Incidence and predictors of loss to follow-up after ART initiation at public health facilities in Sierra Leone (2020-2024): a retrospective cohort study.

Abstract

This study aimed to estimate the incidence and predictors of loss to follow-up (LTFU) among adults after antiretroviral therapy (ART) initiation at five provincial referral hospitals in Sierra Leone. A facility-based retrospective cohort study. This study was conducted at five provincial government referral hospitals in Sierra Leone from January 2020 to December 2024. HIV patients aged 15 and above who initiated ART between 1 January 2020, and 31 December 2020, and attended at least one follow-up visit at the five national referral hospitals. The primary outcome in this study was LTFU. LTFU was defined as absence from care, operationalised as no documented clinical encounter and/or ART refill for ≥90 days after the last expected clinical contact among patients not recorded as dead or transferred out. Of the 1544 patients (67.7% female), the median follow-up was 4.25 years (IQR not stated), totalling 5748.6 PY. Outcomes were 550 LTFU (35.6%), 853 in care (55.2%), 64 (4.1%) transferred and 77 (5.0%) died. The LTFU incidence was 9.57 per 100 PY (95% CI 8.78 to 10.37). Multivariable analyses revealed several factors significantly associated with higher LTFU: lack of tuberculosis (TB) screening (HR=4.47; 95% CI 3.66 to 5.46), WHO stage III/IV (HR=1.51; 95% CI 1.20 to 1.89), no regimen change (HR=5.12; 95% CI 2.39 to 11.00), non-disclosure of HIV status (HR=1.63; 95% CI 1.19 to 2.25), underweight body mass index (BMI) at follow-up (HR=1.37; 95% CI 1.05 to 1.78) and residence in the Southern (HR=1.97; 95% CI 1.57 to 2.48) or Eastern region (HR=2.13; 95% CI 1.49 to 3.03). Conversely, rural residence was associated with lower LTFU (HR=0.58; 95% CI 0.43 to 0.79). The study found a substantial incidence of LTFU. Risk factors of LTFU were gaps in TB screening, advanced clinical stage, absence of timely regimen adjustments, non-disclosure, low BMI and regional disparities. Strengthening integrated TB/HIV services, nutritional support, disclosure-enabling counselling and region-specific retention strategies, especially in urban, Southern and Eastern areas, may improve retention.