1. Patient retention in the public sector ART
programme in Free State province,
South African
Frikkie Booysen & Katinka de Wet
University of the Free State
5th SAHARA conference on Socio-Cultural
Responses to HIV
03 December 2009, Gallagher Estate, Johannesburg

2. Acknowledgement
This research was supported financially by the Canadian
International Development Agency (CIDA), Development
Cooperation Ireland (DCI), Department for International
Development (DfID), International Development
Research Center (IDRC), Joint Economics, Aids and
Poverty Programme (JEAPP), United States Agency for
International Development (USAID), Australian Agency
for International Development (AUSAID), Medical
Research Council (MRC), National Research Foundation
(NRF), The World Bank, and Bank-Netherlands Program
Partnership (BNP). The findings, interpretations and
conclusions expressed in this paper are entirely those of
the author(s) and do not necessarily represent the view
of these agencies or institutions, their Directors, or the
countries they represent.

3. Background
• Substantial strides have been made in rolling out
ART to growing numbers of patients in resource-
poor settings.
• Given the life-long nature of treatment and the
high costs associated with second line
treatment, which is required where drug
resistance arise due to poor adherence, patient
retention in ART programmes is important in
ensuring the long-term efficacy and
sustainability of ARV treatment programmes.

4. Data and method
• Structured personal interviews with 452 clients
enrolled in FS programme in 2004/05
• Multiple regression analysis aimed at identifying
correlates of having miss a clinic visit
• Semi-structured personal interviews with nurses
• Open-ended questions @ why clients default or
missing appointments at the clinic
• Content analysis used to identify key themes

5. Figure 1: Percentage of ART clients in 2004/5 cohort
study missing a visit to the clinic
18
16
14
12
Percentage
10
8
6
4
2
0
1 2 3 4 5 total
Follow-up interview

6. Figure 2: Main reason for having missed a clinic
visit since initiation/previous interview
Reason Number Percentage
Health/illness 31 24.8
Poverty/lack of income 23 18.4
Forgetfulness 22 17.6
Mobility/migration 19 15.2
Dispensing procedure/practice 12 9.6
Employment 10 8
Other responsibilities/commitments 9 7.2
Service delivery problems 9 7.2
Defaulted 4 3.2
Transport/distance 2 1.6
Other 4 3.2

7. Figure 3: Correlates of having missed a clinic
visit since initiating ART / previous interview
Multiple logistic
Variable regression model
Employed (yes/no) 0.313 *
Main breadwinner (yes/no) 0.536 *
Visited a traditional healer (yes/no) 3.105 *
Visited by a lay health worker (yes/no) 3.028 *
Health-related quality of life (EQ-VAS) 0.983 **
Separate waiting areas in clinic (yes/no) 2.246 **
Took time off work, took leave or lost income (yes/no) 3.533 *
Service quality 0.942 ***
Sample (N) 359 (1,197)
Wald chi2 (p-value) 81.8 (0.008)
LR test chi2 (p-value) 4.84 (0.014)

8. Qualitative evidence from
interviews with nurses
• Manifold and complex reasons
• Prominent reasons:
– Poverty, unemployment and lack of money for food/transport
– Migration/mobility
– Side effects and health status
– Stigma and mental health/well-being
– Absence of support from family/treatment buddy
– Provider-patient relationships
– Clinic resources for tracking defaulters

9. Limitations
• Underestimate default or problems with patient
retention: ART clients enrolled in and remaining
in the study are not representative of total
population of ART clients
• Results not generalisable beyond the Free State
public sector ART programme in the 16 phase I
facilities where the study was conducted

10. Conclusion
• What common themes have emerged from this mixed
methods work on patient retention?
– Optimal, holistic treatment response
– Assistance/support to poor and unemployed
– Quality management and management systems
– Infrastructural design
– Role of employers and workplace programmes
– Integration with traditional health practitioners
– Dedicated financial and human resources
• Policy and practice on above should be informed by
current best practice as well as rigorous evaluation of
proposed interventions prior to scale-up