ethiopia is one of the few countries with the highest number of people living with hiv / aids globally . according to ethiopian demographic and health survey ( edhs ) 2011 , federal ministry of health ( fmoh ) and hiv / aids prevention and control office ( hapco ) estimated that adult hiv prevalence was 1.5%
a fee - based art program in 2003 , and a free antiretroviral therapy ( art ) program in early 2005 was started .
subsequently , a number of initiatives have been undertaken to expand the availability of art in ethiopia .
task shifting and decentralization of the service to increasing numbers of both health centers and hospitals was done since august 2006 .
the provision of antiretroviral treatment has decreased morbidity and mortality in people living with hiv [ 37 ] .
there have been several enabling factors for rapid scale - up of art in resource - limited settings . despite recent progress in improving access to art , limited uptake , poor retention , and difficulties in accessing care
remain a serious concern for art programs [ 3 , 4 , 810 ] .  
treatment discontinuation raises some of the concern about drug resistance , which incomplete adherence does , and negates much of the benefit sought by those implementing treatment programs [ 11 , 12 ] .
patients with clinical aids who discontinue art will likely die within a relatively short time .
long - term retention of patients in treatment programs has received far less attention perhaps because most large - scale treatment providers have few resources available to track missing patients [ 4 , 10 ] . as a result ,
much attention has focused on patient day - to - day adherence to antiretroviral medications .
there are also concerns regarding high rates of lost to followup and early mortality in a number of sub - saharan african art programs [ 1416 ] .
high rates of attrition from treatment programs thus pose a serious challenge to program implementers and constitute an inefficient use of scarce treatment resources [ 17 , 18 ] .
attrition from these antiretroviral treatment programs is mainly due to the death and loss to followup of the patient [ 4 , 8 , 19 ] .
there is thus a legitimate concern that a focus on numbers of people initiated on art may compromise quality of care .
the feasibility of implementing art in resource limited countries has been demonstrated in multiple studies , with one - year outcomes often comparable to those in developed countries [ 4 , 5 , 1921 ] .
little is known about the longer - term sustainability of such outcomes in such programs .
the aim of this study is , therefore , to describe the art program practices and clinical outcome as measured by attrition ( mortality and loss to followup ) and retention care at the university of gondar ( uog ) hospital , art clinic , from march 2005 to august 2010 .
examination of these data helps to understand the challenges that must be overcome to ensure the long - term success of treatment services in the treatment program in ethiopia .
a retrospective cohort analysis was conducted at the uog hospital , art clinic , north - west ethiopia .
unpublished report by uog showed that the hospital is a leading referral hospital in north - west ethiopia serving an estimated of five million people .
summary of medical records of the hospital showed that as of january , 2012 , about 9,019 patients were enrolled at the aids care clinic , out of which 3 , 516 adult clients started on art in the clinic .
as part of the government program , the clinic provides care and support to people living with hiv free of charge using the national and who guidelines [ 2 , 22 ] .
the art clinic has begun using electronic database in 2006 to monitor the performance of art program .
patients at the art clinic are referred by art clinician to case managers for adherence and managing art risk factors .
case managers are trained high school graduates with modest experience of community health practice . they are required to conduct planned outreach activities to trace those lost to follow - up and onsite community support . after art initiation ,
all adult , nonpregnant , aids patients in the treatment program from march 2005 through august 2010 were eligible .
patients were excluded if art initiation or termination date was missing , and/or if dates were wrongly recorded such as , art initiation date after art termination date . patients who failed to return on their designated appointments date
initial tracing was attempted by telephone by the clinic nurses on the day following the missed appointment .
patients who could not be traced and did not subsequently return to the clinic during the study period were classified as lost to followup ( ltf ) .
any death confirmed and recorded in the patient card on art was assumed to be related to hiv / aids , unless and otherwise specified .
patients who notified clinic staff of their intention to transfer to another facility were given a written referral form and classified as transfer out ( to ) .
retention to care was defined as those patients under the study known to be alive and receiving art regularly at uog hospital art clinic as of august 30 , 2010 .
attrition was defined as discontinuation of art for reasons related to death or loss to followup .
transfers to another health facility , when reported , were not regarded as attrition because these patients who transferred were assumed to be retained in another facility . however , actual retention to the facility was considered transfer - outs as the patient were assumed to be no more a part of the art program .
data were retrieved from patients ' art card by trained nurses working in the art clinic using uniform data abstraction format prepared for the study . whenever relevant information was missing , the art database was consulted .
