Outcomes of HIV‐positive patients lost to follow‐up in African treatment programmes

Abstract

OBJECTIVE The retention of patients on antiretroviral therapy (ART) is key to achieving global targets in response to the HIV epidemic. Loss to follow-up (LTFU) can be substantial, with unknown outcomes for patients lost to ART programmes. We examined changes in outcomes of patients LTFU over calendar time, assessed associations with other study and programme characteristics and investigated the relative success of different tracing methods. METHODS We performed a systematic review and logistic random-effects meta-regression analysis of studies that traced adults or children who started ART and were LTFU in sub-Saharan African treatment programmes. The primary outcome was mortality, and secondary outcomes were undocumented transfer to another programme, treatment interruption and the success of tracing attempts. RESULTS We included 32 eligible studies from 12 countries in sub-Saharan Africa: 20 365 patients LTFU were traced, and 15 708 patients (77.1%) were found. Compared to telephone calls, tracing that included home visits increased the probability of success: the adjusted odds ratio (aOR) was 9.35 (95% confidence interval [CI] 1.85–47.31). The risk of death declined over calendar time (aOR per 1-year increase 0.86, 95% CI 0.78–0.95), whereas undocumented transfers (aOR 1.13, 95% CI 0.96–1.34) and treatment interruptions (aOR 1.31, 95% CI 1.18–1.45) tended to increase. Mortality was lower in urban than in rural areas (aOR 0.59, 95% CI 0.36–0.98), but there was no difference in mortality between adults and children. The CD4 cell count at the start of ART increased over time. CONCLUSIONS Mortality among HIV-positive patients who started ART in sub-Saharan Africa, were lost to programmes and were successfully traced has declined substantially during the scale-up of ART, probably driven by less severe immunodeficiency at the start of therapy.

All-cause mortality in HIV-positive adults starting combination antiretroviral therapy

“…Moreover, not all patients lost are successfully located. In a recent systematic review of tracing studies, we found that about 80% of patients could be located but this percentage varied widely across studies [21]. With the linkage data from South Africa this problem is less important: bias will only arise if patients with an ID differ systematically from those without ID and the effect of this bias cannot be minimised by the covariates included in the model.…”

“…Determinants of mortality were however similar for the 2012 and the current analysis, with high mortality rates in the first 6 months of ART and with low CD4 cell counts, which decreased with longer ART duration and higher CD4 cell counts. It would be worthwhile to examine trends over calendar years as recent studies have shown that in African programmes mortality among patients lost to follow-up appears to have declined in recent years [5,21]. This may be due to higher CD4 cell counts at the start of ART and to an increase in undocumented transfers to other clinics [5,21].…”

“…It would be worthwhile to examine trends over calendar years as recent studies have shown that in African programmes mortality among patients lost to follow-up appears to have declined in recent years [5,21]. This may be due to higher CD4 cell counts at the start of ART and to an increase in undocumented transfers to other clinics [5,21]. For example, a study in Lilongwe, Malawi found that among patients lost to follow-up and found to be alive on tracing, a majority (56%) were still on ART sourced from another clinic [22].…”

Rheumatic Heart Disease Treatment Cascade in Uganda

“…Third, although we made repeated attempts to contact those who were lost to follow-up, some of these may have died or transferred care causing misclassification. For example, a large meta-analysis found that 24% of HIV+ subjects lost to follow-up had self-transferred care and 34% had died 30 . Fourth, it is possible that differences in follow-up time at the UHI vs. regional centers may explain some of our findings regarding decentralized care, which should be clarified in subsequent analyses of the registry with longer follow-up.…”

Mortality in a Cohort of HIV-Infected Children: A 12-Month Outcome of Antiretroviral Therapy in Makurdi, Nigeria

“…However, a recent systemic review in 2017 suggests that more of sub-Saharan HIV-infected patients that are lost to follow-up are surviving better [59]. Also, the lack of postmortem studies in our program and the reliance on the verbal autopsy for children that died at home may have led to an inaccurate labeling of the cause of death in such cases.…”