title: Patient-reported factors associated with reengagement among HIV-infected patients disengaged from care in East Africa.
abstract: OBJECTIVE
  Engagement in care is key to successful HIV treatment in resource-limited settings; yet little is known about the magnitude and determinants of reengagement among patients out of care. We assessed patient-reported reasons for not returning to clinic, identified latent variables underlying these reasons, and examined their influence on subsequent care reengagement.
  
  
  METHODS
  We used data from the East Africa International Epidemiologic Databases to Evaluate AIDS to identify a cohort of patients disengaged from care (>3 months late for last appointment, reporting no HIV care in preceding 3 months) (n = 430) who were interviewed about reasons why they stopped care. Among the 399 patients for whom follow-up data were available, 104 returned to clinic within a median observation time of 273 days (interquartile range: 165-325).
  
  
  METHODS
  We conducted exploratory and confirmatory factor analyses (EFA, CFA) to identify latent variables underlying patient-reported reasons, then used these factors as predictors of time to clinic return in adjusted Cox regression models.
  
  
  RESULTS
  EFA and CFA findings suggested a six-factor structure that lent coherence to the range of barriers and motivations underlying care disengagement, including poverty, transport costs, and interference with work responsibilities; health system 'failures,' including poor treatment by providers; fearing disclosure of HIV status; feeling healthy; and treatment fatigue/seeking spiritual alternatives to medicine. Factors related to poverty and poor treatment predicted higher rate of return to clinic, whereas the treatment fatigue factor was suggestive of a reduced rate of return.
  
  
  CONCLUSIONS
  Certain barriers to reengagement appear easier to overcome than factors such as treatment fatigue. Further research will be needed to identify the easiest, least expensive interventions to reengage patients lost to HIV care systems. Interpersonal interventions may continue to play an important role in addressing psychological barriers to retention.
authors.affiliation: aDepartment of Obstetrics, Gynecology and Reproductive SciencesbCenter for AIDS Prevention Studies, University of California, San Francisco, California, USAcResearch Care and Training Program, Center for Microbiology Research and the Family AIDS Care and Education Services Program, Kenya Medical Research Institute, Nairobi, KenyadNational AIDS Control Program, Dar es Salaam, TanzaniaeInfectious Diseases Institute, Kampala, UgandafKenya Academic Model Providing Access to Healthcare (AMPATH), Moi University, Eldoret, KenyagMbarara University of Science and Technology, Mbarara, UgandahDivision of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, CanadaiDepartment of Epidemiology and Biostatistics, University of California, San Francisco California USA.jDivision of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, IndianakDivision of HIV/AIDS, Department of Medicine, University of California, San Francisco General Hospital, San Francisco, California, USA.
authors.forename: Carol S
authors.initials: CS
authors.lastname: Camlin
authors.forename: Torsten B
authors.initials: TB
authors.lastname: Neilands
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Odeny
authors.forename: Rita
authors.initials: R
authors.lastname: Lyamuya
authors.forename: Alice
authors.initials: A
authors.lastname: Nakiwogga-Muwanga
authors.forename: Lameck
authors.initials: L
authors.lastname: Diero
authors.forename: Mwebesa
authors.initials: M
authors.lastname: Bwana
authors.forename: Paula
authors.initials: P
authors.lastname: Braitstein
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Somi
authors.forename: Andrew
authors.initials: A
authors.lastname: Kambugu
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Bukusi
authors.forename: David V
authors.initials: DV
authors.lastname: Glidden
authors.forename: Kara K
authors.initials: KK
authors.lastname: Wools-Kaloustian
authors.forename: Megan
authors.initials: M
authors.lastname: Wenger
authors.forename: Elvin H
authors.initials: EH
authors.lastname: Geng
mesh_terms: D000293:Adolescent; D000328:Adult; D000351:Africa, Eastern; D000368:Aged; D005260:Female; D015658:HIV Infections / Q000628:therapy*; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D055815:Young Adult