Mortality of Patients Lost to Follow-Up in Antiretroviral Treatment Programmes in Resource-Limited Settings: Systematic Review and Meta-Analysis

Division of International and Environmental Health, Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.
PLoS ONE (Impact Factor: 3.23). 06/2009; 4(6):e5790. DOI: 10.1371/journal.pone.0005790
Source: PubMed


The retention of patients in antiretroviral therapy (ART) programmes is an important issue in resource-limited settings. Loss to follow up can be substantial, but it is unclear what the outcomes are in patients who are lost to programmes.
We searched the PubMed, EMBASE, Latin American and Caribbean Health Sciences Literature (LILACS), Indian Medlars Centre (IndMed) and African Index Medicus (AIM) databases and the abstracts of three conferences for studies that traced patients lost to follow up to ascertain their vital status. Main outcomes were the proportion of patients traced, the proportion found to be alive and the proportion that had died. Where available, we also examined the reasons why some patients could not be traced, why patients found to be alive did not return to the clinic, and the causes of death. We combined mortality data from several studies using random-effects meta-analysis. Seventeen studies were eligible. All were from sub-Saharan Africa, except one study from India, and none were conducted in children. A total of 6420 patients (range 44 to 1343 patients) were included. Patients were traced using telephone calls, home visits and through social networks. Overall the vital status of 4021 patients could be ascertained (63%, range across studies: 45% to 86%); 1602 patients had died. The combined mortality was 40% (95% confidence interval 33%-48%), with substantial heterogeneity between studies (P<0.0001). Mortality in African programmes ranged from 12% to 87% of patients lost to follow-up. Mortality was inversely associated with the rate of loss to follow up in the programme: it declined from around 60% to 20% as the percentage of patients lost to the programme increased from 5% to 50%. Among patients not found, telephone numbers and addresses were frequently incorrect or missing. Common reasons for not returning to the clinic were transfer to another programme, financial problems and improving or deteriorating health. Causes of death were available for 47 deaths: 29 (62%) died of an AIDS defining illness.
In ART programmes in resource-limited settings a substantial minority of adults lost to follow up cannot be traced, and among those traced 20% to 60% had died. Our findings have implications both for patient care and the monitoring and evaluation of programmes.

