Risk factors for loss to follow-up from antiretroviral therapy programmes in low- and middle-income countries: A systematic review and meta-analysis

INTRODUCTION: Loss to follow up (LTFU) rates from antiretroviral treatment (ART) programmes in low- and middle-income countries (LMIC) are high, forming an important risk factor for poor treatment outcomes and spread of the HIV epidemic. Knowledge of risk factors is required to address LTFU. In this systematic review risk factors for LTFU are identified and meta-analyses performed. METHODS: PubMed, Embase, Psycinfo and Cochrane were searched for studies that report on potential risk factors for LTFU in adults that initiated ART in LMICs. Meta-analysis was performed for risk factors evaluated by at least five studies. Pooled effect estimates and their 95% confidence intervals (95%CI) were calculated using random effect models with inverse variance weights. Risk of bias was assessed and sensitivity analyses performed. RESULTS: Eighty studies were included describing a total of 1,605,320 patients of which 87.4% from Sub-Saharan Africa. The following determinants were significantly associated with an increased risk of LTFU in meta-analysis: male sex, older age, being single, unemployment, lower educational status, advanced WHO stage, low weight, worse functional status, poor adherence, non-disclosure, not receiving cotrimoxazole prophylactic therapy when indicated, receiving care at secondary level and more recent year of initiation. No association was seen for CD4 count, tuberculosis at baseline, regimen, and geographical setting. CONCLUSIONS: There are several socio-demographic, clinical, patient behaviour, treatment related and system level risk factors for LTFU from ART programs. Knowledge of risk factors should be used to better target retention interventions and develop tools to identify high-risk patients

• Determinants of Health
  • Employment
  • Education
  • Stigma/discrimination
• Population(s)
  • General HIV+ population
• Engagement and Care Cascade
  • Treatment