AIDS Care

Psychological and Socio-medical Aspects of AIDS/HIV

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/caic20

Predictors of treatment interruption among

patients on antiretroviral therapy in Akwa Ibom,
Nigeria: outcomes after 12 months

Uduak Akpan, Kunle Kakanfo, Oche D. Ekele, Kufre Ukpong, Otoyo Toyo,
Pius Nwaokoro, Ezekiel James, Satish Pandey, Kolawole Olatubosun & Moses
Bateganya

To cite this article: Uduak Akpan, Kunle Kakanfo, Oche D. Ekele, Kufre Ukpong, Otoyo
Toyo, Pius Nwaokoro, Ezekiel James, Satish Pandey, Kolawole Olatubosun & Moses
Bateganya (2023) Predictors of treatment interruption among patients on antiretroviral
therapy in Akwa Ibom, Nigeria: outcomes after 12 months, AIDS Care, 35:1, 114-122, DOI:
10.1080/09540121.2022.2093826

To link to this article: https://doi.org/10.1080/09540121.2022.2093826

© 2022 The Author(s). Published by Informa

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Group

Published online: 28 Jun 2022.

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AIDS CARE
2023, VOL. 35, NO. 1, 114–122
https://doi.org/10.1080/09540121.2022.2093826

Predictors of treatment interruption among patients on antiretroviral therapy in

Akwa Ibom, Nigeria: outcomes after 12 months
Uduak Akpanb, Kunle Kakanfoa, Oche D. Ekeleb, Kufre Ukpongb, Otoyo Toyob, Pius Nwaokoroa, Ezekiel Jamesc,
Satish Pandeya, Kolawole Olatubosuna and Moses Bateganya d
a
FHI 360, Akwa Ibom, Nigeria; bAchieving Health Nigeria Initiative, Akwa Ibom, Nigeria; cUnited States Agency for International Development,
Abuja, Nigeria; dFHI 360, Durham, NC, USA

ABSTRACT ARTICLE HISTORY

Understanding the characteristics of people living with HIV who interrupt antiretroviral therapy Received 24 February 2021
(ART) is critical for designing client-centered services to ensure optimal outcomes. We assessed Accepted 20 June 2022
predictors of treatment interruption in 22 HIV clinics in Nigeria. We reviewed records of HIV-
KEYWORDS
positive patients aged ≥15 years who started ART 1 January and 31 March 2019. We HIV; AIDS; predictors; lost to
determined treatment status over 12 months as either active, or interrupted treatment (defined follow-up; antiretroviral
as interruption in treatment up to 28 days or longer). Potential predictors were assessed using therapy; adults
Cox hazard regression models. Overall, 1185 patients were enrolled on ART, 829 (70%) were
female, and median age was 32 years. Retention at 1, 3, 6, 9, and 12 months was 85%, 80%,
76%, 72%, and 68%, respectively. Predictors of treatment interruption were post-secondary
education (p = 0.04), diagnosis through voluntary counseling and testing (p < 0.001), receiving
care at low-volume facilities (p < 0.001), lack of access to a peer counselor (p < 0.001), and
residing outside the clinic catchment area (p = 0.03). Treatment interruption was common but
can be improved by focusing on lower volume health facilities, providing peer support
especially to those with higher education, and client-centered HIV services for those who live
further from clinics..

Introduction
Increased access to antiretroviral therapy (ART) has
resulted in declining mortality and improved quality
of life for people living with HIV (PLHIV) (Folasire
et al., 2012; Oguntibeju, 2012). However, the individual
and public health benefits of ART can only be achieved
if patients are retained in an HIV treatment program,
adherent to ART, and achieve viral suppression
(Stricker et al., 2014). These goals are threatened by
treatment interruption.
Loss to follow-up (LTFU) or treatment interruption
is influenced by many factors including sex (Asiimwe
et al., 2015; Balogun et al., 2019; Oguntibeju, 2012;
Onoka et al., 2012; Tadesse & Haile, 2014; Webb &
Hartland, 2018), age (Asiimwe et al., 2015; Assemie
et al., 2018; Berheto et al., 2014; Hønge et al., 2013; Mel-
oni et al., 2014), educational status (Akilimali et al.,
2017; Hønge et al., 2013), marital status (Alvarez-Uria
et al., 2013; Bekolo et al., 2013; Meloni et al., 2014),
occupation (Mberi et al., 2015; Tiruneh et al., 2016), dis-
closure status (Akilimali et al., 2017; Seifu et al., 2018),
distance from health facilities (Bekolo et al., 2013),
and support from caregivers (Agaba et al., 2017;
Eshun-Wilson et al., 2019). In addition, clinical- and
treatment-related factors such as baseline World Health
Organization (WHO) stage (Meloni et al., 2014; Odafe
et al., 2012), baseline CD4 count (Bekolo et al., 2013;
Odafe et al., 2012; Tiruneh et al., 2016), prevalent
opportunistic infections (OIs) (Asiimwe et al., 2015),
baseline functional status (Ayele et al., 2015; Brinkhof
et al., 2009; Eshun-Wilson et al., 2019; Mekonnen
et al., 2019; Odafe et al., 2012), OI prophylaxis (Assemie
et al., 2018; Bekolo et al., 2013; Berheto et al., 2014), and
ART regimen type (Tadesse & Haile, 2014; Tiruneh
et al., 2016) play a role.
Akwa Ibom, one of 36 states in Nigeria, and home to
over 10% (188,562) of the estimated 1,832,266 PLHIV in
the country (National Agency for the Control of AIDS
[NACA], 2019) had initiated only. 120,000 (63.6%) indi-
viduals on ART by March 2020 (Nigeria country oper-
ational plan [COP], 2020). Yet even for those linked
to ART, treatment interruption remains a persistent

