Retention in Care among HIV infected Men who have Sex with Men attending a Community Health Centre, Yaba Lagos, Nigeria

Background: Given the burden of HIV infection among men who have sex with men (MSM), the paucity of research on strategies that could successfully engage and retain them in care is striking. The aim of this study was to assess the retention in care among HIV infected MSM attending a Community Health Centre, Yaba Lagos, Nigeria. Methods: This retrospective study was carried out at Community Health Centre Yaba, Lagos Nigeria. Out of 300 clients in HIV care in the facility, a total number of 181 participants were enrolled into the study. Two approaches were used for data collection. First, the clinical data of 181 participants in HIV care were abstracted from the clinic electronic records from May 2015 and then followed up to June 2016 to assess their retention in care; the second one was pretested interviewer administered semi-structured questionnaire which was used to collect information on the MSM specific factors that either facilitate or act as barriers to their retention in HIV care from the same respondents. Data was analyzed using SPSS 20. Descriptive analysis was used to analyze quantitative variables while chi square was used to measure the association. A p-value<0.05 was considered statistically significant for this study. Result: The mean age of the participants sampled was 25.4. Overall, a total number of 151 (83%) participants were retained in care within 1 year. While distance 50% and full-time job 30% were found as major barriers to retention in care, friendly clinic service 43% was identified as the major facilitators for their retention in HIV care. Conclusion: Majority of the participants were retained in HIV care over time due to robust strategies and policies put in place. Strategies to sustain the retention capacity of MSM in HIV care should be sustained. Citation: Daniel C, Ekanem EE, Njab JE, Oridota ES, Robert AA (2018) Retention in Care among HIV infected Men who have Sex with Men attending a Community Health Centre, Yaba Lagos, Nigeria. J AIDS Clin Res 9: 770. doi: 10.4172/2155-6113.1000770


