Risk Factors For Loss To Follow-up Research Articles

Determinants and Clinical Outcomes of Patients With Tetralogy of Fallot Lost to Cardiology Follow-up

BackgroundVarious rates of loss to follow-up (LTFU) have been reported in patients with congenital heart disease, but return to follow-up is rarely considered in those analyses. Outcomes of LTFU patients are difficult to assess because the patients no longer attend cardiac care. We leveraged data from the TRIVIA cohort, which combines more than 30 years of clinical and administrative data, allowing us to study outcomes even after LTFU. MethodsThis population-based cohort included 904 patients with tetralogy of Fallot (TOF) born from 1982 to 2015 in Québec, Canada. Risk factors for LTFU and outcomes were calculated by Cox models and marginal means/rates models. Outcomes of LTFU patients were compared with propensity score–matched non-LTFU patients. ResultsThe cumulative risk of experiencing 1 episode of LTFU was 50.3% at 30 years. However, return to follow-up was frequent and the proportion of patients actively followed was 85.9% at 10 years, 76.4% at 20 years, and 70.6% at 30 years. Factors associated with a reduced risk of LTFU were primary repair with conduit (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.15-0.58) and transannular patch (HR 0.60, 95% CI 0.46-0.79). LTFU patients had lower rates of cardiac hospitalisations (HR 0.49, 95% CI 0.42-0.56) and cardiac interventions (HR 0.32, 95% CI 0.25-0.42), but similar rates of cardiac mortality (HR 0.95, 95% CI 0.24-3.80). ConclusionsThere was a lower proportion of LTFU patients compared with previous studies. Factors associated with lower rates of LTFU were conduits and non–valve-sparing surgery. LTFU patients had lower rates of cardiac procedures and cardiac hospitalisations.

High Incidence and Predictors of Loss to Follow-up among Children and Adolescents on Life Long Antiretroviral Therapy in the Conflict-affected Northwest and Southwest Regions of Cameroon: A Retrospective Cohort Study

Background: Retention in care and transition to adulthood are critical for children and adolescents living with HIV on Antiretroviral Therapy (ART) in HIV treatment programs in Sub Sahara, Africa. Objective: This study aimed to determine the incidence and predictors of loss-to-follow-up (LTFU) in the context of the ongoing crisis caused by an armed conflict in the Northwest and Southwest Regions of Cameroon, where staff in HIV treatment programs faced unique challenges of retention of children/adolescents. Methods: We employed a multi-stage mixed method design in which we conducted a retrospective cohort study to determine incidence and risk factors for LTFU through data abstraction from medical records of children and adolescents from five (5) ART treatment centers, followed by seventeen (17) key informant interviews conducted with healthcare workers to gain further insights into the reasons for LTFU among children and adolescents enrolled between January 2018 to December 2021. Kaplan–Meier plots were used to determine the probability of LTFU as a function of time. The Cox regression model was used to measure predictors of LTFU. Endpoint-recorded interviews were transcribed, translated, and analyzed using Atlas-ti Version 9. Results: A total of 1,030 children and adolescents (p-y) were enrolled for follow-up. 138 (13.4%) were LTFU, with an overall incidence rate of 33.0 LTFU per 1000 person years. Survival probability decreased for younger children and older adolescents. Receiving care in a rural health facility (AHR:2.14 (1.23-3.76), non-biological caregivers (AHR: 2.44; 95% CI: 1.59-3.74), short duration on ART, being on a sub-optimal regimen (AHR: 17.83; 95% CI: 11.00-29.00) and long distances to health facility (AHR:2.05; 95% CI: 1.10-3.20) were significant predictors of LTFU. Multiple Caregivers (94.1%), long distances/cost of transportation (88.2%), socio-political crises (75.5%), peer pressure, refusal, dating and marriage among adolescents (70.5%), stigma (64.7%), competitive life activities (58.8%), lack of timely disclosure (53%), poverty/lack of partner/family support (48.2%), lack of understanding on the disease process (47.0%), alternative forms of health care (29.4%), and shortage of ARVs (13.8%) were reasons for poor retention from the interviews. Conclusion: The overall incidence rate of LTFU was 33.0 per 1000 person years for children and adolescents initiated on lifelong ART over a period of four (4) years in the conflict-affected areas. The study portrays the need for innovative, multifaceted strategies to mitigate the predictors of this high-risk LTFU in displaced populations in the context of a sociopolitical crisis.

