Determinants of mortality and loss to follow-up among adults enrolled in HIV care services in Rwanda.
BACKGROUND
Antiretroviral therapy (ART) improves morbidity and mortality in patients with HIV, however high rates of loss to follow-up (LTF) and mortality have been documented in HIV care and treatment programs.


METHODS
We analyzed routinely-collected data on HIV-infected patients ≥ 15 years enrolled at 41 healthcare facilities in Rwanda from 2005 to 2010. LTF was defined as not attending clinic in the last 12 months for pre-ART patients and 6 months for ART patients. For the pre-ART period, sub-distribution hazards models were constructed to estimate LTF and death to account for competing risks. Kaplan-Meier (KM) and Cox proportional hazards models were used for patients on ART.


RESULTS
31,033 ART-naïve adults were included, 64% were female and 75% were WHO stage I or II at enrollment. 17,569 (56%) patients initiated ART. Pre-ART competing risk estimates of LTF at 2 years was 11.2% (95%CI, 10.9-11.6%) and 2.9% for death (95%CI 2.7-3.1%). Among pre-ART patients, male gender was associated with higher LTF (adjusted sub-hazard ratio (aSHR) 1.3, 95%CI 1.1-1.5) and death (aSHR 1.7, 95%CI 1.4-2.1). Low CD4 count (CD4<100 vs. ≥ 350 aSHR 0.2, 95%CI 0.1-0.3) and higher WHO stage (WHO stage IV vs. stage I aSHR 0.4, 95%CI 0.2-0.6) were protective against pre-ART LTF. KM estimates for LTF and death in ART patients at 2 years were 4.4% (95%CI 4.4-4.5%) and 6.3% (95%CI 6.2-6.4%). In patients on ART, male gender was associated with LTF (adjusted hazard ratio (AHR) 1.4, 95%CI 1.2-1.7) and death (AHR1.3, 95%CI 1.2-1.5). Mortality was higher for ART patients ≥ 40 years and in those with lower CD4 count at ART initiation.


CONCLUSIONS
Low rates of LTF and death were founds among pre-ART and ART patients in Rwanda but greater efforts are needed to retain patients in care prior to ART initiation, particularly among those who are healthy at enrollment.
International Center for AIDS Care and Treatment Programs-Columbia University, Mailman School of Public Health, New York, New York, United States of America ; Identifying Optimal Models of HIV Care in Africa Study, International Center for AIDS Care and Treatment Programs-Columbia University, New York, New York, United States of America.
Veronicah
V
Mugisha
International Center for AIDS Care and Treatment Programs-Columbia University, Mailman School of Public Health, New York, New York, United States of America ; Identifying Optimal Models of HIV Care in Africa Study, International Center for AIDS Care and Treatment Programs-Columbia University, New York, New York, United States of America ; Department of Epidemiology, Columbia University, New York, New York, United States of America.
Chloe A
CA
Teasdale
International Center for AIDS Care and Treatment Programs-Columbia University, Mailman School of Public Health, New York, New York, United States of America ; Identifying Optimal Models of HIV Care in Africa Study, International Center for AIDS Care and Treatment Programs-Columbia University, New York, New York, United States of America.
Chunhui
C
Wang
International Center for AIDS Care and Treatment Programs-Columbia University, Mailman School of Public Health, New York, New York, United States of America ; Identifying Optimal Models of HIV Care in Africa Study, International Center for AIDS Care and Treatment Programs-Columbia University, New York, New York, United States of America ; Department of Epidemiology, Columbia University, New York, New York, United States of America.
Maria
M
Lahuerta
International Center for AIDS Care and Treatment Programs-Columbia University, Mailman School of Public Health, New York, New York, United States of America ; Identifying Optimal Models of HIV Care in Africa Study, International Center for AIDS Care and Treatment Programs-Columbia University, New York, New York, United States of America.
Harriet
H
Nuwagaba-Biribonwoha
International Center for AIDS Care and Treatment Programs-Columbia University, Mailman School of Public Health, New York, New York, United States of America.
Edwin
E
Tayebwa
International Center for AIDS Care and Treatment Programs-Columbia University, Mailman School of Public Health, New York, New York, United States of America.
Eugenie
E
Ingabire
Department of Epidemiology, Columbia University, New York, New York, United States of America.
Pacifique
P
Ingabire
International Center for AIDS Care and Treatment Programs-Columbia University, Mailman School of Public Health, New York, New York, United States of America.
Ruben
R
Sahabo
International Center for AIDS Care and Treatment Programs-Columbia University, Mailman School of Public Health, New York, New York, United States of America ; Ministry of Health Rwanda, Kigali, Rwanda.
Peter
P
Twyman
International Center for AIDS Care and Treatment Programs-Columbia University, Mailman School of Public Health, New York, New York, United States of America ; Identifying Optimal Models of HIV Care in Africa Study, International Center for AIDS Care and Treatment Programs-Columbia University, New York, New York, United States of America ; Department of Epidemiology, Columbia University, New York, New York, United States of America.
Elaine J
EJ
Abrams
D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy / Q000276:immunology / Q000401:mortality*; D006801:Humans; D053208:Kaplan-Meier Estimate; D059012:Lost to Follow-Up; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012432:Rwanda / Q000453:epidemiology; D017678:Sex Distribution; D055815:Young Adult
D019380:Anti-HIV Agents