Risk factors for unstructured treatment interruptions and association with survival in low to middle income countries

Predictors of the observed high prevalence of loss to follow-up in ART-experienced adult PLHIV: a retrospective longitudinal cohort study in the Tanga Region, Tanzania

BACKGROUND

Antiretroviral therapy (ART) programs have expanded rapidly, and they are now accessible free of charge, yet "loss to follow-up, LTFU" is still a national public health issue. LTFU may result in treatment failure, hospitalization, increased risk of opportunistic infections and drug-resistant strains, and shortening the quality of life. This study described the rates and predictors of LTFU among adults living with human immunodeficiency virus (PLHIV) on ART in the Tanga region, Tanzania.

METHODS

A retrospective longitudinal cohort study was conducted between October 2018 and December 2020 in Tanga's care and treatment health services facilities. The participants were HIV adult PLHIV aged 15 years and above on ART and attended the clinic at least once after ART initiation. LTFU was defined as not taking ART refills for 3 months or beyond from the last attendance of a refill and not yet classified as dead or transferred out. Cox proportional hazard regression models were employed to identify risk factors for LTFU. P values were two-sided, and we considered a p < 0.05 statistically significant.

RESULTS

57,173 adult PLHIV were on ART of them, 15,111 (26.43%) were LTFU, of whom 10,394 (68.78%) were females, and 4717 (31.22%) were males. Factors independently associated with LTFU involved age between 15 and 19 years (HR: 1.85, 95% CI 1.66-2.07), male sex (HR: 2.00 95% CI 1.51-2.62), divorce (HR: 1.35, 95% CI 1.24-1.48), second-line drug type (HR: 1.13, 95% CI 1.09-1.18), poor drug adherence (HR: 1.50, 95% CI 1.23-1.75), unsuppressed viral load (HR: 2.15, 95% CI 2.02-2.29), not on DTG-related drug (HR: 7.51, 95% CI 5.88-10.79), advanced HIV disease WHO stage III and IV (HR: 2.51, 95% CI 2.32-2.72). In contrast to cohabiting, ART duration < 1 year, and being pregnant showed a reduced likelihood of LTFU.

CONCLUSION

A high prevalence of LTFU was observed in this study. Young age, not using DTG-based regimen, WHO clinical stage IV, poor drug adherence, male sex, unsuppressed viral load, divorcee, and second-line regime were independently associated with LTFU. To reduce LTFU, evidence-based interventions targeting the identified risk factors should be employed.

Diagnosis and monitoring of HIV programmes to support treatment initiation and follow up and improve programme quality

PURPOSE OF REVIEW

The HIV 'cascade of care' breaks down at several points, with delayed HIV diagnosis, late treatment initiation, or interruption, leading to new morbidity and mortality and loss of prevention effects. New approaches are needed at each step.

RECENT FINDINGS

HIV testing is still not reaching certain communities, resulting in late presentation. Creative ways to reach these communities is being explored, including with self-testing. HIV misdiagnosis is increasingly recognized as undermining testing programmes, highlighting the need for better quality control. More rapid antiretroviral initiation, even on the same day, initiation outside of health facilities, and more efficient defaulter re-initiation, may mean better retention and virological control. New antiretrovirals may address side effects responsible for poor adherence and treatment failure, as well as requiring lower adherence levels. Viral load monitoring expansion is required, but mechanisms are needed to ensure healthcare workers act on detectable results; point of care technologies may partly address this. Side-effect monitoring at a programme level is needed to characterise 'real world' effectiveness.

SUMMARY

Integrated monitoring systems, using single patient identifiers and utilizing national laboratory data systems, will allow for better characterization and interventions that limit loss to follow up, and allow better pharmacovigilance and programme performance.