Outcomes of Patients Lost to Follow-up in African Antiretroviral Therapy Programs: Individual Patient Data Meta-analysis

Chammartin, Frédérique; Zürcher, Kathrin; Keiser, Olivia; Weigel, Ralf; Chu, Kathryn; Kiragga, Agnes; Ardura‐Garcia, Cristina; Anderegg, Nanina; Laurent, Christian; Cornell, Morna; Tweya, Hannock; Haas, Andreas D; Rice, Brian; Geng, Elvin; Fox, Matthew P.; Hargreaves, James; Egger, Matthias

doi:10.1093/cid/ciy347

Cited by 83 publications

(87 citation statements)

References 47 publications

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“…Our study has some limitations. First, we are likely to have overestimated loss to follow‐up as several studies have demonstrated high mortality and “silent transfers” to other clinics among people not retained in care in LMICs [18]. As we used routinely collected data from eight clinics, we were unable to search for silent transfers to other clinics, and did not have consent to search for deaths on the national registry.…”

Section: Discussionmentioning

confidence: 99%

“…Patients whose records stated “transferred out” to another clinic were not defined as lost to follow‐up, but were censored on the day of last visit. We combined lost to follow‐up and death, as death is poorly recorded in the TIER.net register, and there is evidence that a significant proportion of patients lost to follow‐up in ART programmes have died [18].…”

Section: Methodsmentioning

confidence: 99%

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HIV treatment outcomes among people with initiation CD4 counts >500 cells/µL after implementation of Treat All in South African public clinics: a retrospective cohort study

et al. 2020

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Introduction:The World Health Organisation recommends to Treat All people with HIV, irrespective of CD4 count. However, people with CD4 counts >500 cells/µL may be asymptomatic and therefore less motivated to adhere to antiretroviral therapy (ART). We aimed to assess whether people initiated with CD4 counts >500 cells/µL had worse treatment outcomes compared to those initiated at lower CD4 counts. Methods: We performed a retrospective cohort study among non-pregnant adults initiating ART at eight public clinics in South Africa between September 2016, when Treat All was implemented, and August 2017. We assessed whether initiation CD4 count >500 cells/µL was associated with the outcomes of attrition (death, lost to follow-up or treatment interruption >180 days), and viraemia >1000 copies/mL, by twelve months using Cox proportional hazards and Poisson regression models. Results and discussion: Among 4952 patients initiating ART, the median age was 32.4 years (interquartile range (IQR) 27.2 to 39.7), 58.9% were women and 30.3% had an initiation CD4 count >500 cells/µL. After twelve months, 3382 (68.3%) were retained in care, 303 (6.1%) had transferred to another clinic, 1010 (20.4%) were lost to follow-up, 232 (4.7%) had a treatment interruption >180 days and 25 (0.5%) were known to have died. Overall, 1267 experienced attrition at a median time of 91 days (IQR 23 to 213), with 302 of these (23.8%) experiencing attrition immediately after their ART initiation visit. Among those in care at twelve months with viral load results, 4.6% had viraemia. In multivariable analysis, the hazard of attrition was similar between patients newly eligible for ART with CD4 counts >500 cells/µL compared to those with CD4 ≤500 cells/µL (adjusted hazard ratio 1.03, 95% confidence interval (CI) 0.90 to 1.17). The risk of viraemia was lower among patients with CD4 counts >500 cells/µL compared to those with CD4 ≤500 cells/µL (adjusted risk ratio 0.58, 95% CI 0.37 to 0.92). Conclusions: After implementation of Treat All in South African public clinics, we found that patients newly eligible for ART with initiation CD4 counts >500 cells/µL had comparable or better outcomes compared to those with lower CD4 counts. These finding support ongoing implementation of Treat All in our setting.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

HIV treatment outcomes among people with initiation CD4 counts >500 cells/µL after implementation of Treat All in South African public clinics: a retrospective cohort study

et al. 2020

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“…Similar levels of transfers have been reported other African studies. In an individual patient data meta‐analysis of nine tracing studies conducted in SSA, 15% of the patients had transferred to another facility at the third year . A previous study cited the decentralisation of treatment and the proximity to new health facility offering ART as the main reason for transferring .…”

Section: Discussionmentioning

confidence: 99%

Outcomes of patients lost to follow‐up after antiretroviral therapy initiation in rural north‐eastern South Africa

