{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,2]],"date-time":"2026-06-02T14:30:08Z","timestamp":1780410608911,"version":"3.54.1"},"reference-count":32,"publisher":"BMJ","issue":"8","license":[{"start":{"date-parts":[[2025,8,11]],"date-time":"2025-08-11T00:00:00Z","timestamp":1754870400000},"content-version":"unspecified","delay-in-days":10,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000061","name":"Fogarty International Center","doi-asserted-by":"crossref","award":["U01AI069924"],"award-info":[{"award-number":["U01AI069924"]}],"id":[{"id":"10.13039\/100000061","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100000062","name":"National Institute of Diabetes and Digestive and Kidney Diseases","doi-asserted-by":"crossref","id":[{"id":"10.13039\/100000062","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Gates Foundation","award":["031690"],"award-info":[{"award-number":["031690"]}]},{"name":"Eunice Kennedy Shriver National Institute of Child Health and Human Development"},{"DOI":"10.13039\/100000060","name":"National Institute of Allergy and Infectious Diseases","doi-asserted-by":"crossref","id":[{"id":"10.13039\/100000060","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100000026","name":"National Institute on Drug Abuse","doi-asserted-by":"crossref","id":[{"id":"10.13039\/100000026","id-type":"DOI","asserted-by":"crossref"}]},{"name":"National Cancer Institute"},{"DOI":"10.13039\/100000027","name":"National Institute on Alcohol Abuse and Alcoholism","doi-asserted-by":"crossref","id":[{"id":"10.13039\/100000027","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100000050","name":"National Heart, Lung, and Blood Institute","doi-asserted-by":"crossref","id":[{"id":"10.13039\/100000050","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Glob Health"],"accepted":{"date-parts":[[2025,7,27]]},"published-print":{"date-parts":[[2025,8]]},"abstract":"<jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>The first year after HIV treatment initiation or re-initiation is the period of highest risk of a treatment interruption or disengagement, yet little is known about the timing, patterns and effects of interruptions in the early treatment period.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>Using routinely collected electronic medical record data from 543 Zambian facilities from 2018 to 2023, we described patterns of engagement during the first year of HIV treatment. We defined engagement patterns for months 0\u20136 and months 7\u201312 after initiation or reinitiation as (1) continuous (attended all scheduled clinic and medication pickup visits as planned; (2) cyclical (attended \u22651 visits late &gt;28\u2009days but returned to and remained in care) or (3) disengaged (missed a scheduled visit by &gt;28\u2009days and had no evidence of return).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Our sample population comprised 159\u2009429 adult participants (61% female, median age 33). Of the 513\u2009322 interactions observed \u226412 months after initiation, 53% occurred as planned, 22% were late \u226428 days late, 9% were &gt;28\u2009days late, and 17% were scheduled but never attended. In 0\u20136 months after initiation, 51% clients were continuously engaged, 12% cyclically engaged and 33% disengaged. Two-thirds of disengagers (21% of cohort) did not return after the initiation visit. During months 7\u201312, most clients who had been continuously engaged in months 0\u20136 (54%) remained continuous, while 18% moved to cyclical engagement. Among cyclical engagers in months 0\u20136, nearly half (47%) moved to being continuously engaged by month 12. Only 34% of the study population remained engaged continuously by the end of the 12-month period.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Fewer than 60% of clients initiating antiretroviral therapy care between 2018 and 2022 at Zambian facilities remained continuously engaged at month 6 and 34% at month 12. Cyclical engagement and frequent interruptions should be accepted as the norm and models of service delivery designed to accommodate them.