CONTACT Moses Bateganya bategsm@gmail.com FHI 360, 359 Blackwell St #200, Durham, NC 27701, USA
© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-
nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built
upon in any way.

problem nationally and in Akwa Ibom (Data.FI, Palla-
dium., 2020). The U. S. President’s Emergency Plan
for AIDS Relief (PEPFAR) therefore prioritized Akwa
Ibom for an intensified HIV treatment surge activities
from 2019 with a goal of achieving epidemic control
by September 2020 (Nigeria country operational plan
[COP], 2020). Surge activities have included index and
targeted community testing, community initiation and
maintenance of ART.
In the context of Akwa Ibom’s substantial HIV bur-
den, challenges in delivery of HIV services, and less-
than-ideal service access for PLHIV makes retaining
patients more challenging, understanding the predictors
of treatment interruption is critical. Identifying these
predictors will help reduce AIDS-related deaths and
new HIV infections and, ultimately, achieve epidemic
control. Our study aimed to determine predictors of
treatment interruption among patients enrolled at the
beginning of the PEPFAR surge activities.
Methods
Setting
The study was conducted in Akwa Ibom State, southern
Nigeria. The state comprises 31 local government areas
(LGAs), six of which border the Atlantic Ocean. Agri-
culture is the predominant economic activity for upland
dwellers, whereas the riverine and coastal communities
engage predominantly in fishing. In urban areas, petty
trading, artisanship, and white-collar services are prac-
ticed. Many riverine and coastal communities are separ-
ated by marshes, ravines, creeks, and swamps making
the terrain difficult and transportation costs prohibitive
to access facility care.
HIV treatment services are implemented by
Strengthening Integrated Delivery of HIV/AIDS Ser-
vices (SIDHAS), a United States Agency for Inter-
national Development (USAID)-funded project led by
FHI 360, that supports the government of Nigeria to
implement HIV services. In Akwa Ibom, SIDHAS sup-
ports 102 health facilities across 21 of the 31 LGAs. The
2016 Nigerian National Guidelines for HIV and AIDS
Treatment, revised in 2018 (FMOH, 2016) rec-
ommended ART for all HIV-positive individuals, irre-
spective of CD4. Tenofovir, lamivudine, and efavirenz
was initiated as 1st line. In 2018 eligible adults, adoles-
cents, and older children were transitioned to tenofo-
vir/lamivudine and dolutegravir with zidovudine as an
alternative to tenofovir: and efavirenz as an alternative
for dolutegravir for tuberculosis/HIV-coinfected
patients.
AIDS CARE 115
Clinical evaluation and treatment
After diagnosis, clinical assessment, WHO clinical sta-
ging, and basic laboratory tests are conducted, ART is
initiated on the same day or within 14 days of diagnosis.
After ART initiation, patients are seen monthly for the
first three–six months and once every three–six months
thereafter if they are virally suppressed. At each visit,
weight, WHO clinical stage, and OIs are assessed and
recorded. Viral load testing is done at three, and six
months after ART initiation and annually thereafter
(FMOH, 2016). Patients are re-evaluated six months
from ART initiation and if “stable” – that is viral load
<1000 copies/mL, with no OIs, and good adherence to
ART – they are enrolled in one of the appropriate differ-
entiated service delivery (DSD) models i.e., community
ART refill clubs (CARCs), community pharmacy ART
refill points (CPARPs); and fast-track refill services, in
which stable patients receive three or six months of
ART refills (multi-month dispensing [MMD3 and
MMD6]).
Selection criteria
All 22 health facilities supported by SIDHAS were
included in the study. The total sample size was allo-
cated proportionally among each hospital based on
the number of patients on ART.
Data collection
Baseline and follow-up client data are routinely
recorded on paper files and entered into the Lafiya Man-
agement Information System (LAMIS) – an electronic
medical record system that houses most of Nigeria’s
HIV treatment data. These primary records are routi-
nely audited by the national AIDS program together
with a built-in data quality assurance module for data
accuracy. The study team abstracted de-identified
LAMIS records for patients who initiated ART in the
selected facilities between 1 January 2019 and 31
March 2019 and reviewed their clinic records to deter-
mine if they had interrupted treatment within the first
12 months of ART. Patients who were aged ≥15 years
the time of HIV diagnosis were included. We excluded
patients transferred into the facility with unknown ART
initiation dates, and those who started ART outside the
period of interest.
Baseline data retrieved from LAMIS included clients’