Introduction
Measuring retention in HIV care is complex as it requires an assessment of multiple clinic visits occurring over time [1]. Retention in Care is defined as being an alive and still on any Anti-Retroviral Therapy (ART) within a specified assessment period of time [2]. Retention in care is associated with improved access to Anti-Retroviral Therapy (ART), greater likelihood of virologic suppression, and less rapid HIV disease progression [3][4]. The literature search, thus, revealed that current knowledge on adherence to ART and retention in care among MSM was limited as research was heavily concentrated in the United States unlike in developing countries [5][6][7][8]. There are, consequently, glaring gaps in the literature, as there appeared to be little to no research on retention in care among HIV infected MSM in developing countries, where most MSM living with HIV live [9]. Evidence has shown that one of the factors contributing to higher mortality rate among HIV infected young and adolescents were difficult in retention in care and lack of adherence to antiretroviral therapy regimens [10][11][12]. Studies have demonstrated that HIV biomarkers such as CD4 count and plasma HIV viral load have been used to measure linkage and retention in HIV care, acting as a surrogate for a completed visit [13]. Importantly, HIV infected patients with better retention capacity will be less likely to have a last CD4 cell counts<200 cells/µl. This is because treatment guidelines recommend laboratory assessments and visits for patients every 3-6 months' time intervals [14][15][16]. Research has shown that there is no gold standard for measuring patient retention in care [1]. However, different methods such as counting the number of missed visits, gaps in care and visit constancy had been used to assess retention in care. The behavioral models for vulnerable population reveals that individual and structural barriers impede retention in HIV care among men who have sex with men [17]. At the individual level, multiple cohort and survey studies have revealed that younger age, ethnicity, not having healthcare insurance, having dropped out of school, homelessness, existence of a mental disorder, use of intravenous drugs are associated with poor retention [18][19][20][21][22][23][24]. At the structural level, features of the HIV Clinic and the patient-provider relationship have been implicated as key structural factors that limit retention in care among HIV infected MSM [25][26][27][28]. Studies have revealed that the clinic-level barriers such as transportation problems, and lack of the clinic staff to consistently answer and return phone call impede retention in care [29][30][31], unstable housing conditions [32] and lack of attendance at school acted as barriers to adherence [23]. Distance to clinic and transportation have been identified as major barriers to retention in care in a wide variety of settings in Africa and Asia. In a study conducted in rural Uganda, 50% of patients lost to follow up were as a result of transportation problem and 42% was attributed to excessive distance [33]. Financial constraint contributed about 34% limiting factor to retention in care in South Africa [34]. Black race, younger age, substance abuse and alcohol use have been implicated to be associated with lower retention in care Retention in Care among HIV infected Men who have Sex with Men attending a Community Health Centre, Yaba Lagos, Nigeria among HIV infected outpatients [15,19]. Conversely, studies have identified possible facilitators such as attaining self-sufficiency through the development of a positive gay and HIV-positive identity, having a positive provider-patients relationship, and access to transportation as powerful tools that enhance retention in care [25][26][27][28]34]. Several studies have identified that engaging African American and Latino MSM in social support group interactions serves as a powerful force to retaining them in care [35].
Retention in care among HIV infected MSM has been a persistent challenge to healthcare systems because they are more likely to experience social isolation and disconnectedness to healthcare due to fear of being stigmatized and discriminated against by healthcare providers. The prevalence of HIV infection among these groups has posed a lot of threat to public health. Having discovered that men who have sex with men which are subset of the general population play a major driving role in the spread of HIV infection because of their sexual behavior that heighten their risk of contracting HIV, achieving the UNAIDS 90, 90, 90 strategy which aims to end AIDS by 2020 [36] through the diagnosis of 90% of all persons living with HIV/AIDS ,through the linkage to care of 90% of those diagnosed and through the achievement of viral suppression in 90% of the later has become worrisome. Additionally, the dearth of research (especially in developing country) that is specific for retention in care has contributed significantly in the continued HIV transmission in both minority group and general population.
Research has shown that 17% of men who have sex with men (MSM) are living with HIV in Nigeria [37]. In 12 months follow up study on retention in HIV care conducted in 21 cities in United States, about 64% of MSM were not retained in HIV care [38]. This underscores the need to improve linkage and retention in care for this population. Retaining the HIV infected MSM in care will reduce the HIV transmission and also improve their health outcome. Similarly, keying into this study will be of help in identifying those MSM specific factors that can either enhance or militate against their retention capacity in HIV care.
The goal of this study was to assess the retention in care among HIV infected MSM attending a Community Health Centre, Yaba Lagos, Nigeria. Exploring the MSM specific barriers and enhancers to HIV care will go a long way in providing a good insight on how to retain them in care.

