche Biocliniqued'Abidjan (CIRBA), Abidjan, Côte d'Ivoire; Service des Maladies Infectieuses, CHU de FANN/ISAARV, Dakar, Sénégal; ANRS1215 Cohort, Dakar, Senegal; Service d'Hépato-Gastro-Entérologie, Hôpital Gabriel Touré, Bamako, Mali; Centre de Prise en Chargedes Personnes vivant avec le VIH, Hôpital du Point G, Bamako, Mali; Fajara Cohort, Banjul, Gambia; Service de Médecine Interne,CNHU Hubert Maga, Cotonou, Benin; Service de Médecine Interne, CHU Yalgado, Ouagadougou, Burkina-Faso. Coordinatingcenters: Programme PAC-CI, CHU de Treichville, Abidjan, Côte d'Ivoire; ISPED, Université Victor Segalen Bordeaux 2, France. *IeDEA West Africa Technical Committee member

NIH Public AccessAuthor ManuscriptTrop Med Int Health. Author manuscript; available in PMC 2011 June 1.

Published in final edited form as:Trop Med Int Health. 2010 June ; 15(Suppl 1): 34–42. doi:10.1111/j.1365-3156.2010.02505.x.

-PA Author Manuscript

regression model were used to estimate the 12-month probability of retention in care and theassociated factors.

Results—14,352 patients (61% female) on ART were included in this data merger. Median agewas 37 years (IQR: 31-44 years) and median CD4 count at baseline was 131 cells/mm3 (IQR:48-221 cells/mm3). The first line regimen was NNRTI-based for 78% of patients, protease-inhibitor based for 17%, and three NRTIs for 3%. The probability of retention was 0.90 (95%confidence interval [CI]: 0.89-0.90) at 3 months, 0.84 (95%CI: 0.83-0.85) at 6 months and 0.76(95%CI: 0.75-0.77) at 12 months. The probability of retention in care was lower in patients withbaseline CD4 count <50 cells/mm3 (adjusted Hazard Ratio (aHR)=1.37; 95%CI: 1.27-1.49;p<0.0001) (reference CD4>200 cells/mm3, in men (aHR=1.17; 95%CI: 1.10-1.24; p=0.0002), inyounger patients (<30 years) (aHR=1.10; 95%CI: 1.03-1.19; p=0.01) and in patients with lowhemoglobinemia <8g/dL (aHR=1.33; 95%CI: 1.21-1.45; p<0.0001). Availability of funds forsystematic tracing was associated with better retention (aHR=0.29; 95%CI: 0.16-0.55; p=0.001).

Conclusions—Close follow-up, promoting early access to care and ART and a decentralizedsystem of care may improve the retention in care of HIV-patients on ART.

Keywordscohort studies; HIV infection; West Africa; retention; mortality; loss to follow-up

IntroductionDuring the past five years, unprecedented resources have been mobilized through initiativessuch as the Global Fund to fight HIV, Tuberculosis, and Malaria (Global Fund 2008) and theU.S. President's Emergency Plan for AIDS Relief (PEPFAR 2008) to reach the goal ofuniversal access to HIV treatment. At the end of 2007, about 3 million people werereceiving antiretroviral therapy (ART) (WHO/UNAIDS/UNICEF 2008), but they were only31% of HIV-infected patients who needed ART (WHO/UNAIDS/UNICEF 2008).

ART prolongs the life and improves the quality of life of HIV-infected patients, but only aslong as the patient remains in care (Braitstein et al. 2006; Stringer et al. 2006; Toure et al.2008). The effectiveness of ART of programs should be evaluated regularly using keyindicators including percentage of deaths, percentage of patients lost to follow-up (LTFU),and percentage of patients remaining on ART in the program. Among these indicators,retention is the most meaningful, as poor retention in care predicts poor survival with HIVinfection (Giordano et al. 2007). In lower-income countries, mortality is underestimated inHIV programs because of the misclassification of LTFU patients (Giordano et al. 2007;Anglaret et al. 2004; Bisson et al. 2008; Dalal et al. 2008; Yu et al. 2007). Program-specificfactors should be identified in order to improve adherence to treatment and to achieve betteroutcomes for patients starting ART in developing countries. Data on individual factors andprogram characteristics that could explain retention are scarce (Calmy et al. 2006; Rosen etal. 2007; Tsague et al. 2008), as are data on factors associated with patient loss to follow-up(Calmy et al. 2006; Rosen et al. 2007; Tsague et al. 2008).