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/bmjgh-2024-017930","type":"journal-article","created":{"date-parts":[[2025,8,12]],"date-time":"2025-08-12T02:30:45Z","timestamp":1754965845000},"page":"e017930","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":5,"title":["Patterns of engagement in care during clients\u2019 first 12 months after HIV treatment initiation in Zambia: a retrospective cohort analysis using routinely collected data"],"prefix":"10.1136","volume":"10","author":[{"given":"Mariet","family":"Benade","sequence":"first","affiliation":[{"name":"Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA"},{"name":"Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa"},{"name":"Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mhairi","family":"Maskew","sequence":"additional","affiliation":[{"name":"Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2434-7004","authenticated-orcid":false,"given":"Phillip","family":"Chilembo","sequence":"additional","affiliation":[{"name":"Centre for Infectious Disease Research in Zambia, Lusaka, Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mwansa","family":"Wa Mwansa","sequence":"additional","affiliation":[{"name":"Centre for Infectious Disease Research in Zambia, Lusaka, Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Theodora","family":"Savory","sequence":"additional","affiliation":[{"name":"Centre for Infectious Disease Research in Zambia, Lusaka, Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brooke","family":"Nichols","sequence":"additional","affiliation":[{"name":"Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA"},{"name":"Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa"},{"name":"Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carolyn","family":"Bolton","sequence":"additional","affiliation":[{"name":"Centre for Infectious Disease Research in Zambia, Lusaka, Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lloyd B","family":"Mulenga","sequence":"additional","affiliation":[{"name":"Levy Mwanawasa Medical University and University Teaching Hospitals, Lusaka, Zambia"},{"name":"Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Suilanji","family":"Sivile","sequence":"additional","affiliation":[{"name":"Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3813-2784","authenticated-orcid":false,"given":"Khozya Davie","family":"Zyambo","sequence":"additional","affiliation":[{"name":"Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6560-2964","authenticated-orcid":false,"given":"Sydney","family":"Rosen","sequence":"additional","affiliation":[{"name":"Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA"},{"name":"Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,8,11]]},"reference":[{"key":"2025081119301867000_10.8.e017930.1","unstructured":"The path that ends aids: 2023 UNAIDS global aids update. Geneva: UNAIDS; 2023. Available: http:\/\/www.wipo.int\/amc\/en\/mediation\/rules"},{"key":"2025081119301867000_10.8.e017930.2","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0227572","article-title":"Same-day antiretroviral therapy initiation for HIV-infected adults in South Africa: Analysis of routine data","volume":"15","author":"Lilian","year":"2020","journal-title":"PLoS One"},{"key":"2025081119301867000_10.8.e017930.3","doi-asserted-by":"crossref","first-page":"116","DOI":"10.12688\/gatesopenres.13159.1","article-title":"Models of service delivery for optimizing a patient\u2019s first six months on antiretroviral therapy for HIV: an applied research agenda","volume":"4","author":"Rosen","year":"2020","journal-title":"Gates Open Res"},{"key":"2025081119301867000_10.8.e017930.4","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pgph.0002956","article-title":"Patterns of engagement in care during clients\u2019 first 12 months after HIV treatment initiation in South Africa: A retrospective cohort analysis using routinely collected data","volume":"4","author":"Maskew","year":"2024","journal-title":"PLOS Glob Public Health"},{"key":"2025081119301867000_10.8.e017930.5","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0027919","article-title":"Estimating loss to follow-up in HIV-infected patients on antiretroviral therapy: the effect of the competing risk of death in Zambia and Switzerland","volume":"6","author":"Sch\u00f6ni-Affolter","year":"2011","journal-title":"PLoS One"},{"key":"2025081119301867000_10.8.e017930.6","doi-asserted-by":"publisher","DOI":"10.1097\/QAD.0000000000000559"},{"key":"2025081119301867000_10.8.e017930.7","doi-asserted-by":"crossref","DOI":"10.1002\/jia2.25640","article-title":"Retention in care and viral suppression in differentiated service delivery models for HIV treatment delivery in sub-Saharan Africa: a rapid