Patterns and Predictors of Incident Return to HIV Care Among Traced, Disengaged Patients in Zambia: Analysis of a Prospective Cohort

Beres, Laura K.; Schwartz, Sheree; Simbeza, Sandra; McGready, John; Eshun‐Wilson, Ingrid; Mwamba, Chanda; Sikombe, Kombatende; Topp, Stephanie M.; Somwe, Paul; Mody, Aaloke; Mukamba, Njekwa; Ehrenkranz, Peter; Padian, Nancy; Pry, Jake; Bolton‐Moore, Carolyn; Holmes, Charles B.; Sikazwe, Izukanji; Denison, Julie A.; Geng, Elvin

doi:10.1097/qai.0000000000002554

Cited by 17 publications

(28 citation statements)

References 50 publications

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“…Men, in particular, described encouragement from community health workers as a catalyst for their re-engagement in care. Findings directly address growing calls for focused research and interventions to address intermittent gaps in HIV care [7,14,38,39].…”

Section: Discussionmentioning

confidence: 82%

“…While high rates of re-engagement are promising, even short periods of absence from care remain concerning. People living with HIV (PLWH) who miss ART appointments are more likely to have poor ART adherence leading to increased risk for ART resistance and viral transmission in the short-term, and increased risk of remaining out of care and HIV-related morbidity and mortality in the long-term [2,[9][10][11].…”

Section: Introductionmentioning

confidence: 99%

“…Yet for many, leaving HIV care is not a fixed state [ 7 , 8 ]. A recent study from the region shows that 73% of those who missed an HIV care appointment returned to care, most within one year, suggesting that cycles of disengagement and re-engagement may be central to the ART experience [ 9 ].…”

Section: Introductionmentioning

confidence: 99%

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How HIV Clients Find Their Way Back to the ART Clinic: A Qualitative Study of Disengagement and Re-engagement with HIV Care in Malawi

Chamberlin

Mphande²,

Phiri³

et al. 2021

AIDS Behav

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Retention in antiretroviral therapy (ART) services is critical to achieving positive health outcomes for individuals living with HIV, but accumulating evidence indicates that individuals are likely to miss ART appointments over time. Thus, it is important to understand why individuals miss appointments and how they re-engage in HIV care. We used in-depth interviews with 44 ART clients in Malawi who recently missed an ART appointment (> 14 days) but eventually re-engaged in care (within 60 days) to explore reasons for missed appointments and barriers and facilitators to re-engagement. We found that most individuals missed ART appointments due to unexpected life events such as funerals, work, and illness for both clients and their treatment guardians who were also unable to attend facilities. Several reasons differed by gender—work-related travel was common for men, while caring for sick family members was common for women. Barriers to re-engagement included continued travel, illness, and restricted clinic schedules and/or staff shortages that led to repeat facility visits before being able to re-engage in care. Strong internal motivation combined with social support and reminders from community health workers facilitated re-engagement in HIV care.

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Section: Discussionmentioning

confidence: 82%

Section: Introductionmentioning

confidence: 99%

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How HIV Clients Find Their Way Back to the ART Clinic: A Qualitative Study of Disengagement and Re-engagement with HIV Care in Malawi

Chamberlin

Mphande²,

Phiri³

et al. 2021

AIDS Behav

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“…Being "disengaged" or "engaged" is not a final state: It is an interval within the lifetime of a recipient of care. A cascade that documents actual PLHIV behavior-the cycle of engaging and reengaging in care-would inform and prioritize efforts intended to prevent missed clinic visits, overcome barriers to reentry, and minimize onset of advanced HIV disease [5,[23][24][25].…”

Section: Introductionmentioning

confidence: 99%

The revolving door of HIV care: Revising the service delivery cascade to achieve the UNAIDS 95-95-95 goals

et al. 2021

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Antiretroviral therapy (AAU : PleasenotethatforARTðabbreviationÞ; bothantiretroviraltreatmentan RT) for human immunodeficiency virus (HIV) prevents illness and death from HIV disease and transmission of HIV infection. To encourage global scale-up of ART, the Joint UN Program on HIV/AIDS (UNAIDS) issued the "95-95-95" targets for the HIV "cascade of care." These targets state that by 2030, 95% of individuals living with HIV will know their HIV status, 95% of people with diagnosed HIV infection will receive ART, and 95% of those taking ART will have achieved suppression of the virus.

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“…While some patients return to care, many do not. Observational estimates of re‐engagement in care in Africa and the United States range from one‐quarter to three‐quarters [ 8 , 9 , 10 , 11 , 12 , 13 ]. As HIV programmes transition from an emergency‐focused response to a long‐term maintenance service delivery model, they must allocate limited resources to interventions that support sustained patient engagement [ 14 ].…”

Section: Introductionmentioning

confidence: 99%

The effect of tracer contact on return to care among adult, “lost to follow‐up” patients living with HIV in Zambia: an instrumental variable analysis

et al. 2021

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Introduction Tracing patients lost to follow‐up (LTFU) from HIV care is widely practiced, yet we have little knowledge of its causal effect on care engagement. In a prospective, Zambian cohort, we examined the effect of tracing on return to care within 2 years of LTFU. Methods We traced a stratified, random sample of LTFU patients who had received HIV care between August 2013 and July 2015. LTFU was defined as a gap of >90 days from last scheduled appointment in the routine electronic medical record. Extracting 2 years of follow‐up visit data through 2017, we identified patients who returned. Using random selection for tracing as an instrumental variable (IV), we used conditional two‐stage least squares regression to estimate the local average treatment effect of tracer contact on return. We examined the observational association between tracer contact and return among patient sub‐groups self‐confirmed as disengaged from care. Results Of the 24,164 LTFU patients enumerated, 4380 were randomly selected for tracing and 1158 were contacted by a tracer within a median of 14.8 months post‐loss. IV analysis found that patients contacted by a tracer because they were randomized to tracing were no more likely to return than those not contacted (adjusted risk difference [aRD]: 3%, 95% CI: –2%, 8%, p = 0.23). Observational data showed that among contacted, disengaged patients, the rate of return was higher in the week following tracer contact (IR 5.74, 95% CI: 3.78–8.71) than in the 2 weeks to 1‐month post‐contact (IR 2.28, 95% CI: 1.40–3.72). There was a greater effect of tracing among patients lost for >6 months compared to those contacted within 3 months of loss. Conclusions Overall, tracer contact did not causally increase LTFU patient return to HIV care, demonstrating the limited impact of tracing in this program, where contact occurred months after patients were LTFU. However, observational data suggest that tracing may speed return among some LTFU patients genuinely out‐of‐care. Further studies may improve tracing effectiveness by examining the mechanisms underlying the impact of tracing on return to care, the effect of tracing at different times‐since‐loss and using more accurate identification of patients who are truly disengaged to target tracing.

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Patterns and Predictors of Incident Return to HIV Care Among Traced, Disengaged Patients in Zambia: Analysis of a Prospective Cohort

Cited by 17 publications

References 50 publications

How HIV Clients Find Their Way Back to the ART Clinic: A Qualitative Study of Disengagement and Re-engagement with HIV Care in Malawi

How HIV Clients Find Their Way Back to the ART Clinic: A Qualitative Study of Disengagement and Re-engagement with HIV Care in Malawi

The revolving door of HIV care: Revising the service delivery cascade to achieve the UNAIDS 95-95-95 goals

The effect of tracer contact on return to care among adult, “lost to follow‐up” patients living with HIV in Zambia: an instrumental variable analysis

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