Attrition from HIV treatment after enrollment in a differentiated service delivery model: A cohort analysis of routine care in Zambia

PLOS ONE RESEARCH ARTICLE Attrition from HIV treatment after enrollment in a differentiated service delivery model: A cohort analysis of routine care in Zambia Youngji Jo1, Lise Jamieson2,3, Bevis Phiri4, Anna Grimsrud ID5, Muya Mwansa6, Hilda Shakwelele4, Prudence Haimbe4, Mpande Mukumbwa-Mwenechanya7, Priscilla Lumano Mulenga6, Brooke E. Nichols2,3,8☯, Sydney Rosen ID2,8☯* a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA, United States of America, 2 Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa, 3 Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, Netherlands, 4 Clinton Health Access Initiative, Lusaka, Zambia, 5 HIV Programmes and Advocacy, International AIDS Society, Cape Town, South Africa, 6 Ministry of Health, Lusaka, Zambia, 7 Centre for Infectious Disease Research in Zambia, Lusaka, Zambia, 8 Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America ☯ These authors contributed equally to this work. * OPEN ACCESS Citation: Jo Y, Jamieson L, Phiri B, Grimsrud A, Mwansa M, Shakwelele H, et al. (2023) Attrition from HIV treatment after enrollment in a differentiated service delivery model: A cohort analysis of routine care in Zambia. PLoS ONE 18(3): e0280748. https://doi.org/10.1371/journal. pone.0280748 Editor: Adam W. Bartlett, University of New South Wales, AUSTRALIA Received: July 7, 2022 Accepted: January 7, 2023 Published: March 14, 2023 Copyright: © 2023 Jo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The data used in this manuscript, which comprise a patient-level data set that contains individual patient information, are owned by the Zambian Ministry of Health. Permission to access these data must be obtained from the Ministry of Health. For information on how to request permission, researchers may contact the Zambia National Health Research Authority (NHRA), Paediatric Centre of Excellence, University Teaching Hospital, P.O. Box 30075, Abstract Background Many sub-Saharan Africa countries are scaling up differentiated service delivery (DSD) models for HIV treatment to increase access and remove barriers to care. We assessed factors associated with attrition after DSD model enrollment in Zambia, focusing on patientlevel characteristics. Methods We conducted a retrospective record review using electronic medical records (EMR) of adults (�15 years) initiated on antiretroviral (ART) between 01 January 2018 and 30 November 2021. Attrition was defined as lost to follow-up (LTFU) or died by November 30, 2021. We categorized DSD models into eight groups: fast-track, adherence groups, community pick-up points, home ART delivery, extended facility hours, facility multi-month dispensing (MMD, 4–6-month ART dispensing), frequent refill care (facility 1–2 month dispensing), and conventional care (facility 3 month dispensing, reference group). We used Fine and Gray competing risk regression to assess patient-level factors associated with attrition, stratified by sex and rural/urban setting. Results Of 547,281 eligible patients, 68% (n = 372,409) enrolled in DSD models, most commonly facility MMD (n = 306,430, 82%), frequent refill care (n = 47,142, 13%), and fast track (n = 14,433, 4%), with <2% enrolled in the other DSD groups. Retention was higher in nearly all DSD models for all dispensing intervals, compared to the reference group, except fast track PLOS ONE | https://doi.org/10.1371/journal.pone.0280748 March 14, 2023 1 / 10 PLOS ONE Lusaka, Zambia. Tel: +260211 250309; email: ; website: www.nhra.org.zm. Funding: Funding for the study was provided by the Bill & Melinda Gates Foundation through OPP1192640 to Boston University. YJ is supported by the Ruth L. Kirschstein National Research Service Award, National Institutes of Health F32 Individual Fellowship Grant (grant number: 1F32MH128120-01). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. Attrition from DSD models in Zambia for the �2 month dispensing group. Retention benefits were greatest for patients in the extended clinic hours group and least for fast track dispensing. Conclusion Although retention in HIV treatment differed by DSD type, dispensing interval, and patient characteristics, nearly all DSD models out-performed conventional care. Understanding the factors that influence the retention of patients in DSD models could provide an important step towards improving DSD implementation. Competing interests: The authors have declared that no competing interests exist. Introduction Although access to antiretroviral treatment (ART) for HIV is now widespread, ART programs worldwide continue to face the challenge of retaining patients in lifelong care. Studies in subSaharan Africa (SSA) suggest that only 67% of patients remain in ART programs after five years, with loss to follow-up (patients with unknown outcomes) accounting for 33% of all attrition [1]. One solution to this high attrition from ART programs has been the introduction of differentiated service delivery (DSD) models. DSD models aim to improve long-term ART retention by removing barriers to care, making service delivery more patient-centered [2], generate greater patient satisfaction, reduce costs to patients (and to providers in some cases), and create efficient and convenient service delivery [3]. DSD models differ from conventional HIV care in the location of service delivery, frequency of interactions with the healthcare system, cadre of provider involved, and/or types of services provided [4]. The attractiveness of DSD models is generally considered to be conditional on maintaining at least equivalent clinical outcomes to conventional care, but there remains relatively little evidence on ART retention among patients enrolled in DSD models as part of large-scale routine care in SSA [5, 6]. Zambia, a high-HIV burden country with more than 1.5 million people living with HIV and more than 81% of those individuals on ART, has rapidly scaled up a variety of DSD models [7]. Participation in DSD models and ART treatment outcomes are documented in Zambia’s national electronic medical record (EMR) system, known as SmartCare. We used the SmartCare data set, the largest dataset of its kind available on DSD model uptake and outcomes, to compare patient outcomes in DSD models to conventional care and assess patientlevel factors associated with retention after enrolment in different DSD models. Methods (...truncated)