title: Factors associated with attrition, mortality, and loss to follow up after antiretroviral therapy initiation: data from an HIV cohort study in India.
abstract: BACKGROUND
  Studies from sub-Saharan Africa have shown high incidence of attrition due to mortality or loss to follow-up (LTFU) after initiating antiretroviral therapy (ART). India is the third largest country in the world in terms of HIV infected people, but predictors of attrition after ART initiation are not well known.
  
  
  METHODS
  We describe factors associated with attrition, mortality, and LTFU in 3,159 HIV infected patients who initiated ART between 1 January 2007 and 4 November 2011 in an HIV cohort study in India. The study included 6,852 person-years with a mean follow-up of 2.17 years.
  
  
  RESULTS
  After 5 years of follow-up, the estimated cumulative incidence of attrition was 37.7%. There was no significant difference between attrition due to mortality and attrition due to LTFU. Having CD4 counts <100 cells/µl and being homeless [adjusted hazard ratio (aHR) 3.1, 95% confidence interval (CI) 2.6-3.8] were associated with a higher risk of attrition, and female gender (aHR 0.64, 95% CI 0.6-0.8) was associated with a reduced risk of attrition. Living near a town (aHR 0.82, 95% CI 0.7-0.999) was associated with a reduced risk of mortality. Being single (aHR 1.6, 95% CI 1.2-2.3), illiteracy (aHR 1.3, 95% CI 1.1-1.6), and age <25 years (aHR 1.3, 95% CI 1-1.8) were associated with an increased risk of LTFU. Although the cumulative incidence of attrition in patients diagnosed with tuberculosis after ART initiation was 47.4%, patients who started anti-tuberculous treatment before ART had similar attrition to patients without tuberculosis (36 vs. 35.2%, P=0.19) after four years of follow-up.
  
  
  CONCLUSIONS
  In this cohort study, the attrition was similar to the one found in sub-Saharan Africa. Earlier initiation of ART, improving the diagnosis of tuberculosis before initiating ART, and giving more support to those patients at higher risk of attrition could potentially reduce the mortality and LTFU after ART initiation.
authors.affiliation: Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, India; gerardouria@gmail.com.
authors.forename: Gerardo
authors.initials: G
authors.lastname: Alvarez-Uria
authors.forename: Praveen K
authors.initials: PK
authors.lastname: Naik
authors.forename: Raghavakalyan
authors.initials: R
authors.lastname: Pakam
authors.forename: Manoranjan
authors.initials: M
authors.lastname: Midde
mesh_terms: D000328:Adult; D000367:Age Factors; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count / Q000706:statistics & numerical data; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000401:mortality; D006801:Humans; D007194:India / Q000453:epidemiology; D059012:Lost to Follow-Up; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D016016:Proportional Hazards Models; D012307:Risk Factors; D012737:Sex Factors; D055815:Young Adult; D016903:Drug Monitoring
chemical_list: D019380:Anti-HIV Agents
keywords: attrition; developing countries; highly active antiretroviral therapy; lost to follow up; mortality; rural health
references.citation: AIDS. 2010 Sep;24 Suppl 3:S62-71
references.pmid: 20926930
references.citation: PLoS Med. 2011 Oct;8(10):e1001111
references.pmid: 22039357
references.citation: Bull World Health Organ. 2010 Mar;88(3):222-6
references.pmid: 20428391
references.citation: PeerJ. 2013 Jun 18;1:e90
references.pmid: 23802091
references.citation: Interdiscip Perspect Infect Dis. 2012;2012:502012
references.pmid: 23316226
references.citation: Interdiscip Perspect Infect Dis. 2012;2012:293795
references.pmid: 22611389
references.citation: PLoS Med. 2012;9(7):e1001245
references.pmid: 22802730
references.citation: Trop Med Int Health. 2010 Jun;15 Suppl 1:1-15
references.pmid: 20586956
references.citation: PLoS Med. 2013;10(1):e1001369; discussion e1001369
references.pmid: 23341753
references.citation: J Public Health Res. 2012 Feb 14;1(1):79-82
references.pmid: 25170450
references.citation: Clin Infect Dis. 2009 Mar 15;48(6):829-31
references.pmid: 19207078
references.citation: Clin Infect Dis. 2013 May;56(9):1319-26
references.pmid: 23249611
references.citation: PLoS One. 2009 Jun 04;4(6):e5790
references.pmid: 19495419
references.citation: J Acquir Immune Defic Syndr. 2012 Dec 1;61(4):e50-8
references.pmid: 22842842
references.citation: PLoS One. 2013;8(3):e59197
references.pmid: 23527132
references.citation: J Acquir Immune Defic Syndr. 2012 May 1;60(1):91-8
references.pmid: 22293548
references.citation: PLoS One. 2011 May 03;6(5):e19201
references.pmid: 21559280
references.citation: Infect Dis Rep. 2012 Feb 17;4(1):e19
references.pmid: 24470926
references.citation: PLoS Med. 2006 Mar;3(3):e82
references.pmid: 16509768
references.citation: Int J Infect Dis. 2012 Feb;16(2):e121-3
references.pmid: 22153000
references.citation: PLoS One. 2012;7(6):e39414
references.pmid: 22761787
references.citation: BMC Med. 2006 Dec 13;4:31
references.pmid: 17166257
references.citation: PLoS One. 2009 May 21;4(5):e5648
references.pmid: 19462003