Retention and predictors of attrition among patients who started antiretroviral therapy in Zimbabwe’s national antiretroviral therapy programme between 2012 and 2015

Autoři: Richard Makurumidze aff001;  Tsitsi Mutasa-Apollo aff004;  Tom Decroo aff002;  Regis C. Choto aff004;  Kudakwashe C. Takarinda aff004;  Janet Dzangare aff004;  Lutgarde Lynen aff002;  Wim Van Damme aff002;  James Hakim aff001;  Tapuwa Magure aff007;  Owen Mugurungi aff004;  Simbarashe Rusakaniko aff001
Působiště autorů: College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe aff001;  Institute of Tropical Medicine, Antwerp, Belgium aff002;  Gerontology, Faculty of Medicine & Pharmacy, Free University of Brussels (VUB), Brussels, Belgium aff003;  AIDS & TB Unit, Ministry of Health & Child Care, Harare, Zimbabwe aff004;  Research Foundation of Flanders, Brussels, Belgium aff005;  International Union Against Tuberculosis and Lung Disease, Paris, France aff006;  National AIDS Council, Harare, Zimbabwe aff007
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article
doi: 10.1371/journal.pone.0222309



The last evaluation to assess outcomes for patients receiving antiretroviral therapy (ART) through the Zimbabwe public sector was conducted in 2011, covering the 2007–2010 cohorts. The reported retention at 6, 12, 24 and 36 months were 90.7%, 78.1%, 68.8% and 64.4%, respectively. We report findings of a follow-up evaluation for the 2012–2015 cohorts to assess the implementation and impact of recommendations from this prior evaluation.


A nationwide retrospective study was conducted in 2016. Multi-stage proportional sampling was used to select health facilities and study participants records. The data extracted from patient manual records included demographic, baseline clinical characteristics and patient outcomes (active on treatment, died, transferred out, stopped ART and lost to follow-up (LTFU)) at 6, 12, 24 and 36 months. The data were analysed using Stata/IC 14.2. Retention was estimated using survival analysis. The predictors associated with attrition were determined using a multivariate Cox regression model.


A total of 3,810 participants were recruited in the study. The median age in years was 35 (IQR: 28–42). Overall, retention increased to 92.4% (p-value = 0.060), 86.5% (p-value<0.001), 79.2% (p-value<0.001) and 74.4% (p-value<0.001) at 6, 12, 24 and 36 months respectively. LTFU accounted for 98% of attrition. Being an adolescent or a young adult (15–24 years) (vs adult;1.41; 95% CI:1.14–1.74), children (<15years) (vs adults; aHR 0.64; 95% CI:0.46–0.91), receiving care at primary health care facility (vs central and provincial facility; aHR 1.23; 95% CI:1.01–1.49), having initiated ART between 2014–2015 (vs 2012–2013; aHR1.45; 95%CI:1.24–1.69), having WHO Stage IV (vs Stage I-III; aHR2.06; 95%CI:1.51–2.81) and impaired functional status (vs normal status; aHR1.25; 95%CI:1.04–1.49) predicted attrition.


The overall retention was higher in comparison to the previous 2007–2010 evaluation. Further studies to understand why attrition was found to be higher at primary health care facilities are warranted. Implementation of strategies for managing patients with advanced HIV disease, differentiated care for adolescents and young adults and tracking of LTFU clients should be prioritised to further improve retention.

Klíčová slova:

Adolescents – Antiretroviral therapy – Health care facilities – HIV – HIV diagnosis and management – Pregnancy – Young adults – Zimbabwe


1. The Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS Data. 2019.

2. The Joint United Nations Programme on AIDS (UNAIDS). Global HIV & AIDS statistics—2019 fact sheet [Internet]. 2019.

3. Levi J, Raymond A, Pozniak A, Vernazza P, Kohler P, Hill A. Can the UNAIDS 90-90-90 target be achieved? A systematic analysis of national HIV treatment cascades. BMJ Glob Heal. 2016;1: e000010. doi: 10.1136/bmjgh-2015-000010 28588933

4. Altice F, Evuarherhe O, Shina S, Carter G, Beaubrun AC. Adherence to HIV treatment regimens: systematic literature review and meta-analysis. Patient Prefer Adherence. 2019;Volume 13: 475–490. doi: 10.2147/PPA.S192735 31040651

5. Bulsara SM, Wainberg ML, Newton-John TRO. Predictors of Adult Retention in HIV Care: A Systematic Review. AIDS Behav. 2018;22: 752–764. doi: 10.1007/s10461-016-1644-y 27990582

