Factors affecting attrition in a longitudinal study of patients with AIDS

How much does it cost to retain antiretroviral therapy (ART) clients in care? Routine financial costs of retention interventions at Lighthouse Trust's Martin Preuss Centre (MPC) in Lilongwe, Malawi

Introduction

Antiretroviral therapy (ART) improves the health of people living with HIV (PLHIV). However, a high loss to follow-up, particularly in the first year after ART initiation, is problematic. The financial expenses related to client retention in low- and middle-income countries (LMICs) in sub-Saharan Africa are not well understood. This study aimed to comprehensively assess and quantify the financial costs associated with routine ART retention care at Lighthouse Trust's (LT) Martin Preuss Centre (MPC), a large, public ART clinic in Lilongwe, Malawi.

Methods

We performed activity-based microcosting using routine data to assess the expenses related to routine ART retention services at the MPC for 12 months, January-December 2021. MPC provides an "ART Buddy" from ART initiation to 12 months. The MPC's Back-to-Care (B2C) program traces clients who miss ART visits at any time. Clients may be traced and return to care multiple times per year. We assessed client retention costs for the first 12 months of treatment with ART and conducted a sensitivity analysis.

Results

The total annual cost of ART retention interventions at the MPC was $237,564. The proactive Buddy phase incurred $108,504; personnel costs contributed $97,764. In the reactive B2C phase, the total cost was $129,060, with personnel expenses remaining substantial at $73,778. The Buddy unit cost was $34 per client. The reactive B2C intervention was $17 per tracing event. On average, the unit cost for ART retention in the first year of ART averaged $22 per client.

Conclusion

This study sheds light on the financial dimensions of ART retention interventions at the MPC of LTs. ART retention is both costly and critical for helping clients adhere to visits and remain in care. Continued investment in the human resources needed for both proactive and reactive retention efforts is critical to engaging and retaining patients on lifetime ART.

Role of demographic and clinical factors in survival of HIV patients on antiretroviral therapy

Our retrospective cohort study assesses the survival probability and identifies the demographic and clinical predictors of mortality in HIV patients taking antiretroviral therapy using an antiretroviral therapy centre data in Western India. Secondary data on 7532 registered HIV-infected individuals between September 2006 and January 2013 were analysed. The probability of survival at 75 months was 84.9%. Significant indicators of poor chances of survival were greater age, lower occupation class, lower CD4 count, poor functional status; higher stage of disease, lower weight, the presence and type of opportunistic infections, co-trimoxazole therapy and poor adherence to antiretroviral therapy. We thus find that, in addition to pre-ART, antiretroviral therapy clinical status and treatment adherence, socioeconomic status plays an important influence on ultimate survival of HIV patients on antiretroviral therapy.

Stimulant Use and Study Protocol Completion: Assessing the Ability of Men Who Have Sex with Men to Collect Dried Blood Spots for Laboratory Measurement of HIV Viral Load

Stimulant use is associated with higher HIV viral load (VL) and sexual HIV transmission risk among men who have sex with men (MSM) living with HIV. There is little research on willingness of drug users living with HIV to fully participate in studies, especially those involving self-collection of biomarker data. This study presents findings from an at-home dried blood spot collection study measuring laboratory-quantified VL among U.S. HIV-positive MSM who reported high-risk sexual behavior and/or suboptimal antiretroviral therapy (ART) adherence to assess the association between drug-use behavior and (1) ability to complete a study protocol and (2) VL outcomes. Among recruited participants (n = 766), 35% reported stimulant drug use (amphetamines, cocaine, crack, crystal meth, ecstasy, or a combination of stimulant drugs), 39% reported using other drugs (heroin, marijuana, prescription opioids, and others), and 27% reported no drug use in the past 3 months. In all, 61% of enrolled participants completed the study protocol. Stimulant drug users were less likely (ARR 0.84; 95% CI 0.72-0.98) to complete the protocol than other drug users. Furthermore, other drug users were significantly less likely than non-drug users (ARR 0.52; 95% CI 0.28-0.97) to have an HIV VL result ≥ 1500 copies/mL. This study provides important estimates regarding the likelihood of participation in biomedical research activities among HIV-positive MSM with varying drug-use behaviors, showing that it is feasible to conduct such biomedical studies with drug-using MSM who report high-risk sexual behavior and struggle with their ART adherence.

