Geng EH, Nash D, Kambugu A, et al.. Retention in care among HIV-infected patients in resource-limited settings: emerging insights and new directions

Division of HIV/AIDS at San Francisco General Hospital, 995 Potrero Avenue, San Francisco, CA 94110, USA.
Current HIV/AIDS Reports 11/2010; 7(4):234-44. DOI: 10.1007/s11904-010-0061-5
Source: PubMed

ABSTRACT In resource-limited settings--where a massive scale-up of HIV services has occurred in the last 5 years--both understanding the extent of and improving retention in care presents special challenges. First, retention in care within the decentralizing network of services is likely higher than existing estimates that account only for retention in clinic, and therefore antiretroviral therapy services may be more effective than currently believed. Second, both magnitude and determinants of patient retention vary substantially and therefore encouraging the conduct of locally relevant epidemiology is needed to inform programmatic decisions. Third, socio-structural factors such as program characteristics, transportation, poverty, work/child care responsibilities, and social relations are the major determinants of retention in care, and therefore interventions to improve retention in care should focus on implementation strategies. Research to assess and improve retention in care for HIV-infected patients can be strengthened by incorporating novel methods such as sampling-based approaches and a causal analytic framework.

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Available from: Elvin H Geng, Aug 19, 2015
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    • "However, there are arguments that it also perpetuates a " conveyor belt " approach to nursing (van der Walt & Schwartz, 2002, p. 1001), disempowers patients (Garner & Volmink, 2000), and puts—as we also show— an additional burden on them and their resources because of the need for frequent clinic visits. Acute ill health and transport costs can here create additional access barriers; these issues can be equally problematic for people on ART (Geng et al., 2010; Kapella et al., 2009; Sagbakken, Frich, & Bjune, 2008). A public service providing free ART and TB treatment is thus a necessary but not sufficient aspect of enabling widespread access to therapy in resource-limited settings. "
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    ABSTRACT: Achieving equitable access to health care is an important policy goal, with access influenced by affordability, availability, and acceptability of specific services. We explore patient narratives from a 5-year program of research on health care access to examine relationships between social constructions of illness and the acceptability of health services in the context of tuberculosis treatment and antiretroviral therapy in South Africa. Acceptability of services seems particularly important to the meanings patients attach to illness and care, whereas-conversely-these constructions appear to influence what constitutes acceptability and hence affect access to care. We highlight the underestimated role of individually, socially, and politically constructed healthworlds; traditional and biomedical beliefs; and social support networks. Suggested policy implications for improving acceptability and hence overall health care access include abandoning patronizing approaches to care and refocusing from treating "disease" to responding to "illness" by acknowledging and incorporating patients' healthworlds in patient-provider interactions. © The Author(s) 2015.
    Qualitative Health Research 05/2015; 25(5):622-35. DOI:10.1177/1049732315575315 · 2.19 Impact Factor
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    • "The first, a systematic review, reported self-transfer rates of 12–54% amongst patients found alive (Brinkhof et al. 2009). The second, a narrative review, estimated a crude unweighted median self-transfer rate of 48.5% amongst those reported in 14 cited studies as LTFU (Geng et al. 2010b). We systematically reviewed outcomes reported in tracing studies of adult ART patients who are reported as LTFU in low-and middle-income countries (LMICs) to provide an updated assessment of the extent to which self-transfers – a positive outcome – contributed to the overall proportion of people considered to be lost to care. "
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    ABSTRACT: Objective To ascertain estimates of adult patients, recorded as lost to follow-up (LTFU) within antiretroviral treatment (ART) programmes, who have self-transferred care, died or truly stopped ART in low- and middle-income countries.Methods PubMed, EMBASE, Web of Science, Science Direct, LILACS, IndMed and AIM databases (2003-2013) and IAS/AIDS conference abstracts (2011-2013) were searched for tracing studies reporting the proportion of traced patients found to have self-transferred, died or stopped ART. These estimates were then combined using random-effects meta-analysis. Risk of bias was assessed through subgroup and sensitivity analyses.Results28 studies were eligible for inclusion, reporting true outcomes for 10,806 traced patients attending approximately 258 ART facilities. None were from outside sub-Saharan Africa. 23 studies reported 4.5-54.4% traced LTFU patients self-transferring care, providing a pooled estimate of 18.6% (95% CI 15.8-22.0%). A significant positive association was found between rates of self-transfer and LTFU in the ART cohort. The pooled estimates for unreported deaths was 38.8% (95% CI 30.8-46.8%; 27 studies), and 28.6% (95% CI 21.9-36.0%; 20 studies) for patients stopping ART. A significant decrease in unreported deaths from 50.0% (95% CI 41.5-58.4%) to 30.0% (95% CI 21.1-38.9%) was found comparing study periods before and after 31/12/2007.Conclusions Substantial unaccounted for transfers and deaths among patients LTFU confirms that retention and mortality is underestimated where the true outcomes of LTFU patients are not ascertained.This article is protected by copyright. All rights reserved.
    Tropical Medicine & International Health 11/2014; 20(3). DOI:10.1111/tmi.12434 · 2.30 Impact Factor
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    • "Some of these barriers have been as follows: a low level of expertise of the prescribing health professionals, little investment in training of healthcare workers, and limited laboratory capacity for viral load (VL) and CD4 monitoring [2]. Other more complex factors, such as poor adherence to treatment, antiretroviral drug toxicities, emergence of viral resistance, and social factors that include incarceration, drug abuse, and unmet basic human needs caused by extreme poverty, have also been mentioned as barriers to optimal treatment effectiveness [3] [4]. "
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    ABSTRACT: Background. Universal access to antiretroviral therapy (ARVT) started in Mexico in 2001; no evaluation of the features of ARVT prescriptions over time has been conducted. The aim of the study is to document trends in the quality of ARVT-prescription before and after universal access. Methods. We describe ARVT prescriptions before and after 2001 in three health facilities from the following subsystems: the Mexican Social Security (IMSS), the Ministry of Health (SSA), and National Institutes of Health (INS). Combinations of drugs and reasons for change were classified according to current Mexican guidelines and state-of-the-art therapy. Comparisons were made using χ2 tests. Results. Before 2001, 29% of patients starting ARVT received HAART; after 2001 it increased to 90%. The proportion of adequate prescriptions decreased within the two periods of study in all facilities (P value < 0.01). The INS and SSA were more likely to be prescribed adequately (P value < 0.01) compared to IMSS. The distribution of reasons for change was not significantly different during this time for all facilities (P value > 0.05). Conclusions. Universal ARVT access in Mexico was associated with changes in ARVT-prescription patterns over time. Health providers' performance improved, but not homogeneously. Training of personnel and guidelines updating is essential to improve prescription.
    AIDS research and treatment 12/2013; 2013:170417. DOI:10.1155/2013/170417
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