Patterns of retention in care during clients first 12 months after HIV treatment initiation in South Africa: a retrospective cohort analysis using routinely collected data

BackgroundRetention in HIV care during the early treatment period is one of the most serious challenges facing HIV programs, but the timing and patterns of early disengagement from care remain poorly understood. We describe patterns of engagement in HIV care during the first and second 6-month periods after initiation. MethodsWe analysed retrospective datasets of routinely collected EMR data from [≥]18-year-old clients who initiated ART at public sector clinics in South Africa after 01/01/2018 and had [≥]14 months potential follow up. Using scheduled visit dates, we classified observed visits into "as planned" or "late" and characterized engagement in care as continuous (all scheduled visits attended [≤]28 days late), cyclical (at least one visit >28 days late with a return visit observed) or disengaged (visit not attended and no return visit to the same facility observed). Results33,821 client records were included (65% female, median age 33). By six months after ART initiation, 57% had remained continuously in care, 14% had engaged cyclically, 11% had transferred to another facility, 1% had died and 16% had disengaged from care at the initiating facility. Among disengagers in the first 6 months, 58% did not return after their initiation visit, 10% disengaged within the first three months, and the remaining 32% disengaged between 3-6 months. By 12 months after initiation, the overall proportion disengaged was 23%, and only 38% of the cohort had maintained continuous engagement for the full 12 -month period.. Patterns of engagement that were established during the first 6 months on ART demonstrated little change in months 7-12, with participants who were cyclically engaged in months 0-6 were nearly twice as likely to disengage in months 7-12 as continuous engagers in months 0-6 (relative risk 1.8, 95% CI: 1.70-1.99). ConclusionsAs recently as 2018, fewer than 60% and 45% of clients starting ART in South Africa were continuously engaged in care (no interruptions >28 days) at 6 and 12 months, respectively, at their initiating facilities. The needs of continuous and cyclical engagers and disengagers during the first 6 months after initiation may differ and require different interventions or models of care.