Predictors of loss to follow-up among children registered in an HIV prevention mother-to-child transmission cohort study in Pernambuco, Brazil

Abstract

BackgroundMother-to-child transmission of HIV (MTCT) is the major form of acquiring the disease among children. The loss to follow-up (LTF) of mothers and their children is a problem that affects the effectiveness of programs for the prevention of mother-to-child transmission (PMTCT). The aim of this study is to identify risk factors associated with the LTF of HIV-exposed children in the state of Pernambuco, Brazil.MethodsA retrospective cohort study was carried out with 1200 HIV-exposed children born between 2000 and 2009, registered up to the age of 2 months in a public health PMTCT program. Children were considered LTF if they did not return for scheduled visits to monitor infection status. Univariate and multivariate logistic regression analyses were conducted to identify risk factors for LTF.ResultsA total of 185 children (15.4%; CI: 95%: 13.4 - 17.4%) met the case definition of LTF before the determination of serological HIV status. Risk factors independently associated with LTF were mother-child pairs who reside in rural and remote areas (OR 1.86; 95% CI: 1.30-2.66) and mothers who use illicit drugs (OR 1.8; 95% CI: 1.08-3.0). Initiation of the PMTCT during pregnancy was a protective factor for LTF (OR 0.69; 95% CI: 0.49-0.96).ConclusionsThe decentralization of support services for HIV-exposed children to other cities in the state seems to be crucial for the accurate monitoring of outcomes. It is also important to introduce additional measures addressing mothers who are drug users so that they remain in the program: an intensive follow-up program that actively searches for absentee mother-child pairs, support from social services and treatment for drug-dependency. The findings of this study highlight the importance of diagnosing mothers as early as possible in order to conduct a more complete follow-up period of the children. Solving the above-mentioned problems is a challenge, which must be overcome so as to improve the quality of PMTCT.

Lost to Follow-up and Predictors Among HIV-Exposed Infants in Northwest Ethiopia

“…Infants whose mothers were from the rural residence were at 3.5 times higher risk of lost to follow-up as compared with infants whose mothers were from urban areas. This finding is supported by previous studies conducted in Brazil [ 11 ] and Zambezia, Mozambique [ 28 ]. Possible reasons for this difference may be due to distance from a health facility [ 29 , 30 ], inaccessibility of transport [ 31 ], poor transport infrastructure [ 32 ], economical reasons for transport, and high working burden in the house for mothers [ 33 – 35 ].…”

“…This implies that 6% of infants did not return for PMTCT services for at least 3 months before their final HIV status was declared. The finding is lower than studies conducted in Angola (19.3%) [ 19 ], Cameroon (18%) [ 20 ], Amhara region, Ethiopia (34%) [ 21 ], Addis Ababa, Ethiopia (30.5%) [ 22 ], Malawi (48%) [ 23 ], Central Mozambique (50%) [ 24 ], South region of Nigeria (67%) [ 25 ], Uganda (43%) [ 26 ], Brazil (15.4%) [ 11 ], and North India (29%) [ 27 ]. A possible reason for this discrepancy may be the difference in definition of lost to follow-up: in Brazil lost to follow-up was declared as absent from one schedule visit for PMTCT service and in Malawi missing from appointments for 2 months, but in this study lost to follow-up was defined as absent from PMTCT service for more than 3 months.…”

“…In Africa several studies have verified the huge number LTFU rate of children with an interval of 36.9% and 68.4%; such unacceptably high LTFU prevalence experienced by PMTCT programs impedes the provision of appropriate interventions for HIV-infected children. This resulted in the poor success of PMTCT and is one of the main explanations for why more than 90% of the children who acquired HIV infection in 2011 live in sub-Saharan Africa [ 11 ].…”

“…Some of the factors that have been linked to LTFU are discussed below. A study conducted in India showed that poor educational status, lower wealth quintile, and being registered after 20 weeks of gestation of pregnancy were predicting variables affecting LTFU [ 11 ]. A hospital-based case–control study in Cameroon indicated that mothers who had no formal education were more likely to be lost to follow-up with HIV care programs compared to those who attended formal education [ 17 ] .…”

Mother to child transmission of HIV in Brazil: Data from the "Birth in Brazil study", a national hospital-based study

“…The early initiation of prenatal care is critical for the swift diagnosis of infection and timely start of antiretroviral therapy aiming the achievement of viral suppression. In addition, some studies indicate that early prenatal care initiation [ 25 , 26 ] and the application of ART in pregnancy [ 27 ] are factors that will reduce the frequency of missed follow-ups of exposed women and children. This is possibly due to increased linking of women with health services and the care process.…”