Methods
This retrospective study on retention in care among HIV infected men who have sex with men was conducted in a Community Health Centre, Yaba Lagos. Community Health Centre is located behind Ozone Cinema in Yaba, the heart of Lagos State. This is a Henry Jackson Foundation supported Health Centre under the aegis of Population Council. The mission of this Centre is to provide free clinical, psychosocial, antiretroviral therapy, and laboratory support services to HIV and STI infected vulnerable populations (MSM, people who inject drugs, and commercial sex workers). It was designed to gain the trust of these minority groups by offering confidential services in a convenient atmosphere to them. The Community Health Centre is a two-story building with an inbuilt community Centre. This Community Centre is where MSM congregate to share their experiences after accessing care from healthcare providers. As a Non-profit International Organization sponsored PEPFAR Health Centre, it has been receiving referral HIV/ STIs infected vulnerable populations from other sister NGOs such as Society for Family Health (SFH), The initiative for Equal Rights (TIERs), Heartland Alliance, Nigeria Youth Aid Program (NYAP), and Centre for Right to Health (CRH). This site works closely with 68 Nigeria Army Reference Hospital, Yaba Lagos for other complementary services that could arise. However, the idea of choosing this Community Health Centre Yaba as a site for this study was because it served as a good site that could provide an enough sample size for this study. Also, it operates in line with international best practices, as it has an inbuilt control mechanism of storing all its data generated electronically via Health Management Information System (HMIS) which will reduce the effects of missing data of interest for this study.
A total number of 300 HIV infected MSM was enrolled on Antiretroviral Therapy from May, 2013 to June, 2016 and out of this number, 181 were recruited on this study from May, 2015 and then followed up to June, 2016 (1-year study). These 181 respondents were selected based on the eligibility criteria for the study while the remaining 119 were not eligible for the study. The target populations for this study were male that self-reported ever engaged in anal sex in the last 12 months prior to the study.
During this study, two approaches were used for data collection. The first approach was by reviewing the electronic clinic records of the HIV infected MSM that enrolled in ART from May 2015 to June 2016. Evidence has revealed that an electronic based medical record of storing information are considered one of the best approaches to obtaining valid information on utilization patterns [39]. The second approach was information on the specific factors that either enhance or act as barriers to their retention in HIV; this was collected using pretested semi-structured questionnaire developed by the researchers. These tools were divided into three sections ranging from section A, B, and C. Information on section A and B which were socio-demographic characteristics of the respondents and laboratory-based visit (last known CD4 cell count based clinic visit within the last 6 months of the study) respectively were abstracted from electronic records while section C questions that identified specific MSM factors that either enhance or mitigate their retention in care were obtained through interviewer administered questionnaire. Data on the specific MSM factors that enhance or mitigate their retention in care were collected by the health care providers such as Doctors, Nurses, Laboratorian and Pharmacist.
Retention in HIV care in this study is defined as having at least the last known CD4 cell count visit within the last 6 months of the assessment period. Retention in care was measured by the inclusion of the total enrolled participants minus [(proportion of patients lost to follow up-LFTU) plus (proportion of patients who die) plus (proportion of patients who stop ART)]. For the purpose of this study, LFTU was defined as a withdrawal from the Centre, died and stopped intake of ART before June, 2016 with no formal notice. The inclusion criteria included HIV infected self-reported men that ever engaged in anal sex in the last 12 months prior to the study, enrolled into ART for at least 1 year, age bracket of 15 years and above, and able to provide a written informed consent.
On the other hand, exclusion criteria for this study were HIV infected men that self-reported to had not engaged in anal sex within 12 mon prior to the study, HIV infected men who engaged in anal sex that enrolled in ART less than 1 year prior to the study, less than 15 years and HIV infected MSM that were receiving ART in another clinic.
Data was analyzed using SPSS version 20. Descriptive statistics was used to summarize quantitative variables while the association between the variables and retention in care was measured using chi-square test. A p-value<0.05 was considered statistically significant for the study. Table 1, showed the socio-demographic characteristics of the respondents. Majority of the study participants (53%) was within the age group of ≥ 25 years. Most of the respondents (56%) was from Igbo ethnic background. Eighty six percent (86%) of the respondents were predominantly Christians. Three quarter of participants (86%) were mainly single. Thirty four percent (34%) were Students. The proportion of participants (81%) had sexual preference for both male and female (Bisexual). More than half (72%) played both penetrative and receptive sexual role. Most of the participants (61%) had finished their secondary education. Table 2 revealed that majority of the participants (83%) were retained in HIV care. From Table 3, most of the respondents (85%) with age bracket of ≤ 25 years were retained in care. Most of the Muslim respondents (92%) was retained. Similarly, 87% of the Yoruba ethnic group were retained within 1 year compare to other ethnic group. All the respondents with Master level of education (100%) were retained in care as shown in Table 3. Half of the participant, approximately 50% and 30% of the respondents attributed distance and full-time job respectively as major barriers for not being retained in care as seen in Table 4. Around 43% and 22.5% of the respondents testified that friendly clinic services and secured environment respectively accounted for their retention in care (Table 5).