We hypothesized that both the characteristics of HIV care systems and the individualcharacteristics of patients influence retention in HIV care. We report here the one-yearestimates of the retention of HIV-infected patients on ART and the factors associated withpatient loss to follow-up in large HIV programs participating in the Internationalepidemiological Database to Evaluate AIDS (IeDEA) in West Africa.

Ekouevi et al. Page 2

Trop Med Int Health. Author manuscript; available in PMC 2011 June 1.

MethodsIeDEA West Africa collaboration

This cohort analysis was conducted within the International epidemiological Database toEvaluate AIDS (IeDEA) initiative (www.iedea-hiv.org), by collecting and harmonizing datafrom multiple HIV/AIDS cohorts from industrialized and resource-limited countries. TheIeDEA collaboration aims to address research questions in the field of HIV/AIDS care andtreatment, especially in lower-income countries, where most ART scaling up takes place. Inthe West African region, this collaboration was launched in July 2006. Since April 2008,eleven HIV/AIDS clinics for adults participate in this collaboration(www.iedeawestafrica.org). This first merger analysis includes the data from all of theparticipating adult's clinical centers: Benin (n=1), Côte d'Ivoire (n=6), Gambia (n=1), Mali(n=2), and Senegal (n=1). Data from Burkina-Faso and Nigeria were not yet available at thetime of analysis.

Inclusion criteria and definitionsAll HIV-infected patients aged of 16 years or older starting ART irrespective of the drugregimen and for whom gender and date of ART initiation were documented were eligible.The following information was recorded in the database: age, gender, body mass index, dateof ART initiation, pre-therapy CD4 count, haemoglobinemia and type of ART regimen.Clinical follow-up was generally scheduled every 3 months and CD4 counts were measuredevery 6 months to monitor immunological response to ART. Routine viral load monitoringis generally not available.

Ethical aspectsThe IeDEA West Africa collaboration was approved by the national ethics committees atcountry level with federal-wide assurance number identification.

OutcomesThe main outcomes of this study were (i) loss to follow-up defined as a duration of >6months between the last visit recorded and the closing date of the database, among all HIV-infected patients who had initiated ART and at least one day of follow-up; (ii) retention (oneminus the probability of death or loss to follow-up).

Statistical analysisContinuous variables were compared using the Wilcoxon rank-sum test and comparisonsbetween two categorical variables were done using the chi2 test and Fisher's exact test whenappropriate. For survival analysis, the closing date was defined for each cohort as the date ofthe most recent follow-up recorded in the database. We included in this analysis only thepatients with at least one day of follow-up.

In April 2008, the data set was closed for analysis after the data merger. Follow-up wascensored at the date of death for deceased patients, and the date of the last visit for LTFUpatients. Patients alive and in care on April 2008 were right-censored at the date of their lastvisit before this fixed date.

Kaplan-Meier estimates were used to estimate the probabilities of retention in care and 95%confidence interval (CI). Logrank tests were used for univariable comparison. We usedrandom-effect Weibull regression models to estimate the hazards ratio (HR) of retention andits 95% CI, accounting for heterogeneity between the different HIV clinics (Gutierez 2002;Keiding et al. 1997).

Models included both individual patient's variables (age, gender, pre-therapy baseline CD4cell count, baseline hemoglobinemia level, type of initial regimen, clinical stage of HIVdisease defined as less advanced (CDC stage A/B or WHO stage I/II) or advanced (CDCstage C or WHO stage III/IV), baseline hemoglobinemia level and body mass index) andprogram level characteristics (use of phone calls, tracing methods in case of missedappointment, type and location of facilities, free access to ART and laboratory tests). Allvariables associated with retention in care at P values <0.25 and variables known associatedwith retention were included in the multivariate analysis. The multivariable analysis wasperformed by backward selection procedure. All analyses were performed in an intent-to-continue treatment with the SAS software, version 9.1 (SAS Institute, Cary, NC, USA).

