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



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


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.


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].


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.

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