Lost to follow up: contributing factors and challenges in South African patients on antiretroviral therapy.

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Patients who do not return for follow-up at clinics providing comprehensive HIV/AIDS care require special attention. This is particularly true where resources are limited and clinic loads are high. Themba Lethu Clinic at Helen Joseph Hospital in Johannesburg is a facility supported by PEPFAR funding through Right to Care (Grant CA-574-A-00-02-00018); more than 800 HIV/AIDS patients are seen there each week. Data on a sample of patients who failed to return for follow-up were analysed to identify the causes and to plan strategies to overcome the problem. A group of 182 patients who missed follow-up appointments at the clinic were identified. Their files were examined to identify possible contributing factors. The patients were then contacted telephonically and asked their reasons for non-attendance. Results show that the leading cause of failure to follow up was financial (34% of patients). Patients cited transport costs and having to pay to open a file at each visit as the biggest monetary obstacles to obtaining treatment. Fifty-five per cent of patients lost to follow-up showed an improvement in CD4 count on treatment. Death accounted for 27% of the patients lost to follow-up and the mean ( +/- standard deviation (SD)) duration of treatment in this group was only 8 ( +/- 6) weeks. Of the patients in this group who had been seen at 4 months, 60% had failed to respond to treatment. The mean duration of ARV treatment before being lost to follow-up was 21 ( +/- 28) weeks. The mean CD4+ count was 92 ( +/- 74.5) cells/ microl and the mean number of visits was 3.33 ( +/- 2.17). Seventy-four per cent of the patients were on regimen 1A, and only 1 cited side-effects of medication as a reason for not returning. This study highlighted financial difficulty as the major obstacle to obtaining treatment. There is evidence in support of providing ARV treatment free of charge to HIVpositive patients who qualify, as occurs in other provinces in South Africa. It is also suggested that providing ARV therapy at more local clinics in the community would make treatment more accessible. Provision of several months' supply of medicines per visit would help to reduce transport costs and minimise patient expenditure. These interventions may reduce the incidence of patients lost to follow-up in this community.