Not All Are Lost: Interrupted Laboratory Monitoring, Early Death, and Loss to Follow-Up (LTFU) in a Large South African Treatment Program

Abstract

BackgroundMany HIV treatment programs in resource-limited settings are plagued by high rates of loss to follow-up (LTFU). Most studies have not distinguished between those who briefly interrupt, but return to care, and those more chronically lost to follow-up.MethodsWe conducted a retrospective cohort study of 11,397 adults initiating antiretroviral therapy (ART) in 71 Southern African Catholic Bishops Conference/Catholic Relief Services HIV treatment clinics between January 2004 and December 2008. We distinguished among patients with early death, within the first 7 months on ART; patients with interruptions in laboratory monitoring (ILM), defined as missing visits in the first 7 months on ART, but returning to care by 12 months; and those LTFU, defined as missing all follow-up visits in the first 12 months on ART. We used multilevel logistic regression models to determine patient and clinic-level characteristics associated with these outcomes.ResultsIn the first year on ART, 60% of patients remained in care, 30% missed laboratory visits, and 10% suffered early death. Of the 3,194 patients who missed laboratory visits, 40% had ILM, resuming care by 12 months. After 12 months on ART, patients with ILM had a 30% increase in detectable viremia compared to those who remained in care. Risk of LTFU decreased with increasing enrollment year, and was lowest for patients who enrolled in 2008 compared to 2004 [OR 0.49, 95%CI 0.39–0.62].ConclusionsIn a large community-based cohort in South Africa, nearly 30% of patients miss follow-up visits for CD4 monitoring in the first year after starting ART. Of those, 40% have ILM but return to clinic with worse virologic outcomes than those who remain in care. The risk of chronic LTFU decreased with enrollment year. As ART availability increases, interruptions in care may become more common, and should be accounted for in addressing program LTFU.

Effects of sex and alcohol use on antiretroviral therapy outcomes in Botswana: a cohort study

“…Then, they need to remain in contact with the healthcare system over time to continue to receive and adhere to their antiretrovirals(13, 14). When treatment failure occurs, it is important to determine how the failure occurred since interventions to improve outcomes might be different for different components of the cascade(15). …”

High rates of unplanned interruptions from HIV care early after antiretroviral therapy initiation in Nigeria

“…It is now clear that patients defined as lost to follow-up represent many types of patients; some die, some voluntarily withdraw from care, others transfer care to different treatment facilities, while others interrupt but later return to care [ 10 – 15 ]. Patients with unplanned care interruptions (UCI) are at increased risk for CD4 decline, uncontrolled viremia, opportunistic infections, and long-term mortality [ 11 , 13 , 15 – 18 ].…”

“…This review also describes wide variation in definitions of care interruption ranging from 1 day to 1 year or more without treatment or care [ 15 ]. Risk factors for UCI in HIV care vary in different settings, however studies in RLS remain sparse [ 11 , 15 , 16 , 19 ]. Nigeria is the most populous country in Africa, and has the second largest HIV-infected population, behind South Africa [ 20 , 21 ].…”

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“…In programs that have actively traced patients lost to follow-up, up to 40% were found to be dead [8,10,63]. Some patients transfer care to other programs, and others cycle in and out of care with brief interruptions but worse virologic control than those who remain in care [68,69]. As a result, patient retention has been increasingly recognized as an important program indicator.…”