Retention in Care among HIV-Infected Adults in Ethiopia, 2005- 2011: A Mixed-Methods Study.
BACKGROUND
Poor retention in HIV care challenges the success of antiretroviral therapy (ART). This study assessed how well patients stay in care and explored factors associated with retention in the context of an initial ART rollout in Sub-Saharan Africa.


METHODS
We conducted a mixed-methods study at a teaching hospital in Addis Ababa, Ethiopia. A cohort of 385 patients was followed for a median of 4.6 years from ART initiation to lost-to-follow-up (LTFU-missing appointments for more than three months after last scheduled visit or administrative censoring). We used Kaplan-Meier plots to describe LTFU over time and Cox-regression models to identify factors associated with being LTFU. We held six focus group discussions, each with 6-11 patients enrolled in care; we analyzed data inductively informed by grounded theory.


RESULTS
Patients in the cohort were predominantly female (64%) and the median age was 34 years. Thirty percent were LTFU by study's end; the median time to LTFU was 1,675 days. Higher risk of LTFU was associated with baseline CD4 counts <100 and >200 cells/μL (HR = 1.62; 95% CI:1.03-2.55; and HR = 2.06; 95% CI:1.15-3.70, respectively), compared with patients with baseline CD4 counts of 100-200 cells/μL. Bedridden participants at ART initiation (HR = 2.05; 95% CIs [1.11-3.80]) and those with no or only primary education (HR = 1.50; 95% CIs [1.00-2.24]) were more likely to be LTFU. Our qualitative data revealed that fear of stigma, care dissatisfaction, use of holy water, and economic constraints discouraged retention in care. Social support and restored health and functional ability motivated retention.


CONCLUSIONS
Complex socio-cultural, economic, and health-system factors inhibit optimum patient retention. Better tracking, enhanced social support, and regular adherence counseling addressing stigma and alternative healing options are needed. Intervention strategies aimed at changing clinic routines and improving patient-provider communication could address many of the identified barriers.
Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA.
Yordanos M
YM
Tiruneh
Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA.
Omar
O
Galárraga
Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA.
Becky
B
Genberg
Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA.
Ira B
IB
Wilson
D000328:Adult; D000554:Ambulatory Care Facilities; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D001510:Bed Rest / Q000706:statistics & numerical data; D018791:CD4 Lymphocyte Count; D005002:Ethiopia; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000523:psychology; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D010349:Patient Compliance / Q000523:psychology* / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012307:Risk Factors; D012944:Social Support
D044966:Anti-Retroviral Agents