Movement between facilities for HIV care among a mobile population in Kenya: transfer, loss to follow-up, and reengagement

Abstract

HIV treatment is life-long, yet many patients travel or migrate for their livelihoods, risking treatment interruption. We examine timely reengagement in care among patients who transferred-out or were lost-to-follow-up (LTFU) from a rural HIV facility. We conducted a cohort study among 369 adult patients on antiretroviral therapy between November 2011 and November 2013 on Mfangano Island, Kenya. Patients who transferred or were LTFU (i.e. missed a scheduled appointment by ≥90 days) were traced to determine if they re-engaged or accessed care at another clinic. We report cumulative incidence and time to reengagement using Cox proportional hazards models adjusted for patient demographic and clinical characteristics. Among 369 patients at the clinic, 23(6%) requested an official transfer and 78(21%) were LTFU. Among official transfers, cumulative incidence of linkage to their destination facility was 91% at three months (95%CI 69–98%). Among LTFU, cumulative incidence of reengagement in care at the original or a new clinic was 14% at three months (95%CI 7–23%) and 60% at six months (95%CI 48–69%). In the adjusted Cox model, patients who left with an official transfer reengaged in care six times faster than those who did not (aHR 6.2, 95%CI 3.4–11.0). Patients who left an island-based HIV clinic in Kenya with an official transfer letter reengaged in care faster than those who were LTFU, although many in both groups had treatment gaps long enough to risk viral rebound. Better coordination of transfers between clinics, such as assisting patients with navigating the process or improving inter-clinic communication surrounding transfers, may reduce delays in treatment during transfer and improve overall clinical outcomes.

Discontinuation from Antiretroviral Therapy: A Continuing Challenge among Adults in HIV Care in Ethiopia: A Systematic Review and Meta-Analysis

“…Only Wubshet and colleague [39] reported the number of patients who died, survived and returned to HIV care after LTFU. Previous research reported that only 14% and 60% of LTFU patients re-engaged to HIV care at three and six months respectively[64], and those patients who re-engaged accessed the care after their health had deteriorated[65]. This shows a significant oversight for the need of future research involving the role and benefits of establishing the community-tracking system[66].…”

High levels of retention in care with streamlined care and universal test and treat in East Africa

“…In addition, the care outcomes of the patients with an official transfer are unknown. However, data on patients transferring care in the region indicates almost all patients with an official transfer are linked to care at their destination facility within 3 months[38]. Only retention in the first year is captured so longer follow-up will be necessary to evaluate durability of retention in care.…”

CareConekta: study protocol for a randomized controlled trial of a mobile health intervention to improve engagement in postpartum HIV care in South Africa

“…A challenge to ensuring continuity of HIV care is that the fragmented healthcare system is not adapted for a mobile population. Patients considered LTFU actually may have switched facilities on their own as "silent transfers," which typically are not recognized due to unlinked data across facilities [18][19][20]. This misclassification makes it very difficult to accurately assess the effectiveness of national ART programs.…”