Determinants of Mortality and Loss to Follow-Up among Adults Enrolled in HIV Care Services in Rwanda

Background: Antiretroviral therapy (ART) improves morbidity and mortality in patients with HIV, however high rates of loss to follow-up (LTF) and mortality have been documented in HIV care and treatment programs. Methods: We analyzed routinely-collected data on HIV-infected patients >= 15 years enrolled at 41 healthcare facilities in Rwanda from 2005 to 2010. LTF was defined as not attending clinic in the last 12 months for pre-ART patients and 6 months for ART patients. For the pre-ART period, sub-distribution hazards models were constructed to estimate LTF and death to account for competing risks. Kaplan-Meier (KM) and Cox proportional hazards models were used for patients on ART. Results: 31,033 ART-naive adults were included, 64% were female and 75% were WHO stage I or II at enrollment. 17,569 (56%) patients initiated ART. Pre-ART competing risk estimates of LTF at 2 years was 11.2% (95% CI, 10.9-11.6%) and 2.9% for death (95% CI 2.7-3.1%). Among pre-ART patients, male gender was associated with higher LTF (adjusted sub-hazard ratio (aSHR) 1.3, 95% CI 1.1-1.5) and death (aSHR 1.7, 95% CI 1.4-2.1). Low CD4 count (CD4,<100 vs. $ 350 aSHR 0.2, 95% CI 0.1-0.3) and higher WHO stage (WHO stage IV vs. stage I aSHR 0.4, 95% CI 0.2-0.6) were protective against pre-ART LTF. KM estimates for LTF and death in ART patients at 2 years were 4.4% (95% CI 4.4-4.5%) and 6.3% (95% CI 6.2-6.4%). In patients on ART, male gender was associated with LTF (adjusted hazard ratio (AHR) 1.4, 95% CI 1.2-1.7) and death (AHR1.3, 95% CI 1.2-1.5). Mortality was higher for ART patients >= 40 years and in those with lower CD4 count at ART initiation. Conclusions: Low rates of LTF and death were founds among pre-ART and ART patients in Rwanda but greater efforts are needed to retain patients in care prior to ART initiation, particularly among those who are healthy at enrollment.