Using an electronic medical record system to

identify factors associated with attrition from the

HIV antiretroviral therapy program at two

hospitals in Haiti

BACKGROUND

Patient retention is important for the success of Haiti’s national antiretroviral therapy (ART)program.

METHODS

This retrospective cohort study examined ART attrition among adult patients enrolled on ARTfrom 2005-2011 in two large public-sector Departmental hospitals, using the iSanté electronicdata system. The study characterized ART attrition levels according to definitions of attritionbased upon ART dispensing data and clinic encounter data. The study explored the patientdemographic, clinical, temporal, and service utilization factors associated with ART attrition. Thestudy used time-to-event analysis methods.

RESULTS

Among the 2,023 patients in the study, ART attrition on average was 17.0 per 100 person years(95% CI: 15.8-18.3). In adjusted analyses, risk of ART attrition was up to 89% higher for patientsliving in distant communes compared to patients living in the same commune as the hospital (HR:1.89, 95% CI: 1.54-2.33; p<0.001). Hospital site, earlier year of ART start, spending less timeenrolled in HIV care prior to ART initiation, receiving a non-standard ART regimen, lackingcounseling prior to ART initiation, and higher body mass index were also associated with attritionrisk.

CONCLUSIONS

The findings suggest quality improvement interventions at the two hospitals, including: enhancedretention support and transportation subsidies for patients accessing care from remote areas;counseling for all patients prior to ART initiation; timely outreach to patients who miss ART pick-ups; “bridging services” for patients transferring care to alternative facilities; routine screening foranticipated interruptions in future ART pick-ups; and medical case review for patients placed onnon-standard ART regimens. The findings are also relevant for policy-making on decentralizationof ART services in Haiti.

ACKNOWLEDGMENTS

The authors would like to thank Dr. Newton Jeudy, Dr. Jean Marie Duvilaire, Dr. Jean Ronald Cadet,and Mr. Garilus France from the Ministère de la Santé Publique et de la Population d’Haïti forsupport in the conceptualization of the study; Dr. Jean Gabriel Balan, Dr. Marcia Weaver, and Dr.Barbara Marston for thoughtful comments on the presentation of study results; Dr. Bill Lober fordesign of the iSanté data system; Steven Wagner for generating the iSanté data extracts. Thestudy would not have been possible without the dedicated efforts of disease reporting officersand health care workers at Hôpital St. Michel and Hôpital St. Antoine, who entered patient datato iSanté over many years.

Nancy Puttkammer, PhD(cand)1,2, Steven Zeliadt, PhD1, Jean Gabriel Balan, MD2, Janet Baseman, PhD1, Rodney Destiné, MD, MPH2, Jean Wysler Domercant, MD, MPH3, Nernst Atwood Raphael, MPH2, Kenneth Sherr, PhD1, Krista Yuhas, MPH1, Scott Barnhart, MD, MPH1,2

1University of Washington; 2International Training and Education Center for Health (I-TECH) Haiti Program; 3US Centers for Disease Control and Prevention, Global AIDS Program

Patient Demographic Factors

Measured:

Age; gender; proximity of residence

Unmeasured: Socio-economic position; Occupation; Education

Patient Clinical Factors

Measured:

CD4, BMI, WHO stage; TB status; ART regimen; presence of symptoms associated with WHO stage IV

Temporal Factors

Measured:

Year of ART enrollment; pre- and post- earthquake period

Service Delivery Factors

Measured:

Site; # ART counseling sessions before initiation; time enrolled in pre-ART care

Unmeasured:

Provider cadre, experience, load; ARV supply chain; ancillary services

ART Attrition

30+ Day Pharmacy DefinitionOverall HSA Jérémie HSM Jacmel

Time point % attrition 95% CI % attrition 95% CI % attrition 95% CI

6 months 6.6% (15.0, 18.4) 19.3% (17.0, 21.9) 13.8% (11.7, 16.1)

12 months 26.6% (24.6, 28.7) 30.5% (27.7, 33.5) 22.3% (19.7, 25.2)

18 months 31.4% (29.3, 33.6) 36.4% (33.4, 39.6) 25.7% (22.9, 28.8)

2 years 34.3% (32.1, 36.6) 40.0% (36.9, 43.3) 27.8% (24.8, 31.0)

3 years 38.9% (36.5, 41.3) 46.1% (42.7, 49.6) 30.8% (27.6, 34.2)

5 years 43.8% (41.0, 46.7) 52.8% (48.8, 57.0) 33.5% (30.0, 37.2)