observation was censored at the date of ltf or transfer out or at the end of the study period , 30 august 2010 .
mortality and ltf overtime were evaluated by declaring data at each calendar year , considering time of entry and exit to determine the contribution of time spent in the cohort . every year entry and exit observations
were used to calculate person - time , event counts , and incidence rates at each calendar times .
the overall rate was calculated in the same fashion at the end of the follow - up time .
then mortality and lost to follow - up rates were calculated by dividing deaths or ltf by person - year at each calendar time to get incidence rates per 100 person - years of observation .
we estimated time to death and ltf and retention to care by kaplan - meier failure and survival functions , respectively .
to get insight into the shape of the survival function for each group and give an idea of whether or not the groups were proportional , we used the kaplan - meier curves for all the categorical predictors .
we tested equality across strata to explore whether or not to include the predictor in the final model .
for the categorical variables , we used the log - rank test of equality across strata .
for the continuous variables , we used the cox proportional hazard model with a single continuous predictor .
we considered including the predictor if the test had a p value of 0.20 or less . for our model building , we considered the model which included all the predictors that had a p value of less than 0.20 in the univariate analyses .
covariates predetermined to be in the univariate analysis were entered into full multivariable cox proportional hazard model .
the following baseline covariates were entered into the model : age , gender , marital status , occupation , disclosure status , type of initial regimen , the presence of tuberculosis , place of residence , functional status , who stage , and cd4 count .
this study obtained ethical clearance from the institutional review board of the university of gondar , ethiopia .
no personal identifiers were declared in the data set prepared for analysis and in the study report .
between march 2005 and august 2010 , 3194 patients were initiated on art , out of which 3012 were considered in the analysis ( figure 1 ) .
sociodemographic and clinical baseline patient characteristics of the 3012 aids patients who were on art is presented on tables 1 and 2 .
the median age was 32 years ( iqr 2740 ) ; 55.2% were female , and 45% of the patients were separated , divorced , or widowed .
majority of the patients were christian by religion ( 92.4% ) , and came from urban areas ( 96.1% ) .
thirty - five percent and 54% of the patients were uneducated and unemployed , respectively .
when patients initially presented , 75% disclosed their hiv status to one or more person they knew .
eligibility for art was determined by cd4 count in 55.3% , and both by cd4 and clinically in 39% of the patients .
the majority of the patients ( 84% ) were presented with who stages iii and iv .
the most common type of initial regimen used was stavudine , lamuvudine , and neverapine ( 36% ) or efaveranze ( 19% ) .
during 6,386.2 patient - years of followup , 216 ( 7.2% ) died , 551 ( 18.4% ) ltf , 430 ( 14.3% ) transferred to other health facility , and 1815 ( 60.3% ) were retained in the program .
survival analysis with kaplan meier estimates of retention into care was 87.5% ( 95 ci : 86.388.7 ) at 6 month , 80.7% ( 95 ci : 79.282.1 ) at 12 months , 73.8% ( 95 ci : 72.175.5 ) at 24 months , 69.3% ( 95 ci : 67.271.2 ) at 48 months , and 61.4% ( 95 ci : 47.372.7 ) at the end of the follow - up period ( 5.5 years ) .
attrition was mainly due to ltf ( 31.4% , 95% ci : 19.548.1 ) followed by death ( 10.4% , 95% ci : 9.012.1 ) .
the majority of the deaths and lost to follow - ups occurred at 6 and 12 months of followup .
fifty - six percent of deaths and 46% of lost to follow - ups occurred in the first year of treatment ( table 3 ) . as shown in table 4 ,
the overall incidence of mortality and ltf rates were 3.4 per 100 person - years ( 95% ci : 3.03.9 ) , and 8.4 per 100 person - years ( 95% ci : 7.89.2 ) , respectively .
mortality and ltf were highest in the first 3 months , 8.3 per 100 person - years ( 95% ci : 6.510.7 ) and 18.7 per 100 person - years ( 95% ci : 15.822.2 ) , respectively ; from art initiation to 6 months , these rates were 7.7 per 100 person - years ( 95% ci : 6.49.4 ) and 18.8 per 100 person - years ( 95% ci : 16.721.4 ) , respectively ; between 6 and 12 months after art initiation , these rates declined to 4.0 per 100 person - years ( 95% ci : 2.95.3 ) and 12.1 per 100 person - years ( 95% ci : 10.314.4 ) , respectively .
trend of mortality , ltf and retention in care is presented in figure 2 and table 3 .
