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ATTRITION AMONG PREGNANT AND NON-PREGNANT PATIENTS INITIATING ART IN

HAITI FOLLOWING ADOPTION OF OPTION B+

Jean Wysler Domercant1, Nancy Puttkammer2, Lydia Lu3, Kesner Francois4, Dana Duncan5, Reynold Grand’Pierre4, David Lowrance1, Michelle Adler5

1Centers for Disease Control and Prevention, Port au Prince Haiti; 2International Training and Education Center for Health, Seattle WA, USA; 3Eagle Applied Sciences, Atlanta, GA; 4Ministry of Health of the

Government of Haiti; 5Centers for Disease Control and Prevention, Atlanta GA, USA.

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Background ART services started in 2003

Rapid scale-up with service access in all 42 Districts

High national coverage of HTC in ANC (80%) and ART among HIV infected pregnant women (87%)

Option B+ policy adopted in March 2012 and implementation started in October 2012

Limited data on level of attrition among ART patients following the adoption of Option B+ policy

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Methods Retrospective cohort analysis

Clinical data for 17,084 adult patients at 73 health facilities initiating ART from Oct. 2012 – Aug. 2014

Kaplan-Meier method and Cox proportional hazards regression

Option B+ ART initiation during or within 12 weeks of pregnancy

No breastfeeding data available

Attrition 90 day lapse after a missed clinical or pharmacy-dispensing

appointment Officially-recorded discontinuation due to death or patient

preference

Assessment of “silent transfer” phenomenon

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0 .5 1 1.5 2Analysis time (years after ART start)

Non-pregnant women Option B+Men

Kaplan-Meier Estimates of Retention on ART

Attrition by Patient Group

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Factors Associated with Attrition

a p<0.10, b p<0.05, c p<0.01, d p<0.001After controlling for health facility, marital status, ART regimen, calendar period of ART start, household size, having treatment buddy named, facility-based ART selection committee met to discuss patient case prior to ART start.

Patient Characteristics Hazard Ratio 95% Confidence Interval

Patient group (reference = Non-pregnant women, WHO stage I or II) d

Non-pregnant women, WHO stage III or IV 1.14 (1.03, 1.26) Option B+, WHO stage I or II 1.63 (1.44, 1.83) Option B+, WHO stage III or IV 1.32 (1.14, 1.53) Men, WHO stage I or II 1.11 (0.96, 1.29) Men, WHO stage III or IV 1.35 (1.21, 1.50)

Age (each 10-year increase) d 0.86 (0.84, 0.88) Residence in same commune as health facility b 0.93 (0.88, 1.00) Any known HIV+ household members d 0.80 (0.71, 0.90) Starting ART within 7 days of enrollment in care d 1.41 (1.32, 1.51) Baseline BMI (each 1 unit increase) d 0.97 (0.96, 0.98) Moderate or severe anemia d 1.31 (1.22, 1.42) Pre-ART counseling provided d 0.84 (0.78, 0.91) TB treatment or prophylaxis at baseline a 0.94 (0.89, 1.00) Cotrimoxizole prophylaxis at baseline c 0.88 (0.80, 0.97)

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Role of “Silent Transfers”

5,904 attrition cases from iSanté matched to records in the HIV/AIDS Surveillance System (HASS) database

“Silent transfer” among attrition cases: Overall: 418 of 5,904 (7.1%) Option B+: 143 of 1,766 (8.1%) Non-pregnant women: 151 of 2,440 (6.2%) Men: 124 of 2,043 (6.1%)

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When Option B+ Cases Drop Out of Care Relative to Delivery

prenatal within 1 mo (+/-)

1-2 mo after 2-3 mo after 3-6 mo after >6 mo after0

50

100

150

200

250

0%

10%

20%

30%

40%

50%

60%

Count Percent

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Conclusion Risk of attrition up to 63% higher for Option B+

group compared with non-pregnant of similar characteristics

Modifiable risk factors: Initiating ART immediately after enrollment in HIV care Initiating ART late in pregnancy

Key protective factors: Pre-ART counseling Living in the catchment area of the health facility OI prophylaxis

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Limitations Routine data source, varying quality across sites

Potential misclassification of Option B+ Difficulty of assigning dates of pregnancy, lack of

breastfeeding data

Modest overestimate of attrition due to “silent transfers” and individual-level data on transfers not available for this analysis

Observational data, so findings may reflect selection bias and confounding, or other types of bias

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Recommendations Effort to attract pregnant women into care early in

pregnancy

Ensure access to appropriate social support

Intense adherence counseling Importance of staying on medication Benefit for patient in addition to infant and partners Assessing risk of attrition and barriers to adherence

Proactivity in the retention strategy

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AcknowledgementsMinistère de la Santé Publique et de la Population

US Centers for Disease Control and Prevention Paul Rashad Young, Barbara Marston, Patrice Joseph, Valerie Pelletier,

Reginald Jean Louis

University of Washington Department of Global HealthMartine Myrtil

University of Washington Center for AIDS Research Biometrics CoreKrista Yuhas

Implementing PartnersMSPP-UGP, GHESKIO, PIH, CMMB, IHV, UM, I-TECH, CDS