ResultsSite description

Eleven HIV clinics for adults in urban areas participate in the IeDEA West Africacollaboration. Seven are funded through government, including 5 in university teachinghospitals. Two centres are supported by non-governmental organisations (in Abidjan) and 2others by both public and private funds. As of April 2008, ART was free of charge in 6 ofthese clinics. Laboratories tests were free of charge in all centres except in 1 in Abidjan and1 in Dakar. Only 3 sites had funds for systematic home visits and telephone calls whenpatients missed scheduled clinic visits (Table 1).

Study populationWe included 14,352 HIV-infected patients (61.4% female) in this analysis. Median age was37 years (interquartile range [IQR]: 31-44 years) and baseline median CD4 count(n=12,366) was 131 cells/mm3 (IQR: 48-221 cells). Among 10,564 patients for whom HIVdisease was recorded, 5,580 (38.9%) had advanced HIV disease (WHO stage 3-4 or AIDS).The first-line ART regimen prescribed was NNRTI-based for 78% of patients, proteaseinhibitor-based for 17%, and 3 NRTIs for 3%. We summarise in Table 2 the baselinecharacteristics of this population of HIV-infected patients at ART initiation.

Retention in programAmong the 14,352 HIV-infected patients enrolled, 1,250 (8.7%) had no follow-up visit afterthe initiation of ART (Table 2). Initial defaulters were more often men and had a lowerbaseline median CD4 count than patients with at least1 day of follow-up.

13,102 (91.3%) patients were followed up for a median of 1.8 years (IQR): [0.8-2.8]accounting for 24620.7 person-years of follow-up. During the overall study period, 521(4.0%) patients were known to be dead, and 2,610 (19.9%) were lost to follow-up. 9,971(76.1%) patients remained on ART 12 months after enrolment.

The probability of retention in the program was 0.90 (CI: 0.89-0.90) at 3 months, 0.84 (CI:0.83-0.85) at 6 months, 0.76 (CI: 0.75-0.77) at 12 months, 0.68 (CI: 0.67-0.69) at 18 monthsand 0.60 (0.59-0.61) at 24 months (Figure 1). Probabilities of retention are presentedaccording to CD4 count at baseline (Figure 2a), WHO stage (Figure 2b), type of healthfacility (Figure 2c) and availability of tracing methods (Figure 2d). At 12 months, theprobability of retention was 0.68 (CI: 0.66-0.69) in patients with a baseline CD4 count <50cells/mm3 and 0.80 (CI: 0.79-0.82) in patients with a baseline CD4 count >200 cells/mm3.

Factors associated with the retention in programsIn multivariate analysis (Table 3), the probability of retention was lower in males (adjustedHazard Ratio (aHR): 1.17, CI: 1.10-1.24, p=0.0002), and in younger patients < 30 years old

(aHR=1.10; CI: 1.03-1.19; p=0.01). Two biological factors measured at initiation oftreatment were also associated with a poorer retention: a CD4 count <50 cells/mm3

(aHR=1.37; CI: 1.27-1.49; p<0.001) as compared to those with CD4 count >200 cells/mm3;and low haemoglobinemia <8g/dL (aHR=1.33; CI: 1.21-1.45; p<0.0001) as compared tothose with haemoglobin level >=8 g/dL. Finally, the availability of tracing method in theprogramme (phone calls and systematic home visits when patients missed appointmentvisits) was associated with a much better retention in the program clinics at 12 months(aHR: 0.29, CI: 0.16-0.55, p=0.001).

DiscussionThe 1-year retention, or average chance for a patient to remain in care and on ART, was79% in this large collaborative study with more than 15,000 patients in 5 West Africancountries. Not only individual factors such as gender, age, low CD4 cell count (<50 cells/mm3) and low hemoglobinemia (<8g/dL) were associated with retention, but also programcharacteristics such as tracing. To our knowledge this is the first report on programoutcomes in more than one country in this part of Africa, where the HIV epidemic has beengeneralized for more than 20 years in terms of treatment programs, but the response hasbeen generally delayed except in Senegal (Etard et al. 2006).

