Retention in care during the first 3 years of antiretroviral therapy for women in Malawi's option B+ programme: an observational cohort study.
- Haas AD Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland. Electronic address: andreas.haas@ispm.unibe.ch.
- Tenthani L Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland; International Training & Education Center for Health Malawi (I-TECH), Lilongwe, Malawi.
- Msukwa MT Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland; The Baobab Health Trust, Lilongwe, Malawi.
- Tal K Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland.
- Jahn A International Training & Education Center for Health Malawi (I-TECH), Lilongwe, Malawi; Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi.
- Gadabu OJ The Baobab Health Trust, Lilongwe, Malawi.
- Spoerri A Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland.
- Chimbwandira F Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi.
- van Oosterhout JJ Dignitas International, Zomba, Malawi; Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi.
- Keiser O Institute of Social & Preventive Medicine, University of Bern, Bern, Switzerland.
- 2016-04-03
Published in:
- The lancet. HIV. - 2016
Adolescent
Adult
Anti-HIV Agents
Breast Feeding
Cohort Studies
Female
HIV Infections
Humans
Infectious Disease Transmission, Vertical
Lost to Follow-Up
Malawi
Maternal-Child Health Services
Medication Adherence
Odds Ratio
Patient Dropouts
Pregnancy
Pregnancy Complications, Infectious
Proportional Hazards Models
Risk Factors
Young Adult
English
BACKGROUND
Studies of Malawi's option B+ programme for HIV-positive pregnant and breastfeeding women have reported high loss to follow-up during pregnancy and at the start of antiretroviral therapy (ART), but few data exist about retention during breastfeeding and after weaning. We examined loss to follow-up and retention in care in patients in the option B+ programme during their first 3 years on ART.
METHODS
We analysed two data sources: aggregated facility-level data about patients in option B+ who started ART between Oct 1, 2011, and June 30, 2012, at 546 health facilities; and patient-level data from 20 large facilities with electronic medical record system for HIV-positive women who started ART between Sept 1, 2011, and Dec 31, 2013, under option B+ or because they had WHO clinical stages 3 or 4 disease or had CD4 counts of less than 350 cells per μL. We used facility-level data to calculate representative estimates of retention and loss to follow-up. We used patient-level data to study temporal trends in retention, timing of loss to follow-up, and predictors of no follow-up and loss to follow-up. We defined patients who were more than 60 days late for their first follow-up visit as having no follow-up and patients who were more than 60 days late for a subsequent visit as being lost to follow-up. We calculated proportions and cumulative probabilities of patients who had died, stopped ART, had no follow-up, were lost to follow-up, or were retained alive on ART for 36 months. We calculated odds ratios and hazard ratios to examine predictors of no follow-up and loss to follow-up.
FINDINGS
Analysis of facility-level data about patients in option B+ who had not transferred to a different facility showed retention in care to be 76·8% (20 475 of 26,658 patients) after 12 months, 70·8% (18,306 of 25,849 patients) after 24 months, and 69·7% (17,787 of 25,535 patients) after 36 months. Patient-level data included 29,145 patients. 14,630 (50·2%) began treatment under option B+. Patients in option B+ had a higher risk of having no follow-up and, for the first 2 years of ART, higher risk of loss to follow-up than did patients who started ART because they had CD4 counts less than 350 cells per μL or WHO clinical stage 3 or 4 disease. Risk of loss to follow-up during the third year was low and similar for patients retained for 2 years. Retention rates did not change as the option B+ programme matured.
INTERPRETATION
Our data suggest that pregnant and breastfeeding women who start ART immediately after they are diagnosed with HIV can be retained on ART through the option B+ programme, even after many have stopped breastfeeding. Interventions might be needed to improve retention in the first year on ART in option B+.
FUNDING
Bill & Melinda Gates Foundation, Partnerships for Enhanced Engagement in Research Health, and National Institute of Allergy and Infectious Diseases.
Studies of Malawi's option B+ programme for HIV-positive pregnant and breastfeeding women have reported high loss to follow-up during pregnancy and at the start of antiretroviral therapy (ART), but few data exist about retention during breastfeeding and after weaning. We examined loss to follow-up and retention in care in patients in the option B+ programme during their first 3 years on ART.
METHODS
We analysed two data sources: aggregated facility-level data about patients in option B+ who started ART between Oct 1, 2011, and June 30, 2012, at 546 health facilities; and patient-level data from 20 large facilities with electronic medical record system for HIV-positive women who started ART between Sept 1, 2011, and Dec 31, 2013, under option B+ or because they had WHO clinical stages 3 or 4 disease or had CD4 counts of less than 350 cells per μL. We used facility-level data to calculate representative estimates of retention and loss to follow-up. We used patient-level data to study temporal trends in retention, timing of loss to follow-up, and predictors of no follow-up and loss to follow-up. We defined patients who were more than 60 days late for their first follow-up visit as having no follow-up and patients who were more than 60 days late for a subsequent visit as being lost to follow-up. We calculated proportions and cumulative probabilities of patients who had died, stopped ART, had no follow-up, were lost to follow-up, or were retained alive on ART for 36 months. We calculated odds ratios and hazard ratios to examine predictors of no follow-up and loss to follow-up.
FINDINGS
Analysis of facility-level data about patients in option B+ who had not transferred to a different facility showed retention in care to be 76·8% (20 475 of 26,658 patients) after 12 months, 70·8% (18,306 of 25,849 patients) after 24 months, and 69·7% (17,787 of 25,535 patients) after 36 months. Patient-level data included 29,145 patients. 14,630 (50·2%) began treatment under option B+. Patients in option B+ had a higher risk of having no follow-up and, for the first 2 years of ART, higher risk of loss to follow-up than did patients who started ART because they had CD4 counts less than 350 cells per μL or WHO clinical stage 3 or 4 disease. Risk of loss to follow-up during the third year was low and similar for patients retained for 2 years. Retention rates did not change as the option B+ programme matured.
INTERPRETATION
Our data suggest that pregnant and breastfeeding women who start ART immediately after they are diagnosed with HIV can be retained on ART through the option B+ programme, even after many have stopped breastfeeding. Interventions might be needed to improve retention in the first year on ART in option B+.
FUNDING
Bill & Melinda Gates Foundation, Partnerships for Enhanced Engagement in Research Health, and National Institute of Allergy and Infectious Diseases.
- Language
-
- English
- Open access status
- bronze
- Identifiers
-
- DOI 10.1016/S2352-3018(16)00008-4
- PMID 27036993
- Persistent URL
- https://sonar.ch/global/documents/140324
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