social demographics (sex, age, marital status, edu-
cational status, occupation, and residential distance
from health facility), care entry point (e.g., facility out-
patient, community outreach, prevention of mother-
116 U. AKPAN ET AL.
to-child transmission [PMTCT] clinic, etc.), clinical
characteristics (recent OIs), and ART regimen.
Other information – such as client status at different
time points, duration on ART, and residential categoriz-
ation (defined as “within LGA” if address was within the
designated catchment area of the health facility, other-
wise “outside LGA”) – were gathered from patients’
paper records.
Data abstracted from either LAMIS or the patient
charts were exported to a data collection sheet specifi-
cally designed for this study and cleaned using
data management features in Microsoft Excel. Case
managers – staff responsible for patient adherence
within these health facilities – were trained on data
collection and were responsible for abstracting client
level data.
Sites were categorized as tier 1‒3 based on the num-
ber of patients receiving ART: Tier 1 ≥ 1500 clients; Tier
2, 500‒1499 clients; and Tier 3 having < 500 clients.
Ethical approval
Permission to analyze program data was obtained from
the Akwa Ibom State Health Research Ethics Committee
(HREC) and the FHI 360 Office of International
Research Ethics. Patient informed consent was not
required because only routine, anonymous, operational
monitoring data were collected and analyzed.
Statistical analysis
The primary outcome of interest was treatment inter-
ruption – defined as not picking up ART refill for 28
days or longer from the last expected refill appointment
– within 12 months of ART initiation.
Data were analyzed using IBM SPSS version 20.
Descriptive statistics were used to summarize categori-
cal variables. Kaplan-Meier survival analysis was used
to determine the probability of retention at 1st, 3rd,
6th, 9th, and 12th months after ART initiation. Time
to treatment interruption was calculated as the time
between the date of ART initiation and the date of treat-
ment interruption. Potential predictors of treatment
interruption were assessed using risks regression
model in SPSS. Cox hazards regression models were
used to estimate crude and adjusted hazard ratios
(AHRs) and 95% confidence interval for covariates of
interest. We adjusted for the effects of selected baseline
characteristics in our multivariable regression models.
The variables included in the regression model were
those previously reported to be associated with either
attrition, treatment interruption, or mortality in other
studies (Brinkhof et al., 2009/ 2008; Dalhatu et al.,
2016; Akilimali et al., 2017). Explanatory variables that
had more than 5% missing value were excluded from
the final analysis.
Results
Sociodemographic and baseline characteristics
of PLHIV
Between January and March 2019, 1185 PLHIV
initiated ART across 22 sites. The median age at
enrollment in HIV care was 32 years (IQR: 24‒40).
Of the total, 829 (70%) were female, 603 (60%), were
married; and 529 (45%) had completed postsecondary
education (Table 1).
With regard to entry point into HIV care, 504 (43%)
were identified through outpatient departments,
153 (13%) through community outreach, and
406 (34%) through voluntary counseling and testing
(VCT).
Only 440 (44%) were known to have disclosed their
HIV-positive status to a partner, family member, or
friend. Also, 450 (38%) had named a treatment sup-
porter, and 988 (83%) reported being assigned a peer
counselor immediately after ART initiation for adher-
ence support. The majority, 964 (81%), accessed ART
services in facilities located within communities where
they lived (within LGA), while 221 (19%) received
ART outside their residential locations.
At baseline, 534 (45%) patients were on tenofovir,
lamivudine, and dolutegravir; 641 (54%) were on teno-
fovir and efavirenz; and 1% were on an alternative first-
line regimen. Also, at baseline, 573 (48%) had a docu-
mented OI (Table 1).
Follow-up
Of 1186 clients enrolled, 603 (50.9%) remained
active till end of the 12th month, while 38 (3.2%)
transferred to continue care at other facilities as seen
in Figure 1.
Table 1 above also shows that client continuity
in treatment differed by age (p = 0.001); marital
status (p = 0.001); education (p = 0.006); HIV care
and treatment entry point (p <0.001); residential
distance from clinic (p = 0.016); and ART site category
(p <0.001).
The Kaplan-Meier plot in Figure 2 shows the break-
down of the survival status at month 1, 3, 6, 9, and 12
after ART initiation. The Kaplan-Meier probability of
clients retained on ART at 1, 3, 6, 9, and 12 months
after ART initiation was 85%, 80%, 76%, 72%, and
68%, respectively (Figure 2).
 AIDS CARE 117

