Predictors of lost to follow-up in a “test and treat” programme among adult women with high-risk sexual behavior in Kampala, Uganda

Kamacooko et al. BMC Public Health (2020) 20:353 https://doi.org/10.1186/s12889-020-8439-9 RESEARCH ARTICLE Open Access Predictors of lost to follow-up in a “test and treat” programme among adult women with high-risk sexual behavior in Kampala, Uganda Onesmus Kamacooko1* , Yunia Mayanja1, Daniel Bagiire1, Gertrude Namale1, Christian Holm Hansen1,2 and Janet Seeley1,2 Abstract Background: Immediate uptake of antiretroviral therapy (ART) after an HIV-positive diagnosis (Test and Treat) is now being implemented in Uganda. Data are limited on lost to follow-up (LTFU) in high-risk cohorts that have initiated ‘Test and Treat’. We describe LTFU in a cohort of women of high-risk sexual behaviour who initiated ART under “Test and Treat”. Methods: We performed a retrospective cohort study of participant records at the Good Health for Women Project (GHWP) clinic, a clinic in Kampala for women at high-risk of HIV-infection. We included HIV positive women ≥18 years who initiated ART at GHWP between August 2014 and March 2018. We defined LTFU as not taking an ART refill for ≥3 months from the last clinic appointment among those not registered as dead or transferred to another clinic. We used the Kaplan-Meier technique to estimate time to LTFU after ART initiation. Predictors of LTFU were assessed using a multivariable Cox proportional hazards model. Results: The mean (±SD) age of the 293 study participants was 30.3 (± 6.5) years, with 274 (94%) reporting paid sex while 38 (13%) had never tested for HIV before enrolment into GHWP. LTFU within the first year of ART initiation was 16% and the incidence of LTFU was estimated at 12.7 per 100 person-years (95%CI 9.90–16.3). In multivariable analysis, participants who reported sex work as their main job at ART initiation (Adjusted Hazards Ratio [aHR] =1.95, 95%CI 1.10– 3.45), having baseline WHO clinical stage III or IV (aHR = 2.75, 95% CI 1.30–5.79) were more likely to be LTFU. Conclusion: LTFU in this cohort is high. Follow up strategies are required to support women on Test and Treat to remain on treatment, especially those who engage in sex work and those who initiate ART at a later stage of disease. Keywords: Universal test and treat, Women at high-risk, Lost to follow-up, Loss to follow-up; sub-Saharan Africa Background It is estimated that by the end of 2018, 23.3 million people were receiving antiretroviral therapy (ART) globally and that between 2000 and 2018, HIV-related deaths fell by * Correspondence: 1 MRC/UVRI & LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, P. O Box 49, Entebbe, Uganda Full list of author information is available at the end of the article 45% with 13.6 million lives saved due to ART in the same period [1]. In sub-Saharan Africa (SSA) access to ART has improved from 10.3 million people in 2015 to 12.9 million people by the end of 2018 [2]. In Uganda, by the end of 2018, it was estimated that 1.4 million people were living with HIV of whom 73% were on ART and an estimated 23,000 Ugandans had died of HIV-related illnesses [1]. In Uganda, the general population HIV prevalence has © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. 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 in a credit line to the data. Kamacooko et al. BMC Public Health (2020) 20:353 stabilised at 6% [3] while the prevalence among key populations (such as female sex workers [FSW]) is estimated to be over 30% [4]. Studies have shown that ART is not only improving quality of life and decreasing morbidity in those receiving treatment but that the public health impact of scaling up ART may contribute significantly to prevention efforts [5, 6]. Recent studies have shown that early ART initiation reduced transmission of HIV and that there is great potential of treatment for prevention [6–8]. Given that the risk of HIV infections is high for key populations [9], this scale-up in ART is particularly important to maximize the effectiveness of treatment as prevention in such populations [10]. The scale up among key populations may have an impact on the HIV epidemic, since it is estimated that in SSA they contribute between 7 and 30% of new infections [11, 12]. The scale-up of treatment can only be effective if people living with HIV remain on treatment following diagnosis and ART initiation, but retention in care remains a challenge in both high and low income settings [13]. With the current efforts aimed at initiating all HIV-positive individuals on immediate ART, regardless of CD4 and WHO clinical stage, in an approach called “Test and Treat” [14], retention in care is key if the full potential is to be realised including achieving the 90–9090 targets especially the 3rd 90 which is the one mostly affected by retention [15]. Treatment has become more widely available, but few data have been published on rates of retention and predictors of loss to follow-up (LTFU) among people at highrisk of HIV-infection enrolled on immediate ART. Studies carried out in the general population have shown that LTFU ranged between 14 and 18% for the people living with HIV initiated on ART with some studies indicating that 41% of the LTFU occurred within the first 6 months of ART initiation [16–18]. We build on this work with a cohort of HIV positive women who started ART in a “Test and Treat” facility in Kampala, Uganda during the period of August 2014 to March 2018. We estimated the rate of LTFU and associated factors/predictors. Methods Study design We performed a retrospective cohort study among women at high-risk of HIV infection, on ART, using records between August 2014 and March 2018. Study population and setting This study was embedded within an existing cohort of women living with HIV, or at high risk of HIV infection, attending the Good Health for Women Project (GHWP) clinic in Kampala. The GHWP clinic was established in a peri-urban community in southern Kampala in 2008 under the then Medical Research Council/Uganda Virus Page 2 of 9 Research Institute (MRC/UVRI), Uganda Research Unit on AIDS to s (...truncated)