Rate of and Risk Factors for Loss to Follow Up in HIV-Infected Patients in Korea: The Korea HIV/AIDS Cohort Study.

Owing to antiretroviral therapy (ART), acquired immune deficiency syndrome (AIDS)-related mortality has significantly decreased. Retaining in care is an essential step for human immunodeficiency virus (HIV) care cascade. This study investigated the incidence of and risk factors for loss to follow-up (LTFU) in Korean people living with HIV (PLWH). Data from the Korea HIV/AIDS cohort study (including prospective interval cohort and retrospective clinical cohort) were analyzed. LTFU was defined as not visiting the clinic for more than 1 year. Risk factors for LTFU were identified using the Cox regression hazard model. The study enrolled 3,172 adult HIV patients (median age, 36 years; male 92.97%). The median CD4 T cell count at enrollment was 234 cells/mm3 (interquartile range [IQR]: 85 - 373) and the median viral load at enrollment was 56,100 copies/mL (IQR: 15,000 - 203,992). The total follow-up duration was 16,487 person-years, and the overall incidence rate of LTFU was 85/1,000 person-years. In the multivariable Cox regression model, subjects on ART were less likely to have LTFU than subjects not on ART (hazard ratio [HR] = 0.253, 95% confidence interval [CI]: 0.220 - 0.291, P <0.0001). Among PLWH on ART, female sex (HR = 0.752, 95% CI: 0.582 - 0.971, P = 0.0291) and older age (>50: HR = 0.732, 95% CI: 0.602 - 0.890; 41 - 50: HR = 0.634, 95% CI: 0.530 - 0.750; 31 - 40: HR = 0.724, 95% CI: 0.618 - 0.847; ≤30: reference, P <0.0001) were associated with high rate of retention in care. The viral load at ART initiation ≥1,000,001 (HR = 1.545, 95% CI: 1.126 - 2.121, ≤10,000: reference) was associated with a higher rate of LTFU. Young and male PLWH may have a higher rate of LTFU, and an increased rate of LTFU may induce virologic failure.

Hidden loss to follow-up among tuberculosis patients managed by public–private mix institutions in South Korea

In South Korea, public–private mix (PPM) was launched in 2011. This retrospective cohort study sought to determine the rate of loss to follow-up (LTFU) among drug-susceptible tuberculosis (DS-TB) patients in all nationwide PPM institutions, and the risk factors for LTFU. National notification data for DS-TB patients diagnosed between August 2011 and July 2014 in PPM institutions were analysed. Determination of LTFU included detection of instances where patients were transferred out, but when they did not attend at other TB centres in the following two months. Univariable and multivariable competing risk models were used to determine risk factors for LTFU. 73,046 patients with 78,485 records were enrolled. Nominally, 3426 (4.4%) of records were LTFU. However, after linking the multiple records in each patient, the percentage of LTFU was 12.3% (9004/73,046). Risk factors for LTFU were: being foreign-born (3.13 (95% CI 2.77–3.53)), prior LTFU (2.31 (2.06–2.59)) and greater distance between the patient’s home and the TB centre (4.27 (4.03–4.53)). ‘Transfer-out’ was a risk factor in patients managed by treatment centres close to home (1.65 (1.49–1.83)), but protective for those attending centres further (0.77 (0.66–0.89)) or far-away (0.52 (0.46–0.59)) from home. By considering the complete picture of a patient’s interactions with healthcare, we identified a much higher level of LTFU than previously documented. This has implications for how outcomes of treatment are reported and argues for a joined-up national approach for the management and surveillance of TB patients, in nations with similar healthcare systems.

Loss to follow‐up of patients in HIV care in Burundi: A retrospective cohort study