Table 1. Sociodemographic and clinical characteristics of HIV-positive patients initiated on ART at 22 facilities, Akwa Ibom, Nigeria,
January–March 2019.
Outcome within 12 months on ART
Ever interrupted treatment1 Continuously on ART
Variable Category N (%) n = 544 n = 641 p-value
Sex Male 356 (30.0%) 169 (47.5%) 187 (52.5%)
Female 829 (70.0%) 375 (45.2%) 454 (54.8%) 0.584
Age 15–29 493 (41.6%) 255 (51.7%) 238 (48.3%)
30–49 576 (48.6%) 245 (42.5%) 331 (57.5%) 0.001
50+ 116 (9.8%) 44 (37.9%) 72 (62.1%)
Highest educational qualification None 63 (5.3%) 19 (30.2%) 44 (69.8%)
Primary 223 (18.8%) 73 (32.7%) 150 (67.3%)
Secondary 370 (31.2%) 161 (43.5%) 209 (56.5%) <0.001
Post-secondary 529 (44.6%) 291 (55.0%) 238 (45.0%)
Marital status Single 352 (35%) 174 (49.4%) 178 (50.6)
Married 603 (60%) 262 (43.4%) 341 (56.6%) 0.006
Separated 14 (1%) 8 (57.1%) 6 (42.9%)
Widowed 38 (4%) 10 (26.3%) 28 (73.7%)
Missing = 178
Care entry point Outpatient 504 (43%) 227 (45.0%) 290 (57.5%)
PMTCT 82 (7%) 41 (50.0%) 41 (50.0%)
Outreach 153 (13%) 115 (75.2%) 38 (24.8%) <0.001
VCT 406 (34%) 151 (37.2%) 255 (62.8%)
Transfer-in 27 (2%) 10 (37.0%) 17 (63.0%)
Regimen at ART commencement TDF+3TC + DTG 534 (45.1%) 240 (44.9%) 294 (55.1%)
TDF+3TC + EFV 641 (54.1%) 298 (46.5%) 343 (53.5%) 0.468
Others 10 (0.8%) 6 (60.0%) 4 (40.0%)
Has client disclosed status to anyone? No 745 (62.9%) 412 (55.3%) 333 (44.7%)
Yes 440 (37.1%) 132 (30.0%) 308 (70.0%) 0.088
Missing = 180
Does client have a treatment supporter? No 735 (62.0%) 393 (53.5%) 342 (46.5%)
Yes 450 (38.0%) 151 (33.6%) 299 (66.4%) 0.071
Missing = 1185
Assigned to peer counselor? No 197 (16.6%) 142 (72.1%) 55 (27.9%)
Yes 988 (83.4%) 402 (40.7%) 586 (59.3%) 0.01
Residential distance from ART center Within LGA 964 (81.4%) 426 (44.2%) 538 (55.8%)
Outside LGA 221 (18.6%) 118 (53.4%) 103 (46.6%) 0.016
Reported OI at last clinic visit No 599 (51.1%) 259 (43.2%) 340 (56.8%)
Yes 573 (48.9%) 279 (48.7%) 294 (51.3%) 0.232
Missing = 13
Clients’ ART site category Tier 1 766 (64.6%) 395 (51.6%) 371 (48.4%)
Tier 2 198 (16.7%) 89 (44.9%) 109 (55.1%) <0.001
Tier 3 221 (18.6%) 60 (27.1%) 161 (72.9%)
Note: *p-value based on Kaplan – Meier survival analysis; 1At least one episode of a client interrupting treatment.

