title: Predictors of dropout from care among HIV-infected patients initiating antiretroviral therapy at a public sector HIV treatment clinic in sub-Saharan Africa.
abstract: BACKGROUND
  In sub-Saharan Africa (SSA), antiretroviral therapy (ART) can prolong life for HIV-infected patients. However, patients initiating ART, especially in routine treatment programs, commonly dropout from care either due to death or loss to follow-up.
  
  
  METHODS
  In a cohort of HIV-infected patients initiating ART at a public sector clinic in Uganda, we assessed predictors of dropout from care (a composite outcome combining death and loss to follow-up). From a large set of socio-demographic, clinical, and laboratory variables routinely collected at ART initiation, we selected those predicting dropout at P <0.1 in unadjusted analyses for inclusion into a multivariable proportional hazards regression model. We then used a stepwise backward selection procedure to identify variables which independently predicted dropout at P <0.05.
  
  
  RESULTS
  Data from 5,057 patients were analyzed. The median age was 33 years (IQR 28 to 40) and 27.4% had CD4+ T-cell counts <100 cells/μL at ART initiation. The median duration of follow-up was 24 months (IQR = 14 to 42, maximum follow-up = 64 months). Overall dropout was 26.9% (established cumulative mortality = 2.3%, loss to follow-up = 24.6%), 5.6% were transferred to other service providers, and 67.5% were retained in care. A diagnosis of Kaposi's sarcoma (hazard ratio (HR) = 3.3, 95% CI 2.5 to 4.5); HIV-associated dementia (HR = 2.6, 95% CI 1.5 to 4.6); history of cryptococcosis (HR = 2.2, 95% CI 1.4 to 3.3); and reduced hemoglobin concentration (<11 g/dl versus ≥13.8 g/dl (HR = 1.9, 95% CI 1.6 to 2.2) were strong predictors of dropout. Other independent predictors of dropout were: year of ART initiation; weight loss ≥10%; reduced total lymphocyte count; chronic diarrhea; male sex; young age (≤28 years); and marital status.
  
