Attrition from antiretroviral treatment services among pregnant and non-pregnant patients following adoption of Option B+ in Haiti

Abstract

INTRODUCTION: Attrition from antiretroviral treatment (ART) services is an important determinant of HIV treatment outcomes. This study assessed factors associated with attrition among pregnant and non-pregnant patients initiating ART following adoption of Option B+ (universal ART eligibility for HIV-infected pregnant women) in October 2012 in Haiti. METHODS: Electronic medical records of adult patients initiated on ART from October 2012 to August 2014 at 73 health facilities (HF) from 8 of 10 Haitian administrative departments were analyzed. Within a survival analysis framework, attrition was defined as the first instance of failure to attend a HF visit for 90 days after a missed clinical or pharmacy-dispensing appointment, or an officially-recorded programme discontinuation, whichever came first. Known transfers to alternative HF were treated as censored observations, not attrition cases. ART initiations during or within 12 weeks after pregnancy were deemed Option B+ cases. The Kaplan-Meier method and Cox proportional hazards regression, stratified by HF, were used to determine attrition and associated factors. RESULTS: Among 17,084 patients who initiated ART, 7719 (45.2%) were non-pregnant women, 5920 (34.7%) were men and 3445 (20.2%) were pregnant women. At six months, attrition was 15.6% (95% confidence interval (CI): 14.8–16.4) for non-pregnant women, 17.0% (16.1–18.0) for men and 30.1% (28.5–31.7) for pregnant women. At 12 months, attrition was 31.8% (95% CI: 30.6–33.0), 34.5% (33.2–35.9) and 50.8% (49.0–52.6) respectively. Adjusted for patient-level factors and HF, attrition risk was 63% higher among pregnant women and 16% higher among men, compared to non-pregnant women (p<0.001). Significant protective factors included: receiving psychosocial counselling (hazard ratio (HR): 0.84, p<0.001); cotrimoxazole prophylaxis (HR: 0.83, p<0.001); tuberculosis treatment (HR: 0.88, p<0.001) before ART initiation; having an HIV-positive household member (HR: 0.80, p<0.05); living in the same commune as the HF (HR: 0.94, p<0.05), and greater duration of pre-ART enrolment (HR: 0.99 for each 30-day increase, p<0.001). CONCLUSIONS: Following adoption of Option B+, ART attrition in Haiti was higher than that described in published reports from other resource-limited settings. Early, sustained and tailored interventions are urgently needed to reduce ART attrition in Haiti, particularly among pregnant women.