the rate of mortality declined from 3.3 per 100 person - years ( 95% ci : 1.48.0 ) in 2005 to 0.3 per 100 person - years ( 95% ci : 0.2 , 0.5 ) in 2010 .
this decline in the incidence of mortality was statistically significant ( test for trend , p < 0.02 ) .
likewise the rate of ltf declined from 12.7 per 100 person - years ( 95% ci : 8.1 , 19.9 ) in 2005 to 0.41 ( 95% ci : 0.30.6 ) in 2010 ( test for trend , p < 0.001 ) .
the incidence of mortality for patients with cd4 cell count < 50 cells/l increased from 7.4 per 100 person - years ( 95% ci : 5.99.3 ) from the baseline to 12.9 per 100 person - years ( 95% ci : 8.220.3 ) after 24 months of followup .
however , in patients with cd4 cell count > 200 cells/l , mortality decreased from 2.7 per 100 person - years ( 95% ci : 2.13.4 ) at the baseline to 2.3 per 100 person - years ( 95% ci : 1.63.0 ) after 24 months of followup .
cox proportional hazards model demonstrated that being male ( hr = 3.26 ; 95% ci : ( 2.19 , 4.88 ) , ambulatory and bedridden functional status ( hr = 2.20 ; 95% ci : ( 1.30 , 3.70 ) and ( hr = 12.88 ; 95% ci : ( 8.19 , 20.26 ) , resp . ) .
cd4 count < 200 cells/l ( hr = 5.02 ; 95% ci : ( 2.03 , 12.39 ) , and the presence of hiv - tuberculosis coinfection at art initiation ( hr = 2.91 ; 95% ci : ( 2.11 , 4.02 ) were significantly associated with mortality . in contrast , cd4 count < 200 cells/l ( hr = 1.33 ; 95% ci : ( 0.95 , 1.88 ) and ambulatory functional status ( hr = 1.65 ; 95% ci : ( 1.22 , 2.23 ) were significantly associated with ltf . as shown in figure 3 , who stages iii and iv
were significantly associated with mortality in bivariate analysis ( hr = 2.6 with 95% ci : ( 1.6 , 4.5 ) ; when adjusted for other variables , the direction of the relationship changed and turned out insignificant , which resulted from the small number of deaths occurring at who stages i and ii ( table 5 ) .
this study adds to the limited number of researches on art outcome assessments from sub - saharan africa regarding concerns related to high rates of ltf , early mortality , and challenges of retention of aids patients in long - term care [ 8 , 16 , 20 , 21 , 24 , 25 ] .
the analysis of 3012 patients initiating art in 5.5 years in a referral teaching hospital in north - west ethiopia art program demonstrated that more than 60% of patients initiated on art were retained .
in addition the study shows that the majority of the deaths and ltf occurred in the first 3 months of followup .
this study thus provides longer assessment of aids clinic outcomes over those reported from similar studies , which reported outcomes of up to two years [ 4 , 15 , 19 ] .
retention in long - term care is complex , especially in low- and middle - income countries [ 8 , 25 , 27 ] .
the findings of this study document the difficulties in retaining patients in care for life - long treatment due to ltf .
patient retention in care in this program ( 61.4% ) is comparable to the findings of other sub - saharan countries [ 4 , 15 ] .
for example , assefa et al . , in the study of outcomes of the art services in the 55 health facilities in ethiopia , found out that art programs in ethiopia are able to retain on average 68% ( 95% ci : 5185 ) of their patients in 2 years .
likewise , a recent systematic review in sub - saharan africa art programs by fox and rosen ( 2010 ) demonstrated that these programs were able to retain about 60% of their patients at the end of 2 years . the art program in this hospital ,
therefore , has a better picture of the effectiveness of art delivery at 5.5 years as compared to previous studies , which suggested that less than 50% of the patients were retained at a shorter follow - up time [ 20 , 28 ] .
the probability of surviving 5.5 years is more than 50% and hence the chance of surviving to the last followup was high .
this program , therefore , has better effectiveness in retention of patients in care after 5.5 years , suggesting a better success , although there is no clear threshold at which retention in care is considered adequate .
we observed a low overall mortality rate of 3.4 per 100 person - years , comparable to studies done in africa .
there was also relatively lower death rate of 7.7 per 100 person - years in the first 6 months of art compared to other similar art clinics [ 14 , 16 , 29 ] .
for example , the death rate observed in arbaminch hospital in ethiopia demonstrated an overall mortality rate of 9.1 per 100 person - years .
