Loss to follow-up and associated factors among adult people living with HIV at public health facilities in Wakiso district, Uganda: a retrospective cohort study

Opio et al. BMC Health Services Research https://doi.org/10.1186/s12913-019-4474-6 (2019) 19:628 RESEARCH ARTICLE Open Access Loss to follow-up and associated factors among adult people living with HIV at public health facilities in Wakiso district, Uganda: a retrospective cohort study Denis Opio1,2* , Fred C. Semitala3,4,5, Alex Kakeeto1, Emmanuel Sendaula1, Paul Okimat1,6, Brenda Nakafeero1, Joaniter I. Nankabirwa1,5, Charles Karamagi1,7 and Joan N. Kalyango1,8 Abstract Background: Loss to follow-up (LTFU) from care among people living with HIV (PLHIV) is thought to be more common in the public setting compared to the private health care. It is anticipated that the problem may become worse with the current “test and treat” policy in Uganda due to the likely increases in patient loads and its attendant pressure on health care providers to support patient counseling. This study determined the incidence and factors associated with LTFU from HIV care among adult PLHIV in public health facilities in Wakiso district, Uganda. Methods: This was a retrospective cohort study that involved the review of 646 records of patients initiated on antiretroviral therapy (ART) between January 1st, 2015 and December 31st, 2017 at 13 randomly selected public health facilities in Wakiso district. The cox proportional hazards regression was used to determine the factors associated with LTFU. The results were supported by sequential in-depth and key informant interviews to explore reasons for LTFU. Results: Of the 646 patients enrolled, 391 were female (60.5%), 282 were below 30 years (43.6%) and 207 were married (50.1%). A total of 216 patients (33.4%) had no documented outcomes and were considered LTFU. The incidence of LTFU was 21 per 1000 person months (95% confidence interval (CI): 18–25 per 1000 person months). Factors associated with LTFU included having normal weight compared to underweight (adjusted hazard ratio (aHR) 0.64, 95% CI: 0.45–0.90, p = 0.011), receiving HIV care from hospitals compared to lower level facilities (aHR 0.22, 95% CI: 0.12–0.41, p < 0.001), and no telephone contact compared to those with a telephone contact (aHR 2.16, 95% CI: 1.33–3.51, p = 0.002). Stigmatization and long waiting times were the prominent reasons for LTFU reported from the in-depth and key informant interviews. Conclusions: The incidence of LTFU in public health facilities in Uganda is quite high and is associated with being underweight, not having a telephone contact to receive reminders and receiving care at lower level facilities. Early diagnosis, routine use of patient address locator forms and improved quality of HIV care at lower level health facilities may reduce LTFU among PLHIV. Keywords: Loss to follow-up, HIV care, PLHIV, Public health facilities * Correspondence: 1 Clinical Epidemiology Unit, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda 2 Makerere University- Johns Hopkins University Research Collaboration (MU-JHU), P.O. Box 23491, Kampala, Uganda Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Opio et al. BMC Health Services Research (2019) 19:628 Background The Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) epidemic remains a major problem especially in countries of subSaharan Africa like Uganda [1]. The prevalence of HIV among adults aged 15 to 64 was estimated at 6.2% in 2017, which corresponds to an estimated 1.2 million people living with HIV (PLHIV) in the country [2]. More importantly, it was estimated that 26, 000 Ugandans died of AIDS-related illnesses in 2017 [3]. The available means of management and control of HIV include treatment with antiretroviral therapy (ART), post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) [4]. When effective ART is used, it decreases the risk of transmitting the HIV virus from one person to another [4, 5], and allows for the HIV positive person to live a healthy life [5]. Patient retention in care is crucial to ensure ongoing receipt of ART, timely evaluation of ART toxicity and/or new opportunistic infections; these in turn help to reduce HIV related morbidity, mortality, the incidence of new infections, and development of ART resistance [5–9]. Despite the benefits of retention in care, it is challenging for the health care facilities (HCFs) to keep all patients in HIV-care [10]. Studies in HIV centres of excellence in Uganda have shown the incidence of loss to follow-up (LTFU) from HIV care to range from 9 to 20% [11, 12]. It is hypothesized that the incidence may be higher in public facilities, where patients do not receive the extra support (e.g. provision of transport refund and meals on follow-up visit dates) provided by the centres of excellence (model institutions that provide high quality of comprehensive care for PLHIV, and are often funded by international agencies). This may further be augmented by the “test and treat” policy (where populations at risk are screened for HIV infection, and diagnosed HIV infected individuals receive immediate treatment regardless of their CD4 cell count or clinical stage) since patients are likely to be many and not very ill during ART initiation. Such patients may not perceive themselves to be at risk of the complications of HIV, and it may therefore be more difficult to retain them in care, until such a time as when their immune function has gone down and they present with complications [13]. Although the problem of LTFU in the centres of excellence has been widely evaluated, the burden in public facilities where resources are constrained, and yet a larger load of patients are received, is not well appreciated [10, 14]. We assessed the incidence of, and the factors associated with LTFU from HIV care among adult patients enrolled at public facilities in Wakiso district, Central Uganda, between January 2015 and December 2017. Page 2 of 10 Methods Study setting The study was conducted in Wakiso district, Central Uganda which neighbors the country’s Capital City, Kampala. The district consists of 12 divisions, six subcounties and 720 villages with an estimated population of 2,111,061 people [15]. The district has the highest prevalence of HIV in Uganda at 10% [16]. It has 31 public HCFs including; one hospital at district level, six health centre IVs (HCIVs) at Health Sub District (HSD) le (...truncated)