Contemporary disengagement from antiretroviral therapy in Khayelitsha, South Africa: A cohort study

• Published in: PLoS medicine 2017-11, Vol.14 (11), p.e1002407-e1002407
• Main Authors: Kaplan, Samantha R, Oosthuizen, Christa, Stinson, Kathryn, Little, Francesca, Euvrard, Jonathan, Schomaker, Michael, Osler, Meg, Hilderbrand, Katherine, Boulle, Andrew, Meintjes, Graeme
• Format: Article
• Language: English
• Subjects: Acquired immune deficiency syndrome; Adult; Adults; Age Factors; AIDS; Anti-Retroviral Agents - therapeutic use; Antiretroviral agents; Antiretroviral drugs; Antiretroviral therapy; Biology and Life Sciences; CD4 antigen; Cohort analysis; Dosage and administration; Drug therapy; Editors; Epidemiology; Evaluation; Female; Funding; HIV; HIV infections; HIV Infections - drug therapy; HIV Infections - epidemiology; HIV Infections - mortality; Hospitals; Human immunodeficiency virus; Humans; Incidence; Infectious diseases; Information systems; Male; Medication Adherence - statistics & numerical data; Medicine; Medicine and Health Sciences; Missing data; Patient Acceptance of Health Care; Patient compliance; Patients; People and places; Pregnancy; Public health; Registries; Research and Analysis Methods; Retention; Retrospective Studies; Risk Factors; Sex Factors; Software; South Africa - epidemiology; Statistical models; Supervision; Systematic review; Urban populations; Visualization
• ISSN: 1549-1676; 1549-1277; 1549-1676
• DOI: 10.1371/journal.pmed.1002407

Retention in care is an essential component of meeting the UNAIDS "90-90-90" HIV treatment targets. In Khayelitsha township (population ~500,000) in Cape Town, South Africa, more than 50,000 patients have received antiretroviral therapy (ART) since the inception of this public-sector program in 2001. Disengagement from care remains an important challenge. We sought to determine the incidence of and risk factors associated with disengagement from care during 2013-2014 and outcomes for those who disengaged. We conducted a retrospective cohort study of all patients ≥10 years of age who visited 1 of the 13 Khayelitsha ART clinics from 2013-2014 regardless of the date they initiated ART. We described the cumulative incidence of first disengagement (>180 days not attending clinic) between 1 January 2013 and 31 December 2014 using competing risks methods, enabling us to estimate disengagement incidence up to 10 years after ART initiation. We also described risk factors for disengagement based on a Cox proportional hazards model, using multiple imputation for missing data. We ascertained outcomes (death, return to care, hospital admission, other hospital contact, alive but not in care, no information) after disengagement until 30 June 2015 using province-wide health databases and the National Death Registry. Of 39,884 patients meeting our eligibility criteria, the median time on ART to 31 December 2014 was 33.6 months (IQR 12.4-63.2). Of the total study cohort, 592 (1.5%) died in the study period, 1,231 (3.1%) formally transferred out, 987 (2.5%) were silent transfers and visited another Western Cape province clinic within 180 days, 9,005 (22.6%) disengaged, and 28,069 (70.4%) remained in care. Cumulative incidence of disengagement from care was estimated to be 25.1% by 2 years and 50.3% by 5 years on ART. Key factors associated with disengagement (age, male sex, pregnancy at ART start [HR 1.58, 95% CI 1.47-1.69], most recent CD4 count) and retention (ART club membership, baseline CD4) after adjustment were similar to those found in previous studies; however, notably, the higher hazard of disengagement soon after starting ART was no longer present after adjusting for these risk factors. Of the 9,005 who disengaged, the 2 most common initial outcomes were return to ART care after 180 days (33%; n = 2,976) and being alive but not in care in the Western Cape (25%; n = 2,255). After disengagement, a total of 1,459 (16%) patients were hospitalized and 237 (3%) died. Th