Abstract
Many patients in HIV care in Africa considered lost to follow up (LTFU) at one facility are reportedly accessing care in another. The success of these unofficial transfers as measured by time to re-entry at the new-facility, prevalence of treatment interruptions, speed of ART-initiation, and overall continuity of care is not well characterized but may reveal opportunities for improvement. We traced a random sample of LTFU HIV-infected patients in Zambia. Among those found alive and reported in care at a new-facility, we reviewed records at the receiving facility to verify transfer; and when verified, documented the transfer experience. We used Kaplan-Meier methods to examine incidence of ART-initiation after transfer to new clinic. We assessed demographic and clinical characteristics, official and cross-provincial transfer for associations with HIV treatment re-engagement using Poisson regression models and associations between official-transfer and same-day ART initiation at the new-facility. Among 350 LTFU-patients, 178 (51%) were successfully verified through chart review at the new-facility. 132 (74.2%) were female, 72 (40.4%) aged 25–35, and 51% were ever recorded as previously being on ART. 110 patients (61.8%) were registered under new ART-IDs and 97 (54.5%) received a new HIV test. 54% of those previously on ART-initiated on the same-day. Using the same ART-ID was associated with same-day initiation compared to those receiving a new ART-ID (p = 0.07). 80% (n = 91) of those ever on ART had evidence of medication initiation at new clinic. Among these, initiation reached 66% (95% CI: 56–75) by 30 days, 77.5% (95% CI: 68–86) by 90 days after new-facility presentation. Many patients use new identifiers at new facilities, indicative of inefficiencies. Re-entry into new facilities among the unofficial-transfer population is often delayed and timely treatment initiation is inconsistent, suggesting interruptions in treatment. Health systems innovations to ensure smooth and safe transfers are needed to maintain quality HIV care.
Highlights
In the current era of universal treatment for all persons infected with HIV, poor retention in care remains a substantial barrier to optimizing viral suppression [1]
Existing data suggests that the time between the last visit at the original facility and the visit at the receiving facility is often delayed: one recent study describing the patient transfer experience among people living with HIV (PLHIV) in Kenya showed that treatment gaps greater than 14 days were common [4]
Our study population consisted of patients who were considered lost to follow-up (LTFU) from HIV care (i.e., 90 days late to an appointment at the time of sampling) at their original clinic based on EMR records, reported transferring to a new facility after being actively traced in the field, and whose transfer was verified at the new facility as part of study activities for the Better Information for Health in Zambia cohort study [1]
Summary
In the current era of universal treatment for all persons infected with HIV, poor retention in care remains a substantial barrier to optimizing viral suppression [1]. Routine programmatic data often indicate high level of lost to follow-up (LTFU)- where systems are paper-based with no unique patient identifiers (IDs), several prior studies have demonstrated that many patients considered LTFU at their original facility are accessing care in another [2,3,4,5,6,7,8,9]. Further evidence indicates that time to ART-initiation may vary by the distance from home to the clinic where care is re-accessed [8] These findings are suggestive of gaps in care associated with patient transfer and differential rates of treatment initiation according to where patients transfer and how and/or if they were managed appropriately. Further evidence on what happens to patients after they transfer, such as understanding the engagement process e.g. repeat HIV testing, use of unique identifiers and CD4 testing is not well known
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