Self‐transfer and mortality amongst adults lost to follow‐up in ART programmes in low‐ and middle‐income countries: systematic review and meta‐analysis

Abstract

Abstractobjective To ascertain estimates of adult patients, recorded as lost to follow-up (LTFU) within antiretroviral treatment (ART) programmes, who have self-transferred care, died or truly stopped ART in low-and middle-income countries.methods PubMed, EMBASE, Web of Science, Science Direct, LILACS, IndMed and AIM databases (2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013) and IAS/AIDS conference abstracts (2011)(2012)(2013) were searched for tracing studies reporting the proportion of traced patients found to have self-transferred, died or stopped ART. These estimates were then combined using random-effects meta-analysis. Risk of bias was assessed through subgroup and sensitivity analyses.results Twenty eight studies were eligible for inclusion, reporting true outcomes for 10 806 traced patients attending approximately 258 ART facilities. None were from outside sub-Saharan Africa. Twenty three studies reported 4.5-54.4% traced LTFU patients self-transferring care, providing a pooled estimate of 18.6% (95% CI 15.8-22.0%). A significant positive association was found between rates of selftransfer and LTFU in the ART cohort. The pooled estimates for unreported deaths were 38.8% (95% CI 30.8-46.8%; 27 studies) and 28.6% (95% CI 21.9-36.0%; 20 studies) for patients stopping ART. A significant decrease in unreported deaths from 50.0% (95% CI 41.5-58.4%) to 30.0% (95% CI 21.1-38.9%) was found comparing study periods before and after 31 December 2007.conclusions Substantial unaccounted for transfers and deaths amongst patients LTFU confirms that retention and mortality is underestimated where the true outcomes of LTFU patients are not ascertained.keywords Human immunodeficiency virus, antiretroviral therapy, lost to follow-up, mortality, continuity of care, systematic review

Challenges and successes in the implementation of option B+ to prevent mother-to-child transmission of HIV in southern Swaziland

“…Although national standard operating procedures required a routine phone call three days after a missed appointment in order to re-engage women into care or ascertain the outcome, 60% of women could not be contacted due to incorrect contact details (phone numbers did not exist, were unreachable, or somebody else answered the phone). Weak ascertainment of ART outcomes and suboptimal implementation of physical defaulter tracing activities may have inflated attrition rates [48, 49]. Third, this observational study was likely affected by temporal trends such as patient and community mobilization as well as countrywide adoption and scale-up of PMTCTB+ in the second half of 2014.…”

Retention and mortality outcomes from a community‐supported public–private HIV treatment programme in Myanmar

“…This mortality rate could be an underestimate given recent findings from two reviews suggesting that more than one-third of those lost to follow-up in sub-Saharan Africa die soon afterward [33,34]. However, the generalizability of the proportion of lost to follow-up patients that die in Myanmar is uncertain, given that most data in the above-mentioned reviews were from sub-Saharan Africa.…”

Outcomes from the implementation of a counselling model supporting rapid antiretroviral treatment initiation in a primary healthcare clinic in Khayelitsha, South Africa

“…21,22 Whilst cohorts that started ART prior to 2008 in Khayelitsha were reported to have higher 6-month retention outcomes, 23 a recent study reporting on MSF cohorts has shown higher losses to care in more recently initiated cohorts, with the 2011 cohort retaining 85.5% (95% CI 84.5% -86.4%) at this time point. 22 It is worth noting that it may not be appropriate to compare retention reported in older versus more recently initiated cohorts; this point is due to increasing unaccounted-for self-transfers hidden within the lost to follow-up (LTFU) outcome 24 and a bias towards better retention outcomes in older cohorts introduced by longer follow-up times, which allow transient treatment interrupters to return to care. 25 It took less than a week for patients to initiate ART from starting ART preparation counselling.…”