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Effect of older age at initiation of antiretroviral therapy on patient retention in an urban ART program in Uganda

Etheldreda Nakimuli-Mpungu1,2, Noeline Nakasujja2, Howard Dickens Akena2, Steven Mpungu Kiwuwa3, Elly Katabira4, Elilialia Okello2, Chiadi Onyike5, Seggane Musisi2
1Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; 2Departments of Psychiatry, 3Clinical Epidemiology and Biostatistics, 4Internal Medicine, Makerere College of Health Sciences, School of Medicine, Kampala, Uganda; 5Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins Hospital, Baltimore, MD, USA

Purpose: Patient retention in antiretroviral therapy (ART) programs in Sub-Saharan Africa is estimated at 60%. There is limited information on the effect of older age (>50 years) at ART initiation on patient retention in ART programs in Uganda. This study aimed to investigate demographic and clinical differences between older and younger human immunodeficiency virus (HIV)-positive individuals prior to ART initiation and then to assess the effect of older age at ART initiation on patient retention in an ART program.
Methods: A retrospective chart review of all medical charts belonging to 773 HIV-positive individuals who initiated ART from January 2005 through July 2009 was conducted. Factors associated with older HIV-positive individuals were determined using simple and multivariate logistic regression. Survival analysis techniques were used to compare median survival times in the ART program between older and younger HIV-positive individuals. Cox regression models were used to assess the impact of older age on patient retention while adjusting for variables associated with both older age and patient retention.
Results: Older HIV-positive individuals were significantly more likely to have a clinical diagnosis of HIV-related dementia (odds ratio [OR] = 7.65; P = 0.037), severe mental illness (OR = 1.28; P = 0.39), peripheral neuropathy, (OR = 3.76; P = 0.024), and HIV wasting syndrome (OR = 1.92; P = 0.023). Median survival time for older HIV-positive individuals was eight months longer than that of their younger counterparts (log-rank χ2 = 3.3, P = 0.45) Independent predictors of loss to follow-up were a clinical diagnosis of HIV-related dementia (hazards ratio [HR] = 4.63; P = 0.000), severe mental illness (HR = 1.44; P = 0.005), and HIV wasting syndrome (OR = 1.35; P = 0.008).
Conclusion: There was no difference in patient retention rates between younger and older HIV-positive individuals. However, a clinical diagnosis of HIV dementia, severe mental disorder, HIV wasting syndrome, and CD4 counts less than 200 were independent predictors of low patient retention rates in this ART program.

Keywords: old age, human immunodeficiency virus, acquired immune deficiency syndrome, antiretroviral therapy, neuropsychiatric syndromes, Uganda

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