90+ Day Encounter DefinitionTime point Overall HSA Jérémie HSM Jacmel

% attrition 95% CI % attrition 95% CI % attrition 95% CI

6 months 14.5% (13.0, 16.1) 17.7% (15.4, 20.2) 11.1% (9.2, 13.3)

12 months 26.9% (25.0, 29.1) 33.7% (30.8, 36.8) 19.4% (16.9, 22.2)

18 months 33.9% (31.8, 36.2) 43.3% (40.1, 46.6) 23.3% (20.5, 26.3)

2 years 40.3% (38.0, 42.8) 52.0% (48.7, 55.4) 26.9% (23.9, 30.1)

3 years 50.4% (47.7, 53.0) 68.1% (64.5, 71.7) 30.5% (27.3, 34.0)

5 years 70.6% (67.3, 73.8) 82.3% (78.4, 85.8) 57.6% (52.5, 62.9)

Table 1: Kaplan-Meier Estimates of ART Attrition at 2 Hospitals in Haiti, by Attrition Definition (2005-2011)

Table 2: Adjusted Hazard Ratios for ART Attrition at 2 Hospitals in Haiti, 2005-2011*

Risk Factor Hazard ratio 95% confidence interval p-value

SiteJacmel vs. Jeremied 0.58 (0.49, 0.70) <0.001

Post vs. pre-quake 0.94 (0.73, 1.22) 0.66

Gender (male=reference)

Female (non-pregnant) 0.99 (0.81, 1.21) 0.92

Female (pregnant) 1.08 (0.72, 1.62) 0.71

Age (10 year greater) 1.05 (0.97, 1.13) 0.20

Proximity (same commune=reference)c

Adjacent commune 1.69 (1.39, 2.06) <0.001

Non-adjacent commune 1.89 (1.54, 2.33) <0.001

BMI (<18.5=reference)a

>18.5 1.19 (0.99, 1.42) 0.06

Year of ART start (2005-06=reference)d

2007-08 0.66 (0.54, 0.81) <0.001

2009-10 0.60 (0.44, 0.81) 0.001

2011 0.37 (0.23, 0.61) <0.001

Baseline CD4 (<100=reference)

100-249 1.06 (0.86, 1.30) 0.58

250+ 1.15 (0.86, 1.54) 0.33

ART regimen (AZT-3TC-EFV=reference)b

AZT-3TC-NVP 1.14 (0.92, 1.42) 0.23

d4T or TDF + 3TC-EFV 0.67 (0.42, 1.08) 0.10

d4T or TDF + 3TC-NVP 0.86 (0.55, 1.34) 0.51

non-standard regimens 2.04 (1.16, 3.59) 0.01

WHO Stage (stage I or II=reference)a

stage III or IV 1.16 (0.99, 1.37) 0.07

TB status (No suspicion, prophylaxis or diagnosis=reference)

Yes 0.91 (0.74, 1.10) 0.32

Any stage IV symptom (No=reference)

Yes 0.84 (0.64, 1.11) 0.22

Pre-ART duration (30 day increase)c 0.99 (0.98, 1.00) 0.01

Counseling sessions prior to ART start (None=reference)a

1 session 0.84 (0.70, 1.01) 0.07

2+ sessions 0.74 (0.54, 1.01) 0.06

Figure 1: Conceptual Model for Factors Associated with ART Attrition

*Main effects model using 30+ day pharmacy definition for ART attritionp-values using joint testing of coefficients: a p≤0.10, bp≤0.05, c p≤0.01, d p≤0.001ART= antiretroviral therapy; BMI=body mass index; TB=tuberculosis; WHO=World Health OrganizationART regimen: ZDV=zidovudine; 3TC=lamivudine; EFV=efavirenz; NVP=nevirapine; d4T=stavudine; TDF=tenofovir.

HSA=Hopital St. Antoine; HSM=Hopital St. Michel.

This research has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Health Resources and Services Administration, under award number U91HA0680, and the US Centers for Disease Control and Prevention, under award number 5U2GGH000549-03, to the International Training and Education Center for Health (I-TECH) at the University of Washington. The research has also been supported by the Center for AIDS Research (CFAR) at the University of Washington. CFAR is supported by NIAID, NCI, NIMH, NIDA, NICHD, NHLBI, NIA of the National Institutes of Health under award number P30AI027757. The findings and conclusions in this paper are those of the authors and do not necessarily represent the views of their supporting agencies.