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Objective To determine the rate and predictors of early loss to follow-up (LTFU) for recently diagnosed HIV-infected, antiretroviral therapy (ART)-ineligible adults in rural Kenya.
Methods Prospective cohort study. Clients registering for HIV care between July 2008 and August 2009 were followed up for 6 months. Baseline data were used to assess predictors of pre-ART LTFU (not returning for care within 2 months of a scheduled appointment), LTFU before the second visit and LTFU after the second visit. Logistic regression was used to determine factors associated with LTFU before the second visit, while Cox regression was used to assess predictors of time to LTFU and LTFU after the second visit.
Results Of 530 eligible clients, 178 (33.6%) were LTFU from pre-ART care (11.1/100 person-months). Of these, 96 (53.9%) were LTFU before the second visit. Distance (>5 km vs. <1 km: adjusted hazard ratio 2.6 [1.9–3.7], P < 0.01) and marital status (married vs. single: 0.5 [0.3–0.6], P < 0.01) independently predicted pre-ART LTFU. Distance and marital status were independently associated with LTFU before the second visit, while distance, education status and seasonality showed weak evidence of predicting LTFU after the second visit. HIV disease severity did not predict pre-ART LTFU.
Conclusions A third of recently diagnosed HIV-infected, ART-ineligible clients were LTFU within 6 months of registration. Predictors of LTFU among ART-ineligible clients are different from those among clients on ART. These findings warrant consideration of an enhanced pre-ART care package aimed at improving retention and timely ART initiation.
Objectif: Déterminer le taux et les facteurs prédictifs de la perte précoce au suivi chez les adultes récemment diagnostiqués avec l’infection VIH, inadmissibles pour l’ART, en milieu rural, au Kenya.
Méthodes: Etude de cohorte prospective. Les patients inscrits aux soins VIH entre juillet 2008 et août 2009 ont été suivis pendant six mois. Les données de référence ont été utilisées pour évaluer les facteurs prédictifs de la perte au suivi pré-ART (i.e, ne pas revenir pour des soins dans les deux mois d’un rendez-vous), la perte au suivi avant la deuxième visite et celle après la deuxième visite. La régression logistique a été utilisée pour déterminer les facteurs associés à la perte au suivi avant la deuxième visite et la régression de Cox a été utilisée pour évaluer les facteurs prédictifs du temps à la perte au suivi et la perte au suivi après la deuxième visite.
Résultats: Sur 530 patients éligibles, 178 (33,6%) ont été perdus au suivi durant les soins pré-ART (11,1/100 personnes-mois). Parmi eux, 96 (53,9%) ont été perdus au suivi avant la deuxième visite. La distance (>5 km vs <1 km: rapport de risque ajusté 2,6 [1,9 – 3,7], p <0,01) et le statut marital (marié vs célibataire: 0,5 [0,3 – 0,6], p <0,01) ont indépendamment prédit la perte au suivi pré-ART. La distance et le statut marital ont été indépendamment associés à la perte au suivi avant la deuxième visite alors que la distance, le niveau d’éducation et la saisonnalité présentaient peu d’évidence à prédire la perte au suivi après la deuxième visite. La sévérité de la maladie VIH n’a pas prédit la perte au suivi pré-ART.
Conclusions: Un tiers des patients récemment diagnostiqués avec l’infection VIH, inadmissibles pour l’ART étaient perdus au suivi dans les 6 mois après l’inscription. Les facteurs prédictifs de la perte au suivi chez les patients inéligibles pour l’ART sont différents de ceux des patients sous ARV. Ces résultats justifient la considération d’un ensemble de soins pré-ART fortifiés visant à améliorer la rétention et l’initiation à l’ART en temps opportun.
Objetivo: Determinar la tasa y los vaticinadores de la pérdida temprana en el seguimiento (PTS) de adultos de Kenia rural.