6. Ugoji C, Okere N, Dakum P, Ake-uzoigwe R, Igboelina D, Ndembi N, et al. Correlates of Patient Retention in HIV Care and Treatment Programs in Nigeria. Curr HIV Res. 2015; 300–307. doi: 10.2174/1570162x13999150317155348 25777516

7. Janssen S, Wieten RW, Stolp S, Cremers AL, Rossatanga EG, Klipstein-Grobusch K, et al. Factors Associated with Retention to Care in an HIV Clinic in Gabon, Central Africa. Selvey LA, editor. PLoS One. 2015;10: e0140746. doi: 10.1371/journal.pone.0140746 26473965

8. Charurat M, Oyegunle M, Benjamin R, Habib A, Eze E, Ele P, et al. Patient Retention and Adherence to Antiretrovirals in a Large Antiretroviral Therapy Program in Nigeria: A Longitudinal Analysis for Risk Factors. Myer L, editor. PLoS One. 2010;5: e10584. doi: 10.1371/journal.pone.0010584 20485670

9. Stafford KA, Odafe SF, Lo J, Ibrahim R, Ehoche A, Niyang M, et al. Evaluation of the clinical outcomes of the Test and Treat strategy to implement Treat All in Nigeria: Results from the Nigeria Multi-Center ART Study. Torpey K, editor. PLoS One. 2019;14: e0218555. doi: 10.1371/journal.pone.0218555 31291273

10. Arnesen R, Moll AP, Shenoi S V. Predictors of loss to follow-up among patients on ART at a rural hospital in KwaZulu-Natal, South Africa. Perno CF, editor. PLoS One. 2017;12: e0177168. doi: 10.1371/journal.pone.0177168 28542309

11. Tiruneh YM, Galárraga O, Genberg B, Wilson IB. Retention in Care among HIV-Infected Adults in Ethiopia, 2005–2011: A Mixed-Methods Study. Thorne C, editor. PLoS One. 2016;11: e0156619. doi: 10.1371/journal.pone.0156619 27272890

12. Shamu T, Chimbetete C, Shawarira–Bote S, Mudzviti T, Luthy R. Outcomes of an HIV cohort after a decade of comprehensive care at Newlands Clinic in Harare, Zimbabwe: TENART cohort. Barnabas R V., editor. PLoS One. 2017;12: e0186726. doi: 10.1371/journal.pone.0186726 29065149

13. Auld AF, Ekra KA, Shiraishi RW, Tuho MZ, Kouakou JS, Mohamed F, et al. Temporal Trends in Treatment Outcomes for HIV-1 and HIV-2-Infected Adults Enrolled in Côte d’Ivoire’s National Antiretroviral Therapy Program. Apetrei C, editor. PLoS One. 2014;9: e98183. doi: 10.1371/journal.pone.0098183 24866468

14. Auld AF, Alfredo C, Macassa E, Jobarteh K, Shiraishi RW, Rivadeneira ED, et al. Temporal Trends in Patient Characteristics and Outcomes Among Children Enrolled in Mozambique’s National Antiretroviral Therapy Program. Pediatr Infect Dis J. 2015;34: e191–e199. doi: 10.1097/INF.0000000000000741 25955836

15. Dalhatu I, Onotu D, Odafe S, Abiri O, Debem H, Agolory S, et al. Outcomes of Nigeria’s HIV/AIDS Treatment Program for Patients Initiated on Antiretroviral Treatment between 2004–2012. Anglewicz P, editor. PLoS One. 2016;11: e0165528. doi: 10.1371/journal.pone.0165528 27829033

16. Nabukeera-Barungi N, Elyanu P, Asire B, Katureebe C, Lukabwe I, Namusoke E, et al. Adherence to antiretroviral therapy and retention in care for adolescents living with HIV from 10 districts in Uganda. BMC Infect Dis. 2015;15: 520. doi: 10.1186/s12879-015-1265-5 26573923

17. Mutasa-Apollo T, Shiraishi RW, Takarinda KC, Dzangare J, Mugurungi O, Murungu J, et al. Patient Retention, Clinical Outcomes and Attrition-Associated Factors of HIV-Infected Patients Enrolled in Zimbabwe’s National Antiretroviral Therapy Programme, 2007–2010. Fox MP, editor. PLoS One. 2014;9: e86305. doi: 10.1371/journal.pone.0086305 24489714

