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  • This study is a retrospective cohort study using routine programmatic data. Nasarawa state is located in central Nigeria. Its headquarters are in the town of Lafia. It has an area of 27,117 km2 (10,470 sq mi) and a population of 2,040112 (Density-75/km2) at the 2006 census. The State has three National Senatorial Districts (South, North and West) and consists of 13 Local Government Areas. Our Study sites are situated in Lafia, Akwanga, Karu and Keffi local government areas of Nasarawa state. In collaboration with implementing partners (funded either by PEPFAR or Global fund), the State Ministry of Health and the State Agency for the control of AIDS provide ART services to the general population through the various public health institutions in the state. Implementing partners in the state provide HIV prevention, care and treatment services in priority local government areas in the state. Despite increasing access to ART in the state, there is no national policy or health structure for KP that are living with HIV. In Nasarawa state, a comprehensive community-based HIV care model was adopted to reach KP living with HIV and to increase access and utilization of HIV care services among the KP community in the state. Community-based ART (CBART) was implemented through the Integrated Sexual Health Centre, that is situated at the state capital. From this centre, an outreach team of ART providers are deployed to surrounding communities to provide ART services. Outreach activities are organized in collaboration with community based organizations (CBO). Outreach teams consist of an ART clinician, STI providers, a triage nurse, a counselor, a pharmacist, and a Medical Laboratory Scientists. CBOs engage community facilitators (peer educators, HIV counselors and referral officers -who provide voluntary HIV testing and counselling- and treatment officers -who plan HIV outreach services for KP-. They all work within the community, pay home visits, and render services in outreach venues. KP testing HIV positive in the community are referred to either an outreach venue or to the health facility, depending on their preference. In total, five community-based outreach venues are operational in Nasarawa state since the 31st of July 2016. At these outreach-venues, HIV care is organized by the community facilitators (peer educators and referral officers) in collaboration with the ART outreach teams. Outreach venues were pre-determined locations, usually CBOs’ offices, primary health care facilities and hotels/guest houses, in 5 local government areas in the state. Community-based HIV care includes HIV testing, same-day ART initiation (regardless of CD4 count), ART refill, STI care, and peer education sessions. Services are provided by community facilitators and the ART outreach team. Adopted strategies to improve HIV positivity yield include HIV snowball testing and counseling as well as partner testing; this strategy involves exploring sexual network of index cases and offering HIV test to index partners. Patients who test HIV positive are counselled and are proposed to start ART the same day. Stable patients on ART (clients that are adherent to medication/clinic appointment and have CD4 count > 500/ml on two consecutive tests, 6 months part) can benefit from drug pick-up by proxy. Drug pick-up by proxy involves ART drug dispensing through lay-men (i.e peer educators, community mobilizing officers, treatment partners) to patients on ART. In addition, STI care is provided to all KP. Patients that are lost to follow-up are tracked by phone call and home visits. A list of clinic defaulters is generated using appointment registers at the end of each scheduled outreach/clinic for immediate tracking by the community facilitators. All adult KP (18 years or older), living with HIV that were enrolled and initiated on ART in the community-based ART program (OSS) between the 1st of August 2016 and the 28th of February 2017, in Nasarawa state were enrolled into this study. Data were collected from visits that occurred between 1st of August 2016 and 30th of November 2017. Outcomes were defined on the 31st of August 2017. The follow-up time between 31 August 2017 and 30 November 2017 allowed ascertaining if patients late for their next appointment on 31 August were truly LTFU. Patients who started ART at the end of February 2017, were 6 months on ART at the end of August 2017. Data collection and definition of variables: Data for all included participants were collected with a standardized data extraction template that contained participant-level data of interest. Retrospective data were extracted from the Health Management Information Systems (HMIS) tools. All the data used in the study were routinely collected, and were retrieved from the patient file. The HMIS tools used for routine data collection include paper-based tools, such as the patient file and registers. Periodic programme reports were made using data from these registers, to monitor the project. Data were extracted on paper files and then entered in an electronic database by data clerks and coded collected data were kept in an Excel database. No names or addresses were included. Data on variables of interest was collected i.e. demographic data—including age structure of study participants, sex, occupation, educational level and duration on ART, current WHO clinical stage, retention, adherence and viral suppression. Retention in care on ART was defined as the proportion of patients that are linked to care at 6 months ART, among those who started ART and those that were transferred out to another ART facility. Attrition on ART was the opposite of retention in care, and was defined as the proportion of patients that were either dead, LTFU or who stopped ART, among those who started ART, and that were not transferred out. Patients LTFU included those lost from the care continuum for more than 2 months since the last appointment. We distinguish between clients who were LTFU immediately after starting ART from those LTFU after their second ART visit, once the patient engaged in ART follow-up. Immediate LTFU identifies those who didn’t return after ART initiation (often the same day they were tested for HIV), while LTFU after the second ART visit includes all the others who either stopped or didn’t return for a next visit. Patients who ceased to engage in the continuum of care (stopped ART) because of their own wishes or beliefs or because of barriers to continued access to care were said to have stopped ART. Viral suppression was defined as having a viral load less than 1000 copies/ml. Good adherence to medication was defined as >90% ART pill intake. Poor adherence was defined as the opposite. Adherence was assessed using patient self-report and pill count during each clinic or outreach visit. Patients who missed more than 3 doses/month were categorized having a poor adherence to medication. The data analysis was done using Stata version 11 (College Station, TX: StataCorp LP. ). Numeric variables were analyzed using medians and interquartile ranges while calculation of proportions was used for categorical variables. Some numerical variables were categorized for statistical analysis. Kaplan–Meier techniques was used to estimate retention over time. The Log-rank test was used to estimate differences between Kaplan-Meier curves. We employed univariate and multivariate logistic regression to estimate the association between the type of KP and immediate LTFU. Moreover, we conducted a Cox proportional hazard regression to estimate the association between attrition and sociodemographic and clinical patient characteristics. Patients who died, were LTFU, or stopped ART were considered as having experienced the event. Patients active on 31st August 2017 were censored on this date. Patients transferred out to another clinic were censored the date they were transferred out. Through backwards elimination the saturated multivariable model (including all variables) was simplified until only the variable of interest (key population type) and variables significantly associated with attrition remained. The threshold for significance was set at p<0.05. For covariates, missing observations were handled using the missing indicator method. Patients without outcome were excluded. This research used data collected as part of routine care and treatment services for KP that were supported by the United States Agency for International Development (USAID) through a cooperative agreement with the Society for Family Health (SFH) in Nigeria. Consent was obtained from the local Research Measurement and Result department of SFH to use program data for analysis and as it was not practicable to obtain consent from patients who were retrospectively included in the study, we requested a waiver from the IRB, Institute of Tropical Medicine (ITM) Antwerp. The local IRB (SFH) approved the study while the latter IRB (ITM) also approved the study, including lack of consent. We maximally protected participants as all data were fully anonymized before accessing them: a) data in the study database did not include identifying variables, such as names or addresses, b) the study database was encoded by staff of the routine programme.
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