Loss to follow-up in a cohort of HIV-negative men who have sex with men: Project Horizonte

OBJECTIVE

The objective of this study is to estimate the attrition rates and evaluate factors associated with loss to follow-up between 1994 and 2011 in an open cohort of HIV-negative men who have sex with men.

METHODS

The Project Horizonte is an open cohort study that aimed to assess the incidence of HIV infection, evaluate the impact of educational interventions, and identify potential volunteers for HIV vaccine trials. The rates of losses to follow-up were estimated for three periods (1994–1999, 2000–2005, and 2006–2011). The variables analyzed were collected in a psychosocial questionnaire. Volunteers who dropped out were compared with the ones who remained in the study using a Cox regression model.

RESULTS

A total of 1,197 volunteers were recruited. The median follow-up time in the study (n = 626) was 4.2 years. The median follow-up time for the volunteers who dropped out of the study (n = 571) was 1.46 years. The overall rate of loss to follow-up was 11.6/100 person-years. Attrition rates by period were: 12.60 (1994–1999), 11.80 (2000–2005), and 9.00 (2006–2011) per 100 person-years. Factors associated with losses to follow-up were: age group of 21–30 years old, monthly per capita income of more than six or less than one Brazilian minimum wage, having more than two dependents, report of bisexual practice, and inconsistent use of condoms for receptive anal sex.

CONCLUSIONS

A slight decrease of the loss to follow-up was observed over time. Higher attrition rates happened in the first three years of follow-up. It is possible that the link of the volunteers were not yet well established. Those who reported inconsistent condom use in receptive anal sex were more likely to leave the study, suggesting an underestimation of the incidence of HIV infection in a cohort population. For greater effectiveness, retention strategies must be reassessed considering the connection between the characteristics of homosexual and bisexual behavior and the motivations to engage in health research.

Derivation and Evaluation of a Risk-Scoring Tool to Predict Participant Attrition in a Lifestyle Intervention Project

Participant attrition in clinical trials and community-based interventions is a serious, common, and costly problem. In order to develop a simple predictive scoring system that can quantify the risk of participant attrition in a lifestyle intervention project, we analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), an evidence-based lifestyle intervention to prevent diabetes in 36 American Indian and Alaska Native communities. SDPI-DP participants were randomly divided into a derivation cohort (n = 1600) and a validation cohort (n = 801). Logistic regressions were used to develop a scoring system from the derivation cohort. The discriminatory power and calibration properties of the system were assessed using the validation cohort. Seven independent factors predicted program attrition: gender, age, household income, comorbidity, chronic pain, site's user population size, and average age of site staff. Six factors predicted long-term attrition: gender, age, marital status, chronic pain, site's user population size, and average age of site staff. Each model exhibited moderate to fair discriminatory power (C statistic in the validation set: 0.70 for program attrition, and 0.66 for long-term attrition) and excellent calibration. The resulting scoring system offers a low-technology approach to identify participants at elevated risk for attrition in future similar behavioral modification intervention projects, which may inform appropriate allocation of retention resources. This approach also serves as a model for other efforts to prevent participant attrition.

Participant and site characteristics related to participant retention in a diabetes prevention translational project

Using multilevel analysis, this study investigated participant and site characteristics associated with participant retention in a multisite diabetes prevention translational project among American Indian and Alaska Native (AI/AN) people. We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), a lifestyle intervention to prevent diabetes implemented in 36 AI/AN grantee sites. A total of 2,553 participants were recruited and started the intervention between January 1, 2006 and July 31, 2008. They were offered the 16-session Lifestyle Balance Curriculum from the Diabetes Prevention Program (DPP) in the first 16-24 weeks of intervention. Generalized estimating equation models and proportional hazards models with robust standard error estimates were used to evaluate the relationships of participant and site characteristics with retention. As of July 31, 2009, about 50 % of SDPI-DP participants were lost to follow-up. Those who were younger, male, with lower household income, no family support person, and more baseline chronic pain were at higher risk for both short-term and long-term retention failure (i.e., not completing all 16 DPP sessions and loss to follow-up, respectively). Sites with large user populations and younger staff had lower likelihood of retaining participants successfully. Other site characteristics related to higher risk for retention failure included staff rating of participant disinterest in SDPI-DP and barriers to participant transportation and child/elder care. Future translational initiatives need to pay attention to both participant- and site-level factors in order to maximize participant retention.

