Patterns and Predictors of Incident Return to HIV Care Among Traced, Disengaged Patients in Zambia: Analysis of a prospective cohort.

BACKGROUND Dynamic movement of patients in and out of HIV care is prevalent, but there is limited information on patterns of patient re-engagement or predictors of return to guide HIV programs to better support patient engagement. METHODS From a probability-based sample of lost to follow-up, adult patients traced by peer educators from 31 Zambian health facilities, we prospectively followed disengaged HIV patients for return clinic visits. We estimated cumulative incidence of return and time to return using Kaplan Meier methods. We used univariate and multivariable Cox proportional hazards regression to conduct a risk factor analysis identifying predictors of incident return across a social ecological framework. RESULTS Of the 556 disengaged patients, 73.0% (95% CI: 61.0-83.8) returned to HIV care. Median follow-up time from disengagement was 32.3 months (IQR: 23.6-38.9). The rate of return decreased with time post-disengagement. Independent predictors of incident return included a prior gap in care (aHR: 1.95, 95%CI: 1.23-3.09) and confronting a stigmatizer once in the past year (aHR: 2.14, 95%CI: 1.25-3.65). Compared to a rural facility, patients were less likely to return if they sought care from an urban facility (aHR: 0.68, 95%CI: 0.48-0.96) or hospital (aHR: 0.52, 95%CI: 0.33-0.82). CONCLUSIONS Interventions are needed to hasten re-engagement in HIV care. Early and differential interventions by time since disengagement may improve intervention effectiveness. Patients in urban and tertiary care settings may need additional support. Improving patient resilience, outreach after a care gap, and community stigma reduction may facilitate return. Future re-engagement research should include causal evaluation of identified factors.