Métodos: Estudio prospectivo de cohortes. Se siguió durante seis meses a los clientes que se registraban para recibir cuidados para el VIH entre Julio 2008 y Agosto 2009. Los datos de base se utilizaron para evaluar los vaticinadores de PTS pre-TAR (no volver al centro durante los dos meses siguientes a una cita programada), PTS antes de una segunda visita y PTS tras la segunda visita. Se utilizó la regresión logística para evaluar los vaticinadores de tiempo a PTS y PTS antes de la segunda visita, mientras que se utilizó una regresión de Cox para evaluar los vaticinadores de tiempo a PTS y PTS después de la segunda visita
Resultados: De 530 clientes elegibles, 178 (33.6%) eran PTS desde los cuidados pre-TAR (11.1/100 personas-meses). De estos, 96 (53.9%) eran PTS antes de la segunda visita. La distancia (>5 km vs. <1 km: hazard ratio ajustado 2.6 [1.9 – 3.7], p<0.01) y el estado civil (casado vs. soltero: 0.5 [0.3 – 0.6], p<0.01) eran vaticinadores independientes del PTS pre-TAR. La distancia y el estado civil estaban independientemente asociados con la PTS antes de la segunda visita, mientras que la distancia, el nivel de estudios y la estacionalidad mostraban una débil evidencia para predecir la PTS después de la segunda visita.
Conclusiones: Una tercera parte de los clientes con diagnóstico reciente de infección por VIH y no elegibles para TAR eran PTS dentro de los 6 meses posteriores al momento de registrarse. Los vaticinadores de la PTS para clientes no elegibles para TAR son diferentes de aquellos para clientes recibiendo TAR. Estos hallazgos sugieren considerar un paquete mejorado de pre-TAR con el objetivo de mejorar la retención y la iniciación a tiempo del TAR.
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During the past decade, there has been a substantial roll out of HIV/AIDS services in sub-Saharan Africa (sSA), where an estimated 24 million people are infected (UNAIDS 2010). A critical barrier to effective scale up of these services is attrition of patients from care. The main component of attrition has been identified as loss to follow-up (LTFU) (Rosen et al. 2007).
Strategies to improve follow-up generally focus on bringing lost patients back into the healthcare system through tracing. However, for example, in Zambia’s national treatment programme, more than two thirds of patients who had dropped out of care could not be contacted, even after several attempts (Krebs et al. 2008). A systematic review of outcomes of patients lost from HIV care and treatment programmes in resource-limited settings found that 20–60% of patients who could be traced had died (Brinkhof et al. 2009). As tracing patients is time-consuming, expensive and often unsuccessful, LTFU from HIV care remains a major challenge.
A better understanding of pre-ART LTFU is critical to designing interventions aimed at improving long-term care and timely initiation of ART. Few studies have exclusively assessed pre-ART LTFU in Africa (Larson et al. 2010; Bassett et al. 2010; Amuron et al. 2009; Losina et al. 2010; Lessells et al. 2011). Of these, only one study from South Africa has assessed factors associated with retention in patients who were not eligible for ART at enrolment into HIV care (Lessells et al. 2011). It is unclear whether their findings are generalizable to other regions in sSA with differing HIV prevalence, services and social context.
In this study, we aim to determine the rate of early LTFU among adults who were recently diagnosed with HIV but not yet eligible for ART and to identify baseline predictors associated with pre-ART LTFU in a rural district hospital in Kenya.
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Our findings from a routine HIV care clinic in a rural district hospital in Kenya suggest that a third of recently diagnosed HIV-infected clients registered for pre-ART care were LTFU within 6 months of registration. More than half of those who were LTFU did not return for follow-up HIV care in the 6 months after registration. Distance and marital status at registration into HIV care independently predicted LTFU. Distance and marital status were also independently associated with LTFU before the second visit, while distance, level of education at registration into HIV care and seasonality independently predicted LTFU after the second visit.
Longer distances from health facilities reduce accessibility as clients have to spend more money on travel and take more time away from work. Although HIV services are mostly offered free of charge, indirect costs are a deterrent to retention of clients in care. Longer distance, long travel time and high costs of transport are major barriers to the access of HIV care (Amuron et al. 2009; Ochieng-Ooko et al. 2010; Maskew et al. 2007; Losina et al. 2010). It is possible that a small number of clients may also have opted for HIV care in more accessible peripheral clinics without notifying the CCRC of their transfer.
Single clients were more likely to be LTFU from HIV care immediately after registration. This may be because single clients do not have a support person, hence more likely to be negatively affected by HIV-related stigma. This has been shown to be an important barrier to adherence and retention in care (Merten et al. 2010; McGuire et al. 2010). Most single people are also conventionally young, and young age has been found to be a risk factor for LTFU, albeit in patients on ART (Karcher et al. 2007; Ochieng-Ooko et al. 2010). However, age was not found to be an independent predictor of pre-ART LTFU in our setting.