systematic review","volume":"23","author":"Long","year":"2020","journal-title":"J Int AIDS Soc"},{"key":"2025081119301867000_10.8.e017930.8","doi-asserted-by":"crossref","first-page":"e755","DOI":"10.1016\/S2352-3018(21)00186-7","article-title":"Effects of implementing universal and rapid HIV treatment on initiation of antiretroviral therapy and retention in care in Zambia: a natural experiment using regression discontinuity","volume":"8","author":"Mody","year":"2021","journal-title":"Lancet HIV"},{"key":"2025081119301867000_10.8.e017930.9","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0222309","article-title":"Retention and predictors of attrition among patients who started antiretroviral therapy in Zimbabwe\u2019s national antiretroviral therapy programme between 2012 and 2015","volume":"15","author":"Makurumidze","year":"2020","journal-title":"PLoS One"},{"key":"2025081119301867000_10.8.e017930.10","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2022-064070","article-title":"How soon should patients be eligible for differentiated service delivery models for antiretroviral treatment? Evidence from a retrospective cohort study in Zambia","volume":"12","author":"Jamieson","year":"2022","journal-title":"BMJ Open"},{"key":"2025081119301867000_10.8.e017930.11","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1002268","article-title":"A new cascade of HIV care for the era of \u201ctreat all\u201d","volume":"14","author":"Fox","year":"2017","journal-title":"PLoS Med"},{"key":"2025081119301867000_10.8.e017930.12","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1003651","article-title":"The revolving door of HIV care: Revising the service delivery cascade to achieve the UNAIDS 95-95-95 goals","volume":"18","author":"Ehrenkranz","year":"2021","journal-title":"PLoS Med"},{"key":"2025081119301867000_10.8.e017930.13","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1004407","article-title":"The cyclical cascade of HIV care: Temporal care engagement trends within a population-wide cohort","volume":"21","author":"Euvrard","year":"2024","journal-title":"PLoS Med"},{"key":"2025081119301867000_10.8.e017930.14","doi-asserted-by":"crossref","first-page":"e561","DOI":"10.1093\/cid\/ciaa268","article-title":"Longitudinal Care Cascade Outcomes Among People Eligible for Antiretroviral Therapy Who Are Newly Linking to Care in Zambia: A Multistate Analysis","volume":"71","author":"Mody","year":"2020","journal-title":"Clin Infect Dis"},{"key":"2025081119301867000_10.8.e017930.15","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2019-035246","article-title":"International epidemiology databases to evaluate AIDS (IeDEA) in sub-Saharan Africa, 2012-2019","volume":"10","author":"Chammartin","year":"2020","journal-title":"BMJ Open"},{"key":"2025081119301867000_10.8.e017930.16","first-page":"20","article-title":"Trends in CD4 and viral load testing 2005 to 2018: multi-cohort study of people living with HIV in Southern Africa","volume":"10","author":"Zaniewski","year":"2020","journal-title":"Josephine Muhairwe"},{"key":"2025081119301867000_10.8.e017930.17","doi-asserted-by":"crossref","first-page":"e26","DOI":"10.1016\/S2352-3018(24)00264-9","article-title":"Effect of a multicomponent, person-centred care intervention on client experience and HIV treatment outcomes in Zambia: a stepped-wedge, cluster-randomised trial","volume":"12","author":"Sikombe","year":"2025","journal-title":"Lancet HIV"},{"key":"2025081119301867000_10.8.e017930.18","doi-asserted-by":"crossref","DOI":"10.1038\/s41598-024-57774-9","article-title":"Supporting re-engagement with HIV services after treatment interruption in South Africa: a mixed method program evaluation of MSF\u2019s Welcome Service","volume":"14","author":"Arendse","year":"2024","journal-title":"Sci Rep"},{"key":"2025081119301867000_10.8.e017930.19","doi-asserted-by":"crossref","DOI":"10.1002\/jia2.25853","article-title":"The effect of tracer contact on return to care among adult, \u201clost to follow-up\u201d patients living with HIV in Zambia: an instrumental variable analysis","volume":"24","author":"Beres","year":"2021","journal-title":"J Int AIDS Soc"},{"key":"2025081119301867000_10.8.e017930.20","doi-asserted-by":"publisher","DOI":"10.1093\/cid\/cix191"},{"key":"2025081119301867000_10.8.e017930.21","doi-asserted-by":"crossref","first-page":"2130","DOI":"10.1016\/S0140-6736(21)01163-6","article-title":"HIV services in sub-Saharan Africa: the greatest gap is men","volume":"397","author":"Cornell","year":"2021","journal-title":"The Lancet"},{"key":"2025081119301867000_10.8.e017930.22","unstructured":"World Health Organization . Men and HIV: evidence-based approaches and interventions a framework for person-centred health services. 