Determinants of loss to follow-up in patients on antiretroviral treatment, South Africa, 2004–2012: a cohort study

Mberi, Mazvita Naome; Kuonza, Lazarus; Dube, Nomathemba; Nattey, Cornelius; Manda, Samuel; Rs, Summers

doi:10.1186/s12913-015-0912-2

Cited by 84 publications

(89 citation statements)

References 19 publications

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“…The annual time points reflect the WHO recommendations for VL testing to monitor for treatment failure 8 . We have chosen to include data up to three years after ART initiation to minimise LTFU as patient retention has been shown to decrease to 65% at three years 9 . As different sites have different definitions of LTFU, patients in this study were considered to be LTFU according to the LTFU indicator provided in each regional database.…”

Section: Methodsmentioning

confidence: 99%

HIV Viral Load Suppression in Adults and Children Receiving Antiretroviral Therapy—Results From the IeDEA Collaboration

Jiamsakul

Kariminia

Althoff

et al. 2017

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Background Having 90% of patients on antiretroviral therapy (ART) and achieving an undetectable viral load (VL) is one of the 90:90:90 by 2020 targets. In this global analysis, we investigated the proportions of adult and paediatric patients with VL suppression in the first three years after ART initiation. Methods Patients from the IeDEA cohorts who initiated ART between 2010 and 2014 were included. Proportions with VL suppression (<1000 copies/mL) were estimated using: (i) strict intention-to-treat (ITT) – loss to follow-up (LTFU) and dead patients counted as having detectable VL; and (ii) modified ITT – LTFU and dead patients were excluded. Logistic regression was used to identify predictors of viral suppression at one year after ART initiation using modified ITT. Results A total of 35561 adults from 38 sites/16 countries and 2601 children from 18 sites/6 countries were included. When comparing strict with modified ITT methods, the proportion achieving VL suppression at three years from ART initiation changed from 45.1% to 90.2% in adults, and 60.6% to 80.4% in children. In adults, older age, higher CD4 count pre-ART, and homosexual/bisexual HIV exposure were associated VL suppression. In children, older age and higher CD4 percentage pre-ART showed significant associations with VL suppression. Conclusions Large increases in the proportion of VL suppression in adults were observed when we excluded those who were LTFU or had died. The increases were less pronounced in children. Greater emphasis should be made to minimise LTFU and maximise patient retention in HIV-infected patients of all age groups.

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Section: Methodsmentioning

confidence: 99%

HIV Viral Load Suppression in Adults and Children Receiving Antiretroviral Therapy—Results From the IeDEA Collaboration

Jiamsakul

Kariminia

Althoff

et al. 2017

JAIDS Journal of Acquired Immune Deficiency Syndromes

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“…Previous studies have identified the factors associated with LTFU among persons on ART to include younger age, male sex, single, divorced or separated marital status, illiteracy, having no income-generating occupation, non-disclosure of HIV diagnosis, stigma, distance to health facilities, poor nutrition, normal body mass index, pregnancy, high or low CD4 count, tuberculosis co-infection, advanced clinical staging, detectable viral load and adverse drug reactions [5,8,9,[13][14][15][16][17][18][19][20][21]. However, most of these studies employed retrospective LTFU definitions; to our knowledge, no studies have assessed factors associated with recurrent LTFU episodes from HIV programmes.…”

Section: Introductionmentioning

confidence: 99%

Prospective assessment of loss to follow‐up: incidence and associated factors in a cohort of HIV‐positive adults in rural Tanzania

et al. 2020

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Introduction Lifelong antiretroviral therapy (ART) improves health outcomes for HIV‐positive individuals, but is jeopardized by irregular clinic attendance and hence poor adherence. Loss to follow‐up (LTFU) is typically defined retrospectively but this may lead to biased inferences. We assessed incidence of and factors associated with LTFU, prospectively and accounting for recurrent LTFU episodes, in the Kilombero and Ulanga Antiretroviral Cohort (KIULARCO) of HIV‐positive persons in rural Tanzania. Methods We included adults (≥15 years) enrolled in 2005 to 2016, regardless of ART status, with follow‐up through April 2017. LTFU was defined as >60 days late for a scheduled appointment. Participants could experience multiple LTFU episodes. We performed analyses based on the first (prospective) and last (retrospective) events observed during follow‐up, and accounting for recurrent LTFU episodes. Time to LTFU was estimated using cumulative incidence functions. We assessed factors associated with LTFU using cause‐specific proportional hazards, marginal means/rates, and Prentice, Williams and Peterson models. Results Among 8087 participants (65% female, 60% aged ≥35 years, 42% WHO stage 3/4, and 47% CD4 count <200 cells/mm3), there were 8140 LTFU episodes, after which there were 2483 (31%) returns to care. One‐year LTFU probabilities were 0.41 (95% confidence interval 0.40, 0.42) and 0.21 (0.20, 0.22) considering the first and last events respectively. Factors associated with LTFU were broadly consistent across different models: being male, younger age, never married, living far from the clinic, not having an HIV‐positive partner, lower BMI, advanced WHO stage, not having tuberculosis, and shorter time since ART initiation. Associations between LTFU and pregnancy, CD4 count, and enrolment year depended on the analysis approach. Conclusions LTFU episodes were common and prompt tracing efforts are urgently needed. We identified socio‐demographic and clinical characteristics associated with LTFU that can be used to target tracing efforts and to help inform the design of appropriate interventions. Incidence of and risk factors for LTFU differed based on the LTFU definition applied, highlighting the importance of appropriately accounting for recurrent LTFU episodes. We recommend using a prospective definition of LTFU combined with recurrent event analyses in cohorts where repeated interruptions in care are common.