In terms of frequency, our results are similar to those reported by Tsague et al. (2008) inCameroon, who reported a retention rate of 82% at 12 months. In 21 centers of MedecinsSans Frontière programs (none in West Africa), Calmy et al. (2006) reported that 82% ofHIV-infected patients remained on ART at 12 months. These two studies did not includedata on program characteristics. A meta-analysis on published results including 32 scientificreports from 13 countries in Sub-Saharan Africa revealed that the average retention rate at12 months was 75% (Rosen et al. 2007). This low rate of retention in care of HIV-infectedpatients on ART may be the next challenge once universal access to ART has been achieved(WHO/UNAIDS/UNICEF 2008).

A proportion of 19% LTFU patients at 12 months is almost five times the reported risk ofdeath. 19% was also reported by an NGO-funded program with rapid scale-up in Côted'Ivoire (Toure et al. 2008); 24% were reported in an urban area in Uganda (Weidle et al.2002). However, this indicator is rarely used in the majority of reports on the mortality ofHIV-infected patients in lower income countries (Lawn et al. 2008), which impairs the fullinterpretation of survival estimates (Anglaret et al. 2004).

The fact that the definition of LTFU varies in each program or study complicates thecomparison between different settings (Rosen et al. 2007, Lawn et al. 2008). In our study,we defined patients as LTFU when they had not been in contact with the HIV clinics for atleast six months and were not known to have moved or died. This definition is consistentwith the largest report to date on the matter (Braitstein et al. 2006).

In this collaborative analysis, we were unable to investigate thoroughly primary reasons forLTFU. In a study conducted in South Africa in 2004-2005, 35% of HIV-infected patientscould not be traced because of incorrect contact information (Dalal et al. 2008) probablygiven for fear of being identified as HIV-infected. In the same study, among the 48% ofpatients who were successfully traced, death was the most common outcome. Anotherinvestigation of patients LTFU in four facilities in northern Malawi found that 50% of themhad died, 23% were alive and 27% untraceable (Yu et al. 2007). Indeed, for cultural andsocial reasons, many African patients on ART at advanced stage of disease return to theirvillage to die in order to reduce the funeral costs; these patients are generally classified asLTFU. Whether this was true in our 11 participating clinics in West African capitals remains

unverified but has been documented in the context of a clinical trial cohort in Abidjan(Anglaret et al. 2006). Investigating vital status by research in newspaper obituaries,telephone calls to relatives and home visits has been used to obtain more accurateinformation on mortality (Anglaret et al. 2006).

Another factor explaining a high rate of LTFU is that the patients find other sources of care(Stringer et al. 2006). This should normally be documented by reviewing transfer form atclinic level. However, this information is inconsistently reported, thus preventing the properdocumentation of retention. In the ACONDA program in Côte d'Ivoire, which includedmore than 10,000 HIV-infected patients on ART, 3% had been transferred to other HIV careprograms (Toure et al. 2008).

In our study, multivariable analysis identified 5 factors associated with low retention rates.The first was low CD4 cell counts (<50 cells/mm3), a factor known to be associated withearly mortality in lower-income countries (Stringer et al. 2006, Toure et al. 2008, Calmy etal. 2006, Tsague et al. 2008). This favours the hypothesis that a certain proportion ofpatients LTFU are in fact dying. In accordance with the Cameroon report, WHO stage atART initiation was not associated with retention (Tsague et al. 2008). However, in Côted'Ivoire, advanced HIV disease was associated with LTFU (Toure et al. 2008). Lowhemoglobin level, which is a known risk factor of disease progression in ART treatedpatients (Srasuebkul et al. 2009), was associated with poor retention in our study. The otherindividual factors associated with retention were male gender and younger age. This may bedue to the higher mobility in young men as reported by Brinkhof et al. (2008). Theassociation between retention and female sex may depend on the sex ratio of clinicattendees, itself related to the setting (Dalal et al. 2008, Brinkhof et al. 2008).

A program factor strongly associated with good retention was the availability of fundsforsystematic tracing of patients who missed scheduled visits. However, this approach isexpensive and not fully supported by most donors programs. Home follow-up visits seemedinefficient and relatively expensive (Stringer et al. 2006) in an urban program in Zambia,although systematic tracing can be an efficacious strategy (Braitstein et al. 2006). In Côted'Ivoire, at 12 months, it was clear that the rate of LTFU was lower in the HIV clinics withmore logistical support and experienced staff (Toure et al. 2008). The ART-LINCcollaboration observed that 12-month survival was paradoxically lower in patients withpassive follow-up, but this difference had to be corrected by the fact that 12% of patientswere considered as LTFU in programs with active follow-up versus 19% in programs withpassive follow-up (Braitstein et al. 2006). In general, our affiliated centers did not have thefunds to retrieve patients who had missed their clinic visit. A cost-effectiveness analysis isunder way to document the relation between the intensity and organization of effective careand its impact on the retention of patients (Losina et al. 2008).

