Abstract
ObjectivesThe purpose of this study was to analyze characteristics, reasons for transferring, and reasons for discontinuing care among patients defined as lost to follow-up (LTFU) from an antiretroviral therapy (ART) clinic in Nairobi, Kenya.DesignThe study used a prospective cohort of patients who participated in a randomized, controlled ART adherence trial between 2006 and 2008.MethodsParticipants were followed from pre-ART clinic enrollment to 18 months after ART initiation, and were defined as LTFU if they failed to return to clinic 4 weeks after their last scheduled visit. Reasons for loss were captured through phone call or home visit. Characteristics of LTFU who transferred care and LTFU who did not transfer were compared to those who remained in clinic using log-binomial regression to estimate risk ratios.ResultsOf 393 enrolled participants, total attrition was 83 (21%), of whom 75 (90%) were successfully traced. Thirty-seven (49%) were alive at tracing and 22 (59%) of these reported having transferred their antiretroviral care. In the final model, transfers were more likely to have salaried employment [Risk Ratio (RR), 2.7; 95% confidence interval (CI), 1.2-6.1; p=0.020)] and pay a higher monthly rent (RR, 5.8; 95% CI, 1.3-25.0; p=0.018) compared to those retained in clinic. LTFU who did not transfer care were three times as likely to be men (RR, 3.1; 95% CI, 1.1-8.1; p=0.028) and nearly 4 times as likely to have a primary education or less (RR, 3.8; 95% CI, 1.3-10.6; p=0.013). Overall, the most common reason for LTFU was moving residence, predominantly due to job loss or change in employment.ConclusionA broad definition of LTFU may include those who have transferred their antiretroviral care and thereby overestimate negative effects on ART continuation. Interventions targeting men and considering mobility due to employment may improve retention in urban African ART clinics.Clinical TrialsThe study’s ClinicalTrials.gov identifier is NCT00273780.
Highlights
Retention in antiretroviral clinics has been identified as a critical component of HIV care
While funding such as the President’s Emergency Plan for AIDS Relief (PEPFAR) has increased global access to antiretroviral therapy (ART) over the past decade [8], growing patient numbers have challenged the ability of many clinics to successfully track and retain individuals who are at risk for lost to follow-up (LTFU) [9,10]
Thirty one participants never returned to the Hope Center for ART initiation, and 52 participants returned for a median of 4.3 months (IQR, 1-8) before subsequently failing to return (Figure 1)
Summary
Retention in antiretroviral clinics has been identified as a critical component of HIV care. Patients who miss visits or are lost to follow-up (LTFU) from an ART clinic lack continuous access to their medications and are unable to reach optimal adherence levels necessary for viral suppression [4]. LTFU is problematic in sub-Saharan Africa, where there are limited resources to track and retain patients in HIV care. While funding such as the President’s Emergency Plan for AIDS Relief (PEPFAR) has increased global access to ART over the past decade [8], growing patient numbers have challenged the ability of many clinics to successfully track and retain individuals who are at risk for LTFU [9,10]. Two systematic reviews of ART clinic retention in sub-Saharan Africa indicate that attrition is approximately 20% at six months after ART initiation, over half of which is attributed to LTFU [11,12]
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