Early loss to follow‐up of recently diagnosed HIV‐infected adults from routine pre‐ART care in a rural district hospital in Kenya: a cohort study

Amin S Hassan,Katherine L Fielding,Nahashon M Thuo,Helen M Nabwera,James A Berkley,Eduard J Sanders

doi:10.1111/j.1365-3156.2011.02889.x

Abstract

ObjectiveTo 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.MethodsProspective 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.ResultsOf 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.ConclusionsA 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.

Highlights

During the past decade, there has been a substantial roll out of HIV ⁄ AIDS services in sub-Saharan Africa, where an estimated 24 million people are infected (UNAIDS 2010)
During the 6-month follow-up period, 184 of these clients enrolled in the Anti Helminthic Trial (AHT) [61 (11.5%)] and ⁄ or Food By Prescription (FBP) [75 (14.2%)], while 89 (16.8%) started antiretroviral therapy (ART); 178 (33.6%) were loss to follow-up (LTFU), of whom 96 (53.9%) were LTFU before the second visit (Figure 2)
There were no substantial differences in the baseline characteristics between clients who were later enrolled in the AHT and ⁄ or FBP programmes compared to those who were not: age, Body Mass Index (BMI), haemoglobin levels and World Health Organization (WHO) staging (WHO stage II: 40.6% vs. 47.6%, P = 0.179)

Summary

Introduction

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). The main risk factors for LTFU are lower baseline body mass index (BMI), lower CD4 count, lower haemoglobin, WHO stage III ⁄ IV, younger patients and being men (Amuron et al 2009; Bassett et al 2009; Brinkhof et al 2008; Toure et al 2008; Ochieng-Ooko et al 2010). These data suggest that LTFU from ART programmes is mainly associated with advanced HIV disease. Most deaths among patients on ART occur in the early months after treatment initiation, which has been attributed to late access to ART and consequent severe immunosuppression (Lawn et al 2008; Brinkhof et al 2008; Bassett et al 2010; Boulle et al 2008; Fenner et al 2010; Russell et al 2010)

Objectives

Methods

Results

Conclusion