Loss to follow-up in a community clinic in South Africa - roles of gender, pregnancy, and CD4 count

Abstract

Background Faith-based organizations have expanded access to antiretroviral therapy (ART) in community clinics across South Africa. Loss to follow-up (LTFU), however, limits both the potential individual and population treatment benefits and is an obstacle to optimal care. Objective To identify patient characteristics associated with LTFU six months after starting ART in patients in a large South African community clinic. Methods Patients initiating ART between April 2004 and October 2006 in one Catholic Relief Services HIV treatment clinic who had at least one follow-up visit were included in the analysis. Standardized instruments were used for data collection. Routine monitoring was performed every 6 months following ART initiation. Rates of LTFU over time were estimated by the Kaplan-Meier method. The log-rank test was used to examine the impact of age, baseline CD4 count, HIV RNA, gender and pregnancy status for women on LTFU. Cox proportional hazard regression was performed to analyze hazard ratios for LTFU. Results Data from 925 patients (age > 14 years), median age 36 years, 70% female (16% pregnant) were included in the analysis. Fifty one patients (6%) were lost to follow-up six months after ART initiation. When stratified by baseline CD4 count, gender and pregnancy status, pregnant women with lower baseline CD4 count (≤200 /μl) had 6.06 times (95% CI: 2.20 – 16.71) the hazard of LTFU compared to men. Conclusions HIV-infected pregnant women initiating ART are significantly more likely to be lost to follow-up in a community clinic in South Africa. Interventions to successfully retain pregnant women in care are urgently needed.

Incidence and Predictors of Death, Retention, and Switch to Second‐Line Regimens in Antiretroviral‐Treated Patients in Sub‐Saharan African Sites with Comprehensive Monitoring Availability

“…Although patients were selected on the basis of at least 1 clinical visit or laboratory follow-up, the drop-out incidence remained low, particularly in comparison with other recent observations that have shown rates of 20 dropouts per 100 person-years [37] or the loss to follow-up of 7%-8% of patients at 6-8 months after ART initiation [3,38]. This is probably the result of the active adherence implementation and of active patient followup in this program (see Patients and Methods) [37].…”

Twelve-month outcomes of patients admitted to the acute general medical service at Groote Schuur Hospital

“…Lost-to-follow-up rates of between 5% and 15% are not uncommon in research and community clinic settings in South Africa. 11,12 From a public health perspective, the need for strengthening hospital record-keeping, as well as the human resources to improve service delivery, is exposed.…”

Follow-Up Care Among HIV-Infected Pregnant Women in Mississippi

“…Recent studies from South Africa, however, indicate that pregnant women are more likely to be lost to follow-up (LTFU) compared with their nonpregnant counterparts. 22,23 One study comparing LTFU rates over 3 years between pregnant and nonpregnant women who were referred to an antiretroviral treatment center found that pregnant women had higher LTFU, and this continued throughout the follow-up period. This suggests that influences affecting follow-up extend beyond the immediate postpartum period.…”