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Patient Volume, Human Resource Levels, and Attrition From HIV Treatment Programs in Central Mozambique

Lambdin, Barrot H PhD, MPH*; Micek, Mark A MD, MPH†‡; Koepsell, Thomas D MD, MPH§‖; Hughes, James P PhD, MS; Sherr, Kenneth PhD, MPH†‡; Pfeiffer, James PhD, MPH†‡‖; Karagianis, Marina MBChB#; Lara, Joseph MPH**; Gloyd, Stephen S MD, MPH†‡‖; Stergachis, Andy PhD, MS†§††

JAIDS Journal of Acquired Immune Deficiency Syndromes: July 1st, 2011 - Volume 57 - Issue 3 - p e33-e39
doi: 10.1097/QAI.0b013e3182167e90
Implementation and Operational Research: Epidemiology and Prevention

Introduction: Human resource shortages are viewed as one of the primary obstacles to provide effective services to growing patient populations receiving antiretroviral therapy (ART) and to expand ART access further. We examined the relationship of patient volume, human resource levels, and patient characteristics with attrition from HIV treatment programs in central Mozambique.

Methods: We conducted a retrospective cohort study of adult, ART-naive, nonpregnant patients who initiated ART between January 2006 and June 2008 in the national HIV care program. Cox proportional hazards models were used to assess the association of patient volume, clinical staff burden, and pharmacy staff burden with attrition, adjusting for patient characteristics.

Results: A total of 11,793 patients from 18 clinics were studied. After adjusting for patient characteristics, patients attending clinics with medium pharmacy staff burden [hazard ratio (HR) = 1.39 (95% CI: 1.07 to 1.80)] and high pharmacy staff burden [HR = 2.09 (95% CI: 1.50 to 2.91)] tended to have a higher risk of attrition (P value for trend: <0.001). Patients attending clinics with higher clinical staff burden did not have a statistically higher risk of attrition. Patients attending clinics with medium patient volume levels [HR = 1.45 (95% CI: 1.04 to 2.04)] and high patient volume levels [HR = 1.41 (95% CI: 1.04 to 1.92)] had a higher risk of attrition, but the trend test was not significant (P = 0.198).

Discussion: Patients attending clinics with higher pharmacy staff burden had a higher risk of attrition. These results highlight a potential area within the health system where interventions could be applied to improve the retention of these patient populations.

From the *Pangaea Global AIDS Foundation, Oakland, CA; †Department of Global Health, University of Washington, Seattle, WA; ‡Health Alliance International, Seattle, WA; §Department of Epidemiology, University of Washington, Seattle, WA; ‖Department of Health Services, University of Washington, Seattle, WA; ¶Department of Biostatistics, University of Washington, Seattle, WA; #Ministry of Health, Mozambique, Beira, Sofala, MZ; **Health Alliance International, Beira, Sofala, MZ; and ††Global Medicines Program, University of Washington, Seattle, WA.

Received for publication November 29, 2010; accepted February 18, 2011.

Supported by a grant from the United States Centers for Disease Control as part of the President's Emergency Plan for AIDS Relief.

Portions of these data have been previously presented as an abstract at the International AIDS Conference, 2010, Vienna, Austria; and at the American Public Health Association meeting, 2009, Philadelphia, PA.

B.L. and J.L. performed the literature search. B.L., A.S., M.M., T.K., J.H., J.P., K.S., and S.G. contributed to the study design. B.L., J.L., and M.K. assisted with data collection. B.L., J.H., T.K., A.S., and M.M. informed the data analysis. All authors contributed to the interpretation of study results and article preparation.

The authors have no conflicts of interest to disclose.

Correspondence to: Barrot H. Lambdin, PhD, MPH, Director of Implementation Science, Pangaea Global AIDS Foundation, 472 Ninth Street, Oakland, CA 94607 (e-mail:

© 2011 Lippincott Williams & Wilkins, Inc.