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Retention in care after early enrolment into differentiated service delivery models for antiretroviral treatment: a case for policy change

Title
Retention in care after early enrolment into differentiated service delivery models for antiretroviral treatment: a case for policy change
Presenter
Lise Jamieson
Authors
L. Jamieson * (1), S. Rosen (2,1), B. Phiri (3), A. Grimsrud (4), M. Mwansa (5), H. Shakwelele (3), P. Haimbe (3), M.M Mwenechanya (6), P.L. Mulenga (5), B. Nichols (7,2,1)
Institutions
(1) Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa, (2) School of Public Health, Boston University, Department of Global Health, Boston, United States, (3) Clinton Health Access Initiative, Lusaka, Zambia, (4) International AIDS Society, Cape Town, South Africa, (5) Ministry of Health, Lusaka, Zambia, (6) The Centre for Infectious Disease Research in Zambia, Lusaka, Zambia, (7) Amsterdam University Medical Center, Department of Medical Microbiology, Amsterdam, Netherlands

BACKGROUND: Differentiated service delivery (DSD) models intend to make HIV treatment more person-centered and support long-term retention. Most models require '¥6 or '¥12 months on ART for eligibility. However, attrition is highest among newly-initiated antiretroviral treatment (ART) patients who are usually ineligible for DSD models. We investigated attrition among patients in Zambia enrolled in DSD models, after <12 months on ART.
METHODS: Data were extracted from electronic medical records of patients (age'¥16 years) enrolled in six DSD models between October 2019-March 2020. We evaluated 12-month loss to follow-up (LTFU), defined at 9-15 months after DSD enrolment, comparing patients '¥12 months on ART to those enrolled after <6 and 6-12 months on ART. We adjusted for age, sex, urban/rural status, ART dispensing duration. To address potential selection bias, we conducted a sub-analysis restricted to those with known viral suppression at DSD entry.
RESULTS: Of 90,373 patients enrolled, 3% (n=3,109) and 7% (n=6,630) were on ART <6 and 6-12 months at DSD entry, respectively. Patients on ART for <6 and 6-12 months were less likely to be LTFU compared to those on ART '¥12 months (adjusted risk ratio (aRR) 0.83, 95% confidence interval (CI) 0.72-0.95; aRR 0.84, 95%CI 0.77-0.92, respectively) for almost all models and dispensing durations. Among patients with known viral suppression (n=27,741), patients enrolled early in DSD models had equivalent or less LTFU risk compared to those enrolled after ART '¥12 months (<6 months: aRR 0.88, 95%CI 0.67-1.16; 6-12 months: aRR 0.80, 95%CI 0.68-0.92).


CONCLUSIONS: Patients enrolled in DSD models in Zambia after <12 months ART were more likely to be retained in care 12 months later than patients enrolled after '¥12 months ART. In alignment with updated recommendations from the World Health Organization, criteria for determining established on treatment should be reconsidered to support earlier eligibility for DSD for HIV treatment models.