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Open Access Research article

Low risk of attrition among adults on antiretroviral therapy in the Rwandan national program: a retrospective cohort analysis of 6, 12, and 18 month outcomes

Harriet Nuwagaba-Biribonwoha12*, Aleksandra Jakubowski1, Veronicah Mugisha1, Paulin Basinga3, Anita Asiimwe4, Denis Nash5 and Batya Elul12

Author Affiliations

1 ICAP, Columbia University, Mailman School of Public Health, New York, New York, USA

2 Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA

3 Bill and Melinda Gates Foundation, Seattle, Washington, USA

4 Rwanda Biomedical Center [RBC], Ministry of Health, Kigali, Rwanda

5 Hunter College, City University of New York, New York, New York, USA

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BMC Public Health 2014, 14:889  doi:10.1186/1471-2458-14-889

Published: 29 August 2014

Abstract

Background

We report levels and determinants of attrition in Rwanda, one of the few African countries with universal ART access.

Methods

We analyzed data abstracted from health facility records of a nationally representative sample of adults [≥18 years] who initiated ART 6, 12, and 18 months prior to data collection; and collected facility characteristics with a health facility assessment questionnaire. Weighted proportions and rates of attrition [loss to follow-up or death] were calculated, and patient- and health facility-level factors associated with attrition examined using Cox proportional hazard models.

Results

1678 adults initiated ART 6, 12 and 18 months prior to data collection, with 1508 person-years [PY] on ART. Attrition was 6.8% [95% confidence interval [CI] 6.0-7.8]: 2.9% [2.4-3.5] recorded deaths and 3.9% [3.4-4.5] lost to follow-up. Population attrition rate was 7.5/100PY [6.1-9.3]. Adjusted hazard ratio [aHR] for attrition was 4.2 [3.0-5.7] among adults enrolled from in-patient wards [vs 2.2 [1.6-3.0] from PMTCT, ref: VCT]. Compared to adults who initiated ART 18 months earlier, aHR for adults who initiated ART 12 and 6 months earlier was 1.8 [1.3-2.5] and 1.3 [0.9-1.9] respectively. Male aHR was 1.4 [1.0-1.8]. AHR of adults enrolled at urban health facilities was 1.4 [1.1-1.8, ref: rural health facilities]. AHR for adults with CD4+ ≥200 cells/μL vs <200 cells/μL was 0.8 [0.6-1.0]; and adults attending facilities with performance-based financing since 2004–2006 [vs. 2007–2008] had aHR 0.8 [0.6-0.9].

Conclusions

Attrition was low in the Rwandan national program. The above patient and facility correlates of attrition can be the focus of interventions to sustain high retention.

Keywords:
Antiretroviral therapy [ART]; Retention; Attrition; Mortality; Loss to follow-up; Rwanda