18. Ministry of Health and Child Care (MoHCC). Zimbabwe ART Annual Report. 2018.

19. Tlhajoane M, Masoka T, Mpandaguta E, Rhead R, Church K, Wringe A, et al. A longitudinal review of national HIV policy and progress made in health facility implementation in Eastern Zimbabwe. Heal Res Policy Syst. 2018;16: 92. doi: 10.1186/s12961-018-0358-1 30241489

20. Zimbabwe National Statistics Agency (ZIMSTAT). Zimbabwe National Census Report. Harare, Zimbabwe; 2012.

21. ICAP at Columbia University. Zimbabwe Population Based HIV Impact Assessment Preliminary Report. 2016.

22. National AIDS Council of Zimbabwe (NAC). Zimbabwe National HIV and AIDS Strategic Plan (ZNASP II) 2011–2015. 2011;

23. Ministry of Health and Child Care (MoHCC). Zimbabwe ART Annual Report. 2015.

24. Ministry of Health and Child Care(MoHCC). An Evaluation of the Use of Point of CarePIMA CD4 Cell Count Machines for HIV Positive Women and their Families in Maternal Newborn And Child Health (MNCH) Settings in Seven Districts in Zimbabwe. 2012;

25. StataCorp. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP.; 2015.

26. Murray KR, Dulli LS, Ridgeway K, Dal Santo L, Darrow de Mora D, Olsen P, et al. Improving retention in HIV care among adolescents and adults in low- and middle-income countries: A systematic review of the literature. Sued O, editor. PLoS One. 2017;12: e0184879. doi: 10.1371/journal.pone.0184879 28961253

27. Fox MP, Rosen S. Systematic review of retention of pediatric patients on HIV treatment in low and middle-income countries 2008–2013. AIDS. 2015;29: 493–502. doi: 10.1097/QAD.0000000000000559 25565496

28. Fox MP, Rosen S. Retention of Adult Patients on Antiretroviral Therapy in Low- and Middle-Income Countries. JAIDS J Acquir Immune Defic Syndr. 2015;69: 98–108. doi: 10.1097/QAI.0000000000000553 25942461

29. Kredo T, Ford N, Adeniyi FB, Garner P. Decentralising HIV treatment in lower- and middle-income countries. Cochrane Database Syst Rev. 2013;132: 383. doi: 10.1002/14651858.CD009987.pub2 23807693

30. Ministry of Health and Child Care (MoHCC). ART Outcomes of People Living with HIV Enrolled in the National ART Programme, Zimbabwe, October 2012 –January 2015—Technical Report. 2016.

31. Decroo T, Panunzi I, das Dores C, Maldonado F, Biot M, Ford N, et al. Lessons learned during down referral of antiretroviral treatment in Tete, Mozambique. J Int AIDS Soc. 2009;12: 6. doi: 10.1186/1758-2652-12-6 19419543

32. Zürcher K, Mooser A, Anderegg N, Tymejczyk O, Couvillon MJ, Nash D, et al. Outcomes of HIV-positive patients lost to follow-up in African treatment programmes. Trop Med Int Heal. 2017;22: 375–387. doi: 10.1111/tmi.12843 28102610

33. Wilkinson LS, Skordis-Worrall J, Ajose O, Ford N. Self-transfer and mortality amongst adults lost to follow-up in ART programmes in low- and middle-income countries: systematic review and meta-analysis. Trop Med Int Heal. 2015;20: 365–379. doi: 10.1111/tmi.12434 25418366

34. Cornell M, Lessells R, Fox MP, Garone DB, Giddy J, Fenner L, et al. Mortality Among Adults Transferred and Lost to Follow-up From Antiretroviral Therapy Programmes in South Africa. JAIDS J Acquir Immune Defic Syndr. 2014;67: e67–e75. doi: 10.1097/QAI.0000000000000269 24977471

35. United States of America President’s Emergency Plan for AIDS Relief (PEPFAR). Loss to Follow-Up Tool: Tracking and Tracing HIV Patients [Internet]. PEPFAR Beta Solutions; 2019.