Ambia

Kabudula

Risher

et al. 2019

Tropical Med Int Health

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Objective The vital status of patients lost to follow‐up often remains unknown in antiretroviral therapy (ART) programmes in sub‐Saharan Africa because medical records are no longer updated once the patient disengages from care. Thus, we aimed to assess the outcomes of patients lost to follow‐up after ART initiation in north‐eastern South Africa. Methods Using data from a rural area in north‐eastern South Africa, we estimated the cumulative incidence of patient outcomes (i) after treatment initiation using clinical records, and (ii) after loss to follow‐up (LTFU) using data from clients that have been individually linked to Agincourt Health and Demographic Surveillance System (AHDSS) database. Aside from LTFU, we considered mortality, re‐engagement and migration out of the study site. Cox proportional hazards regression was used to identify covariates of these patient outcomes. Results Between April 2014 and July 2017, 3700 patients initiated ART and contributed a total of 6818 person‐years of follow‐up time. Three years after ART initiation, clinical record‐based estimates of LTFU, mortality and documented transfers were 41.0% (95% CI: 38.5–43.4%), 1.9% (95% CI 1.0–3.2%) and 0.1% (95% CI 0.0–0.9%), respectively. Among those who were LTFU, the cumulative incidence of re‐engagement, out‐migration and mortality at 3 years were 38.1% (95% CI 33.1–43.0%), 49.4% (95% CI 43.1–55.3%) and 4.7% (95% CI 3.5–6.2%), respectively. Pregnant or breastfeeding women, foreigners and those who initiated ART most recently were at an increased risk of LTFU. Conclusion LTFU among patients starting ART in north‐eastern South Africa is relatively high and has increased in recent years as more asymptomatic patients have initiated treatment. Even though this tendency is of concern in light of the prevention of onwards transmission, we also found that re‐engagement in care is common and mortality among persons LTFU relatively low.

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“…In our cohort this number was even higher in those with EPTB diagnosis. A recent meta-analysis including data of 7,377 patients who started cART and were subsequently LTFU showed a rate of 21.8% of subjects to be deceased while 14.8% of patients LTFU have been transferred to another clinic [46]. Factors associated with poor outcome in patients with EPTB in our study were age of >45 years and not being on cART.…”

Section: Discussionmentioning

confidence: 51%

Extrapulmonary tuberculosis in HIV-infected patients in rural Tanzania: The prospective Kilombero and Ulanga antiretroviral cohort

et al. 2020

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BackgroundIn sub-Saharan Africa, diagnosis and management of extrapulmonary tuberculosis (EPTB) in people living with HIV (PLHIV) remains a major challenge. This study aimed to characterize the epidemiology and risk factors for poor outcome of extrapulmonary tuberculosis in people living with HIV (PLHIV) in a rural setting in Tanzania. MethodsWe included PLHIV >18 years of age enrolled into the Kilombero and Ulanga antiretroviral cohort (KIULARCO) from 2013 to 2017. We assessed the diagnosis of tuberculosis by integrating prospectively collected clinical and microbiological data. We calculated prevalenceand incidence rates and used Cox regression analysis to evaluate the association of risk factors in extrapulmonary tuberculosis (EPTB) with a combined endpoint of lost to follow-up (LTFU) and death. ResultsWe included 3,129 subjects (64.5% female) with a median age of 38 years (interquartile range [IQR] 31-46) and a median CD4+ cell count of 229/μl (IQR 94-421) at baseline. During the median follow-up of 1.25 years (IQR 0.46-2.85), 574 (18.4%) subjects were diagnosed with tuberculosis, whereof 175 (30.5%) had an extrapulmonary manifestation. Microbiological evidence by Acid-Fast-Bacillus stain (AFB-stain) or Xpert ® MTB/RIF was present in 178/483 (36.9%) patients with pulmonary and in 28/175 (16.0%) of patients with extrapulmonary manifestations, respectively. Incidence density rates for pulmonary Tuberculosis (PTB and EPTB were 17.9/1000person-years (py) (95% CI 14.2-22.6) and 5.8/1000 PLOS ONEPLOS ONE | https://doi.org/10.

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Outcomes of Patients Lost to Follow-up in African Antiretroviral Therapy Programs: Individual Patient Data Meta-analysis

Abstract: Retention on antiretrovirals is of concern in Africa. We analyzed outcomes in patients lost to follow-up: at 4 years after last contact, 22% had died, 23% had stopped therapy, 15% were in another clinic, and 32% could not be found.

Cited by 83 publications

References 47 publications

HIV treatment outcomes among people with initiation CD4 counts >500 cells/µL after implementation of Treat All in South African public clinics: a retrospective cohort study

HIV treatment outcomes among people with initiation CD4 counts >500 cells/µL after implementation of Treat All in South African public clinics: a retrospective cohort study

Outcomes of patients lost to follow‐up after antiretroviral therapy initiation in rural north‐eastern South Africa

Extrapulmonary tuberculosis in HIV-infected patients in rural Tanzania: The prospective Kilombero and Ulanga antiretroviral cohort

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