Many strategies proposed to increase retention in HIV clinics are similar across theprograms. A family-based approach is considered as one option to increase retention, butthis needs to be better documented (Tonwe-Gold et al. 2009). Other strategies such asoutreach initiatives, peer educators, or maintaining updated contact information duringfollow-up have been suggested, but none have been fully investigated. The education ofHIV-infected patients regarding ART should be reinforced before the initiation of ART andat each visit, but the impact of such strategies on program retention is largely unknown.

The main limitation of the study is the underestimation of the risk of death, 4% at 12months. This could be largely explained by the low notification of death in certain cohorts.Indeed, Lawn et al. (2008) reported in an editorial review that between 8% and 26% ofpatients died within the first year of ART, with most deaths occurring in the first months. In

a recent systematic review, mortality was inversely associated with the rate of loss to follow-up in the program: it declined from around 60% to 20% as the percentage of patients lost tothe program increased from 5% to 50% (Brinkhof et al. 2009). We addressed this limit byusing a combined outcome defining retention as the complement of death and loss to follow-up. The second limitation was the lack of long-term data on retention. This is due to recentintroduction of ART in most of these clinics like elsewhere except in pilot site (Etard et al.2006). To our knowledge, long term data have not been reported in large collaborativestudies in low-income countries. Finally, missing data is a common phenomenon, especiallyfor CD4 count, at initiation of ART. In this study it could be largely attributed to the factthat we used data routinely collected from 11 cohorts in West Africa.

Program retention in care now appears to be a more reliable indicator than mortality alone inlow-income countries because of the misclassification of HIV-infected patients LTFU. Oneimportant methodological recommendation for further analyses on this issue is tosystematically include the LTFU effect in survival analysis. Promising approaches such aspatient tracing, reimbursing transportation costs, adherence support during each follow-upvisit and peer educators need to be evaluated for cost-effectiveness. More analyses areneeded find out why HIV-infected adults drop out of care, and policy makers should focuson retention in care.

AcknowledgmentsThe International epidemiological Database to Evaluate AIDS in West Africa (IeDEA West Africa) is supportedby: the National Cancer Institute (NCI), the Eunice Kennedy Shriver National Institute of Child Health and HumanDevelopment (NICHD) and the National Institute of Allergy And Infectious Diseases (NIAID) as part of theInternational Epidemiologic Databases to Evaluate AIDS (IeDEA) (grant no. 5U01AI069919-03). The content ofthis publication is solely the responsibility of the authors and does not necessarily represent the official views ofany of these institutions.

ReferencesAnglaret X, Toure S, Gourvellec G, et al. Impact of vital status investigation procedures on estimates

of survival in cohorts of HIV-infected patients from Sub-Saharan Africa. Journal of AcquiredImmune Deficiency Syndrome. 2004; 35:320–3.

Bisson GP, Gaolathe T, Gross R, et al. Overestimates of survival after HAART: implications forglobal scale-up efforts. PLoS One. 2008; 3:e1725. [PubMed: 18320045]

Braitstein P, Brinkhof MW, Dabis F, et al. Mortality of HIV-1-infected patients in the first year ofantiretroviral therapy: comparison between low-income and high-income countries. Lancet. 2006;367:817–24. [PubMed: 16530575]

Brinkhof MW, Dabis F, Myer L, et al. Early loss of HIV-infected patients on potent antiretroviraltherapy programs in lower-income countries. Bulletin of the World Health Organization. 2008;86:559–67. [PubMed: 18670668]

Brinkhof MW, Pujades-Rodriguez M, Egger M. Mortality of patients lost to follow-up in antiretroviraltreatment programs in resource-limited settings: systematic review and meta-analysis. PLoS ONE.2009; 4:e5790. [PubMed: 19495419]

Calmy A, Pinoges L, Szumilin E, et al. Generic fixed-dose combination antiretroviral treatment inresource-poor settings: multicentric observational cohort. AIDS. 2006; 20:1163–9. [PubMed:16691068]

Dalal RP, Macphail C, Mqhayi M, et al. Characteristics and outcomes of adult patients lost to follow-up at an antiretroviral treatment clinic in Johannesburg, South Africa. Journal of Acquired ImmuneDeficiency Syndrome. 2008; 47:101–7.