Factors significantly associated with treatment inter- CI:1.02–2.71)] and enrolling through VCT [aHR 1.8
ruption on multivariable analysis included having post- (p-value < 0.001; 95% CI: 1.41–2.35)]. In addition,
secondary education [aHR 1.7 (p-value = 0.04; 95% PLHIV in low-client-volume sites (Tier 3) had higher

Figure 1. Outcomes after 12 months among PLHIV started on ART January to March 2019.
118 U. AKPAN ET AL.
Figure 2. Kaplan-Meier 12-month retention probabilities for PLHIV initiated on ART January to March 2019.
risk of treatment interruption [aHR 0.57 (p-value <
0.001; 95% CI: 0.42–0.77] compared to those in Tier 2
and Tier 1. Clients who had not been assigned peer
counselors [aHR 1.7 (p-value < 0.001; 95% CI: 1.35–
2.09] and those residing outside LGAs [aHR 1.265 (p-
value < 0.03; 95% CI: 1.03–1.56] also had higher risk
of treatment interruption (Table 2).
Discussion
The 12-month retention rate of 68% in the PLHIV
cohort in Nigeria was substantially lower than the 98%
retention benchmark set by PEPFAR Nigeria (Nigeria
country operational plan [COP], 2020) and highlights
the challenges of continuity of HIV treatment in
Akwa Ibom. In addition, this is lower than the 12-
month retention of 81.2% previously reported from a
nationally representative sample (Dalhatu et al., 2016),
and an average of 80% across 39 cohorts in sub-Saharan
Africa (Fox & Rosen, 2010), and calls for supportive
retention interventions (Penn et al., 2018).
Similar to other studies that have reported highest
drop-off in the first month of ART initiation (Aliyu
et al., 2019; Alvarez-Uria et al., 2013; Brinkhof et al.,
2009), our study finding shows up to 16% of treatment
interruptions occurred within the first month of ART
initiation; signifying that these months are critical to
maintaining patients in care. Although we did not
investigate reasons for treatment interruption in our
study population within their first month of ART
initiation, up to 48.9% of the study cohort presented
with opportunistic infection after ART initiation.
Poor baseline clinical and immunological status are
associated with increased mortality among PLHIV
(Rubaihayo et al., 2015). However, accounting for all
deaths in low-income countries is challenging as mor-
tality reporting is mostly passive, and deaths not
reported to health facilities may be misclassified as
LTFU. The mortality rate in our study was 4.4%,
lower than in other Nigerian studies (Eguzo et al.,
2014) possibly because some patients reported as hav-
ing interrupted treatment may have actually died
(Asiimwe et al., 2015; Harries et al., 2010).
Our study did not show any significant difference in
treatment interruption rates between PLHIV started on
ART with dolutegravir-based regimens compared to
those on the efavirenz-based or other regimens.
Other studies citing adverse events with efavirenz-
based regimens have reported more discontinuations
on that regimen than on dolutegravir-based ones
(Nabitaka et al., 2020). Further analysis could be
done with a larger cohort and with longer follow-up
to determine if dolutegravir-based regimens have
retention benefits.
Our analysis also showed no difference in risk of
treatment interruption by sex unlike studies that
 AIDS CARE 119

Table 2. Analysis of factors associated with treatment interruption in HIV-positive patients on ART in Akwa Ibom January–March 2019.
Characteristics HR (95% CI) p_value aHR (95% CI) p_value
Sex Male 1 1
Female 1.097 (0.899–1.339) 0.362 1.097 (0.898–1.340) 0.365
Age 15–29 1 1
30–49 0.788 (0.652–0.952) 0.014* 0.783 (0.572–1.073) 0.128
≥50 0.716 (0.512–1.002) 0.052 0.706 (0.359–1.390) 0.341
Residence Within LGA 1 1
Outside LGA 1.265 (1.027–1.558) 0.027* 1.265 (1.027–1.558) 0.027*
Highest educational qualification None 1 1
Primary 1.106 (0.663–1.846) 0.700 1.106 (0.663–1.846) 0.699
Secondary 1.425 (0.880–2.310) 0.150 1.426 (0.880–2.311) 0.150
Post-Secondary 1.660 (1.018–2.708) 0.042* 1.661 (1.018–2.710) 0.042*
Regimen at ART initiation TDF+3TC + DTG 1 1
TDF+3TC + EFV 1.076 (0.896–1.244) 0.433 1.077 (0.896 - 1.294) 0.432
Others 2.245 (0.985–5.117) 0.054 2.248 (0.985–5.133) 0.054
Assigned peer counselor Yes 1 1
no 1.670 (1.336–2.088) <0.001* 1.669 (1.35–2.088) <0.001*
Care entry point OPD 1 1
PMTCT 0.964 (0.678–1.372) 0.840 0.965 (0.678–1.373) 0.842
Outreach 0.821 (0.663–1.015) 0.069 0.821 (0.663–1.015) 0.069
VCT 1.819 (1.408–2.349) <0.001* 1.819 (1.407–2.352) <0.001*
Transfer-in 0.626 (0.330–1.190) 0.153 0.627 (0.330–1.190) 0.153
Clients’ ART site category Tier 1 1 1
Tier 2 0.991 (0.767–1.280) 0.945 0.991 (0.767–1.280) 0.945
Tier 3 0.569 (0.423–0.766) <0.001* 0.570 (0.423–0.767) <0.001*
*Cox regression model with significant p-value <0.05.