The objective was to assess the loss to follow-up (LTFU) rates and associated factors amongst patients in HIV care in Burundi. We conducted a retrospective cohort study in HIV-positive patients aged ≥15 years who started antiretroviral therapy (ART) between January 2015 and July 2020, with 31 December 2020 as the end point. The outcome of LTFU was defined as failure of a patient to report for drug refill within 90 days from the last appointment. Study data were extracted from the national AIDS Info database. The LTFU proportion was determined using the Kaplan-Meier method with the log-rank test, whereas LTFU risk factors were explored using the Cox regression model. A total of 29,829 patients on ART were included in the analysis. Cumulative incidence of LTFU was 2.3% at 12 months, 6.5% at 24 months, 12.7% at 36 months, 19.0% at 48 months, 24.1% at 60 months and 25.3% at 72 months. The overall LTFU incidence rate was 11.2 per 100 person-years of observation. The risk of LTFU was higher amongst patients who started ART after 2016 (adjusted hazard ratio [aHR] 1.75, 95% confidence interval [CI] 1.65-1.85) or within 7 days after diagnosis (aHR 1.27, 95% CI 1.21-1.35). Our findings demonstrate the relatively high incidence of LTFU in the Burundi HIV programme. Interventions targeting patients with risk factors for LTFU are particularly necessary.

Virologic non-suppression and early loss to follow up among pregnant and non-pregnant adolescents aged 15-19 years initiating antiretroviral therapy in South Africa: a retrospective cohort study.

IntroductionOlder adolescents aged 15–19 years continue to have high rates of loss to follow up (LTFU), and high rates of virologic non‐suppression (VNS) compared to younger adolescents and adults. Adolescent females are at risk of pregnancy, which puts those living with HIV at a dual vulnerability. Our study assessed the factors associated with VNS and LTFU in older adolescents (including pregnant females) who initiated antiretroviral therapy (ART) in South Africa.MethodsWe included adolescents aged 15–19 years initiating ART between 2004 and 2019, with ≥ one viral load (VL) measurement between 4 and 24.5 months, and ≥ 6 months follow‐up, from six South African cohorts of the International epidemiology Databases to Evaluate AIDS‐Southern Africa (IeDEA‐SA). We defined VNS as VL ≥400 copies/ml and LTFU as not being in care for ≥180 days from ART start and not known as transferred out of the clinic or dead in the first 24 months on ART. We examined factors associated with VNS and LTFU using Fine&Gray competing risk models.ResultsWe included a total of 2733 adolescents, 415 (15.2%) males, median (IQR) age at ART start of 18.6 (17.3, 19.4) years. Among females, 585/2318 (25.2%) were pregnant. Over the 24‐month follow‐up, 424 (15.5%) of all adolescents experienced VNS: range (11.1% pregnant females and 20.5% males). Over half of all adolescents were LTFU before any other event could occur. The hazard of VNS reduced with increasing age and CD4 count above 200 cells/μl at ART initiation among all adolescents having adjusted for all measured patient characteristics [adjusted sub‐distribution hazard ratio (aSHR) 19 vs. 15 years: 0.50 (95% CI: 0.36, 0.68), aSHR: >500 vs. ≤200 cells/μl: 0.22 (95% CI: 0.16, 0.31)]. The effect of CD4 count persisted in pregnant females. Increasing age and CD4 count >200 cells/μl were risk factors for LTFU among all adolescents.ConclusionsOlder adolescents had a high risk of LTFU shortly after ART start and a low risk of VNS, especially those initiating treatment during pregnancy. Interventions addressing adherence and retention should be incorporated into adolescent‐friendly services to prevent VNS and LTFU and endeavour to trace lost adolescents as soon as they are identified.

Ophthalmic Emergency Department Visits: Factors Associated With Loss to Follow-up

To describe follow-up rates for patients referred for outpatient ophthalmic care after emergency department (ED) discharge and identify patient and visit characteristics associated with loss to follow-up (LTFU). Single-institution retrospective cohort study. We analyzed the medical records of 2,206 patients seen in the ED for an eye-related issue who were subsequently scheduled for ophthalmology follow-up between 2013 and 2019 at a single tertiary health system. The main outcome measures were the frequency of and risk factors for LTFU and ED revisits. In total, 1,649 (74.8%) patients completed follow-up within 2months of an index ED visit. In multivariable analysis, younger age (P < .001), a nonurgent ophthalmic condition or nonophthalmic primary diagnosis (P < .001), scheduled follow-up >5days after the ED visit (P < .001), additional follow-up appointments (<.001), no prior history of ophthalmology appointments (P= .045), a visual acuity of 20/40 or better (P= .027), and having Medicaid or being uninsured (P < .001) were significantly associated with LTFU. The presence of an interpreter significantly increased the likelihood of follow-up among non-English speaking patients (P < .001). LTFU was significantly associated with an ED revisit within 4months of an index visit, and the ED revisit rate was significantly higher for patients LTFU vs those who completed follow-up (5.7% vs 1.1%; P < .001). A quarter of patients referred for ophthalmic care after an ED presentation were LTFU. We identified numerous factors associated with LTFU that could be used to develop interventions to enhance follow-up. In addition, patients who were LTFU were more likely to revisit the ED for the same ophthalmic condition.

