Systematic review and meta-analysis of retention and disengagement after initiation on antiretroviral therapy in low- and middle-income countries after the introduction of Universal Test and Treat policies.

Introduction: We previously published a systematic review evaluating retention in care after antiretroviral therapy initiation among adults in low- and middle-income countries from 2008 to 2013. This review evaluates retention after the implementation of Universal Test and Treat (UTT) in 2015.

Methods: We searched PubMed, ISI Web of Science, Cochrane Database of Systematic Reviews and EMBASE for studies published 1 January 2017, through 31 December 2024 and searched conference abstract repositories from AIDS, IAS and CROI from 2015 to 2024. Retention for each study was estimated using (1) simple averages and (2) interpolated for missing time points through the last reported time point. Our outcomes were all-cause attrition and retention. We estimated retention rates using a generalized linear mixed model (GLMM) with a logit distribution using interpolated data.

Results: Seventy studies met our inclusion criteria. Most studies came from Africa, with very few from Europe and Asia. Few studies reported retention past the first 12 months following treatment initiation. Across all studies, we estimated simple average retention without interpolation of missing time points to be 72.6% at 12 months, 75.2% at 24 months, 67.7% at 36 months and 64.8% at 48 months. Utilizing a GLMM model, we estimated retention to be 79.6% at 12 months, 81.2% at 24 months, 75.6% at 36 months and 72.8% at 48 months. Whereas in our prior 2015 review, we estimated retention rates to be 86.0% at 12 months, 79.0% at 24 months, 75.0% at 36 months, and 69.0% at 48 months. These results generally reflect retention at the initiating facility and omit the effect of unreported transfers.

Discussion: Retention in care at 36 months was estimated to be between 67% and 75%. Compared to results from our prior review, retention is largely similar in the post-UTT era. Further research evaluating retention in other geographic areas (i.e. Latin America and the Caribbean, Europe, and Asia) is needed.

Conclusions: Attrition after the first 2 years in treatment remains a concern, and concerted efforts should be made to ensure patients remain engaged in care over their lifetime. The impact of PEPFAR's recent cuts needs to be evaluated further to understand the effect it may have on long-term retention.