Etard JF, Ndiaye I, Thierry-Mieg M, et al. Mortality and causes of death in adults receiving highlyactive antiretroviral therapy in Senegal. AIDS. 2006; 20:1181–9. [PubMed: 16691070]

Giordano TP, Gifford AL, White AC, et al. Retention in care: a challenge to survival with HIVinfection. Clinical Infectious Diseases. 2007; 44:1493–9. [PubMed: 17479948]

Gutierez R. Parametric frailty and shared frailty survival models. STATA. 2002:22–44.Keiding N, Andersen PK, Klein JP. The role of frailty models and accelerated failure time models in

describing heterogeneity due to omitted covariates. Statistics in Medicine. 1997; 16:215–24.[PubMed: 9004393]

Lawn SD, Harries AD, Anglaret X, et al. Early mortality among adults accessing antiretroviraltreatment programmes in sub-Saharan Africa. AIDS. 2008; 22:1897–908. [PubMed: 18784453]

Losina E, Toure H, Uhler L, et al. The clinical and economic impact of interventions to prevent loss tofollow-up (LTFU) in resource-limited settings. PLoS Medicine. 2008; 10:e174.

Rosen S, Fox MP, Gill CJ. Patient retention in antiretroviral therapy programs in sub-Saharan Africa.PLoS Medicine. 2007; 4:e298. [PubMed: 17941716]

Srasuebkul P, Lim PL, Lee MP, et al. Short-term clinical disease progression in HIV-infected patientsreceiving combination antiretroviral therapy: results from the TREAT Asia HIV observationaldatabase. Clinical Infectious Diseases. 2009; 48:940–50. [PubMed: 19226231]

Stringer JS, Zulu I, Levy J, et al. Rapid scale-up of antiretroviral therapy at primary care sites inZambia. JAMA. 2006; 296:782–93. [PubMed: 16905784]

The Global Fund to fight AIDS Tuberculosis and Malaria. Annual Report 2008. 2008 [30 September2009]. Available at:http://www.theglobalfund.org/documents/publications/annualreports/2008/AnnualReport2008.pdf

Tonwe-Gold B, Ekouevi DK, Amani-Bosse C, et al. Implementing family-focused HIV care andtreatment: The first two years' experience of the MTCT-Plus program in Abidjan, Côte d'Ivoire.Tropical Medicine and International Health. 2009; 14:204–12. [PubMed: 19236666]

Toure S, Kouadio B, Seyler C, et al. Rapid scaling-up of antiretroviral therapy in 10,000 adults in Coted'Ivoire:2-year outcomes and determinants. AIDS. 2008; 22:873–82. [PubMed: 18427206]

Tsague L, Koulla S, Kenfak A, et al. Determinants of retention in care in an antiretroviral therapy(ART) program in urban Cameroon. The Pan African Medical Journal. 2008; 1

PEPFAR. U.S. President's Emergency Plan for AIDS Relief. 2008 [30 September 2009]. Available at:http://www.pepfar.gov/documents/organization/115411.pdf

Weidle PJ, Malamba S, Mwebaze R, et al. Assessment of a pilot antiretroviral drug therapyprogramme in Uganda: patients' response, survival, and drug resistance. Lancet. 2002; 360:34–40.[PubMed: 12114039]

WHO/UNAIDS/UNICEF. Towards universal access. Scaling up priority HIV/AIDS interventions inthe health sector. 2008 [30 September 2009]. Available at:http://www.who.int/hiv/pub/towards_universal_access_report_2008.pdf

Yu JK, Chen SC, Wang KY, et al. True outcomes for patients on antiretroviral therapy who are “lost tofollow-up” in Malawi. Bulletin of the World Health Organization. 2007; 85:550–4. [PubMed:17768504]

