title: Patient attrition from the HIV antiretroviral therapy program at two hospitals in Haiti.
abstract: OBJECTIVE
  To identify factors associated with antiretroviral therapy (ART) attrition among patients initiating therapy in 2005-2011 at two large, public-sector department-level hospitals, and to inform interventions to improve ART retention.
  
  
  METHODS
  This retrospective cohort study used data from the iSanté electronic medical record (EMR) system. The study characterized ART attrition levels and explored the patient demographic, clinical, temporal, and service utilization factors associated with ART attrition, using time-to-event analysis methods.
  
  
  RESULTS
  Among the 2 023 patients in the study, ART attrition on average was 17.0 per 100 person-years (95% confidence interval (CI): 15.8-18.3). In adjusted analyses, risk of ART attrition was up to 89% higher for patients living in distant communes compared to patients living in the same commune as the hospital (hazard ratio: 1.89, 95%CI: 1.54-2.33; P < 0.001). Hospital site, earlier year of ART start, spending less time enrolled in HIV care prior to ART initiation, receiving a non-standard ART regimen, lacking counseling prior to ART initiation, and having a higher body mass index were also associated with attrition risk.
  
  
  CONCLUSIONS
  The findings suggest quality improvement interventions at the two hospitals, including: enhanced retention support and transportation subsidies for patients accessing care from remote areas; counseling for all patients prior to ART initiation; timely outreach to patients who miss ART pick-ups; "bridging services" for patients transferring care to alternative facilities; routine screening for anticipated interruptions in future ART pick-ups; and medical case review for patients placed on non-standard ART regimens. The findings are also relevant for policymaking on decentralization of ART services in Haiti.
authors.affiliation: International Training and Education Center for Health, University of Washington, Washington, United States of America, nputt@uw.edu.
authors.forename: Nancy H
authors.initials: NH
authors.lastname: Puttkammer
authors.affiliation: University of Washington, Haiti.
authors.forename: Steven B
authors.initials: SB
authors.lastname: Zeliadt
authors.affiliation: Department of Health Services, University of Washington, Washington, United States.
authors.forename: Janet G
authors.initials: JG
authors.lastname: Baseman
authors.affiliation: University of Washington, Haiti.
authors.forename: Rodney
authors.initials: R
authors.lastname: Destiné
authors.affiliation: United States Centers for Disease Control and Prevention, Haiti.
authors.forename: Jean
authors.initials: J
authors.lastname: Wysler Domerçant
authors.affiliation: University of Washington, Haiti.
authors.forename: Nancy Rachel
authors.initials: NR
authors.lastname: Labbé Coq
authors.affiliation: University of Washington, Haiti.
authors.forename: Nernst
authors.initials: N
authors.lastname: Atwood Raphael
authors.affiliation: Department of Global Health, University of Washington, Washington, United States of America.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Sherr
authors.affiliation: International Training and Education Center for Health, University of Washington, Washington, United States of America, nputt@uw.edu.
authors.forename: Mary
authors.initials: M
authors.lastname: Tegger
authors.affiliation: Center for AIDS Research Biometrics Core, University of Washington, Washington, United States of America.
authors.forename: Krista
authors.initials: K
authors.lastname: Yuhas
authors.affiliation: Department of Global Health, University of Washington, Washington, United States of America.
authors.forename: Scott
authors.initials: S
authors.lastname: Barnhart
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D015897:Comorbidity; D004359:Drug Therapy, Combination; D055866:Earthquakes; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology; D006205:Haiti / Q000453:epidemiology; D006297:Health Services Accessibility; D006779:Hospitals, Public / Q000706:statistics & numerical data; D006780:Hospitals, Rural / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D010352:Patient Dropouts / Q000706:statistics & numerical data*; D010607:Pharmacy Service, Hospital / Q000706:statistics & numerical data; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000453:epidemiology; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012306:Risk; D012959:Socioeconomic Factors; D014376:Tuberculosis / Q000453:epidemiology; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents