Pre-Antiretroviral Therapy Attrition Prevalence and Associated Factors in Six Antiretroviral Therapy Centers in Sudan

Introduction: Attrition of patients from care is a critical barrier toward an effective scale-up of HIV services in Sub-Saharan Africa. As part of the HIV care cascade, pre-Antiretroviral Therapy (ART) care is an important pre-requisite for early initiation of ART and optimal clinical outcomes. However, the body of evidence on pre-ART care attrition is limited in Sudan. Baseline data on the scale of pre-ART attrition and associated factors was needed to develop interventions as part of the Sudan National AIDS and STI control Program (SNAP) HIV care scale-up process.;Methods: Cross-sectional study using a questionnaire and facility checklist as study tools. The Study tools were filled from primary (study index cases) and secondary data sources (Patient HIV Cards, Pre-ART and Tracking/Appointment Registers) collected between November 1st, 2012 and May 31st, 2013 of pre-ART patients in six ART facilities in Sudan. Prevalence of retention was estimated using crude proportions. Bivariate and multivariate logistic regression analyses were performed to determine the factors associated with pre-ART attrition. Qualitative assessment was also conducted using phone interviews to determine possible causes of attrition.;Results: We found 78.5% of newly diagnosed patients (n=497) were registered in HIV care with 233 patients enrolled in pre-ART care. Out of which 64.8% (95% Confidence Interval, CI 58.8-70.8) were lost to follow-up (LTFU). Only 48 (31.8%) of those LTFU were successfully traced and out of which 45.8% were dead. Nondisclosure of HIV status (Odds Ratio, OR 2.69, 95% CI 1.09-6.62) and advanced HIV clinical staging (OR 5.94, 95% CI 2.84-12.44) were factors significantly associated with attrition in multivariate analysis. Non-adherence to guidelines and poor utilization of monitoring and follow-up tools at facility level also seem to attribute to pre-ART attrition. Qualitative analyses found that patient relocation and perception of good health were the main reasons cited for attrition.;Conclusion: Existent high rates of attrition are related to disclosure status, advanced disease stage, residence in state with treatment services and patients understanding of the disease. These factors from patients' records can be used as "early warning default indicators" to initiate ART rapidly, provide intensive counseling or transfer to nearby treatment center which may reduce attrition. The national program will also need to make concerted efforts to strengthen pre-ART quality of care. This will require further evaluation in future studies.