Abstract
Purpose of Review
Retention measures in antiretroviral therapy programs are important, but there is wide variation in their calculation and relatively little systematic discussion of their relative advantages and limitations.
Recent Findings
We extracted and compared distinctive approaches to quantifying retention through a systematic search in PubMed and undertook a purposive selection of articles published in peer-reviewed journals and policy documents. We also created a simulated dataset and code examples to help illustrate observations about each metric. Among identified retention approaches, were metrics based only on proportions of either visits alone (constancy) or visits and appointments (visit adherence), which are simple and most accessible in settings using only paper records and registries. However, they are generally appropriate for patients with similar potential follow-up times and do not incorporate all available information. Survival analysis techniques such as Kaplan-Meier and competing risk approaches offer more nuanced retention measures over time, and can combine individuals with different potential follow-up times into one summary, but have trouble capturing the dynamic nature of retention. Newer approaches, including multi-state models and trajectory analyses, enable more nuanced examination of retention but are analytically difficult to carry out and do not yield one single summary.
Summary
Simple analytical approaches are more widely useable but may miss important gaps in retention. Use of complex analytical approaches might be limited by requirements of electronically available data, data management requirements, and analytic capacity. Overall, efforts to evaluate retention may benefit from informed selection of one or more approaches to meet a range of objectives.
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References
Papers of particular interest, published recently, have been highlighted as:•• Of major Importance
Li JZ, Paredes R, Ribaudo HJ, Svarovskaia ES, Metzner KJ, Kozal MJ, et al. Minority HIV-1 drug resistance mutations and the risk of NNRTI-based antiretroviral treatment failure: a systematic review and pooled analysis. JAMA. 2011;305(13):1327–35.
Holmes CB, Sikazwe I, Sikombe K, Eshun-Wilson I, Czaicki N, Beres LK, et al. Estimated mortality on HIV treatment among active patients and patients lost to follow-up in 4 provinces of Zambia: findings from a multistage sampling-based survey. PLoS Med. 2018;15(1):e1002489.
Mugavero MJ, Westfall AO, Cole SR, Geng EH, Crane HM, Kitahata MM, et al. Centers for AIDS Research Network of Integrated Clinical Systems (CNICS). Beyond core indicators of retention in HIV care: missed clinic visits are independently associated with all-cause mortality. Clin Infect Dis. 2014;59(10):1471–9.
Yehia BR, French B, Fleishman JA, Metlay JP, Berry SA, Korthuis PT, et al. Retention in care is more strongly associated with viral suppression in HIV-infected patients with lower versus higher CD4 counts. J Acquir Immune Defic Syndr. 2014;65(3):333–9.
Mugavero MJ, Westfall AO, Zinski A, Davila J, Drainoni ML, Gardner LI, et al. Retention in care (RIC) study group. Measuring retention in HIV care: the elusive gold standard. J Acquir Immune Defic Syndr. 2012;61(5):574–80.
Mugavero MJ, Amico KR, Westfall AO, Crane HM, Zinski A, Willig JH, et al. Early retention in HIV care and viral load suppression: implications for a test and treat approach to HIV prevention. J Acquir Immune Defic Syndr. 2012;59(1):86–93.
Palma A, Lounsbury DW, Messer L, Quinlivan EB. Patterns of HIV service use and HIV viral suppression among patients treated in an academic infectious diseases clinic in North Carolina. AIDS Behav. 2015;19(4):694–703.
Joint United Nations Programme on HIV/AIDS (UNAIDS). Ending AIDS: progress towards the 90–90-90 targets. Geneva: WHO; 2017.
The US President's emergency plan for AIDS relief (PEPFAR): 5 year strategy. 2008. https://2009-2017.pepfar.gov/documents/organization/133035.pdf. Accessed 28 Feb 2018.
The US President's emergency plan for AIDS relief (PEPFAR). Accelerating Children's HIV/AIDS Treatment. 2017. https://www.pepfar.gov/documents/organization/270700.pdf. Accessed 28 Feb 2018.
The World Health Organization (WHO). Retention in HIV programmes: defining the challenges and identifying the solutions. Geneva: WHO; 2011.
Yehia BR, Fleishman JA, Metlay JP, Korthuis PT, Agwu AL, Berry SA, et al. Comparing different measures of retention in outpatient HIV care. AIDS. 2012;26(9):1131–9.
Rollins NC, Becquet R, Orne-Gliemann J, Phiri S, Hayashi C, Baller A, et al. Defining and analyzing retention-in-care among pregnant and breastfeeding HIV-infected women: unpacking the data to interpret and improve PMTCT outcomes. J Acquir Immune Defic Syndr. 2014;67(2):S150–6.
Giordano TP, Gifford AL, White AC Jr, Suarez-Almazor ME, Rabeneck L, Hartman C, et al. Retention in care: a challenge to survival with HIV infection. Clin Infect Dis. 2007;44(11):1493–9.
Horstmann E, Brown J, Islam F, Buck J, Agins BD. Retaining HIV-infected patients in care: where are we? Where do we go from here? Clin Infect Dis. 2010;50(5):752–61.
Hickey MD, Salmen CR, Omollo D, Mattah B, Fiorella KJ, Geng EH, et al. Implementation and operational research: pulling the network together: Quasiexperimental Trial of a Patient-Defined Support Network Intervention for Promoting Engagement in HIV Care and Medication Adherence on Mfangano Island, Kenya. J Acquir Immune Defic Syndr. 2015;69(4):e127–34.
World Health Organization (WHO). Consolidated strategic information guidelines for HIV in the health sector. Geneva: WHO; 2015.
Hallett TB, Eaton JW. A side door into care cascade for HIV-infected patients? J Acquir Immune Defic Syndr. 2013;63(2):S228–32.
Coviello V, Boggess M. Cumulative incidence estimation in the presence of competing risks. Stata J. 2004;4(2):103–12.
Satagopan JM, Ben-Porat L, Berwick M, Robson M, Kutler D, Auerbach AD. A note on competing risks in survival data analysis. Br J Cancer. 2004;91(7):1229–35.
•• Gillis J, Loutfy M, Bayoumi AM, Antoniou T, Burchell AN, Walmsley S, et al. A multi-state model examining patterns of transitioning among states of engagement in care in HIV-positive individuals initiating combination antiretroviral therapy. J Acquir Immune Defic Syndr. 2016;73(5):531–9. A very good paper which shows how multi-state models (unlike common measures of engagement in care or retention) can account for patterns in transitions of antiretroviral therapy outcomes that may arise due to infrequent patient follow-up occurring either intentionally among patients with sustained virologic suppression or unintentionally among patients with poor clinical outcomes.
•• Agaba PA, Genberg BL, Sagay AS, Agbaji OO, Meloni ST, Dadem NY, et al. Retention in differentiated care: multiple measures analysis for a decentralized HIV care and treatment program in North Central Nigeria. J AIDS Clin Res. 2018;9:756. https://doi.org/10.4172/2155-6113.1000756. This is a well written paper which shows how antiretorival therapy (ART) retention estimates produced by incorporating multiple retention measures can result in substantial variation, thus confirming the influence of different measurement strategies on the results of ART retention research.
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Takarinda, K.C., Wallenta, J., Scheve, A. et al. Measuring Retention in Antiretroviral Therapy Programs—a Synthetic Review of Different Approaches for Field Use in Low- and Middle-Income Settings. Curr Trop Med Rep 5, 179–185 (2018). https://doi.org/10.1007/s40475-018-0153-7
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DOI: https://doi.org/10.1007/s40475-018-0153-7