Factors influencing attrition among adults in HIV care at two referral hospitals in northern coastal Eritrea from 2005 to 2021.

Attrition is regarded as one of the biggest barriers to effective delivery of antiretroviral therapy (ART) to HIV patients in high-burden settings in sub-Saharan Africa (SSA). In this study, our aim was to assess attrition rates and associated risk factors in patients from a predominantly rural community in the Red Sea region of Eritrea. This was a retrospective study that involved a review of records of HIV patients enrolled for treatment in two referral hospitals in the northern coastal areas of Eritrea between 2005 and 2021. The main outcome measures were attrition (loss-to-follow-up (LTFU) plus mortality) and associated outcomes. The association between outcomes measures and covariates was evaluated investigated using Kaplan-Meir analysis and multivariate Cox regression models. A total of 418 patients were studied. At ART initiation, 269 (64.4%) were females, mean age (±SD) was 34(±11.2) years, median (±IQR) CD4+ T-cell count was 151 (IQR: 87-257) cells/µL, and 230(55%) had stage III/IV disease. Over 39 883 person-months of follow-up (PMFU), retention and attrition comprised 291(69.6%) and 127 (39.4%) of the cases, respectively. Among attrition cases, 97(74. 91%) of the respondents died and 32(25.19%) were LTFU. Overall, the incidence of attrition was 2.9/1000(2.4-3.5) per 1000 PMs. The cumulative risk of attrition at ≤6-, > 6-12-, >12-24-, >24-36-, and at >36-48- and > 48 months were 32(25.2%), 12(9.4%), 17(13.4%), 6(8.7%), 11(8.7%) and 49(38.6%), respectively. In the adjusted multivariate Cox regression model, increased risk of attrition was associated with year of enrollment (aHR = 1.07, 95% CI 1.00-1.15, p-value = 0.04); ethnicity (Afar: aHR=3.21, 95% CI: 1.84-5.59, P< 0.001) (Others: aHR = 2.67, 95% CI: 1.14-6.25, P=0.024) and ART backbone: (TDF+FTC: aHR=2, 95% CI: 1.21-3.32, P=0.007). Further, the risk of attrition decreased per unit increase in baseline CD4+ T-cells/μL (uHR=0.998, 95% CI 0.996-0.999, P<0.001). Attrition in ART centers in the Northern Red Sea regions of Eritrea is largely due to mortality. The high mortality was due to advanced disease at enrollment. A concerted effort is required to reduce late enrollment and improve the management of patients with advanced disease in decentralized programs.