ART attrition across health facilities implementing Option B+ in Haiti

Thesis (Master's)--University of Washington, 2016-08

Background: In 2015, the first study on retention that included pregnant women in Haiti showed that Option B+ clients had 1.5 fold excess risk of attrition at 12 months of ART initiation compared to other ART patients. Describing the variation of ART retention across Haiti and exploring health facility-level factors related to high attrition are important in order to improve implementation of the Option B+ strategy in Haiti. Methods: This retrospective cohort study is based on information collected on iSanté, the largest electronic medical record in the country. I described the variability of ART retention across health facilities among pregnant and lactating women enrolled on ART from October 2012 to December 2013. I assessed for differences in ART retention between Option B+ clients and other ART patients and described the variability of this comparison across health facilities. Finally, I used generalized estimating equations to assess the association between health facility factors and risk of attrition, after controlling for individual-level risk factors. Results: During the study period, 1,989 Option B+ clients were enrolled on ART in 45 health facilities. The percentage of attrition varied from 9% to 71% across the facilities. More than 40% of the health facilities had a statistically significant excess risk of attrition among Option B+ clients compared to other adults enrolled on treatment in those facilities. After adjusting for both individual-level and facility-level risk factors, the largest health facilities (those that enrolled more than 55 patients) had 38% higher risk of attrition (RR 1.38, 95% CI 1.08-1.77, p-value=0.009) compared with the smallest facilities. Compared to public health facilities, private institutions had 18% less risk of attrition (RR 0.82, 95% CI 0.70-0.96, p-value=0.020). Health facilities located in the West department and the south region had lower risk of attrition than those located in the north region. Conclusion: The study demonstrated high facility-level variability and significant risk factors associated with high attrition among Option B+ clients. Moreover, as attrition was higher in Option B+ clients than other adults on ART across a majority of health facilities, retention on treatment is a major concern for PMTCT programs in Haiti. The implementation of the Option B+ strategy must be re-evaluated throughout the country in order to effectively eliminate mother-to-child HIV transmission and prevent the emergence of drug resistance.