Incidence and predictors of loss to follow-up among adults on antiretroviral therapy in Ethiopia: a systematic review and meta-analysis of cohort studies

BACKGROUND: Loss to follow-up (LTFU) from antiretroviral therapy (ART) remains a major public health concern worldwide, including in Ethiopia. However, nationally representative pooled cohort data on LTFU among adults receiving ART are limited. To address this gap, we conducted a meta-analysis to estimate the incidence and identify predictors of LTFU among adults on ART in Ethiopia. METHODS: This systematic review and meta-analysis adhered to the PRISMA guidelines. Relevant studies were identified through a comprehensive search of multiple databases, including PubMed, CINAHL, Scopus, EMBASE, and Google Scholar. Data analysis for pooled estimates of incidence and predictors was performed using STATA version 17 with the DerSimonian and Laird random-effects model. Heterogeneity was assessed using Cochrane’s Q-test and the I² statistic, while publication bias was evaluated using funnel plots and Egger’s test. RESULTS: Out of 1,245 studies identified, 24 met the inclusion criteria, comprising a total of 24,637 participants. The pooled incidence rate of LTFU among adults on ART was 8 per 100 person-years (95% CI: 7–10), and the pooled median time to LTFU was 27.77 months (95% CI: 19.22–36.32). Moreover, variation in study sample size (R² = 34.10%) contributed substantially to the high level of heterogeneity among the included studies. Predictors of LTFU included not receiving isoniazid prophylaxis (HR = 1.39, 95% CI: 1.30–1.49), fair or poor ART adherence (HR = 1.56, 95% CI: 1.49–1.64), WHO clinical stages III–IV (HR = 1.29, 95% CI: 1.21–1.38), undisclosed HIV status (HR = 1.34, 95% CI: 1.24–1.45), CD4 count < 200 cells/mm³ (HR = 1.28, 95% CI: 1.19–1.33), BMI < 18.5 kg/m² (HR = 1.34, 95% CI: 1.27–1.43), and age 15–24 years (HR = 1.31, 95% CI: 1.22–1.41). CONCLUSION: The median time to LTFU among adults on ART in Ethiopia was close to the national target, suggesting the need to enhance retention strategies. Targeted interventions should focus on young adults, undernourished patients, and those with poor adherence. Strengthening adherence support and preventive care, including isoniazid prophylaxis, is essential to improve ART retention outcomes.