Risk factors for loss to follow‐up, transfer or death among people living with HIV on their first antiretroviral therapy regimen in Mali

Risk factors for loss to follow-up (LTFU) were assessed for people living with HIV (PLHIV) at various reference out-patient clinics (expertise level II) and hospitals (expertise level III) in Mali. HIV-1-positive adults starting antiretroviral therapy (ART) in 2006-2013 were eligible for inclusion. Risk factors for LTFU, defined as no visit in the 6 months preceding the last database update, were assessed with the Cox model, taking into account the competing risks of transfer and death. Potential risk factors at the start of ART were demographic and socioeconomic variables, World Health Organization (WHO) stage, CD4 count, period of ART initiation, type of ART, region of care, expertise level and distance from home. We included 9821 PLHIV, 33% of whom were male, starting ART at nine out-patient clinics and seven hospitals [five and two in the capital Bamako and four and five in the 'regions' (i.e. districts outside the capital), respectively] with a median (interquartile range) CD4 count of 153 (56-270) cells/μL. Five-year cumulative incidences of LTFU, transfer and death were 35.2, 9.7 and 6.7%, respectively. People followed at Bamako hospitals >5km from home, at regional hospitals or at regional out-patient clinics <5km from home were at higher risk of LTFU than people followed at Bamako out-patient clinics, whereas people followed at regional out-patient clinics 5-50km away from home were at lower risk for LTFU. Deaths were less frequent at hospitals, whether in Bamako or in the regions, than at Bamako out-patient clinics, and more frequent at regional out-patient clinics. Expertise level and distance to care were associated with LTFU. Stigmatization may play a role for PLHIV living close to the centres in the regions.

Reducing attrition through a vital status tracing methodology in Swiss spinal cord injured patients

Introduction Attrition, or loss to follow-up (LTFU), in longitudinal studies can result in selection bias and hinder study validity. Previous researches on attrition in chronic disease populations have suggested attrition to be associated with an increased risk of mortality. Spinal cord injuries (SCI) are a chronic disease with evidenced reductions in life expectancy and increased premature mortality. If an individual's risk of adverse outcomes is associated with irregular or discontinued care in a SCI-specialized rehabilitation center, loss to clinic would be an additional concern for the rehabilitation setting. Given the potential impact of attrition for this population, a comprehensive tracing strategy was undertaken to ascertain and update the vital status (VS) of persons included in the Swiss Spinal Cord Injury (SwiSCI) cohort study. The objective of this study is to therefore outline the tracing methodology used to ascertain vital status, and to assess risk factors for attrition and loss to clinic, and the potential impact of loss to clinic on longevity outcomes. Methods Vital status of persons with SCI was updated through medical records of SwiSCI-covered specialized rehabilitation centers and, where-needed, tracing through Swiss municipalities. Lost to clinic (LTC) and lost to follow-up (LTFU) were defined as having no available VS information 18 months before the population censoring date (September 30, 2011), with the latter involving the additional tracing through one or more municipalities. For a proportion of cases, municipalities were contacted without first checking medical records due to practicality issues (e.g., historical, paper-based records). Risk factors for LTC were assessed using a flexible parametric survival model, with time since injury until LTC (yes/no) as the underlying timescale. In a secondary analysis, hazard ratios (HRs) for risk of mortality (dead/alive) among those LTC compared to not LTC were estimated using a flexible parametric survival model, whereas follow-up time was split at date of LTC, if applicable. Risk factors for LTFU (yes/no) were assessed using logistic regression, which was conditional on being LTC. Results In total, 3270 individuals were included in the vital status update. In total, 1041 individuals were identified as LTC and required additional tracing through municipalities; among those with an identified VS (N = 889), 336 had died by the cutoff date. Among individuals with a traumatic SCI (TSCI), risk factors for LTC included: incomplete lesions, older age at injury, and rehabilitation center. Individuals with a non-traumatic SCI (NTSCI) had a higher risk of going LTC is they were female and older at time of NTSCI; contrary to individuals with TSCI, lesion characteristics did not have an effect on risk of LTC. Additionally, preliminary results suggest that individuals LTC who have incurred a TSCI have a nearly five-fold increase in risk of premature mortality compared to those not LTC (HR = 4.83; 95% confidence interval [CI] = 2.87–8.12). There was no evidence of a risk differential among individuals with an NTSCI (HR = 1.29; 95% CI = 0.91–1.84). Finally, both time since LTC and age at SCI were associated with LTFU, while the probability of going LTFU declined with age. Of the 1′368 cases that were traced directly through municipalities - and thereby excluded from analyses - VS was ascertained for 75.8% of cases, of which 546 (52.7%) had died. Conclusion The impact of LTC status on risk of premature mortality could be indicative of the value of continued specialized care in the years following initial trauma and beyond first rehabilitation. Additional research is thus needed that can verify the true impact of continued specialized care on mortality outcomes. Furthermore, this study confirms the likelihood of attrition to cause selection bias in the evaluation of mortality and life expectancy. Results from this study can help facilitate the correction of mortality estimates in future analyses.

