Retention in HIV care before and after implementation of a case management program in Malawi.

backgroundRetaining persons living with HIV (PLHIV) on antiretroviral therapy (ART) and preventing loss-to-follow-up (LTFU) is an ongoing challenge. In Malawi, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) implemented a facility-based case management initiative targeting PLHIV at risk of discontinuing care. Using a risk assessment tool, the program provided personalized support through psychosocial counselors, adherence officers, and expert clients. Our evaluation assessed the impact of this initiative on retaining newly initiated ART clients.

methodsWe conducted a pre-/post quasi-experimental study using routine data from electronic medical records and case management registers across ten EGPAF-supported health facilities in Blantyre and Zomba districts. Using stratified random sampling, we selected PLHIV who were initiated on ART before (January-June 2019) and after (January-June 2021) implementation of the program, with a 12-month follow-up. We used survival analysis to compare LTFU over the 12-month follow-up period between PLHIV enrolled during the pre-intervention and post-intervention periods, and Cox hazards proportion analysis to assess factors associated with LTFU in the first year.

resultsAmong the 1,466 participants, 33.8% (n = 496) were from the pre-intervention period, and 66.2% (n = 970) were from the post-intervention period. Comparing pre- and post-intervention, there were significant differences in the probability of remaining in care at six months (75.7% vs. 93.9%, respectively, p < 0.001) and twelve months (59.3% vs. 70.7%, p < 0.001). Patients in the post-intervention period had a lower risk of LTFU than those in the pre-intervention period: adjusted Hazards Ratio (aHR) 0.46 (95% CI 0.34–0.63). Participants who initiated on non-DTG-based ART were more likely to be LTFU than those who initiated on DTG-based ART: aHR 1.63 (95% CI 1.11–2.41). Participants who received ART in rural facilities had an increased risk of LTFU than those in urban facilities (aHR: 1.49; 95% CI 1.14–1.96).

conclusionRetention in the care of newly initiated ART patients during their first year was higher after the implementation of the case management program than before program implementation. Scaling up the model could help reduce discontinuity of care in the country and other resource-limited settings.