Observational study of impact of cost of transportation to clinic and retention in HIV care in a rural clinic in Northern Haiti

1. Transportation cost and
retention in HIV care in Haiti
Leonard Sowah, MBChB, MPH
Assistant Professor of Medicine
University of Maryland School of Medicine

2. Acknowledgements
• Dr. Christa Desiral – who helped with data
collection
• Miss Blaise – Who was very helpful with our
data collection
• Dr. Ivy Mwangi – Who gave advice on data
analysis
• Regine – Who helped in data collection

3. Background
• HIV infection has been shown to
disproportionately affect economically
disadvantaged individuals
• Studies in most resource limited settings and
even in developed world suggest that
transportation cost can affect HIV treatment
outcomes

4. Background
• Even in the US studies done in Southern USA suggest that
cost of transportation may affect retention in HIV clinic1
• Studies done in Sub-Saharan Africa using qualitative data
suggests that patients have to make difficult decisions to
make it to clinic appointment2
• In one study on loss to follow-up in Uganda a participant
stated; “sometimes I have to do without maybe salt,
paraffin, kerosene, so that I can get transportation to come
here2
• There is a strong correlation between compliance to clinic
appointment and failure of treatment
1. Sherer R, Stieglitz K, Narra J, et al. HIV multidisciplinary teams work: support services improve access to and retention in HIV primary care. AIDS care.
2002;14(S1):31-44.
2. Tuller DM, Bangsberg DR, Senkungu J, Ware NC, Emenyonu N, Weiser SD. Transportation costs impede sustained adherence and access to HAART in a clinic
population in southwestern Uganda: a qualitative study. AIDS and Behavior. 2010;14(4):778-784.

5. Background
• Cost of HIV care however increases
significantly if patients fail first line regimens
• HIV treatment interruptions therefore
significantly affect the stability and economic
indices of the health system1
• Losina et al calculated that treatment
interruption on average reduces life-expectancy
by 4.67 years2
1. Sanders D, Sambo A. AIDS in Africa: the implications of economic recession and structural adjustment. Health Policy and
Planning. 1991;6(2):157-165.
Losina E, Touré H, Uhler LM, et al. Cost-effectiveness of preventing loss to follow-up in HIV treatment programs: a Cote
d'Ivoire appraisal. PLoS medicine. 2009;6(10):e1000173.

6. Study Rational
Aim
• To determine if the cost of transportation
predicts loss to follow up in HIV Care
• Study Hypothesis
– Patients living in locations with transportation cost
greater than $2 are more likely to be lost to care
– Patients living in locations that require two or
more public transport trips to travel to clinic
would be more likely to be lost to care

7. Study Rational
• We also considered other variables such
as:
– Age of patient
– Sex
– Milot residents vrs non-residents
– Residence in proposed clinic catchment area
– Enrolment CD4 count

8. Study Setting
• Hopital Sacre Coeur de Milot, HIV Clinic
• Located in Northern Haiti 12 miles southwest
of Cap Haitien
• There are several other HIV treatment sites in
the area
• Clinic offers transportation assistance to
patients however policy on assistance has
gone through multiple revisions

9. HÔpital Sacre Coeur de Milot

10. Study Population
• All patients enrolled in clinic prior to
December 31st, 2006
• Exclusion Criteria
– Patients < 18 yrs of age as at December 31st 2006
– Patients without any form of address information
in Medical Record
– Patients resident in locales outside the Northern
Department

11. Patient Enrollment

12. Patient Enrollment Chart
599 individuals enrolled in clinic from
November 2004 – December 2006
53 individuals with age <18yrs
by year end 2006 excluded
546 adult patients
439 adults > 18 years old with
addresses remaining
107 individuals without
addresses excluded
29 individuals resident outside
of the Northern Department
excluded
Final sample of 410 adult patients

13. Study Methods
• Retrospective cohort design
• Data collection was by chart review of patients
enrolled from November 2004 – December 31st,
2006
• Social workers were interviewed to obtain
information on clinic policies on patient
enrolment follow-up and patient support
• Data was analyzed using Cox’s proportional
hazards regression to determine independent
predictors of being lost to follow-up.

