Research Article: Individual factors associated with time to non-adherence to ART pick-up within HIV care and treatment services in three health facilities of Zambézia Province, Mozambique

Date Published: March 25, 2019

Publisher: Public Library of Science

Author(s): Dércio B. C. Filimão, Troy D. Moon, Jorge F. Senise, Ricardo S. Diaz, Mohsin Sidat, Adauto Castelo, Denis Bourgeois.


Mozambique has made significant gains in addressing its HIV epidemic, yet adherence to visit schedules remains a challenge. HIV programmatic gains to date could be impaired if adherence and retention to ART remains low. We investigate individual factors associated with non-adherence to ART pick-up in Mozambique.

This was a retrospective cohort of patients initiating ART between January 2013 and June 2014. Non-adherence to ART pick-up was defined as a delay in pick-up ≥ 15 days. Descriptive statistics were used to calculate socio-demographic and clinical characteristics. Adherence to ART pick-up was assessed using Kaplan Meier estimates. Cox proportional hazards model was used to determine factors associated with non-adherence.

1,413 participants were included (77% female). Median age was 30.4 years. 19% of patients remained adherent to ART pick-up during the evaluation period, while 81% of patients were non-adherent to ART pick-up. Probability of being non-adherent to ART pick-up by 166 days following initiation was 50%. In univariate analysis, being widowed was associated with higher adherence to ART pick-up than other marital status groups (p = 0.01). After adjusting, being ≥35 years (aHR: 0.843, 95% CI: 0.738–0.964, p = 0.012); receiving efavirenz (aHR: 0.932, 95% CI: 0.875–0.992, p = 0.026); and being urban (aHR: 0.754, 95% CI: 0.661–0.861, p<0.0001) were associated with improved adherence. Non-participation in a Community ART Support Group (CASG) was associated with a 43% increased hazard of non-adherence to ART pick-up (aHR 1.431, 1.192–1.717, p<0.0001) Interventions should focus on the first 6 months following ARV initiation for improvements. Younger persons and widows are two target groups for better understanding facilitators and barriers to visit schedule adherence. Future strategies should explore the benefits of joining CASGs earlier in one´s treatment course. Finally, greater efforts should be made to accelerate the scale-up of viral load capacity and HIV resistance monitoring.

Partial Text

Mozambique is one of the countries most affected by HIV infection, with a 2015 estimated national HIV prevalence of 13.2% in individuals between 15–49 years of age, translating to approximately 1.5 million adults living with HIV out of a total estimated population of 28 million persons [1–3]. As of December 2017, approximately 1,150,000 persons nationally were receiving antiretroviral therapy (ART). The National HIV/AIDS and Sexually Transmitted Infections (STI) control program of Mozambique (Programa Nacional de Controle de ITS-HIV/SIDA) provides ART to all eligible patients free of charge and as of December 2017, ART services were provided in 81% of all health facilities within the National Health System [4].

This retrospective cohort study was conducted in three health facilities of Zambézia Province, Mozambique, representing three different urban-rural zones: 24thof July, an urban health facility in the provincial capital city of Quelimane; the District Hospital of Maganja da Costa, a rural district capital hospital; and Nante Health Facility, an even more rural peripheral health facility in the district of Maganja da Costa (Fig 2). We identified HIV infected individuals at these three sites, aged 15 years or older who started ART between January 1, 2013 and June 30, 2014. For purposes of service delivery, the Ministry of Health (MOH) considers adults to be ≥15 years of age. Each patient was followed from the point of initiation of ART treatment, until June 30, 2016 for a minimum 24-month follow-up (Fig 3).

A total of 1,413 patients aged ≥15 years old were included in analysis for the study period following triangulation between the electronic medical record and the FILA (Table 1). The median age was 30.4 years (IQR: 25.2–36.8) and 77% were female. The majority of patients (65%) lived in rural areas and were either married or involved in a stable relationship (51%). Forty-four percent of patients had achieved only a secondary education or less and 54% were unemployed. The median CD4+ T cell count at treatment initiation was 343 cells/mm3 and median BMI was 20.1kg/mm2 (IQR: 18.1–22.2). Nearly 67% of patients initiated ART early in their course of disease (WHO Stage I or II). ART fixed dose combinations for 758 (53.6%) patients included Lamivudine (3TC) + Tenofovir (TDF) + Efavirenz (EFV), and for 531 (37.6%) patients included 3TC + Zidovudine (AZT) + Nevirapine (NVP).

Retention in HIV care and treatment services and adherence to ART pharmacy pick-up schedules continues to be a significant challenge in Zambézia Province, with only 65% of our study population remaining adherent to ART pick-up after the first three months following treatment initiation. While our study´s poor ART pick-up results are cause for alarm and a need for greater reflection as to what changes can be implemented to help move Zambézia Province´s HIV program towards fully realizing the 90-90-90 initiative, it is important to contextualize these findings based on each study´s inclusion criteria and definition of adherence and retention used. The impact of non-standardized inclusion criteria and definitions of LTFU and retention in HIV programming has previously been shown to impact study conclusions and limit comparability across programs [32]. For example, had the present assessment also been restricted to patients with more than three, six or twelve months of treatment, the observed adherence to ART pick-up rates at twelve months would be 40%, 65% and 67% respectively, rather than the 31% reported here. Policy makers must take this into account when evaluating a program´s reported successes or shortcomings. Our study findings provide additional strong motivation for the establishment of uniform definitions across studies and cohorts to allow for more equitable comparisons.

Mozambique has made significant gains in recent years towards addressing its HIV epidemic and in reaching the first two 90´s of the 90-90-90 initiative. However, continued poor retention in care and poor adherence to medication pick-up threatens its ability to meet the third 90. Interventions aimed to improve ART retention and medication pick-up in Zambézia Province should focus mainly on the first three to six months following ART initiation. Persons <35 years of age with a heightened risk for non-adherence to ART pick-up and widows with better adherence rates are two target groups for future study to better understand factors that are facilitators and barriers to retention. We highlight attainment of CASGs in improving adherence to ART pick-up, but caution is required in over interpreting current implementation strategies due to a potential pre-selection bias for patients eligible for inclusion that have already shown to be retained in care and treatment for six months following treatment initiation. Future strategies should include exploring the benefits of joining CASGs earlier in one´s treatment course. Finally, greater efforts should be made to accelerate the scale-up of viral load capacity and HIV resistance monitoring.   Source:


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