Factors associated with poor outcomes among people living with HIV started on anti-retroviral therapy before and after implementation of “test and treat” program in Coastal Kenya

Abstract

Objectives To determine the factors associated with poor outcomes among people living with HIV (PLHIV) started on anti- retroviral therapy before and after implementation of “Test and treat” program in 18 facilities in Coastal Kenya. Methods A retrospective cohort study design was used to study PLHIV aged > 15 years and started on ART in the periods of April to August 2016, and April to August 2017, then followed up for 24 months. Primary outcome was retention defined as being alive and on ARVs after 24 months. Death and loss to follow-up were considered as poor outcomes. Kaplan–Meier survival methods were used to describe time to primary outcome. Cox proportional regression analysis was used to determine factors associated with poor outcomes. Results 86 patients (470 before test and treat, and 316 after test and treat cohorts) were enrolled. Overall, the median [IQR] age was 39.3 [32.5–47.5] years and 539 (69%) were female. After 24 months, retention rates for the before (68%) and after (64%) test and start groups were similar (absolute difference: -4.0%, 95%CI: -11-3.1, P = 0.27). There were 240(31%, 95%CI 27 to 34%) PLHIV with poor outcomes, 102 (32%) and 138 (29%) occurred among the test and treat group, and delayed treatment patients respectively. In multivariable regression model, test and treat had no significant effect on risk of poor outcomes (aHR = 1.17, 95%CI 0.89–1.54). Increasing age (aHR = 0.98, 95%CI 0.97–0.99), formal employment (aHR = 0.42, 95%CI 0.23–0.76) and not being employed (aHR = 0.53, 95%CI 0.34–0.81) were negatively associated with poor outcomes. The risk of poor outcomes was higher among males compared to female patients (aHR = 1.37, 95%CI 1.03–1.82) and among divorced/separated patients compared to the married (aHR = 1.44, 95%CI 1.04–1.99). Conclusion Retention patterns for the “test and treat” cohort were comparable to those who started ART before “test and treat”. Patients who are males, young, divorced/separated, with poor socio-economic status had higher risks for poor clinical outcomes. Interventions targeting PLHIV who are young, male and economically disadvantaged provide an opportunity to improve the long-term outcomes.