14. Municipality Cost of two-way Taxi
Data on (Haitien Transportation Gourde)
Costs
Cost of two-way
taxi (US Dollar)
Distance in Miles
to Milot
Milot 40.00 0.94
Cap Haitien 40.00 0.94 11.24
Grande Riviere du Nord 80.00 1.88 3.63
Plaine du Nord 80.00 1.88 5.46
Quartier Morin 80.00 1.88 7.58
Limonade 80.00 1.88 8.03
Dondon 240.00 5.65 6.73
Limbe 90.00 2.12 15.21
Acul du Nord 100.00 2.35 9.16
Bahon 140.00 3.29 14.06
Borgne 280.00 6.59 30.06
Bas Limbe 200.00 4.71 19.16
Ranquitte 240.00 5.65 18.75
Sainte Raphael 240.00 5.65 14.61
Pignon 380.00 8.94 24.98
Pilate 340.00 8.00 25.24

15. Table showing distribution of patients by various covariates and adjusted
and unadjusted hazard ratios with age groups up to 60yr and above

16. Table showing unadjusted and adjusted hazards of
loss to follow by cost of transportation and distance
with age as two categories.

17. Kaplan-Meier curves of retention by
transportation cost using $1.00 cut point

18. Kaplan-Meier curves of retention by transportation cost
and number of trips
All p-values are calculated by the log-rank test with the null hypothesis that the
retention for the two groups are equal

19. Table Showing Differences in Mean Four Year
Retention time by various categories

20. Summary of Results
• The four year retention rates for patients from
communities with < $2 transportation cost is
81.9% cf 68.9% for those > $2
• Individuals from communities requiring more
than $2 for two way transportation costs are
1.91 times as likely to be lost to care in 48
mths (p-value – 0.02)

21. Summary of Results
• Younger patients aged < 30 yrs were 3 times
as likely to be lost to care in 48 mths
compared to older patients (p-value – 0.001)
• Individuals living in Milot did not have
significantly better retention in clinic
compared to all other patients
• Male patients were 1.7 times as likely to be
lost to care compared to their female
counterparts (p-value – 0.02)

22. Summary of Results
• Patients with CD4 counts less than 200 at time
of enrolment are 1.68 times more likely to be
lost to care after 48 mths (p-value 0.02)
• Male patients were 1.5 times more likely to
come from places with transportation cost >
$2 (p-value – 0.16)
• Mean transportation cost for females $1.36
(SD: 0.94), males $ 1.67 (SD:1.74)

23. Discussion
• Are patients with transportation cost > $2 who do
not show up in clinic lost to care or just
transferred to another facility?
• Why are younger patients < 30 yrs 3 times more
likely to be lost to care?
• Why are men more likely to come from places
with higher transportation costs?
• Why are some patients coming from places like
Hinche 40 miles, Borgne 30 miles and Pilate 25
miles?

24. Study Team
• Leonard Sowah1, MD,
MPH
• Franck Turenne2, MD
• Ulrike Buchwald1, MD
• Nephtalie Mesidor2, MD
• Guesly Delva1, MD
• Camille Dessaigne3, MS
• Anthony Edozien1, MD
• Harold Previl4, MD
• Devang Patel1, MD
• Robert Redfield1, MD
• Anthony Amoroso1, MD
• Institutions
– Institute of Human
Virology, Baltimore
MD1,
– Université Notre
Dame d’Haiti, Port
au Prince, Haiti2,
– University of
Miami, Miami FL3,
– Hopital Sacre
Coeur, Milot, Haiti4

25. THANK YOU VERY MUCH FOR YOUR
ATTENTION