The impact of out-of-pocket expenditures on missed appointments at HIV care and treatment centers in Northern Tanzania

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Background: Missed clinic appointments negatively impact clinic patient flow and health outcomes of people living with HIV (PLHIV). PLHIV likelihood of missing clinic appointments is associated with direct and indirect expenditures made while accessing HIV care. The objective of this study was to examine the relationship between out-of-pocket (OOP) health expenditures and the likelihood of missing appointments. Method: Totally 618 PLHIV older than 18 years attending two HIV care and treatment centres (CTC) in Northern Tanzania were enrolled in the study. Clinic attendance and clinical characteristics were abstracted from medical records. Information on OOP health expenditures, demographics, and socio-economic factors were self-reported by the participants. We used a hurdle model. The first part of the hurdle model assessed the marginal effect of a one Tanzanian Shillings (TZS) increase in OOP health expenditure on the probability of having a missed appointment and the second part assessed the probability of having missed appointments for those who had missed an appointment over the study period. Results: Among these 618 participants, 242 (39%) had at least one missed clinic appointment in the past year. OOP expenditure was not significantly associated with the number of missed clinic appointments. The median amount of OOP paid was 5 100 TZS per visit, about 7% of the median monthly income. Participants who were separated from their partners (adjusted odds ratio [AOR] = 1.83, 95% confidence interval [CI]:1.11‒8.03) and those aged above 50 years (AOR = 2.85, 95% CI: 1.01‒8.03) were significantly associated with missing an appointment. For those who had at least one missed appointment over the study period, the probability of missing a clinic appointment was significantly associated with seeking care in a public CTC (P = 0.49, 95% CI: 0.88‒0.09) and aged between > 25‒35 years (P = 0.90, 95% CI: 0.11‒1.69). Conclusion: Interventions focused on improving compliance to clinic appointments should target public CTCs, PLHIV aged between > 25‒35 years, above 50 years of age and those who are separated from their partners.






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Mhina, C, H Bosworth, JA Bartlett, H Vilme, JH Mosha, DF Shoo, TJ Kakumbi, G Jacob, et al. (2021). The impact of out-of-pocket expenditures on missed appointments at HIV care and treatment centers in Northern Tanzania. Global Health Journal, 5(2). pp. 90–96. 10.1016/j.glohj.2021.04.004 Retrieved from

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Carl Mhina


Hayden Barry Bosworth

Professor in Population Health Sciences

Dr. Bosworth is a health services researcher and Deputy Director of the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)  at the Durham VA Medical Center. He is also Vice Chair of Education and Professor of Population Health Sciences. He is also a Professor of Medicine, Psychiatry, and Nursing at Duke University Medical Center and Adjunct Professor in Health Policy and Administration at the School of Public Health at the University of North Carolina at Chapel Hill. His research interests comprise three overarching areas of research: 1) clinical research that provides knowledge for improving patients’ treatment adherence and self-management in chronic care; 2) translation research to improve access to quality of care; and 3) eliminate health care disparities. 

Dr. Bosworth is the recipient of an American Heart Association established investigator award, the 2013 VA Undersecretary Award for Outstanding Achievement in Health Services Research (The annual award is the highest honor for VA health services researchers), and a VA Senior Career Scientist Award. In terms of self-management, Dr. Bosworth has expertise developing interventions to improve health behaviors related to hypertension, coronary artery disease, and depression, and has been developing and implementing tailored patient interventions to reduce the burden of other chronic diseases. These trials focus on motivating individuals to initiate health behaviors and sustaining them long term and use members of the healthcare team, particularly pharmacists and nurses. He has been the Principal Investigator of over 30 trials resulting in over 400 peer reviewed publications and four books. This work has been or is being implemented in multiple arenas including Medicaid of North Carolina, private payers, The United Kingdom National Health System Direct, Kaiser Health care system, and the Veterans Affairs.

Areas of Expertise: Health Behavior, Health Services Research, Implementation Science, Health Measurement, and Health Policy


John Alexander Bartlett

Professor of Medicine

My clinical investigation is focused on the pathogenesis and treatment of HIV infection and its complications, especially in resource-limited settings.

Key Words: HIV infection, AIDS, treatment strategies, treatment failure, co-infections, resource-limited settings

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