Brief Report: Mortality After Loss to Follow-Up—A Linkage Study of People Living With HIV in Thailand and Malaysia

Abstract

Background: Linkage studies have reported high rates of previously unascertained mortality among people living with HIV (PLHIV) who have been lost to follow-up (LTFU). We assessed survival outcomes among PLHIV who were LTFU in Thailand and Malaysia, through linkages to a national death registry or HIV database.Methods: Data linkages with the national death registry or national HIV database were conducted in 2020 on all PLHIV who met LTFU criteria while enrolled in care at participating HIV clinical sites. LTFU was defined as having no documented clinical contact in the previous year, excluding transfers and deaths. Survival time was analyzed using the Cox regression, stratified by site.Results: Data linkages were performed for 489 PLHIV who had been LTFU at sites in Malaysia (n = 2) and Thailand (n = 4). There were 151 (31%) deaths after being LTFU; the mortality rate was 4.89 per 100 person-years. Risk factors for mortality after being LTFU were older age [41-50 years: hazard ratio (HR) = 1.99, 95% confidence interval (CI): 1.08 to 3.68; and older than 50 years: HR = 4.93, 95% CI: 2.63 to 9.22; vs. age 30 years or younger]; receiving NRTI + PI (HR = 1.87, 95% CI: 1.22 to 2.85 vs. NRTI + NNRTI); positive hepatitis C antibody (HR = 2.25, 95% CI: 1.40 to 3.62); and having previous AIDS illness (HR = 1.45, 95% CI: 1.03 to 2.05). An improved survival was seen with a higher CD4 count (CD4 351-500 cells/mL: HR = 0.40, 95%CI: 0.21-0.76; and CD4 .500 cells/mL: HR = 0.43, 95%CI: 0.25-0.75; vs. CD4 #200 cells/mL).Conclusions: Almost one-third of PLHIV who were LTFU in this cohort had died while out of care, emphasizing the importance of efforts to reengage PLHIV after they have been LTFU and ensure they have access to ongoing ART.

Long-term HIV care outcomes under universal HIV treatment guidelines: A retrospective cohort study in 25 countries

“…Study limitations include well-known limitations of observational studies for causal attribution, along with possible underascertainment of deaths and transfers to other sites of care in routine HIV service delivery data [ 30 – 32 ]. As tracing studies have reported rates of undocumented (i.e., “silent”) transfer ranging from 4% to 54% among patients lost to follow-up [ 30 – 32 ], true LTC may be overestimated in our study, and deaths and transfers are likely underestimated [ 33 ]. Although WHO began recommending the decentralization of HIV care in LMICs in the mid- to late 2000s, well before the adoption of universal HIV treatment guidelines in these settings [ 34 – 36 ] and we used a conservative definition of LTC [ 37 ], it is possible that decentralization has accelerated with the rollout of universal treatment policies, resulting more undocumented transfers, particularly among patients at centralized or tertiary care sites who silently transfer to peripheral HIV care facilities [ 31 , 32 ].…”

Advanced HIV disease in Homa Bay County, Kenya: Characteristics of newly-diagnosed and antiretroviral therapy-experienced clients

“…[ 21 , 22 ] Additionally, LTFU could be an indicator of death. [ 23 , 24 ] It is possible that some of the ART-experienced clients previously initiated and reengaged in care may have been failing on treatment but continued to receive suboptimal non-suppressive treatment and hence had increased risk of mortality. A systematic review and meta-analysis from sub-Saharan Africa reported a mean delay between confirmation of treatment failure and switch of therapy of 530 days.…”