the low mortality rates observed in our cohort may , in part , be due to access to tertiary care level diagnostics and hospital care .
as a program expands , its ability to accurately ascertain patient deaths deteriorates , and high observed ltf may be associated with poor mortality ascertainment [ 14 , 30 ] .
nonetheless , mortality is not regarded as a major reason for patient attrition in large art programs in developing countries .
the greater threat to the success of many african art program is the observation of high levels of ltf , insofar as this outcome reflects patients who have truly left care .
ltf increases throughout the follow - up period resulting in decline in retention of care .
rate of ltf of 8.4 per 100 person - years in our cohort is comparable to that observed in the south africa studies [ 9 , 16 ] , but relatively higher as compared to the rate observed in aids clinical trial group ( actg ) analysis , which is 5.1 per 100 person - years of observation .
the size and pace of art scale - up may have contributed to the observed ltf . the program has grown in size dramatically , with our cohort increasing enrolment about 8-fold from 2005 to 2010 .
in contrast to these individuals , patients who are truly ltf are likely to be nonadherent to treatment and at higher risk of death [ 31 , 32 ] .
in addition , they face increased risk of drug resistance to art , undermining the long - term effectiveness of treatment programs [ 9 , 33 ] .
the finding of this study should be interpreted with caution and has got a number of limitations . to start with
consequently , deaths which occurred at home might have not been documented in the patient card .
this may underestimate the rate of mortality . besides , patients ' card was the main source of information in our study . in the data collection , however , we learned that some of the data lack accuracy and completeness .
second , there were a high number of patients who were ltf or transferred to another art site following the country - wide roll - out of art in our study . though we assumed that those transfered out were retained in another health facility , our assumption may not hold true as these patients might not be in care .
the actual retention in our study considering this scenario of transfer out as a means of attrition reduces retention to the level of 46% . besides
, some ltf might have died , although we have little reason to believe these misclassifications would be anything more than random .
lastly , the study is institutional based and more than 96% of the study cohort was from urban residence that might be able to reach to get the service than the rural people .
this may overestimate retention , though residence was not a predictor for both mortality and ltf in our cohort . as a result ,
future research should be targeted to population level and rural areas of the country . in conclusion
, this study highlights that patient retention in chronic aids care remains a challenge during scalingup of the program .
though overall mortality rate has declined , attrition from the program is mainly due to increase in rates of ltf and early mortality .
facilities must set up simple , standardized monitoring system to track the numbers of patients starting therapy every quarter and determine the treatment outcomes .
in addition , future research should also be directed towards understanding the contextual reasons and outcomes of patients ltf and transferred to other treatment facilitates .
this information could also be potentially useful in the development of strategies designed to increase patient followup and long - term retention in treatment programs .
 
 background . there has been a rapid scale up of antiretroviral therapy ( art ) in ethiopia since 2005 . 
 we aimed to evaluate mortality , loss to followup , and retention in care at hiv clinic , university of gondar hospital , north - west ethiopia . method . 
 a retrospective patient chart record analysis was performed on adult aids patients enrolled in the treatment program starting from 1 march 2005 . 
 we performed survival analysis to determine , mortality , loss to followup and retention in care . 
 results . a total of 3012 
 aids patients were enrolled in the art program between march 2005 and august 2010 . at the end of the 66 months of the program initiation , 
 61.4% of the patients were retained on treatment , 10.4% died , and 31.4% were lost to followup . 
 fifty - six percent of the deaths and 46% of those lost to followup occurred in the first year of treatment . 
 male gender ( adjusted hazard ratio ( ahr ) was 3.26 ; 95% ci : 2.194.88 ) ; cd4 count 200 cells/l ( ahr 5.02 ; 95% ci : 2.0312.39 ) , tuberculosis ( ahr 2.91 ; 95% ci : 2.114.02 ) ; bed - ridden functional status ( ahr 12.88 ; 95% ci : 8.1920.26 ) were predictors of mortality , whereas only cd4 count < 200 cells/l ( hr = 1.33 ; 95% ci : ( 0.95 , 1.88 ) and ambulatory functional status ( hr = 1.65 ; 95% ci : ( 1.22 , 2.23 ) were significantly associated with ltf . 
 conclusion . 
 loss to followup and mortality in the first year following enrollment remain a challenge for retention of patients in care . 
 strengthening patient monitoring can improve patient retention aids care . 
1. Background
2. Method
3. Result
4. Discussion