Patient Retention in Antiretroviral Therapy Programs in Sub-Saharan Africa: A Systematic Review
Date
2007-10
DOI
Authors
Rosen, Sydney
Fox, Matthew P.
Gill, Chris G.
Version
OA Version
Citation
Rosen S, Fox MP, Gill CJ (2007) Patient retention in antiretroviral therapy programs in sub-Saharan Africa: A systematic review. PLoS Med 4(10): e298. doi:10. 1371/journal.pmed.0040298
Abstract
Background
Long-term retention of patients in Africa’s rapidly expanding antiretroviral therapy (ART)
programs for HIV/AIDS is essential for these programs’ success but has received relatively little
attention. In this paper we present a systematic review of patient retention in ART programs in
sub-Saharan Africa.
Methods and Findings
We searched Medline, other literature databases, conference abstracts, publications archives,
and the ‘‘gray literature’’ (project reports available online) between 2000 and 2007 for reports
on the proportion of adult patients retained (i.e., remaining in care and on ART) after 6 mo or
longer in sub-Saharan African, non-research ART programs, with and without donor support.
Estimated retention rates at 6, 12, and 24 mo were calculated and plotted for each program.
Retention was also estimated using Kaplan-Meier curves. In sensitivity analyses we considered
best-case, worst-case, and midpoint scenarios for retention at 2 y; the best-case scenario
assumed no further attrition beyond that reported, while the worst-case scenario assumed that
attrition would continue in a linear fashion. We reviewed 32 publications reporting on 33
patient cohorts (74,192 patients, 13 countries). For all studies, the weighted average follow-up
period reported was 9.9 mo, after which 77.5% of patients were retained. Loss to follow-up and
death accounted for 56% and 40% of attrition, respectively. Weighted mean retention rates as
reported were 79.1%, 75.0% and 61.6 % at 6, 12, and 24 mo, respectively. Of those reporting 24
mo of follow-up, the best program retained 85% of patients and the worst retained 46%.
Attrition was higher in studies with shorter reporting periods, leading to monthly weighted
mean attrition rates of 3.3%/mo, 1.9%/mo, and 1.6%/month for studies reporting to 6, 12, and
24 months, respectively, and suggesting that overall patient retention may be overestimated in
the published reports. In sensitivity analyses, estimated retention rates ranged from 24% in the
worse case to 77% in the best case at the end of 2 y, with a plausible midpoint scenario of 50%.
Conclusions
Since the inception of large-scale ART access early in this decade, ART programs in Africa
have retained about 60% of their patients at the end of 2 y. Loss to follow-up is the major cause
of attrition, followed by death. Better patient tracing procedures, better understanding of loss
to follow-up, and earlier initiation of ART to reduce mortality are needed if retention is to be
improved. Retention varies widely across programs, and programs that have achieved higher
retention rates can serve as models for future improvements.
Description
Paper published in PLoS Medicine in 2007.