title: Improved retention of patients starting antiretroviral treatment in Karonga District, northern Malawi, 2005-2012.
abstract: BACKGROUND
  Patient retention in antiretroviral therapy (ART) programs remains a major challenge in sub-Saharan Africa. We examined whether and why retention in ART care has changed with increasing access.
  
  
  METHODS
  Retrospective cohort study combining individual data from ART registers and interview data, enabling us to link patients across different ART clinics in Karonga District, Malawi. We recorded information on all adults (≥15 years) starting ART between July 2005 and August 2012, including those initiating due to pregnancy and breastfeeding (Option B+). Retention in care was defined as being alive and receiving ART at the end of study. Predictors of attrition were assessed using a multivariable Cox proportional hazards model.
  
  
  RESULTS
  The number of clinics providing ART increased from 1 in 2005 to 16 in 2012. Six-month retention increased from 73% [95% confidence interval (CI): 71 to 76] to 93% (95% CI: 92 to 94) when comparing the 2005-2006 and 2011-2012 cohorts, and 12-month retention increased from 70% (95% CI: 67 to 73) to 92% (95% CI: 90 to 93). Over the study period, the proportion of patients starting ART at World Health Organization stage 4 declined from 62% to 10%. Being a man, younger than 35 years, having a more advanced World Health Organization stage and being part of an earlier cohort were all independently associated with attrition. Women starting ART for Option B+ experienced higher attrition than women of childbearing age starting for other reasons.
  
  
  CONCLUSIONS
  In this area, retention in care has increased dramatically. Improved health in patients starting ART and decentralization of ART care to peripheral health centers seem to be the major drivers for this change.
authors: Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.|Karonga Prevention Study, Chilumba, Malawi.
authors: Olivier
authors: O
authors: Koole
authors: TB Modelling Group, TB Centre, Department of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK.
authors: Rein Mgj
authors: RM
authors: Houben
authors: Karonga Prevention Study, Chilumba, Malawi.
authors: Themba
authors: T
authors: Mzembe
authors: Ecology and Evolutionary Biology Department, Princeton University, Princeton, NJ, USA.|Princeton Environmental Institute, Princeton, NJ, USA.
authors: Thomas P
authors: TP
authors: Van Boeckel
authors: Ministry of Health, Karonga, Malawi.
authors: Michael
authors: M
authors: Kayange
authors: Ministry of Health - HIV/AIDS unit, Lilongwe, Malawi.|International Training and Education Center for Health, University of Washington, Seattle, USA.
authors: Andreas
authors: A
authors: Jahn
authors: Ministry of Health - HIV/AIDS unit, Lilongwe, Malawi.
authors: Frank
authors: F
authors: Chimbwandira
authors: Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
authors: Judith R
authors: JR
authors: Glynn
authors: Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.|Karonga Prevention Study, Chilumba, Malawi.
authors: Amelia C
authors: AC
authors: Crampin
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000494:pharmacology* / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D053208:Kaplan-Meier Estimate; D059012:Lost to Follow-Up; D008295:Malawi / Q000453:epidemiology; D008297:Male; D019829:Nevirapine / Q000494:pharmacology* / Q000627:therapeutic use; D010342:Patient Acceptance of Health Care; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents; D019829:Nevirapine