title: Factors associated with loss to clinic among HIV patients not yet known to be eligible for antiretroviral therapy (ART) in Mozambique.
abstract: BACKGROUND
  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.
authors.affiliation: Spencer Cox Center for Health, St. Luke's Hospital, New York, NY 10025, United States. rpati@chpnet.org
authors.forename: Rituparna
authors.initials: R
authors.lastname: Pati
authors.forename: Maria
authors.initials: M
authors.lastname: Lahuerta
authors.forename: Batya
authors.initials: B
authors.lastname: Elul
authors.forename: Mie
authors.initials: M
authors.lastname: Okamura
authors.forename: Maria Fernanda
authors.initials: MF
authors.lastname: Alvim
authors.forename: Bruce
authors.initials: B
authors.lastname: Schackman
authors.forename: Heejung
authors.initials: H
authors.lastname: Bang
authors.forename: Rufino
authors.initials: R
authors.lastname: Fernandes
authors.forename: Americo
authors.initials: A
authors.lastname: Assan
authors.forename: Josue
authors.initials: J
authors.lastname: Lima
authors.forename: Denis
authors.initials: D
authors.lastname: Nash
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000553:Ambulatory Care / Q000706:statistics & numerical data*; D000554:Ambulatory Care Facilities; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D004608:Eligibility Determination; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy*; D006301:Health Services Needs and Demand; D006801:Humans; D008297:Male; D008875:Middle Aged; D009073:Mozambique; D010045:Outpatients / Q000706:statistics & numerical data*; D011247:Pregnancy; D012189:Retrospective Studies; D055815:Young Adult
keywords: ART eligibility; Mozambique; PEPFAR; loss to care; operations research; pre-ART; pregnancy; retention