Abstract
BackgroundLoss to follow-up (LFTU) among HIV patients remains a major obstacle to achieving treatment goals with the risk of failure to achieve viral suppression and thereby increased HIV transmission. Although use of clinical decision support systems (CDSS) has been shown to improve adherence to HIV clinical guidance, to our knowledge, this is among the first studies conducted to show its effect on LTFU in low-resource settings.MethodsWe analyzed data from a cluster randomized controlled trial in adults and children (aged ≥ 18 months) who were receiving antiretroviral therapy at 20 HIV clinics in western Kenya between Sept 1, 2012 and Jan 31, 2014. Participating clinics were randomly assigned, via block randomization. Clinics in the control arm had electronic health records (EHR) only while the intervention arm had an EHR with CDSS. The study objectives were to assess the effects of a CDSS, implemented as alerts on an EHR system, on: (1) the proportion of patients that were LTFU, (2) LTFU patients traced and successfully linked back to treatment, and (3) time from enrollment on the study to documentation of LTFU.ResultsAmong 5901 eligible patients receiving ART, 40.6% (n = 2396) were LTFU during the study period. CDSS was associated with lower LTFU among the patients (Adjusted Odds Ratio—aOR 0.70 (95% CI 0.65–0.77)). The proportions of patients linked back to treatment were 25.8% (95% CI 21.5–25.0) and 30.6% (95% CI 27.9–33.4)) in EHR only and EHR with CDSS sites respectively. CDSS was marginally associated with reduced time from enrollment on the study to first documentation of LTFU (adjusted Hazard Ratio—aHR 0.85 (95% CI 0.78–0.92)).ConclusionA CDSS can potentially improve quality of care through reduction and early detection of defaulting and LTFU among HIV patients and their re-engagement in care in a resource-limited country. Future research is needed on how CDSS can best be combined with other interventions to reduce LTFU.Trial registration NCT01634802. Registered at www.clinicaltrials.gov on 12-Jul-2012. Registered prospectively.
Highlights
Loss to follow-up (LFTU) among HIV patients remains a major obstacle to achieving treatment goals with the risk of failure to achieve viral suppression and thereby increased HIV transmission
The study was conducted between September 1st, 2012 and January 31st, 2014, during which 13 eligible clinics were randomly assigned to the control (n = 7) or intervention (n = 6) arms (Fig. 1)
Our study showed that clinics with a clinical decision support systems (CDSS) had a 30% lower proportion of antiretroviral therapy (ART) patients who were loss to follow-up (LTFU) compared to those without a CDSS
Summary
Loss to follow-up (LFTU) among HIV patients remains a major obstacle to achieving treatment goals with the risk of failure to achieve viral suppression and thereby increased HIV transmission. Use of clinical decision support systems (CDSS) has been shown to improve adherence to HIV clinical guidance, to our knowledge, this is among the first studies conducted to show its effect on LTFU in low-resource settings. Sub-Saharan Africa (SSA) is home to 25.6 million HIV-infected persons of which 64% (n = 16.4 million) were receiving ART at the end of 2018 [1]. The UNAIDS Fast-Track goals, commonly referred to as the 95–95–95 goals, recommend that countries should have 95% of all HIV-infected persons know their HIV status, 95% of those who know their HIV positive status initiated on ART and 95% of those on treatment achieving viral suppression by 2030 in order to end the AIDS pandemic [2]. Many countries in SSA still suffer high loss to follow-up (LTFU) of patients on ART, poor adherence to treatment and low retention rates. Studies have shown that LTFU in SSA countries could be as high as 40% among the general population after 36 months of enrollment on treatment [4,5,6] and as high as 57% among youth [7]
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