36. Egger M. Electronic medical record systems, data quality and loss to follow-up: survey of antiretroviral therapy programmes in resource-limited settings. Bull World Health Organ. 2008;86: 939–947. doi: 10.2471/BLT.07.049908 19142294

37. Ministry of Health and Child Care Zimbabwe (MoHCC). Operations and Service delivery manual for the Prevention, Care and Treatment of HIV in Zimbabwe. Harare. 2015;

38. Mills EJ, Beyrer C, Birungi J, Dybul MR. Engaging Men in Prevention and Care for HIV/AIDS in Africa. PLoS Med. 2012;9: e1001167. doi: 10.1371/journal.pmed.1001167 22346735

39. Coker M, Etiebet M-A, Chang H, Awwal G, Jumare J, Musa B, et al. Socio-Demographic and Adherence Factors Associated with Viral Load Suppression in HIV-Infected Adults Initiating Therapy in Northern Nigeria: A Randomized Controlled Trial of a Peer Support Intervention. Curr HIV Res. 2015;13: 279–285. doi: 10.2174/1570162x13666150407143838 25845393

40. Koole O, Tsui S, Wabwire-Mangen F, Kwesigabo G, Menten J, Mulenga M, et al. Retention and risk factors for attrition among adults in antiretroviral treatment programmes in Tanzania, Uganda and Zambia. Trop Med Int Heal. 2014;19: 1397–1410. doi: 10.1111/tmi.12386 25227621

41. Brown LB, Getahun M, Ayieko J, Kwarisiima D, Owaraganise A, Atukunda M, et al. Factors predictive of successful retention in care among HIV-infected men in a universal test-and-treat setting in Uganda and Kenya: A mixed methods analysis. Madiba S, editor. PLoS One. 2019;14: e0210126. doi: 10.1371/journal.pone.0210126 30673744

42. Busza J, Dauya E, Bandason T, Mujuru H, Ferrand RA. “I don’t want financial support but verbal support.” How do caregivers manage children’s access to and retention in HIV care in urban Zimbabwe? J Int AIDS Soc. 2014;17: 18839. doi: 10.7448/IAS.17.1.18839 24815595

43. Phelps BR, Ahmed S, Amzel A, Diallo MO, Jacobs T, Kellerman SE, et al. Linkage, initiation and retention of children in the antiretroviral therapy cascade. AIDS. 2013;27: S207–S213. doi: 10.1097/QAD.0000000000000095 24361630

44. Abuogi LL, Smith C, McFarland EJ. Retention of HIV-Infected Children in the First 12 Months of Anti-Retroviral Therapy and Predictors of Attrition in Resource Limited Settings: A Systematic Review. Okulicz JF, editor. PLoS One. 2016;11: e0156506. doi: 10.1371/journal.pone.0156506 27280404

45. Ferrand RA, Simms V, Dauya E, Bandason T, Mchugh G, Mujuru H, et al. The effect of community-based support for caregivers on the risk of virological failure in children and adolescents with HIV in Harare, Zimbabwe (ZENITH): an open-label, randomised controlled trial. Lancet Child Adolesc Heal. 2017;1: 175–183. doi: 10.1016/S2352-4642(17)30051-2 29104904

46. Shroufi A, Mafara E, Saint-Sauveur JF, Taziwa F, Viñoles MC. Mother to Mother (M2M) Peer Support for Women in Prevention of Mother to Child Transmission (PMTCT) Programmes: A Qualitative Study. Sluis-Cremer N, editor. PLoS One. 2013;8: e64717. doi: 10.1371/journal.pone.0064717 23755137

47. Ministry of Health and Child Care (MoHCC). National Child Survival Strategy for Zimbabwe 2010–2015. 2010.

48. Woelk G, Lin Y, Zieman B, Machekano R, Chadambuka A, Muchuchuti C, et al. Enhancing retention in care for HIV-positive mothers and their infants by improving facility tracking and community health worker tracing in Zimbabwe. 2016;

49. Evans D, Menezes C, Mahomed K, Macdonald P, Untiedt S, Levin L, et al. Treatment Outcomes of HIV-Infected Adolescents Attending Public-Sector HIV Clinics Across Gauteng and Mpumalanga, South Africa. AIDS Res Hum Retroviruses. 2013;29: 892–900. doi: 10.1089/AID.2012.0215 23373540

50. Ferrand RA. Attrition from HIV care among adolescents and adults in a low-income setting. Public Heal Action. 2016;6: 53–53. doi: 10.5588/pha.16.0035 27358795

51. Matyanga CMJ, Takarinda KC, Owiti P, Mutasa-Apollo T, Mugurungi O, Buruwe L, et al. Outcomes of antiretroviral therapy among younger versus older adolescents and adults in an urban clinic, Zimbabwe. Public Heal Action. 2016;6: 97–104. doi: 10.5588/pha.15.0077 27358802

