title: Incidence and predictors of attrition from antiretroviral care among adults in a rural HIV clinic in Coastal Kenya: a retrospective cohort study.
abstract: BACKGROUND
  Scale up of antiretroviral therapy (ART) has led to substantial declines in HIV related morbidity and mortality. However, attrition from ART care remains a major public health concern and has been identified as one of the key reportable indicators in assessing the success of ART programs. This study describes the incidence and predictors of attrition among adults initiating ART in a rural HIV clinic in Coastal Kenya.
  
  
  METHODS
  A retrospective cohort study design was used. Adults (≥ 15 years) initiated ART between January 2008 and December 2010 were followed up for two years. Attrition was defined as individuals who were either reported dead or lost to follow up (LFU, ≥ 180 days late since the last clinic visit). Kaplan Meier survival probabilities and Weibull baseline hazard regression analyses were used to model the incidence and predictors of time to attrition.
  
  
  RESULTS
  Of the 928 eligible participants, 308 (33.2% [95% CI, 30.2 - 36.3]) underwent attrition at an incident rate of 23.1 (95% CI, 20.6 - 25.8)/100 pyo. Attrition at 6 and 12 months was 18.4% (95% CI, 16.0 - 21.1) and 23.2% (95% CI, 19.9 - 25.3) respectively. Gender (male vs. female, adjusted hazard ratio [95% CI], p-value: 1.5 [1.1 - 2.0], p = 0.014), age (15 - 24 vs. ≥ 45 years, 2.2 [1.3 - 3.7], p = 0.034) and baseline CD4 T-cell count (100 - 350 cells/uL vs. < 100 cells/uL, 0.5 [0.3 - 0.7], p = 0.002) were independent predictors of time to attrition.
  
  
  CONCLUSIONS
  A third of individuals initiating ART were either reported dead or LFU during two years of care, with more than a half of these occurring within six months of treatment initiation. Practical and sustainable biomedical interventions and psychosocial support systems are warranted to improve ART retention in this setting.
authors.affiliation: KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya. ahassan@kemri-wellcome.org.
authors.forename: Amin S
authors.initials: AS
authors.lastname: Hassan
authors.affiliation: KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya. smwaringa@kemri-wellcome.org.
authors.forename: Shalton M
authors.initials: SM
authors.lastname: Mwaringa
authors.affiliation: Kilifi District Hospital, Kilifi, Kenya. placbo1@gmail.com.
authors.forename: Kennedy K
authors.initials: KK
authors.lastname: Ndirangu
authors.affiliation: KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya. esanders@kemri-wellcome.org.|Centre for Clinical Vaccinology & Tropical Medicine, University of Oxford, Oxford, UK. esanders@kemri-wellcome.org.
authors.forename: Eduard J
authors.initials: EJ
authors.lastname: Sanders
authors.affiliation: Amsterdam Institute for Global health and Development, Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands. t.rinkedewit@pharmaccess.org.
authors.forename: Tobias F Rinke
authors.initials: TF
authors.lastname: de Wit
authors.affiliation: KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya. jberkley@kemri-wellcome.org.|Centre for Clinical Vaccinology & Tropical Medicine, University of Oxford, Oxford, UK. jberkley@kemri-wellcome.org.
authors.forename: James A
authors.initials: JA
authors.lastname: Berkley
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D001294:Attitude to Health; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000523:psychology*; D006801:Humans; D015994:Incidence; D007630:Kenya / Q000453:epidemiology; D008297:Male; D055118:Medication Adherence / Q000523:psychology; D008875:Middle Aged; D011634:Public Health; D012189:Retrospective Studies; D012424:Rural Population / Q000706:statistics & numerical data*; D017678:Sex Distribution; D012944:Social Support; D016903:Drug Monitoring
chemical_list: D044966:Anti-Retroviral Agents