Retention in HIV Care and Predictors of Attrition from Care among HIV-Infected Adults Receiving Combination Anti-Retroviral Therapy in Addis Ababa

Background

Patient retention in chronic HIV care is a major challenge following the rapid expansion of combination antiretroviral therapy (cART) in Ethiopia.

Objective

To describe the proportion of patients who are retained in HIV care and characterize predictors of attrition among HIV-infected adults receiving cART in Addis Ababa.

Method

A retrospective analysis was conducted among 836 treatment naïve patients, who started cART between May 2009 and April 2012. Patients were randomly selected from ten health-care facilities, and their current status in HIV care was determined based on routinely available data in the medical records. Patients lost to follow-up (LTFU) were traced by telephone. Kaplan-Meier technique was used to estimate survival probabilities of retention and Cox proportional hazards regression was performed to identify the predictors of attrition.

Results

Based on individual patient data from the medical records, nearly 80% (95%CI: 76.7, 82.1) of the patients were retained in care in the first 3 and half years of antiretroviral therapy. After successfully tracing more than half of the LTFU patients, the updated one year retention in care estimate became 86% (95% CI: 83.41%, 88.17%). In the multivariate Cox regression analyses, severe immune deficiency at enrolment in care/or at cART initiation and ‘bed-ridden’ or ‘ambulatory’ functional status at the start of cART predicted attrition.

Conclusion

Retention in HIV care in Addis Ababa is comparable with or even better than previous findings from other resource-limited as well as EU/USA settings. However, measures to detect and enroll patients in HIV care as early as possible are still necessary.

Predictors of Attrition in a Cohort Study of HIV Infection and Methamphetamine Dependence

Longitudinal cohort studies of HIV and substance use disorders play an important role in understanding these conditions, but high rates of attrition can threaten their integrity and generalizability. This study aimed to identify factors associated with attrition in a 5-year observational cohort study of 469 individuals with and without HIV infection and methamphetamine (MA) dependence. Rates of attrition in our four study groups were approximately 24% in HIV-MA-, 15% in HIV+MA-, 56% in HIV-MA+, and 47% in HIV+MA+ individuals. Predictors of attrition in the overall cohort included history of MA, alcohol, and other substance dependence, learning impairment, reduced cognitive reserve, and independence in activities of daily living (all ps < .05), but varied somewhat by clinical group. Of particular note, enrollment in a neuroimaging substudy was associated with significantly boosted rates of retention in the MA groups. Results from this investigation highlight the complexity of the clinical factors that influence retention in cohort studies of HIV-infected MA users and might guide the development and implementation of targeted retention efforts.

Risk of cataract among subjects with acquired immune deficiency syndrome free of ocular opportunistic infections

PURPOSE

To evaluate the risk of cataract in the setting of AIDS.

DESIGN

Prospective cohort study.

PARTICIPANTS

Subjects with AIDS free of ocular opportunistic infections throughout catamnesis.

METHODS

From 1998 through 2008, subjects 13 years of age or older were enrolled. Demographic characteristics and clinical characteristics were documented at enrollment and semiannually.

MAIN OUTCOME MEASURES

Cataract was defined as high-grade lens opacity observed by biomicroscopy judged to be the cause of a best-corrected visual acuity worse than 20/40. Eyes that underwent cataract surgery during follow-up were considered to have developed cataract before the first visit when pseudophakia or aphakia was observed.

RESULTS

Among 1606 participants (3212 eyes) at enrollment, 1.9% (95% confidence interval [CI]: 1.3%-2.7%) were observed to have cataract or prior cataract surgery. Among the 2812 eyes initially free of cataract and followed longitudinally (median follow-up, 4.6 years), the incidence of cataract was 0.37%/eye-year (95% CI: 0.26%-0.53%). In addition to age, significant cataract risk factors included prior cataract in the contralateral eye (adjusted hazard ratio [aHR], 21.6; 95% CI: 10.4-44.8), anterior segment inflammation (aHR, 4.40; 95% CI: 1.64-11.9), prior retinal detachment (aHR, 4.94; 95% CI: 2.21-11.0), and vitreous inflammation (aHR, 7.12; 95% CI: 2.02-25.0), each studied as a time-updated characteristic. Detectable human immunodeficiency virus RNA in peripheral blood was associated with lower risk of cataract at enrollment (adjusted odds ratio, 0.32; 95% CI: 0.12-0.80) but not of incident cataract (aHR, 1.58; 95% CI: 0.90-2.76). After adjustment for other factors, neither the then-current absolute CD4+ T-cell count nor antiretroviral therapy status showed consistent association with cataract risk, nor did an additive diagnosis of other comorbidities. Compared with the available population-based studies that used similar definitions of cataract, the age-specific prevalence of cataract in our cohort was higher than in 1 of 2 such studies, and the age-specific incidence of cataract surgery was higher.

