Outcomes of Patients Lost to Follow-up in African Antiretroviral Therapy Programs: Individual Patient Data Meta-analysis (July 2018)

Figure: Vital and treatment status of patients lost to follow-up (LTFU), including death, stop of combination antiretroviral therapy (cART), transfer to another clinic, and retention on cART.

Summary written by Nanina Anderegg, Statistician at Institute of Social and Preventive Medicine (ISPM), University of Bern.

Retention in HIV care following a diagnosis, and adherence to treatment, are crucial for viral suppression and preventing HIV-related morbidity/mortality, HIV drug resistance and onward transmission. However, the retention of HIV+ patients in programmes is a matter of concern, as substantial proportions are lost to follow-up (LTFU). Interest has grown in tracing patients LTFU to ascertain their vital and treatment status, and to bring patients back to care. For this collaborative study, outcomes of almost 7500 patients LTFU and traced in 9 HIV treatment programmes in 8 African countries were examined. The study revealed that 4 years after the last clinic visit about one-fifth of patients LTFU had died, a similar proportion had stopped treatment, one-sixth had transferred to another clinic, and about one-third were not found. In addition, patients were more likely to remain LTFU as the delay between LTFU and tracing increased. Mortality was associated with male sex and more advanced disease, transfer with female sex and less advanced disease, and stopping therapy with less advanced disease. Death, stopping antiretroviral therapy, and unsuccessful tracing were all associated with shorter duration of antiretroviral therapy at the time of LTFU.

These findings have several implications. First, as the proportion transferred amongst those LTFU is substantial, program-level retention in care will be underestimated. Clearly, improving communication between clinics and programs, for example, through a national treatment database and unique patient identifiers, is urgently needed for an accurate assessment of overall retention in care. At the same time, program-level mortality will be underestimated if mortality amongst patients LTFU is not taken in to care. In addition, the risk factors for death identified are directly relevant to HIV care and treatment programs in sub-Saharan Africa. Patients who initiated antiretroviral therapy <1 year prior to being lost, especially those with low CD4 counts or advanced clinical stage, were at higher mortality risk. These patients should be prioritised for tracing to trigger early action so that they can be supported to remain in care and on treatment as soon as possible.

This is a summary from the full paper entitled “Outcomes of Patients Lost to Follow-up in African Antiretroviral Therapy Programs: Individual Patient Data Meta-analysis” which can be found here.