title: Implementation of free cotrimoxazole prophylaxis improves clinic retention among antiretroviral therapy-ineligible clients in Kenya.
abstract: OBJECTIVE
  To determine whether implementation of free cotrimoxazole (CTX) provision was associated with improved retention among clients ineligible for antiretroviral therapy (ART) enrolled in an HIV treatment program in Kenya.
  
  
  METHODS
  Data were obtained from a clinical cohort for program evaluation purposes. Twelve-month clinic retention was compared among ART-ineligible clients enrolled in the time period before free CTX versus the time period after.
  
  
  METHODS
  Statistical comparisons were made using Kaplan-Meier survival curves, log-rank tests, and multivariate Cox proportional hazards models. To exclude potential temporal program changes that may have influenced retention, ART clients before and after the same cut-off date were compared.
  
  
  RESULTS
  Among adult clients enrolled between 2005 and 2007, 3234 began ART within 1 year of enrollment, and 1024 of those who did not start treatment were defined as ART-ineligible. ART-ineligible clients enrolled in the period following free CTX provision had higher 12-month retention (84%) than those who enrolled prior to free CTX (63%; P < 0.001). Retention did not change significantly during these periods among ART clients (P = 0.55). In multivariate analysis, ART-ineligible clients enrolled prior to free CTX were more than twice as likely to be lost to follow-up compared to those following free CTX [adjusted hazard ratio (aHR) = 2.64, 95% confidence interval 1.95-3.57, P < 0.001].
  
  
  CONCLUSIONS
  Provision of free CTX was associated with significantly improved retention among ART-ineligible clients. Retention and CD4-monitoring of ART-ineligible clients are essential to promptly identify ART eligibility and provide treatment. Implementation of free CTX may improve retention in sub-Saharan Africa and, via increasing timely ART initiation, provide survival benefit.
authors.affiliation: Department of Global Health, University of Washington, Seattle, 98104, USA. pkohler2@uw.edu
authors.forename: Pamela K
authors.initials: PK
authors.lastname: Kohler
authors.forename: Michael H
authors.initials: MH
authors.lastname: Chung
authors.forename: Christine J
authors.initials: CJ
authors.lastname: McGrath
authors.forename: Sarah F
authors.initials: SF
authors.lastname: Benki-Nugent
authors.forename: Joan W
authors.initials: JW
authors.lastname: Thiga
authors.forename: Grace C
authors.initials: GC
authors.lastname: John-Stewart
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities / Q000706:statistics & numerical data*; D000890:Anti-Infective Agents / Q000191:economics / Q000627:therapeutic use*; D019072:Antibiotic Prophylaxis; D018791:CD4 Lymphocyte Count; D016527:Drug Costs; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D053208:Kaplan-Meier Estimate; D007630:Kenya; D008297:Male; D010349:Patient Compliance; D015397:Program Evaluation; D016896:Treatment Outcome; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000191:economics / Q000627:therapeutic use*
chemical_list: D000890:Anti-Infective Agents; D015662:Trimethoprim, Sulfamethoxazole Drug Combination