showed higher rates among males (Brinkhof et al., 2009;
Dalhatu et al., 2016; Tadesse & Haile, 2014).
We observed twice the treatment interruption rates
among those who had completed postsecondary edu-
cation when compared to those with no formal edu-
cation. In contrast, other studies in similar settings
where treatment interruption among those without for-
mal education was higher (Charurat et al., 2010). This
observation calls for strategies that address the unique
care needs of those with higher education.
Treatment interruption was twice as high among
patients who were diagnosed through VCT. It has
been reported elsewhere that patients diagnosed
through VCT have less advanced disease and may not
perceive themselves as requiring medical care nor
appreciate the importance of remaining in HIV care
(Babatunde et al., 2015, Oct 14). Promoting adherence
is key in retaining PLHIV especially early following
initiation of ART. Some studies have highlighted suc-
cesses in interventions such as Short Message Service
(SMS) reminders, phone calls, and home visits (Shah
et al., 2019; Amankwaa et al., 2018) in addition to
implementation of treatment support systems.
Similar to other studies, our analysis indicated that
assigning patients to peer counselors was associated with
less treatment interruption. Peer supporters – PLHIV
who have been trained to provide basic adherence coun-
seling and psychosocial support – have been shown to
improve outcomes among PLHIV (Monroe et al., 2017).
As expected, patients who went to health facilities
outside the geographical area where they resided had
higher treatment interruption rates. This is not surpris-
ing because transportation across the vast Akwa Ibom
State increases the cost of accessing care. Some studies
show that clinic visits are easier to keep when transport
distances are shorter, reducing the time and expense
required to keep appointments (Bilinski et al., 2017;
Kolawole et al., 2017). However, with the introduction
of differentiated service delivery to shift service settings
from hospital-based clinics to communities (FMOH,
2016), better retention outcomes can be achieved
(Faturiyele et al., 2018; PEPFAR Solutions, 2018).
Health workforce constraint at low volume sites
could be a limiting factor for achieving better outcomes
for PLHIV (Dalhatu et al., 2016). The introduction of
the task-shifting and task-sharing policy in Nigeria
(Federal Ministry of Health, 2014) was aimed at redu-
cing gaps in services provision across these sites. How-
ever, our study reported significant variation in
retention by sites’ patient volume with high- and med-
ium-volume sites generally having better retention
rates. Some studies have recommended a combination
of significant training, support and other interventions
where task shifting is implemented, for equivalent out-
comes irrespective of site type (Emdin et al., 2013).
This study had some limitations. First, because we
used routine program records, data were missing for
some demographic, clinical, and laboratory variables,
including but not limited to those assessed in the
study, that might help predict treatment interruption.
We recruited a cohort of individuals who started ART
in the first quarter of 2019. This cohort may not be
120 U. AKPAN ET AL.
typical of patients who seek care the rest of the year.
Lastly, these data are from a unique state in Nigeria
and may not be generalizable to other states. Nonethe-
less, the analysis shows important predictors of treat-
ment interruption – such as post-secondary education,
diagnosis through VCT, seeking care outside the geo-
graphic catchment area – which, when addressed,
might improve program outcomes.
Conclusion
Almost half of PLHIV in our cohort were found to have
interrupted ART. We also identified important predic-
tors of LTFU, a finding that provides programs with
opportunities to improve retention. Specific interven-
tions are required to support patients with higher edu-
cational status and those diagnosed through VCT.
Continued work is needed to improve care at low-
volume and potentially understaffed facilities. Ongoing
efforts also are required to reduce stigma that limits dis-
closure and may prompt patients to seek care far from
where they live.
Acknowledgements
We thank PEPFAR through USAID for providing the
resources to carry out this study. We also thank all staff mem-
bers of FHI 360 Akwa Ibom State Office and the health facili-
ties in Akwa Ibom State that participated in the study.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
Supported by the President’s Emergency Plan for AIDS Relief
(PEPFAR) through the United States Agency for International
Development (USAID)- under the terms of grant number
AID-620-A-11-00002.
ORCID
Moses Bateganya http://orcid.org/0000-0001-9442-7854
References
Agaba, P. A., Meloni, S. T., Sule, H. M., Agbaji, O. O., Sagay,
A. S., Okonkwo, P., Idoko, J. A., & Kanki, P. J. (2017).
Treatment outcomes among older human immunodefi-
ciency virus-infected adults in Nigeria. Open Forum
Infectious Diseases, 4(2), ofx031. https://doi.org/10.1093/
ofid/ofx031
Akilimali, P. Z., Musumari, P. M., Kashala-Abotnes, E.,
Kayembe, P. K., Lepira, F. B., Mutombo, P. B., Tylleskar,
T., Ali, M. M., & Faragher, E. B. (2017). Disclosure of
HIV status and its impact on the loss in the follow-up of
HIV-infected patients on potent anti-retroviral therapy
programs in a (post-) conflict setting: A retrospective
cohort study from Goma, democratic Republic of Congo.
PLOS ONE, 12(2), e0171407. https://doi.org/10.1371/
journal.pone.0171407
Aliyu, A., Adelekan, B., Andrew, N., Ekong, E., Dapiap, S.,
Murtala-Ibrahim, F., Nta, I., Ndembi, N., Mensah, C., &
Dakum, P. (2019). Predictors of loss to follow-up in art
experienced patients in Nigeria: A 13-year review (2004–
2017). AIDS Research and Therapy, 16(1), 30. https://doi.
org/10.1186/s12981-019-0241-3
Alvarez-Uria, G., Naik, P. K., Pakam, R., & Midde, M. (2013).
Factors associated with attrition, mortality, and loss to fol-
low up after antiretroviral therapy initiation: Data from an
HIV cohort study in India. Global Health Action, 6(1),
21682. https://doi.org/10.3402/gha.v6i0.21682
Amankwaa, I., Boateng, D., Quansah, D. Y., Akuoko, C. P., &
Evans, C. (2018). Effectiveness of short message services
and voice call interventions for antiretroviral therapy
adherence and other outcomes: A systematic review and
meta-analysis. PLoS One, 13(9), e0204091. https://doi.org/
10.1371/journal.pone.0204091. PMID: 30240417; PMCID:
PMC6150661.
Asiimwe, S. B., Kanyesigye, M., Bwana, B., Okello, S., &
Muyindike, W. (2015). Predictors of dropout from care
among HIV-infected patients initiating antiretroviral
therapy at a public sector HIV treatment clinic in sub-
Saharan Africa. BMC Infectious Diseases, 16(1), 43.
https://doi.org/10.1186/s12879-016-1392-7
Assemie, M. A., Muchie, K. F., & Ayele, T. A. (2018). Incidence
and predictors of loss to follow up among HIV-infected
adults at Pawi general hospital, northwest Ethiopia:
Competing risk regression model. BMC Research Notes, 11
(1), 1–6. https://doi.org/10.1186/s13104-018-3407-5
Ayele, W., Mulugeta, A., Desta, A., & Rabito, F. A. (2015).
Treatment outcomes and their determinants in HIV
patients on anti-retroviral treatment program in selected
health facilities of Kembata and Hadiya zones, southern
nations, nationalities and peoples region, Ethiopia. BMC
Public Health, 15(1), 826. https://doi.org/10.1186/s12889-
015-2176-5
Babatunde, O., Ojo, O. J., Atoyebi, O. A., Ekpo, D. S.,
Ogundana, A. O., Olaniyan, T. O., & Owoade, J. A. (2015
Oct 14). Seven-year review of retention in HIV care and
treatment in federal medical centre Ido-ekiti. Pan African
Medical Journal, 22(139), 139. https://doi.org/10.11604/
pamj.2015.22.139.4981
Balogun, M., Meloni, S. T., Igwilo, U. U., Roberts, A., Okafor,
I., Sekoni, A., Ogunsola, F., Kanki, P. J., & Akanmu, S.
(2019). Status of HIV-infected patients classified as lost to
follow up from a large antiretroviral program in southwest
Nigeria. PloS One, 14(7), e0219903. https://doi.org/10.
1371/journal.pone.0219903
Bekolo, C. E., Webster, J., Bateganya, M., Sume, G. E., & Kollo,
B. (2013). Trends in mortality and loss to follow-up in HIV
care at the Nkongsamba regional hospital, Cameroon. BMC
Research Notes, 6(1), 1–16. https://doi.org/10.1186/1756-
0500-6-512
Berheto, T. M., Haile, D. B., & Mohammed, S. (2014).
Predictors of loss to follow-up in patients living with