CONCLUSIONS

Our results suggest cataract may occur earlier among patients with AIDS free of ocular opportunistic infections than in the general population. Cataract risk was associated most strongly with age and with other ocular morbidity in this population. With improved survival, the burden of cataract likely will increase for persons with the human immunodeficiency virus or AIDS.

Inadequate monitoring in advanced stages of disease with lack of supportive counseling increases attrition among patients on antiretroviral treatment at a large urban clinic in Uganda

BACKGROUND

The purpose of this case-control study was to identify risk factors for loss to follow-up (LTFU).

METHODS

Cases and controls were selected from HIV-positive patients, aged 18 years and older, on antiretroviral therapy (ART) at the Infectious Diseases Clinic (IDC) in January 2008. As cases, we selected 209 patients who in 2008 did not return to the clinic within 90 days of their scheduled appointment date. As controls, we randomly selected 626 patients from the 5872 patients who were following up at the end of December 2008.

RESULTS

In multivariable logistic regression analysis, urban or semiurban residence, World Health Organization disease stage III or IV at ART initiation, a median CD4 count at last visit <200 cells/mm(3), tuberculosis (TB) in the 6 months before the last visit, absence of counseling before ART initiation, and no disclosure of HIV status were associated with LTFU.

CONCLUSION

This study demonstrates the importance of close patient monitoring in advanced stages of disease, supportive counseling for patients initiating ART, extra psychosocial support for patients with TB and HIV coinfection, assisting patients with disclosure, and setting up a good referral system to retain patients on ART.

Sleep quality in efavirenz-treated Chinese HIV patients – comparing between GT and GG genotype of CYP2B6-516 G/T polymorphisms

Seventy-two adult Chinese HIV-positive treatment-naïve patients were recruited in a study to evaluate prospectively the associations between CYP2B6 516 G/T polymorphisms and sleep quality following treatment with an efavirenz-based regimen. Overall, the patients gave an allelic frequency of 0.3 for CYP2B6 516 T, and a genotype frequency of 9.4% for TT. Compared to GG, GT gave a higher median value of plasma efavirenz level at four weeks (3.77 mg/L vs 2.59 mg/L, p < 0.001) and 12 months (3.57 mg/L vs 2.97 mg/L, p = 0.026). Using generalised estimating equations analysis to track the variance over time, there was poorer Pittsburgh Sleep Quality Index in GT compared to GG, while GT was associated with a higher efavirenz level of >4 mg/L. There was however no difference in the component sleep scores nor was there direct association between sleep quality and plasma efavirenz levels. The results suggested that CYP2B6 genotype was associated with different patterns of sleep problems, further investigation of which is warranted with the objective of optimizing therapy with efavirenz-based regimens.

Risk of cataract in persons with cytomegalovirus retinitis and the acquired immune deficiency syndrome

OBJECTIVE

To evaluate cataract risk in eyes of patients with AIDS and cytomegalovirus (CMV) retinitis and to identify risk factors.

DESIGN

Prospective cohort study.

PARTICIPANTS

Patients with AIDS and CMV retinitis.

METHODS

Patients 13 years of age and older were enrolled between 1998 and 2008. Demographic and clinical characteristics, slit-lamp biomicroscopy findings, and dilated ophthalmoscopy results were documented at quarterly visits. Cataract status was determined at the initial visit (prevalence) and at follow-up visits (incidence).

MAIN OUTCOME MEASURES

For cataract, a high grade of lens opacity by biomicroscopy to which best-corrected visual acuity worse than 20/40 was attributed. Eyes that had undergone cataract surgery before enrollment or between visits also were counted as having cataract.