  
  CONCLUSIONS
  Among HIV-infected patients initiating ART at a public sector clinic in SSA, biological factors that usually predict death were especially predictive of dropout. As most of the dropouts were lost to follow-up, this observation suggests that many losses to follow-up may have died. Future studies are needed to identify appropriate interventions that may improve both individual-level patient outcomes and outcome ascertainment among HIV-infected ART initiators in this setting.
authors.affiliation: Department of Medicine, Mbarara Regional Referral Hospital, P.O Box 40, Mbarara, Uganda. asiimwesteve@gmail.com.|Department of Epidemiology and Biostatistics, University of California San Francisco, California, USA. asiimwesteve@gmail.com.
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Asiimwe
authors.affiliation: Department of Medicine, Mbarara Regional Referral Hospital, P.O Box 40, Mbarara, Uganda. mkanyesigye2010@gmail.com.
authors.forename: Michael
authors.initials: M
authors.lastname: Kanyesigye
authors.affiliation: Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda. mwebesa_bwana@yahoo.com.
authors.forename: Bosco
authors.initials: B
authors.lastname: Bwana
authors.affiliation: Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda. okello.samson@must.ac.ug.
authors.forename: Samson
authors.initials: S
authors.lastname: Okello
authors.affiliation: Department of Medicine, Mbarara Regional Referral Hospital, P.O Box 40, Mbarara, Uganda. wmuyindike@gmail.com.
authors.forename: Winnie
authors.initials: W
authors.lastname: Muyindike
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara / Q000453:epidemiology; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D015496:CD4-Positive T-Lymphocytes; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000276:immunology; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D010352:Patient Dropouts / Q000706:statistics & numerical data*; D016016:Proportional Hazards Models; D017150:Public Sector
chemical_list: D019380:Anti-HIV Agents
references.citation: J Acquir Immune Defic Syndr. 2007 Apr 1;44(4):478-83
references.pmid: 17259906
references.citation: PLoS Med. 2007 Oct 16;4(10):e298
references.pmid: 17941716
references.citation: Prev Sci. 2007 Sep;8(3):206-13
references.pmid: 17549635
references.citation: Ann Epidemiol. 2009 Jul;19(7):504-11
references.pmid: 19457685
references.citation: PLoS Med. 2011;8(1):e1000390
references.pmid: 21267057
references.citation: N Am J Med Sci. 2014 Sep;6(9):453-9
references.pmid: 25317390
references.citation: AIDS. 2013 Jun 19;27(10):1603-13
references.pmid: 23462220
references.citation: Oncology. 2015;89(1):60-5
references.pmid: 25765812
references.citation: AIDS. 2011 Nov 13;25(17):2123-31
references.pmid: 21881481
references.citation: Am J Epidemiol. 2012 May 15;175(10):1080-7
references.pmid: 22306557
references.citation: Trop Med Int Health. 2010 Jun;15 Suppl 1:1-15
references.pmid: 20586956
references.citation: J Int AIDS Soc. 2014 Nov 02;17(4 Suppl 3):19623
references.pmid: 25394127
references.citation: Trop Med Int Health. 2010 Jun;15 Suppl 1:63-9
references.pmid: 20586962
references.citation: J Acquir Immune Defic Syndr. 2011 Dec 15;58(5):475-81
references.pmid: 21857354
references.citation: J Int AIDS Soc. 2014;17:18797
references.pmid: 24713375
references.citation: Clin Infect Dis. 2008 Dec 15;47(12):1556-61
references.pmid: 18990067
references.citation: Open Forum Infect Dis. 2014 Aug 06;1(2):ofu055
references.pmid: 25734125
references.citation: Int J Tuberc Lung Dis. 2014 Jul;18(7):843-6
references.pmid: 24902563
references.citation: N Engl J Med. 2014 Jun 26;370(26):2487-98
references.pmid: 24963568
references.citation: Stat Med. 2014 Jan 15;33(1):129-42
references.pmid: 23873614
references.citation: PLoS One. 2014;9(1):e86305
references.pmid: 24489714
references.citation: Int J Epidemiol. 2010 Oct;39(5):1311-23
references.pmid: 20406793
references.citation: JAMA. 2008 Aug 6;300(5):506-7
references.pmid: 18677022
references.citation: N Engl J Med. 2011 Aug 11;365(6):493-505
references.pmid: 21767103
references.citation: J Health Care Poor Underserved. 2013 Feb;24(1):359-83
references.pmid: 23377739
references.citation: PLoS One. 2015;10(6):e0130649
references.pmid: 26114436
references.citation: PLoS One. 2015;10(3):e0120350
references.pmid: 25807553
references.citation: BMC Med Res Methodol. 2014;14:75
references.pmid: 24903709
references.citation: PLoS One. 2010;5(6):e11094
references.pmid: 20559425
references.citation: PLoS Med. 2014 Sep;11(9):e1001718
references.pmid: 25203931
references.citation: J Acquir Immune Defic Syndr. 2014 Apr 15;65(5):e179-86
references.pmid: 24326599
references.citation: Bull World Health Organ. 2010 Sep 1;88(9):681-8
references.pmid: 20865073
references.citation: Lancet. 2014 Sep 13;384(9947):1005-70
references.pmid: 25059949
references.citation: J Neurovirol. 2012 Jun;18(3):200-4
references.pmid: 22528481
references.citation: Int J Tuberc Lung Dis. 2012 Oct;16(10):1371-6
references.pmid: 22863182
references.citation: PLoS One. 2012;7(2):e31706
references.pmid: 22384061
references.citation: Trop Med Int Health. 2014 Dec;19(12):1397-410
references.pmid: 25227621
references.citation: J Infect Dis. 2013 Jan 1;207(1):72-9
references.pmid: 23100567
references.citation: Int J Med Inform. 2010 Feb;79(2):90-6
references.pmid: 20036193