HIV/AIDS after initiation of antiretroviral therapy. North
American Journal of Medical Sciences, 6(9), 453–459.
https://doi.org/10.4103/1947-2714.141636
Bilinski, A., Birru, E., Peckarsky, M., Herce, M., Kalanga, N.,
et al. (2017). Distance to care, enrollment and loss to fol-
low-up of HIV patients during decentralization of antire-
troviral therapy in Neno district, Malawi: A retrospective
cohort study. PLoS One, 12(10), e0185699.
Brinkhof, M. W., Pujades-Rodriguez, M., & Egger, M. (2009).
Mortality of patients lost to follow-up in antiretroviral
treatment programmes in resource-limited settings:
Systematic review and meta-analysis. PLoS One, 4(6),
e5790. https://doi.org/10.1371/journal.pone.0005790
Charurat, M., Oyegunle, M., Benjamin, R., Habib, A., Eze, E.,
Ele, P., Ibanga, I., Ajayi, S., Eng, M., Mondal, P., Gebi, U.,
Iwu, E., Etiebet, M-A., Abimiku, A., Dakum, P., Farley, J.,
Blattner, W., & Myer, L. (2010). Patient retention, and
adherence to antiretrovirals in a large antiretroviral therapy
program in Nigeria: A longitudinal analysis for risk factors.
PLoS One, 5(5), e10584. https://doi.org/10.1371/journal.
pone.0010584
Dalhatu, I., Onotu, D., Odafe, S., Abiri, O., Debem, H., Agolory,
S., Shiraishi, R.W., Auld, A. F., Swaminathan, M., Dokubo,
K., Ngige, E., Asadu, C., Abatta, E., Ellerbrock, T. V., &
Anglewicz, P. (2016). Outcomes of Nigeria’s HIV/AIDS
treatment program for patients initiated on antiretroviral
treatment between 2004–2012. PLoS One, 11(11),
e0165528. https://doi.org/10.1371/journal.pone.0165528
Data.FI. (2020). Improving patient retention on antiretroviral
treatment through high frequency reporting in Akwa Ibom
state. Data.FI, Palladium.
Eguzo, K. N., Lawal, A. K., Eseigbe, C. E., & Umezurike, C.
(2014, August 6). Determinants of mortality among adult
HIV-infected patients on antiretroviral therapy in a rural
hospital in southeastern Nigeria: A 5-year cohort study.
AIDS Research and Treatment, 2014, Article ID 867827.
https://doi.org/10.1155/2014/867827
Emdin, C., Chong, N. J., & Millson, P. E. (2013). Non-phys-
ician clinician provided HIV treatment results in equivalent
outcomes as physician-provided care: A meta-analysis.
Journal of the International AIDS Society, 16, 18445.
Eshun-Wilson, I., Rohwer, A., Hendricks, L., Oliver, S., Garner,
P., & Isaakidis, P. (2019). Being HIV positive and staying on
antiretroviral therapy in Africa: A qualitative systematic
review and theoretical model. PLoS One, 14(1), e0210408–
30. https://doi.org/10.1371/journal.pone.0210408
Faturiyele, I. O., Appolinare, T., Ngorima-Mabhena, N., Fatti
G., Tshabalala I., Tukei V. J., & Pisa P. T. (2018). Outcomes
of community-based differentiated models of multi-month
dispensing of antiretroviral medication among stable HIV-
infected patients in Lesotho: A cluster randomised non-
inferiority trial protocol. BMC Public Health, 18(1), 1069.
https://doi.org/10.1186/s12889-018-5961-0
Federal Ministry of Health. (2014). Task-shifting and task
sharing policy for essential health care services in Nigeria.
Federal Ministry of Health. (2016). National Guidelines for
HIV prevention treatment and care. National AIDS and
STIs Control programme. https://naca.gov.ng/wp-content/
uploads/2019/03/NATIONAL-HIV-AND-AIDS-
STRATEGIC-FRAMEWORK-1.pdf
Folasire, O. F., Irabor, A. E., & Folasire, A. M. (2012). Quality of
life of people living with HIV and AIDS attending the
AIDS CARE 121
antiretroviral clinic, University college hospital, Nigeria.
African Journal of Primary Health Care & Family
Medicine, 4(1), 294. https://doi.org/10.4102/phcfm.v4i1.294
Fox, M. P., & Rosen, S. (2010). Patient retention in antiretro-
viral therapy programs up to three years on treatment in
sub-Saharan Africa, 2007–2009: A systematic review.
Tropical Medicine & International Health, 15(Suppl 1), 1–
15. https://doi.org/10.1111/j.1365-3156.2010.02508.x
Harries, A. D., Zachariah, R., Lawn, S. D., & Rosen, S. (2010).
Strategies to improve patient retention on antiretroviral
therapy in sub-Saharan Africa. Tropical Medicine &
International Health, 15(Suppl 1), 70–75. https://doi.org/
10.1111/j.1365-3156.2010.02506.x
Hønge, B. L., Jespersen, S., Nordentoft, P. B., Medina, C., da
Silva, D., da Silva, Z. J., Østergaard, L., Laursen, A. L., &
Wejse, C. (2013). Loss to follow-up occurs at all stages in
the diagnostic and follow-up period among HIV-infected
patients in Guinea-Bissau: A 7-year retrospective cohort
study. BMJ Open, 3(10), e003499–10. https://doi.org/10.
1136/bmjopen-2013-003499
Kolawole, G. A., Gilbert, H. N., Dadem, N. Y., Genberg, B. L.,
Agaba, P. A., et al. (2017). Patient experiences of decentra-
lized HIV treatment and care in plateau state, North central
Nigeria: A qualitative study. Aids Research and Treatment,
2017, 2838059. https://doi.org/10.1155/2017/2838059
Mberi, M. N., Kuonza, L. R., Dube, N. M., Nattey, C.,
Manda, S., & Summers, R. (2015). Determinants of loss
to follow-up in patients on antiretroviral treatment,
South Africa, 2004-2012: A cohort study. BMC Health
Services Research, 15(1), 259. https://doi.org/10.1186/
s12913-015-0912-2
Mekonnen, N., Abdulkadir, M., Shumetie, E., Baraki, A. G., &
Yenit, M. K. (2019). Incidence and predictors of loss to fol-
low-up among HIV infected adults after initiation of first
