Trends in and Determinants of Loss to Follow Up and Early Mortality in a Rapid Expansion of the Antiretroviral Treatment Program in Vietnam: Findings from 13 Outpatient Clinics

Abstract

BackgroundThis study aims to describe the trends in and determinants of six month mortality and loss to follow up (LTFU) during 2005–2009 in 13 outpatient clinics in Vietnam.MethodData were obtained from clinical records of 3,449 Vietnamese HIV/AIDS patients aged 18 years or older who initiated ART between 1 January 2005 and 31 December 2009. Mantel-Haenszel chi-square test, log rank test were conducted to examine the trends of baseline characteristics, six month mortality and LTFU. Cox proportional hazards regression models were performed to compute hazard ratio (HR) and 95% Confidence Interval (CI).ResultsThough there was a declining trend, the incidence of six month mortality and LTFU remained as high as 6% and 15%, respectively. Characteristics associated with six month mortality were gender (HR females versus males 0.54, 95%CI: 0.34–0.85), years of initiation (HR 2009 versus 2005 0.54, 95%CI: 0.41–0.80), low baseline CD4 (HR 350–500 cells/mm3 versus <50 cells/mm3 0.26, 95%CI: 0.18–0.52), low baseline BMI (one unit increase: HR 0.96, 95%CI: 0.94–0.97), co-infection with TB (HR 1.61, 95%CI: 1.46–1.95), history of injecting drugs (HR 1.58, 95%CI: 1.31–1.78). Characteristics associated with LTFU were younger age (one year younger: HR 0.97, 95%CI: 0.95–0.98), males (HR females versus males 0.82, 95%CI: 0.63–0.95), and poor adherence (HR 0.55, 95%CI: 0.13–0.87).ConclusionsTo reduce early mortality, special attention is required to ensure timely access to ART services, particularly for patients at higher risk. Patients at risk for LTFU after ART initiation should be targeted through enhancing treatment counselling and improving patient tracing system at ART clinics.

Determinants of virological failure after 1 year's antiretroviral therapy in Vietnamese people with HIV: findings from a retrospective cohort of 13 outpatient clinics in six provinces

“…These findings underline the importance of removing barriers to timely ART initiation. In Vietnam, a low baseline CD4 cell count is also an independent predictor of early mortality and LTFU 8. Furthermore, recent research has reported that 69% of people with HIV in a similar cohort did not initiate ART until their CD4 cell count dropped to <50 cells/mm 3 17.…”

“…First, our evaluation was limited to patients for whom viral load measured within the first 12 months of ART could be obtained, those retained in ART and those who had not been switched to second-line treatments within 12 months of starting ART. However, published data have indicated high early mortality and LTFU in the first year of ART 8. Those who died or were LTFU in the first year of ART are likely to have had treatment failure.…”

“…They studied targeted viral load testing in 100 patients with HIV from a clinic in Hai Phong, a province in north Vietnam;6 228 patients from a clinic in HCMC, a province in south Vietnam;7 and a further 138 patients from 10 clinics in HCMC 8. These studies, however, examined the results from targeted, not routine, viral load testing, and such results are poor predictors of virological failure 1.…”

Mortality and survival patterns of people living with HIV-2

“…In the report of the IeDEA West Africa collaboration, the largest ever for ART-treated people living with HIV-2, mortality seems underestimated because of the high number of patients lost to follow as already described in HIV-1 patients in the West Africa region (46). No cohort of HIV-2 infected patients reported having implemented an active search in case of loss to follow up as often done for HIV-1 patients (47). Finally the causes of death have not been usually reported in the studies we reviewed, and the all-cause mortality is probably insufficient to provide an insight of what could be an HIV-2 specific mortality pattern.…”

Cost-Effectiveness of Antiretroviral Therapy Expansion Strategies in Vietnam

“…This finding is consistent with previous studies from Vietnam. 12,17,33 More specifically, this study shows that the most cost-effective method of scaling-up ART in Vietnam would be to maintain the current ART treatment initiation threshold (CD4 cell count £ 350 cells/mm 3 ) but increase access from 19% to 30% of all eligible patients. The second most cost-effective method would be to maintain the current ART treatment initiation threshold but increase access to 90% of all eligible patients.…”