Discussion
This is the first study in Nigeria to assess the retention in care among HIV infected men who have sex with men. This study used being alive, still on ART and having laboratory based last CD4 cell count visits within the last 6 months of the assessment period as a method to assess retention in care. From the appendix below, overall, as shown in Table 2, Eighty three percent (83%) of the participants were retained in care within 1 year. This finding revealed that large percentage of the participants were retained as against what was obtained in the previous study conducted in 21 cities in the United States [38]. Perhaps, this sharp disparity may not be unconnected to the availability of MSM individual and structural service enhancers at the study site [25][26][27][28]34,35]     found to be more retained in care than older age group of ≥ 25 years as shown in Table 3. This outcome was contrary to cohort study conducted in United States that revealed an association between younger age and poor retention in care [15,19]. Majority of Muslim respondents (92%) were more retained than Christians while the Yoruba ethnic group (87%) were mostly retained in care than other ethnic groups (Igbo and Hausa). This findings was consistent with the previous research conducted in US that religion and Ethnicity limit retention in care [18][19][20][21][22][23][24][25][26][27][28][29]. Also, most of the respondents' cohabitating (100%) and single (84%) were more retained in care than others. Respondents that were identified to be practicing both penetrative and receptive sexual role (87%) were more retained than others that were engaged in either penetrative or receptive sexual role only. Respondent with Master level of education (100%) were all retained in care than those who had less education. Similarly, those respondents that were not homeless (84%) were mostly retained than those who were homeless. All these findings were consistent with the previous research that demonstrated that lack of education, and homelessness impede retention in care [18][19][20][21][22][23]32]. Table 4 revealed that around 30% of the participants attributed full time job as one of the major barriers to retention. This finding was similar to other study that identified a competing life activity such as work schedule as a major barrier to retention in care [24][25][26][27][28][29]. Similarly, most of the participant (50%) attributed distance as a major barrier for not being retained in care. This finding was consistent with other study conducted in rural Uganda that has the same economic status with Nigeria which revealed that 42% of barrier to retention in care was distance [33]. Also, ten percent (10%) of barrier to retention was found to be self-denial and this outcome was similar to the previous study that stated that difficulty with self-acceptance affect the willingness to be retained [24][25][26][27][28][29], and finally, 3.3% of them were not retained because they trusted in the efficacy of herbal medication.
Conversely, from Table 5, majority of the participants (43%) ascribed Clients-friendly clinic services they have been receiving as the major facilitator for their retention in HIV care. This may not be unconnected to the previous study that revealed that having a positive provider-patients relationship enhances retention in care [25][26][27][28]34]. It was also found that 22.5% of respondents observed friendly and secured environment as a factor that encouraged them to remain in HIV care over time. While 17.9% of the participants identified less clients' waiting times as a source of their motivator for accessing HIV care services over time, 9.3% of them attributed their retention enhancer to the availability of free health care services and drugs. This finding was in line with a study conducted by Ulett et al. [15,[25][26][27].

Conclusion
Engagement and retention in care has been linked to improved health outcomes, better medication adherence and increased overall survival [15][16][17][18][19][20]. This study was able to reveal the retention capacity of MSM in HIV care, and the associated factors that either facilitate or act as barriers to their retention in HIV care. Therefore, improving retention in care among these underserved groups begins with addressing the relevant social, economic, geographical, and political forces that are acting against them. Importantly, more research that focuses on retention in care among not only the HIV infected MSM but also all the MSM population in Nigeria will provide some effective strategies for optimizing HIV care among this groups and invariably stem down the HIV prevalence in Nigeria.

Ethical Approval
This study received ethical approval from of the Lagos University Teaching Hospital (LUTH) Health Research Ethics Committee (HREC), Idi-Araba, Lagos and Management of Population Council, Nigeria before commencing the study. Sufficient information that was enough to make an informed decision on whether or not to participate in the study were adequately explained to each respondent and signed informed consent obtained. All the respondents were assured of absolute confidentiality in the information provided and that nonparticipation or withdrawal from the study attract no penalty.

Study Limitations
The limitations encountered during the study assessment period were sexual harassment, and death that snatched the two participants away at the tail end of the assessment period.