Background:  Mother-to-Child Transmission-Plus provides comprehensive, multidisciplinary, family-focused HIV care (including antiretroviral therapy when indicated) to women in preventing mother-to-child transmission (MTCT) programs and to their household members. From February 2003 to July 2004, 5131 patients (3362 adults and 1769 children) were enrolled in 12 programs in 7 countries in sub-Saharan Africa and in Thailand. We describe factors associated with loss to follow up (LTF) among adults.

Methods:  LTF was defined as not returning to clinic for > 3 months after a missed visit (LTF-3), and not returning for > 6 months after a missed visit (LTF-6). Patients known to have died are excluded. Associations between indicator variables and the dichotomous outcome LTF were determined using odds ratios and 95% confidence intervals (CI).

Results:  Of 3362 patients, 466 (14%) were LTF at 3 months and 182 (5.5%) were LTF at 6 months. Subsequent analyses use the stricter 3-month definition. LTF-3 rates were significantly higher in patients who had never initiated ART (17%; n = 2329) compared with those who had ever been on ART (7.2%, n = 988). Among patients never on ART, factors associated with an increased likelihood of LTF-3 were non-disclosure of HIV (OR 1.7 [p < 0.001, 95% CI = 1.3 to 2.3]), younger age (OR 1.3 for each 5-year decrease in age [p < 0.001, 95% CI = 1.2 to 1.4]), and travel time > 2 hours to clinic (OR 2.0 [p < 0.026, 95% CI 1.1 to 3.8]). Program site was also associated with LTF-3. Among patients ever on ART, factors associated with an increased likelihood of LTF-3 were travel time > 2 hours to clinic (OR 3.2 [p < 0.003, 95% CI 1.5 to 7.0]), and, among women, antepartum enrollment in MTCT+ (vs postpartum enrollment) (OR 4.5 [p < 0.008, 95% CI = 1.5-14.3]). The program site was also associated with LTF-3.  Sex, World Health organization stage, educational attainment, and number of children in the household were not associated with LTF in either group.

Conclusions:  MTCT+ programs successfully retained patients in care. To enhance retention, HIV treatment programs in resource-limited settings should consider assisting patients with transportation to clinic or providing access to treatment near patients’ homes. Programs should also provide ongoing counseling and support regarding disclosure of HIV status. Women initiating HIV care and ART during pregnancy require particular attention to support their retention in care, as do patients with less-advanced disease who do not yet require ART.

Keywords: Adherence; Resource-limited settings; Follow-up