2023."},{"key":"2025081119301867000_10.8.e017930.23","doi-asserted-by":"crossref","DOI":"10.3389\/fpubh.2023.1244125","article-title":"HIV test-and-treat policy improves clinical outcomes in Zambian adults from Southern Province: a multicenter retrospective cohort study","volume":"11","author":"Hamooya","year":"2023","journal-title":"Front Public Health"},{"key":"2025081119301867000_10.8.e017930.24","doi-asserted-by":"crossref","unstructured":"Maskew M , Smith S , De Voux L , et al . Triaging clients at risk of disengagement from hiv care: application of a predictive model to clinical trial data in south africa. Epidemiology [Preprint] 2024. doi:10.1101\/2024.08.05.24311488","DOI":"10.1101\/2024.08.05.24311488"},{"key":"2025081119301867000_10.8.e017930.25","first-page":"1","article-title":"Factors Associated with Retention of HIV Patients on Antiretroviral Therapy in Care: Evidence from Outpatient Clinics in Two Provinces of the Democratic Republic of the Congo (DRC)","volume":"7","author":"Shah","year":"2022","journal-title":"Trop Med Infect Dis"},{"key":"2025081119301867000_10.8.e017930.26","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1002811","article-title":"Retention and viral suppression in a cohort of HIV patients on antiretroviral therapy in Zambia: Regionally representative estimates using a multistage-sampling-based approach","volume":"16","author":"Sikazwe","year":"2019","journal-title":"PLoS Med"},{"key":"2025081119301867000_10.8.e017930.27","doi-asserted-by":"crossref","DOI":"10.1186\/s43058-023-00430-6","article-title":"Exploring communication and implementation challenges of the HIV\/AIDS policy change to test-and-treat-all in selected public health facilities in Lusaka District, Zambia","volume":"4","author":"Simooya","year":"2023","journal-title":"Implement Sci Commun"},{"key":"2025081119301867000_10.8.e017930.28","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2022-070384","article-title":"Estimating potential silent transfer using baseline viral load measures among people presenting as new to HIV care in Lusaka, Zambia: a cross-sectional study","volume":"13","author":"Pry","year":"2023","journal-title":"BMJ Open"},{"key":"2025081119301867000_10.8.e017930.29","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0241477","article-title":"Understanding patient transfers across multiple clinics in Zambia among HIV infected adults","volume":"15","author":"Sikombe","year":"2020","journal-title":"PLoS ONE"},{"key":"2025081119301867000_10.8.e017930.30","article-title":"Factors affecting the implementation of the SmartCare EHR system in Zambia","volume":"7","author":"Kaumba","year":"2023","journal-title":"Soc Sci Humanit Open"},{"key":"2025081119301867000_10.8.e017930.31","doi-asserted-by":"crossref","first-page":"47","DOI":"10.5588\/pha.19.0068","article-title":"Effects of real-time electronic data entry on HIV programme data quality in Lusaka, Zambia","volume":"10","author":"Moomba","year":"2020","journal-title":"Public Health Action"},{"key":"2025081119301867000_10.8.e017930.32","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2021-007312","article-title":"Mitigating the effects of COVID-19 on HIV treatment and care in Lusaka, Zambia: a before-after cohort study using mixed effects regression","volume":"7","author":"Pry","year":"2022","journal-title":"BMJ Glob Health"}],"container-title":["BMJ Global Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjgh-2024-017930","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,12]],"date-time":"2025-08-12T02:30:53Z","timestamp":1754965853000},"score":1,"resource":{"primary":{"URL":"https:\/\/gh.bmj.com\/lookup\/doi\/10.1136\/bmjgh-2024-017930"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,8]]},"references-count":32,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2025,8,11]]},"published-print":{"date-parts":[[2025,8]]}},"alternative-id":["10.1136\/bmjgh-2024-017930"],"URL":"https:\/\/doi.org\/10.1136\/bmjgh-2024-017930","relation":{},"ISSN":["2059-7908"],"issn-type":[{"value":"2059-7908","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,8]]}}}