Inadequate Monitoring and Attrition Among Patients on ART
Inadequate Monitoring and Attrition Among Patients on ART
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, 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.
Although the success of antiretroviral therapy (ART) scale-up has been widely acknowledged in resource-constrained settings, poor retention in care is a major challenge faced by ART programs. Most patient attrition occurs within the first year on ART, and patient retention across low- and middle-income countries in 2009 was estimated at 82% after 12 months on ART.
A meta-analysis in 2008 showed a retention rate of 86% at 6 months and 76% at the end of 2 years. Brinkhof et al reported that over 40% of HIV-positive African adults who did not return for their clinic appointment were dead. This high risk of death is associated with late initiation of ART in patients with advanced disease.
Long distance to the clinic is one of the major causes for loss to follow-up (LTFU). Some patients may self-transfer to clinics closer to their homes or workplaces, while others may move to a different location in search of jobs and business opportunities. Others may become LTFU because of family relocation, marriage, or war. Other factors influencing LTFU include stigma, low education level, religious beliefs, poor quality of services, formal and informal costs, poverty, adverse effects of drugs, nondisclosure, pregnancy, long waiting times, alcohol abuse, and use of traditional medicines.
Causes of attrition may vary in different clinics and among different patient populations. The purpose of our study was to identify factors associated with increased LTFU at the Infectious Diseases Clinic (IDC), a large HIV clinic in Kampala, Uganda.
Abstract and Introduction
Abstract
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, 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.
Introduction
Although the success of antiretroviral therapy (ART) scale-up has been widely acknowledged in resource-constrained settings, poor retention in care is a major challenge faced by ART programs. Most patient attrition occurs within the first year on ART, and patient retention across low- and middle-income countries in 2009 was estimated at 82% after 12 months on ART.
A meta-analysis in 2008 showed a retention rate of 86% at 6 months and 76% at the end of 2 years. Brinkhof et al reported that over 40% of HIV-positive African adults who did not return for their clinic appointment were dead. This high risk of death is associated with late initiation of ART in patients with advanced disease.
Long distance to the clinic is one of the major causes for loss to follow-up (LTFU). Some patients may self-transfer to clinics closer to their homes or workplaces, while others may move to a different location in search of jobs and business opportunities. Others may become LTFU because of family relocation, marriage, or war. Other factors influencing LTFU include stigma, low education level, religious beliefs, poor quality of services, formal and informal costs, poverty, adverse effects of drugs, nondisclosure, pregnancy, long waiting times, alcohol abuse, and use of traditional medicines.
Causes of attrition may vary in different clinics and among different patient populations. The purpose of our study was to identify factors associated with increased LTFU at the Infectious Diseases Clinic (IDC), a large HIV clinic in Kampala, Uganda.