RESULTS

Seven hundred twenty-nine eyes of 489 patients diagnosed with CMV retinitis were evaluated. Higher prevalence was observed for patients with bilateral versus unilateral CMV retinitis (adjusted odds ratio [aOR], 2.74; 95% confidence interval [CI], 1.76-4.26) and, among unilateral CMV retinitis cases, for eyes with retinitis versus without retinitis (15% vs. 1.4%; P<0.0001). The age-adjusted prevalence of cataract among CMV retinitis cases was higher than that in a population-based sample (P<0.0001). Cataract prevalence increased with age (aOR, 11.77; 95% CI, 2.28-60.65 for age ≥ 60 years vs. younger than 40 years) and longer duration of retinitis (aOR, 1.36; 95% CI, 1.20-1.54 per year). Among eyes with CMV retinitis initially free of cataract, the cataract incidence was 8.1%/eye-year (95% CI, 6.7%-10.0%). Prior retinal detachment was associated with higher cataract risk (if repaired with silicone oil: adjusted hazard ratio [aHR], 10.37; 95% CI, 6.51-16.52; otherwise: aHR, 2.90; 95% CI, 1.73-4.87). Large CMV retinitis lesions also were associated with higher risk of cataract (for involvement of 25-49% retinal area: aHR, 2.30; 95% CI, 1.51-3.50; for ≥ 50% involvement: aHR, 3.63; 95% CI, 2.18-6.04), each with respect to ≤ 24% involvement, as were anterior segment inflammation (aHR, 2.27; 95% CI, 1.59-3.25) and contralateral cataract (aHR, 2.52; 95% CI, 1.74-3.66).

CONCLUSIONS

Cytomegalovirus retinitis is associated with a high absolute and relative risk of cataract. Among several risk factors, large retinal lesion size and use of silicone oil in retinal detachment repair are potentially modifiable, albeit not in all cases. Cataract is likely to be an increasingly important cause of visual morbidity in this population.

Incidence rate of and factors associated with loss to follow-up in a longitudinal cohort of antiretroviral-treated HIV-infected persons: an AIDS Clinical Trials Group (ACTG) Longitudinal Linked Randomized Trials (ALLRT) analysis

PURPOSE

Examine incidence and factors associated with loss to follow-up (LTFU) in the AIDS Clinical Trials Group (ACTG) Longitudinal Linked Randomized Trials (ALLRT) cohort.

METHOD

ALLRT is a prospective cohort of HIV-infected persons randomized to antiretroviral (ARV) regimens/strategies in ACTG trials and followed long-term after the trial ends. Person-years were calculated from ALLRT entry until loss to follow-up (LTFU; defined using off-study reasons or ≥ 3 consecutive missed visits), death/ severe debilitation/site closures, or June 2009 (censored). Poisson regression was used to examine LTFU factors separately among participants who were ARV naïve or ARV experienced at trial entry.

RESULTS

Among 4,630 participants (22,524 person-years), 1,140 were lost to follow-up, 237 died, 29 were severely debilitated, and 443 were at sites that closed. The LTFU incidence was 5.5 and 4.2 per 100 person-years among previously ARV-naïve and ARV-experienced participants, respectively. In both groups, age ≤ 50, site location, being off ARVs, and viral load ≥ 400 copies/mL were associated with a higher risk of LTFU. Among ARV-naïve participants, male sex, education <16 years, intravenous drug use, and cigarette smoking were also associated with LTFU.

CONCLUSION

Knowledge of differential LTFU can help researchers identify participants at risk of LTFU in longitudinal HIV cohorts and design retention strategies, thereby limiting study bias. The identified factors should be included in inverse probability of weighting models to account for LTFU.

Special diabetes program for Indians: retention in cardiovascular risk reduction

PURPOSE

This study examined the associations between participant and site characteristics and retention in a multisite cardiovascular disease risk reduction project.

DESIGN AND METHODS

Data were derived from the Special Diabetes Program for Indians Healthy Heart Demonstration Project, an intervention to reduce cardiovascular risk among American Indians and Alaska Natives with diabetes. In 2006, a total of 1,072 participants from 30 participating sites completed baseline questionnaires measuring demographics and sociobehavioral factors. They also underwent a medical examination at baseline and were reassessed annually after baseline. A Provider Annual Questionnaire was administered to staff members of each grantee site at the end of each year to assess site characteristics. Generalized estimating equation models were used to evaluate the relationships between participant and site characteristics and retention 1 year after baseline.