Loss to Follow-Up in Patients with Proliferative Diabetic Retinopathy after Panretinal Photocoagulation or Intravitreal Anti-VEGF Injections

Loss to follow-up (LTFU) may contribute to vision loss in patients with active proliferative diabetic retinopathy (PDR). The aim of this study is to determine and compare the rates of LTFU in patients with PDR receiving panretinal photocoagulation (PRP) or intravitreal injections (IVIs) with anti-vascular endothelial growth factor (VEGF) over approximately 4 years. Moreover, this study evaluates various risk factors for LTFU. Retrospective cohort study. A total of 2302 patients with PDR receiving IVIs with anti-VEGF or PRP between January 1, 2012, and April 20,2016. Intervals between each procedure and the subsequent follow-up visit were measured. Loss to follow-up was defined as at least 1 interval exceeding 12 months duration. The LTFU rates and associated risk factors. A total of 1718 patients (74.6%) followed up postprocedure and 584 patients (25.4%) were LTFU over approximately 4 years. Of the patients receiving PRP, 28.0% were LTFU compared with 22.1% of patients receiving IVI with anti-VEGF (P= 0.001). The LTFU rates decreased as age increased, with rates of 28.1% for patients aged ≤55 years, 27.0% for patients aged 56 to 65 years, and 20.9% for patients aged >65 years (P=0.002). Loss to follow-up also differed by race, with rates of 19.4% for whites, 30.2% for African Americans, 19.7% for Asians, 38.0% for Hispanics, Native Americans, and Pacific Islanders, and 34.9% for patients of unreported race (P < 0.001). The LTFU rates also increased as regional average adjusted gross incomes (AGIs) decreased, with rates of 33.9% for patients with regional average AGI of ≤$40 000, 24.0% for patients with regional average AGI from $41 000 to $80 000, and 19.7% for patients with regional average AGI >$80 000 (P<0.001). Procedure type, age, race, and regional average AGI were all significant (P < 0.05) independent risk factors of LTFU in the multivariate regression. A large proportion of patients with PDR were LTFU after receiving PRP or an anti-VEGF injection over approximately 4 years. Key risk factors included age, race, and regional average AGI.

Risk factors for unfavourable treatment outcome among new smear-positive pulmonary tuberculosis cases in China.

Setting: Three projects of the Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB. Objectives: To assess unfavourable treatment outcomes (UTOs), including failure, died, loss to follow-up (LTFU), transferred out and unknown outcome, and to identify risk factors associated with UTOs. Design: This was a cross-sectional study using routine programme data. Results: Of 30 277 new smear-positive tuberculosis (TB) patients, 4261 (14.1%) had UTOs: 2048 (6.8%) LTFU, 1418 (4.7%) transferred out, 390 (1.3%) died, 340 (1.1%) failed and 65 (0.2%) had an unknown outcome. Risk factors for LTFU (including LTFU, transfer out and unknown outcome) were residing in Anhui, age > 55 years, service delay > 10 days, patient delay < 30 days, directly observed treatment (DOT) provided by a family member or others and unknown DOT provider. The outcome of 'died' was associated with residing in Shaanxi, age > 55 years, male sex, patient delay > 30 days and unknown DOT provider. 'Failed' was associated with having unlimited access to health services, patient delay of >30 days and unknown DOT provider. Conclusion: This study highlights the predominance of lost patients among UTOs. Patients with family members or other non-medical DOT providers or unknown DOT providers had a high risk of a UTO. There is an urgent need to address these service-related factors.

