The Majority of the Pre-Antiretroviral Population Who Were Lost to Follow-Up Stopped Their Care in Freetown, Sierra Leone: A 12-Month Prospective Cohort Study Starting with HIV Diagnosis.

J Daniel Kelly,Gabriel Warren Schlough,Brima Kargbo,Sulaiman Conteh,Thomas P Giordano,M Bailor Barrie,Esaki M Shankar

doi:10.1371/journal.pone.0149584

J Daniel Kelly, Gabriel Warren Schlough + Show 5 more

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https://doi.org/10.1371/journal.pone.0149584

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Abstract

BackgroundThe heterogeneity of the pre-antiretroviral (pre-ART) population calls for more granular depictions of the cascade of HIV care.MethodsWe studied a prospective cohort of persons newly diagnosed with HIV infection from a single center in Freetown, Sierra Leone, over a 12-month period and then traced those persons who were lost to follow-up (LTFU) during pre-ART care (before ART initiation). ART eligibility was based on a CD4 cell count result of ≤ 350 mm/cells and/or WHO clinical stage 3 or 4. Persons who attended an appointment in the final three months were considered to be retained in care. Adherence to ART was measured using pharmacy refill dates. “Effective HIV care” was defined as completion of the cascade of care at 12-months regardless of whether patients are on ART. Tracing outcomes were obtained for those who were LTFU during pre-ART care.Results408 persons newly diagnosed with HIV infection were screened, 338 were enrolled, and 255 persons were staged for ART. ART-ineligible persons had higher retention rates than ART-eligible persons (59.6% vs 41.8%, p = 0.03). 77 (22.8%) of 338 persons received effective HIV care. Most attrition (61.9%) occurred with persons during pre-ART care. 123 of 138 persons (89.1%) who were LTFU prior to ART initiation were found, and 91 of those 123 (74.0%) were alive. Of the 74 persons who were alive and described their engagement in care, 40 (54.1%) stopped care. Nearly half (42.5%) of those 40 stopped after assessment of ART-eligibility but before ART initiation. The main limitation of this study was the lack of tracing outcomes for those lost during ART care.ConclusionsThe majority of the pre-ART LTFU population stopped their care, particularly after ART-eligibility but before ART initiation. Interventions to hasten ART initiation and retain this at-risk group may have significant downstream impact on effective HIV care.

Highlights

A decade ago, the steps of HIV care–from testing to treatment–became a visionary roadmap for controlling the epidemic as well as reducing morbidity and mortality.[1]
408 persons newly diagnosed with HIV infection were screened, 338 were enrolled, and 255 persons were staged for antiretroviral therapy (ART)
The Majority of the Pre-ART lost to follow-up (LTFU) Population Stopped Their Care in care, 40 (54.1%) stopped care

Summary

Introduction

A decade ago, the steps of HIV care–from testing to treatment–became a visionary roadmap for controlling the epidemic as well as reducing morbidity and mortality.[1] After HIV diagnosis, patients needed to be linked to care, retained over time, initiated on antiretroviral therapy (ART) and adherent to ART in order to realize the full benefits of ART This process later became widely known as the cascade of care.[2] The importance of the cascade of care grew as treatment was increasingly recognized as a prevention tool.[3] Yet, even after ART was made accessible around the world, a minority of HIV-infected persons succeeded in completing the cascade of care and achieving viral suppression.[4]. The heterogeneity of the pre-antiretroviral (pre-ART) population calls for more granular depictions of the cascade of HIV care

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