Interventions to improve early retention of patients in antiretroviral therapy programmes in sub-Saharan Africa: A systematic review

Background: Several interventions to improve long term retention (12 months and above) on treatment have been rigorously evaluated in Sub-Saharan Africa (SSA). However, research on interventions to improve retention of patients in the early stages of treatment (6 months) during this era of Universal Test and Treat has only recently emerged. The aim of this study is to systematically map evidence of interventions used to improve early retention of patients in antiretroviral therapy (ART) programmes in SSA. Methods: We searched PubMed, EMBASE and Cochrane electronic databases to identify studies describing interventions aimed at improving early retention in ART treatment. We applied the methodological frameworks by Arksey and O’Malley (2005) and Levac et al. (2010). We also followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Interventions were categorized according to key broad areas in the existing literature. Results: A total of 2,241 articles were identified of which 19 met the inclusion criteria and were eligible for this review, with the majority either being randomized control trials 32% (n = 6) or cohort studies 32% (n = 6). The studies reviewed were conducted in 11 SSA countries. The most common interventions described under key broad areas included: Health system interventions such as Universal Test-and-Treat, integration of ART initiation, HIV Testing and Counselling and Antenatal Care services and reduction of ART drug costs; Patient centered approaches such as fast track ART initiation, Differentiated Drug Delivery models and point of care HIV birth testing; Behavioral interventions and support through lay counselors, mentor mothers, nurse counselors and application of quality improvement interventions and financial incentives. Majority of the studies targeted the HIV positive adults and pregnant women. Conclusion: With the introduction of Universal Test-and-Treat and same-day initiation of ART, findings suggest that adoption of policies that expand ART uptake with the goal of reducing HIV transmission at the population level, promoting patient centered approaches such as fast track ART initiation, Differentiated Service Delivery models and providing adequate support through Mentor Mothers, lay and nurse counselors may improve early retention in HIV care in SSA. However, these interventions have only been tested in few countries in the region which points to how hard evidence based HIV programming is. Further research investigating the impact of individual and a combination of interventions to improve early retention in HIV care, including for various groups at high risk of attrition, is warranted across SSA countries to fast track the achievement of 95-95-95 Joint United Nations Programme on HIV/AIDS (UNAIDS) targets by 2030.