52. Alhaj M, Amberbir A, Singogo E, Banda V, van Lettow M, Matengeni A, et al. Retention on antiretroviral therapy during Universal Test and Treat implementation in Zomba district, Malawi: a retrospective cohort study. J Int AIDS Soc. 2019;22: e25239. doi: 10.1002/jia2.25239 30734510

53. Zanoni BC, Sibaya T, Cairns C, Haberer JE. Barriers to Retention in Care are Overcome by Adolescent-Friendly Services for Adolescents Living with HIV in South Africa: A Qualitative Analysis. AIDS Behav. 2019;23: 957–965. doi: 10.1007/s10461-018-2352-6 30535836

54. Murray KR, Dulli LS, Ridgeway K, Dal Santo L, Darrow de Mora D, Olsen P, et al. Improving retention in HIV care among adolescents and adults in low- and middle-income countries: A systematic review of the literature. Sued O, editor. PLoS One. 2017;12: e0184879. doi: 10.1371/journal.pone.0184879 28961253

55. Willis N, Milanzi A, Mawodzeke M, Dziwa C, Armstrong A, Yekeye I, et al. Effectiveness of community adolescent treatment supporters (CATS) interventions in improving linkage and retention in care, adherence to ART and psychosocial well-being: a randomised trial among adolescents living with HIV in rural Zimbabwe. BMC Public Health. 2019;19: 117. doi: 10.1186/s12889-019-6447-4 30691425

56. Harries AD, Zachariah R, Lawn SD, Rosen S. Strategies to improve patient retention on antiretroviral therapy in sub-Saharan Africa. Trop Med Int Heal. 2010;15: 70–75. doi: 10.1111/j.1365-3156.2010.02506.x 20586963

57. Lawn SD, Harries AD, Wood R. Strategies to reduce early morbidity and mortality in adults receiving antiretroviral therapy in resource-limited settings. Curr Opin HIV AIDS. 2010;5: 18–26. doi: 10.1097/COH.0b013e328333850f 20046144

58. Marazzi MC, Liotta G, Germano P, Guidotti G, Altan AD, Ceffa S, et al. Excessive Early Mortality in the First Year of Treatment in HIV Type 1-Infected Patients Initiating Antiretroviral Therapy in Resource-Limited Settings. AIDS Res Hum Retroviruses. 2008;24: 555–560. doi: 10.1089/aid.2007.0217 18366314

59. Takarinda KC, Choto RC, Mutasa-Apollo T, Chakanyuka-Musanhu C, Timire C, Harries AD. Scaling up isoniazid preventive therapy in Zimbabwe: has operational research influenced policy and practice? Public Heal Action. 2018;8: 218–224. doi: 10.5588/pha.18.0051 30775283

60. Gonese G, Bochner AF, Makurumidze R, Apollo T, Makunike B, Meacham E, et al. Challenges in Managing Cryptococcal Meningitis in Resource-Limited Settings: A Baseline Assessment. Abstr Accept Poster Present Int AIDS Conf 23–26 July 2017. 2017;

61. Mfinanga S, Chanda D, Kivuyo SL, Guinness L, Bottomley C, Simms V, et al. Cryptococcal meningitis screening and community-based early adherence support in people with advanced HIV infection starting antiretroviral therapy in Tanzania and Zambia: An open-label, randomised controlled trial. Lancet. 2015;385: 2173–2182. doi: 10.1016/S0140-6736(15)60164-7 25765698

62. Hakim J, Musiime V, Szubert AJ, Mallewa J, Siika A, Agutu C, et al. Enhanced Prophylaxis plus Antiretroviral Therapy for Advanced HIV Infection in Africa. N Engl J Med. 2017;377: 233–245. doi: 10.1056/NEJMoa1615822 28723333

63. Benzekri NA, Sambou JF, Ndong S, Tamba IT, Faye D, Diallo MB, et al. Prevalence, predictors, and management of advanced HIV disease among individuals initiating ART in Senegal, West Africa. BMC Infect Dis. 2019;19: 261. doi: 10.1186/s12879-019-3826-5 30876400

64. Bigna JJR, Plottel CS, Koulla-shiro S. Challenges in initiating antiretroviral therapy for all HIV-infected people regardless of CD4 cell count. Infect Dis Poverty. 2016; 1–6.

65. Jones MP. Indicator and Stratification Methods for Missing Explanatory Variables in Multiple Linear Regression. J Am Stat Assoc. 1996;91: 222–230. doi: 10.1080/01621459.1996.10476680

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