line anti-retroviral therapy at University of Gondar com-
prehensive specialized hospital northwest Ethiopia, 2018:
Retrospective follow up study. BMC Research Notes, 12
(1), 111. https://doi.org/10.1186/s13104-019-4154-y
Meloni, S. T., Chang, C., Chaplin, B., Rawizza, H., Jolayemi,
O., Banigbe, B., Okonkwo, P., & Kanki, P. (2014). Time-
Dependent predictors of loss to follow-Up in a
large HIV treatment cohort in Nigeria. Open Forum
Infectious Diseases, 1(2), ofu055. https://doi.org/10.1093/
ofid/ofu055
Monroe, A., Nakigozi, G., Ddaaki, W., Bazaale, J. M., Gray, R.
H., Wawer, M. J., Reynolds, S. J., Kennedy, C. E., & Chang,
L. W. (2017). Qualitative insights into implementation,
processes, and outcomes of a randomized trial on peer sup-
port and HIV care engagement in Rakai, Uganda. BMC
Infectious Diseases, 17(1), 54. https://doi.org/10.1186/
s12879-016-2156-0
Nabitaka, V. M., Nawaggi, P., Campbell, J., Conroy, J.,
Harwell, J., Magambo, K., Middlecote, C., Caldwell, B.,
Katureebe, C., Namuwenge, N., Atugonza, R., Musoke,
A., Musinguzi, J., & Torpey, K. (2020). High acceptability,
and viral suppression of patients on dolutegravir-based
first-line regimens in pilot sites in Uganda: A mixed-
methods prospective cohort study. PLoS One, 15(5),
e0232419. https://doi.org/10.1371/journal.pone.0232419
National Agency for the Control of AIDS (NACA). (2019).
Nigeria HIV/AIDS indicator and impact survey (NAIIS)
south zone summary sheet. NACA. https://naca.gov.ng/
122 U. AKPAN ET AL.
wp-content/uploads/2019/03/NAIIS-SOUTH-SOUTH-
ZONE-FACTSHEET_V0.9_030719-edits.pdf
Nigeria Government. Nigeria country operational plan
(COP). (2020). 2020 strategic direction summary. Abuja
(Nigeria): Nigeria Government; 2020. https://www.state.
gov/wp-content/uploads/2020/07/COP-2020-Nigeria-SDS-
Final-.pdf
Odafe, S., Idoko, O., Badru, T., Aiyenigba, B., Suzuki, C.,
Khamofu, H., Onyekwena, O., Okechukwu, E., Torpey, K.,
& Chabikuli, O. N. (2012). Patients’ demographic and clini-
cal characteristics and level of care associated with lost to fol-
low-up and mortality in adult patients on first-line ART in
Nigerian hospitals. Journal of the International AIDS
Society, 15(2), 17424. https://doi.org/10.7448/IAS.15.2.17424
Oguntibeju, O. O. (2012). Quality of life of people living with
HIV and AIDS and antiretroviral therapy. HIV/AIDS -
Research and Palliative Care, 4(4), 117–124. https://doi.
org/10.2147/HIV.S32321
Onoka, C. A., Uzochukwu, B. S., Onwujekwe, O. E.,
Chukwuka, C., Ilozumba, J., Onyedum, C., Nwobi, E. A.,
& Onwasigwe, C. (2012). Retention and loss to follow-up
in antiretroviral treatment programmes in southeast
Nigeria. Pathogens and Global Health, 106(1), 46–54.
https://doi.org/10.1179/2047773211Y.0000000018
Penn, A. W., Azman, H., Horvath, H., Taylor, K. D., Hickey, M.
D., Rajan, J., Negussie, E. K., Doherty, M., & Rutherford, G.
W. (2018, December 14). Supportive interventions to improve
retention on ART in people with HIV in low- and middle-
income countries: A systematic review. PLoS One, 13(12),
e0208814. https://doi.org/10.1371/journal.pone.0208814
Pepfar Solutions Platform. (2018). Improving patient antire-
troviral therapy retention through Community Adherence
Groups in Zambia. https://www.pepfarsolutions.org/solut
ions/2018/1/16/decongesting-art-clinics-in-zambia-and-im
proving-patients-retention-through-community-adherence
-groups-mrbtk
Rubaihayo, J., Tumwesigye, N. M., & Konde-Lule, J. (2015).
Trends in prevalence of selected opportunistic infections
associated with HIV/AIDS in Uganda. BMC Infectious
Diseases, 15(1), 187. https://doi.org/10.1186/s12879-015-
0927-7
Seifu, W., Ali, W., & Meresa, B. (2018). Predictors of loss to
follow up among adult clients attending antiretroviral treat-
ment at Karamara general hospital, Jigjiga town, Eastern
Ethiopia, 2015: A retrospective cohort study. BMC
Infectious Diseases, 18(1), 1–8. https://doi.org/10.1186/
s12879-017-2892-9
Shah, R., Watson, J., & Free, C. (2019). A systematic review
and meta-analysis in the effectiveness of mobile phone
interventions used to improve adherence to antiretroviral
therapy in HIV infection. BMC Public Health, 19(1), 915.
https://doi.org/10.1186/s12889-019-6899-6. PMID:
31288772; PMCID: PMC6617638.
Stricker, S. M., Fox, K. A., Baggaley, R., Negussie, E., de Pee, S.,
Grede, N., & Bloem, M. W. (2014). Retention in care and
adherence to ART are critical elements of HIV care inter-
ventions. AIDS and Behavior, 18(S5), 465–475. https://
doi.org/10.1007/s10461-013-0598-6
Tadesse, K., & Haile, F. (2014). Predictors of loss to follow up
of patients enrolled on antiretroviral therapy: A retrospec-
tive cohort study. Journal of AIDS & Clinical Research, 5(5),
393. https://doi.org/10.4172/2155-6113.1000393
Tiruneh, Y. M., Galárraga, O., Genberg, B., Wilson, I. B., &
Thorne, C. (2016). Retention in care among HIV-infected
adults in Ethiopia, 2005–2011: A mixed-methods study.
PLoS One, 11(6), e0156619–11. https://doi.org/10.1371/
journal.pone.0156619
Webb, S., & Hartland, J. (2018). A retrospective notes-based
review of patients lost to follow-up from anti-retroviral
therapy at Mulanje mission hospital, Malawi. Malawi
Medical Journal, 30(2), 73–78. https://doi.org/10.4314/
mmj.v30i2.4