Risk factors associated with loss to follow-up from tuberculosis treatment in Tajikistan: a case-control study

BackgroundThere are very few studies on reasons for loss to follow-up from TB treatment in Central Asia. This study assessed risk factors for LTFU and compared their occurrence with successfully treated (ST) patients in Tajikistan.MethodsThis study took place in all TB facilities in the 19 districts with at least 5 TB patients registered as loss to follow-up (LTFU) from treatment. With a matched case control design we included all LTFU patients registered in the selected districts in 2011 and 2012 as cases, with ST patients from the same districts being controls. Data were copied from patient records and registers. Conditional logistic regressions were run to analyse associations between collected variables and LTFU as dependent variable.ResultsThree hundred cases were compared to 592 controls. Half of the cases had migrated or moved. In multivariate analysis, risk factors associated with increased LTFU were migration to another country (OR 10.6, 95% CI 6.12–18.4), moving within country (OR 11.0, 95% CI 3.50–34.9), having side effects of treatment (OR 3.67, 95% CI 1.68–8.00) and being previously treated for TB (OR 2.03, 95% CI 1.05–3.93). Medical staff also mentioned patient refusal, stigma and family problems as risk factors.ConclusionsLTFU of TB patients in Tajikistan is largely a result of migration, and to a lesser extent associated with side-effects and previous treatment. There is a need to strengthen referral between health facilities within Tajikistan and with neighbouring countries and support patients with side effects and/or previous TB to prevent loss to follow-up from treatment.

Assessing factors for loss to follow-up of HIV infected patients in Guinea-Bissau.

The objective of this study was to ascertain vital status of patients considered lost to follow-up at an HIV clinic in Guinea-Bissau, and describe reasons for loss to follow-up (LTFU). This study was a cross-sectional sample of a prospective cohort, carried out between May 15, 2013, and January 31, 2014. Patients lost to follow-up, who lived within the area of the Bandim Health Project, a demographic surveillance site (DSS), were eligible for inclusion. Active follow-up was attempted by telephone and tracing by a field assistant. Semi-structured interviews were done face to face or by phone by a field assistant and patients were asked why they had not shown up for the scheduled appointment. Patients were included by date of HIV testing and risk factors for LTFU were assessed using Cox proportional hazard model. Among 561 patients (69.5% HIV-1, 18.0% HIV-2 and 12.6% HIV-1/2) living within the DSS, 292 patients had been lost to follow-up and were, therefore, eligible for active follow-up. Vital status was ascertained in 65.9% of eligible patients and 42.7% were alive, while 23.2% had died. Information on reasons for LTFU existed for 103 patients. Major reasons were moving (29.1%), travelling (17.5%), and transferring to other clinics (11.7%). A large proportion of the patients at the clinic were lost to follow-up. The main reason for this was found to be the geographic mobility of the population in Guinea-Bissau.

Retention in a public healthcare system with free access to treatment

We aimed to assess retention of HIV-infected individuals in the Danish healthcare system over a 15-year period. Loss to follow-up (LTFU) was defined as 365 days without contact to the HIV care system. Data were obtained from the nationwide Danish HIV Cohort study, The Danish National Hospital Registry and The Danish Civil Registration System. Incidence rates, risk factors for LTFU and return to care and mortality rate ratios (MRRs) were estimated using Poisson regression analyses. We included 4745 HIV patients who were followed for 36,692 person-years. Patients were retained in care 95.0% of person-years under observation, increasing to 98.1% after initiation of highly active antiretroviral treatment (HAART). The overall incidence rate/100 person-years for first episode of LTFU was 2.6 [95% confidence interval (CI) 2.5-2.8] and was significantly lower after initiation of HAART [1.2 (95% CI 1.0-1.3)]. Five years after LTFU the probability of return to care was 0.87 (95% CI 0.84-0.90). The risk of death was significantly increased after LTFU [MRR 1.9 (95% CI 1.6-2.6)] and 6 months or less after return to care [MRR 10.9 (95% CI 5.9-19.9)]. Retention in care of Danish HIV patients is high, especially after initiation of HAART. Absence from HIV care is associated with increased mortality. We conclude that high rates of retention can be achieved in a healthcare system with free access to treatment and is associated with a favorable outcome.