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“…Berheto et al and Honge et al classified patients as LTFU if they failed to pick their ART after 90 days from the last scheduled date [40,42], a similar definition to that used in our study. In the papers written by Berheto et al and Honge et al, an elevated risk of LTFU was noticeable in patients that had a baseline CD4 cell count of <200 cells/ml [37,39] while a similar risk was observed in patients with a CD4 cell count of >200 cells/ml by Mberi et al [41]. In comparison to our cohort, we categorized CD4 cell count as <350 cells/ml, 350-500 cells/ml and >500 cells/ml.…”

Section: Discussionmentioning

confidence: 99%

“…One possibility for the contrast could be differences in the determination of LTFU as well as the differing CD4 cell count thresholds used across the studies. A patient was classified LTFU if they had spent at least 180 days without picking their ART from the HIV clinic after a scheduled visit [41]. Berheto et al and Honge et al classified patients as LTFU if they failed to pick their ART after 90 days from the last scheduled date [40,42], a similar definition to that used in our study.…”

Section: Discussionmentioning

confidence: 99%

Starting antiretroviral therapy within seven days of a positive HIV test increased the risk of loss to follow up in a primary healthcare clinic: a retrospective cohort study in Masaka, Uganda

Kiwanuka

Waila

Muhindo

et al. 2019

Preprint

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19Background: Retention of patients initiated on antiretroviral therapy (ART) and good adherence 20 remain cornerstones to long-term viral suppression. In this era of test and treat (T&T), ensuring that 21 patients initiated on ART remain connected to HIV clinics will be key to the achievement of the 22 UNAIDS 90-90-90 targets. Currently, limited studies have evaluated the effect instant ART initiation 23 has on loss to follow up in a typical service healthcare setting. We studied the cumulative incidence, 24 incidence rate of loss to follow up (LTFU), and factors associated with loss to follow up (LTFU) in a 25 primary healthcare clinic that has practiced test and treat since 2012. 26Methods: We retrospectively drew routine program data of patients initiated on ART from January 27 2012 to December 2016. We defined LTFU as failure of a patient to return to the HIV clinic for at 28 least 90 days from the date of their last appointment. We calculated cumulative incidence, incidence 29 rate and fitted a multivariable Cox proportion hazards regression model to determine factors associated 30 with LTFU. 31Results: Of the 8,136 patients included in our sample, 3,606 (44.3%) started ART within seven days 32 of HIV diagnosis. Females were 62.3%, median (interquartile range) age at start of ART was 30 (25, 33 37) years, 50.1% had access to a mobile phone, 54.0% had a baseline CD4 cell count of <350 cells/ml, 34 14.8% were in either WHO stage 3 or 4 at baseline and 75.9% had a normal body mass index (BMI). 35There were 1,207 cases of LTFU observed over 15953.0 person years at risk. The overall incidence 36 rate (IR) of LTFU was 7.6 (95% CI=7.2-8.0) per 100 person years of observation (pyo). Cumulative 37 incidence of LTFU increased with duration of follow up from 8.8% (95% CI=8.2-9.4%) and 12.0% 38 (95% CI=11.2-12.7%) at 6 and 12 months, to 17.9% (95% CI=16.9-18.9%) and 20.1% (95% CI=18.9-39 21.3%) at 36, and 48 months respectively. Predictors of elevated risk of LTFU were; starting ART 40 within 7 days of a positive diagnosis ((aHR) =1.39, 95% CI, 1.13-1.71), lack of access to a telephone 41 set (aHR=1.60, 95% CI, 1.29-1.99) and baseline WHO clinical stage 3 or 4 (aHR =1.53, 95% CI, 1.11-42 2.11). Factors associated with a reduced risk of LTFU were; baseline age ≥25years, and having a BMI 43 ≥ 30 (aHR =0.28, 95% CI, 0.15-0.51). 44 Conclusion: Initiation of ART within 7 days of an HIV diagnosis was associated with an elevated risk 45 of loss to follow up. Steep ART initiation needs to be backed by enhanced adherence and retention 46 counseling to reach the 2020 UNAIDS goals and beyond.47 Keywords: Loss to follow up, Test and Treat, antiretroviral therapy, Retention.48 49 Background and rationale 50 By the end of 2017, the World Health Organization (WHO) estimated that globally about 36.9 million 51 people were living with HIV (PLHIV) and 1.8 million new infections occurred that year; over two 52 thirds of the new infections were in Sub Saharan Africa (SSA) with about 50,000 in Uganda. During 53 the same time, about 21.7 mi...

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Determinants of loss to follow-up in patients on antiretroviral treatment, South Africa, 2004–2012: a cohort study

Cited by 84 publications

References 19 publications

HIV Viral Load Suppression in Adults and Children Receiving Antiretroviral Therapy—Results From the IeDEA Collaboration

HIV Viral Load Suppression in Adults and Children Receiving Antiretroviral Therapy—Results From the IeDEA Collaboration

Prospective assessment of loss to follow‐up: incidence and associated factors in a cohort of HIV‐positive adults in rural Tanzania

Starting antiretroviral therapy within seven days of a positive HIV test increased the risk of loss to follow up in a primary healthcare clinic: a retrospective cohort study in Masaka, Uganda

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