Abstract
BackgroundHigh rates of loss to follow-up (LTFU) are undermining rapidly expanding antiretroviral treatment (ART) services in sub-Saharan Africa. The intelligent dispensing of ART (iDART) is an open-source electronic pharmacy system that provides an efficient means of generating lists of patients who have failed to pick-up medication. We determined the duration of pharmacy delay that optimally identified true LTFU.MethodsWe conducted a retrospective cross-sectional study of a community-based ART cohort in Cape Town, South Africa. We used iDART to identify groups of patients known to be still enrolled in the cohort on the 1st of April 2008 that had failed to pick-up medication for periods of ≥ 6, ≥ 12, ≥ 18 and ≥ 24 weeks. We defined true LTFU as confirmed failure to pick up medication for 3 months since last attendance. We then assessed short-term and long-term outcomes using a prospectively maintained database and patient records.ResultsOn the date of the survey, 2548 patients were registered as receiving ART but of these 85 patients (3.3%) were found to be true LTFU. The numbers of individuals (proportion of the cohort) identified by iDART as having failed to collect medication for periods of ≥6, ≥12, ≥18 and ≥24 weeks were 560 (22%), 194 (8%), 117 (5%) and 80 (3%), respectively. The sensitivities of these pharmacy delays for detecting true LTFU were 100%, 100%, 62.4% and 47.1%, respectively. The corresponding specificities were 80.7%, 95.6%, 97.4% and 98.4%. Thus, the optimal delay was ≥12 weeks since last attendance at this clinic (equivalent to 8 weeks since medication ran out). Pharmacy delays were also found to be significantly associated with LTFU and death one year later.ConclusionsThe iDART electronic pharmacy system can be used to detect patients potentially LTFU and who require recall. Using a short a cut-off period was too non-specific for LTFU and would require the tracing of very large numbers of patients. Conversely prolonged delays were too insensitive. Of the periods assessed, a ≥12 weeks delay appeared optimal. This system requires prospective evaluation to further refine its utility.
Highlights
High rates of loss to follow-up (LTFU) are undermining rapidly expanding antiretroviral treatment (ART) services in sub-Saharan Africa
8%-26% of patients die in the first year of ART [2] and a further proportion may be lost to follow-up (LTFU), with combined attrition rates of approximately 40% at 2 years in many programmes [3]
334 (9.9%) were LTFU, 249 (7.4%) were transferred out, and 253 (7.5%) had died. This left 2548 patients who were registered as still receiving ART and formed the patient cohort at the time of this cross-sectional survey
Summary
High rates of loss to follow-up (LTFU) are undermining rapidly expanding antiretroviral treatment (ART) services in sub-Saharan Africa. Antiretroviral therapy (ART) has become much more widely available in resource-limited countries with a high burden of HIV/AIDS. Four million people were estimated to be receiving ART in low- or middleincome countries by the end of 2008, of whom 2.9 million were in sub-Saharan Africa and 701,000 were in. Low levels of retention threaten to undermine ART programmes in sub-Saharan Africa. 8%-26% of patients die in the first year of ART [2] and a further proportion may be lost to follow-up (LTFU), with combined attrition rates of approximately 40% at 2 years in many programmes [3]. Identifying and tracing patients who are potentially LTFU is essential to maintain programme quality. The human resources needed for this are very limited and development of information systems that permit the most effective deployment of these resources would be of great benefit
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