Predictors of lost to follow up from antiretroviral therapy among adults in sub-Saharan Africa: a systematic review and meta-analysis

Background: It is known that ‘drop out’ from human immunodeficiency virus (HIV) treatment, the so called lost-to-follow-up (LTFU) occurs to persons enrolled in HIV care services. However, in sub-Saharan Africa (SSA), the risk factors for the LTFU are not well understood. Methods: We performed a systematic review and meta-analysis of risk factors for LTFU among adults living with HIV in SSA. A systematic search of literature using identified keywords and index terms was conducted across five databases: MEDLINE, PubMed, CINAHL, Scopus, and Web of Science. We included quantitative studies published in English from 2002 to 2019. The Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used for methodological validity assessment and data extraction. Mantel Haenszel method using Revman-5 software was used for meta-analysis. We demonstrated the meta-analytic measure of association using pooled odds ratio (OR), 95% confidence interval (CI) and heterogeneity using I² tests. Results: Thirty studies met the search criteria and were included in the meta-analysis. Predictors of LTFU were: demographic factors including being: (i) a male (OR = 1.2, 95% CI 1.1–1.3, I² = 59%), (ii) between 15 and 35 years old (OR = 1.3, 95% CI 1.1–1.3, I² = 0%), (iii) unmarried (OR = 1.2, 95% CI 1.2–1.3, I² = 21%), (iv) a rural dweller (OR = 2.01, 95% CI 1.5–2.7, I² = 40%), (v) unemployed (OR = 1.2, 95% CI 1.04–1.4, I² = 58%); (vi) diagnosed with behavioral factors including illegal drug use(OR = 13.5, 95% CI 7.2–25.5, I² = 60%), alcohol drinking (OR = 2.9, 95% CI 1.9–4.4, I² = 39%), and tobacco smoking (OR = 2.6, 95% CI 1.6–4.3, I² = 74%); and clinical diagnosis of mental illness (OR = 3.4, 95% CI 2.2–5.2, I² = 1%), bed ridden or ambulatory functional status (OR = 2.2, 95% CI 1.5–3.1, I² = 74%), low CD4 count in the last visit (OR = 1.4, 95% CI 1.1–1.9, I² = 75%), tuberculosis co-infection (OR = 1.2, 95% CI 1.02–1.4, I² = 66%) and a history of opportunistic infections (OR = 2.5, 95% CI 1.7–2.8, I² = 75%). Conclusions: The current review identifies demographic, behavioral and clinical factors to be determinants of LTFU. We recommend strengthening of HIV care services in SSA targeting the aforementioned group of patients. Trial registration Protocol: the PROSPERO Registration Number is CRD42018114418 [Figure not available: see fulltext.]