Figure 1.Program retention probability in the first 12 months after ART initiation

Figure 2.Figure 2a. Program retention probability in the first 12 months after ART initiation bybaseline CD4 cell count (log-rank test: p<0.0001)Figure 2b. Program retention probability in the first 12 months after ART initiation bybaseline clinical stage (log-rank test: p<0.0001)Figure 2c. Program retention probability in the first 12 months after ART initiation by typeof center (log-rank test: p<0.0001)Figure 2d. Program retention probability in the first 12 months after ART initiationaccording to tracing method for patients lost to follow-up (home visit and phone call) (log-rank test: p<0.0001)

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Table 2

Baseline characteristics of HIV-infected patients. IeDEA West Africa Collaboration (N=14352)

Total of patient N=14352 Follow up > 1 day N=13102 No follow-up N=1250 P value

Gender, n(%)

Male 5542 (38.6) 4976 (38.0) 566 (45.3) <0.0001

Female 8810 (61.4) 8126 (62.0) 684 (54.7)

Age, years, median [IQR] 37 [31-44] 37 [31-44] 37 [32-44] 0.23

HIV type <0.0001

HIV-1 13107 (91.3) 11983 (91.5) 1124 (89.9)

HIV-2 371 (2.6) 342 (2.6) 29 (2.3)

Dual infected 445 (3.1) 421 (3.2) 24 (1.9)

Missing 429 (3.0) 356 (2.7) 73 (5.8)

Body mass index, Kg/m2 (n=7989)

Median [IQR] 21 [18-23] 21 [18-23] 20 [17-24] 0.28

WHO clinical stage, n (%) <0.0001

CDC (A, B) or WHO stage (l, II) 4984 (34.7) 4585 (35.0) 399 (31.9)

CDC (C) or WHO stage (III, IV) 5580 (38.9) 5351 (40.8) 229 (18.3)

Missing 3788 (26.4) 3166 (24.2) 622 (49.8)

CD4 counts, cells/mm3 (n=12366) <0.0001

Median [IQR] 131 [48-221] 134 [51-223] 86 [24-187]

[0-50[ 3135 (21.8) 2813 (21.5) 322 (25.8) <0.0001

[50-200[ 5503 (38.3) 5160 (39.4) 343 (27.4)

>=200 3728 (26.0) 3529 (26.9) 199 (15.9)

Missing 1986(13.8) 1600 (12.2) 386 (30.9)

Hemoglobinemia, g/dL (n=12366) <0.0001

Median [IQR] 10.1 [8.9-11.4] 10.1 [8.9-11.4] 9.7 [8.3-10.9]

[0-8[ 1495 (10.4) 1332 (10.2) 163 (13.0) <0.0001

>=8 10738 (74.8) 10046 (76.7) 692 (55.4)

Missing 2119(14.8) 1724(13.2) 395 (31.6)

First HAART regimen, n(%)

2 NRTIs + 1 INNRTI 11213 (78.1) 10340 (78.9) 873 (69.8) <0.0001

2 NRTIs + 1 PI 2406(16.8) 2120(16.1) 286(17.0)

3 NRTIs 477 (3.3) 432 (3.3) 45 (3.6)

Others 35 (0.2) 30 (0.2) 5 (0.2)

Mono-bitherapy 221 (1.6) 180(1.4) 40 (3.2)

Year of HAART regimen, n (%)

<2004 2111 (14.7) 1821 (13.9) 290 (23.2) <0.0001

2004 3903 (27.2) 3523 (26.9) 380 (30.4)

2005 4712 (32.8) 4359 (33.3) 353 (28.2)

2006-2007 3626 (25.2) 3399 (26.0) 227 (18.2)

Follow-up

Total of patient N=14352 Follow up > 1 day N=13102 No follow-up N=1250 P value

Follow-up > 1 days 13102 (91.3)

Cumulative, person-years 24620.7

Per patient, year, median [IQR] 1.8 [0.8-2.8]

Status at 12-month

Dead, n (%) 521 (4.0)

Lost to follow-up, n (%) 2610(19.9)

HAART: Highly active antiretroviral therapy; WHO: World Health Organization; CDC: Center Diseases Control and Prevention, IQR:interquartile range

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