ABSTRACT
Background: Since 2004, USAID Nigeria has supported the provision of antiretroviral therapy (ART) to 575,000 people living with HIV (PLHIV) in Nigeria through PEPFAR. Six decentralized drug distribution (DDD) ART delivery models were implemented in Akwa Ibom and Cross River states to improve continuous access to treatment for PLHIV, with the goal of achieving long-term retention in care and viral suppression. Methods: A retrospective analysis of 85,245 treatment patients who began ART between October 2001 and December 2020 was conducted. Patient data was extracted from electronic record systems and anonymized. All patients on first-line ART were included. Retention was defined as being alive and remaining on ART after initiation for at least 12 months after starting ART. While eligibility to all DDD models was restricted to stable patients, Community Pharmacy ART Refills Program (CPARP), Community ART Refill Clubs (CARCs), Family-Centered ART Refills Groups (F-CARGs), Fast-track clinic, and Adolescents Refill Clubs (ARCs) were all expanded to include stable and unstable patients after the onset of COVID-19. The Self-forming Community ART Refill Groups (S-CARG) model remained open only to stable patients. The Kaplan-Meier method was used to estimate retention probabilities, and Cox Proportional Hazards model was used to examine factors associated with retention. Results: Of the total sample, 63,175 (74%) remained on treatment and 13,800 (16%) experienced treatment interruption/LTFU. Median age at ART initiation was 39 years (IQR:32-47) and 69% of the cohort was female. Overall retention probability was 95%, 72% and 62% at 12, 24 and 36 months, respectively. The median retention time in the CPARP model was 73 months (95%CI: 71-74) compared to 49, 47, 18, 16, and 14 months in the CARC, Fast-track, ARC, F-CARG, and S-CARG models, respectively, log-rank test (p<.001). CARC DDD model [Hazard Ratio (HR):0.70 (0.66-0.73), ref: ARC], CPARP [HR:0.56 (0.53-0.60), ref: ARC], Fast-track [HR:0.70 (0.79-0.83), ref: ARC], female sex [HR:0.96 (0.94-0.97), ref: male], and 15+ years Age [HR:0.80 (0.77-0.84), ref: <15 years] were associated with long-term retention;while unemployed Occupation [HR:1.10 (1.08-1.13), ref: employed] and senior secondary Education [HR:1.20 (1.14-1.26), ref: junior secondary] were associated with short-term retention. Conclusion: Decentralized Drug Delivery models were associated with improved rates of continuity of ART treatment in a large real-world cohort in Nigeria.