Background: The success of antiretroviral therapy in resource-scarce settings is an illustration that complex healthcare\ninterventions can be successfully delivered even in fragile health systems. Documenting the success factors in\nthe scale-up of HIV care and treatment in resource constrained settings will enable health systems to prepare for\nchanging population health needs. This study describes changing demographic and clinical characteristics of adult\npre-ART cohorts, and identifies predictors of pre-ART attrition at a large urban HIV clinic in Nairobi, Kenya.\nMethods: We conducted a retrospective cohort analysis of data on HIV infected adults (ââ?°Â¥15 years) enrolling in\npre-ART care between January 2004 and September 2015. Attrition (loss to program) was defined as those who died\nor were lost to follow-up (having no contact with the facility for at least 6 months). We used Kaplan-Meier survival\nanalysis to determine time to event for the different modes of transition, and Cox proportional hazards models to\ndetermine predictors of pre-ART attrition.\nResults: Over the 12 years of observation, there were increases in the proportions of young people (age 15 to\n24 years); and patients presenting with early disease (by WHO clinical stage and higher median CD4 cell counts),\np = 0.0001 for trend. Independent predictors of attrition included: aHR (95% CI): male gender 1.98 (1.69ââ?¬â??2.33),\np = 0.0001; age 20ââ?¬â??24 years 1.80 (1.37ââ?¬â??2.37), p = 0.0001), or 25ââ?¬â??34 years 1.22 (1.01ââ?¬â??1.47), p = 0.0364; marital status\nsingle 1.55 (1.29ââ?¬â??1.86), p = 0.0001) or divorced 1.41(1.02ââ?¬â??1.95), p = 0.0370; urban residency 1.83 (1.40ââ?¬â??2.38),\np = 0.0001; CD4 count of 0ââ?¬â??100 cells/Ã?¼l 1.63 (1.003ââ?¬â??2.658), p = 0.0486 or CD4 count >500 cells/Ã?¼l 2.14(1.46ââ?¬â??3.14),\np = 0.0001.\nConclusions: In order to optimize the impact of HIV prevention, care and treatment in resource scarce settings,\nthere is an urgent need to implement prevention and treatment interventions targeting young people and patients\nentering care with severe immunosuppression (CD4 cell counts <100 cells/Ã?¼l). Additionally, care and treatment programmes\nshould strengthen inter-facility referrals and linkages to improve care coordination and prevent leakages in\nthe HIV care continuum.
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