Interestingly, level of education at registration into HIV care had a weak association with LTFU after the second visit, suggesting that better-educated clients were likely to return after registration for follow-up visits but dropout thereafter. A plausible explanation is that educated clients have better-paying jobs, and may opt to acquire the main pre-ART intervention, the cheap and readily available cotrimoxazole, over the counter to avoid the HIV-related stigma of being seen in the clinic.
We also found weak evidence of an association between dry seasons and LTFU after the second visit. Given that the community is mainly agrarian, some clients may be forced to seek alternative socio-economic activities to sustain their livelihoods during the dry seasons. This may necessitate working long hours or out-migration to other districts in search of jobs.
Importantly, HIV disease severity as determined by lower CD4 count, lower haemoglobin levels, lower BMI and late clinical staging did not predict pre-ART LTFU in this setting. Most previous studies on loss to HIV care in clients on ART have identified these factors as independently associated with LTFU. Our findings, together with recent data from South Africa (Losina et al. 2010), suggest that the dynamics and risk factors for pre-ART retention differ considerably from those found among clients who have started ART.
In view of the fact that literature suggests high rates of early mortality after ART initiation in Africa (Lawn et al. 2008; Brinkhof et al. 2008; Bassett et al. 2010), it is plausible that recently diagnosed HIV-infected clients register for care and dropout while they are still healthy, only to present later with advanced HIV disease necessitating immediate ART initiation. If this is the case, then we argue that focusing and redirecting resources towards provision of an enhanced standard package of pre-ART care may improve timely initiation of ART and influence early adverse outcomes.
The pre-ART package of care may include a structured framework of counselling and support at both testing and registration into HIV care. This approach has been applied in ART programmes to enhance retention and ART adherence in different settings with relative success (Etienne et al. 2010). Evidently, the same approach is equally important in pre-ART clients registering for HIV care.
Other pre-ART care services may include provision of prophylactic anthelmintics, isoniazid preventive therapy (IPT), multivitamins and nutritional support in form of food programmes. These interventions may serve as an incentive for follow-up and counter the indirect costs incurred.
Studies on anthelminthic drugs and IPT have shown that these cheap and readily available interventions administered in pre-ART clients have the potential to slow HIV disease progression (Walson et al. 2008; Grant et al. 2005). Hence, an improved pre-ART package of care may serve not only to enhance retention but also to slow disease progression, treat intercurrent infections, enable timely initiation on ART for those eligible, reduce early mortality after starting ART and thus prolong overall survival.
Our findings should be interpreted in the light of several limitations. First, more than a third of the immunological data were missing. This may have reduced the power of our study to show an effect of CD4 count on pre-ART LTFU. However, clinical indicators have been found to be equally good as markers of immunosuppression and are, in fact, the most commonly adopted method of assessing for HIV disease severity in resource-limited settings. Our data had almost 90% of the clinical data available, none of which suggested an effect on LTFU.
Secondly, although we used an outcome definition that was empirically defined, this definition was only previously studied among patients on ART. Thus, applying the definition on a pre-ART cohort may be deemed restrictive. The narrow time interval used may have resulted in clients being misclassified as LTFU even when they resumed care later, which may have resulted in an overestimation of the LTFU rate. This limitation implies need for a standardized approach to defining LTFU in the pre-ART population based on empiric evidence.
Lastly, censoring clients who were later enrolled in the AHT/FBP programmes may have biased our findings. A comparison of clients that were enrolled in the AHT/FBP programmes to those that were not suggested these groups had similar baseline characteristics for most variables. However, the mean baseline CD4 count of clients enrolled in the AHT/FBP programmes was higher compared to that of those who were not enrolled. This suggests that censored clients were in fact less immunocompromised, which may have potentially resulted in a shift in the results with an effect being observed on LTFU among healthier clients if they were not enrolled in the AHT/FBP programmes.
In conclusion, so far most attention has been given to LTFU among patients on ART. Our study with recent published data suggests that pre-ART LTFU is a widespread problem in Africa. Importantly, risk factors for pre-ART LTFU are different from those in clients on ART. Our findings warrant consideration of an enhanced pre-ART package aimed at improving retention, care, timely initiation of ART and overall survival.
Further studies are needed to assess the burden and risk factors for pre-ART LTFU in different settings. Cost effectiveness, adherence and side effects of interventions targeted at the pre-ART populations should be assessed to justify their roll out.