objectiveCommunity ART groups (CAG), peer support groups involved in community ARTdistribution and mutual psychosocial support, were piloted to respond to staggering antiretroviraltreatment (ART) attrition in Mozambique. To understand the impact of CAG on long-term retention,we estimated mortality and lost-to-follow-up (LTFU) rates and assessed predictors for attrition.methodsRetrospective cohort study. Kaplan–Meier techniques were used to estimate mortality andLTFU in CAG. Individual- and CAG-level predictors of attrition were assessed using a multivariableCox proportional hazards model, adjusted for site-level clustering.resultsMortality and LTFU rates among 5729 CAG members were, respectively, 2.1 and 0.1 per100 person-years. Retention was 97.7% at 12 months, 96.0% at 24 months, 93.4% at 36 monthsand 91.8% at 48 months. At individual level, attrition in CAG was significantly associated withimmunosuppression when joining a CAG, and being male. At CAG level, attrition was associatedwith lack of rotational representation at the clinic, lack of a regular CD4 count among fellowmembers and linkage to a rural or district clinic compared with linkage to a peri-urban clinic.conclusionsLong-term retention in this community-based ART model compares favourably withpublished data on stable ART patients. Nevertheless, to reduce attrition, further efforts need to bemade to enrol patients earlier on ART, promote health-seeking behaviour, especially for men,promote a strong peer dynamic to assure rotational representation at the clinic and regular CD4follow-up and reinforce referral of sick patients.keywordsantiretroviral therapy, community participation, health services accessibility, HIV, peersupportIntroductionIn the past decade, the scale-up of antiretroviral therapy(ART) was spectacular. In low- and middle-income coun-tries, 9.7 million people were reported on ART at theend of 2012. But still, it is not enough. Still 1.7 millionpeople died because of AIDS in 2011 (WHO 2013a). Toreduce AIDS-related deaths, WHO recommends a newtarget of 25.9 million receiving ART in low- and middle-income countries, an unprecedented public health chal-lenge (WHO 2013b). A major bottleneck is attrition onART, which includes patients who died or who are lostto follow-up (LTFU). A meta-analysis from more than 17countries revealed a patient attrition of 30.0% and35.4% at 24 and 36 months, respectively (Fox & Rosen2010). Transport costs and distance are the mostfrequently cited barriers to adherence (Govindasamyet al.2012).In Mozambique, with a prevalence of 11.5% amongadults, more than 1.5 million Mozambicans are livingwith HIV (Ministry of Health Mozambique 2010). At theend of 2012, only 42% (308 577) of the 690 000 esti-mated in need were on ART (WHO 2012). Meanwhile,almost one-third of the people living with HIV/AIDS(PLWHA) who had started ART were either dead orLTFU (Ministry of Health Mozambique 2012a). Thedecentralisation of ART care, which aimed to decreasethe burden on overloaded clinics and increase accessibil-ity for the patients, was hampered by a lack of infrastruc-ture, a lack of human resources for health and514© 2014 John Wiley & Sons LtdTropical Medicine and International Healthdoi:10.1111/tmi.12278volume 19 no 5 pp 514–521 may 2014