Download full-text


Available from: Mar Pujades-Rodríguez
  • Source
    • "Another explanation for the higher loss to follow-up among men could be that some of them actually died, with the loss to follow-up rate reflecting a higher mortality among men. Other studies performed in Africa have found that mortality is inversely related to the loss to follow-up rate[48]. If a more thorough follow-up had been performed during the study period, the mortality rate would presumably be higher. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Objectives: Several studies have reported conflicting effects of sex on HIV-1 infection. We describe differences in baseline characteristics and assess the impact of sex on HIV progression among patients at a clinic with many HIV-2 and dually infected patients. Methods: The study utilized a retrospective cohort of treatment-naïve adults at the largest HIV clinic in Guinea-Bissau from June 6, 2005, to December 1, 2013. Baseline characteristics were assessed and the patients followed until death, transfer, loss to follow-up, or June 1, 2014. We estimated the time from the first clinic visit until initiation of ART, death, or loss to follow-up using Cox proportional hazard models. Results: A total of 5,694 patients were included in the study, 3,702 women (65%) and 1,992 men (35%). Women were more likely than men to be infected with HIV-2 (19% vs. 15%, p<0.01) or dually infected with HIV-1/2 (11% vs. 9%, p=0.02). For all HIV types, women were younger (median 35 vs. 40 years), less likely to have schooling (55% vs. 77%) or to be married (46% vs. 67%), and had higher baseline CD4 cell counts (median 214 vs. 178 cells/μl). Men had a higher age-adjusted mortality rate (hazard rate ratio (HRR) 1.29, 95% confidence interval (CI) 1.09-1.52) and were more often lost to follow-up (HRR 1.27, 95% CI 1.17-1.39). Conclusion: Significant differences exist between HIV-infected men and women regardless of HIV type. Men seek treatment at a later stage and, despite better socioeconomic status, have higher mortality and loss to follow-up than women. This article is protected by copyright. All rights reserved.
    Full-text · Article · Nov 2015 · Tropical Medicine & International Health
  • Source
    • "Transportation comprises the highest proportion of costs: 62 and 43 % for patients with CD4 cell counts below and above 200 cells/mm 3 , respectively, and this is comparable with the finding of Riyarto et al. [16] in Indonesia. A study by Haroen et al. [49] in Bandung, Indonesia, and international studies by Portelli et al. [47], Brinkhof et al. [48], and Posse et al. [15] have shown that transportation costs are a common reason why patients cease ARV. This information provides another reason to scale up ART at community level, as it likely reduces transportation costs for patients and may increase the uptake of ART, especially of patients with CD4 cell counts <200 cells/mm 3 . "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background We report an economic analysis of Human Immunodeficiency Virus (HIV) care and treatment in Indonesia to assess the options and limitations of costs reduction, improving access, and scaling up services. Methods We calculated the cost of providing HIV care and treatment in a main referral hospital in West Java, Indonesia from 2008 to 2010, differentiated by initiation of treatment at different CD4 cell count levels (0–50, 50–100, 100–150, 150–200, and >200 cells/mm3); time of treatment; HIV care and opportunistic infections cost components; and the costs of patients for seeking and undergoing care. Discussion Before antiretroviral treatment (ART) initiation, costs were dominated by laboratory tests (>65 %), and after initiation, by antiretroviral drugs (≥60 %). Average treatment costs per patient decreased with time on treatment (e.g. from US$580 per patient in the first 6 month to US$473 per patient in months 19–24 for those with CD4 cell counts under 50 cells/mm3). Higher CD4 cell counts at initiation resulted in lower laboratory and opportunistic infection treatment costs. Transportation cost dominated the costs of patients for seeking and undergoing care (>40 %). Conclusions Costs of providing ART are highest during the early phase of treatment. Costs reductions can potentially be realized by early treatment initiation and applying alternative laboratory tests with caution. Scaling up ART at the community level in certain high prevalence settings may improve early uptake, adherence, and reduce transportation costs.
    Full-text · Article · Sep 2015 · BMC Health Services Research
  • Source
    • "All mothers enrolled in the study were counseled to exclusively breastfeed for 24 weeks and then wean over a 4-week period. Mother–infant pairs were followed at 1,2,4,6,8,12,18,21,24,28,32,36,42, and 48 weeks postpartum or until a study endpoint was reached. In this study, three events were considered as endpoints: infant HIV infection, infant death, and maternal death. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Retaining patients in prevention of mother-to-child transmission of HIV studies can be challenging in resource-limited settings, where high lost to follow-up rates have been reported. In this article, we describe the effectiveness of methods used to encourage retention in the Breastfeeding, Antiretrovirals, and Nutrition study and analyze factors associated with lost to follow-up in the study. The Breastfeeding, Antiretrovirals, and Nutrition clinical trial was designed to evaluate the efficacy of three different mother-to-child HIV transmission prevention strategies. Lower than expected participant retention prompted enhanced efforts to reduce lost to follow-up during the conduct of the trial. Following study completion, we employed regression modeling to determine predictors of perfect attendance and variables associated with being lost to follow-up. During the study, intensive tracing efforts were initiated after the first 1686 mother-infant pairs had been enrolled, and 327 pairs were missing. Of these pairs, 60 were located and had complete data obtained. Among the 683 participants enrolling after initiation of intensive tracing efforts, the lost to follow-up rate was 3.4%. At study's end, 290 (12.2%) of the 2369 mother-infant pairs were lost to follow-up. Among successfully traced missing pairs, relocation was common and three were deceased. Log-binomial regression modeling revealed higher maternal hemoglobin and older maternal age to be significant predictors of perfect attendance. These factors and the presence of food insecurity were also significantly associated with lower rates of lost to follow-up. In this large HIV prevention trial, intensive tracing efforts centered on reaching study participants at their homes succeeded in finding a substantial proportion of lost to follow-up participants and were very effective in preventing further lost to follow-up during the remainder of the trial. The association between food insecurity and lower rates of lost to follow-up is likely related to the study's provision of nutritional support, including a family maize supplement, which may have contributed to patient retention. © The Author(s) 2014.
    Full-text · Article · Dec 2014 · Clinical Trials
Show more