RESULTS

Among enrolled participants, 792 (74%) completed their first annual assessment. Participants who completed the first annual assessment tended to be older and had, at baseline, higher body mass index and higher level of physical activity. Site characteristics associated with retention included average age of staff, proportion of female staff members, and percentage of staff members having completed graduate or professional school.

IMPLICATIONS

Understanding successful retention must reach beyond individual characteristics of participants to include features of the settings that house the interventions.

Incidence and risk factors associated with lost to follow-up in a Belgian cohort of HIV-infected patients treated with highly active antiretroviral therapy

Being lost to follow-up (LTFU) is a major problem in caring for persons with HIV infection. We describe the proportions and characteristics of LTFU in a Belgian outpatient HIV clinic. All patients treated with highly active antiretroviral therapy (HAART) who attended at least two consultations were included. Patients not returning within the following year were considered LTFU. Multivariate analysis using logistic regression was performed. The LTFU rate was 5.5% on average and remained stable over the years. Patients LTFU were more often intravenous drug users (odds ratio [OR] = 3.48), not covered by health insurance (OR = 6.69), living outside the province (OR = 1.49) and treated with a complex initial HAART regimen (OR = 5.80). Increased age was also associated with a higher risk of LTFU. Patients at risk for LTFU after starting HAART should be the targeted for reinforced counselling and HIV treatment centres should establish systems to trace patients LTFU.

Determinants of survival in adult HIV patients on antiretroviral therapy in Oromiyaa, Ethiopia

BACKGROUND

The antiretroviral treatment (ART) scale-up service has been a recent development in Ethiopia, but its impact on mortality has not been well investigated. The aim of this study was to assess the early survival outcome of the scale-up service by utilizing routine hospital data.

METHODS

All adult HIV/AIDS patients who started on antiretroviral treatment in Shashemene and Assela hospitals from January 1, 2006 to May 31, 2006 were included and followed up for 2 years. Data were extracted from standard patient medical registrations. Kaplan-Meier curves were used to estimate survival probability and the Cox proportional hazard model was applied to determine predictors of mortality. Two alterative assumptions (real case and worst case) were made in determining predictors of mortality.

RESULTS

The median age of patients was 33 years and 57% were female. Eighty-five percent had CD4 <200 cells/µL with a median CD4 count of 103 cells/µL. The median survival time was 104.4 weeks. A total of 28 (10.3%) deaths were observed during the 2-year period and 48 patients (18%) were lost to follow up. The majority of deaths occurred in the first 4 months of treatment. In multivariate analysis, 2-year survival was significantly associated with the clinical stage of the disease, baseline hemoglobin, and cotrimoxazole prophylaxis therapy (CPT) at or before ART initiation in both assumptions. The median CD4 count and body weight showed a marked improvement during the first 6 months of treatment, followed by stagnation thereafter.

CONCLUSION

The study has shown an overall low mortality but a high loss to follow-up rate of the cohort. Advanced clinical stage, anemia, low body weight, and lack of CPT initiation were independent predictors of mortality - but not gender. CPT initiation should be encouraged in routine HIV care services, and patient retention mechanisms have to be strengthened. Stagnation in immunological and weight recovery after the first 6 months should be further investigated. The utilization of routine data should be encouraged in order to facilitate appropriate decision making.

Retrospective study on the critical factors for retaining patients on antiretroviral therapy in KwaZulu-Natal, South Africa

OBJECTIVE

To analyze the critical factors favoring the retention of patients under antiretroviral therapy (ART) in KwaZulu-Natal (KZN), South Africa.

DESIGN AND METHODS

This retrospective study was based on the review of a representative sample of patients who began ART between March 2004 and May 2006 in 32 public sector sites and were followed up to July 1, 2007. Extended Cox proportional hazard models were used to identify the factors which significantly influenced treatment retention during the first 2 years of treatment. Kaplan-Meyer provided the probabilities of remaining on ART if these factors were present.

RESULTS

The 2835 sampled patients corresponded to about 10% of the universe of patients under ART in the 32 sites; 929 (33%) were males, and the median age of the sampled patients was 34 (interquartile range: 28-41). The analysis identified factors that significantly decreased the probability of remaining on ART. Patients' risk factors were initial CD4 <100 cells per microliter, lack of a telephone contact number, and being male. Sites' risk factors were the presence of a part time (PT) versus a full time (FT) senior professional nurse, a PT versus FT doctor, and intakes of 200 or more new patients per doctor per year. The probability of remaining on ART declined significantly for each increasing level of workload, but having a FT versus a PT doctor made a significant difference only for level of workload of 200 or more new patients per year.

