ART attrition across health facilities implementing Option B+ in Haiti

Thesis (Master's)--University of Washington, 2016-08Background: In 2015, the first study on retention that included pregnant women in Haiti showed that Option B+ clients had 1.5 fold excess risk of attrition at 12 months of ART initiation compared to other ART patients. Describing the variation of ART retention across Haiti and exploring health facility-level factors related to high attrition are important in order to improve implementation of the Option B+ strategy in Haiti. Methods: This retrospective cohort study is based on information collected on iSanté, the largest electronic medical record in the country. I described the variability of ART retention across health facilities among pregnant and lactating women enrolled on ART from October 2012 to December 2013. I assessed for differences in ART retention between Option B+ clients and other ART patients and described the variability of this comparison across health facilities. Finally, I used generalized estimating equations to assess the association between health facility factors and risk of attrition, after controlling for individual-level risk factors. Results: During the study period, 1,989 Option B+ clients were enrolled on ART in 45 health facilities. The percentage of attrition varied from 9% to 71% across the facilities. More than 40% of the health facilities had a statistically significant excess risk of attrition among Option B+ clients compared to other adults enrolled on treatment in those facilities. After adjusting for both individual-level and facility-level risk factors, the largest health facilities (those that enrolled more than 55 patients) had 38% higher risk of attrition (RR 1.38, 95% CI 1.08-1.77, p-value=0.009) compared with the smallest facilities. Compared to public health facilities, private institutions had 18% less risk of attrition (RR 0.82, 95% CI 0.70-0.96, p-value=0.020). Health facilities located in the West department and the south region had lower risk of attrition than those located in the north region. Conclusion: The study demonstrated high facility-level variability and significant risk factors associated with high attrition among Option B+ clients. Moreover, as attrition was higher in Option B+ clients than other adults on ART across a majority of health facilities, retention on treatment is a major concern for PMTCT programs in Haiti. The implementation of the Option B+ strategy must be re-evaluated throughout the country in order to effectively eliminate mother-to-child HIV transmission and prevent the emergence of drug resistance

ART attrition and risk factors among Option B+ patients in Haiti: A retrospective cohort study.

OBJECTIVES:In October 2012, the Haitian Ministry of Health endorsed the "Option B+" strategy to eliminate mother-to-child transmission of HIV and achieve HIV epidemic control. The objective of this paper is to assess and identify risk factors for attrition from the national ART program among Option B+ patients in the 12 months after ART initiation. DESIGN:This retrospective cohort study included patients newly initiating ART from October 2012-August 2013 at 68 ART sites covering 45% of all newly enrolled ART patients in all regions of Haiti. METHODS:With data from electronic medical records, we carried out descriptive analysis of sociodemographic, clinical, and pregnancy-related correlates of ART attrition, and used a modified Poisson regression approach to estimate relative risks in a multivariable model. RESULTS:There were 2,166 Option B+ patients who initiated ART, of whom 1,023 were not retained by 12 months (47.2%). One quarter (25.3%) dropped out within 3 months of ART initiation. Protective factors included older age, more advanced HIV disease progression, and any adherence counseling prior to ART initiation, while risk factors included starting ART late in gestation, starting ART within 7 days of HIV testing, and using an atypical ART regimen. DISCUSSION:Our study demonstrates early ART attrition among Option B+ patients and contributes evidence on the characteristics of women who are most at risk of attrition in Haiti. Our findings highlight the importance of targeted strategies to support retention among Option B+ patients

ART attrition and risk factors among Option B+ patients in Haiti: A retrospective cohort study.

OBJECTIVES:In October 2012, the Haitian Ministry of Health endorsed the "Option B+" strategy to eliminate mother-to-child transmission of HIV and achieve HIV epidemic control. The objective of this paper is to assess and identify risk factors for attrition from the national ART program among Option B+ patients in the 12 months after ART initiation. DESIGN:This retrospective cohort study included patients newly initiating ART from October 2012-August 2013 at 68 ART sites covering 45% of all newly enrolled ART patients in all regions of Haiti. METHODS:With data from electronic medical records, we carried out descriptive analysis of sociodemographic, clinical, and pregnancy-related correlates of ART attrition, and used a modified Poisson regression approach to estimate relative risks in a multivariable model. RESULTS:There were 2,166 Option B+ patients who initiated ART, of whom 1,023 were not retained by 12 months (47.2%). One quarter (25.3%) dropped out within 3 months of ART initiation. Protective factors included older age, more advanced HIV disease progression, and any adherence counseling prior to ART initiation, while risk factors included starting ART late in gestation, starting ART within 7 days of HIV testing, and using an atypical ART regimen. DISCUSSION:Our study demonstrates early ART attrition among Option B+ patients and contributes evidence on the characteristics of women who are most at risk of attrition in Haiti. Our findings highlight the importance of targeted strategies to support retention among Option B+ patients

Timing of last visit in 12 months after ART start.

<p>*Among 2,166 Option B+ clients. **Among 850 Option B+ clients with known pregnancy and HIV testing dates. Rapid ART start = ART start within 7 days of registration in HIV care; No rapid ART start = ART start >7 days after registration in HIV care. ǂp<0.001 for Chi2 test of equality of proportions between Rapid ART start vs. No rapid ART start and between HIV test before vs. after start of pregnancy.</p

Characteristics of Option B+ patients (Categorical variables).

<p>Characteristics of Option B+ patients (Categorical variables).</p

Risk factors for ART attrition among Option B+ patients^*.

<p>Risk factors for ART attrition among Option B+ patients^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0173123#t003fn001" target="_blank">*</a>}.</p

ART attrition indicators by gestational age at ART start.

<p>**Among 968 Option B+ patients with available data on pregnancy dates. ǂ p<0.001 ǁ p = 0.01 * p = 0.54 for Chi2 test of equality of proportions across gestational age groups.</p

Characteristics of Option B+ patients (Continuous variables).

<p>Characteristics of Option B+ patients (Continuous variables).</p