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

Abstract

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.

Institutional Factors Affecting Retention of HIV Patient on Treatment at Wuse General Hospital, Abuja, Nigeria

“…Previous studies reported that travel distance to ART centers was a barrier to accessing treatment, and some mentioned transportation cost as a reason for defaulting. A similar study revealed that a substantial proportion of participants that lived far from the clinic (31% >50 km) was associated with a higher risk of LTFU [34]. Accessibility problems such as lack of transport, cost, or distance have previously been identified as barriers to clinic attendance.…”

Does undernutrition increase the risk of lost to follow-up in adults living with HIV in sub-Saharan Africa? Protocol for a systematic review and meta-analysis

“…4 10 11 Evidence shows that undernutrition significantly increases the risk of LTUF among adults living with HIV. [42][43][44][45][46][47] Therefore, understanding the impact of undernutrition on LTFU is essential in designing appropriate interventions. However, there is no systematic review and metaanalysis summarising available evidence about the pooled effect of undernutrition on LTFU among adults living with HIV in SSA.…”

“…[33][34][35][36][37][38][39][40][41] Studies have shown that undernutrition (ie, BMI <18.5 kg/m 2 ) is one of the main factors that significantly increases the risk of LTFU among adults living with HIV. [42][43][44][45][46][47] This finding may reflect that undernourished patients are more likely to develop OIs and later died but were under-reported to the HIV clinics due to a passive reporting system. 48 For example, a meta-analysis in SSA conducted by our team found that the risk of developing TB in undernourished adults living with HIV is twice that of well-nourished counterparts.…”

“…Some studies showed that undernutrition significantly increases the risk of LTUF among adults living with HIV. [42][43][44][45][46][47] Conversely, a few studies found that undernutrition and LTFU among adults living with HIV have no significant association. 47 Estimating the pooled effect of undernutrition on LTFU among adults living with HIV is important to provide evidence for healthcare workers and policymakers in designing specific interventions to minimise undernutrition-related LTFU among adults living with HIV.…”

HIV Viral Suppression among People Living with HIV on Antiretroviral Therapy in Haut-Katanga and Kinshasa Provinces of Democratic Republic of Congo

“…Data linkage with other social services databases may also reduce the risk of IIT. In a recent cohort study, interventions that included longer periods between ART refills (i.e., multi-month dispensation), home delivery of ART refills, linkage to social service support programs after diagnosis, and “silent” transfer of care between clinics for patients relocating (e.g., due to change in employment) were all possible successful strategies for increasing retention in care and preventing the potential for therapy interruption [ 28 ].…”