CONCLUSIONS

The analysis has identified the conditions influencing retention of ART patients in KZN. This has provided a method to estimate absorption capacity of the ART delivery sites, which is of added value for a sustainable expansion of the ART coverage.

High rate of loss to clinical follow up among African HIV-infected patients attending a London clinic: a retrospective analysis of a clinical cohort

Background

Long-term regular clinic follow up is an important component of HIV care. We determined the frequency and characteristics of HIV-infected patients lost to follow up from a London HIV clinic, and factors associated with loss to all HIV follow up in the UK.

Methods

We identified 1859 HIV-infected adults who had registered and attended a London clinic on one or more occasions between January 1997 and December 2005. Loss to follow up was defined as clinic non-attendance for one or more years. Through anonymized linkage with the Survey of Prevalent HIV Infections Diagnosed and Health Protection Scotland, national databases of all HIV patients in care in the UK up to December 2006, loss-to-follow-up patients were categorized as Transfers (subsequently received care at another UK HIV clinic) or UKLFU (no record of subsequent attendance at any HIV clinic in the UK). Logistic regression analysis was used to identify factors associated with UKLFU for those both on highly active antiretroviral therapy (HAART) and not on HAART.

Results

In total, 722 (38.8%) of 1859 patients were defined as lost to follow up. Of these, 347 (48.1%) were Transfers and 375 (51.9%), or 20.2% of all patients, were UKLFU. Overall, 11.9% of all patients receiving HAART, and 32.2% not receiving HAART were UKLFU. Among those on HAART, risk factors for UKLFU were: African heterosexual female (OR = 2.22, 95% CI: 1.11-4.56) versus white men who have sex with men; earlier year of HIV clinic registration (1997-1999 OR: 3.51, 95% CI: 1.97-6.26; 2000-02 OR: 2.49, 95% CI: 1.43-4.32 vs. 2003-2005); CD4 count of < 200 versus > 350 cells/mm³ (OR = 1.99, 95% CI:1.05-3.74); and a detectable viral load of > 400 copies/ml (OR = 5.03, 95% CI: 2.95-8.57 vs. ≤ 400 copies/ml) at last clinic visit.

Among those not receiving HAART, factors were: African heterosexual male (OR = 3.91, 95% CI: 1.77-8.64) versus white men who have sex with men; earlier HIV clinic registration (2000-2002 OR: 2.91, 95% CI: 1.77-4.78; 1997-1999: OR: 5.26, 95% CI: 2.71-10.19); and a CD4 count of < 200 cells/mm³ (OR: 3.24, 95% CI: 1.49-7.04).

Conclusions

One in five HIV-infected patients (one in three not on HAART and one in nine on HAART) from a London clinic were lost to all clinical follow up in the UK. Black African ethnicity, earlier year of clinic registration and advanced immunological suppression were the most important predictors of UKLFU. There is a need for all HIV clinics to establish systems for monitoring and tracing loss-to-follow-up patients, and to implement strategies for improving retention in care.

Cost-effectiveness of preventing loss to follow-up in HIV treatment programs: a Côte d'Ivoire appraisal

BACKGROUND

Data from HIV treatment programs in resource-limited settings show extensive rates of loss to follow-up (LTFU) ranging from 5% to 40% within 6 mo of antiretroviral therapy (ART) initiation. Our objective was to project the clinical impact and cost-effectiveness of interventions to prevent LTFU from HIV care in West Africa.

METHODS AND FINDINGS

We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) International model to project the clinical benefits and cost-effectiveness of LTFU-prevention programs from a payer perspective. These programs include components such as eliminating ART co-payments, eliminating charges to patients for opportunistic infection-related drugs, improving personnel training, and providing meals and reimbursing for transportation for participants. The efficacies and costs of these interventions were extensively varied in sensitivity analyses. We used World Health Organization criteria of <3x gross domestic product per capita (3x GDP per capita = US$2,823 for Côte d'Ivoire) as a plausible threshold for "cost-effectiveness." The main results are based on a reported 18% 1-y LTFU rate. With full retention in care, projected per-person discounted life expectancy starting from age 37 y was 144.7 mo (12.1 y). Survival losses from LTFU within 1 y of ART initiation ranged from 73.9 to 80.7 mo. The intervention costing US$22/person/year (e.g., eliminating ART co-payment) would be cost-effective with an efficacy of at least 12%. An intervention costing US$77/person/year (inclusive of all the components described above) would be cost-effective with an efficacy of at least 41%.

