Are there differences in HIV retention in care between female and male patients in Indonesia? A multi-state analysis of a retrospective cohort study

PLoS One. 2019 Jun 25;14(6):e0218781. doi: 10.1371/journal.pone.0218781. eCollection 2019.


Background: Little is known about HIV treatment outcomes in Indonesia, which has one of the most rapidly growing HIV epidemics worldwide.

Methods: We examined possible differences in loss to follow-up (LTFU) and survival between HIV-infected females and males over a 7-year period in an HIV clinic in Bandung, West Java. Data imputation was performed on missing covariates and a multi-state Cox regression was used to investigate the effects of sex and other covariates on patient transitions among four states: (1) clinic enrollment with HIV, (2) initiation/continuation/re-initiation of antiretroviral therapy (ART), (3) LTFU, and (4) death.

Results: We followed 3215 patients (33% females), for a total of 8430 person-years. ART was used by 59% of patients at some point. One-year retention was 73% for females and 77% for males (p = 0.06). One-year survival was 98% for both females and males (p = 0.15). Females experienced a higher relative hazard to transition from HIV to LTFU (adjusted hazard ratio 1.21; 95% confidence interval 1.00-1.45), but this decreased after adjustments for clinical variables (aHR 0.94; 95% CI 0.79-1.11). Similarly, a lower relative hazard in females to transition from ART to death (aHR 0.59; 95% CI 0.35-0.99) decreased after adjustments for demographic variables.

Conclusion: This Indonesian cohort has low ART uptake and poor overall pre- and post-ART retention. Female-male differences in survival and retention were gone after adjusting for clinical and sociodemographic factors such as CD4 count and education level. Efforts should be made to improve retention among patients with lower education.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Anti-HIV Agents / therapeutic use
  • Cohort Studies
  • Female
  • HIV Infections / drug therapy*
  • HIV Infections / mortality
  • Humans
  • Indonesia / epidemiology
  • Lost to Follow-Up
  • Male
  • Middle Aged
  • Proportional Hazards Models
  • Retention in Care* / statistics & numerical data
  • Retrospective Studies
  • Sex Factors
  • Treatment Outcome
  • Young Adult


  • Anti-HIV Agents

Grant support

Data collection was partially supported by ‘IMPACT’ (Integrated management of Prevention And Care and Treatment of HIV/AIDS), a collaborative research and implementation program of Padjadjaran University, Bandung, Indonesia; Maastrict University and Radboud University Nijmegen, The Netherlands; and University of Antwerp, Belgium. The European Commission (SANTE/2005/105-033) funded IMPACT. AR received PhD funding from Netherlands Fellowship Programme and conducted this study as part of her PhD, programme/netherlands-fellowship-programmes; RW has a fellowship from Radboud University; BA has a post-doc fellowship from the Royal Dutch Academy of Arts and Science (KNAW); RvC has a VIDI grant from the Netherlands Foundation of Scientific Research (NWO). No other authors received specific funding for this work. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.