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 (Impact Factor: 3.8). 11/2010; 7(4):234-44. DOI: 10.1007/s11904-010-0061-5
Source: PubMed


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,
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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 · 2.33 Impact Factor
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    • "However, the current approach for measuring retention focuses on a particular clinic or health facility, not on a network of health facilities. This underestimates the level of retention in care, as there are patients who change from their original clinic to (an) other clinic(s) during their lifelong ART journey while they are reported as lost to follow-up [47,48,53,54,65]. Moreover, the currently available information systems are not designed around a continuum of care that should start at the time of HIV diagnosis. "
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    ABSTRACT: Background Antiretroviral treatment (ART) was provided to more than nine million people by the end of 2012. Although ART programs in resource-limited settings have expanded treatment, inadequate retention in care has been a challenge. Ethiopia has been scaling up ART and improving retention (defined as continuous engagement of patients in care) in care. We aimed to analyze the ART program in Ethiopia. Methods A mix of quantitative and qualitative methods was used. Routine ART program data was used to study ART scale up and patient retention in care. In-depth interviews and focus group discussions were conducted with program managers. Results The number of people receiving ART in Ethiopia increased from less than 9,000 in 2005 to more than 439, 000 in 2013. Initially, the public health approach, health system strengthening, community mobilization and provision of care and support services allowed scaling up of ART services. While ART was being scaled up, retention was recognized to be insufficient. To improve retention, a second wave of interventions, related to programmatic, structural, socio-cultural, and patient information systems, have been implemented. Retention rate increased from 77% in 2004/5 to 92% in 2012/13. Conclusion Ethiopia has been able to scale up ART and improve retention in care in spite of its limited resources. This has been possible due to interventions by the ART program, supported by health systems strengthening, community-based organizations and the communities themselves. ART programs in resource-limited settings need to put in place similar measures to scale up ART and retain patients in care.
    Globalization and Health 05/2014; 10(1):43. DOI:10.1186/1744-8603-10-43 · 2.25 Impact Factor
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