CONCLUSIONS

Interventions that prevent LTFU in resource-limited settings would substantially improve survival and would be cost-effective by international criteria with efficacy of at least 12%-41%, depending on the cost of intervention, based on a reported 18% cumulative incidence of LTFU at 1 y after ART initiation. The commitment to start ART and treat HIV in these settings should include interventions to prevent LTFU.

Attrition and related trends in scientific rigor: a score card for ART adherence intervention research and recommendations for future directions

Scientific rigor in intervention trials is frequently used in systems that identify effective interventions for dissemination. In these systems, and in work that synthesizes bodies of research, percent attrition is often considered a fatal threat to validity. However, differential attrition, versus percent total, is of primary concern. Key methodologic, design, and analytic issues pertaining to scientific rigor in longitudinal designs were identified, and the current literature on antiretroviral therapy adherence interventions (k = 51) was evaluated in relation to these. Although results suggest that this body of literature has progressed in rigor, improvements are needed in transparency of reporting participant flow, retention strategies, handling of missing data, and characterization of retained and lost cohorts. Attrition averaged 30% total, and differential by study arm was estimated at 9%. Differential attrition continues to be underreported and is not well represented by the more frequently used, though arguably less appropriate, metric of overall percent attrition.

Association of site-specific and participant-specific factors with retention of children in a long-term pediatric HIV cohort study

Minimizing loss to follow-up (LTFU) in long-term cohort studies is essential for reducing bias and maintaining statistical stability. However, factors associated with attrition of children in observational studies have received little attention. The authors used survival analysis methods to evaluate the association of participant and site characteristics with time to LTFU in a multicenter cohort study conducted in the United States of 2,693 human immunodeficiency virus (HIV)-infected and 1,370 HIV-exposed-but-uninfected children enrolled in 2000-2004. As of 2004, 91% of HIV-infected and 86% of uninfected children had been retained in the study. Among the HIV infected, factors associated with higher risk of LTFU included site prohibition of participant compensation, low caregiver educational level, age >15 years, and higher viral load, whereas death of a family member was associated with better retention. Among uninfected children, sites accruing low numbers of subjects, social worker responsible for retention, young age (1-2 years), and birth abnormalities were associated with higher risk of LTFU. Occurrences of certain stressful life events, such as a death in the family or financial instability, were associated with higher retention, but risk of LTFU increased when children started school or mothers began employment. Although participant characteristics are difficult to modify, the authors identified several potentially modifiable site practices that could be targeted to improve retention.

Defaulters from antiretroviral treatment in Jimma University Specialized Hospital, Southwest Ethiopia

OBJECTIVE

To determine the prevalence of and factors associated with defaulting from antiretroviral treatment (ART) in Jimma, Ethiopia.

METHODS

Unmatched case control study: cases were individuals who had missed two or more clinical appointments (i.e. had not been seen for the last 2 months) between January 2005 and February 2007; controls were individuals who had been on ART at least for 1 year and were rated as excellent adherers by the providers. Data were collected from patient records, and by telephone call and home visit to identify the reason for defaulting.

RESULTS

Of 1270 patients who started ART, 915 (72.0%) were active ART users and 355 (28.0%) had missed two or more clinical appointments. The latter comprised 173 (13.6%) defaulters, 101 (8.0%) who transferred out, 75 (5.9%) who died, and 6 (0.5%) who restarted ART. Reasons for defaulting were unclear in most cases. Reasons given were loss of hope in medication, lack of food, mental illness, holy water, no money for transport, and other illnesses. Tracing was not successful because of incorrect address on the register in 61.6% of the cases. Taking hard drugs (cocaine, cannabis and IV drugs), excessive alcohol consumption, being bedridden, living outside Jimma town and having an HIV negative or unknown HIV status partner were associated with defaulting ART.

CONCLUSION

A significant proportion of patients defaulted from ART treatment. ART clinics should ensure that patients' addresses are correct and complete. Programmatic and counseling efforts to decrease ART defaulting should address illicit drug and excessive alcohol use, decentralise ART services, institute home-based treatment options for seriously ill and bedridden patients, and address patients concerns.