Risk factors for loss to follow‐up, transfer or death among people living with HIV on their first antiretroviral therapy regimen in Mali

Abstract

Objectives Risk factors for loss to follow‐up (LTFU) were assessed for people living with HIV (PLHIV) at various reference out‐patient clinics (expertise level II) and hospitals (expertise level III) in Mali. Methods HIV‐1‐positive adults starting antiretroviral therapy (ART) in 2006–2013 were eligible for inclusion. Risk factors for LTFU, defined as no visit in the 6 months preceding the last database update, were assessed with the Cox model, taking into account the competing risks of transfer and death. Potential risk factors at the start of ART were demographic and socioeconomic variables, World Health Organization (WHO) stage, CD4 count, period of ART initiation, type of ART, region of care, expertise level and distance from home. Results We included 9821 PLHIV, 33% of whom were male, starting ART at nine out‐patient clinics and seven hospitals [five and two in the capital Bamako and four and five in the ‘regions’ (i.e. districts outside the capital), respectively] with a median (interquartile range) CD4 count of 153 (56–270) cells/μL. Five‐year cumulative incidences of LTFU, transfer and death were 35.2, 9.7 and 6.7%, respectively. People followed at Bamako hospitals > 5 km from home, at regional hospitals or at regional out‐patient clinics < 5 km from home were at higher risk of LTFU than people followed at Bamako out‐patient clinics, whereas people followed at regional out‐patient clinics 5–50 km away from home were at lower risk for LTFU. Deaths were less frequent at hospitals, whether in Bamako or in the regions, than at Bamako out‐patient clinics, and more frequent at regional out‐patient clinics. Conclusions Expertise level and distance to care were associated with LTFU. Stigmatization may play a role for PLHIV living close to the centres in the regions.

Re-engagement in care of people living with HIV lost to follow-up after initiation of antiretroviral therapy in Mali: Who returns to care?

“…We did not have the possibility to assess those data, or to assess social support from the family and the community, and HIV status disclosure. We also did not show differences according to social data such as educational level contrary to what has been shown in studies of LTFU risk factors [8,41]. However, difficulties to return to care when living more than 5 km to the care centre in the regions could be due to financial or transportation issues.…”

“…ART programme is often faced with issues of reagents out of stock and VL device maintenance. The ESTHER initiative [10] focused on reinforcing the clinical skills and capacity of health professionals through peer-to-peer partnerships between French hospitals and their African counterparts and provided an electronic medical records system "Evaluation et Suivi Opérationnel des Programmes d'ESTHER" (ESOPE, Epiconcept, France) for monitoring PLHIV care and the effectiveness of ART, which was progressively implemented at five reference outpatient clinics and two hospitals in Bamako, and at four reference outpatient clinics and five hospitals in five regions (Fig 1), as previously described [8]. The PLHIV included in the ESOPE database accounted for 64% of the 51,000 PLHIV in healthcare for HIV in Mali at the last database update on March 31, 2015 [11].…”

“…In Mali, a West African country with 18 million inhabitants, a non-governmental organisation, "Association de Recherche, de Communication et d'Accompagnement à Domicile des Personnes Vivant avec le VIH/SIDA" (ARCAD-SIDA), began to provide healthcare to PLHIV in Bamako (the capital of Mali) in 1998, gradually expanding its activities to several regions after November 2001, as previously described [8]. Healthcare for PLHIV became free after mid-2004, with support from the Global Fund, "Ensemble pour une Solidarité Thérapeutique Hospitalière en Réseau" (ESTHER), a French agency for AIDS care in developing countries, and the Malian government [9,10].…”

“…Furthermore, PLHIV with a duration of ART until LTFU of[6][7][8][9][10][11][12] [months with an estimated 12-month change in CD4 count < 50 cells/μL (aHR 1.46; 95%CI 1.23-1.73) or an…”

Nearly one in every six HIV-infected children lost from ART follow-up at Debre Markos Referral Hospital, Northwest Ethiopia: A 14-year retrospective follow-up study

“…The possible justification could be due to the fact that children living in rural areas travel long distances to get access to ART. Studies suggested that patients living far from a health facility had a greater risk of LTFU [34,35]. Moreover, children living in rural areas could have difficulties to access favorable transportation; as a result, they could miss their appointments.…”