Patient retention in antiretroviral therapy programs up to three years on treatment in sub-Saharan Africa, 2007-2009: systematic review

Matthew P Fox, Sydney Rosen, Matthew P Fox, Sydney Rosen

Abstract

Objectives: To estimate the proportion of all-cause adult patient attrition from antiretroviral therapy (ART) programs in service delivery settings in sub-Saharan Africa through 36 months on treatment.

Methods: We identified cohorts within Ovid Medline, ISI Web of Knowledge, Cochrane Database of Systematic Reviews and four conference abstract archives. We summarized retention rates from studies describing observational cohorts from sub-Saharan Africa reporting on adult HIV 1- infected patients initiating first-line three-drug ART. We estimated all-cause attrition rates for 6, 12, 18, 24, or 36 months after ART initiation including patients who died or were lost to follow-up (as defined by the author), but excluding transferred patients.

Results: We analysed 33 sources describing 39 cohorts and 226 307 patients. Patients were more likely to be female (median 65%) and had a median age at initiation of 37 (range 34-40). Median starting CD4 count was 109 cells/mm(3). Loss to follow-up was the most common cause of attrition (59%), followed by death (41%). Median attrition at 12, 24 and 36 months was 22.6% (range 7%-45%), 25% (range 11%-32%) and 29.5% (range 13%-36.1%) respectively. After pooling data in a random-effects meta-analysis, retention declined from 86.1% at 6 months to 80.2% at 12 months, 76.8% at 24 months and 72.3% at 36 months. Adjusting for variable follow-up time in a sensitivity analysis, 24 month retention was 70.0% (range: 66.7%-73.3%), while 36 month retention was 64.6% (range: 57.5%-72.1%).

Conclusions: Our findings document the difficulties in retaining patients in care for lifelong treatment, and the progress being made in raising overall retention rates.

Figures

Figure 1
Figure 1
Literature Search and Application of Eligibility Criteria in a Systematic Review of Retention in Antiretroviral Therapy Programs in Sub-Saharan Africa.
Figure 2
Figure 2
a–d Forest Plots of Reported Retention at 6, 12, 24 and 36 Months after Initiation of Antiretroviral Therapy in Sub-Saharan Africa*. *Pooled estimates were created using random-effects meta-analysis. Data include both actual reported rates for studies that reported to each time point and linear interpolation for studies which reported to a later time point but not the current time point.
Figure 3
Figure 3
Weighted Average Retention Rates Over Time in Antiretroviral Therapy Programs in Sub-Saharan Africa*. *Studies reporting later time points and not earlier ones had the earlier attrition rates interpolated as described in the methods section and then weighted by cohort size.
Figure 4
Figure 4
Projected Retention Rates Over Time in Antiretroviral Therapy Programs in Sub-Saharan Africa Using Varying Assumptions*. *Best-case scenario uses last observation carried forward and assumes no additional attrition after the last time point reported to. Worst-case scenario assumes a continued linear decline from the last time point reported to through 36 months. The mid-point scenario is the average of the best and worst-case scenarios. Studies are weighted by their sample size.

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